Keeping Current: A Commitment to Patient Care Excellence through Evidence Based Practice

What is Evidence-Based Decision Making?

EBDM is defined as “the integration of best research evidence with our clinical expertise and our patient's unique values and circumstances.”¹ Thus, optimal decisions are made when all components are considered (Figure 1). EBDM is not unique to any specific health discipline and focuses on the decision-making process, which is why it is referred to here as EBDM or evidence-based practice (EBP) rather than evidence-based dentistry or evidence-based dental hygiene.

Milestones in the Evolution of EBDM

1. The Birth of Evidence Based Medicine – McMaster University, Ontario Canada

In 1981, David Sackett, along with a group of clinical epidemiologists at McMaster University, published articles advising clinicians how to read clinical journals.² The group proposed the term “critical appraisal” and recognized its value in using the approach of identifying the best evidence to solve patient problems. This approach to medical care represented a fundamental change of practice and warranted a new term that would capture this difference. In 1990, Gordon Guyatt proposed the term “evidence-based medicine” (EBM).³ The approach took hold and began to spread to other health care disciplines. In 2007, the development of EBM by researchers at McMaster University was recognized as one of the 15 greatest medical breakthroughs since 1840.⁴ Table I provides a summary of the milestones in the evolution of EBDM.

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Figure 1:

Evidence-Based Decision Making

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Table I:

The milestones in the evolution of EBDM

Using Evidence in Practice

The EBDM movement has come very far in a relatively short time, however, the challenge for all health care practitioners, including dental hygienists, is to integrate EBDM into clinical practice. For example, how would one respond to a client who questions how adequate an oral cancer screening was performed since neither of the adjunctive devices that she saw on a popular daytime TV show were used? Or, how would one respond to clients who refuse to have radiographs taken because a report on the evening news discussed a possible association between dental x-rays and Meningiomas? Finally, how does one respond to a client who has always taken an antibiotic prior to treatment and now questions why he no longer needs to be premedicated? Knowing how to answer these questions requires skills in:

1. Efficiently finding the most current scientific information

2. Understanding the research design, the data/findings, and the level of evidence that was obtained

3. Knowing how to present this information in a way that the client understands it and can make an informed decision

While EBDM is now incorporated into dental hygiene education, this is a fairly recent occurrence. Many will still be unfamiliar with the skills to practice EBDM.

Mastering the skills of EBDM can help dental hygienists identify the best evidence to solve patient problems. However, other challenges may be encountered. Even when a search yields a citation that seems perfect to answer a clinical question, much of the scientific literature is not available for free. Partnering with an academic institution may assist with access to full text. Once the best evidence is found, translating the findings into clinical practice is another potential barrier. One of our human traits is to hold cognitive biases. When new evidence goes against current beliefs, we find ways to discount that evidence. When there is conflicting evidence or uncertainty, we tend to stick with what we have always done. Academic institutions are wrestling with these barriers as they work to make their educational programs models of evidence based practice. EBDM is evolving and improving to help clinicians overcome these barriers.

Future Developments to Support Clinical Decision Making

A recent development in EBDM is clinical decision support (CDS). CDS systems have their greatest potential at the point-of-care, i.e., chairside, using an electronic dental record integrated with a large patient database and algorithms that help sort and present evidence-based recommendations. These types of systems are more advanced in medicine, where as patient-specific information is entered, individual patient characteristics are automatically linked to the current best evidence that matches his or her specific circumstances. This can assist the clinician by suggesting appropriate care or warning about adverse effects.⁹

CDS systems provide clinicians with knowledge and person-specific information (such as computerized alerts and reminders) rather than general guidelines.¹⁰ “The goal of CDS is to provide the right information, to the right person, in the right format, through the right channel, at the right point in workflow to improve health and health care decisions and outcomes.”¹¹ In dental hygiene, the best CDS are drug databases, which can be accessed chairside over the internet by computer and mobile devices. By linking to one of several drug database websites, detailed information about a particular drug and drug interactions can be obtained. As with all patient information, one must be careful when using personal/mobile devices so that confidentiality is maintained to prevent any HIPAA violations of protected patient information.

The infrastructure to support EBDM at the point of care is evolving. However, until electronic patient records are fully integrated with a CDS system, evidence resources can be accessed via the internet. Table II presents examples of resources that support CDS. Levels 2 through 6 provide access to pre-appraised evidence, which means that the research evidence has undergone a filtering process to include only those studies that are of higher quality, and they are regularly updated so that the evidence accessed through these resources is current.¹²

Getting Started

Recognizing that clinicians have time constraints and yet want to provide the best possible care to their patients, an evidence-based approach provides an effective strategy for keeping current. It also requires understanding new concepts and developing new skills (Table III). Many of the resources listed in Table IV can assist in learning these concepts and skills, and are free. For example, the PubMed tutorial presents information on its key features in short segments, some of which are YouTube videos. The online CE course on “Strategies for Searching the Literature Using PubMed” walks the user step-by-step through how to conduct a traditional and Clinical Queries search. For those who have not had a research design course or who need a refresher, the Guide to Research Methods, the Evidence Pyramid provides a graphical display and explanation of research designs and levels of evidence.

Understanding evidence-based methodology and distinctions between different types of research allows clinicians to better judge the validity and relevance of reported findings. Being able to search electronically across hundreds of journals at the same time using PubMed overcomes the challenge of finding relevant evidence when it is needed to make a well-informed decision. Ideally, accessing new research that is valid, easy to read and pre-appraised will make keeping current the norm for practice, and in the future, further development of CDS will help clinicians implement EBDM in real time by linking electronic patient records with evidence based resources.