9: Evidence-Based Decision Making in a Geriatric Practice

Chapter 9
Evidence-Based Decision Making in a Geriatric Practice

Mary R. Truhlar

Department of General Dentistry, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA

Introduction

Evidence-based decision making is defined as:

The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients

(Sackett et al., 1996).

Older adults, generally considered persons over the age of 65 years, comprise a distinct population that often provides diagnostic and therapeutic challenges to clinicians. Practitioners working with this cohort need the skills to search and critically evaluate the literature, problem solve, and make evidence-based decisions in the care of patients. The practice of evidence-based medicine integrates individual clinical expertise with the best available external clinical evidence from systematic research. Taken one step further it integrates the best research evidence with clinical expertise and patient values (Sackett et al., 2000). In applying evidence-based decision making (EBDM) to the field of dentistry The American Dental Association (ADA) Center for Evidence-Based Dentistry defines it as the process of finding relevant information in the dental literature to address a specific problem, using some simple rules of science and common sense to quickly judge the validity of health information, and finally the application of the information to answer the original clinical question (ADA: ebd.ada.org/about.aspx).

Twenty-five years ago we got our news and information from a few universal sources; today both the dental professional and patient get an abundance of information from many sources. The dental profession is no longer the only or the main source of dental healthcare information for our patients.

Evidence-based decision making provides practitioners with an approach for the management of information and facilitates the translation of scientific evidence into clinical practice decisions, thus supporting the delivery of quality patient care. The term “information overload” is frequently applied to the experience of managing today’s data influx; however, too much data may not be the real issue. Complaints about “too many books” emerged during the course of the 18th century in England, France, and Germany (Blair, 2010). The late 18th-century reader felt themselves to be overwhelmed by the number of books being printed. The anxiety felt in the later part of the 18th century was related to a rapid increase in new print titles, an increase of about 150% over 30 years. Today we are not so dissimilar, we find ourselves to be overwhelmed by meteoric rise in emails and digital communications. Wellmon (2012) believes that much of the way that we deal with the information around us have their antecedents throughout history, and the real issue lies not in the sheer volume of information but in a perceived inability to manage new information. Therefore, developing a technique to manage, distill, and analyze information would greatly enhance our ability to remain current and conversant in patient care.

The process

Evidence-based decision making in clinical practice begins with a clearly defined question related to patient care. The second step consists of efficiently accessing established sources of relevant topic information. This is followed by a critical appraisal of the evidence. Implementation of the findings is followed by continuous re-evaluation and assessment with the goal of maintaining a constant state of best practice.

Sources of evidence

In “searching for the truth” an array of information can be obtained from diverse sources. Primary sources include clinical trials, cohort and case-controlled studies, and case reports. Secondary sources include systematic reviews, reviews of literature, meta-analysis, evidence-based journals, and evidence-based clinical guidelines (e.g., ADA). Web-based sources cover all the domains and offer point of care tools.

Scholarly articles/communications, whether in a hard copy or online format, present substantiated research and academic discussion among professionals and are an appropriate source for EBDM. There are popular and readily available communications that fall into a gray area. In these sources it is frequently difficult to distinguish research-based material from unsubstantiated “expert” information given by a distinguished editorial panel. Popular communications such as dental magazines designed to inform and entertain may contain some research-based evidence but are not considered rigorous enough for EBDM. Trade communications that reach out to practitioners in specific industries to share market and production information are for business purposes and should be viewed in this manner.

A well-written systematic review provides the practitioner with a quick and encompassing look at the state of scientific research on a specific clinical question. An SR synthesizes the results from multiple studies addressing the same question by: statistically combining and distilling large quantities of data, evaluating the quality of each study and overall evidence in an objective manner, and concluding with an organized review of clinically useful information. In contrast, the case study and expert opinion provide less robust evidence, which frequently is limited to observational data reflecting the sentiment “We do this in my practice.”

Critical appraisal of the evidence

Reviewing the evidence requires a method to assess the statistical and clinical significance as well as the applicability of the material presented. A journal’s “impact factor” (IF) is a good starting point for evaluation of the quality articles it contains. Not all journals are created equal or are perceived as being equal, and the impact factor can be used as a tool to rate a journal’s importance within its field. It can serve as an indication of how reliable an article may be; however, it should not be used to assess the importance of individual articles, nor as a measure of an individual investigator’s relevance. Impact factor is calculated yearly for journals and indexed in Thomson Reuters’s Journal Citation Reports© (go.thomsonreuters.com/jcr/). This is the most universally used and understood journal rating system. Impact factor is a numerical measure of a scientific journal’s average number of citations of recent articles. Citations can include but are not limited to articles, reviews, meeting proceedings, or notes. Editorials or letters-to-the-editor are not included. The larger the IF value, the more important the journal is considered.

The validity of IF is impacted by several factors including the fact that most investigators cite their own articles; the current popularity of the field of study; and if a survey of experts feel it shows limited correlation to actual journal quality. However, it remains the gold standard for rating a journal’s contribution to scientific literature. Table 9.1 lists the journals of interest to a geriatric practice.

Table 9.1 Journals of interest to a geriatric practice sorted by impact factora

Abbreviated journal title ISSN 2010 total citations Impact factor 5-Year impact factor Immediacy index 2010 articles Cited half-life Eigenfactor® score Article Influence® score
J Dent Res 0022-0345 13 593 3.773 4.389 0.437 229 >10.0 0.02257 1.296
J Am Dent Assoc 0002-8177 5458 2.195 2.282 0.281 121 >10.0 0.00876 0.667
J Oral Rehabil

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 9: Evidence-Based Decision Making in a Geriatric Practice
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