Evidence-Based Practice: Toward Optimizing Clinical Outcomes

251 Pages·2010·4.127 MB·English

by  Francesco Chiappelli, Xenia M. C. Brant, Oluwadayo O. Oluwadara, Negoita Neagos (auth.), Francesco Chiappelli (eds.)

Evidence-Based Practice:
toward Optimizing Clinical Outcomes
Francesco Chiappelli (Editor)
Xenia Maria Caldeira Brant
Negoita Neagos
Oluwadayo O. Oluwadara
Manisha Harish Ramchandani (Co-Editors)
Evidence-Based
Practice: toward
Optimizing
Clinical Outcomes
Prof. Dr. Francesco Chiappelli Dr. Oluwadayo O. Oluwadara
ADA Champion, Evidence-Based Dentistry University of California, Los Angeles
Divisions of Oral Biology and Medicine School of Dentistry
and Associated Clinical Specialties (Joint) Divisions of Oral Biology and Medicine
University of California, Los Angeles Los Angeles, CA 90095-1668
School of Dentistry USA
Divisions of Oral Biology and Medicine [email protected]
Los Angeles, CA 90095-1668
USA Dr. Manisha Harish Ramchandani
[email protected] University of California, Los Angeles
School of Dentistry
Prof. Dr. Xenia Maria Caldeira Brant Divisions of Oral Biology and Medicine
Rua Aimorés 2480/609 Los Angeles, CA 90095-1668
Belo Horizonte-MG USA
Brazil [email protected]
[email protected]
Dr. Negoita Neagos
University of California, Los Angeles
School of Dentistry
Divisions of Oral Biology and Medicine
Los Angeles, CA 90095-1668
USA
[email protected]
ISBN: 978-3-642-05024-4 e-ISBN: 978-3-642-05025-1
DOI: 10.1007/978-3-642-05025-1
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Foreword
Evidence-Based Decision-Making in Health Care: Implications
and Directions for the Future
In the current political climate, health care is in crisis with no conceivable, long-term
solution. Its future portends a shortage of primary care physicians with an estimated
50 million new patients needing basic health care [1]. It is expected that in the next
decade 40,000 medical providers must be added to the existing 100,000 or the system
for health care response to expected need will be overwhelmed. While the agenda for
universal health care and reform has become a major stimulus for political action,
dentistry has provided concrete advances in knowledge, technology, and mechanisms
toward credible and practical responses to this crisis.
These advances come in the form of new knowledge and research into oral bio-
markers in screening for systemic diseases with mechanisms to systematically review
published information for best evidence, and practical models to implement this best
evidence for service providers and their patients. This implementation is integrated
into the shared decision-making, patient assessment, evaluation, and treatment plan-
ning encounter occurring within real timeframes and without disturbing practice rou-
tines. The effort of dentistry to provide these workable solutions is particularly
profound in that the knowledge, mechanisms, and models offered attempt to maxi-
mize effective, efficacious, and cost containment treatment options for patients with
best health care evidence for all within the dynamics of change in knowledge and
treatments.
Thus, there is a paradigm shift occurring in the concept of health care practice in
general and dental practice in particular. The approach to patient-centered care is
envisioning dental practice as part of primary care, creating a concept in which dental
practice has expanded to become a center for dental medicine and oral health well-
ness. Evidence of this paradigm shift is the work being done by David Wong in sali-
vary diagnostics. Malamud [2] extols this new approach as “point-of-care (POC)”
diagnostics that will revolutionize the way a limited amount of resources may be used
to handle increased patient loads, providing the ability to diagnose disease condi-
tions: reciprocal and inclusive of those performed in diagnostic medicine. Here,
a “noninvasive, well-tolerated” oral sampling may be used to identify biomarkers
in diagnosing disease at initial or periodic dental maintenance visits.
As part of primary care, dental providers become part of the interdisciplinary team
whose responsibility is to manage health care, including dental services, for shared
patients. This health care management and service delivery may occur in hospital,
v
vi Foreword
nursing home, or private practices and clinics. For dentists, or any health care pro-
vider, this requires a knowledge base for interpretation of data and translation of its
information into service or treatment options. EBR and translational evidence mecha-
nisms are needed to provide trusted best evidence to perform within the dynamics of
this new concept of dental practice.
