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Evidence Based Practice in Prosthodontics. 7/11/2009. 37th IPS Conference, Thrissur. 1. Evidence Based Practice In Prosthodontics. Dr.R.Murali Reader, Dept of Prosthodontics Sinhgad Dental College & Hospital. 7/11/2009. 37th IPS Conference, Thrissur. 2. Traditional practice.

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7/11/2009

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  1. Evidence Based Practice in Prosthodontics 7/11/2009 37th IPS Conference, Thrissur 1

  2. Evidence Based Practice In Prosthodontics • Dr.R.Murali • Reader, Dept of Prosthodontics • Sinhgad Dental College & Hospital 7/11/2009 37th IPS Conference, Thrissur 2

  3. Traditional practice Patient Doctor Burden of illness Advice Training Decisions Personal Treatment Colleagues Journal CE courses Signs Symptoms Complaints 7/11/2009 37th IPS Conference, Thrissur

  4. 7/11/2009 37th IPS Conference, Thrissur

  5. Problems? • Explosion in the volume of literature. • Subscribing to every journal. • Deterioration of clinical skills. • Litigation. • Treatment effectiveness . 7/11/2009 37th IPS Conference, Thrissur

  6. Prosthodontic LiteratureMedline + Periodical [1900-2009] 7/11/2009 37th IPS Conference, Thrissur

  7. Prosthodontic LiteratureMedline + Periodical [1900-2009] 7/11/2009 37th IPS Conference, Thrissur

  8. Prosthodontic LiteratureMedline + Periodical [1900-2009] 7/11/2009 37th IPS Conference, Thrissur

  9. Patient Can it apply to the patients? Answerable question Critical appraisal of evidence Search for best evidence New Paradigm Complaint Signs Symptoms Treatment Decisions Burden of Illness 7/11/2009 37th IPS Conference, Thrissur

  10. David Sacket defined EBM as “ the conscientious, explicit, and judicious use of best evidence in making decisions about care of individual patients” Over the years this has been modified to ‘ Evidence- Based medicine is the integration of best research evidence with clinical expertise and patient values’ 7/11/2009 37th IPS Conference, Thrissur

  11. Whatis Evidence Based Practice? • …an approach to practicing medicine in which the clinician is aware of the evidence in support of clinical practice, and the strength of that evidence. • Combines your clinical knowledge with your knowledge of your patient, with evidence from the literature 7/11/2009 37th IPS Conference, Thrissur

  12. EBP is a life long learning process that includes: • Converting clinical questions into a searchable format. • Efficient searching skills. • Critically assessing the information for validity and usefulness. 7/11/2009 37th IPS Conference, Thrissur

  13. EBP is a lifelong learning process that includes: • Evaluating the performance of the information in clinical practice. • Discovering areas where more research is needed. • Applying the information in clinical practice with physicians. 7/11/2009 37th IPS Conference, Thrissur

  14. Steps in Practicing • Asking focused questions : translation of uncertainty to an answerable questions • Finding the evidence: systematic retrieval of best evidence available. • Critical appraisal: testing evidence for validity, clinical relevance, and applicability. • Making a decision: application of results in practice. • Evaluating performance: auditing evidence based decisions. 7/11/2009 37th IPS Conference, Thrissur

  15. The First Step of EBP • Convert a clinical situation into a searchable, (and hopefully answerable) question using • PICO • PATIENT • INTERVENTION • COMPARISON • OUTCOME 7/11/2009 37th IPS Conference, Thrissur 15

  16. PICO P “Patient” refers to the person presenting with the problem, or more simply, to the problem itself. Both concepts are important in searching. atient or problem I ntervention C omparison O utcome 7/11/2009 37th IPS Conference, Thrissur 16

  17. PICO P “Intervention” refers to the action taken in response to the problem. This is often a drug or surgical procedure, but it can take many forms atient or Problem I ntervention C omparison O utcome 7/11/2009 37th IPS Conference, Thrissur

  18. PICO P “Comparison” refers to the benchmark against which the intervention is measured. Often it refers to another treatment, no treatment, or a placebo. atient or Problem I ntervention C omparison O utcome 7/11/2009 37th IPS Conference, Thrissur 18

  19. PICO P atient or Problem I “Outcome” refers to the anticipated result of the intervention. ntervention C omparison O utcome 7/11/2009 37th IPS Conference, Thrissur

  20. 7/11/2009 37th IPS Conference, Thrissur

  21. EBPtool 7/11/2009 37th IPS Conference, Thrissur

  22. Evidence 7/11/2009 37th IPS Conference, Thrissur 22

  23. Cochrane systematic reviews. • Other SRs & Meta Analyses. • Evidence guidelines. • Evidence summaries. • RCTs case Cohorts, Control study. • Clinical Research Critiques • Other reviews of the literature. • Case reports, Case series, Practical guidelines. • Clinical reference Texts. 7/11/2009 37th IPS Conference, Thrissur

