J Dent Educ. 72(11): 1333-1342 2008
© 2008 American Dental Education Association
Evidence-Based Practice Among a Group of Malaysian Dental Practitioners
Zamros Y.M. Yusof, B.D.S., M.Sc., D.D.P.H.R.C.S.;
Lee Jin Han, B.D.S.;
Poon Pei San, B.D.S.;
Anis S. Ramli, M.R.C.G.P.
Key words: evidence-based practice (EBP), dentists, Malaysia
Submitted for publication 03/11/08;
accepted 08/01/08
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Abstract
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The objective of this study was to assess dentists’ knowledge and use of evidence-based practice (EBP), including their attitudes toward and perceptions of barriers that limit the use of EBP. A cross-sectional survey was used with self-administered questionnaires involving dental practitioners in the state of Selangor, Malaysia. One hundred ninety-three replies were returned, for a response rate of 50.3 percent. More than two-thirds (135/193, 69.9 percent) of the respondents had heard of EBP. Out of the 135 respondents who had heard of EBP, a majority agreed it was a decision-making process based on evidence (127/135, 94.2 percent) and involved a series of steps from formulating the research question, locating and assessing the evidence, to applying it if suitable (129/135, 95.6 percent). Out of the 135 respondents who had heard of EBP, a high percentage agreed that EBP improved their knowledge and skills (132/135, 97.8 percent) and treatment quality (132/135, 97.8 percent). For advice, a majority of the 135 respondents frequently consulted friends and colleagues (123/135, 91.1 percent), made referrals (120/135, 88.9 percent), consulted textbooks (112/135, 83.0 percent), and referred to electronic databases (90/135, 66.7 percent). Out of the 135 respondents, many perceived EBP as very important (59/135, 43.7 percent) and important (58/135, 43.0 percent) and were interested to learn further information about EBP (132/135, 97.8 percent). The main reported barriers were lack of time (87/135, 64.4 percent), financial constraints (54/135, 40.0 percent), and lack of knowledge (38/135, 28.1 percent). A majority of the 135 respondents had knowledge of and positive attitudes towards EBP. However, due to barriers, a majority of them preferred colleagues, textbooks, and referrals for advice instead of seeking evidence from electronic databases.
Evidence-based practice (EBP) is a widely accepted term in the medical fields around the world. It can be defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."1 In dentistry, EBP can be defined as "the practice of dentistry that integrates the best available evidence with clinical experience and patient preferences in making clinical decisions."2 In other words, EBP is an approach to decision making in which the clinician uses the best evidence available, in the context of his or her own experience and in consultation with the patient, to decide upon the treatment that suits that patient the best.3
Dentistry can benefit from EBP in several ways. First and foremost, it is a means of lifelong learning in which dentists who based their decisions on evidence rather than opinions have been shown to be able to continuously monitor and develop their clinical skills and performance.4–7 By basing treatment decisions on the best evidence for clinical outcomes and cost-effectiveness, dentists can improve the quality and outcomes of treatment provided to patients after taking into account their values and preferences.7–9 As for the patients, knowing that they will be cared for in a consistent evidence-based approach empowers them to be more accountable for their health and helps build their confidence in dental services.10
The process of EBP consists of five steps as outlined in Figure 1
. The first step involves identifying and converting a clinical problem into an answerable question. The information sought needs to be relevant to the patient’s problem and needs to point towards an accurate answer.11 For example, important questions may arise from daily encounters with the patients in a practice setting or are related to therapy, diagnosis, prognosis, or causation.12
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Figure 1. Overview of the stages in evidence-based practice (EBP)
Source: adapted from Needleman I. Introduction to evidence-based dentistry. In: Clarkson J, Harrison JE, Ismail AI, Needleman I, Worthington H, eds. Evidence-based dentistry: for effective practice. London: Martin Dunitz, 2003:1–17.
