J Dent Educ. 72(6): 736-744 2008
© 2008 American Dental Education Association
Obstacles to Implementing Evidence-Based Dentistry: A Focus Group-Based Study
Karin Hannes, M.Sc.;
David Norré, M.D.;
Jo Goedhuys, Ph.D.;
Ignace Naert, M.D., Ph.D.;
Bert Aertgeerts, M.D., Ph.D.
Key words: evidence-based dentistry, qualitative research, focus groups
Submitted for publication 08/01/07;
accepted 03/13/08
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Abstract
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In many countries, questions have been raised about the use of evidence-based practice (EBP) in oral health care. The call for an increase in EBP seems to face many obstacles. Only limited empirical studies address these obstacles. We present a qualitative study that explores the obstacles that Flemish (Belgian, Dutch-speaking) dentists experience in the implementation of EBP in routine clinical work. We collected data from discussions in focus groups. Seventy-nine dentists participated. The data were analyzed using constant comparative analysis. Three major categories of obstacles were identified. These categories relate to obstacles in 1) evidence, 2) partners in health care (medical doctors, patients, and government), and 3) the field of dentistry. Our findings suggest that educators should provide communication skills to aid decision making, address the technical dimensions of dentistry, promote lifelong learning, and close the gap between academics and general practitioners (dentists) in order to create mutual understanding. The obstacles identified are considered useful to support future quantitative research that can be generalized to a broader group.
In many countries, there has been increasing concern about the use of evidence-based practice (EBP) in oral health care. The call for the implementation of EBP to increase the effectiveness of dental care seems to face many obstacles. We searched Medline, the Cochrane Library, the American College of Physicians-Journal Club, the Database of Abstracts of Reviews of Effectiveness, and Sociological Abstracts and found several articles addressing these barriers. Despite the substantial number of contributions on the theme of EBP, our literature search yielded few empirical studies reporting on obstacles. Two quantitative studies reporting on obstacles in dental health care were found.1,2 These studies identified lack of time, poor availability of evidence, and financial constraints as the main barriers. All other publications only skimmed the surface, in the form of descriptive articles or discussion papers. A number of barriers inherent to research evidence itself were identified, such as lack of high-quality evidence; lack of clear diagnostic criteria; difficulty in measuring outcomes; the use of reviews of randomized controlled trials as the gold standard; incomplete, inconsistent, or conflicting evidence; and the broad range of very specialized, expensive, academic journals.3–13,14 A general lack of knowledge and skills for reading, selecting, interpreting, and generalizing evidence has also been reported.5,10,15,16 Although a lot of the current education is considered outdated, inappropriate, or inconsistent with current evidence, many dentists rely on what was taught during their training or on personal experience instead of trying to keep up-to-date with ever-changing knowledge.4,5,8,10,16–18 Other barriers relate to the practice environment of the oral health care practitioner: heavy workload, inefficient organizational structures and information systems, slow dissemination and uptake of evidence, insufficient staff support, limited access to literature, and limited financial support for research and development.10,15,16,19,20 In addition, the bulk of the existing research evidence has not been generated in settings such as primary care and is therefore hardly relevant for daily practice.7,15 Furthermore, some dentists fear medicolegal action by the government or restrictions in National Health Service fee scales. It might limit the adoption of new techniques and lead to a poorer reimbursement system.10,13 Some studies also report dentists’ fear of losing their clinical autonomy, as well as a lack of motivation to reduce the large variation in practice patterns and skills.4,5,8,10,14,15,21,22 Furthermore, care providers and their patients are sensitive to the promotion of certain products and equipment, often in the absence of scientifically sound data.1,10,16,21
In general, research findings are more likely to be accepted as a fact if they are quantified (expressed in numbers). We chose a qualitative, empirical study design instead of a survey presenting an average view of dentists in an attempt to validate statements made by academic opinion leaders and educators. The main goal of our study was to gain an in-depth understanding of obstacles concerning evidence-based dentistry (EBD), taking into account the richness and variability of data brought forward by particular individuals or groups.24 To this end, we aimed at making sense of the meaning, expectations, attitudes, and suggestions that academics as well as general dentists bring to the EBD debate.