There are two major categories within which EBR has provided to meet changes
in future health care practices. One has been in the reasoning of evidence and the
other in application of this reasoning to improving patient decision-making in the
presence of uncertainty about health care options, their value to individuals, and cost
trade-offs.
Evidence-based advances in reasoning have expanded knowledge or data to
include the value and application of best evidence to patients and society. Current
mechanisms include comparative effectiveness research (CER) and EBR. CER may
be independent or synergistic with EBR. CER both conducts studies and uses system-
atic review analyses to compare similar treatments or procedures in maximizing the
choice of the most effective cost/benefit option within the context of new evidence [3].
EBR uses similar analyses; however, the result is to determine best evidence in maxi-
mizing best outcomes not costs. Clinicians use these advances to promote shared
understanding and decision-making in providing informed consent as well as oral
health services and their maintenance along with disease control in individuals, their
patients [5].
While CER and EBD in health care assist in reasoning individual health and treat-
ment choices during shared-decision making with dentists, translational evidence
mechanisms explain the development of data, its transformation into best evidence,
clinical relevance, and meaning in practice. These mechanisms, which rely on human
information technology (HIT) systems, propose to understand, define, and characterize
the underlying process involved in clinical decision-making for CER and EBD. For
health care in the twenty-first Century, the triad of CER-EBD-HIT defines the com-
pact between researcher (research synthesis), clinician (clinical expertise, local long-
term monitoring and implementation of evidence), patients (patient choice and
compliance) in providing the essential components of the biological, behavioral,
and social interventions involved in clinical decision-making related to health care
delivery, and coverage of costs by third-party providers [4].
The future of these advances is profound for patients because dentists and physi-
cians are known for providing services, treatments, and therapies in the nongovern-
mental, private business sector that responds to market forces in maximizing effective,
efficacious, and cost containment for oral health care and service delivery. Dentistry
and medicine, as well as nursing and allied health care professions, function as part
of the primary care – interdisciplinary team systems approach. This is a reality today,
which will subsist in coming decades.
Therefore, the contributions contained within this book explain the advances made
in evidence-based and CER for decision-making in health care. This literature pro-
vides the background and knowledge of the development, validation, and implemen-
tation of research methodologies and mechanisms in providing relevant and practical
solutions for physicians, dentists, nurses, and patients. These advances are timely in
their promotion of best evidence used in informed consent and assisting the choices
and trade-offs patients often are required to make when uncertainties in health care
choices and options arise. The benefit of these developments toward resolving the
current crisis in health care delivery nationally and internationally is critical and
Foreword vii
timely as it proffers practical models for translating the best available research evi-
dence to patients and society for improvement in health care and well-being of the
patient populations we serve.
Janet G. Bauer, DDS, MSEd, MSPH, MBA
Associate Professor and Director
June and Paul Ehrlich Endowed Program
in Geriatric Dentistry
UCLA School of Dentistry
23-088E CHS, 10833 Le Conte Avenue
Los Angeles, CA 90095-1668, USA
References
1. Associated press: 50 million new patients? Expect doc shortages. Revamped health care system
could swamp primary care physicians. [article online] cited 14 September 2009. Available from:
http://www.msnbc.msn.com/id/32829974
2. Malamud D (2006) Salivary diagnostics: the future is now. J Am Dent Ass 137:284–286
3. A new analysis released by the RAND Corporation (8 September 2009) suggests that while there
are benefits to having better information for health care providers, third-party providers (e.g.,
insurance companies), and patients about what works best in treating different health problems
short-term, it is uncertain that comparative effectiveness research will lead to reductions in spend-
ing and waste or improvements in patient health…. “there is not enough evidence at this point to
predict exactly what the result might be for the cost of the nation’s health care system..” Elizabeth
McGlynn, codirector of COMPARE, RAND Corporation http://www.randcompare.org/publica-
tions/summary/comparative_effectiveness_research_may_not_lead_to_lower_health_
costs_or_improve_health_analysis_finds
4. Chiappelli F, Cajulis O, Newman M. Comparative Effectiveness Research in Evidence-Based
Dental Practice. J Evid Based Dent Pract 2009 9:57–8
5. Chiappelli F, Cajulis OS. The logic model in evidence-based clinical decision-making in dental
practice. J Evid Based Dent Pract 2009 9:206–10
Preface
Just over 10 years ago, the American Dental Association produced its original policy
statement on evidence-based dentistry (February, 1999). Later that year, a colleague
at UCLA School of Dentistry, Professor Lindemann, told me “Francesco, you really
should look into this evidence-based dentistry.” His suggestion changed my research
direction, and, I suppose, that moment was the true genesis of this book.
