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Concordance between clinical practice and published evidence: Findings from The National Dental Practice-Based Research Network Wynne E. Norton, Ellen Funkhouser, Sonia K. Makhija, Valeria V. Gordan, James D. Bader, D. Brad Rindal, Daniel J. Pihlstrom, Thomas J. Hilton, Julie Frantsve-Hawley, Gregg H. Gilbert and The National Dental Practice-Based Research Network Collaborative Group JADA 2014;145(1):22-31 10.14219/jada.2013.21 The following resources related to this article are available online at jada.ada.org (this information is current as of June 28, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/1/22

This article cites 47 articles, 12 of which can be accessed free: http://jada.ada.org/content/145/1/22/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx

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ORIGINAL CONTRIBUTIONS

ARTICLE 1

cover story

Concordance between clinical practice and published evidence Findings from The National Dental Practice-Based Research Network Wynne E. Norton, PhD; Ellen Funkhouser, DrPH; Sonia K. Makhija, DDS, MPH; Valeria V. Gordan, DDS, MS, MS-CI; James D. Bader, DDS, MPH; D. Brad Rindal, DDS; Daniel J. Pihlstrom, DDS; Thomas J. Hilton, DMD, MS; Julie Frantsve-Hawley, RDH, PhD; Gregg H. Gilbert, DDS, MBA; The National Dental Practice-Based Research Network Collaborative Group

R

igorous research findings provide the foundation for many clinical practice guidelines developed to improve care processes and improve patient outcomes. Although additional empirical evidence is needed to guide many areas of dentistry, a substantial amount of evidence already exists to support the use (or nonuse) of specific materials, techniques or treatment across a range of preventive, diagnostic and treatment procedures. These include some of the most common issues faced by general dentists (for example, caries diagnosis and treatment, deep caries diagnosis and treatment, third-molar extraction, restoration diagnosis and treatment).1-11 Unfortunately, not all evidence-based recommendations are adopted in clinical practice settings, reflecting a gap between what we know works (or does not work) and what is actually being performed. Indeed, research results suggest that dentists often do not engage in clinical practice behaviors that are consistent with evidence-based guidelines, recommendations or published research findings. For example, in one study,12 only 69 percent of dental practitioners reported performing caries risk assessment (CRA) for their patients despite published recommendations to include CRA for all patients.5,9,13 In another study, only 44 percent of general dentists reported using a rubber dam for all root canal treatments.14 Investigators in several studies found that dentists did not use sealants for caries prevention and treatment for adults or children,12,15,16 as is often recommended in evidence-based guidelines.1,17

abstract Background. Documenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network (“the network”). Methods. Network dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent (“1”) or inconsistent (“0”) with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence. Results. The authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent). Conclusion. Dentists reported a medium-range concordance between practice and published evidence. Practical Implications. Efforts to bring research findings into routine practice are needed. Key Words. Clinical practice; evidence-based dentistry; dentistry; implementation science. JADA 2014;145(1):22-31. doi:10.14219/jada.2013.21

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ORIGINAL CONTRIBUTIONS

The majority of studies documenting the gap between clinical practice behavior and evidence-based recommendations in dentistry, however, have focused on a single behavior (for example, CRA, rubber dam use, sealant placement). Few, if any, have attempted to examine the gap between practitioners’ clinical practice behaviors and published evidence across a range of preventive, treatment and diagnostic behaviors. Thus, the extent to which the gap between clinical practice behaviors and empirical evidence exists across various preventive, diagnostic and treatment procedures remains unknown. Assessing practitioners’ use of evidence in practice across several preventive, diagnostic and treatment procedures may be a better indicator of their broader use of published evidence in practice than is their behavior with regard to a single procedure. Moreover, investigators in relatively few studies have focused on identifying practitioner- and organizational-level correlates of use (or nonuse) of published evidence in routine practice. Quantifying the gap between clinical practice behavior and published evidence-based findings—and identifying practitioner- and organizational-level correlates of use (or nonuse) of published evidence—is a critical first step toward understanding and improving clinical practice behaviors and patient health outcomes.18 To address this gap in the literature, we quantified the concordance between clinical practice and published evidence in The National Dental Practice-Based Research Network (the “network”), a consortium of dental practices and dental organizations focused on improving the scientific basis for clinical decision making.19 The network was funded in 2012 and builds on the former regional dental networks20 that existed from 2005 to 2012. The network consists of a wide representation of practice types, treatment philosophies and patient populations and has diversity regarding race, ethnicity, geographical region and area of residence (that is, rural or urban) of its practitioners and their patients. Analyses of these characteristics confirm that network dentists have much in common with dentists at large,21 while offering substantial diversity.22 Our objectives in conducting this study were to quantify the concordance between clinical practice and published evidence available at the time of data collection across a range of preventive, diagnostic and treatment procedures, as well as to test the hypothesis that certain practitioner- and organizational-level factors are associated significantly with that concordance. METHODS