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Methods
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A qualitative study was conducted (2004–05), for which we planned six focus groups in the Dutch-speaking part of Belgium (Flanders). One group of six academics was chosen because of their status as good informants on EBD. For groups two to six, seventy-three dentists were recruited from local peer groups. Focus groups were organized into four different provinces in Flanders and in the Brussels area. We used a theoretical sample, based on three major criteria: 1) variability in interest in EBD, 2) variability in expertise with EBD, and 3) geographical variability in the locations where the focus groups were organized. Our presentation of demographics (Table 1
) and study settings enables the reader to ascertain for which situation the findings might provide valid, applicable information.25
An independent moderator was brought in to facilitate the focus group discussion using a semi-structured interview guide. Two investigators observed the participants’ nonverbal behavior. One of them was a dentist, the other a sociomedical scientist. To explore the potential influences of group processes on the ideas expressed, the notes were added to the citations supporting the findings section. We analyzed the data on two major topics that were discussed: 1) applicability of EBD and 2) specific barriers to implement EBD. At the end of the focus group session (one and a half to two hours), dentists were asked to complete a short questionnaire so we could collect demographic data. The discussions of each group were recorded and transcribed verbatim.
The comparative analysis was guided by a grounded theory approach.26 Two independent investigators identified the main obstacles by coding the data from all focus groups separately. The process of analysis involved examining each paragraph of the transcripts for emergent themes in relation to the issues explored and labelling them accordingly. We used the software program ATLAS-ti (5.0) to group the codes from the transcripts into categories of obstacles and refined them with an inductive process27 (Figure 1). The citations supporting our findings should assist the reader in evaluating the trustworthiness of the interpretation of the data.28
To increase reliability of the findings, we calculated an inter-rater reliability for the codes given, which ranged between 40 percent and 82 percent in a first round and 70 percent and 96 percent in a second round (corrections from initial score "disagree" to "agree" between investigators, i.e., investigator triangulation). The remaining part of text fragments for which the interpretation given by the two encoders was fundamentally different were looked at and discussed by a third investigator. We ensured technical accuracy in recording and transcribing the data and included nonverbal aspects of communication in the citations from the transcript. These citations were used to support the findings. Validity was ensured by using an independent moderator and investigators with different backgrounds to collect, code, and interpret data, so as to prevent bias (disciplinary triangulation). We cross-checked our findings with published literature (methods triangulation).
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Findings
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Three major categories emerged from the data: obstacles related to 1) evidence, 2) other partners in dental health care, and 3) dentistry as a discipline. These obstacles are presented in Tables 2–6, followed by a short reflection on what was known from previous opinion papers and quantitative designs and which nuances were added by the focus group participants. The reflections from the researchers are supported by citations from the interview excerpts.
Obstacles Related to Evidence
Many of the barriers brought forward by Flemish dentists are similar to those discussed by opinion leaders, editors, and quantitatively oriented investigators. The findings presented in Table 2
validate many of these statements.
Although EBD is meant as a tool to simplify choices for oral health practitioners, a number of dentists in our sample stated that it only complicated their decision-making process. As one said, "Basically, you used to have the dentist and the patient, simple treatment methods and a patient that wasn’t aware of much. Sit down, be afraid, pain, mouth open and done (G: laughing: 1). And now there are so many different treatments, and the patient has become very aware, and then there’s the evidence as well that you have to take into account. That makes it really complicated" (G: I: 2). [Key for all quotations: G=behavior/I=agreement by other respondents/ O=disagreement by other respondents, followed by the total number of respondents reacting.]
Several dentists admitted having problems staying up-to-date or choosing from among a number of devices and products. However, some expressed considerable doubt that the majority of dentists are ready to actively explore and engage in the EB discourse. One commented: "EBM is a very subtle area; nobody says buy this, or do prevention this way; they say; we’ve found this, in the light of this discovery it should be interpreted thus, somebody else said this. . . . If you read a scientific article, there is such a subtle dialogue going on, while Jo Bloggs or Josie Bloggs, all they want to know is ‘I need to do it like this and then I’m happy.’" Several elements brought forward by participants of the focus groups endorse this attitude: preference for clinical cases reported in handbooks, use of patient satisfaction as the main source of evidence of effectiveness, complaints about the applicability of evidence, and the feasibility of using it in daily practice due to considerable time delays in publishing results of new devices or a lack of studies on negative effects. One dentist said: "Recently there was a promotion for a certain toothbrush; the representative comes along with the information. So is it any good or not? I tried it myself and I thought it was good (G: laughter: all) and then told the patient that it was probably good, but I don’t think that there is any real scientific research on it . . . you have to wait a year or two before you see a study" (G: laughter: 2). In addition, those who actively search for high-quality information are often disappointed by the lack of answers to their questions.
Obstacles Related to Partners in Health Care
Government.
