Download - 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
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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