Practice-based Research Network Study Research Articles

Practice-based research in dentistry: Exploring methodologies, benefits, and challenges.

Practice-Based Research Network (PBRN) studies typically assess the effectiveness of clinical interventions in settings that match real-world conditions. Dental PBRNs have the capacity to amass, identify, and analyze vast amounts of data from patient populations that include diverse racial, ethnic, socio-economic, and geographic backgrounds. These dental studies encompass a broad spectrum of healthcare aspects, including prevention, diagnosis, symptom and disease treatment, quality enhancement, and care coordination. An extensive range of research methodologies can be employed within dental PBRNs to investigate these topics, including randomized controlled trials. Dental PBRNs have evolved from primarily focusing on case observations to leveraging advanced network infrastructure and collaborating across multiple regional and national sites. In addition to producing numerous high-impact peer-reviewed publications, study results have led to improved clinical care. However, PBRNs encounter challenges, such as the sustainability of research capacity (relying heavily on ongoing support from funding agencies), diverse research cultures, and an imperative to design studies that are both feasible and relevant to everyday clinical practice. Recognizing the pivotal role of real-world evidence, it is important to have sustained investment in dental PBRN infrastructure and feasible opportunities for practitioners to participate in network activities nationwide. Practice-Based Research Network studies capitalize on an important research context within which to investigate a range of clinical topics that can employ multiple research methodologies. However, sustaining productive networks requires strategic effort, ongoing financial support, and customized organizational skills.

Treatment acceptance in adult patients with anterior open bite: A National Dental Practice-Based Research Network study

Orthodontists have many techniques to treat anterior open bites and must involve patients in making treatment decisions. This study aimed to investigate orthodontic treatment plan acceptance by United States adults with anterior open bites and to identify associations between treatment acceptance and patient demographics and dentofacial characteristics. A prospective, observational cohort study enrolled the patients of 91 orthodontic providers. A total of 345 adults were included in the sample. Provider personal and practice demographics were captured. Patient demographics, treatment goals, dentofacial characteristics, and reasons for not accepting the recommended plans were recorded. Adjusted regression models were used to identify associations between patient characteristics and the likelihood of accepting the most highly recommended plan. Approximately 78% of patients accepted the most highly recommended treatment plan. 60% of the patients who were recommended surgical plans accepted them. Patients with a history of orthodontics and a concave profile were more likely to accept the most highly recommended plan. Insurance coverage for orthognathic surgery was associated with a higher acceptance rate for surgery. Severe crowding was associated with a lower acceptance of surgery. The most common reasons for declining the recommended plan were not wanting jaw surgery and considering the treatment to be too invasive, risky, and/or costly. Patient acceptance is less common at higher levels of invasiveness of treatment. Prior orthodontic treatment, concave profile, and insurance coverage for surgery were associated with accepting treatment. Most patients accepted a surgical plan when it was the most recommended option.

Dental staff and patient attitudes about nicotine replacement therapy samples in dental care: A National Dental Practice-Based Research Network study.

Cigarette smoking negatively affects oral health. Nicotine replacement therapies (NRT; e.g. nicotine patch or lozenge) and brief interventions (e.g. Ask-Advise-Refer; AAR) can improve cessation outcomes but are underutilized. NRT sampling (NRTS) increases NRT utilization by providing patients with samples of NRT as part of routine healthcare. Ask-Advise-Refer is a brief intervention where practitioners: ask patients about tobacco use, advise those using tobacco to quit and refer to the state quit line. The objective of this qualitative study was to explore dental care practitioners' and patients' attitudes and experiences regarding tobacco cessation treatment and perceptions of two brief intervention models, assessed separately: NRTS and AAR. Twenty-four dental care practitioners and nine patients, recruited through the National Dental Practice-Based Research Network, participated in semi-structured telephone interviews. Interviews assessed experiences with tobacco use intervention and attitudes towards NRTS and AAR. Thematic analysis identified emergent themes related to feasibility and acceptability of NRTS and AAR. Practitioners varied on how they address tobacco use, from systematically to idiosyncratically. Some practitioners recommend NRT; few had prescribed it. Practitioners had favourable attitudes towards AAR and NRTS, with most believing that both interventions would be acceptable and feasible to implement. Concerns regarding AAR were time and patient resistance to discussing tobacco use. Concerns regarding NRTS were patient resistance to using NRT, side effects or medication interactions, and capacity to provide follow-up. Patients reported that oral health practitioners generally ask about tobacco use but do not provide interventions. Patients were open to discussing their tobacco use with practitioners and had favourable attitudes about NRTS. This formative work suggests that NRTS and AAR may be feasible to implement in dental care settings. Future studies are needed to assess the effectiveness and implementation potential of NRTS in dental care settings.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study.

Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders. FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar. Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability. Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Refugee and migrants' involvement in participatory spaces in a US practice-based research network study: Responding to unanticipated priorities.

Refugees and migrants face suboptimal involvement in spaces for primary healthcare decision-making. Given the rising numbers of resettled refugees and migrants in primary care settings in the United States, there is an urgent need for patient-centred outcome research in practice-based research networks (PBRNs) with diverse ethnolinguistic communities. This study explored whether researchers, clinicians and patients would achieve consensus on (1) a common set of clinical problems that were applicable across a PBRNand (2) potential clinical interventions to address those problems to inform a patient-centred outcomes research (PCOR) study in a similar research network. In this qualitative participatory health research study, patients from diverse ethnolinguistic communities and clinicians from seven practices in a US PBRN discussed preferences for PCOR responsive to patients and the clinicians who serve them in language-discordant settings. Researchers and an advisory panel that included patients and clinicians from each participating practice held regular advisory meetings to monitor progress on project milestones and solve emerging problems. Participants took part in 10 sessions using Participatory Learning in Action and the World Café methods to identify and prioritise their ideas, using questions set for them by the advisory panel. Data were analysed based on principles of qualitative thematic content analysis. Participants identified common barriers in language-discordant healthcare settings, principally patient-clinician communication barriers and suggestions to overcome these barriers. A key finding was an unanticipated consensus about the need for attention to healthcare processes rather than a clinical research priority. Negotiation with research funders enabled further analysis of potential interventions for care processes to improve communication and shared decision-making in consultations and the practice as a whole. PCOR studies should examine interventions for improving communication between patients from diverse ethnolinguistic communities and primary care staff if the sorts of harms experienced by patients experiencing language-discordant healthcare are to be reduced or prevented. Flexibility and responsiveness from funders to unanticipated findings are key structural supports for participatory health research in primary care clinical settings with this population and others who experience marginalisation and exclusion. Patients and clinicians participated in the study both in the formulation of the study question, data collection, analysis and dissemination of these results; consented to their individual participation;and reviewed early drafts of the manuscript.

Deep caries removal strategies: Findings from The National Dental Practice-Based Research Network

BackgroundThe International Caries Consensus Collaboration (ICCC) has published recommendations on carious tissue removal to treat cavitated carious lesions in a manner that preserves hard tissue and retains teeth long term. This study quantifies The National Dental Practice-Based Research Network dentists’ use of selective caries removal. MethodsThis cross-sectional questionnaire study assessed reported use of selective caries removal when treating deep caries in asymptomatic and symptomatic teeth in response to clinical case scenarios. Statistical methods included the proportion of respondents concordant with ICCC guidelines at various thresholds and logistic regression to model factors associated with concordance. ResultsA total of 500 dentists responded. The study sample was 57% male, mean (SD) age was 50.9 (12.6) years, and 60% worked in private practice settings. Higher levels of concordance for choosing selective caries removal 50% or greater of the time were found for asymptomatic (62.4%; 95% CI, 57.6 to 67.2) than for symptomatic caries (49.3%; 95% CI, 44.4 to 54.2). These differences were significantly associated with type of practice setting. ConclusionsThe National Dental Practice-Based Research Network dentists reported using selective caries removal strategies when managing deep carious lesions more often than in previous US and Japanese practice-based research network studies and from results of a systematic review and meta-analysis. Nonetheless, substantive discordance with the ICCC guidelines was seen by the authors of this study. Practical ImplicationsMore dissemination and continuing education activities, as well as implementation studies, may further encourage use of selective caries removal to soft or firm dentin when indicated.

