PARTNERING TO ADVANCE EVIDENCE-BASED CARE

THE RECENTLY ESTABLISHED COCHRANE ORAL HEALTH COLLABORATING CENTER AT PENN DENTAL MEDICINE PLACES THE SCHOOL AT THE FOREFRONT OF THE ORAL-HEALTH-EVIDENCE-SYNTHESIS FIELD GLOBALLY

EARLIER THIS YEAR, Penn Dental Medicine’s Center for Integrative Global Oral Health (CIGOH) partnered with Cochrane Oral Health to form the Cochrane Oral Health Collaborating Center at Penn Dental Medicine.. The new Center marks a significant step in helping to expand evidence-based knowledge to inform practice and oral health policy worldwide.

Cochrane Oral Health, headquartered at The University of Manchester in the UK, is one of over 50 review groups within Cochrane, a global independent not-for-profit network that produces systematic reviews across all areas of medicine. Since its inception, Cochrane has defined the methodological standards for conducting systematic reviews around the world and is recognized as representing an international gold standard for high quality, trusted information and methods.

“We are thrilled to be joining with Cochrane Oral Health and our colleagues at The University of Manchester to help move oral healthcare practice and policy forward through this new Center,” says Dr. Michael Glick, the Executive Director of CIGOH, the School’s first policy center, where the Collaborating Center is based.

The Collaborating Center at Penn Dental Medicine will build upon the work of Cochrane Oral Health, engaging researchers from around the globe in systematic reviews summarizing the best available evidence on oral health topics to help patients, caregivers, clinicians, and policymakers, make well-informed decisions. Currently, Cochrane Oral Health has a curated collection of more than 200 systematic reviews and meta-analyses of over 34 clinical areas of dentistry.

Leading the new Collaborating Center as Director is Dr. Alonso Carrasco-Labra, who joined Penn Dental Medicine in November of 2021 and brings a depth of experience in health research and evidence-synthesis methods to this role. Prior to coming to Penn Dental Medicine, Carrasco-Labra was Senior Director of the Department of Evidence Synthesis and Translation Research at the American Dental Association Science and Research Institute. He has also worked with governments and healthcare agencies around the world, facilitating guideline and policy creation for the Pan-American Health Organization/World Health Organization, the World Bank, the U.S. Food and Drug Administration (FDA), and the American Gastroenterological Association. Along with a D.D.S. from the University of Chile, he holds a master’s degree in clinical epidemiology and a Ph.D. from McMaster University in health research methodology.

Soon after the establishment of the Cochrane Oral Health Collaborating Center at Penn Dental Medicine, we sat down with Carrasco-Labra for a conversation on the goals and vision for the Center moving forward.

HOW DID THE COLLABORATION WITH COCHRANE ORAL HEALTH EVOLVE?

The COVID-19 pandemic made the need to base healthcare decisions on scientific evidence very clear to many stakeholders — not only scientists, but also the public in general. So, the timing is right; there is growing interest on a global level for summaries of the best available scientific evidence to answer policy and clinical questions. The organization that has been providing this type of information for a very long time is Cochrane, and more specifically as it relates to dentistry, the Cochrane Oral Health Group. The rising demand for systematic reviews combined with our goals for CIGOH and the long-term relationship I’ve had with Cochrane led to formalizing our work with them through this partnership. Now, we will be collaborating directly with our colleagues at the University of Manchester, where Cochrane Oral Health is based, on these reviews.

WHY DO YOU SEE THIS AS AN IMPORTANT PARTNERSHIP?

There is a large need for this type of evidence to inform guidelines and policies for clinical practice. We can do so much with Cochrane’s available resources, and this is a way for us at Penn Dental Medicine to continue leading this field.

WHAT IS THE PRIMARY FOCUS OF THE CENTER?

The primary focus of the Center is to help patients and clinicians make decisions related to health outcomes using pre-appraised, trustworthy evidence. That means we need to produce reports that are easy to read, high quality, and trustworthy — free from financial and intellectual conflict of interest that can provide an objective perspective on what is available to inform a decision.

A secondary goal of the Center is capacity building and the training of future researchers and clinicians who are interested in producing these types of documents with the standards that Cochrane has established. Cochrane is distinguished for the rigor of its reviews — it is among the best in the world. It is a commitment to high quality methods, including transparency and engagement with patients and other consumers. They read the reports and help us to clarify and simplify certain language that at times is too technical and creates barriers to accessibility. We want anyone who wants to know about a particular issue to read a document that is accessible and that is why those partnerships are so important.

Cochrane has worked extensively to create consumer/patient networks and platforms to request input from members of the public. It is a well-organized group within Cochrane, and we will be able to tap into that resource for the reviews we manage.

HOW DO YOU SEE SYSTEMATIC REVIEWS OF THIS SORT IMPACTING ORAL HEALTHCARE DELIVERY AND POLICY?

We calculated that between the moment a new intervention is developed to the point that it becomes mainstream and available to patients can be between 15 to17 years. That is a very long time and some people who could benefit from that intervention won’t simply because clinicians, policymakers, and the health system need to deal with issues of summarizing the evidence – who makes the case that a new intervention creates more good than harm? That is where these types of reviews can play a key role in helping to accelerate the process of translating research findings into practice and improved outcomes.