Belgium has a particular way of financing oral health care. Most of the dentists are independent entrepreneurs, financed by their number of clinical acts as defined in the Belgian nomenclature. The nomenclature is a list of (para)medical interventions, established by law in a Royal Decree, based on which a practitioner’s fee, the medical reimbursement to the patient, and the nonrefundable part of medical expenses are defined. Dentists who adapt to the norms of this convention on dental treatments charge fixed prices and get social security advantages instead (±75 percent). All patients have compulsory public insurance, which covers most of their health care costs for a reasonable price, including most (non-esthetical) dental procedures. Contrary to the Belgian health care system, the U.S. health care system is predominantly organized via private health insurance, the so-called fee-for-service systems, or affiliations with a health maintenance organization. The latter is cheaper but restricts the choice of health care provider to those with whom the organization has a contract. Only the more vulnerable groups (elderly, handicapped, or poor persons) fall under public health insurance programs, called Medicare and Medicaid. Most dental procedures are excluded from reimbursement. Several dentists in our sample fear the trend towards privatization of health care. Said one: "Crown and bridge work is not included in the current nomenclature, which in fact means that you have to saddle everyone with loose dentures because that is reimbursed from the age of 50. It would be better if there was reimbursement for that. I think it’s wrong to arrange that via the private insurance companies because you’re going to get two tiers in dentistry. . . . the lower social classes can’t afford it" (G: I: 1). Other macro elements related to the health care systems that can be counterproductive for EBD are summarized in Table 3.
New items brought forward by focus group participants included the lack of (financial) incentives to provide EB dental care. For example: "Someone who is putting in an amalgam filling. I’ll lay it out for you. An amalgam filling: that costs about 750 euro per kilo. If you use composite materials, they cost about 12,500 euro per kilo. So colleague X works with amalgam, and colleague Y works with composites. Colleague Y then has three times the costs of the others, and he can only actually ask the same amount for it. The same goes for all the hygiene in dentistry. Anybody who sterilises his turbines and handpieces and all the rest after every patient, he has to spend a lot more money than his colleague who does not bother with all that. That is something in dentistry that really annoys me" (G: I: 2). According to several participants, patients too are very much aware of the financial consequences of dental choices. One dentist commented: "The most frequently asked question is: how much do I get reimbursed? That is something that has to change in Belgium. I always say: you do not get anything back from the hairdresser or the butcher; why should you get it from us?" (G: laughter: all). Although several dentists in our sample state that preventive oral health care would probably lead to a decrease in costs, the current nomenclature is mainly focussed on cure. Defending the interests and position of dentists appears to be a difficult task for professional dental organizations. Doctors still enjoy a higher status and dominate discussions. One participant in our study said: "On many occasions we’ve sat well into the night giving EB information on fluoride to the authorities. The minister says, yes but I don’t want to throw doubt on the decisions of my high council. Meaning, you are just dentists, they are doctors, and dentists are not as prestigious, so that can go straight in the bin. It is often about coincidences, stupidities, bad advice, not wanting to concede. . . . Just like someone once said about the war in Iraq: how many people have lost their lives because their leaders didn’t want to lose face?"
Commercial Companies.
The influence of commercial companies on EB practice is seldom addressed by opinion leaders or academics. However, several dentists in our sample complained about the impact of pharmaceutical companies on scientific research, which undermines EBD (Table 4).
Several participants criticized the economic attitude of many academics and doubt the objectivity of the results from sponsored research. One stated: "A company that is objective—there’s no such thing! I recently heard about a contract that was signed for scientific research into implants. When you hear about contracts being signed for things like that, all the data is collected and sent to the company to be processed. What do you think happens to it?" (G: I: 1). However, the true discussion seems to focus on the pressure on academics to publish and the lack of finances or quality control from independent sources, such as government. One dentist said: "A control organism is lacking. Anyone can throw anything on the market and promote it in a way that suits them best" (G: I: 4). In addition, representatives of commercial firms are often not capable of providing accurate, evidence-based information about their products or devices. However, dentists admit using many of them; for example: "And yet there is a lot of technology that is brought on the market by companies, and you use it because it’s useful. Has it all been scientifically proven? Perhaps it isn’t always necessary!" (G: I: 1) Several participants also mentioned that managers are starting to take over the organization of dental practices, a trend that already seems to be widespread in the United States. Whether this leads to better care was not discussed.
Patients.
Few investigators have focused on the role of patients in the EBD debate, and little is found on patient-related barriers. The participants in our focus groups, however, addressed a number of patient-specific obstacles (Table 5).
