| | Implementing Evidence-Based Decision Making in the Private Practice Setting: The 4-Step ProcessAn important goal of EBDM is to improve outcomes where it matters the most: at the point of care. All dental clinicians need practical tools that facilitate access to the clinical information needed to enable our patients to make better-informed choices. This article provides a 4-step guide for practical implementation of EBDM in the private practice setting. Step 1 is defining your practice purpose. Step 2 describes the use of Ethical Practice Parameters to guide clinical decision-making. Step 3 illustrates how to implement Ethical Practice Parameters. Step 4 describes a simple process for searching for scientific evidence. Online resources are provided and the benefits of the 4-step process are elucidated. In the first article in this series, “Implementing Evidence-Based Decision-Making in the Private Practice Setting, Why do it?” we explored some of the advantages and benefits gained by using evidence-based decision-making (EBDM) in private practice.1 The strong desire to both improve skills and knowledge and to keep up to date are other key reasons that resonate with the members of the San Francisco and Napa EBDM Interactive Learning Groups, described in a previous article.2 Both groups are passionate about ensuring that we advise and treat patients in the best ways possible and this commitment to clinical excellence is a major driving force that motivates the entire group. What follows is a 4-Step “How-to” practical method for implementing EBDM into your private practice. Ironically, this article is not based on scientific evidence; it is based on observational reporting and personal preferences. While this may seem out of place in the context of the Journal of Evidence-Based Dental Practice, we believe it is part of the EB approach since it clearly falls under the clinical judgment and experience component of EBDM and it is an example of how to approach a problem when insufficient evidence is available. Some of what follows may seem quite ordinary and some of it requires effort and change on the part of the clinician. However, all of what is described is fundamental to developing a successful program. Although there probably are other paths to take, following these 4 steps will get most of you where you want to go. Step 1. Define Your Practice Purpose  What is the ultimate purpose of your dental practice? For the clinician motivated to implement EBDM in private practice, the answer to this focused question is simply to provide the best possible dental health care for people who need and/or want it. It is all about putting the patient first. Stated differently, this is the primary outcome of practice. There are many important tangible secondary outcomes in practice. These include: •income •profitability •personal satisfaction •retirement funding •enabling career opportunities •being a tax revenue source for your community Private practice dentistry is a business and it needs to be profitable in order to survive and thrive. However, for the EBDM-oriented practice, the primary purpose needs to be at the forefront of the minds of the entire dental team on a daily basis. It should not be an afterthought or quietly assumed. In no uncertain terms, putting the patient first and effectively using EBDM can be a profitable “win-win” enterprise. However, not prioritizing this primary purpose for the dental team allows secondary outcomes to predominate. When this happens the daily practice routine often shifts focus to things like production and salesmanship. Patients today are increasingly savvy consumers and they value knowing that their health comes first in your practice.3., 4. Bottom Line Implementing EBDM in your practice is about putting the patient first. Revisit your practice mission statement. If you don't have one, now is a good time to write one. Remember the old admonition: “If you don't know where you're going, you're sure to get there.” Your mission statement should lucidly state that putting the patient first is the primary practice purpose. Share this with your team. They need to believe in you and your clear practice vision. On a daily basis, the dentist(s) and the entire dental team need to engrain this concept. Believe, reiterate, and refocus on this reason-to-be. A great team project is to develop a list of creative ways to increase your community's awareness of your practice purpose. Step 2. Identify Your Ethical Practice Parameters What are Ethical Practice Parameters? These are the philosophical parameters, the boundaries that you decide your practice will not go beyond. They clarify the risks we choose to avoid in our practice setting. They color and influence almost all clinical decisions. Consider the delineation of your practice's Ethical Practice Parameters as professional “boundary setting.” Two core clinical Ethical Practice Parameters that override clinical care delivery are: •Maximize safety, effectiveness, and long-term value •Minimize risks of harm Why do we need Ethical Practice Parameters? They provide a higher-level perspective from which to assess the multitude of therapeutic choices we have to make on a daily basis. From treatment recommendations to product selection and clinical care delivery, Ethical Practice Parameters are the conscience of the practice. EBDM is better viewed through the lens of Ethical Practice Parameters. “Evidence alone is never sufficient to make a clinical decision. Decision makers must always trade the benefits and risks, inconvenience, and costs associated with alternative management strategies and in doing so consider the patient's values.”5 Because of the scarceness of high-level scientific evidence and the complexity of many clinical decisions, implementing the evidence-based approach in dental clinical practice is challenging.6 But despite these limitations, ethical clinicians must do the best they can. Three solid reasons to have clearly delineated Ethical Practice Parameters in your practice are: 1.Establishing an overriding context of Ethical Practice Parameters helps manage dilemmas of evidence and facilitates the challenging task of translating best available scientific evidence into appropriate clinical care. 2.With Ethical Practice Parameters in place and used on a daily basis, diagnostic and treatment decisions are no longer mostly guided by limitations such as clinician experience, low-level evidence (eg, expert opinion, case reports), and/or third-party benefit plans. 