Cheryl Straub-Morarend DDS David Holmes DDS, MS Teresa Marshall PhD Engaging the Private Sector in Evidence-Based Dentistry ADEA Program Objectives ADEA Program Objectives Share gleaned from a survey of dental practitioners regarding acquisition and utilization of scientific information resources Share insights gleaned from a survey of dental practitioners regarding acquisition and utilization of scientific information resources Demonstrate the and of pragmatic EBD continuing education programs for dental teams in the private sector ADEA Program Objectives Share insights gleaned from a survey of dental practitioners regarding acquisition and utilization of scientific information resources Demonstrate the development and design of pragmatic EBD continuing education programs for dental teams in the private sector Summarize the, and of audiences of the CE programs ADEA Program Objectives Share insights gleaned from a survey of dental practitioners regarding acquisition and utilization of scientific information resources Demonstrate the development and design of pragmatic EBD continuing education programs for dental teams in the private sector Summarize the awareness, perceptions and preferences of audiences of the CE programs Highlight and utilized to educate and engage the private dental practice team in an evidence-based approach to practice 1
ADEA Learning Objectives ADEA Learning Objectives Identify current trends of private dental practitioners with regard to Evidence-Based Dentistry Identify current trends of private dental practitioners with regard to Evidence-Based Dentistry Refine existing pre-doctoral, post-doctoral and allied dental curricula to enhance the readiness of graduates for success in the contemporary dental practice environment ADEA Learning Objectives Identify current trends of private dental practitioners with regard to Evidence-Based Dentistry Refine existing pre-doctoral, post-doctoral and allied dental curricula to enhance the readiness of graduates for success in the contemporary dental practice environment Formulate appropriate continuing education programs in EBD for use in the attendee s community We are drowning in information but starved for knowledge. John Naisbitt Megatrends Purpose of the Iowa EBD Assist practitioners in adapting to changes in the dynamics of contemporary practice 2
Purpose of the Iowa EBD Assist practitioners in adapting to changes in the dynamics of contemporary practice Equip the dental team to adopt realistic, efficient strategies for the implementation of evidence-based decision making Purpose of the Iowa EBD Assist practitioners in adapting to changes in the dynamics of contemporary practice Equip the dental team to adopt realistic, efficient strategies for the implementation of evidence-based decision making Impact behavior at the point of care Purpose of the Iowa EBD Assist practitioners in adapting to changes in the dynamics of contemporary practice Equip the dental team to adopt realistic, efficient strategies for the implementation of evidence-based decision making Impact behavior at the point of care Assist practitioners in utilizing evidence-based decision making to improve their practice of dentistry Investigation of Current Trends Literature search Investigation of Current Trends Literature search Survey of Iowa Dentists 1,348 surveys mailed Over 60 percent of private practice dentists in Iowa practice in communities with populations of less than 50,000. 3
Distribution of Private Practice Dentists in Iowa by Community Population (2008) Community population Communities in Iowa with at least one dentist Total number of private practice dentists in Iowa 33.7% of Iowa private practice dentists practice in communities with fewer than 10,000 people. 85.4% practice in communities with fewer than100,000. McKernan S, Kuthy RA. Iowa Dentist Workforce Trends: 1997-2008. Iowa Dent J 2010;96(1):33-6. % of all private practice dentists in Iowa <1000 14 15 1.1% 1000-4999 127 217 16.5% 5000-9999 43 211 16.1% 10,000-49,999 25 377 28.7% 50,000-99,999 7 301 23. >100,000 2 192 14.6% 8 of Iowa dentists are alumni from The University of Iowa College of Dentistry. An estimated 9 of Iowans are within a 30-minute drive of a practicing alumnus. Dr. David C. Johnsen Year of your graduation from dental school: 0 1 8 13 12 12 9 12 11 10 10 14 10 4 11 9 7 Respondents (n=518) to 2009 Survey of Iowa Dentists 4 7 8 6 11 13 19 11 22 14 18 11 23 22 22 29 22 11 10 4 7 8 6 8 3 5 3 5 3 1 0 0 0 3 1 0 0 0 1 0 1 0 0 0 0 0 0 0 2010 2005 2000 1995 1990 1985 1980 1975 1970 1965 1960 1955 1950 1945 Year of Graduation from Dental School 1 Which of the following best describes the current scope of your primary practice? (please select only one answer) General Practice/Comprehensive Dental Care Practice limited to a specialty (please specify specialty) Other (please specify) I do not currently practice dentistry. 