Evidence-based Dental Practice Developing guidelines or clinical recommendations

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Evidence-based Dental PracticeDeveloping
guidelines or clinical recommendations
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Outline

• The practice of EBD at a community health center
• Define clinical questions
• Locate and critique systematic reviews
• If no reviews are available, locate and critique
  primary research
• Develop clinical protocols
• Implement the protocols in practice

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What is EBD practice?

• EBD is a set of principles and methods intended
  to ensure that, to the greatest extent possible,
  medical dental decisions, guidelines, and other
  types of policies are based on and consistent
  with good evidence of effectiveness and benefit.
• Eddy M. Health Affairs 2005249-17

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EBD Practice at a Community Health Center

• Step 1
• Identify procedures that require standardization
  or reduction in variability
• Review of procedures provided, word-of-mouth
• Review of cost variation
• Review of charts
• Determine the benefits and harms of different
  approaches

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EBD Practice at a Community Health Center

• Step 2
• Share the data with the practitioners (dentists
  and dental hygienists) and decide on the need for
  developing clinical protocols (guidelines), or
  standards
• Guidelines are statements that should be
  followed, but can be adapted based on patients
  needs and conditions.
• Clinical protocols define in steps how guidelines
  are implemented in clinical care.
• Standards are statements and policies that must
  be followed without modification.

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EBD Practice at a Community Health Center

• Step 2
• Form a committee to steer the process
• Representatives from different groups (dentists,
  hygienists, medical and allied health)
• Content consultants from dental schools
• Other consultants
• Methods
• Search for evidence
• EBD experts

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EBD Practice at a Community Health Center

• Step 3
• Decide on the clinical question(s) which, if
  answered, can resolve the clinical issue defined
  in the first step.
• Use a modified PICO standard
• Population
• Intervention
• Conditions or disease state
• Outcomes

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EBD Practice at a Community Health Center

• Step 4
• Using PICO, define inclusion and exclusion
  criteria for guidelines or standards
• Conduct a systematic review of all guidelines or
  standards relevant to the question
• Retrieve and review the documents using the
  inclusion and exclusion criteria
• Select a preliminary set for analysis
• Prepare a summary table of standards or
  guidelines using the PICO format

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EBD Practice at a Community Health Center

• Step 4
• Rate the quality of the guidelines using the
  GRADE system
• Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-Ytter
  Y, Alonso-Coello P, Schünemann HJ, for the GRADE
  Working Group.
• Rating quality of evidence and strength of
  recommendations GRADE an emerging consensus on
  rating quality of evidence and strength of
  recommendations. BMJ

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The Grade System
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The GRADE system
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The GRADE system
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EBD Practice at a Community Health Center

• Step 6
• Decide whether the current guidelines or
  standards are adequate for your institution or
  you need to revise them
• The only change that can be made is not in the
  evidence, but rather in the conditions which
  dictate implementation of the guidelines (The C
  in PICO)
• E.g. Your organization may decide to apply
  topical fluorides based on the risk status of
  adult patients, if the original evidence
  supporting the application is based on expert
  opinion.

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EBD Practice at a Community Health Center

• Step 6
• Disseminate the guideline
• Train the practitioners to apply the guidelines
• Conduct calibration exercises using case
  summaries or patients
• Monitor the implementation using reviews and
  chart audits
• Review and disseminate the findings

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EBD Practice at a Community Health Center

• Step 4 Revised
• If no standards or guidelines are available to
  answer your PICO question, then search for
  systematic reviews or the most appropriate
  evidence to answer the question
• This process is more time consuming (i.e. more
  costly) and requires the help of experienced
  reviewers

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EBD Practice at a Community Health Center

• Step 5 Revised
• Select systematic reviews or primary studies for
  consideration for further analysis
• Agree (committee decision) on which studies or
  reviews will be included in the development of
  guidelines
• Summarize the evidence using the PICO format
• Rate the quality of each bit of evidence using
  the tools in the ADA EBD website

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Appraisal Tools in the EBD Website
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EBD Practice at a Community Health Center

• While each study should be critiqued for its
  strengths and weaknesses, decisions on best
  practices should rely on the best available
  evidence.
• In addition to the GRADE system, there are
  several other classification systems
• The most applicable to community health centers,
  in my opinion, is the one used in the UK National
  Health Service.

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EBD Practice at a Community Health Center

• UK National Health Service
• Level A Consistent randomized controlled
  clinical trial, cohort trial, cohort study,
  clinical decision rule validated in different
  populations.
• Level B Consistent Retrospective Cohort,
  Exploratory Cohort, Ecological Study, Outcomes
  Research, case-control study or extrapolations
  from level A studies.
• Level C Case-series study or extrapolations from
  level B studies.
• Level D Expert opinion without explicit critical
  appraisal, or based on physiology (or
  microbiology, biology), bench research....

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EBD Practice at a Community Health Center

• Step 6
• After summarizing and grading the evidence, the
  panel should decide on how to answer the PICO
  question
• State the guidance by population group or
  specific targets
• State what are the key points (what, when, and
  how) for each intervention
• Identify conditions when the guidance should be
  applied (risk factors, patient factors, operator
  factors)
• Define the anticipated outcomes that should be
  collected, analyzed and followed

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EBD Practice at a Community Health Center

• Step 7
• Disseminate the guidelines, seek comments, and
  edit the text to clarify it
• Prepare training of staff to implement the
  guidelines
• Define targets for follow-up in implementation
• Calibrate the providers
• Assess process and final outcomes
• Be vigilant for new evidence and modify the
  guidelines, if necessary
• Review the application and usability of the
  guidelines at least once year

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EBD Practice as an Individual Dentist or Dental
Hygienist

• Clinical question
• Has your institution developed EBD guidelines to
  answer the question?
• If no, search for published guidelines and
  relevant evidence
• Critique the evidence using the tools referenced
  in the previous slides
• Make a decision on how best to answer the
  clinical question and strength of evidence
  supporting your decision
• Communicate all information evidence
  for/against, risks and benefits to the patient
• Training and calibration of the providers
• Quality assurance