Of course, the movement toward evidence-based practice in dentistry had been
ushered in a few years earlier by medicine (evidence-based medicine). The notion
had spread fast both nationally and internationally and across fields, and, within a few
years, one could find common references to evidence-based nursing, evidence-based
specialties across the branches of health care, and even evidence-based law, econom-
ics, and the like. As I began to explore the field, I was fortunate to develop colleagues
interested in evidence-based research (EBR) and decision-making in the health
sciences in general, and in dentistry in particular, across the globe.
Students and post-docs in my research group became increasingly actively engaged
in this new and cutting edge field, and we soon published a carefully crafted definition of
the meta-construct of evidence-based dentistry [1], and of salient issues in this emerging
field [2]. In 2003, the Brazilian Journal of Oral Sciences invited me to be the guest editor
of a special issue dedicated to evidence-based dentistry – to my knowledge, the first ever
peer-reviewed journal dedicating a special issue to evidence-based dentistry. By 2006,
when the California Dental Association Journal invited me to do the same, evidence-
based dentistry was fast becoming established in the national and international dental
literature. Working on both these issues was transforming, that is, it gave me a broad
awareness of the depth of the field, its potentials, impediments, hurdles, and benefits.
It was during that time that my students, coresearchers, and I realized the method-
ological void that still remained to be addressed in the field. We developed the Wong
scale [3] to assess and to quantify the quality of the research methodology, design,
and data analysis based on commonly accepted criteria, and soon revised it and
improved its validity and reliability [4]. We refined our skills in research synthesis,
and in our ability to generate the best available evidence, be it in dentistry, medicine,
alternative and complementary medicine, or any domain of the health sciences [5].
We realized that, whereas our research group was well versed in obtaining a consen-
sus of the best available evidence, we had done little in terms of utilizing the evi-
dence-based paradigm to optimize clinical outcomes. We were aware of the need to
fill the gap between clinical practice based on the evidence, patient-oriented evidence
that matters (POEM), and research synthesis (or, specifically for the field of dentistry:
research evaluation and appraisal in dentistry [READ]) [6], and endeavored to do
more in that domain. Hence this book.
ix
x Preface
Upon this fertile ground, an idea burgeoned, which we shared with Stephanie
Benko at Springer, and the proposal for this comprehensive book addressing cutting
edge issues about utilizing evidence-based concepts in clinical practice in order to
optimize clinical outcomes was in the making. Soon, Irmela Bohn (Springer) stepped
in the project, and we were most fortunate because, without Irmela’s expertise,
patience, and guidance, the project would have remained just that: an idea – a good
idea perhaps, but just an idea. I will never be able to thank Irmela enough for her dedi-
cation, encouragement, and superlative hard work along the way.
It was mainly because of her, and through her consistent support that the project
really took a life of its own. And soon I was discussing it with selected colleagues in
various countries – from Brazil to Nigeria, from Romenia to the US - inviting them
to be on the editorial team. Together, we carefully chose the “rose” of experts in the
field to invite to contribute chapters. Therefore, of course, I must thank profusely my
friends and colleagues – Drs. Brant, Neagos, and Oluwadara – who worked long and
arduous hours on this project as coeditors. Without them, the final product would
never have achieved the level of perfection and excellence it has.
My profound thanks, which I know are shared as well by the coeditors, go to the
authors of the chapters in this work. They wrote assiduously, edited and perfected
their chapters patiently responding to each and every one of Irmela’s and my and the
coeditors’ requests for timeliness, precision, format, and all the possible details one
could imagine. It is their expertise and their dedication to this project that makes this
book the superb ouvrage and the timely and critical anthology of evidence-based
decision (EBD)-making in health care the high quality product that it is.