Study population. We conducted this study with dentists in the network. The Dental Practice-Based Research Network (DPBRN) was one of three regional dental PBRNs established in 2005 with a seven-year grant from the National Institute of Dental and Craniofacial Research, National Institutes of Health. It was a consortium of dental practices, established to answer questions

that affect the daily practice of dentistry and the delivery of oral health care. The data for this study were collected under the auspices of The DPBRN. That organization subsequently evolved into The National Dental PBRN, under the aegis of which we prepared the manuscript of this article. At the time of the survey discussed in this report, the network comprised four main regions: Alabama/Mississippi (AL/MS); Florida/Georgia (FL/GA); Minnesota (MN), which consisted of practitioners in the HealthPartners Dental Group (HPDG) and other community practitioners; and Permanente Dental Associates (PDA) in Oregon and Washington. An additional region in Scandinavia (specifically, Denmark, Norway and Sweden) is not included in this report because of substantial differences in practice patterns, insurance coverage and reimbursement structures compared with those in the United States. Study design. This was a cross-sectional study, consisting of a single administration of a questionnaire entitled “Dental Practice-Based Research Network Practice Impact Questionnaire” to all network dentists who had participated previously in one or more network studies of any type and who were in current practice with an active practice address. We collected data from 2009 through 2010. The institutional review boards (IRBs) at the University of Alabama at Birmingham and all of the network’s regional IRBs approved the study. Enrollment questionnaire. On enrollment in the network, dental practitioners complete a 101-item enrollment questionnaire about their practice characteristics and themselves. This questionnaire is publicly available, and the distribution of these characteristics among network dentists has been reported elsewhere.21,22 Some of the items on this questionnaire are practice location, type of practice, whether the dentist is a generalist or a specialist, year of graduation from dental school, and the dentist’s sex, race and Hispanic/Latino ethnicity. Practice impact questionnaire. A copy of the practice impact questionnaire can be found online (http:// nationaldentalpbrn.org/peer-reviewed-publications. php). The questionnaire includes 25 items and takes approximately 30 minutes to complete. In this study, we examined responses to 12 of the 25 questions for which sufficient published evidence was available to enable us to classify responses as consistent or inconsistent with published evidence. We provide a brief description of each item and categorization of the responses as consistent or inconsistent with the evidence, corresponding to clinical area, clinical question or scenario, and response options, as shown in Table 1. Caries diagnosis and treatment. We used five ABBREVIATION KEY. AL/MS: Alabama/Mississippi. CRA: Caries risk assessment. DPBRN: Dental Practice-Based Research Network. FL/GA: Florida/Georgia. HPDG: HealthPartners Dental Group. IRB: Institutional review board. MN: Minnesota. PDA: Permanente Dental Associates.  JADA 145(1) http://jada.ada.org January 2014 23

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ORIGINAL CONTRIBUTIONS TABLE 1

Concordance between clinical practice and published evidence. CLINICAL AREA

QUESTION OR SCENARIO NO.

CLINICAL QUESTION OR SCENARIO*

RESPONSE OPTIONS CLASSIFIED AS INCONSISTENT WITH EVIDENCE

RESPONSE OPTIONS CLASSIFIED AS CONSISTENT WITH EVIDENCE

1

Use of air drying to help diagnose primary caries lesion

< 75% of the time

≥ 75% of the time

2

Assess caries risk for individual patients in any way

No

Yes

3

Treatment of unrestored occlusal Amalgam restoration, surface of a mandibular left composite restoration, first molar that has brown indirect restoration discoloration in some of the fissures and no cavitation

Any noninvasive restorative procedure

4

Treatment of unrestored occlusal Amalgam restoration, surface of a mandibular left composite restoration, first molar that has brown indirect restoration discoloration in most of the fissures and no cavitation

Any noninvasive restorative procedure

5

Use of magnification to help diagnose caries lesions

< 75% of the time

≥ 75% of the time

6

Treatment options for patient with deep occlusal caries in the mandibular right first molar and possible mild pulpitis

Stop before removing all caries and perform an indirect pulp cap < 25% of the time

Stop before removing all caries and perform an indirect pulp cap ≥ 25% of the time

7

Treatment options for excavation of caries deeper than anticipated in patient with deep occlusal caries in the right mandibular first molar and perhaps involving mesiobuccal pulp horn

Continue and remove all of the decay; temporize and treat or refer the patient for endodontic treatment

Stop removing decay near the pulp horn and remove it elsewhere

Third-Molar Extraction

8

Third-molar referrals

Recommend removal of most third molars for preventive reasons

Recommend removal of third molars if they are asymptomatic but have a poor eruption path (full or partial impaction) or do not appear to have sufficient space for eruption; recommend removal of third molars only if a patient has symptoms or pathology associated with third molars

Restoration Diagnosis and Treatment

9

Defective composite restoration with enamel margins (as determined via photograph)

Responses include (but not limited to) replace entire restoration

Responses include (but not limited to) polish, re-surface or repair restoration but not replace

10

Defective amalgam restoration (as determined via photograph)

Responses include (but not limited to) replace entire restoration

Responses include (but not limited to) polish, re-surface or repair restoration but not replace

11

Defective composite restoration with cementodentinal margins (as determined via photograph)

Responses include (but not limited to) replace entire restoration

Responses include (but not limited to) polish, re-surface or repair restoration but not replace

12

Lesion depth for permanent restoration instead of preventive or nonsurgical therapy (proximal caries) (as determined via a series of fi ve radiographs)

Radiograph 1 or 2 (lesion in enamel only)

Radiograph 3, 4 or 5 (lesion into dentin)

Caries Diagnosis and Treatment

Deep Caries Diagnosis and Treatment

* Brief statement or summary of the clinical question or scenario. The exact wording and associated clinical photographs and radiographs, as appropriate, are available online (http://nationaldentalpbrn.org/tyfoon/site/fckeditor/file/Concordance%20Questionnaire.pdf).

