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J Am Dent Assoc, Vol 137, No 11, 1488-1491.
© 2006 American Dental Association |
COMMENTARY |
You are closer than you think
Clinical and laboratory studies often are conducted with the eventual goal of translating findings into clinical practice. Unfortunately, this process has fallen far short of expectations. For example, in the last 50 years, the vast majority of research funded by the National Institutes of Health (NIH) has taken place in academic centers, where less than 1 percent of patients are seen.1,2 Historically, office-based clinicians have been isolated from the NIH research enterprise.3 It has been estimated, on the basis of several published studies, that on average, it takes 17 years to turn 14 percent of original research findings into changes in care that benefit patients.4 This stagnation of information defeats the purpose of funded research designed to benefit public health and has led to a recognized need for more relevant research and for better ways to translate research into practice.5
Improvements in medical/dental practice traditionally have been measured in a unidirectional top-down manner: a typical study starts from a laboratory or academic site and ends at an academically based faculty practice. This process excludes the primary means of achieving the greatest impact in terms of change: the general practitioner.
Furthermore, there is a lack of data available for clinical decision making. The statements "in my hands" and "in my opinion," while frequently used, often signal information that has little basis in scientific validity. Until now, there has been no mechanism for comparing clinical outcomes reported by practitioners who have decades of experience with findings generated by academic research centers.
The NIH has made an attempt to balance this equation and formalize the knowledge base acquired by practitioners in a concept termed "practice-based research networks" (PBRNs).6 PBRNs are hybrid organizations between academic centers and site management organizations, in which private practitioners are coordinated by an academic center to ensure consistency in research standards for investigations conducted in a private office setting. Furthermore, to emphasize the practical relevance of the investigations, ideas for the clinical studies emanate from the practitioners and ascend via a specified format for ultimate approval by the NIH, independent protocol review committees and institutional review boards.
Medical PBRNs have been in existence for more than 25 years7 and have examined a wide variety of clinically relevant issues. For example, clinical practice guidelines for the treatment of otitis media are based on clinical research data obtained from medical PBRNs.8–10 The 1996 Institute of Medicine11 report viewed PBRNs as "a significant underpinning for studies in primary care" but noted that they were underfunded. In 2004, a national survey conducted by the PBRN Resource Center12 identified 111 networks in 44 states that met established criteria for being active primary care PBRNs. Medical PBRNs that are well-designed and properly funded can support a wide range of research with direct value to society. The PBRN practitioner-investigator model benefits from using practitioners’ clinical experience as well as intellectual curiosity, which become the basis for the research conducted in the PBRN, and provides the practitioner with an opportunity to become an integral member of a research team. In many cases, the curiosity stems from the practitioner’s common experience of being unable to answer a question that presents itself in day-to-day practice.13
Dental PBRNs are a relatively recent phenomenon14 and, before 2005, existed only in Cleveland and cities in England and Scotland.15,16 The 2001 American Dental Association report, "Future of Dentistry," mirrored observations from medical care and cited a need to improve the speed and quality of information transferred from research settings to the public domain, and it recommended establishing "clinical research networks that link treatment approaches and treatment outcomes in private practice settings and enable large-scale evaluations of treatment protocols."17 The National Institute of Dental and Craniofacial Research (NIDCR) responded to that report as well as to the need to develop a database of common elements (for sharing and combining findings) to conduct "clinical research relevant to practicing clinicians."18 In 2005, the NIDCR committed approximately $75 million over seven years to three dental PBRNs, each mandated to recruit at least 100 general dental practitioners, each one differing in its approach.19 The novelty of the dental (as opposed to the medical) PBRNs is the amount of money dedicated to support the networks for a fixed amount of time (seven years), which was identified as a major issue for the medical PBRNs in their ability to both recruit and retain general practitioners.
The Northwest network is conducted by a consortium of the University of Washington (Seattle) and Oregon Health and Science University (Eugene, Ore.). Referred to as Northwest Precedent (an abbreviation of "Practice-based Research Collaborative in Evidence-based Dentistry") ("http://clinicaltrialsworkbench.axioresearch.com/nwprecedent/"), this network is conducting a wide variety of oral health research studies in diverse practice settings across a five-state region covering Idaho, Montana, Oregon, Utah and Washington.
The Southeast network is a partnership of The University of Alabama at Birmingham with the University of Florida ("www.dentalpbrn.org"), and it uses groups of organized dentists also participating in research in the Southeast (Alabama, Florida, Georgia, Mississippi), as well as several other centers in the United States (Minnesota, Oregon) and Scandinavia. It is referred to as the Dental Practice-Based Research Network, with a mission "to improve oral health by conducting dental practice-based research and by serving dental professionals through education and collegiality."