84. 7% 15.3% General Practice limited to a Practice/Comprehensive specialty (please specify Dental Care specialty) Respondents (n=518) to 2009 Survey of Iowa Dentists 4.5% 3. 2.2% 0. 0. Other (please specify) 2.4% 0.2% 1.2% 1. I do not currently practice dentistry. In the past year, how often have you referred to the following resources to support clinical decisions in your clinical practice of dentistry? Traditional CE courses Print journals Consultation with other professionals Organizational websites Manufacturer s representative Dental practice expert Textbooks published since graduation Consultation with UIowa faculty Textbooks from dental school Manufacturers websites Electronic journals Electronic pharmacology database Electronic library database Online CE Courses Respondents (n=518) to 2009 Survey of Iowa Dentists 29% 17% 14% 15% 1 7% 6% 11% 7% 3% 43% 61% 67% 67% 6 61% 63% 57% 55% 46% 35% 35% 37% 37% 54% 66% 2% 3% 5% 16% 19% 24% 29% 29% 36% 39% 46% 55% 5 6 1 2 3 4 5 6 7 8 9 10 Frequently Sometimes Never From the following sources please select your five favorites, and rank them from 1-5 (1 being your first choice) in your order of preference for answering clinical questions. CE Courses Journals Consultation with other professionals Textbooks Consultation with UIowa faculty Dental practice expert 5% 15% 14% 19% 26% 1 7% Organizational websites 3% 6% 3% 11% 7% Manufacturer s representatives 4% 7% 9% 19% 14% 14% Online databases 5% 5% 6% 9% 7% Manufacturers websites Other Respondents (n=518) to 2009 Survey of Iowa Dentists 1 21% 7% 17% 17% 12% 1 1 17% 9% 16% 11% 12% 11% 1 2 3 4 5 6 7 8 9 1 2 3 4 5 4
Trends The majority of respondents reported utilization of: -multiple information resources -resources with variable levels of unbiased, valid, reliable scientific evidence Over half of all respondents indicated that they were very likely or somewhat likely to actively seek out a scientific article to answer a clinical question (Somewhat likely: 56.2%, Very likely: 26.2%) Trends The majority of respondents reported they were somewhat comfortable in their ability to: -evaluate the scientific basis of information (59.4%) -implement research findings (54.3%) into their practices Straub-Morarend CL, Marshall TA, Holmes DC, Finkelstein MW. Informational resources utilized in clinical decision making: Common practices in dentistry. J Dent Educ 2011;75(4):441-52. Regardless of whether or not you use Evidence-Based Dentistry in your daily clinical practice, what is your primary obstacle to practicing EBD? (please select only one answer your most likely choice) inadequate training or knowledge lack of access to resources insufficient time limited or no perceived value Other (please specify) 25.6% What is your primary obstacle to practicing Evidence Based Dentistry? Respondents (n=518) to 2009 Survey of Iowa Dentists 16.9% 36. 12.9% 8.7% Trends Dental school graduates from the 21 st century were the highest percentage (44.7%) to report insufficient time as the primary obstacle to practicing Evidence- Based Dentistry inadequate training or knowledge lack of access to resources insufficient time (Χ 2 = 29.07; df = 16; p = 0.0234) limited or no perceived value Other (please specify) Objectives of the Iowa EBD Provide an interactive educational experience Objectives of the Iowa EBD Provide an interactive educational experience A systematic review was conducted by Forsetlund et al to assess the effects of continuing education meetings on professional practice and healthcare outcomes (included 81 trials involving educational meetings) mixed interactive and didactic education meetings were more effective than either didactic meetings or interactive meetings. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003030. DOI: 10.1002/14651858.CD003030.pub2. 5
Objectives of the Iowa EBD Educate the dental team in effective strategies to address gaps in clinical knowledge Skills in formulating clinical questions Skills in advanced search strategies for current evidence Critical evaluation of the available evidence Objectives of the Iowa EBD Assist the dental team in engaging patients in this paradigm shift Objectives of the Iowa EBD Address integration of evidence at the point of care University of Iowa, College of Dentistry CE District Dental Society Meeting Interactive small group workshop 20 Dentists 19 Hygienists 2 Assistants/Staff Interactive course 38 Dentists 20 Hygienists 26 Assistants/Staff 6