Patient Research Interest Differences by Gender and Race/Ethnicity: A North Texas Primary Care Practice-Based Research Network (NorTex) Study.

Recruiting and increasing participation of women and racial/ethnic groups remains an ongoing struggle despite the National Institutes of Health Revitalization Act mandating the inclusion of these populations. This study examined gender and racial/ethnic differences in research interest in participating in Practice-Based Research Network studies focused on cardiovascular disease (CVD), diabetes, cancer, and mental health research. A total of 1348 participants and 18 NorTex clinics from the North Texas Primary Care Registry Project (NRP) database were included in this cross-sectional study. Participants who signed up through the registry to participate in future research projects and self-reported as non-Hispanic White, Hispanic, or non-Hispanic Black were included. Research interest in heart disease, high cholesterol, high blood pressure and heart failure were categorized as CVD; depression and anxiety were categorized as mental health; diabetes and cancer research were coded as single item dependent variables. Of registry participants, 72% were female, 34.5% were Black, and 24.4% were Hispanic. Of participants, 70% (n = 942) were interested in CVD research, the leading area of interest. Mental health research (56.3%, n = 755) was the second highest area of interest, while cancer had the least interest (38.4%, n = 515). After controlling for age, smoking, and having a diagnosis of the medical condition, gender did not predict interest in CVD, diabetes, cancer, or mental health research. However, race/ethnicity significantly predicted interest in diabetes and cancer research. Results indicate there are racial/ethnic differences in interest in specific research topics among our registry participants. This information may be helpful to develop successful recruitment strategies.

Preoperative Factors Associated with Anesthesia Failure for Patients Undergoing Nonsurgical Root Canal Therapy: A National Dental Practice-Based Research Network Study

IntroductionThe aim of this study was to identify preoperative factors associated with local anesthesia failure. MethodsThe National Dental Practice-Based Research Network (www.NationalDentalPBRN.org) data from 534 patients who received a nonsurgical root canal treatment completed in a single appointment were included in this analysis. Three methods for defining anesthesia failure were used: definition 1, patient-reported level of numbness; definition 2, provider-reported quality of anesthesia; and definition 3, provider-reported use of supplemental anesthesia. Fifty-one preoperative factors were investigated and analyzed individually against the overall failure rate for each method, and multivariate generalized estimating equation logistic models were fit with predictors chosen using stepwise model selection to evaluate factors that may interact with each other. ResultsThe overall anesthesia failure rates were 5%, 15%, and 30% for definitions 1, 2, and 3, respectively. Provider experience, diabetes, absence of sharp or aching pain, absence of smoking, and a fair expected outcome were associated with anesthesia failure (definition 1). Provider level of training, absence of a sinus tract, bite sensitivity, and stress making the pain worse were associated with anesthesia failure (definition 2). Provider level of training, pain provoked by stimulus, mandibular teeth, teeth with vital pulps, and pain interfering with daily activities were associated with the use of supplemental anesthesia (definition 3). ConclusionsWith the range of 5%–30% of anesthesia failures, a few common factors across the models assessed were elucidated. Providers with higher levels of training had significantly fewer anesthesia failures. Patient self-reported history of diabetes and preoperative pain-related interference with daily activities were associated with more anesthesia failures. Greater severity of various tooth-related pain characteristics, as a group but not individually, accounted for more anesthesia failures.

Efficacy of an adenosine triphosphate meter for evaluating caries risk in clinical dental practice