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When a particular clinical question has been decided upon, the next step involves searching through suitable databases for relevant evidence. There are several ways to do this. The most up-to-date evidence-based information can be best sought from electronic databases in which clinicians can select relevant articles on the subject.13 In general, there are two types of electronic databases. The first one is bibliographic, which contains primary research, e.g., Medline and Embase. The second type consists of databases whose application takes the user directly to primary or secondary research publications or relevant clinical evidence, e.g., the Cochrane Database of Systematic Reviews.14 Primary research involves the collection of data that does not already exist, and secondary research refers to studies on existing data such as from clinical records, mortality statistics, and household surveys.15
Once the relevant articles have been gathered, the third step involves appraising the evidence to ascertain its quality, strength, and validity and to determine if it suffers from biases in the conduct of the study or inappropriate methods used to investigate the problem.16 A study that produces strong evidence (and hence is least biased) is the one that utilizes a rigorous research design. For example, evidence is strongest when it comes from systematic reviews of randomized controlled trials (RCTs). These trials represent the gold standard or best levels of evidence, compared to other study designs. However, not all forms of evidence are created equally; therefore, dentists must be able to use their own judgment and evaluate the evidence available when arriving at a specific clinical decision.17 As a guide, Jaeschke et al. developed a hierarchy of evidence, which grades the evidence according to its strength (Figure 2).18
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Figure 2. The hierarchy of evidence: as research design becomes more rigorous, the quality of evidence increases and the chance for bias decreases
Source: adapted from
Jaeschke R, Schünemann HJ, Devereaux PJ, Guyatt GH. Evidence-based health care. J Evid Based Dent Pract 2004;4(1):4–7
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Once suitable evidence has been identified, the next step is to apply the information to clinical practice. Apart from acting on it, the clinician can also discard, keep, and disseminate the information. However, storing the information for too long is not recommended, as new evidence is always emerging. Ideally, evidence should be updated regularly to stay abreast of new developments.
Evaluating the clinical outcome and performance is the final step in EBP. This step involves the clinician evaluating the performance of the technique, procedure, and material chosen. Clinicians should also take this step as an opportunity for self-appraisal and to reflect upon the applicability of the evidence to their settings and patients.
A cross-sectional survey was conducted in the United Kingdom looking at the acceptance of EBP among general dental practitioners, and the results were encouraging.5 The dentists were reported to be enthusiastic and expressed their willingness and desire to implement the concept in daily clinical practice. Many were interested to find out more information about EBP. However, no study of dental practitioner perceptions of EBP has been conducted in Malaysia. Although EBP has been accepted in Western countries, there is no evidence to indicate its acceptance among practitioners in Malaysia. Therefore, the objectives of this study were to appraise Malaysian dentists’ knowledge of evidence-based practice, determine the extent of EBP, and assess practitioners’ attitudes and barriers to EBP using a self-report survey as the data collection method.
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Methods and Materials
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A cross-sectional survey, involving all dentists in the Malaysian state of Selangor, was conducted using a self-administered questionnaire. This state, which houses the Malaysian capital city, Kuala Lumpur, was chosen because it has both the highest population rate in Malaysia and the highest number of dentists per state with a dentist to population ratio of 1:9,490.19
The survey was constructed based on thorough reviews of the dental literature, with the aim of gathering information from the practitioners on their overall knowledge about EBP and their attitudes and perceived barriers towards it. The survey was prepared and administered in English with closed-ended responses. Content validation of the survey was conducted by three dental public health academicians prior to pretesting. Pretesting was then conducted with three practitioners before finalizing the questionnaire. There were 387 dental practitioners actively working in Selangor in 2007,19 and excluding the three dentists who were involved in pretesting, a total of 384 dentists were included in the study sample.
Personal communications with other researchers have suggested it is typical to receive a rather poor response rate from postal questionnaires involving dentists. To overcome this, a strategy aimed at improving the response rate was developed by distributing the questionnaires in two stages. First, data were collected from Selangor dentists attending a local conference. Then, the remaining target group were sent postal questionnaires including a self-addressed envelope and a stamp. Nonrespondents were reminded a week later by telephone calls to complete and return the questionnaires. Data were analyzed using SPSS software version 12.0.
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Results
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Altogether, data were available for 193 respondents, representing 50.3 percent of the total dental practitioners in Selangor. Forty-one responses came from Selangor dentists who attended a conference, and the remaining 152 came from postal questionnaires. There were 101 males (52.3 percent) and 92 females (47.7 percent). More than half of the respondents were Chinese (53.9 percent), followed by Indians (22.8 percent), Malays (18.7 percent), and other ethnic groups (4.1 percent). In terms of working experience, more than one-third (36.8 percent) of the respondents had working experience for at least twenty years or more, followed by those who had working experience between ten and fourteen years (24.4 percent), between five and nine years (18.1 percent), and between fifteen and nineteen years (15.0 percent) (Table 1). In terms of place of graduation, 114 (59.1 percent) respondents graduated from a local university, while the remaining seventy-eight (40.4 percent) graduated from other countries, such as India, Singapore, Australia, United Kingdom, Indonesia, Taiwan, and New Zealand.
