Making clinical decisions for dental care: concepts to consider

Clinical decisions are often made with incomplete information, yet patient care decisions are made every day. Patients vary clinically, uncertainty exists in diagnostic and prognostic information, and many preventive and treatment alternatives have not been formally assessed for their effectiveness. Because scientific information will never answer all clinical questions, clinical decisions are partially based on probabilistic information.
This paper describes how to apply clinical decision making to diagnosing and managing dental caries and periodontal diseases. By using explicit information to quantify probabilities and outcomes, clinical decision making analyzes decisions made under uncertain conditions and the uncertain impact of clinical information.
Clinical decision making incorporates concepts for preventing, diagnosing and treating dental caries and periodontal diseases: risk assessment, evidence-based dentistry, and multiple oral health outcomes. This information can serve as a tool for clinicians to augment clinical judgment and expertise.     

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

Objectives

To examine the effect of an emergency department (ED )‐based transitional care nurse (TCN ) on hospital use.

Design

Prospective observational cohort.

Setting

Three U.S. (NY , IL , NJ ) ED s from January 1, 2013, to June 30, 2015.

Participants

Individuals aged 65 and older in the ED (N = 57,287).

Intervention

The intervention was first TCN contact. Controls never saw a TCN during the study period.

Measurements

We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30‐day admission (any admission on Days 0–30) and 72‐hour ED revisits.

Results

A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: ?9.9% risk of inpatient admission, 95% confidence interval (CI ) = ?12.3% to ?7.5%; site 2: ?16.5%, 95% CI = ?18.7% to ?14.2%; site 3: ?4.7%, 95% CI = ?7.5% to ?2.0%). Participants with TCN contact had greater risk of a 72‐hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7–2.3%; site 2: 1.4%, 95% CI = 0.7–2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: ?7.8%, 95% CI = ?10.3% to ?5.3%; site 2: ?13.8%, 95% CI = ?16.1% to ?11.6%).

Conclusion

Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.

     

Low positive predictive value of the oral brush biopsy in detecting dysplastic oral lesions

BACKGROUND:

The authors evaluated the effectiveness of the oral brush biopsy technique as a diagnostic tool in detecting dysplastic oral lesions.

METHODS:

In this cross‐sectional study, pathologic reports (n = 152) from the scalpel biopsies (tissue samples) in patients who previously tested either “positive” (n = 3) or “atypical” (n = 149) for dysplasia by brush biopsy (OralCDx) were evaluated. Information on the age and sex of the patient, the site of the lesion, the brush biopsy results, and the histopathologic diagnosis of the scalpel biopsy was collected. The positive predictive values (PPVs) for “abnormal,” “atypical,” and “positive” brush biopsies were determined.

RESULTS:

Overall, the PPV of an abnormal brush biopsy was only 7.9% (95% confidence interval [CI], 4.2%‐13.4%), and the PPV of an “atypical” brush biopsy was 7.4% (95% CI, 3.7%‐12.8%). Of the 3 positive brush biopsies, only 1 was identified as dysplastic. The proportion of false‐positive biopsy results was as high as 92.1% (95% CI, 86.6%‐95.9%).

CONCLUSIONS:

The OralCDx technique overestimated dysplastic lesions and produced a high number of false‐positive results. Cancer 2009. © 2009 American Cancer Society.