BackgroundAdenosine triphosphate bioluminescence (ATP-B) readings have been proposed as markers of caries risk. ATP readings may indicate bacteria or oral streptococci activity in microbial plaque. The authors of this study aimed to evaluate whether readings using a commercial ATP meter (CariScreen Testing Meter, Oral BioTech) are significantly different for patients with low, moderate, and high caries risk in the Caries Management by Risk Assessment Practice-Based Research Network study. MethodsTwenty practice-based research network dentists enrolled 460 patients; 271 returned for 2 or more semiannual follow-up visits over 2 years. Dentists were trained and calibrated to perform ATP-B testing and caries risk assessment (CRA) using established protocols. ATP-B readings were compared via CRA category (low, moderate, high). Generalized estimating equations were used to compare the risk of experiencing incident clinical outcomes (newly recorded decayed, missing, or restored tooth surfaces and CRA disease indicators) according to ATP-B reading at prior patient visits (≥ 1,500 versus < 1,500 relative light units). ResultsMedian ATP-B readings did not differ statistically significantly by clinician-assessed caries risk level (low, 2,323; moderate, 2,940; high, 3,217; P = .65). Adjusted for patient demographics and trial intervention assignment, higher readings were not associated with newly developed decayed, missing, or restored tooth surface (relative risk, 1.57; 95% confidence interval, 0.55 to 4.45) or disease indicators (relative risk, 1.08; 95% confidence interval, 0.85 to 1.37) at the following visit, whereas clinician-assessed caries risk level was strongly associated. ConclusionsATP-B readings poorly predicted caries risk and future clinical outcomes. CRA incorporating multiple risk, protective, and disease indicators has superior predictive performance. Practical ImplicationsThe findings of this study do not provide evidence supporting the use of ATP-B to predict caries risk.

The Use of the Patient Reported Outcomes Measurement Information System and the RAND VSQ9 to Measure the Quality of Life and Visit-Specific Satisfaction of Pregnant Patients Under Chiropractic Care Utilizing the Webster Technique.

Objective: To quantify the quality of life (QoL) and visit-specific satisfaction of pregnant women.Design: A prospective cohort within a practice-based research network (PBRN).Setting/Locations: Individual chiropractic offices.Subjects: Pregnant women (age ≥18 years) attending chiropractic care.Intervention(s): Chiropractic care (i.e., The Webster Technique, spinal adjustments, and adjunctive therapies).Main outcome measures: The RAND VSQ9 to measure visit-specific satisfaction and the Patient Reported Outcomes Measurement Information System (PROMIS®)-29 to measure QoL.Results: A convenience sample of 343 pregnant patients (average age = 30.96 years) comprised their study population. They were highly educated with 75% attaining a 2-year associate's degree or higher. The pregnant patients presented for chiropractic care with a mean week of gestation of 25.67 weeks (median = 28 weeks; range = 0–42 weeks) and parity (i.e., the number of live births) of 0.92 live births (median = 1; range = 0–6). From baseline (i.e., at study entrance with minimum first visit) and comparative (i.e., following a course of chiropractic care), the VSQ9 measurements revealed increasingly high satisfaction on the part of the subjects (i.e., the mean difference of baseline minus comparative measures = −0.7322; p < 0.005). The median number of visits (i.e., visits attended) at baseline and comparative measures was 1.00 (standard deviation [SD] = 22.69) and 3.30 (SD = 22.71), respectively. Across outcomes, QoL improved from baseline to comparative measurement after holding constant for visit number and time lapse, trimester of pregnancy, and care provider type. There was a reduction in mean T scores associated with fatigue (p < 0.05), pain interference (p < 0.05), sleep disturbance (p < 0.05), and an improvement in satisfaction with social roles (p < 0.05). A significant decrease was also found with pain interference (p < 0.05). No evidence was found that anxiety (p = 0.1404) or depression (p = 0.8785) changed.Conclusion: A PBRN study was successfully implemented among chiropractors to find pregnant patients highly satisfied and their QoL scores improving with care beyond chance.

Dentists’ decision strategies for suspicious occlusal caries lesions in a National Dental PBRN study

ObjectiveCase presentations (vignettes) were completed by dentists in the National Dental Practice-Based Research Network study “Decision Aids for the Management of Suspicious Occlusal Caries Lesions (SOCLs)”. The objective was to determine dentists’ decision strategies for SOCLs. Methods107 dentists viewed a series of 16 vignettes that represented all combinations of 4 clinical cues: color, luster, lesion roughness, and patient-level caries risk. Each vignette included a patient description and a photograph of a tooth presenting the 4 cues. Dentists were asked to decide the likelihood that a suspected lesion extended into dentin. A lens model analysis was used to examine how dentists use these cues in making their decisions. Results86% of dentists had a consistent pattern of cue use that defined their decision strategy. On average, 70% of the variance in their decisions was accounted for by their use of the 4 cues. However, there was considerable variability in the individual cues used by each dentist. The percentages of dentists who used the different cues consistently were: luster (58%), color (48%), roughness (36%), and risk (35%). 14% of dentists reliably used only color, 7% used only luster, 4% used only roughness, and 1% used only risk when making SOCL decisions. ConclusionsThe online vignette system suggests that clinical SOCL decision strategies are highly individualized and dentists do not use all cues available to them to make these decisions. Clinical significancePrior to this study, there has been little evidence about how dentists use these cues (either individually or in combination) when judging the extent of caries progression. Such knowledge would be valuable when designing interventions to help dentists maximize the likelihood of appropriate treatment decisions.

