Committees. Much of the work of DPBRN is handled via various committees. They are the EC, steering committee, protocol review committee, publications and presentations committee, and NIDCR PBRN monitoring committee.

EC. The EC is the main decision-making body of the network, and it is structured to make DPBRN a practitioner-driven network. It is designed so that the majority voting authority resides with its practitioner-investigator representatives. One vote also is given to each of three nonpractitioner-investigators (network chair, principal investigator of the Coordinating Center and NIDCR representative). The committee makes decisions on operational issues, considers appropriateness of and suggests changes to study procedures, reviews the network’s progress and prioritizes research topics, among other duties. The committee meets approximately seven times each year. Most meetings are held by videoconference, with the remainder being held face-to-face.

Steering committee. The steering committee was not formed until 2006 when it became apparent that such a committee could help optimize DPBRN administration. The purpose of the steering committee is to determine how best to implement decisions made by the EC, help protocol working groups develop study applications into a more final form before they are sent to the EC, and maximize coordination of tasks across regions, in conjunction with the regional coordination team. The steering committee includes the principal investigators from each region, as well as the network chair and principal investigator of the Coordinating Center. The committee meets monthly by telephone conference call and annually face-to-face.

Protocol review committee. Once the EC has approved the study applications, they are sent to the protocol review committee for final scientific review. This committee includes three dental clinical scientists, a biostatistician, a medical PBRN director, a practicing dentist and an NIDCR representative. All committee members are unaffiliated with DPBRN so that they can provide an objective and independent scientific review. This committee, which is constituted by NIDCR and not DPBRN, has the mandate to approve, disapprove or recommend changes to all studies.

Publications and presentations committee. The EC approved a DPBRN publications and presentations policy in 2006. One component of the policy was the creation of the publications and presentations committee. This committee implements publications and presentations policy and reviews and approves all DPBRN manuscripts, publications, abstracts and presentations. The committee includes a practitioner-investigator, representatives from two DPBRN regions and representatives from the network chair office and Coordinating Center. This committee encourages DPBRN publications and presentations, manages the publications process, and ensures compliance with the publications and presentations policy.

NIDCR PBRN monitoring committee. Because of NIDCR’s large financial commitment, it created a monitoring committee to oversee and make recommendations regarding the progress of the PBRN initiative. The committee meets twice each year and has representatives from several dental organizations (for example, the American Dental Association), medical PBRN directors and a patient advocate. For DPBRN, this committee functions as its external advisory board.

Trans-PBRN entities. In addition to DPBRN, NIDCR funded two other dental PBRNs. To foster communication between these three NIDCR-funded PBRNs, a "trans-PBRN" monthly telephone conference is held between the NIDCR representative, the network chairs and the coordinating centers principal investigators. Best practices, successes and failures are shared with the intent of improving the operation of all three dental PBRNs. This trans-PBRN entity is called the Collaboration on Networked Dental and Oral Health Research (CONDOR).

Because each PBRN study must have standardized data elements to maximize comparability, an informatics committee that includes the director of informatics and the director of the coordinating center from each PBRN meets as studies are approved to reach consensus on all of the data elements collected by the PBRNs. The committee requires attendance by a member from each PBRN and approval by all three PBRNs.

Best practices, successes and failures are shared with the intent of improving the operation of all three dental practice-based research networks.

A CONDOR study of osteonecrosis of the jaw was approved in 2006. To have sufficient statistical power to conduct such a study, the CONDOR study group realized that it would need data from all three networks, necessitating a highly collaborative single project to which all three PBRNs have contributed. Consequently, a CONDOR group was created specifically for this study, and it successfully created a single grant application and administers this project on behalf of the three networks.

	THE STUDY DEVELOPMENT PROCESS

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A key operating principle for DPBRN is that the research questions originate from dental practitioner-investigators and that the answers to these questions have the potential to improve the practice of dentistry. Furthermore, the research has to be conducted in the network members’ practices. This situation creates a healthy tension between the needs of a sound research project and the need not to be overly disruptive of daily clinical practice. In this sense, the process cannot require the researchers to become practitioners nor the practitioners to become full-time researchers.

The overall process of study development is shown in the figure. Practitioner-investigators provide input at each step of the process, and this is especially true of the practitioner-investigators on the EC. The success of DPBRN relies on the fact that it conducts studies that practitioner-investigators find useful, interesting and feasible, as well as those that have the potential to provide results to improve daily clinical practice. Ideas for studies are obtained from completed enrollment questionnaires, in face-to-face meetings (for example, at orientation sessions delivered in continuing education format, at DPBRN annual meetings or in visits to the practice) or the DPBRN Web site. Ideas for studies are discussed and prioritized by the EC. The EC has rejected some study ideas, typically because it does not think they will be of broad interest to DPBRN practitioners or because they are not feasible to conduct in daily clinical practice. If the EC approves a study concept, it forwards the study concept to NIDCR to determine whether it overlaps with a study already funded by NIDCR. If not, DPBRN forms a protocol working group.

View larger version (59K): [in this window] [in a new window]   Figure. The life cycle of a Dental Practice-Based Research Network (DPBRN) study. EC: Executive committee. NIDCR: National Institute of Dental and Craniofacial Research.

