Best practice dental class

BEST PRACTICES / E B P
DR RAJESH G KONNUR
PROFESSOR
1

CONCEPT OF EBP:
• Evidence based practice is an approach that enables
clinicians to provide the highest quality of care in
meeting the multiphase needs to their parents and
family.
2

INTRODUCTION:
Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care
that integrates the best evidence from studies and patient care data with clinician expertise
and patient preferences and values. (Fineout-Overholt E, 2010).
EBP is the integration of clinical expertise, patient values, and the best research evidence
into the decision making process for patient care.
Clinical expertise refers tothe clinician’s cumulated experience, education & clinical skills.
The patient brings to the encounter his or her own personal preferences and unique
concerns, expectations, and values.
3

DEFINITION
 Evidence based practice (EBP) is the process of making clinical decisions based
upon evidence,combined with clinical experienceand patientsexpectations.
 Evidence based practice is the conscientious explicit and judicious use of current. Best
evidence in making decision about the care of individual patients.The practiceof
evidence based medicine means integrating individual clinical expertisewith the best
availableexternalclinicalevidence fro systematic research.
(Sackett. et al1996)
4

CONT…
• Health care that is evidence-based and conducted in a
caring context leads to better clinical decisions and
patient outcomes. Gaining knowledge and skills in the
EBP process provides dentists and other clinicians the
tools needed to take ownership of their practices and
transform health care.
5

WAYS OF ACQUIRING KNOWLEDGE IN DENTISTRY /
MEDICAL SCIENCE
Traditions
Borrowing
Trial & Error
Personal Experience
Role Modeling
Intuition
Reasoning
Research
7

KEY COMPONENTS OF EBP
A.Research evidence.
B.Clinical expertise, judicious
use.
C.Patient values and
circumstances.
8

KEY COMPONENTS OF EBP
Resear
ch
Eviden
ce
Patient Values,
Circumstances
Randomized
controlled trials
Laboratory
experiments Clinical
trials Epidemiological
research Outcomes
research Qualitative
research
Expert practice
knowledge,
inductive
reasoning
Clinical
Expertise
Knowledge gained
from practice over time
Inductive reasoning
Unique preferences
Concerns
Expectations
Financial resources
Social support
9

AIMS OF EVIDENCE BASED PRACTICE
 To provide the high quality and most cost-efficient care possible.
 To advance quality of care provided by dental practioners.
 To increase satisfaction among patients.
 To focus on medical practice away from habits and tradition to evidence and
research.
 It results in better patient outcomes.
 It contributes to the science of medical / dental science.
 It keeps practices current and relevant.
 It increases confidence in decision-making.
10

FEATURES OF EBP
Problem based and within the scope of the practitioners experience.
It brings together the best available evidence and current practice by combining
research with knowledge and theory. So it narrows the research practice gap. It
facilitates application of research into practice by including both primary and secondary
research findings.
It concerned with quality of service and is therefore a Quality assurance
activity.
EBP projects are team projects and therefore require team support and collaborative
action.
It support research projects and outcomes that are cost effective EBP de- emphasizes
ritual, isolated and unsystematic clinical experiences ungrounded opinions and tradition
as a basis of practice. It stresses the use of research findings.
11

WHY IS EBP RELEVANT TO THE MEDICAL PRACTICE?
There is a gap between what we know and what we do. Medical
practice can and must be changed from tradition-based to
science-based:
Research-practice gap: Much of what is known from research
has not been applied in practice. This is known as Research-
Practice Gap.
12

THREE COMPONENTS OF EBD
• Is an approach to oral health care.
• Is a method to acquire, understand
and apply the most current science.
Evidence
Patients’
needs &
preferences
Clinical
Expertise
14

STEPS OF EVIDENCE BASED
PRACTICE
Step 1: formulating a well built question.
Step 2: collecting the most relevant and best
evidence to answer the clinical question including
searching for systematic reviews / identifying articles.
Step 3: Critically appraising the evidence that has been
collected for its validity, relevance and applicability.
15

Step 4: integrating the evidence with ones clinical expertise,
assessment of patient’s condition and available health care
resources along with the patients preferences and values to
implement the evidence.
Step 5: Evaluating the change resulting from application of evidence
in practice.
- Determine the areas for improvement.
16

STEP1: FORMULATING THE
QUESTION
With clinical areas ,there is often a barrage of details to
digest. a well built question includes the following
components
the patients disorder or disease
the intervention or finding under review
a comparison intervention
the question should be in PICOT or PICO format
17

