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Systematic Reviews and Evidence-Based Recommendations

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Systematic Reviews and Evidence-Based Recommendations

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  1. The Evidence Base for Community Preventative Services and Examples from States of ASTDD Best PracticesDolores Malvitz, DrPHChiefSurveillance, Investigation, and Research TeamDivision of Oral Health Centers for Disease Control and Prevention (CDC)Atlanta, GeorgiaTexas Oral Health Summit: Advocacy, Equity & AccessAustin, TexasSeptember 9-10, 2004

  2. Promoting Oral Health Systematic Reviews and Evidence-Based Recommendations

  3. The Community Guide Is: • A set of recommendations for action based on the scientific evidence • Evidence comes from systematic reviews • Reviews coordinated by CDC staff • Recommendations determined by independent Task Force

  4. What Will Be Reviewed in the Community Guide? Risk Behaviors Specific Conditions • Tobacco Use • Alcohol Abuse/Misuse • Other Substance Abuse • Poor Nutrition • Inadequate Physical Activity • Unhealthy Sexual Behaviors • Vaccine Preventable Disease • Pregnancy Outcomes • Violence • Motor Vehicle Injuries • Depression • Cancer • Diabetes • Oral Health The Environment • Sociocultural Issues

  5. The Community Guide is Part of a Family of Federal Initiatives Healthy People 2010 Guide to Clinical Preventive Services Priorities for Prevention Put Prevention into Practice

  6. Promoting Oral Health Recommendations from the Guide to Community Preventive Services

  7. Oral Health ChapterCommunity Guide Interventions for Preventing: • Dental Caries • Oral and Pharyngeal Cancers • Sports-related Craniofacial Injuries

  8. Methods for Conducting Systematic Reviews: Five Steps • Develop conceptual approach • Search for and retrieve evidence • Rate quality of evidence • Summarize evidence • Translate strength of evidence into recommendation

  9. Key Findings

  10. Oral Health ChapterCommunity Guide Strong evidence for: • Community water fluoridation • School sealant programs

  11. Translate strength of evidence into recommendations Preventing dental caries • Community water fluoridation (strongly recommended) • School-based sealant programs (strongly recommended)

  12. Oral Health ChapterCommunity Guide Insufficient evidence for: • Community-wide sealant promotion programs • Oral cancer awareness and screening programs • Promoting use of dental and craniofacial protectors in contact sports

  13. Insufficient evidence should not be confused with evidence of ineffectiveness

  14. Benefits of the Community Guide • Stronger foundation for advocacy, research, and programs • proof of effectiveness may be better (semi-quantitative vs. narrative summary) • recommendations issued by independent, objective Task Force

  15. www.thecommunityguide.org

  16. ASTDD Best Practices Project Putting science into practice www.astdd.org

  17. Purpose of the Project (1) Provide guidance for programs (2) Meet the Surgeon General’s Call to Action (3) Help achieve Healthy People 2010 objectives

  18. Best Practice Approaches Dental public health strategies supported by evidence of effectiveness.

  19. Best Practice ApproachesStrength of Evidence PromisingProven Approaches ....................….….…….....….… Approaches Strength of Evidence Research + Research +++ Expert Opinion +Expert Opinion +++ Field Lessons +Field Lessons +++ Theoretical Rationale +++ Theoretical Rationale +++

  20. Research Evidence +++ Systematic review Expert Opinion +++ Multiple authoritative sources Field Lessons +++ Cluster evaluation of several states Strong Evidence

  21. Best Practice ApproachesStrength of Evidence Best Practice Research Expert Field Theoretical Approaches Opinion Lessons Rationale Surveillance Systems+ +++ ++ +++ State Coalitions+ +++ ++ +++ State Plans+ +++ ++ +++ State Mandate for Program+ +++ ++ +++ Community Water Fluoridation +++ +++ ++ +++ School Sealant Programs +++ +++ ++ +++ School Fluoride Programs ++ +++ + +++ Workforce Development + +++ ++ +++

  22. Community Water Program Evidence Supporting Effectiveness Summary of Evidence Supporting Community Water Fluoridation Research +++ Expert Opinion +++ Field Lessons ++ Theoretical Rationale +++

  23. School-based Sealant ProgramsEvidence Supporting Effectiveness Summary of Evidence Supporting School-based Dental Sealant Programs Research +++ Expert Opinion +++ Field Lessons ++ Theoretical Rationale +++

  24. Best Practice Criteria Effectiveness Efficiency Sustainability “Best Practice” Rationale & Objectives Collaboration & Integration

  25. ASTDD Best Practices Project Community Water Fluoridation

  26. Description of a Community Water Fluoridation Program  Legislation & policies  Advocacy & promotion  Supporting communities starting fluoridation  Training, monitoring, surveillance, reporting and inspection