Some dentists in the sample mentioned the low level of concern about the condition of their teeth: "When a patient is ill, say he has a cardiac disorder, the doctor tells him he has to lose weight and take pills, but all we say is you have to brush your teeth properly. There is less of an emergency with us. Actually, a lot people should die of toothache" (G: laughing: all). According to several participants, compliance with EB treatments is generally low. Furthermore, it is stated that the media often present subjective information or raise high and unrealistic expectations that cannot be fulfilled. This influences many patients. Said one participant: "Take the amalgam discussion; this was conducted on TV in Germany. They had a discussion forum where they had a dentist, a first assistant at a university, who talked about limit values and toxicity. And then there was a woman who was in floods of tears, it was a sort of Oprah Winfrey situation, telling everyone that amalgam had ruined her life. (G: laughter: all) Why do we have media—not to inform the public, but to support those who finance it, so the more emotional it is, the better the viewing figures." Some participants further stated that they are increasingly confronted with patients entering their practice with information from the Internet, often drawing the wrong conclusions about the proposed treatments. Said one: "Patients come in and plonk a pile of papers on my desk and have already drawn their conclusion, based on a lack of knowledge, and then it is very difficult to confront that as a practitioner and to tell them that their information is correct to an extent, but that their conclusion is wrong" (G: I: 4). The expectations of patients concerning dentists’ availability are high. Some dentists in the sample suggested that a daily practice with fixed working hours could probably lead to more time for education and the search for information, although others admitted that they would use the free time for leisure or to be with their families.
Obstacles Related to the Field of Dentistry
Many general dentists in the sample stated that the concept of EBD was new to them; others were familiar with it but could not explain it. This and other obstacles mentioned are listed in Table 6.
Discussions on the field of dentistry in general are mainly dominated by the gap between academics and general dentists working in the field. General dentists in our sample shared the impression that EBD is typically targeted at academics. Many of them also said they found it impossible to work with new developments, without cost and time limits. One stated: "I can’t spend three hours on a denervation and ask 700 euro for it. At university they can, and they run a course on it there, but it’s of no interest to me" (G: I: 1). Field workers also criticized the lack of exchange of information between them and academics. As one said: "If all our colleagues noted down right now what they achieved on a daily basis and drew up a short report on it, we’d get an EB restoration technique a lot quicker than if we had to pick it up from literature and there may be millions of restorations performed daily but who the hell knows how long they’ve been in the mouth, how they were made, etc. That too is an important source of information that the academic world doesn’t have a clue about and that you alone between your own four walls know."
In essence, what seems to hamper the use of EBD is the technical dimension of dentistry. Although many focus group participants prefer practical, technical courses to theoretical ones, they argue that skills have a bigger influence on the outcome for the patient than reading an evidence-based article and applying its recommendations. One participant stated: "You can use a technique that you learned at university and then learn a new one and you can’t apply the new one that is so much better, so you’re better off sticking to the old technique that you can apply." Several dentists admit knowing about the better effects of certain treatments but only few actually change practice: "Take composite fillings; haven’t they been saying for years that they are best done under a rubber dam? (G: I: 1) But who does it?" (G: sticks finger up: 1). According to our focus group participants, many dentists work alone, facing a heavy workload. Some acknowledged that differences in practice among different dentists are questionable in the context of evidence-based practice. However, there are few incentives to change.
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Discussion
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Issues with the Methods
Although the focus group technique is considered appropriate to make an inventory of obstacles, there are some methodological flaws. To ensure a fruitful discussion, focus groups ideally consist of six to twelve people.29,30 Our study involved four focus groups with more than twelve participants each. Because of the large groups, we cannot guarantee that all viewpoints have been discussed in depth. It was difficult for the moderator to stimulate all participants to actively engage in the discussion. Some groups also suffered from domineering members who took the lead in the discussions as described by Bloor et al.31
Our comprehensive study was comprised of a small sample group of Flemish dentists; however, in terms of informational redundancy, we were close to the saturation point. The last focus group generated few new ideas. Further observations would probably only yield minimal or no new information. The obstacles identified are considered useful to support future research, e.g., the development of a questionnaire to retrieve data that can be generalized to a broader group. Multiple and diverse observations can only enrich the description of the topic under study and increase its understanding.25 By comparing our findings with data from previous statements made in opinion and descriptive papers, we enabled ourselves to validate certain statements,32 but also to capture important messages on how the obstacles identified relate to factors that dental education can help address.
