EBD in Dental Schools

EBD in Dental Schools:

The San Antonio “CATs Initiative”

ADA

Evidence-Based Dentistry Champions Conference

April, 2013 UTHSCSA

JOHN D RUGH, Ph.D.

University of Texas Health Science Center San Antonio

PURPOSE & OBJECTIVES

1. Provide an overview of a Dental School Evidence Based Practice program.

2. Describe specific EBP learning tools and exercises.

3. Review Student & Faculty outcomes

UTHSCSA

UTHSCSA

What’s the Problem?

1) There is just toooooo much to read!

Dental Publications Indexed by

National Library of Medicine

Keeping up-to-Date in

Orthodontics)

1965 50 pages

every 10

Days

2013 ~300 pages

Every 10

Days

1 paper / Day 6 Papers / Day

3-8 years

The Medical Education and Research Trust & Continuing Medical Education Programs,” www.mertonline.com

The Half-Life of New Knowledge

Another Problem!

Another Problem

UTHSCSA

New Biomedical

Information

Biomedical Misinformation

Competing Problems of Private Practice

STAFFING ISSUES

OVERHEAD COSTS LABORATORY

WORK

PATIENT NO-SHOWS EQUIPMENT

FAILURES

TAXES

KEEPING UP-TO-DATE

OSHA REGULATIONS

CATCHING UP ON CHART

NOTES

Original Research

Publication

Bibliographic Databases

Textbook

Implementation 16 – 23

Years

Transfer of Research into Practice

E.A. Balas, S.A.Boren. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000

August 6, 2010 Accreditation Standards for Dental Education Programs Adopted

New Accreditation Standards

“We need new Educational models

to fix this”

UTHSCSA

Right

Traditional Dental Education Knowledge

BANK

MEMORIZE FACTS &

THEORIES

“Read Everything”

Patient Care

UTHSCSA

Knowledge

BANK

“INFORMATION AS NEEDED” Model

Focus on problems your patients have

……..rather than trying to keep with everything

ONLINE BIOMEDICAL RESORCES

EBP & PROBLEM SOLVING TOOLS

Patient Care

The Solution ?

The Solution ?

Teach skills of:

1. Asking focused clinical questions,

2. Finding the strongest evidence,

3. Critical appraisal of the evidence and

4. Judgment regarding application of the evidence.

The aim is to promote lifelong learning skills.

Critically Appraised

Topic (CAT)

1) Ask a Question

Classroom or

Clinical Encounter

Student Faculty

2) Search 3) Appraise

4) Write CAT

UTHSCSA CATs Online Library

The COCHRANE LIBRARY

What is a

CAT?

“A CAT is a structured one-page summary and critique of the best available evidence on a focused question.”

CATs Library

DSI

Informatics Instruction

DSII EBD/CATs

Instruction 16hrs

Requirement in 8 Clinical

Courses

DSIV

CATs Requirement

In Clinical Courses &

Clinic

DSIII

CATs Requirement

in Clinical Courses &

Clinic

Residencies

CATs Requirement in Clinical Courses

Res Meths & CATs Instruction

Selection Criteria Keyword Index Update Policy

ONLINE SCIENCE TRANSFER FACULTY, STUDENTS,

PRACTITIONERS & PUBLIC

DS FACULTY….In-service

RESIDENTS …..Core Course

FACULTY DEVELOPMENT

= DONE

Hypothesis: The CAT will serve as a mechanism to infuse science & critical thinking skills into Dental Education at all levels.

The CATs Program

~30 Hours

Fall Soph EBP Course

• 16 hours • Focus on: 1. Asking PICO Questions

2. Searching for Evidence 3. Evaluating the Evidence 4. Writing the CAT

UTHSCSA

CATs Initiative DS2s

INTD 6010

EBD/CATs

Basics 16 hrs

FALL

Full CAT INTD 6088

SPRING

Mini CAT Exercises

in Clinical Courses 5-10 min

Search OSCE

INTD 6088 30 min

SUMMER

FAST CATs ACAD Detailing

24 hrs

Summer Research

Program

CTSA PBRN Clinical Research

UTHSCSA

Mini CAT Exercises: Examples

1) Format a focused (PICO) question: Example #1

Clinical Question The KaVo website states: “DIAGNOdent aids in the detections of caries. Even very small lesions are detected at the earliest stage, enabling you to protect and preserve the tooth substance.”