  27. Description of a Community Water Fluoridation Program  Collaborate with water quality and other partners  Develop human resources to support community water fluoridation efforts  Secure financial resources to support community water fluoridation efforts

  28. Review Standard: Compare % population served by water systems with optimally fluoridated water to HP 2010 target (75%). State population with optimally fluoridated water Illinois 99% Indiana 95% Texas 66% Arkansas 60% Mississippi 39% California 29% Best Practice Criteria(1) Effectiveness

  29. Review Standard: Document number of communities or public water systems with optimally fluoridated water. In 2002: 44 of the 50 largest cities in the U.S. fluoridated Illinois: 860 of the 1800 community water systems adjust their fluoride levels Indiana: 482 water systems adjust their fluoride levels Best Practice Criteria(1) Effectiveness

  30. Review Standard: Compare average state cost for fluoridation (cost per per person year) to national estimates. Best Practice Criteria(2) Efficiency Estimating costs  Initial cost of capital equipment  Replacement cost of capital equipment  Annual operational costs (chemicals, human resources, maintenance & repairs)

  31. Review Standard: Demonstrate sustainability through the number of years that identifiable water fluoridation program at state level has operated. Best Practice Criteria(3) Sustainability State Community Water Fluoridation Programs Indiana since 1950’s Oklahoma since 1950’s Missouri since 1960’s Virginia since 1980’s

  32. Review Standard: Demonstrate partnerships & coalitions with stakeholders and organizations to provide political, financial and scientific expertise to local constituents. Best Practice Criteria(4) Collaboration & Integration Fluoridation Partners Professional association Grant makers Health departments Water authorities Universities (dental, medical and public health schools) Dental hygiene programs Local community leaders

  33. Review Standard: Program is linked to state &/or national goals and objectives. Best Practice Criteria(5) Rationale & Objectives Healthy People 2010 Objective 21-9 Increase proportion of U.S. population served by community water systems with optimally fluoridated water 2010 target: 75%

  34. ASTDD Best Practices Project School-based Dental Sealant Programs

  35. Description of School-based Sealant Programs  Program conducted within the school setting  Provide education to increase awareness of the benefit of sealants  Obtain parental consent for screening/sealants  Program provider teams include dentists, dental hygienists and dental assistants  Utilize portable dental equipment or a fixed dental facility within the school setting

  36. Description of School-based Sealant Programs  Usual practice: Dentists examine the children and prescribe the sealants; dental hygienists apply the sealants  For quality assurance, children re-examined within 1 year after sealant placement to check on retention and need for repair  The program should address unmet dental care needs of children

  37. State Practice Examples Illinois Dental Sealant Grant Program Ohio Dept. of Health School-based Dental Sealant Program Arizona Dental Sealant Program New Mexico School-based Dental Sealant Program

  38. Review Standard: Program delivers to a large number of high risk children. Sealant Programs Ohio 28,000 children Illinois 21,000 children Target Schools 50-65% students in free & reduced lunch programs Best Practice Criteria(1) Effectiveness

  39. Review Standard: Program maintains a quality assurance system. Sealant retention Arizona 1-week assessment 1-year assessment New Mexico 1-year assessment Best Practice Criteria(1) Effectiveness

  40. Best Practice Criteria(1) Effectiveness Sealant Prevalence Ohio children aged 8: 11% in 1988 30% in 1999 New Mexico 3rd graders: 47-52% in health district with program 19% in health district without program Review Standard: Documentation of program benefits or outcomes.

  41. Review Standard: Program uses the least expensive personnel permitted by state law. Best Practice Criteria(2) Efficiency New Mexico Dentists screen children Dental hygienists apply sealants Dental assistants also apply sealants

  42. Review Standard: Program with a track record or a plan for covering program expenses. Best Practice Criteria(3) Sustainability Sealant Programs New Mexico 26 yrs. Ohio 20 yrs. Illinois 19 yrs. Arizona 17 yrs. Funding Ohio…MCH/Tobacco $ Arizona………Medicaid

  43. Review Standard: Partnerships are established to administer & sustain the program. Best Practice Criteria(4) Collaboration & Integration Sealant Partners Local health departments Community agencies School health services Medicaid Primary Care Office Foundations Private dentists & dental hygienists

  44. Review Standard: Program is linked to state &/or national goals and objectives. Best Practice Criteria(5) Rationale & Objectives Healthy People 2010 Objective 21-8: Increase of children who have received sealants on their molar teeth Aged 8 years 50% Aged 14 years 50%

  45. ASTDD Best Practices Project Putting science into practice

  46. www.astdd.org ASTDD Web Site Best Practice Approach Reports

  47. www.astdd.org

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