Lessons Learned
In 2004, the Association of Dental Education in Europe published a report providing guidance for dental education on the professional competences and profile of the newly graduating dentist.33 Apart from having a broad academic and dental education in all areas of clinical dentistry and being able to network with other health care professions, dentists should 1) have good communicative skills, 2) engage in lifelong learning, and 3) be able to practice evidence-based dentistry. Each of these aspects relates to obstacles mentioned by the focus group participants.
First of all, providing training in communication skills and including communication skills training in the dental curriculum could facilitate the decision-making process with a generation of emancipated patients. Consultations during which both dentist and patient can consult evidence online (connecting the patient, the dentist, and the evidence34 through an online search) might decrease the impact of media messages.
Secondly, dentists should be stimulated to engage in lifelong learning. This would be very helpful to disseminate the evidence-based message. The Belgian government has established a system of accreditation in which doctors and dentists are financially rewarded for their participation in training programs organized and developed by academics or colleague dentists. Since the introduction of this system, more than 80 percent of the Belgian (Flemish) dentists have participated in training programs, compared to a small 25 percent in previous years. Theories on EBD put forward by academics have their merit, but do not contribute much to the improvement of outcomes for patients unless the theories are supported by thorough skills training. In dental care, skills training is all the more necessary as dental care also implies technical abilities. The focus on the technical dimension of the oral health care profession further led to the understanding that the rapid changes in know-how within the field of dentistry seem to exceed the capacity of dentists to gather the necessary skills and use them in an effective manner. To provide extensive technical training, academics will be forced to work in a close alliance with developers and manufacturers of dental devices, who might themselves be more interested in selling rather than fine-tuning skills in the context of delivering better outcomes to patients.
However, the biggest challenge will be to engage both academics and general dentists working in the field in the implementation of EBD. In analyzing the data, we noted that no single obstacle mentioned was exclusive for academics. However, some obstacles were more strongly expressed by general dentists, including the lack of communication on EBD, the lack of time to invest in EBD, the complexity of dental care, and criticism on the rigidity of EBD and scientific studies. Although we expect the new generation of students to be less vulnerable to some of these obstacles, today’s educators’ challenge is to improve outcomes where it matters the most: at the point of care. Educators have to become aware of dental actions that are desirable from an evidence-based perspective as well as feasible in practice. Relying on a top-down approach as the sole strategy to stimulate the implementation of EBD is not recommended. A bottom-up approach in which the questions useful for daily practice are inventoried, explored, answered, and subsequently integrated into existing training programs could assist general dentists in working evidence-based. Involving them in delivering data and contributing experiences from their daily practice could enhance mutual understanding and lead to a professional group that is able to look beyond the borders of their general practice, have a consistent voice towards government, and, as such, enhance the quality of dental care.
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Conclusion
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The findings of our qualitative study validate many of the insights gathered from opinion and descriptive papers. These findings can be understood as an empirically based contribution to the ongoing dialogue and exploration of obstacles to EBD. Our study adds to the discussion on EBD, and it also serves as a useful source of information for investigators developing questionnaires for oral health care practitioners. We are convinced that the more we are aware of the different obstacles that prevent practitioners from delivering high-quality, scientifically supported dental care, the greater improvement in care will occur. Educators have an important role to play in providing communication skills to aid decision making, addressing the technical dimensions of dentistry, promoting lifelong learning, and closing the gap between academics and general dentists in order to create mutual understanding.
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Acknowledgments
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We wish to acknowledge the time and enthusiasm of the dentists who took part in the focus groups and Jacques Vanobbergen for his support in shaping the discussion section.
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Author Information
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Ms. Hannes is Staff Member, Belgian Centre for Evidence-Based Medicine, Belgian Branch of the Cochrane Collaboration; Dr. Norré is Research Assistant, Department of Prosthetic Dentistry, Catholic University, Leuven; Dr. Goedhuys is Associate Professor, Academic Centre for General Practice, Catholic University, Leuven; Dr. Naert is Head, Department of Prosthetic Dentistry, Catholic University, Leuven; and Dr. Aertgeerts is Director, Belgian Centre for Evidence-Based Medicine, Belgian Branch of the Cochrane Collaboration and Associate Professor, Catholic University, Leuven. Direct correspondence and requests for reprints to Ms. Karin Hannes, Kapucijnenvoer 33 blok J, PB 7001, 3000 Leuven, Belgium; 32-16-33-26-93 phone; 32-16-33-74-80 fax; karin.hannes{at}med.kuleuven.be.
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D. W. Chambers
QUESTIONS ABOUT EBD
J Am Dent Assoc,
June 1, 2009;
140(6):
632 - 632.
[Full Text]
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Abstract
Methods