A Northeast network was awarded to the New York University College of Dentistry (NYUCD) (New York City) and The EMMES Corp. (Rockville, Md.), referred to as the PEARL Network (an abbreviation for "Practitioners Engaged in Applied Research and Learning") ("www.pearlnetwork.org"). This network, based in the Bluestone Center for Clinical Research at NYUCD, uses a three-tier system of practitioner-investigators. The first tier comprises about 20 dentists from three states in close proximity to NYU who function as a core group to conduct initial tests of clinical proposals, as well as conduct controlled clinical trials. A second tier of dentists conduct the bulk of PEARL studies (prospective and retrospective observational investigations); this group includes more than 80 dentists in a more than 200-mile radius primarily from Maryland in the south to New England in the north and Michigan in the west. Third-tier dentists are recruited from anywhere in the United States, and they conduct anonymous surveys of patients and dentists and administer prevalence questionnaires of oral-facial conditions.
The PEARL Network differs from entities established with conventional government-supported grants in that the management follows a business model with a board of directors, termed the "executive management team" (EMT), in which each director has an assigned core or responsibility. The business model is further strengthened in that each member of the EMT is a dentist, each with different expertise as well as a background in research, clinical care and education, which adds to the synergy moving the PBRN enterprise forward. Furthermore, the PEARL Network is the only dental PBRN originating from a single dental institution. It includes a structure representing the interests of the dentists as well as patients in the form of a patient advocate, and, where applicable, patient-centered interests are represented in clinical studies.
The NIDCR vision for creating regional PBRNs has extended to a collection of several dental databases that will permit their integration with medical databases, part of the NIH road map for the future of research.20 The three dental PBRNs already have begun a trans-PBRN–coordinated study examining the incidence of and risk factors for osteonecrosis of the jaws in dental practice. The potential to merge dental and medical PBRN databases will provide the profession with a unique opportunity to more thoroughly and globally investigate possible links between diseases and conditions that affect the oral and craniofacial structures and those that affect other organ systems. Furthermore, the dental PBRNs may be able to provide patient-based data to promote the concept of "total patient care," and to suggest how patient care could be managed more efficiently and effectively from a global medical and dental perspective.
Interoperability between medical and dental PBRN data sets will permit collaborations among clinicians and scientists, thereby enhancing the statistical power of research efforts and the ability to identify common trends in oral health care. Furthermore, the NIDCR has partnered with the National Cancer Institute’s Center for Biomedical Informatics to establish a dental vocabulary of common data elements. This is consistent with the national effort to modernize health care and facilitate the electronic transfer of patients’ medical/dental information.
Dentists and their office personnel are well-suited for participation in PBRNs for several reasons:
The majority of dentists (70 percent) still practice as solo practitioners.21 PBRNs offer intellectual stimulation and collegiality, as well as a forum for professional socialization. The PBRN, with its central core emanating from an academic center, can act as a link connecting dental offices, integrating these offices into a larger organization and uniting the practitioners with academic researchers. This alone has the potential to change the way dentistry is practiced in the future. Most importantly, the final measure of the success of dental PBRNs is their ability to influence dentistry to change clinical procedures on the basis of objective and reproducible evidence gathered by multiple practitioners using a variety of patients, clinicians and office locations.
PBRNs function at the interface between research and quality improvement. They have the potential to make a significant impact on dentistry by adding a learning dimension to the dental practice, with the ability to improve primary dental care and to create a connected learning community.22 They provide opportunities to address patient-centered issues that previously have been neglected. NIDCR-funded dental PBRNs now provide an unprecedented opportunity to assemble the vast clinical experiences of a robust patient network of private dental practitioners into a collection of standardized patient data. PBRNs will become problem solvers for the dentist—a team of peers to help the clinical practitioner obtain and use more scientifically validated patient care data. Dentists now can turn to PBRNs to seek solutions to long-standing questions and common problems faced in clinical practice. Dentists should view PBRNs as a venue in which to become involved with advancing the profession by applying scientific guidelines to generate robust—and practice-applicable—clinical data.
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  G. H. Gilbert, O. D. Williams, D. B. Rindal, D. J. Pihlstrom, P. L. Benjamin, M. C. Wallace, and for the DPBRN Collaborative Group The Creation and Development of the Dental Practice-Based Research Network J Am Dent Assoc, January 1, 2008; 139(1): 74 - 81. [Abstract] [Full Text] [PDF]
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