The first section of the questionnaire was designed to gather information on the knowledge of EBP among the dental practitioners. When the dentists were asked about EBP, more than two-thirds of the respondents (135/193, 69.9 percent) reported to have heard of EBP prior to the study. There were no significant differences between the awareness level and gender, race, number of years in practice, and place of graduation (Table 1
). Out of these (n=135), more than half were male (56.3 percent) and of Chinese origin (59.0 percent); more than one-fifth (24.9 percent) had working experience between ten and fourteen years; and more than three-fifths (61.2 percent) graduated from University Malaya (Table 1). In terms of those who were aware of EBP, the percentage of male dentists (39.4 percent) was slightly higher than the female dentists (30.6 percent); about two-fifths (40.9 percent) were of Chinese origin and were graduates of University Malaya (42.5 percent); and more than one-fifth (22.8 percent) had working experience for at least twenty years or more.
Of the respondents who had heard of EBP (n=135), a majority rightly agreed that EBP is a process of making decisions based on scientifically proven evidence (127/135, 94.2 percent) and involves a series of steps from identifying the clinical question, finding the answer or evidence, assessing the validity of the evidence, and applying it if clinically suitable (129/135, 95.6 percent). Also, a majority rightly agreed that EBP benefits patients by improving the quality and effectiveness of clinical treatments (132/135, 97.8 percent) and allows dentists to improve their scientific knowledge and clinical skills (132/135, 97.8 percent). On the other hand, 43.7 percent (59/134) of the respondents had the wrong impression that evidence from all published articles in scientific journals could be used in EBP. More than two-fifths (57/134, 42.2 percent) of the respondents thought the best and quickest way to find evidence was by reading textbooks or asking experienced colleagues (Table 2).
When the respondents who had heard of EBP (n=135) were asked about their perceived understanding of the terms commonly associated with EBP, a majority of them reported they understood the terms "EBP" (108/135, 80.0 percent), "clinical effectiveness" (109/135, 80.7 percent), and "systematic reviews" (96/135, 71.1 percent). Only about three-fifths of them (83/134, 61.5 percent) understood the term "critical appraisal." Less than half of them (67/133, 49.6 percent) knew the term "clinical governance." Only 23.0 percent felt they knew the term "Cochrane Collaboration," while 58.5 percent (79/132) had never heard of it before (Figure 3).
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Figure 3. Percentages of the respondents according whether they "understand," "know little of," or are "unaware of" EBP terms (N=135)
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When the respondents who had heard of EBP (n=135) were asked to evaluate the extent of their evidence-based practice, it was found that consulting electronic databases as a source of information was ranked as the fourth most frequent evidence-searching option (90/135, 66.7 percent). The dentists reported that their most frequent source of information, when faced with clinical uncertainties, was consulting friends and colleagues (123/135, 91.1 percent), followed by making referrals (120/135, 88.9 percent) and reading textbooks (112/135, 83.0 percent). Almost half (61/135, 45.2 percent) of them indicated that they would continue treatment, without an evidence search, based on their own judgment and experience (Table 3). When they were asked about their reading routine, it was found that most of the respondents (n=135) read scientific articles at varying frequencies in order to improve their knowledge. Forty-seven percent (64/135) of the respondents admitted to reading scientific articles occasionally, 31.0 percent (42/135) at least once a month, 20.0 percent (27/135) at least once a week, and a few respondents (3/135, 2.0 percent) admitted they never do at all. In terms of their perceived skills in understanding scientific articles, the respondents perceived their skills to be very good (18/135, 13.3 percent), good (74/135, 54.8 percent), average (42/135, 31.1 percent), and poor (1/135, 0.7 percent).
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Table 3. The frequency distribution of respondents by frequent source of information when faced with clinical uncertainties (N=135)
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The dental practitioners were also assessed in terms of their attitudes towards and perceptions of EBP. It was found that the majority of the respondents who had heard of EBP perceived it as very important (59/135, 43.7 percent), important (58/135, 43.0 percent), and necessary (15/135, 11.1 percent) to their dental careers. A majority of them also desired to learn more about EBP (131/134, 97.8 percent) and were interested in attending seminars and lectures in order to improve their knowledge and skills (109/134, 81.3 percent). When the respondents who had heard of EBP were asked whether their undergraduate training had equipped them with the necessary skills to appraise scientific articles, a majority of them answered "a little" (55/135, 40.7 percent) and "moderate" (49/135, 36.3 percent). Fourteen percent (19/135) answered "no," and 7.4 percent (10/135) responded "very much."