Once the EC approves the final version of the study application, it is forwarded to the protocol review committee. If the protocol review committee approves the study, DPBRN then submits institutional review board applications from each of its regions for review of human subjects considerations. Approved versions of data collection forms for each study are pilot-tested with practitioner-investigators on the EC and selected practitioner-investigators across the network. These forms are used to collect data at each practice and then are sent to the Coordinating Center for data analysis. Pilot-testing thus far has led to substantial changes in the forms and has optimized their use in a diverse range of practice settings. Once the final versions of all forms have been completed, a study is implemented in all regions. The practitioner-investigators obtain informed consent from all study participants after they fully explained the nature of the procedures to them. To date, approved studies have to do with restorative dentistry and osteonecrosis of the jaw. Ideas for studies and a list of approved studies are updated regularly at the DPBRN Web site.

	RECRUITMENT AND RETENTION OF DENTAL PRACTICES

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We recruit dental practices in several ways. Practitioners in a region receive a mailing that describes DPBRN and invites them to participate. We also recruit practitioners at DPBRN booths at dental meetings, at DPBRN orientation sessions, via DPBRN practitioner-investigators and via the DPBRN Web site.

When practitioners enroll in DPBRN, they complete a 101-item online questionnaire that describes their characteristics and those of their practices. After the practitioners complete the questionnaire, we place them on the DPBRN mailing list, which means that they receive newsletters and other postal and e-mail communications from DPBRN. As of August 2007, 1,152 practitioners had enrolled. Practitioners who wish to participate in clinical studies are required to attend a DPBRN annual meeting, attend an orientation session or view a digital video disk version of the orientation session. As of August 2007, 306 practitioners had done so, and they received continuing education credit. Practitioners also are required to complete an online course in human participants research (253 had done this as of August 2007) and complete documents required to affiliate them with an institutional review board (as of August 2007, 194 had done this for DPBRN Study 2, which is the first study for which this was required).

DPBRN practitioner-investigators have reported to us that the orientation sessions that DPBRN academic faculty have provided are interesting, but they are more highly motivated when they see that another full-time practitioner has completed a study successfully and is the one presenting DPBRN information and experiences. Seeing other practitioners conduct successful DPBRN studies and hearing them report that it is a positive experience can be more validating than seeing these experiences being discussed by an academic faculty member or DPBRN staff member. This has led DPBRN to create a "Testimonials" page to convey these practical experiences to practitioners.²⁵ The box lists the benefits of participating in DPBRN that have been reported by DPBRN practitioner-investigators thus far.

Each region has a coordinator or coordinators who are responsible for day-to-day interaction with DPBRN practices in their region. They are the "face" of DPBRN for practitioners until the next annual meeting. The DPBRN regional coordination team meets by conference call twice each month.

Because of DPBRN’s commitment to making the network about, with and for practitioner-investigators, the style of regional coordinators’ interaction with practices has evolved toward an emphasis on relationship-building, which helps practices identify needs and problems and customize DPBRN studies to the flow of their offices. Although the main focus of DPBRN is science and quality improvement, it is also about relationship-building, which may be the most important factor in retaining active practitioner-investigators.

To begin this relationship-building process, individual regional coordinator staff members are assigned to particular practices. Typically, during the first visit to a practice, the regional coordinator meets with the practitioner-investigator to explain the DPBRN study and to complete the paperwork to affiliate the practitioner-investigator with the region’s institutional review board. At a later visit, the regional coordinator conducts a "lunch and learn" training session with the practitioner-investigator and his or her staff members.

In addition to training the staff members for a study, the regional coordinator seeks to understand how patient flow is handled in the practice and to customize how the study is explained to patients in the practice and how the data forms are to be completed. For example, some practices prefer to introduce eligible patients to the study while they are in the waiting room, while others prefer that the entire discussion take place in an operatory. Some practices prefer to keep study enrollment forms in each operatory, while others find it more feasible to keep enrollment forms in a central area. As part of the relationship-building process, regional coordinators emphasize a "customer-service" orientation and see each practice as an equal partner whose needs he or she is there to meet. Consequently, regional coordinators often remain in the practice while data collection is initiated, and they make a point of being responsive to calls from the practice. Regional coordinators continue to collaborate with and monitor the progress of each study until all data forms have been returned and validated.

	DISCUSSION

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Early challenges in the development of DPBRN were delays in study implementation owing to institutional review board requirements in certain regions and the initially slow recruitment of practitioner-investigators into the network. Now, however, we have found that dentists from an array of practice settings and geographic regions will readily contribute research ideas and participate in practice-based studies. As dentists become knowledgeable about the benefits to their practices and patients and see other dentists being successful with their PBRN participation, they become motivated to interact with fellow practitioner-investigators in DPBRN.

At some DPBRN presentations, audience members suggested that dentists who participate in PBRN research might be substantively different from dentists at large. Information from medical PBRNs, however, suggests that if practitioner performance is the focus of the research, findings from a PBRN may not be representative, but when study topics have to do with patients and disease, practitioner self-selection likely does not affect the conclusions from the research.^26,27 Results from the DPBRN enrollment questionnaire allow us to quantify how similar DPBRN practitioner-investigators participating in particular studies are to dentists nationally.²⁸

	CONCLUSIONS

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Although the nature of PBRN research presents many challenges to the organization, communication, implementation and dissemination of research and quality improvement, these challenges can be overcome and managed. PBRNs are based on the understanding that the experience, insight and practical wisdom of daily clinical practitioners and their patients are powerful means of advancing the health of the population and addressing challenges encountered in daily clinical practice. Dentistry can play an active role in these advancements, showing that knowledge transfer not only happens in the research-to-practice direction, but also in the practice-to-research direction.