Los Angeles, California, USA Francesco Chiappelli
References
1. Chiappelli F, Prolo P (2001) The meta-construct of evidence based dentistry: Part I. J Evid Based
Dental Pract 1:159–165
2. Chiappelli F, Prolo P, Newman M, Cruz M, Sunga E, Concepcion E, Edgerton M (2003) Evidence-
based dentistry: benefit or hindrance. J Dental Res 82:6–7
3. Wong J, Prolo P, Chiappelli F (2003) Extending evidence-based dentistry beyond clinical trials:
implications for materials research in endodontics. Braz J Oral Sci 2:227–231
4. Chiappelli F, Prolo P, Rosenblum M, Edgeron M, Cajulis OS (2006) Evidence-based research in
complementary and alternative medicine II: the process of evidence-based research. Evid Based
Complement Altern Med 3:3–12
5. Chiappelli F (2008) The science of research synthesis: a manual of evidence-based research for
the health sciences – implications and applications in dentistry. NY, NovaScience, pp 1–327
6. Chiappelli F, Cajulis OS (2008) Transitioning toward evidence-based research in the health sci-
ences for the XXI century. Evid Based Complement Altern Med 5:123–128
Acknowledgements
This work would not have been possible without the arduous and serious dedication
of the many predental students who, in the past several years, have contributed to our
research groups. Most of them have found over the years a most deserved acceptance
into dental school, some jointly with a Master’s degree or even a PhD degree. To
name only a few, I wish to commend Dr. Jason Wong for his original work on the
Wong scale, and Dr. Jason Kung for his original work on the revision of the AMSTAR.
I also want to mention particularly Ms. Audrey Navarro (dental student and PhD
candidate), Mr. David Moradi (dental student and Master’s candidate); and Ms. Raisa
Avezova, Mr. George Kossan, Mr. Cesar Perez, Ms. Linda Phi, and Ms. Nancy
Shagian, predental students, for their current contribution to our research progress in
EBD-making. By their assiduous dedication to forwarding the field of research syn-
thesis for EBD-making and for comparative effectiveness analysis, they enact the
beautiful words uttered not so long ago by the French writer Antoine de Saint-Exupéry
(29 June 1900 – 31 July 1944): “Fais de ta vie un rêve et de tes rêves la réalité…”
I thank colleagues at UCLA and beyond for their precious intellectual contribu-
tions, especially Drs. Janet Bauer, Carl Maida, and Jeanne Nervina, and the Evidence-
Based Dentistry Center at the American Dental Association.
I thank the UCLA Senate for funding in support of this and other research endeav-
ors by my group.
And most of all, I, on behalf as well of the coeditors of this work, profusely thank
Ms. Irmela Bohn of Springer (Heidelberg, Germany) for her kind support, patience, and
guidance in making this anthology of EBD-making the high-quality product that it is.
I dedicate this and all of my academic endeavors to Olivia, to Aymerica and to
Fredi, and to honor …la gloria di Colui che tutto move/per l’universo penetra e ris-
plende/in una parte più e meno altrove…(Dante Alighieri, 1265–1321; La Divina
Commedia, Paradiso, I 1–3).
xi
Contents
Part I: The Science of Research Synthesis in Clinical Decision-Making
1 Introduction: Research Synthesis in Evidence-Based
Clinical Decision-Making .................................... 3
Francesco Chiappelli, Xenia M.C. Brant, Oluwadayo O. Oluwadara,
Negoita Neagos, and Manisha Harish Ramchandani
2 Overview, Strengths, and Limitations of Systematic Reviews
and Meta-Analyses.......................................... 17
Alfred A. Bartolucci and William B. Hillegass
3 Understanding and Interpreting Systematic Review
and Meta-Analysis Results ................................... 35
Cristiano Susin, Alex Nogueira Haas,
and Cassiano Kuchenbecker Rösing
Part II: Making Evidence-Based Decisions
4 Making Evidence-Based Decisions in Nursing ................... 53
Corazon B. Cajulis, Pauline S. Beam, and Susan M. Davis
5 A Model for Implementing Evidence-Based Decisions
in Dental Practice........................................... 67
Clovis Mariano Faggion Jr., Stefan M. Listl,
and Marc Schmitter
6 Evidence-Based Decisions in Human Immunodeficiency
Virus Infection and Cardiac Disease ........................... 79
Raluca Arimie and Zohreh Movahedi
7 Bringing Evidence Basis to Decision Making in Complementary
and Alternative Medicine (CAM): Prakriti (Constitution)
Analysis in Ayurveda........................................ 91
Sanjeev Rastogi and Francesco Chiappelli
xiii