3.Ethical practice parameters enable the clinician with a higher level “operating system,” which guides how he or she will advise and treat patients as well as operate the dental business. Using Ethical Practice Parameters is not a new way of framing decision making. In medicine, it can be traced back to the phrase “First Do No Harm” originated by Hippocrates in his work, “Of the Epidemics,” Book I, Section XI (400 BCE).7 Recently introduced, the Translational Clinical Practice System (TCPS) is a practice model designed to facilitate the challenging task of translating best available scientific evidence information into appropriate clinical care. It introduced the facilitation of Ethical Practice Parameters to assist the clinician in evidence-based decision making.6 See Diagram A. Step 3. Putting Ethical Practice Parameters to Work Restorative Therapy Example Therapy/Procedure/Intervention Posterior Restorative Crowns Method/Material/Type For posterior crowns, there are 4 types that you might want to score: ▪Metal ceramic crown ▪High noble alloy crown ▪Low noble alloy crown ▪All ceramic crown Here's what you do: 1.Set up 4 separate cards. 2.For all 4 cards, write in Posterior Crowns on the line “Therapy/Procedure/Intervention”. 3.On the line “Method/Material/Type,” write in only 1 crown type per card (eg, Metal Ceramic, High Noble Alloy, Low Noble Alloy, All Ceramic). 4.Search the evidence (see Section 4, “Get the Goods”). 5.Rank the Ethical Practice Parameters as indicated on the score card. 6.Grade the evidence level (see Section 4, “Get the Goods”). Periodontal Therapy Example Perhaps nonsurgical periodontal therapy is in your Top 5 production procedures. For patients with periodontitis you might want to assess Scaling and Root Planing (SRP), local drug delivery, systemic drug therapy, and subgingival irrigation for clinically significant outcomes, as well as safety, effectiveness, and long-term value. Therapy/Procedure/Intervention Nonsurgical Periodontal Therapy Method/Material/Type: ▪SRP ▪SRP + local drug delivery ▪Systemic drug therapy ▪Irrigation Here's what you do: 1.Set up 4 separate cards 2.For all 4 cards, write in Nonsurgical Periodontal Therapy on the line “Therapy/Procedure/Intervention” 3.On the line “Method/Material/Type,” write in only 1 method per card (eg, SRP, SRP + local drug delivery, Systemic drug therapy, Irrigation) 4.Search the evidence (see Section 4, “Get the Goods”) 5.Rank the Ethical Practice Parameters as indicated on the score card 6.Grade the evidence level (see Section 4, “Get the Goods”) The Payoff—Analyze the Results Now you can make decisions on the basis of your analysis: ▪Can you better rank the crown types and nonsurgical periodontal methods so that your dental team and patients will understand the available choices in terms of safety, effectiveness, and long-term value? ▪Are you better able to recommend certain crown types and nonsurgical periodontal methods over others based on the evidence and Ethical Practice Parameters? Educate and Communicate The dental team and the patients need to understand and appreciate that our clinical decision making is based on the complex interplay of Ethical Practice Parameters; best available scientific evidence; clinician judgment and experience; and patient preference and values. Here are a few practical tips for you to consider: ▪Take the time to fully educate your dental team about this process. Remember, this is an investment in your practice and your bottom line. It will pay big dividends in terms of galvanizing your staff and improving patient treatment acceptance and increasing referrals. ▪Get your dental team involved with the analysis and/or decision making. Make it fun for them. The more they understand and participate, the better their motivation and communication with your patients. When your team values your efforts and philosophy, they can more easily promote the very special qualities of your practice. ▪Always look for opportunities to inform your patients about the unique approach your practice embraces with regard to their treatment. Bottom Line Start assessing your care delivery through the perspective of the Ethical Practice Parameters. 1.Print out a routine computer-generated report of the Top 5 production therapies/procedures/interventions that your practice performs. 2.Using Fig. 1 as your guide set up a spreadsheet (or individual index cards) listing the therapies/procedures/interventions in production rank order. 3.Stop. It is now time to assess the quality of evidence supporting your Top 5 production procedures. Step 4. Get the Goods: Accessing the Evidence Next we acquire the best evidence for our Top 5 production procedures. This is most efficiently done online using filtered (pre-appraised) sources and, as needed, unfiltered sources. Using pre-appraised sources is much more efficient compared to unfiltered sources, and will provide additional information useful for making management decisions. The Journal of Evidence-Based Dental Practice, the Evidence-Based Dentistry journal, and the Cochrane Database of Systematic Reviews (see Fig. 2) are excellent pre-appraised sources of evidence for the busy clinician. With an unfiltered source, such as Medline, the clinician can query through an electronic search engine like PubMed.8 However, using an unfiltered source can be more time consuming if one is not very familiar with proper search protocols. From an expediency point-of-view, I recommend using PubMed only if you cannot find what you are looking for through the pre-appraised sources. Searches should be guided by PICO-formatted clinical questions.9 The PubMed online tutorials guide you through the process. See Fig. 2 for a list and description of high-quality online resources. Follow These Steps 1.Open your Web browser and bookmark (add to “favorites”) all 4 URLs listed in Fig. 2. 