  24. Cochrane Systematic Reviews 1. Cochrane library www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME. Updated quarterly. 2. Cochrane Database of systematic reviews.[Cochrane reviews] * Gold standard for high quality systematic reviews * Full text included in Cochrane library * Cochrane reviews includes complete reviews and protocols[reviews that are still in progress]. * Cochrane reviews abstract are in PubMed. 7/11/2009 37th IPS Conference, Thrissur 24

  25. Other SRs & Meta-analyses www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml # Identifies systematic reviews and other similar type of studies found in biomedical journals included in Pub Med database. # No evaluation of comparative quality of different reviews on a topic. # No separate evaluation of quality research. # Much larger collection than other evidence based practice resources. 7/11/2009 37th IPS Conference, Thrissur

  26. Evidence Guidelines/Summaries www.clinicalevidence.com Compendium of evidence on the effects of clinical interventions. Limited number of users. Summarizes the current state of knowledge, including known's and unknowns, based on thorough search. Categorizes interventions as beneficial, likely beneficial, no known benefit, harmful… DynaMed[ www.ebscohost.com/dynamed] Outline format to quickly identify key conclusions. Updated daily. 7/11/2009 37th IPS Conference, Thrissur

  27. Meta-Search Engines TRIP – Turning Research Into Practice www.tripdatabase.com Meta search from UK Searches over 55 sites of evidence based information. Includes link to peer reviewed journals and publications SUM Search www. sumserach.uthscsa.edu Produced by university of Texas health sciences center, san Antonio. Results grouped by reviews, practice guidelines, systematic reviews and research based articles. 7/11/2009 37th IPS Conference, Thrissur 27

  28. EBP Resources • Databases • http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed • Cochrane library. http://www.thecochranelibrary.com/ • PubMed • TRIP database. http://www.tripdatabase.com/index.html • DARE[ Database of Abstracts of Reviews of Effectiveness] http://www.crd.york.ac.uk/crdweb/ • National Guideline Clearinghouse. http://www.ngc.gov/ 7/11/2009 37th IPS Conference, Thrissur

  29. Journals • Bandolier http://www.medicine.ox.ac.uk/bandolier/ • Evidence based Dentistry http://www.nature.com/ebd/index.html • Journal of American dental association. http://jada.ada.org/ • Journal of evidence based practice. http://www.elsevier.com/wps/find/journaldescription.cws_home/623234/description#description 7/11/2009 37th IPS Conference, Thrissur

  30. EBD sites • Evidence based dentistry resource guide[virgin commonwealth university] http://www.library.vcu.edu/tml/bibs/ebd.html • Evidence based resource center. http://ebmny.org/glossary.html • Evidence based on call. http://www.eboncall.org/ • Evidentia. http://us.evidentista.org/ • EviDents search engine for EBD • http://medinformatics.uthscsa.edu/EviDents/ • Health on the net foundation http://www.hon.ch/MedHunt/ 7/11/2009 37th IPS Conference, Thrissur

  31. Critical Appraisal & Evidence Analysis Study Designs and Levels of Evidence(Centre for Evidence-Based Medicine, UK) http://www.cebm.net/index.aspx?o=1039 Study Designs and Clinical Decision-making(Medical Journal of Australia) http://www.mja.com.au/public/issues/174_05_050301/craig/craig.html Appraisal Tools--Critical Appraisal Skills Programme(Public Health Resource Unit, UK) http://www.phru.nhs.uk/Pages/PHD/resources.htm AMSTAR(Assessment of Multiple Systematic Reviews) http://www.biomedcentral.com/1471-2288/7/10 Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group Publications http://www.consort-statement.org/index.aspx?o=1346 QUOROM Statement (Quality of Reporting of Meta-Analyses) http://www.gradeworkinggroup.org/publications/index. CONSORT Statement (Consolidated Standards of Reporting Trials) Critical Appraisal Tools (Centre for Evidence-Based Medicine, UK) http://www.cebm.net/index.aspx?o=1157 Meta-analysis of Observational Studies in Epidemiology (MOOSE): A Proposal for Reporting http://jama.ama-assn.org/cgi/content/full/283/15/2008 7/11/2009 37th IPS Conference, Thrissur 31

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  33. Critical appraisal for selecting an article 1. Are the results of the study valid? 2. What were the results? 3. Will the results help me in caring for my patients? 7/11/2009 37th IPS Conference, Thrissur