questions or scenarios to assess participants’ practice behaviors regarding caries assessment and treatment. Question 1 asked participants how often they used air drying to diagnose a primary caries lesion; a response of 75 percent of the time or higher was categorized as consistent with the evidence base, whereas a response

of less than 75 percent was categorized as inconsistent.23 Question 2 asked participants if they assess caries risk for individual patients in any way. We categorized a response of “yes” as consistent with the evidence base, whereas we categorized a response of “no” as inconsistent.24,25 For questions 3 and 4, participants were shown two different

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ORIGINAL CONTRIBUTIONS TABLE 2

Characteristics of 591 participating dentists. CHARACTERISTIC

NO. (%) OF PARTICIPANTS

MEAN PERCENTAGE (SD*) CONCORDANCE†

P VALUE

NO. (%) OF HIGH PERFORMERS ( ≥ 75% CONCORDANCE)

P VALUE

—‡

187 (32)



All Participants

591 (100)

62 (18)

Sex Male Female Missing data

487 (82) 103 (17) 1

61 (18) 66 (20) —

Race Non-Hispanic white Other Missing data

457 (89) 56 (11) 78

62 (19) 60 (20) —

General Practice Yes No

561 (95) 30 (5)

62 (18) 61 (19)

.8 §

179 (32) 8 (27)

.5 ¶

Year of Dental School Graduation Before 1990 1990 or later Missing data

401 (68) 189 (32) 1

62 (18) 61 (20) —

.99 §

130 (32) 57 (30) —

.90 ¶

Network Administrative Region# AL/MS FL/GA MN PDA U.S.-Other**

334 125 47 52 33

57 62 74 77 62

PDA/HealthPartners Dental Group Yes No

82 (14) 509 (86)

(57) (21) (8) (9) (6)

(18) (18) (16) (12) (16)

77 (12) 59 (18)

.007§

.4§

< .001§

< .001§

140 (29) 47 (46) — 149 (33) 19 (34) —

79 36 32 34 6

(24) (29) (68) (65) (18)

55 (67) 132 (26)

< .001¶

.8 ¶

< .001¶

< .001¶

* SD: Standard deviation. † Overall and according to each practice/practitioner characteristic; the mean percentage of the 12 questions for which the practitioners’ responses were consistent or concordant with published evidence. ‡ Dash indicates not applicable. § Significance of differences in mean percentage of responses concordant with published evidence using t test or analysis of variance. ¶ Significance of differences in proportions of practitioners classified as high performers, according to indicated practitioner/practice characteristics using c2 test. # AL/MS: Alabama/Mississippi; FL/GA: Florida/Georgia; MN: Community practitioners in Minnesota and HealthPartners Dental Group; PDA: Permanente Dental Associates (Washington and Oregon); U.S.-Other: Participants outside the main regions in the network. ** U.S.-Other: 17 respondents in North Carolina, four in South Carolina, four in Tennessee, two in New York State and one each in California, Colorado, Delaware, Maine, New Mexico, Ohio, Pennsylvania and Texas.

clinical photographs of an unrestored occlusal surface of a mandibular left first molar, together with a description of the patient, and asked how they would treat each one. For both questions, we coded a response of “amalgam restoration,” “composite restoration” or “indirect restoration” as inconsistent with the evidence, and we coded any other response as consistent.26 Finally, question 5 asked participants how often they used magnification to help diagnose caries lesions; we categorized a response of 75 percent or higher as consistent with published evidence, whereas we categorized a response of less than 75 percent as inconsistent.27 Deep caries diagnosis and treatment. We used two items to assess dentists’ behavior regarding deep caries diagnosis and treatment. The first question asked participants to indicate what percentage of the time they used three treatment options when caring for a patient with deep occlusal caries—with a possible mild pulpitis—in the mandibular right first molar. We categorized responses indicating that they would stop the procedure

before removing all caries and place an indirect pulp cap 25 percent of the time or more as consistent with the evidence; we categorized responses of less than 25 percent as inconsistent.28,29 The second item asked participants what they would do in a scenario involving excavation of caries in a lesion deeper than anticipated (in the same mandibular right first molar in the previous scenario) and perhaps involving the mesiobuccal pulp horn. We classified responses of “stop removing decay near the pulp horn and remove it elsewhere” as consistent with the evidence; we classified other responses as inconsistent with the evidence.28,29 Third-molar extraction. We used a single item to assess the respondent’s philosophy regarding third-molar extraction. We excluded from this question any participants who responded that they do not refer pediatric patients for third-molar extraction or “cannot provide a meaningful estimate” of the percentage of patients they refer by age 20 years. We classified the following two responses as being consistent with the literature:  JADA 145(1) http://jada.ada.org January 2014 25