Assignment: Formulate a PICO question to help you find the best evidence about the accuracy of DIAGNOdent in detecting early dental caries. P: In adult dental patients… I: …how effective is DIAGNOdent… C: …compared to the gold standard histology… O: …in the detection of proximal dental caries limited to enamel?

Mini CAT Exercises: Examples

UTHSCSA

Pick 2 articles or advertisements and write 2 PICO questions

Email the PICO Questions to Mabel Hernandez by Wed., Jan 11, 5:00 pm

2) Given a PICO question, select appropriate MeSH search terms:

Clinical Question The KaVo website states: “DIAGNOdent aids in the detections of caries. Even very small lesions are detected at the earliest stage, enabling you to protect and preserve the tooth substance.” PICO Question In dental patients how effective is DIAGNOdent compared to the gold standard histology in the detection of proximal dental caries limited to enamel? Skill Assessment Using PubMed, identify 3 appropriate terms to search for the strongest evidence related to the PICO question. 1.

2. 3.

Mini CAT Exercises: Examples

Finding the Strongest Evidence OSCE

15 min per PICO

Hierarchical Search

Strategy PubMed “Limits”

1) Meta–Analysis (under “Type of Article”)

2) Systematic Review (under “Subsets”)

3) RCT (under “Clinical

Queries”

CASE STUDY

CASE SERIES

COHORT STUDY

RANDOMIZED

TRIAL

META-ANALYSIS

Systematic Review of

randomized clinical trials

UTHSCSA

3) Given a PICO question, find the

strongest evidence:

TIME 2002

CASE STUDY

RANDOMIZED TRIAL

CASE SERIES

2013 1967

COHORT STUDY

SYSTEMATIC REVIEW

Mini CAT Exercises: Examples

TIME 2011 1967

CASE STUDY

RANDOMIZED TRIAL

CASE SERIES

COHORT STUDY Test for questions with different

levels of evidence: example

Example of treatment with very little evidence

Example of treatment with lots of evidence

UTHSCSA

4) Assess Strength of Evidence

CASE STUDY

CASE SERIES

COHORT STUDY

RANDOMIZED TRIAL

META-ANALYSIS Systematic Review

Mini CAT Exercises: Examples

CATs Initiative DS2s

INTD 6010

EBD/CATs

Basics 16 hrs

FALL

Full CAT INTD 6088 4hrs

SPRING

Mini CAT Exercises

Clinical Courses 5-10min

Search OSCE

INTD 6088 30 min

SUMMER

FAST CATs ACAD Detailing

24 hrs

COSTAR Research

Program

CTSA PBRN Clinical Research

UTHSCSA

Faculty Development 104 of 132 Faculty Trained as CAT Mentors

4 to 6 hour workshops

UTHSCSA

Critically Appraised

Topic (CAT)

1) Ask a Question

Classroom or

Clinical Encounter

Student Faculty

2) Search 3) Appraise

4) Write CAT

UTHSCSA CATs Online Library

The COCHRANE LIBRARY

http://cats.uthscsa.edu/

http://cats.uthscsa.edu/

612 Published CATs March 12, 2013

http://cats.uthscsa.edu/

http://cats.uthscsa.edu/

Keeping CATs up-to-date

Our Students Comment on the CATs

Practitioner Comments on the CATs

Authors are now notified when there is a new comment on their CAT

Faculty & Students at Other Schools Comment on the CATs

Comments provide: 1) A learning experience for students. 2) A method to engage the practitioner and receive real world experience related to the CAT. 3) A mechanism to keep the CATs up-to-date. The comments are reviewed by the editor before being published.

Our CATs Library went

online May 15, 2011

Worldwide Source for Up-To-Date Oral Health Knowledge for the Public and Profession

May 15th, 2011

Visits from 2,323 Cities Worldwide

Visitors to our CATs

~40%

~35%

~20%

5% Other

>500 UT CATs Indexed on TRIP

http://www.tripdatabase.com/

http://www.tripdatabase.com/

• British Meta-search Engine • Searches over 70 Evidence Based Databases

All Students graduate with a Published CAT indexed by Trip

(~115 per year)

What is the evidence that teaching Evidence Based Practice changes anything AND how should we teach it?