PICOT FORMAT
Patient, Population or Problem :
What are the characteristics of the patient or population?
What is the condition or disease you are interested in?
( i.e. age, gender, ethnicity, with a certain disorder)
Intervention or exposure :
What do you want to do with this patient (e.g. treat, diagnose, observe)?
(exposure to a disease, risk behavior, prognostic factor)
18

CONT…
• Comparison:
• What is the alternative to the intervention (e.g. placebo, different drug,
• surgery)?
•(could be a placebo or "business as usual" as in no disease, absence of risk
factor, Prognostic factor B )
19

Outcome
What are the relevant outcomes (e.g. morbidity, death,
complications, risk of disease, accuracy of a diagnosis, rate of
occurrence of adverse outcome)
Time
What time it takes to demonstrate an outcome (e.g. the time it
takes for the intervention to achieve an outcome or how long
participants are observed).
20

ARE INSULIN PUMPS MORE EFFECTIVE THAN
CONVENTIONAL THERAPIES IN MANAGING TYPE 2
DIABETES IN PREGNANT WOMEN?
Patient/Population - Pregnant women with type 2
diabetes.
Intervention - Insulin pump therapy.
Comparison - Conventional insulin therapy.
Outcome - Improved management of glucose levels.
21

SEARCH STRATEGIES BACKGROUND
INFORMATION
Background information may be found in sources
such as:
reference book entries
textbooks, chapters, appendices
drug monographs, guides to diagnostic tests
the library’s Bobcat catalog
selected electronic Reference Tools for Background
information in the health science.
22

STEP 2. DATABASE /RESOURCE
SEARCHI
NG
Once a clinical practice question has been selected, the
next step is to search and assemble research evidence
on the topic. In doing a literature review as a background
for a new study, the central goal is to discover where the
gap are and how best to advance knowledge. The
resourses falls into 3 categories:
23

General information/background resourses-
to collect the past information of a particular disease. e.g measles has been nearly
eradicated, but there has been a fairly recent outbreak. If you need to refresh your
knowledge of the clinical presentation, diagnosis etc of measles, a background
resource would be the best place to start.
Filtered resourses-
If you are trying to decide on a course of action for a patient (diagnosis, treatment
etc)and want to base your decision on the best available evidence, consult a filtered
resource. clinical experts and subject specialists pose a question and then synthesize
evidence to state conclusions based on the available research. because of this pre
evaluation, the clinician does not have to do the literature searching and evaluate each
study that comes up, saving time and ensuring a level of completeness.
24

· Unfiltered resources-
If you don’t find an appropriate answer in the filtered resourses
,you will need to search unfiltered resourses (the primary literature) to
locate studies that answer your question. unfiltered resourses provide
the most recent information ,but its upto to the clinician to evaluate
each study found to determine its validity and applicability to the
patient.
Effectvely searching and evaluating the studies found in unfiltered
resources takes more time and skill, which is why filtered resources
are the first choice of answering clinical questions.
25

EBP RESOURCES
A. PRE-APPRAISED RESOURCES: Filtered resource have
been reviewed for quality and relevance to clinical care.
ACP Journal Club. This Web site comprises a 10- year
archive of the cumulative electronic contents of "ACP Journal
Club", with recurrent weeding of out-of- date articles. The
content is carefully selected from over 100 clinical journals
through reliable application of explicit criteria for scientific merit,
followed by assessment of relevance to medical practice by
clinical specialists.
26

Clinical Evidence.
Clinical Evidence describes the best available evidence from systematic reviews,
RCTs, and observational studies when appropriate for assessing the benefits and
harms of treatments.
Dynamed.
Dynamed is a point-of-care reference resource designed to provide clinicians with
current, evidence-based information to support clinical decision-making.
Essential Evidence.
Essential Evidence is a one-stop reference that includes evidence-based answers
to clinical questions concerning symptoms, diseases, and treatment.
27

FPIN Clinical Inquiries.
Clinical Inquiries provides answers to clinical questions by
using a structured search, critical appraisal, clinical
perspective, and rigorous peer review. FPIN Clinical
Inquiries deliver evidence for point of care use.
UpToDate.
UpToDate is an evidence-based, peer reviewed information
resource available via the Web, desktop/laptop computer,
and PDA/mobile device.
28