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ORIGINAL CONTRIBUTIONS

“I recommend removal of third molars if they are asymptomatic but have a poor eruption path (e.g., full/ partial impaction) or do not appear to have sufficient space for eruption,” and “I recommend removal of third molars only if a patient presents with symptoms or pathology associated with third molars.” We classified the third response option (“I recommend removal of most third molars for preventive reasons”) as inconsistent with the literature.3,4,6,30-32 Restoration diagnosis and treatment. Four items assessed restoration diagnosis and treatment practices. For each of the first three questions, participants were shown a clinical photograph of a tooth accompanied by a brief description of the patient and were asked to indicate which treatment or treatments they would recommend from a list of 10 options. For all three questions, we classified responses of “replace entire restoration” as inconsistent with published evidence, whereas we classified all other options as consistent with published evidence.33 For the fourth question, participants were shown five different radiographs of the same tooth and asked to indicate the one corresponding to the lesion depth at which they would place a permanent restoration instead of performing only preventive therapy. We classified responses corresponding to radiographs 3, 4 and 5 as consistent with published evidence, and we classified responses corresponding to radiographs 1 and 2 as inconsistent.11,25 Data collection. We mailed the practice impact questionnaires with uniquely identified bar codes in July 2009 to 1,013 dentists enrolled in The DPBRN who had provided descriptive practice-level data and who were general dentists or pediatric dentists or indicated that they performed at least some restorative dentistry. This included practitioners who enrolled by completing the online network enrollment questionnaire but who were outside the network’s five main administrative regions; most of these dentists were in the southeastern region of the United States. We sent reminders to nonresponders two or three times. A total of 657 dentists completed the questionnaire between July 2009 and February 2010, for a response rate of 64.9 percent. We restricted analyses for this study to the 591 U.S. dentists. To measure test-retest reliability, we administered the questionnaire twice to 18 DPBRN practitioners, who completed the second questionnaire a mean (standard deviation) of 63 (30) days after the first questionnaire. The median value of the k statistic for these 12 questions was 0.81, with an interquartile range of 0.55 to 0.94. Data analysis. We calculated an overall concordance score as the percentage of responses that were consistent with published evidence. To examine concordance, we coded responses to each of the 12 clinical procedures as consistent (that is, “1”) or inconsistent (that is, “0”) with published evidence. We then summed the coded responses and divided the sum by the total number of responses to create an overall concordance score for each practitioner; a higher percentage indicates greater

concordance between clinical practice and published evidence. We classified practitioners as being highly concordant if their score was 75 percent or greater. We conducted two sets of analyses: one using a continuous measure of concordance as the outcome (that is, 0-100 percent) and the other using a dichotomous measure of concordance as the outcome (that is, < 75 percent versus ≥ 75 percent). We conducted a bivariate analysis to quantify associations between concordance and practitioner sex, race, general or specialty practice, year of graduation from dental school, network administrative region, and whether the practitioner belonged to either of two large group practices (PDA and HPDG) in the network. The continuous measure of concordance did not strictly satisfy the normality assumption of one-way analysis of variance; however, the deviation was minor (slightly skewed). We also assessed statistical significance by using rank statistics. The findings were virtually identical with parametric and nonparametric test findings. Because people are more familiar with parametric tests and these tests have a measure of variability (SD), we present these results in the Results section. We used c2 tests for dichotomous measures of high performers. We built models by using backwards elimination regression (linear and logistic). We entered all variables shown in Table 2 and retained them if P < .10. We then repeated analyses separately, according to whether the dentist practiced in PDA/HPDG. We performed sensitivity analyses with stricter requirements for three of the 12 scenarios: questions 1 and 5, in which we required respondents to use air drying and magnification 100 percent of the time (instead of 75 percent or greater) when diagnosing primary caries; and question 6, in which we required respondents to “stop before removing all caries and perform an indirect pulp cap” 50 percent or more of the time (instead of ≥ 25 percent). We performed all analyses by using statistical software (SAS Version 9.3, SAS Institute, Cary, N.C.). RESULTS

Participant characteristics. Participant characteristics are displayed in Table 2. Most participants were male, non-Hispanic white and in general practice; received their dental degrees before 1990; and were from the southeastern United States (AL, MS, FL, GA); 14 percent worked in a large group practice in Oregon (PDA) or Minnesota (HPDG). These two large group practices had higher proportions of female practitioners and nonHispanic white practitioners and more recent graduates (since 1990). Concordance score. Concordance scores (overall and according to participants’ characteristics) are displayed in Table 2. The mean procedure-specific concordance score was 62 percent (SD = 18 percent) (range, 8-100 percent); the median procedure-specific concordance score was 64 percent (interquartile range, 50-75 percent). Table 3 presents the concordance results, according to

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ORIGINAL CONTRIBUTIONS TABLE 3

Participants who reported concordance with published evidence, according to specific clinical question or scenario. CLINICAL AREA

Caries Diagnosis and Treatment

QUESTIONNAIRE ITEM NO.

RESPONSE CODED AS CONSISTENT WITH EVIDENCE

NO. OF CONCORDANT PARTICIPANTS/TOTAL NO. OF PARTICIPANTS*

PERCENTAGE OF PARTICIPANTS 63

1

Use of air drying (≥ 75% of the time)

373/588

2

Assess caries risk in all patients

463/545

85

3

Noninvasive treatment (occlusal surface no. 1)

515/586

88

4

Noninvasive treatment (occlusal surface no. 2)

392/588

67

5

Use magnification to diagnose caries lesions (≥ 75% of the time)

335/583

57

6

Stop before removing all caries and perform indirect pulp capping (≥ 25% of the time)

131/584

22

7

Stop removing decay near pulp horn and remove it elsewhere

190/578

33

Third-Molar Extraction

8

Recommend removal of third molars if they are asymptomatic but have a poor eruption path (such as full/ partial impaction) or do not appear to have sufficient space for eruption; recommend removal of third molars only if a patient has symptoms or pathology associated with third molars

497/582

85

Restoration Diagnosis and Treatment

9

Polish, re-surface or repair but do not replace

246/589

42

10

Polish, re-surface or repair but do not replace

381/588

65

11

Polish, re-surface or repair but do not replace

388/582

67

12

Lesion depth for permanent restoration (proximal caries)

297/588

51

Deep Caries Diagnosis and Treatment

* The difference between the denominator and 591 is the number of missing responses.