A systematic review 23 Studies Results:

Stand alone teaching of EBM improved knowledge but not

skills, attitudes, or behaviour.

Clinically integrated teaching improved knowledge, skills,

attitudes, and behaviour.

Conclusion: Teaching of evidence based medicine must be

moved from classrooms to clinical practice.

Coomarasamy and Khan

BMJ 2004;329(7473): 1017

DSI

EBD, Informatics Instruction

DSII

EBD/CATs Instruction

16hrs

DSIV

CATs Requirement

In Clinical Courses

& 8 GPGs

DSIII CATs

Requirement in Clinical Courses, Case Conf & 8 GPGs

Residencies

CATs Requirement in Clinical Courses

Res Meths & CATs

Instruction 4hrs

UTHSCSA CATs INITIATIVE

UTHSCSA

EBP EBP

DS2 DS3&4

DS3 INTD 7020

Dr. Guest

Student CAT Videos

Faculty

Student 20/yr

Alumni

CAT

FACULTY, ALUMNI, STUDENT TEAM

Program

Prepare a CAT & an Office Visit Workbook

662 Students visited >250 Offices

Faculty

Student 20/yr

Alumni 100/yr

CAT

FACULTY, ALUMNI, STUDENT TEAM

Program

UTHSCSA

CATs Library ONLINE SCIENCE TRANSFER

FACULTY, STUDENTS, PRACTITIONERS

& PUBLIC

Practitioner comments are added to the CATs in the Library.

Monthly Student/ Faculty CAT Publication Texas Dental Journal

Dr. Cristina Villar is currently an Assistant

Professor in the Dept. of Periodontics at

UTHSCSA.

Authors:

Critically Appraised Topics

CAT OF THE MONTH

Clinical Quest ion: In a patient with a pronounced frenulum labii superioris, or lingual frenulum, does laser frenectomy provide a faster healing time and/or less pain when compared to conventional surgical frenectomy? Clinical Bot tom Line: Laser frenectomy results in significantly less postoperative pain and impairment of function compared to conventional surgical frenectomy. Best Evidence: Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques. J Periodontol. 2006 Nov;77(11):1815-9. PMID: 17076605 Kara C: Evaluation of patient perceptions of frenectomy: A comparison of Nd:YAG laser and conventional techniques. Photomed Laser Surg. 2008 26(2):147-152, PMID: 18341414 Key Results: Postoperative pain scores in both studies were significantly lower at 1 and 7 days in patients treated with laser surgery. Eighty-five percent and 92.5% of patients in the conventional surgery group used analgesics during the first postoperative week compared to 33% and 5% of the laser surgery group in the two studies. Patient assessments of discomfort during eating and speaking were also lower in the laser groups. Comments on Evidence: Both studies were Randomized Clinical Trials completed in two different Turkish university clinics using two different laser instruments, the Smarty A10; DEKA, (Firenze Italy) and the Luxar Nova Pulse LX-20SP, (Bothell WA). Forty patients completed both studies and groups were treated the same, except for the intervention. The investigators aimed to create equivalent sizes of surgical wound in both groups. Subjects were asked to measure and report postoperative pain, postoperative discomfort in eating, and postoperative discomfort in speaking on visual analog scales at days 1 and 7. Applicabilit y or Significance: Subjects were females and males, all non-medicated and healthy, with good oral hygiene, ranging from 18-26 years of age. All had labial or lingual frena extending to the interdental papilla of the central incisors.

Stephanie Cervetto is currently a Junior

Dental Student at

UTHSCSA.

Dr. Edward Ellis is Chair

and a Professor of Surgery in the Dept. of Oral and Maxillofacial Surgery at UTHSCSA.

!

___ Randomized Tr ials

___ Systematic Review & Meta Analysis

___ Cohort Study

___ Case Series

___ Case Repor ts

___ Editor ials & Opinions

___Animal Research

St rengt h of Evidence

___ In-Vitro Research

Laser Frenect omy Post operat ively Less U ncomfort able than

Scalpel Frenectomy (U T CAT 0769)

CATs Student Technical Editor: Judy Philip. For more information on the CATs program, contact Mabel Hernandez at 210-567-3516 or visit http://cats.uthscsa.edu. The CATs program is supported by NIH R25DE018663.