When the respondents who had heard of EBP were asked to identify perceived barriers to EBP, the most commonly reported barrier was lack of time (87/135, 64.4 percent), followed by financial constraints (54/135, 40.0 percent), having very little knowledge of the concept of EBP (38/135, 28.1 percent), being satisfied with current knowledge and practice (32/135, 23.7 percent), lacking the necessary skills to appraise scientific papers (30/135, 22.2 percent), and having limited access to computers and the Internet (23/135, 17.0 percent) (Figure 4).
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Discussion
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The objectives of the study were to appraise Malaysian dentists’ knowledge and extent of use of EBP, including their overall attitudes and perceived barriers, based on self-reporting. One of the limitations of the study was the difficulty in achieving good feedback from postal questionnaires involving these practitioners. To mitigate this problem, dentists who attended a local conference and whose practices were located in Selangor at the time of the study were targeted. Overall, this group of practitioners contributed 21.3 percent of the available data; the remaining responses were gathered through postal questionnaires.
In this study, more than two-thirds of the respondents were aware of EBP. This finding is important and reflects an essential quality of modern-day clinicians in which the changing sociodemographic patterns of the population and knowledgeable consumers have resulted in high demands for best practice and clinical decision making.
It is enlightening to discover that a majority of the respondents who had heard of EBP had some knowledge of EBP particularly with regard to the concept and process involved. This is an important finding because EBP not only allows clinicians to apply research findings to solve everyday patient care problems but also serves as a methodology to improve their knowledge and clinical skills and help them monitor the quality and effectiveness of clinical treatments.20 Where possible, clinicians should seek evidence from systematic reviews or meta-analysis of randomized controlled trials (RCTs), followed by evidence from other study types such as longitudinal studies, case-control, cross-sectional, and case series.21 In this study, more then 43.0 percent of the respondents who had heard of EBP appeared unaware of the strength and types of available evidence in the epidemiological studies, which led them to think that all evidence from scientific journals was acceptable for EBP. Instead, as clinicians, it is essential for them to recognize that many scientific articles are narrative reviews, which means the content often reflects the opinion of the review’s authors with unclear basis of evidence. On the other hand, the key tool in the evidence-based approach is the systematic literature review that follows explicit, well-documented, scientific methodology in order to reduce errors or biases and to provide a more objective, comprehensive view of the research literature.22 However, in dentistry, such reviews are relatively small in number. Therefore, with other types of evidence, dentists need to critically assess the findings in terms of their validity and relevance before incorporating them into clinical practice.23
Regarding the various technical terms commonly used in EBP, it was encouraging to discover that a majority of the respondents who had heard of EBP indicated that they understood many of the terms such as "evidence-based practice," "clinical effectiveness," and "systematic reviews." More than half of them also claimed they understood the term "critical appraisal." Critical appraisal is the process of assessing and interpreting evidence by systematically considering its validity, results, and relevance. The learning of skills needed to critically appraise scientific articles is central to the practice of EBP.24 However, it is worth noting that, despite the respondents’ claims of understanding some of the EBP terms, their perceived knowledge might not necessarily reflect an accurate understanding of the terms. On the other hand, a majority of the respondents who had heard of EBP reported that they did not understand the term "clinical governance" and were unaware of the term "Cochrane Collaboration." The Cochrane Collaboration, established in 1992, is an independent international organization that aims to help clinicians, researchers, and patients make well-informed decisions about health care by preparing, maintaining, and promoting the accessibility of systematic reviews of the effects of health care interventions. The main product of the Cochrane Collaboration is the Cochrane Library, an electronic resource that contains databases of controlled trials and systematic reviews. There are fifty Cochrane Collaborative Review Groups (CRGs) responsible for reviews within areas of health; collectively, they provide a home for reviews in all aspects of health care.14 One of the CRGs is the Cochrane Oral Health Group, which prepares and maintains systematic reviews of RCTs in oral health.9
Another EBP term that was rated low in recognition was "clinical governance." Clinical governance can be defined as a system of total quality assurance in which the chief executive of the organization had responsibility for clinical as well as financial matters. EBP forms an essential component of clinical governance since use of evidence would directly influence quality and cost-effectiveness in choice of treatment.