the clinical question or scenario. Missing data for questions pertaining to concordance with published evidence were rare. Of the 591 practitioners, 507 (86 percent) had no missing data for the concordance questions and 72 (12 percent) were missing data for only one question. There was a weak inverse association between the number of missing responses and the concordance score (Spearman r = -0.12, P = .004). Only two participants omitted a majority of responses; however, these two participants were not responsible for the weak inverse relationship (with the omission of these two people, Spearman r = 0.14, P = .0008). Procedures for which more than 80 percent of practitioners were concordant with published evidence were as follows: assessing caries risk, noninvasive treatment of an unrestored occlusal surface of a mandibular left first molar (item 3), and not extracting third molars solely for preventive reasons. The only procedure for which few practitioners’ responses were concordant with the evidence was indirect pulp capping. Dentist and practice characteristics. Table 2 displays bivariate results for the association between dentist and practice characteristics and concordance with published evidence. Using the continuous measure of concordance

as the outcome, female practitioners and practitioners from Oregon or Minnesota—or, in terms of practice setting, practitioners from PDA/HPDG—had higher concordance scores than those of their counterparts in the bivariate analysis. Table 4 shows that the adjusted mean concordance was higher for those practicing in PDA/ HPDG (P < .001), for women (P = .06) and for dentists who graduated from dental school before 1990 (P = .02). Dichotomous associations with high concordance were similar to those observed with the continuous measure; namely, in the adjusted analysis, female sex and practicing in PDA/HPDG or having graduated before 1990 were significantly associated with high concordance with published evidence. In an analysis stratified according to whether or not the dentist practiced in PDA/HPDG (Table 4), the associations of higher concordance for women and for those graduating before 1990 still were present among nonPDA/HPDG practitioners. In contrast, we found virtually no differences in concordance by sex or graduation year among PDA/HPDG practitioners. Analyses in which we used the stricter requirement for concordance resulted in a slightly lower mean  JADA 145(1) http://jada.ada.org January 2014 27

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ORIGINAL CONTRIBUTIONS TABLE 4

Adjusted* mean percentage of concordant participants and association with high performers. CHARACTERISTIC

All Participants Sex: Female versus male PDA/HPDG † : yes versus no Graduated from dental school before 1990 versus 1990 or later Stratified According to PDA/HPDG Among non-PDA/HPDG practitioners Sex: female versus male Graduated from dental school before 1990 versus 1990 or later Among PDA/HPDG practitioners Sex: female versus male Graduated from dental school before 1990 versus 1990 or later

MEAN PERCENTAGE OF CONCORDANT PARTICIPANTS

P VALUE

70 versus 67 77 versus 60

HIGH PERFORMERS ( ≥ 75 PERCENT CONCORDANCE) Odds Ratio

95% Confidence Interval

P Value

.06 < .001

2.0 6.0

1.2-3.2 3.6-10.1

.007 < .001

65 versus 62

.02

1.7

1.1-2.6

.01

62 versus 58

.08

2.2

1.3-3.8

.004

62 versus 57

.01

1.7

1.1-2.8

.02

78 versus 76

.5

1.2

0.4-3.3

.7

77 versus 78

.8

1.7

0.6-4.4

.3

* Adjusted for characteristics listed. † PDA/HPDG: Permanente Dental Associates/HealthPartners Dental Group.

concordance of 56 percent; however, the concordance in associations with sex, year of dental school graduation or practice setting was virtually no different from that under the less strict requirement. DISCUSSION

The objectives of this study were to examine the concordance between clinical practice and published evidence across a range of preventive, diagnostic and treatment procedures, as well as to identify practitioner- and organizational-level correlates associated with high concordance. Among a sample of 591 dentists, the mean concordance score across 12 clinical practices was 62 percent (SD = 18 percent). Concordance was considerably higher among practitioners in PDA/HPDG than among those not in PDA/HPDG (P < .001); moderately higher for less-recent graduates (P = .02); and slightly higher for women (P = .06) (Table 4). Among non-PDA/ HPDG practitioners, the associations with sex and year of graduation remained, whereas no such associations were indicated among PDA/HPDG practitioners. The findings for the high-performer category were similar to those obtained with use of a continuous measure of concordance. Although not optimal, the concordance rates reported here are similar to those reported in medicine. In a landmark study conducted by McGlynn and colleagues,34 patients received 54.9 percent of recommended care— according to published evidence—across 439 indicators of quality of care, including 30 acute and chronic conditions, as well as preventive care. Similar rates of concordance between evidence-based care and actual care received have been reported across other health conditions and health care contexts.35-37 It is worth noting, however, that differences in data collection methods (that is, medical records abstraction or review versus self-reported survey) may limit head-to-head compari-

sons between the results of these studies conducted in medicine and the findings reported here for dentistry.35-37 Because the gap between recommended and actual care has been documented,38 widespread effort has been made to better understand the problem and ultimately improve the quality of health care, perhaps providing an example for dentistry to follow. Higher concordance levels. The data set from this study cannot provide definitive explanations for why the PDA/HPDG group practice setting and female sex were associated with higher levels of concordance. Therefore, we can only speculate and state that additional research is warranted to explain these findings. Regarding the association between concordance with published evidence and the PDA/HPDG group practice, we do know that both of these groups have formalized programs and conduct practitioner meetings that are designed to facilitate discussion about the latest clinical evidence and how it applies to routine clinical practice. It is possible that these organizational efforts are effective at closing the research-to-practice gap for these groups of practitioners. In addition, clinicians at both PDA and HPDG create evidence-based guidelines on various topics, and these guidelines are disseminated to staff members. Regarding the association with sex, our study results show that female dentists were more likely to have high concordance with published evidence on the dichotomous measure (that is, ≥ 75 percent), even when we took into account other key factors in the same regressions (namely, year of graduation and PDA/HPDG group practice membership). Investigators from the network observed a similar finding by using a different questionnaire that was limited to caries diagnosis and treatment; female dentists were more likely to recommend at-home fluoride use (compared with in-office fluoride application, which was recommended more often by male dentists) and chose preventive therapy more often at the