2.Place the bookmarks in your Web browser tool bar folder for quick access. Or, in your Web browser, go to “favorites”; create a new folder; name it “EBDM Searches”; add all bookmarks to the folder. 3.Start your evidence search with your #1 top production item and scan the 3 pre-appraised online sources for the quality of evidence that is available. For the journal searches, start with the most recent publications and work backwards to locate your topic. 4.Grade your item according to the grading system as used in the Journal of Evidence-Based Dental Practice (see Diagram B in 2005;5(3):118.) or simply grade it on a 1 to 5 scale, with 1 being highest level of evidence and 5 being the lowest level of evidence. 5.If you still need additional evidence information, search the unfiltered source (PubMed). Bottom Line Searching for evidence is a terrific reality check process that will greatly benefit your patients, your employees, and your practice. In your consultations, your patients will feel more confident knowing your practice is committed to recommending procedures that: ▪Have the strongest evidence ▪Are the safest ▪Are the most effective ▪Provide the best long-term value ▪Minimize risks of harm Accessing the evidence (Step 4) is a time investment. Be patient: it is incredibly rewarding. Make it a priority and set aside time to do this on a regular basis. Perhaps you do 1 search per week. Maybe it's 1 per month. No matter. Start the process with your highest production procedures because it makes the process much more reality-based and tangible for you. Putting It All Together You have defined your practice mission, identified your Ethical Practice Parameters, assessed your Top 5 production procedures for appropriate evidence and filtered them through your Ethical Practice Parameters. Your dental team understands this process and is confident in communicating it to your patients. Undoubtedly, certain of your Top 5 production items have been well-validated and you now feel more confident in your recommendations. You may discover that others should be changed or discontinued. Please do so and replace with better-validated methodologies that pass according to your Ethical Practice Parameters Score Card. Simply repeat this process with your next Top 5 grouping. Continue until you complete your review of procedures. Congratulations! You have officially indoctrinated a powerful EBDM model into your practice. With the dental team understanding the process, change will now be much easier to implement and communicate. Conclusions Embrace the concept that clinicians who choose to incorporate EBDM into their practices are perpetual students, life-long learners: they are never done improving care delivery! Make the process of accessing evidence and improving care delivery a routine professional activity. In the near future, dental clinicians will have available more clinical decision support and efficient therapeutic assessment tools that will be readily accessed at chair side, at the point of care. By staying up to date with your online resources, you will automatically make changes and improvements in your care based on the strength of evidence, Ethical Practice Parameters, and your clinical experience and judgments, all the while focusing on the patients' preferences and values. Your employees, both clinical and administrative, will be better empowered and feel more confident in their recommendations and explanations. The process of putting the patient first, having in place Ethical Practice Parameters, and providing care that is supported by the best available evidence is empowering: your patients and team will have greater trust in you and your practice. References 1.. 1.Merijohn G. Implementing Evidence-Based Decision Making in the Private Practice Setting. Why do it?”. J Evid Base Dent Pract. 2006;6(3):206–208. 2.. 2.Merijohn G. Advances in clinical practice and continuing education. The precautionary context clinical practice model: a means to implement the evidence-based approach. Interactive learning groups for evidence-based knowledge sharing. J Evid Base Dent Pract. 2005;5:120–123. 3.. 3.Main DS, Tressler C, Staudenmaier A, Nearing KA, Westfall JM, Silverstein M. Patient perspectives on the doctor of the future. Fam Med. 2002;34(4):251–257. MEDLINE 4.. 4.Coulter A. What do patients and the public want from primary care?. BMJ. 2005;331:1199–1201. 5.. 5.Guyatt G, Rennie D. Users' guide to the medical literature. Essentials of evidence-based practice. USA: AMA Press; 2002;. 6.. 6.Merijohn G, Newman M. The translational clinical practice system: a way to implement the evidence-based approach in the dental office. CDA J. 2006;34(7):529–539. 7.. 7.Hippocrates, of the epidemics, book 1, section XI (400 BCE). http://www.geocities.com/everwild7/noharm.html. 8.. 8.National Library of Medicine, National Institutes of Health. PubMed. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed. 9.. 9.Forrest J, Miller SA. Enhancing your practice through evidence-based decision making. J Evid Base Dent Pract. 2001;1(1):51–57. Private Practice, Periodontics, San Francisco, CA PII: S1532-3382(06)00155-2 doi:10.1016/j.jebdp.2006.10.002 © 2006 Elsevier Inc. All rights reserved. | |
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