Integrative health care services utilization as a function of body mass index: A BraveNet practice-based research network study

BackgroundObesity is a significant public health issue with no consensus regarding optimal medical management. Integrative medicine (IM) may help to fill this gap. Objectives(1) To characterize the sociodemographics, psychosocial functioning, health behaviors, and current medical conditions across BMI classifications in patients seeking IM; and (2) to examine how patients’ reasons for seeking IM care, treatment goals, services sought, and services provided differ based on BMI. MethodsSurvey data were collected from patients seeking care at nine BraveNet IM centers. Sociodemographics, psychosocial health, lifestyle behaviors, and reasons for seeking specific IM services were compared across BMI categories using Chi-square test, Fisher's exact test, or one-way analysis of variance. Logistical regression was used to compare reasons for seeking IM care, treatment goals, and services sought and provided across BMI categories. Results2015 patients were included in this study; 300 (14.9%) were obese and 580 (28.8%) were overweight. Obese patients were more likely to be non-White, unmarried, and uninsured, and have lower education, lower income, and at least one chronic disease (p<0.05). They also had the lowest rates of aerobic activity (67.4% exercise<3×/week, p<0.01), and greater depression (CESD-10 score 10.1±6.6, p<0.01), stress (PSS score 6.3±3.5, p<0.01), fatigue (avg 5.5±2.4 on scale 1–10, p<0.01), and pain (avg 3.6±2.5 on scale 1–10, p<0.01). Obese patients were more likely to seek manipulative/body-based services (OR=1.46, 95% CI=1.10–1.93, p<0.05) and to seek and receive energy therapies (seek: OR=1.49, 95% CI=1.07–2.07; receive: OR=2.56, 95% CI=1.28–5.10), but less likely to seek IM care for greater compatibility with their beliefs and culture (OR=0.72, 95% CI=0.53–0.97). There were no significant differences between BMI categories for IM treatment goals. ConclusionObese adults seeking IM care may represent a unique patient population with potential unmet health needs. IM may provide approaches to more effectively address the multifaceted complexities of obesity.

Validity of Preoperative Clinical Findings to Identify Dental Pulp Status: A National Dental Practice-Based Research Network Study

IntroductionEndodontic diagnostic tests are often used clinically to assess pulp status as a basis for the diagnosis and determination of whether root canal treatment (RCT) is indicated. Response to cold and pain on percussion are 2 common tests, yet their validity in identifying nonvital pulp in regular dental practice has not been reported. MethodsWe assessed the validity of cold and percussion tests to identify nonvital pulp in teeth requiring RCT in a dental practice setting performed by 46 general dentists and 16 endodontists in the National Dental Practice-Based Research Network. The influence of patient-, tooth-, and dentist-related characteristics was investigated. Observed bleeding from the pulp chamber was the clinical reference. Sensitivity (SN), specificity (SP), overall test accuracy (TA), positive (PPV) and negative (NPV) predictive values, and likelihood and diagnostic odds ratios (LR+, LR−, dORs) were calculated for each single test and the combined cold and percussion tests. ResultsSeven hundred eight patient teeth were included. Cold test showed high validity to identify a nonvital pulp status (SN = 89%, SP = 80%, TA = 84%, PPV = 81%, NPV = 88%, LR+ = 4.35, LR− = 0.14, dOR = 31.4), whereas pain on percussion had lower validity (SN = 72%, SP = 41%, TA = 56%, PPV = 54%, NPV = 60%, LR+ = 1.22, LR− = 0.69, dOR = 1.78). Combining the 2 tests did not increase validity, whereas preoperative pain, medication intake, patient age and sex, and dentist training level affected test validity significantly. ConclusionsIn regular dental practice, the cold test exhibits higher validity to discriminate between vital and nonvital pulp than the tooth percussion test.