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ORIGINAL CONTRIBUTIONS

earlier stages of dental caries.39 Study limitations. We should point out limitations of this study. First, responses may be subject to social desirability bias; it is possible that participants provided less-than-accurate responses because they wanted to portray themselves in a way that would be perceived positively by others (that is, engaging in clinical behavior that is consistent with published evidence). This, however, is not supported by the data, as many participants reported poor concordance between clinical practice and published evidence, which one would not expect to find if participants’ responses were influenced by social desirability bias. Second, we collected data via self-reports and did not validate them by means of other methods (such as observational data or dental records abstraction). As

on systematically developed ratings of the strength of the evidence. Nonetheless, results from both the continuous and dichotomous outcome measures of concordance, as well as those from the sensitivity analyses, suggest a substantive gap between clinical practice and published findings. Finally, it is important to note that we were unable to assess how clinical expertise and patients’ needs and preferences played a role in practitioners’ responses to the 12 preventive, diagnostic and treatment scenarios. Research is needed to better understand how the components of evidence-based dentistry (that is, evidence, clinical expertise and patients’ needs and preferences42) interact to influence practitioners’ decision-making process and provision of care.

The study results show that female dentists were more likely to have high concordance with published evidence on the dichotomous measure, even when the authors took into account other key factors. with all self-reported data, it is possible that participants’ responses may not reflect their actual behavior; research is needed to validate participants’ responses to clinical practice scenarios for all of the procedures of interest in this report, perhaps through the use of observational or ethnographic methods. Nonetheless, the results of a previous study conducted by the network show that the lesion depth at which a practitioner would intervene in proximal caries—on the basis of responses to a clinical scenario in a questionnaire—is a valid predictor of actual clinical behavior,40 as is whether a defective restoration should be repaired or replaced.41 In addition, network practitioners who stated that they would intervene surgically early in the caries process (for both occlusal caries and proximal caries) also were more likely to report that they would replace a restoration rather than repair it. This suggests a consistency across a range of clinical restorative situations regarding the extent to which a practitioner was likely to perform surgically invasive procedures.41 It is possible that participants misinterpreted some of the questions or case scenarios or perceived them as too ambiguous, resulting in lower concordance scores that are not actually reflective of a gap between practice and published evidence. We should note, however, that survey questions and case scenarios were written by content experts, pilot tested with practitioners and assessed for test-retest reliability before being included in the final version of the survey in an effort to enhance face validity and content validity. Our classification of responses to each of the 12 preventive, diagnostic and treatment scenarios or clinical procedures as being consistent or inconsistent with published evidence may spark debate, because such assessments were based on the strongest available published evidence and expert reviews at the time we collected data for this study; they were not based

conclusions

In this study, we aimed to quantify the gap between clinical practice and published evidence across a range of preventive, diagnostic and treatment scenarios among dentists, as well as to understand factors associated with concordance between clinical practice and published evidence. The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent) and a procedure-specific concordance ranging from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent). The often-lamented 17-year gap between published clinical evidence and actual application in routine clinical practice is a problem described for many health professions.34,43-45 Documenting the gap between clinical practice and published research findings is an important, albeit sometimes uncomfortable, first step toward being able to improve quality of care and patient outcomes. More research is needed to identify and help us better understand factors that contribute to the discrepancy between clinical practice and published research results. Possible drivers of this gap may include limited access to peer-reviewed publications, lack of social normative support, rigid organizational cultures, reimbursement schemes and other factors that serve as barriers toward the timely and effective adoption of clinical research findings.46-52 The results of this study can serve as the foundation for developing and testing strategies to facilitate the systematic implementation of published evidence into clinical dental practice to improve the profession and the oral health of the public.53-56 n Dr. Norton is an assistant professor, Department of Health Behavior, School of Public Health, University of Alabama at Birmingham. Dr. Funkhouser is an associate professor, Division of Preventive Medicine,