We recently published a systematic review (non-Cochrane) on acute dental pain that suggests clinicians would need to find and read more than 86 studies before they could reach a full conclusion on what to do. With a systematic review, investigators look at every one of those studies very closely, summarize the findings, and put it in a simple format that is high quality and trustworthy. Systematic reviews simplify the clinician’s life — she just needs to read that one document, not the 86 published studies.

HOW DO YOU SEE OUR CENTER FILLING ANY VOID IN THIS AREA?

Currently, there is an underutilization of systematic reviews for high-level decision-making. One specific goal for our Center is to be able to connect these reviews with policymakers and other stakeholders. We would bring the data, and we will partner to produce policies and clinical practice guidelines. Then, when the policy or guideline needs to be updated as new evidence emerges, we take that burden from the policymakers, collecting and updating the data to inform those policy or guideline documents. Currently, that partnership is still suboptimal and needs to be improved to truly make policies and guidelines evidence based, which is the ultimate goal.

HOW WILL THE ORAL HEALTH TOPICS STUDIED AT OUR CENTER BE DETERMINED?

In 2020, Cochrane Oral Health’s team in Manchester ran its most recent prioritization exercise to set the agenda of review topics for 2021-2024. They look at current reviews and emerging topics and did extensive stakeholder engagement asking for input on the topics that are priorities. It is a very participatory process, and they solicit a global perspective. So the Cochrane Oral Health agenda of topics is set through 2024, but which of those our Center will conduct de novo or will be an update of a previous review is not yet determined.

HOW LONG DOES A SYSTEMATIC REVIEW TAKE TO PRODUCE?

Depending on the number of primary studies, a novel review involves a one- to two-year process with a multidisciplinary group of statisticians, methodologists, clinical experts, and consumers. When it is an update of an existing review, the process is shorter.

ARE GUIDELINES AND CLINICAL RECOMMENDATIONS ALWAYS PRODUCED WITH A REVIEW?

No. A systematic review informing the effects of healthcare interventions (i.e., balance between benefits and harms) and the certainty of the evidence is one piece when producing a clinical practice guideline.

NEW MASTER’S IN ORAL, POPULATION HEALTH

In a related initiative, Penn Dental Medicine has launched a new master’s program — a Master of Science in Oral & Population Health (MOPH). “The program is developed to answer a critical need for public and population health leaders who can inform, develop, implement, and evaluate policies that address current and future challenges in oral health,” says Dr. Alonso Carrasco-Labra, Director of the program.

A full-time online program (synchronous and asynchronous), the MOPH covers a diversity of disciplines in creating, synthesizing, and disseminating evidence to inform clinical practice and policies at all levels of the healthcare system and the research enterprise. Through elective courses, students can develop a curriculum of their preference in one of three streams — oral and population health research; health services research, management, and policy in oral health; and starting in the fall of 2024, community and population-based oral health promotion.

The first cohort of students will begin the program starting September 2023. Learn more at www.dental.upenn.edu/MOPH.

There are other important factors involved as well — patients’ values and preferences, issues of equity, issues of feasibility, issues of stakeholder acceptability, and implementation considerations — that are not addressed in systematic reviews of interventions. For example, a panel may say based on this Cochrane review everyone should get some intervention, but the health system may say wait a minute, we don’t have people trained, we don’t have the resources, this is not covered by insurance, so the body producing the guideline needs to also address those aspects. That is why we say systematic reviews should not provide clinical recommendations, yet systematic reviews are the cornerstone to inform clinical practice guidelines.

WHO WILL BE INVOLVED IN CONDUCTING THE REVIEWS?

We will be gathering investigators from all over the world to produce these reviews.

Currently, Cochrane Oral Health has over 1,600 members and over 900 review authors from more than 40 different countries. Then, our Center works primarily as a coordinating group — coordinating investigators’ access to the available resources, from statisticians to the primary studies. We also make sure that throughout the process methodological standards that are necessary to secure trustworthy results are being met at every stage.

HOW CAN THE REVIEWS PRODUCED BY OUR CENTER BE ACCESSED?

All reviews produced through our Center will become part of the Cochrane Library (www.cochranelibrary.com). The library has a very intuitive search engine where anyone can access the abstracts and plain language summaries of the reviews.

WHAT ARE SOME OTHER INITIATIVES OF THE CENTER?

Training investigators and clinicians in the systematic review process is also part of our mission. We will be presenting in-person conferences and developing online resources. Our first conference it set for June 5-9 on how to conduct and publish systematic reviews and meta-analyses. Colleagues from Cochrane Oral Health at the University of Manchester UK will be presenting along with faculty from the Center for Integrative Global Oral Health at Penn Dental Medicine. I encourage alumni to join us as we begin our work to help advance evidence-based care. n

OPPOSITE: Olivia Urquhart joined CIGOH in September 2022, coming to Penn Dental Medicine from the Department of Evidence Synthesis and Translation Research at the American Dental Association’s Science & Research Institute where she was a lead data analyst and a clinical practice guideline methodologist.