District Dental Society Meeting Interactive course 217 Dentists 224 Hygienists 301 Assistants/Staff Cheryl Straub-Morarend DDS David Holmes DDS, MS Teresa Marshall PhD EBD Awareness, Perceptions, and Preferences of CE Program Audiences Students indicated that ARS keeps them fully engaged in the class. Elashvili A et al. Evaluation of an audience response system in a preclinical operative dentistry course. J Dent Educ 2008 Nov;72(11):1296-303. How large is the metropolitan area where your dental school is located? Are most of the dentists who practice in your community graduates of your dental school? 1. Population >1,000,000 32% 1. Yes 6 2. Population 250,000-1,000,000 37% 2. No 4 3. Population <250,000 32% 7
Which of the following best describes your primary role in the field of Dentistry? (please select only one answer) Which do you guess is the most common reason for dental health professionals to attend CE programs about EBD? 1. Particular interest in the topic(s) 16% Administrative Assistant 3% Other 2% Dentist Dentist 29% Hygienist Dental Assistant 39% Administrative Assistant Other (please specify) Hygienist I do not currently work in the 27% field of dentistry. 2. Need the CE credit hours for licensure 3. Sponsored by the District Dental Society 4. Office staff came as a group 5. Other 11% 74% Attendees at EBD CE programs in Cedar Rapids on 10/6/2010 (67 respondents) and Des Moines on 3/4/2011 (433 respondents) Do you think that most attendees at a CE program about EBD have ever taken a statistics course? Do you think that most attendees at a CE program about EBD have ever been personally involved in conducting research? 1. Yes 25% 1. Yes 2. No 75% 2. No 10 How often do you guess that most CE attendees search for health care literature to address gaps in knowledge? How often do you guess that most CE attendees read professional health care literature relevant to the practice of dentistry? 1. Daily 1. Daily 2. Weekly 5% 2. Weekly 25% 3. Monthly 47% 3. Monthly 7 4. Yearly 37% 4. Yearly 5% 5. Never 11% 5. Never 8
How would you guess that CE course attendees describe the editorial review process for most of the health care literature that they read? Which internet resource do you guess that CE attendees use most frequently? 1. Peer reviewed 35% 1. Common Search Engines (Google) 7 2. Non-peer reviewed 25% 2. Organizational Websites 25% 3. Not sure 4 3. Manufacturer's Websites 5% 4. Evidence-based Databases (Cochrane, etc.) 5. Other When CE course attendees read a scientific article, which parts do you think they usually read? Regardless of whether or not they use EBD, what do you guess that CE attendees cite most often as their primary obstacle to practicing EBD? 1. Entire article 5% 1. inadequate training or knowledge 45% 2. Abstract only 65% 2. lack of access to resources 1 3. Conclusions only 3 3. insufficient time 4 4. limited or no perceived value 5% 5. Other Continuing Education Curriculum Cheryl Straub-Morarend DDS David Holmes DDS, MS Teresa Marshall PhD 9
Outline Resources Course content Modifications Lessons learned Essential components RESOURCES To teach the teachers Books How to read a paper: the basics of evidence-based medicine Trisha Greenhalgh Interpreting the medical literature; Stephen H. Gehlbach Evidence-based dentistry: Managing information for better practice Derek Richards, Jan Clarkson, Debora Matthews, Rick Niederman Users guides to the medical literature: a manual for evidence-based clinical practice Gordon Guyatt, Drummond Rennie, Maureen Meade, Deborah Cook. To teach the teachers Online sites Oxford s Center for Evidence-based Medicine Duke/UNC s Introduction to Evidence-based Practice UNC s Evidence Based Dentistry Dartmouth s Evidence-based Medicine Resources American Dental Association s Center for Evidence-based Dentistry Resources To teach the teachers Journal articles Editorials Manuscripts Courses ADA/Forsyth Course on EBD ADA Evidence Reviewer Workshop To teach the CE students Iowa survey results; Straub s article Straub-Morarend CL, Marshall TA, Holmes DC, Finkelstein MW. Informational resources utilized in clinical decision making: common practices in dentistry. J Dent Edu. 2011 Apr;75(4):441-52. Olav Alvares Award for Outstanding Articles, 2012 Course handouts/list of sources Paper Flash drive 10
To teach the CE students Online/Live PubMed Clinical Queries ADA Center for Evidence-based Dentistry Systematic reviews & summaries Oxford s Center for Evidence Based Dentistry Critical appraisal skills program (CASP) tools University of York NHS Centre for Reviews and Dissemination Database of abstract reviews and effects (DARE) Cochrane Collaboration COURSE CONTENT Content Information explosion Identify volume of information Survey audience s behaviors with respect to information seeking & share results of Statewide survey Identify resources available through state and Iowa health science library Introduction to EBD Define EBD Rationale for incorporation of EBD into private practice Provide a clinician s perspective of keeping up with new science using EBD tools Content Sources of information Science vs. pseudoscience Critique web sources with emphasis on lay sites Peer reviewed science Review types of information (1 vs. 2 ) and journal quality Question development & design Define the question (PICO format) Review research designs Live demonstrations Lay information PubMed Live activities/practice Content Corporate Sponsors Procter & Gamble Johnson & Johnson Corporate perspective on EBD Practice & Resources Unrestricted educational grants 11