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ORIGINAL CONTRIBUTIONS

Department of Medicine, School of Medicine, University of Alabama at Birmingham. Dr. Makhija is an associate professor, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham. Dr. Gordan is a professor, Department of Restorative Dental Sciences, and director for practice-based research, College of Dentistry, University of Florida, Gainesville. Dr. Bader is a research professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill. Dr. Rindal is a practitioner in the HealthPartners Dental Group, Minneapolis, and an investigator at the HealthPartners Institute for Education and Research, Minneapolis. Dr. Pihlstrom is a practitioner and associate director for evidence-based care and oral health research, Permanente Dental Associates, Portland, Ore. Dr. Hilton is Alumni Centennial Professor, Department of Restorative Dentistry, Oregon Health and Science University, Portland. Dr. Frantsve-Hawley is the senior director, Center for Evidence-Based Dentistry, American Dental Association, Chicago. Dr. Gilbert is a professor and the chair, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham, 109 School of Dentistry Building, 1919 Seventh Ave. South, Birmingham, Ala. 352940007, e-mail [email protected]. Address correspondence to Dr. Gilbert. Disclosure. None of the authors reported any disclosures. The research described in this article was supported by grants U01-DE-16746, U01-DE-16747 and U19-DE-22516 from the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md. Opinions and assertions contained herein are not to be construed as necessarily representing the views of the authors’ respective organizations or the National Institutes of Health. All participants in this investigation provided informed consent after receiving a full explanation of the nature of the procedures. The National Dental Practice-Based Research Network Collaborative Group comprises practitioners, faculty and staff investigators who contributed to this network activity. A list of these people is available at http://nationaldentalpbrn. org/collaborative-group.php. 1. Beauchamp J, Caufield PW, Crall JJ, et al; American Dental Association Council on Scientific Affairs. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. JADA 2008;139(3):257-268. 2. American Dental Association. Policy on Evidence-Based Dentistry. www.ada.org/1754.aspx. Accessed Nov. 15, 2013. 3. American Public Health Association. Policy Statement Database. Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth). Policy Date: 10/28/2008. www.apha.org/advocacy/policy/policysearch/default.htm?id=1371. Accessed Nov. 26, 2013. 4. Daley TD. Third molar prophylactic extraction: a review and analysis of the literature. Gen Dent 1996;44(4):310-320. 5. Evans RW, Pakdaman A, Dennison PJ, Howe EL. The Caries Management System: an evidence-based preventive strategy for dental practitioners—application for adults. Aust Dent J 2008;53(1):83-92. 6. National Institute for Clinical Excellence. Guidance on the Extraction of Wisdom Teeth. London: National Institute for Clincial Excellence; 2000. www. nice.org.uk/nicemedia/live/11385/31993/31993.pdf. Accessed Nov. 18, 2013. 7. Felton D, Cooper L, Duqum I, et al; American College of Prosthodontists; Academy of General Dentistry; American Dental Association Council on Scientific Affairs; American Dental Hygienists’ Association; National Association of Dental Laboratories; GlaxoSmithKline Consumer Healthcare. Evidence-based guidelines for the care and maintenance of complete dentures: a publication of the American College of Prosthodontists. JADA 2011;142(suppl 1):1S-20S. 8. Felton DA. The ACP’s evidence-based guidelines for the care and maintenance of complete dentures. J Prosthodont 2010;19(8):591. 9. Fontana M, Young DA, Wolff MS. Evidence-based caries, risk assessment, and treatment. Dent Clin North Am 2009;53(1):149-161, x. 10. Frantsve-Hawley J, Jeske A. The American Dental Association’s Center for Evidence-Based Dentistry: a critical resource for 21st century dental practice. Tex Dent J 2011;128(2):201-205. 11. U.S. Department of Health and Human Services, National Institutes of Health (NIH). Diagnosis and Management of Dental Caries Throughout Life: NIH Consensus Statement, March 26-28, 2001;18(1):1-24. http://consensus.nih. gov/2001/2001Dentalcaries115html.htm. Accessed Nov. 15, 2013. 12. Riley JL 3rd, Gordan VV, Ajmo CT, Bockman H, Jackson MB, Gilbert GH; Dental PBRN Collaborative Group. Dentists’ use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network. Community Dent Oral Epidemiol

2011;39(6):564-573. 13. Young DA, Featherstone JD, Roth JR, et al. Caries management by risk assessment: implementation guidelines. J Calif Dent Assoc 2007;35(11):799-805. 14. Anabtawi MF, Gilbert GH, Bauer MR, et al; National Dental Practice-Based Research Network Collaborative Group. Rubber dam use during root canal treatment: findings from The Dental Practice-Based Research Network. JADA 2013;144(2):179-186. 15. Tellez M, Gray SL, Gray S, Lim S, Ismail AI. Sealants and dental caries: dentists’ perspectives on evidence-based recommendations. JADA 2011;142(9): 1033-1040. 16. Riley JL 3rd, Gordan VV, Rindal DB, et al; Dental Practice-Based Research Network Collaborative Group. General practitioners’ use of caries-preventive agents in adult patients versus pediatric patients: findings from the dental practice-based research network. JADA 2010;141(6):679-687. 17. Feigal RJ, Donly KJ. The use of pit and fissure sealants. Pediatr Dent 2006;28(2):143-150. 18. Stetler CB, Mittman BS, Francis J. Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series. Implement Sci 2008;3:8. 19. Gilbert GH, Williams OD, Korelitz JJ, et al; National Dental PBRN Collaborative Group. Purpose, structure, and function of the United States National Dental Practice-Based Research Network. J Dent 2013;41(11):1051-1059. 20. Gilbert GH, Williams OD, Rindal DB, Pihlstrom DJ, Benjamin PL, Wallace MC; DPBRN Collaborative Group. The creation and development of the dental practice-based research network. JADA 2008;139(1):74-81. 21. Makhija SK, Gilbert GH, Rindal DB, Benjamin PL, Richman JS, Pihlstrom DJ; DPBRN Collaborative Group. Dentists in practice-based research networks have much in common with dentists at large: evidence from the Dental PracticeBased Research Network. Gen Dent 2009;57(3):270-275. 22. Makhija SK, Gilbert GH, Rindal DB, et al; DPBRN Collaborative Group. Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large. BMC Oral Health 2009;9:26. 23. Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for identifying carious lesions. J Public Health Dent 2002;62(4): 201-213. 24. Fontana M, Zero DT. Assessing patients’ caries risk. JADA 2006;137(9): 1231-1239. 25. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. JADA 2006;137(8):1151-1159. 26. Bader JD, Shugars DA. The evidence supporting alternative management strategies for early occlusal caries and suspected occlusal dentinal caries. J Evid Based Dent Pract 2006;6(1):91-100. 27. Ismail AI. Visual and visuo-tactile detection of dental caries. J Dent Res 2004;83(spec no. C):C56-C66. 28. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth (published update appears in Cochrane Database Syst Rev 2013;3:CD003808). Cochrane Database Syst Rev 2006(3):CD003808. 29. Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. Oper Dent 2009;34(5):615-625. 30. Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J Public Health 2007;97(9):1554-1559. 31. Song F, Landes DP, Glenny AM, Sheldon TA. Prophylactic removal of impacted third molars: an assessment of published reviews. Br Dent J 1997; 182(9):339-346. 32. Mettes TG, Nienhuijs ME, van der Sanden WJ, Verdonschot EH, Plasschaert AJ. Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults (published update appears in Cochrane Database Syst Rev 2012;6:CD003879). Cochrane Database Syst Rev 2005;(2):CD003879. 33. Gordan VV, Garvan CW, Blaser PK, Mondragon E, Mjor IA. A long-term evaluation of alternative treatments to replacement of resin-based composite restorations: results of a seven-year study. JADA 2009;140(12):1476-1484. 34. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348(26):2635-2645. 35. Mularski RA, Asch SM, Shrank WH, et al. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest 2006;130(6):1844-1850. 36. Shrank WH, Asch SM, Adams J, et al. The quality of pharmacologic care for adults in the United States. Med Care 2006;44(10):936-945. 37. Asch SM, McGlynn EA, Hiatt L, et al. Quality of care for hypertension in the United States. BMC Cardiovasc Disord 2005;5(1):1. 38. McDonald KM, Chang C, Schultz E. Through the Quality Kaleidoscope: Reflections on the Science and Practice of Improving Health Care Quality. Closing the Quality Gap: Revisiting the State of the Science. Rockville, Md.: Agency for Healthcare Research and Quality; February 2013. AHRQ publication 13-EHC041-EF. http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-