DATABASES:
PubMed. PubMed comprises more than 22 million citations for biomedical
articles from MEDLINE and life science journals. Citations may include links to
full-text articles from PubMed Central or publisher web sites.
Cochrane Library. The Cochrane Library contains high- quality, independent
evidence to inform healthcare decision-making. It includes reliable evidence
from Cochrane systematic reviews and a registry of published clinical trials. The
methodology used to create the Cochrane reviews is recognized as the gold
standard for developing systematic reviews.
Center for Reviews and Dissemination (DARE). The databases DARE,
NHS, EED and HTA assist decision- makers by identifying and describing
systematic reviews and economic evaluations, appraising their quality, and
highlighting their relative strengths and weaknesses.
29

ELECTRONIC TEXTBOOKS AND LIBRARIES:
AccessMedicine: Access Medicine is an online resource that provides students,
residents, clinicians, researchers, and other health professionals with access to
"Harrisons Online".
Scientific American Medicine. Formerly known as ACP Medicine, Scientific
American Medicine includes science, medicine, health and technology
information. It is also available from Stat!Ref.
ACP Smart Medicine. Formerly known as ACP PIER, ACP Smart Medicine is an
online clinical tool that provides evidence-based clinical guidance to improve clinical
care. It is free to ACP members or can be purchased as asubscription.
Stat!Ref. STAT!Ref is a collection of online electronic textbooks for healthcare
professionals.
30

META-SEARCH ENGINES:
Trip. The TRIP Database searches across multiple
internet sites for evidence-based content. It covers
key medical journals, Cochrane Systematic
reviews, clinical quidelines, and other highly
relevant websites to help health professionals find
high quality clinical evidence for clinical practice.
31

STEP3. CRITICALLY APPRAISING THE
ARTIC
LE
The assessment of evidence by systematically reviewing its relevance,
validity and results of specific situations.
In determining the implementation potential of an innovation in a particular
setting, several issues should be considered, particularly the transferability of the
innovation, the feasibility of implementing it and its cost benefit ratio. For
example, the traditional method for verifying the placement of a nasogastric tube
was air insufflation.
However, according to current research, the accurate method for verifying
placement is radiologic examination (Metheny & Titler, 2001).
32

If the implementation assessment suggests that
there might be problems in testing the innovation
in that particular practice setting, then the team
can either identify a new problem and begin the
process anew or consider adopting the plan to
improve the implementation potential (e.g.
seeking external resources if cost were the
inhibiting factors).
33

STEP 4. APPLYING THE
EVIDENCE/INTEGRATING
EVIDENCE
WITH ONES
CLINICAL
EXPERTISE
If the implementation criteria are met the team can design and plot the
innovation. To reach your conclusion you may consult questions related
to diagnosis ,therapy, harm and prognosis keep in mind that you must
interpret the information based on a number of criteria and depending
on your skill and experience ,you may need to confer with a peer.
example- Sample evidence practice e.g. consider a nine year old
girl present in the ER with abdominal pain and you suspect
appendicitis. which imaging modality is best for making the
diagnosis CT or ultrasound.
34

STEP 5. EVALUATING THE CHANGE
The fifth step of the process, outcome evaluation, attempts to interpret
the results and evaluate the outcomes of the applied evidence
(intervention). Outcome measures may be psychosocial (quality of life,
improved patient perception of care, reduction in depressive and
anxiety symptoms), physiologic
(improved health, reduced complications), or functional improvement.
Evaluation of the process and the results may occur through peer
assessment, audit, or even self reflection. Depending on the type of
outcomes achieved, it may be possible to compare the outcomes of a
study with similar outcomes on a local, regional, national, or
international level.
35

MODELS FOR EVIDENCE BASED MEDICAL CARE
T
H
EM
O
D
E
L
SOFFER GUIDELINES FOR DESIGNING AND IMPLEMENTING A
UTILIZATION PROJECT IN A PRACTICE SETTING. THE TWO MODELS
STELTER MODEL AND IOWA MODEL INCORPORATE EVIDENCE
PRACTICE PROCESSES RATHER THAN RESEARCH UTILIZATION ALONE.
John Hopkins Model
Stelter Model
CURN
Iowa Model of Evidence Based Practice
36

A. THE STELTER MODEL
The stelter model was designed with the assumption
that Research Utilization could be undertaken.
not only by organizations but by individual clinicians and
managers. It was a model designed to promote and
facilititate critical thinking about the application of research
findings in practice.
The current model presented graphically involves five
sequential phases:
37