Content Content Applying EBD: clinical cases Ask: PICO Present clinical dilemma Acquire: Live use of appropriate sources PubMed clinical queries ADA EBD site DARE Cochrane Appraise: Reading, appraising and interpreting clinical literature Critiquing an original research manuscript Manuscript structure ~Grad student protocol Systematic review CEBM s Critical appraisal sheet http://www.cebm.net/index.aspx?o=1157 Content Apply: application of science to case Consider patient preferences & clinician experience Content CE sponsor specific EBD content EBD & dental materials Resources available Evaluation of manufacturers scientific literature EBD pharmacology resources Modifications MODIFICATIONS Audience requests Dental materials vs. drugs 2 hour journal club presentations Question development Research design Manuscript appraisal Statistics by Zooth criteria Schork, MA Critical appraisal sheets (> 1 source/format) Resources ADA site Understanding Statistics primers Evidence Based Dentistry, Elliot Abt 12
Lessons learned: content LESSONS LEARNED Dental student EBD curriculum Iterative process CE and dental student benefits Manuscript appraisal Manuscript structure 3 question rule 6 question rule Statistics by Zooth criteria Multiple CASP examples Lessons learned: content Critical appraisal worksheets for original manuscripts Categorical vs. linear data Dartmouth Critical summary appraisal Lack of published criteria Design evolution CE participant limitation Minimal background in statistics ESSENTIAL COMPONENTS Essential CE content 5 Steps of the EBD Process Ask PICO Acquire Original research Critical summaries Appraise Critical appraisal sheets Critical summary appraisals Apply Science, patient preferences & experience Assess Evaluate the outcome Resources EBD tutorials EBD didactic content Cheryl Straub-Morarend DDS David Holmes DDS, MS Teresa Marshall PhD 13
Reflections Positive Aspects Informed continuing education curriculum Opportunity for concurrent learning Engaged the audience & challenged biases Interactive sessions with online access Insight gained for pre-doctoral curricular reform Corporate support Limitations Challenges Survey instruments were not validated Data from the surveys were self-reported No outcome assessment was conducted Topic is boring to some Challenges Topic is boring(?) to some Diverse audience Access to information Readiness of practitioners to integrate changes Change is more likely if specific behavior is targeted (Tu & Davis) Tu K, Davis D. Can we alter physician behavior by educational methods? Lessons learned from studies of the management and follow-up of hypertension. J Contin Educ Health Prof. 2002;22:11-22. Challenges Imperfect system We don t have evidence to support everything we do in dentistry Contradictions in evidence can cloud degree of usefulness our evidence is either outdated by the date it is published or not clinically based 14
Feedback Topic was not interesting to the entire staff. Need excitement! I would like more clinical/research examples. I am not as intimidated by this process. I will spend more time reading quality sources of information instead of spending time sorting through articles. I feel more educated on how to search for answers in literature and better able to evaluate. Feedback I will search for answers to my questions instead of asking others. We got some great sites for information. I feel we re better informed for patient s questions. Serve a cold beverage at break. Impact Future Directions We have introduced 867 dental team members to evidence-based decision making. Emphasize awareness of resources and effective strategies of evidence-based decision making within the curriculum Investigate the impact of teaching strategies on learner confidence and behavior Continue to promote evidence-based practice in the dental community Cheryl L. Straub-Morarend, DDS Department of Family Dentistry The University of Iowa cheryl-morarend@uiowa.edu David C. Holmes, DDS, MS Department of Family Dentistry The University of Iowa dc-holmes@uiowa.edu Teresa A. Marshall, PhD Department of Preventive & Community Dentistry The University of Iowa teresa-marshall@uiowa.edu Cheryl Straub-Morarend DDS David Holmes DDS, MS Teresa Marshall PhD 15