Six Protocols, Neuroscience, and Near Death: An Emerging Paradigm Incorporating Nonlocal Consciousness

Integrative medicine (IM) is a rapidly growing field whose providers report clinical success in treating significant stress, chronic pain, and depressive and anxiety symptoms. While IM therapies have demonstrated efficacy for numerous medical conditions, IM for psychological symptoms has been slower to gain recognition in the medical community.This large, cross-sectional study is the first of its kind to document the psychosocial profiles of 4182 patients at 9 IM clinics that form the BraveNet Practice-Based Research Network (PBRN).IM patients reported higher levels of perceived stress, pain, and depressive symptoms, and lower levels of quality of life compared with national norms. Per provider reports, 60% of patients had at least one of the following: stress (9.3%), fatigue (10.2%), anxiety (7.7%), depression (7.2%), and/or sleep disorders (4.8%). Pain, having both physiological and psychological components, was also included and is the most common condition treated at IM clinics. Those with high stress, psychological conditions, and pain were most frequently treated with acupuncture, IM physician consultation, exercise, chiropractic services, diet/nutrition counseling, and massage.With baseline information on clinical presentation and service utilization, future PBRN studies can examine promising interventions delivered at the clinic to treat stress and psychological conditions.

Integrative Medicine Patients Have High Stress, Pain, and Psychological Symptoms

Integrative medicine (IM) is a rapidly growing field whose providers report clinical success in treating significant stress, chronic pain, and depressive and anxiety symptoms. While IM therapies have demonstrated efficacy for numerous medical conditions, IM for psychological symptoms has been slower to gain recognition in the medical community. This large, cross-sectional study is the first of its kind to document the psychosocial profiles of 4182 patients at 9 IM clinics that form the BraveNet Practice-Based Research Network (PBRN). IM patients reported higher levels of perceived stress, pain, and depressive symptoms, and lower levels of quality of life compared with national norms. Per provider reports, 60% of patients had at least one of the following: stress (9.3%), fatigue (10.2%), anxiety (7.7%), depression (7.2%), and/or sleep disorders (4.8%). Pain, having both physiological and psychological components, was also included and is the most common condition treated at IM clinics. Those with high stress, psychological conditions, and pain were most frequently treated with acupuncture, IM physician consultation, exercise, chiropractic services, diet/nutrition counseling, and massage. With baseline information on clinical presentation and service utilization, future PBRN studies can examine promising interventions delivered at the clinic to treat stress and psychological conditions.

A Fond Farewell

Integrative medicine (IM) is a rapidly growing field whose providers report clinical success in treating significant stress, chronic pain, and depressive and anxiety symptoms. While IM therapies have demonstrated efficacy for numerous medical conditions, IM for psychological symptoms has been slower to gain recognition in the medical community.This large, cross-sectional study is the first of its kind to document the psychosocial profiles of 4182 patients at 9 IM clinics that form the BraveNet Practice-Based Research Network (PBRN).IM patients reported higher levels of perceived stress, pain, and depressive symptoms, and lower levels of quality of life compared with national norms. Per provider reports, 60% of patients had at least one of the following: stress (9.3%), fatigue (10.2%), anxiety (7.7%), depression (7.2%), and/or sleep disorders (4.8%). Pain, having both physiological and psychological components, was also included and is the most common condition treated at IM clinics. Those with high stress, psychological conditions, and pain were most frequently treated with acupuncture, IM physician consultation, exercise, chiropractic services, diet/nutrition counseling, and massage.With baseline information on clinical presentation and service utilization, future PBRN studies can examine promising interventions delivered at the clinic to treat stress and psychological conditions.

Preventing the Voltage Drop: Keeping Practice-based Research Network (PBRN) Practices Engaged in Studies

Practice-based research continues to evolve and has become a major methodology for many pragmatic studies. While early practice-based network projects were usually short term, current studies often introduce or compare practice innovations that require long-term evaluation. That change requires that practice sites remain engaged in research work for up to 5 years, a time that can allow for a significant "voltage drop," or decline in active participation. Over the past 15 years we have developed and adapted several strategies to facilitate and encourage the continued active engagement of practices in practice-based research network studies of up to 5 years' duration. The concepts, details, evaluation, and results (when available) of the strategies are described. Eight strategies that enhance practice sites' attention to enrollment, data collection and continued use of the implemented practice change are described. The loss of momentum, or "voltage drop," that happens in longer-term practice-based research network studies can be addressed using multiple strategies.