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ORIGINAL CONTRIBUTIONS reviews-and-reports/?productid=1406&pageaction=displayproduct. Accessed Dec. 5, 2013. 39. Riley JL 3rd, Gordan VV, Rouisse KM, McClelland J, Gilbert GH; Dental Practice-Based Research Network Collaborative Group. Differences in male and female dentists’ practice patterns regarding diagnosis and treatment of dental caries: findings from The Dental Practice-Based Research Network. JADA 2011;142(4):429-440. 40. Rindal DB, Gordan VV, Fellows JL, et al: DPBRN Collaborative Group. Differences between reported and actual restored caries lesion depths: results from The Dental PBRN. J Dent 2012;40(3):248-254. 41. Heaven TJ, Gordan VV, Litaker MS, et al: National Dental PBRN Collaborative Group. Agreement among dentists’ restorative treatment planning thresholds for primary occlusal caries, primary proximal caries, and existing restorations: findings from The National Dental Practice-Based Research Network. J Dent 2013;41(8):718-725. 42. American Dental Association Center for Evidence-Based Dentistry. ebd.ada.org. Accessed Nov. 18, 2013. 43. U.S. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academy Press; 2001. 44. Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, eds. Yearbook of Medical Informatics: Patient-Centered Systems. Stuttgart, Germany: Schattauer; 2000:65-70. 45. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362(9391):1225-1230. 46. Fontana M, Wolff M. Translating the caries management paradigm into practice: challenges and opportunities. J Calif Dent Assoc 2011;39(10):702-708.

47. Merijohn GK. The practicing clinician’s perspective: using the EBD approach and CDS tools in private practice. J Evid Based Dent Pract 2008;8(3): 203-205. 48. Kao RT. The challenges of transferring evidence-based dentistry into practice. Tex Dent J 2011;128(2):193-199. 49. Spallek H, Song M, Polk DE, Bekhuis T, Frantsve-Hawley J, Aravamudhan K. Barriers to implementing evidence-based clinical guidelines: a survey of early adopters. J Evid Based Dent Pract 2010;10(4):195-206. 50. Anderson GC. Dissemination tools and resources: assisting colleagues in the implementation and promotion of EBD principles. J Evid Based Dent Pract 2008;8(3):155-158. 51. Hannes K, Norre D, Goedhuys J, Naert I, Aertgeerts B. Obstacles to implementing evidence-based dentistry: a focus group-based study. J Dent Educ 2008;72(6):736-744. 52. Shaneyfelt TM. Building bridges to quality. JAMA 2001;286(20):2600-2601. 53. Simpson DD. A framework for implementing sustainable oral health promotion interventions. J Public Health Dent 2011;71(suppl 1):S84-S94. 54. Petersen PE, Kwan S. Evaluation of community-based oral health promotion and oral disease prevention: WHO recommendations for improved evidence in public health practice. Community Dent Health 2004;21(4 suppl):319-329. 55. Merijohn GK, Bader JD, Frantsve-Hawley J, Aravamudhan K. Clinical decision support chairside tools for evidence-based dental practice. J Evid Based Dent Pract 2008;8(3):119-132. 56. Frantsve-Hawley J, Meyer DM. The evidence-based dentistry champions: a grassroots approach to the implementation of EBD. J Evid Based Dent Pract 2008;8(2):64-69.

 JADA 145(1) http://jada.ada.org January 2014 31 Copyright © 2014 American Dental Association. All Rights Reserved.

Concordance between clinical practice and published evidence: findings from The National Dental Practice-Based Research Network.

Documenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important st...
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