Preparation
In this phase, the medics define the underlying purpose and outcomes of the project, search,
sort and select sources of research evidence.
She considers external factors that can influence potential application and internal factors that
can diminish objectivity and affirm the priority of perceived problem.
Validation
This phase involves a utilization of focused critique of each source of evidence, focusing in
particular on whether it is sufficiently sound for potential application in practice.
Comparative evaluation and decision- making :
This phase involves a synthesis of findings and application of criteria that taken together are
used to determine the desirability and feasibility of applying findings from validated source to
medical practice. The end result of the comparative evaluation is to make a decision about
using the study findings.
39

Translation/application:
This phase involves activities to conform how the findings will
be used (e.g. formally or informally) and spell out the
operational details of the application and implement them.
Evaluation:
In the final phase, the application is evaluated.
Informal use of the innovation versus formal use would
lead to different evaluative strategies.
40

IOWA MODEL
Efforts to use research evidence to improve medical / nursing practice
are often addressed by group of doctors /nurses interested in the same
practice issues.
This model, like the stelter model, was revised recently an renamed the
Iowa Model of evidence Based Practice to promote quality of care.
The current version of Iowa Model acknowledges that formal RU/EB
Project begins with a trigger an impetus to explore possible changes to
practice. The start point can be either knowledge focused trigger that
emerges from awareness of innovative research findings.
41

The model outlines a series of activities with three
clinical decision points.
I. Deciding whether the problem is a sufficient priority for the
organization exploring possible changes; if yes, a team is formed to
proceed with the project: if No, a new trigger would be sought.
II. Deciding whether there is sufficient Research base; if Yes, the
innovation is piloted in the practice setting. If No, the team would
either search for other sources of evidence or conduct its own
research.
III. Deciding whether the change is appropriate for adoption in
practice; if yes, a change would be instituted and monitored. If No;
the team would continue to evaluate quality of care and search for
new knowledge.
43

The points of entry to this model were problem and knowledge
focused triggers.
Problem focused triggers encompassed frequently encountered clinical problems, risk
management and quality improvement data and total quality management programs/ in
contrast,
Knowledge focused triggers include new information that resulted from such sources as the
Agency for Health care policy and Research, specialty organizations and research
publications.
When a trigger was identified the next step included assembling, critiquing, and evaluating the
applicability of relevant research literature.
After the research base was evaluated and critiqued, a decision was made regarding whether
or not a change in practice was warranted. If, however, a sufficient and appropriate research
base was found that supported modification of current practice, changes were initiated that
were congruent with those suggested by the research results. If research base had
insufficiencies, further research was conducted, experts were consulted and applications of
scientific principles were considered.
44

To translate research findings into practice several steps
were necessary:
1) Expected outcomes of the change and baseline or current status were
documented.
2) Dental/ Nursing/ multidisciplinary interventions were designed
3) Practice changes were implemented on a pilot unit.
4) Process and outcomes were evaluated; and
5) The interventions were modified as necessary
The next critical decision point involved determination of whether practice
changes should be made for all patient populations affected by the research
based interventions. Considerations included cost of implementations, overall
impact on quality of care, staff competency and support of administration.
45

This model used a process of planned change . staff need to
be empowered with ownership of the change, as well as,
with the knowledge and resources necessary to make this
change.
This model supported the monitoring of patient outcomes by unit
staff members for atleast two consecutive quarters after
implementation. These activities assisted in maintaining the
practice change and facilitating feedback to the staff. Outcome
measurements are also focused on the effects of change on the
staff and fiscal parameters. Without thorough monitoring of all
these areas an accurate reflection of the cost/benefit
relationship could not be realized.
46

THE EVIDENCE HIERARCHY:
The best evidence for interventions comes from systematic reviews and
RCTs as we move down this hierarchy in evidence, we usually have less
good information available.
Systematic review
Randomized controlled trial
Cohort study
Case control study
Cross-section analytical study
Descriptive/narrative study
49

LIMITATIONS
Resistant to changes in clinical practice.
Ability to critically appraise research findings.
Time, workload pressures, and competing priorities.
Lack of continuing education programs.
Fearof "stepping on one'stoes“
Poor administrative support.
51

THE CLINICIAN’S ROLE :
 Information
 Data
 Statistics
 Knowledge
 Judgment
 Values
 Decisions
52