The three most frequent actions chosen by the respondents when faced with clinical uncertainties were "ask friends and colleagues," "refer the patient," and "consult textbooks." Although experienced colleagues are often knowledgeable and trustworthy and can offer valuable advice to cope with situational issues (which could inform the practice of other colleagues in this specific situation), their opinions are often based on experience within their settings and may not reflect best practice. However, asking colleagues means the information can be sought relatively easily and bypasses the stages in EBP. Respondents indicated that they referred to textbooks or made referrals only when colleagues were not able to provide the answers. The problem of using textbooks as a source of evidence is that the information may be out of date and, as a result, may not be accurate.25
Approximately 45 percent of the respondents who had heard of EBP reported that they continued treatment based on their own judgment and experience despite being uncertain. Dentists as professionals should refrain from unsafe practice and must always act in the best interest of their patients. Practice based on intuition is unethical, violates the confidence placed in dentists by the society, and may be detrimental to their patients. Such practice compromises the integrity of the profession and should be avoided at all times.
In this study, consulting electronic databases as sources of evidence was the fourth most frequent information search option chosen by the respondents. Nevertheless, this finding suggests that clinicians are now gradually moving towards EBP and away from traditional approaches to care.26 Improving the skills of retrieving evidence from electronic databases could be accomplished through courses, seminars, and workshops. Journal clubs and peer review sessions can also be useful forums to develop and enhance these skills.27 Such activities would empower dentists to be more independent and promote confidence in clinical decision making.
Another key issue in using EBP is the ability to appraise scientific articles in a critical way. To do this, a person needs the necessary knowledge and skills and does numerous appraisal exercises by means of continuous reading. However, it appears that reading scientific journals is not a daily routine for the majority of these dentists despite their claim that many of them have good skills in understanding scientific articles. In this study, lack of reading might be attributed to the lack of time, interest, and perceived need to improve themselves. However, it is rewarding to know that a proportion of the respondents indicated that they read scientific articles regularly, at the rate of at least once a week.
A majority of the respondents who had heard of EBP were very impressed by its usefulness and showed great interest in obtaining further information. This positive attitude should be looked upon as an opportunity for dental educators to identify weaknesses and promote understanding and change of attitude. Relevant courses such as seminars on EBP are the ideal platform. A majority of the respondents to our survey admitted that their undergraduate curriculum had not prepared them well to appraise scientific articles. Therefore, it is highly recommended that EBP be introduced into the dental curriculum as a component of continuing professional education.
In terms of perceived barriers in the use of EBP, it appears that lack of time was the most common barrier, followed by financial constraints. This finding was similar to the finding by Iqbal and Glenny in a study involving a group of dentists in England.5 In our study, it seemed that the method of payment and other realities of dental practice were also major hindrances to EBP despite a majority of dentists being in favor of the concept. As all dentists in Malaysia work under private arrangement, time and funding were major influences on their decisions. As such, it is no surprise that EBP was perceived as time-consuming and financially unsustainable. However, it is worth noting that, in order to save time, dentists can directly locate relevant systematic reviews in the Cochrane Library rather then searching through other databases such as Medline and Embase that contain varieties of articles of different study types. Clinicians can choose between the Cochrane Database of Systematic Reviews (CDSR), which contains full-text systematic reviews, and the Database of Abstracts for Reviews of Effectiveness (DARE), which contains a compilation of abstracts of systematic reviews. One search on the Cochrane Library allows the clinician to scan through relevant systematic reviews, without having to wade through all the other studies in the subject area, and thus results in time saving. Dental educators, through partnership with the government, are the best ones to offer guidance and empower clinicians to initiate this change. Suitable schemes that offer training in accessing and interpreting evidence, as part of continuing professional development, should be developed. For example, learning could be made easier by compensating the dentists for their costs, providing refreshments, and offering other incentives for taking time off work to attend classes. This would allow clinicians to improve their knowledge without fear of financial loss. Other reported barriers could also be overcome by offering similar incentives for the courses they attend.
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Conclusion
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EBP is a relatively new paradigm in dentistry and thus may not be a concept well known to every dentist. Based on the findings of this study, EBP educational programs should be developed for dental practitioners in Malaysia to enhance their knowledge and skills. These programs should be implemented through multisectoral approaches and planning that makes attendance feasible.
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Author Information
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Dr. Yusof is Senior Lecturer, Department of Community Dentistry, School of Dentistry, University Malaya; Dr. Lee is Dental Officer, Queen Elizabeth Hospital, Sabah, Malaysia; Dr. Poon is Dental Officer, Tuanku Jaafar Hospital, Seremban, Malaysia; and Dr. Ramli is Senior Lecturer, Primary Care Medicine Discipline, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia. Direct correspondence and requests for reprints to Dr. Zamros Y.M. Yusof, Department of Community Dentistry, School of Dentistry, University Malaya, Kuala Lumpur, 50603, Malaysia; 00603-79674805 phone; 00603-79674532 fax; zamros{at}um.edu.my.
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Abstract
Methods and Materials