52 Students & Faculty Coauthors 2012-13

Group Spring/Summer

2008

Year 1

2008-2009

Year 2

2009-2010

Year 3

2010-2011

Year 4

2011-2012

1 2006-2007

Cohort

DS1 Year

(Spring 2008)

Student Course

Evaluations

Focus Group

(May 2008)

OSCE (Test run)

DS2 Year

(Spring 2009)

Focus Group

DS3 Year

(Spring 2010)

Focus Group

DS4 Year

_______________

_______________

2 2007-2008

Cohort

(Current DS2s)

(September 2008)

Baseline KACE at

beginning of DS2

CATS course

(January 2009)

KACE Post-test

Student Course

Evaluations

(March 2009)

Focus Group

(May 2009)

OSCE

DS2s Year

(Spring 2010)

Fresno Test of EBP

Competence

Focus Group

DS3 Year

(Fall 2010)

KACE

(Spring 2011)

Fresno Test of

EBP Competence

Focus Group

DS4 Year

_______________

3 2008-2009

Cohort

(New DS1s

matriculating in

(July 2008)

KACE Reliability

testing

(October 2008)

Pre and Post-test

reliability

DS1 Year

(September 2009)

KACE at beginning of

DS2 CATS course

(November 2009)

KACE at end of CATS

course

(January 2010)

Focus Group

(May 2010)

OSCE

DS2 Year

(Spring 2011)

Fresno Test of

EBP

Competence

Focus Group

DS3 Year

(Fall 2011)

KACE

(Spring 2012)

Fresno Test of EBP

Competence

Focus Group

DS4 Year

Outcome Assessments

Dental Students Residents Faculty

Outcome Assessments

Hendricson et al 2011

KACE for

3 Groups

UTHSCSA

63 Student Abstracts & Posters

at professional meetings 2009-2013

Program Outcomes

Traditional Dental Education

Knowledge BANK

MEMORIZE FACTS &

THEORIES

“Read Everything”

Patient Care

UTHSCSA

Summary

Knowledge BANK

“INFORMATION AS NEEDED” Model Focus on problems your patients have

……..rather than trying to keep with everything.

ONLINE BIOMEDICAL RESORCES

IT & PROBLEM SOLVING TOOLS

Patient Care

Lessons Learned

What’s Ideal What’s feasible

VS

Lessons Learned

Doer vs User

In-Depth Critiques VS Efficient Search

Original Research VS Evidence Summaries

Is it realistic & doable in Private Practice setting?

….and inspiration from the 2008 ADA EBD Champion Conference

• Harald Löe Scholars Program, Sponsored by: AADS/AADR/NIDCR/Procter & Gamble • ADA Foundation Grant: “Building Professional Bridges”

• NIH/NIDCR R25 Research Education Grant DE018663 (2008-2012)

• UTHSCSA Dental Dean’s office

This Program was made possible with funding from:

UTHSCSA

FURTHER INFORMATION http://ebp.uthscsa.edu/

FURTHER INFORMATION

• Rugh JD, Hendricson WD, et al. Teaching Evidence-Based Practice at the University of Texas Health Science Center San Antonio Dental School. Tex Dent J 2011: 128(2):187-190.

• Rugh JD, Hendricson WD, Hatch JP, Glass BJ. The San Antonio CATs Initiative. J Am Coll Dent. 2010 Summer; 77(2):16-21.

FURTHER INFORMATION

• Hendricson WD, Rugh JD, Hatch JP, Stark DL , Deahl TD, Wallmann ER . Validation of an Instrument to Assess Evidence-Based Practice (EBP) Knowledge, Attitudes, Access and Confidence. J Dent Educ. 2011 Feb; 75(2):131-44.

• Rugh JD, Sever N, Glass BJ, Matteson SR. Transferring evidence-based information from dental school to practitioners: a pilot "academic detailing" program involving dental students. J Dent Educ. 2011 Oct;75(10):1316-22.

FURTHER INFORMATION

FURTHER INFORMATION

QUESTIONS? COMMENTS?

UTHSCSA