ACKNOWLEDGING THE DIFFERENCE BETWEEN EBP AND
TRADITIONAL PRACTICE:
Evidence-Based Practice
• Uses best evidence
• Systematic appraisal of quality of
evidence
• Objective, transparent, less biased
• Acceptance of levels of uncertainty
Traditional Practice
• Unknown basis of evidence
• Limited/incomplete appraisal of
quality of evidence
• Subjective, opaque, potentially
biased
• Black and white conclusions
53

THE VALUE OF EVIDENCE-BASED PRACTICE
54

BARRIERS TO CHANGE :
• Time
• Access
• Complexity of
information
55

What is pre-appraised evidence?
Clinical practice
guidelines
Critical summaries of
systematic reviews
Systematic reviews
57

Systematic reviews Implementation into
clinical practice
1. Clinical Practice
Guidelines
2. Critical summaries
of systematic reviews
3. Independent
appraisal of systematic
reviews (and/or other
trials)
TIERED APPROACH TO FINDING EVIDENCE-BASED
INFORMATION
58

HOW DO I FIND THE BEST EVIDENCE-BASED
INFORMATION TO GUIDE MY PRACTICE?
59

ADA CLINICAL PRACTICE GUIDELINES:
61

What are the levels of primary evidence?
Randomized
Controlled Trial
Controlled study
without
randomization
Non-experimental studies
(i.e. cohort and case-control)
Expert committee reports or opinions or
clinical experience of respected authorities
62

The EBD Process
Ask
Access
Appraise
Apply
Assess
64

Population or Problem
STEP 1: FRAMING THE ANSWERABLE QUESTION
Intervention
Comparison (Optional)
Outcome
65

• Framing the question
• Increase chances of finding the answer
• Know when you’ve found the answer
• Help to find it quickly
• Identify search terms
66

IN PATIENTS WITH PERIODONTAL
DISEASE, WILL SHORT-TERM SYSTEMIC
ANTIBIOTICS, WHEN COMPARED TO
SURGERY, REDUCE POCKET DEPTH?
Population
67

Population
68

DISEASE, WILL SHORT-TERM
SYSTEMIC ANTIBIOTICS, WHEN
COMPARED TO SURGERY, REDUCE
POCKET DEPTH?
Intervention
69

IN PATIENTS WITH PERIODONTAL DISEASE,
WILL SHORT-TERM SYSTEMIC ANTIBIOTICS,
WHEN COMPARED TO SURGERY, REDUCE
POCKET DEPTH?
Intervention
70

POCKET DEPTH?
Comparison
71

POCKET DEPTH?
Comparison
72

Outcome
73

POCKET DEPTH?
Outcome
74

Ask
Access
Appraise
Apply
Assess
75

Formulate question (PICO)
Develop list of search terms
Guidelines and Summaries
NO
Systematic Reviews
NO
Primary Studies
EBD website ebd.ada.org YES STOP
EBD website and PubMed YES STOP
PubMed
(Clinical Studies)
YES STOP
SEARCH STRATEGY
76

Ask
Access
Appraise
Apply
Assess
77

OTHER LEVELS OF EVIDENCE :
Population
Intervention
Outcome
Control
Outcome
78

Ask
Access
Appraise
Apply
Assess
79

1.Are the results valid?
Quality
• Are the studies well designed and
executed?
• What types of studies are there?
Quantity
• How many studies are there?
• What are the population sizes?
Consistency
• How consistent are their results?
80

2.What are the results?
• Certainty of the
effect
• Magnitude of
the effect
81

2.What are the results?
3.Can the results be
applied to my patient?
• Is the
population
similar?
• Is the provider
similar?
• Is the setting
similar?
82

Ask
Access
Appraise
Apply
Assess
83

The better the research, the more confident the
decision. Victor Montori, Mayo Clinic
Evidence alone is never sufficient to make a
clinical decision. Victor Montori, Mayo Clinic
External clinical evidence can inform, but can
never replace, individual clinical expertise. David
Sackett
84

Summary /
Conclusion:
Health Research is systematic inquiry to develop knowledge about issues
of importance to practitioners. Health practioners like nurses, doctors ,
allied health practioners are developing an evidence – based practice
(EBP) that incorporates research findings into their clinical decisions. Best
practice includes choosing the appropriate research finding related to
care aspect.
85

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