  34. Is the study valid? • Was the assignment of patients to treatments randomized? • Were all the patients who entered the trial properly accounted for and attributed at its conclusion? • Were patients their clinicians and study personnel blinded to treatment? • Were the groups similar to start of the trial? • Aside from experimental interventions, were the groups treated equally? 7/11/2009 37th IPS Conference, Thrissur

  35. What were the results? • How large was the treatment effect? • How precise was the estimate of the treatment effect? • Willthe results help me in caring for my patients? • Can the results be applied to my patient care? • Were all clinically important outcomes considered? • Are the likely treatment benefits worth the potential harms and costs? 7/11/2009 37th IPS Conference, Thrissur

  36. 7/11/2009 37th IPS Conference, Thrissur

  37. Misperceptions of EBP • Evidence based practice denigrates clinical expertise. • Ignores patient value and preference. • Promotes a cookbook approach to practice. • Simply a cost cutting tool. • An ivory tower concept. • Limited to clinical research. • Leads to therapeutic nihilism in the absence of evidence from randomized trials. 7/11/2009 37th IPS Conference, Thrissur

  38. Limitations Of EBP • Shortage of coherent, consistent scientific evidence. • Difficulties in applying evidence to the care of individual patients. • Barriers to the practice of high quality practice. • The need to develop new skills. • Limited time and resources. • Paucity of evidence that evidence –based medicine “works” 7/11/2009 37th IPS Conference, Thrissur

  39. Advantages of EBP • Enables clinicians to upgrade their knowledge base routinely • Improves clinicians' understanding of research methods and makes them more critical in using data • Improves confidence in management decisions • Improves computer literacy and data searching technique • Gives team a framework for group problem solving and for teaching • More effective use of resources • Better communication with patients 7/11/2009 37th IPS Conference, Thrissur

  40. Disadvantages • It takestime both to learn and to practice. • Establishing the infrastructure for practicing EBP costs money. • Medline and the other electronic databasesused for finding relevant evidence are not comprehensive andare not always well indexed. • Computer literacy. 7/11/2009 37th IPS Conference, Thrissur

  41. Conclusion • One problem is that most doctors have a very narrow perspective, limiting themselves to their own, and a few other colleagues’ experience. • This leads them to make erroneous conclusions, &, in their narrowness they fail to search for evidence which might cause them to come to a more balanced decision. 7/11/2009 37th IPS Conference, Thrissur

  42. Application of statistical studies in the form of double blind, randomized clinical trial helps to remove bias. • EBP helps doctors take a wide view of the results of the clinical trials and practice, and avoids the tendency to rely too much on their own limited experience. • EBP has developed statistical methods and reasoning to enable a dispassionate overview of the results. 7/11/2009 37th IPS Conference, Thrissur

  43. Access to such evidence maybe difficult, as scientists and doctors avoid getting their negative results published. • EBP uses sophisticated methods for unearthing information about the efficacy of treatments and case management worldwide. 7/11/2009 37th IPS Conference, Thrissur

  44. A large number of doctors practice cost ineffective medicine, thus boosting EBP. • Main barrier perceived by EBP enthusiasts: anarchic profession spending unnecessary money. • EBP may be used as a means to shackle doctors and bend them. • We have to be cautious not to be used as a dupe in a political game of health economics. 7/11/2009 37th IPS Conference, Thrissur

  45. Finally, any new invention is for the betterment of the society. But, people find ways and means to use it for dubious purposes too. • Thus, EBP can be considered as a double edged sword necessitating cautious treading to safeguard our interests. 7/11/2009 37th IPS Conference, Thrissur

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  49. References • Anderson JD .Need for evidence-based practice in prosthodontics. J Prosth Dent 2000;83:58-65. • Jokstad A. Prosthodontics 21: towards a new era? Evid Based Dent 2002;3:2-4. • Mc Naughter J.Anecdotes and empiricism. Br J Gen Pract 1995;45:571-2. • Moher D, Olkin I. Meta-analysis of randomized controlled trials. A concern for standard. JAMA 1995;274:1962-4. • Sacket DL et al.Evidence based medicine:what is and what it isn’t[editorial]. Brit Med J1996;312:71-2. • Sacket DL et al.Evidence based medicine:How to practice and teach EBM.London[UK] Churchill livingstone,1997. Brit Med J1996;312:71-2 7/11/2009 37th IPS Conference, Thrissur

  50. Strauss SE, Mcalister FA. Evidence-based medicine: a commentary on common criticisms. Can Med Assoc J 2000;163:837-40. • Sutherland SE.Evidence based dentistry:Part II.Searching for answers to clinical questions:how to use MEDLINE.J Can Dent Assoc 2001;67[5]:277-80. • http://www.cochrane.org • http://www.library.utoronto.ca • http://www.ncbi.nlm.gov/pubmed/advanced?term 7/11/2009 37th IPS Conference, Thrissur

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