Using Electronic Dental Record Data for Research

Anecdotal evidence suggests that, during the clinical care process, many dental practices record some data that are also collected in dental practice based research network (PBRN) studies. Since the use of existing, electronically stored data for research has multiple benefits, we investigated the overlap between research data fields used in dental PBRN studies and clinical data fields typically found in general dental records. We mapped 734 unique data elements from the Dental Information Model (DIM) to 2,487 Common Data Elements (CDE) curated by the NIDCR’s PBRNs in the Cancer Data Standards Registry and Repository (caDSR). Thirty-three percent of the DIM data elements matched at least one CDE completely and 9% partially, translating to about 9% and 2%, respectively, of all data elements used in PBRN studies. The most frequently used CDEs found in the DIM included data about dental anatomy, medications, and items such as oral biopsy and caries. Our study shows that a non-trivial number of data elements in general dental records can be mapped either completely or partially to data fields in research studies. Further studies should investigate the feasibility of electronic clinical data for research purposes.

Institutional Review Board Barriers and Solutions Encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now Study: A National Multicenter Practice-Based Implementation Trial

To categorize institutional review board (IRB) challenges and solutions encountered in a multicenter practice-based research network (PBRN) study and to assess the impact of IRB requirements on the willingness of individual principal investigators (PIs) to participate in future PBRN studies. Descriptive analysis of IRB challenges and solutions encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now (CAPTION) trial, a multicenter prospective cluster-randomized study conducted by the National Interdisciplinary Primary Care PBRN, and a correlational analysis from a survey of individual site PIs. IRB barriers encountered and solutions were categorized for study sites. A survey of study-site PIs was conducted with a correlational analysis assessing the impact of various IRB requirements and the willingness of individual PIs to participate in future PBRN studies; of 31 study sites participating in the CAPTION study, 28 study-site PIs were surveyed. IRBs posed a number of challenges including bias regarding the source of the application, issues regarding study design, study instruments, access to patient records, study procedures, Spanish-only speaking subjects, role of clinic physicians, interdepartmental concerns, and updates at continuing review. Responses from the PI survey (21 of 28 PIs surveyed [75% response rate]) indicated that the willingness of an individual to serve as a PI in the future was inversely related to the perceived difficulty of obtaining initial (rS =-0.599, p=0.004) and continuing (rS =-0.464, p=0.034) IRB approval. Significant time and resources were required to address various challenges associated with IRB approval, which had a negative impact on an individual PI's willingness to participate in future PBRN projects. A revision of current rules and regulations regarding the protection of human subjects for practice-based studies, improvement in IRB processes, and support from coordinating centers may decrease the burden associated with IRB approval and increase participation in practice-based research.

Practice based research networks impacting periodontal care: PEARL Initiative.

In 2005, the National Institute of Dental and Craniofacial Research /National Institutes of Health funded the largest initiative to date to affect change in the delivery of oral care. This commentary provides the background for the first study related to periodontics in a Practice Based Research Network (PBRN). It was conducted in the Practitioners Engaged in Applied Research & Learning (PEARL) Network. The PEARL Network is headquartered at New York University College of Dentistry. The basic tenet of the PBRN initiative is to engage clinicians to participate in clinical studies, where they will be more likely to accept the results and to incorporate the findings into their practices. This process may reduce the translational gap that exists between new findings and the time it takes for them to be incorporated into clinical practice. The cornerstone of the PBRN studies is to conduct comparative effectiveness research studies to disseminate findings to the profession and improve care. This is particularly important because the majority of dentists practice independently. Having practitioners generate clinical data allows them to contribute in the process of knowledge development and incorporate the results in their practice to assist in closing the translational gap. With the advent of electronic health systems on the horizon, dentistry may be brought into the mainstream health care paradigm and the PBRN concept can serve as the skeletal framework for advancing the profession provided there is consensus on the terminology used.