Academic detailing in oral healthcare – results of the ADVOCATE Field Studies

Figures & data

Figure 1. The aim, intervention and outcomes of the Field Studies.

Figure 2. Screenshot of the questionnaire application used to collect patient self-reported data.

Figure 3. Timeline; ADG meetings and data collection periods of the Field Studies.

Figure 4. Screenshot of the feedback data presented in the dashboard.

Figure 5. Attendance of ADG meetings in Denmark, Germany, and The Netherlands.

Table 1. Characteristics of GDPs (n = 39) participating in the Field Studies.

Characteristic	Mean (range)
Age (years)	44 (28–70)
	n (%)
Gender
Male	20 (51)
Female	19 (49)
Denmark
Group 1	10 (59)
Group 2	7 (41)
Germany
Group 1	7 (58)
Group 2	5 (42)
The Netherlands
Group 1	6 (50)
Group 2	6 (50)
Special interest
Endodontics	22 (56)
Periodontics	20 (51)
Implantology	16 (41)
Paediatrics	7 (18)
Gnathology	5 (13)
Maxillofacial surgery	3 (8)
Orthodontics	2 (5)
Special needs dental care	2 (5)
Practice
Group	30 (77)
Solo	8 (20)
Both	1 (3)
Number of dentists in dental practice
1	7 (18)
2	8 (21)
3	6 (15)
4	0 (0)
5	7 (18)
6	2 (5)
Missing	9 (23)
Years since graduation
1–9 years	15 (38)
10–19 years	10 (26)
20–29 years	7 (18)
30–39 years	6 (15)
More than 40 years	1 (3)
Days per week working in practice
2 days	1 (3)
3 days	6 (15)
4 days	9 (23)
5 days	21 (54)
Missing	2 (5)

Table 2. Barriers and facilitators in the ADVOCATE Field Studies.

Themes	Subthemes	Barriers	Facilitators
Recruitment of GDPs		GDPs not having enough time GDPs not seeing the added benefit	Stewards having a pre-existing network of GDPs in place
Communication with GDPs		Lack of response from GDPs to open ended questions in emails from Stewards	Email contact between Stewards and GDPs, which includes clear and directed communication Phone calls and visits to the GDPs’ practice when support was needed
ADG meetings	Steward		Stewards being committed, well prepared and organized moderators Having a neutral and positive environment for open discussions Stewards summarizing discussion points Stewards clarifying the feedback data Stewards aiding in the interpretation of the feedback data
	Logistics	Non-response or late response from GDPs to emails Busy schedules of GDPs Missing a meeting creating a feeling of lagging behind Absent and late GDPs disturbing the meeting	Having preparatory meetings with the research team
	Experiences	Feedback-data as a stand-alone resource is not sufficient to understand, discuss and reflect Not having included new feedback data in meeting 2	Feedback data and AD motivated and stimulated discussion AD meetings are essential to identify action points and make sense of the data Feedback data allows cross-country comparisons and comparison with different localities
Patient questionnaire application	Questionnaire	Long questionnaire Questionnaire including unclear and difficult questions Questionnaire not being available in different languages for the patients	Patients not minding the length of the questionnaire Patients liking to provide feedback The questionnaire being anonymous
	Data collection	Two months being too short to collect data Not enough effort taken to collect data Receptionists or assistants having time constraints to collect data Patients requiring detailed explanations from receptionists or assistants Receptionists or assistants not feeling responsible for data collection Receptionists or assistants not giving priority to data collection The questionnaire not having the option to leave questions blank The questionnaire not having the option to be paused Inappropriate instances for asking patients to fill in the questionnaire Technical difficulties with login Uncomfortable feeling of GDPS having the tablets in the waiting room Use of tablets introducing bias in selecting patients to complete the questionnaire	Establishing data-collection into the practices’ daily routine
			An external person facilitating the data collection in the practice Motivated receptionists or assistants Incentivizing data collection for the receptionist or assistant Having a digital questionnaire available outside of the practice Electronic questionnaire meant not having a lot of paper laying around
	Feedback data	Misinterpretation of questions by patients Small and selective number of collected questionnaires	Feedback data stimulating discussion Feedback data not being a tool to measure quality performance and give normative judgements
Claims data		Claims data being aggregated from regions within countries Data not being attractively and intuitively presented in the dashboard Having different oral healthcare systems across countries	Having claims data on practice or GDP level Claims data allowing cross-country comparisons
Dashboard	Usage	Not being able to see changes made to clinical practice in the feedback data Not having enough free time to look at the dashboard Having difficulties logging in to the dashboard GDPs not considering it their role to look at the dashboard	Dashboard allowing identification of points for improving care delivery
	Functionality	Dashboard providing unclear and not intuitive access to the data Receiving maintenance emails from the host of the dashboard	Dashboard presenting simple and summarized data
Overall opinion on the Field Studies		Duration of the study being too long Technical problems with the patient-app questionnaire and dashboard Unclarity amongst the GDPs regarding the aim of the study	Field studies not using normative benchmarking Field studies providing the opportunity to understand the clinical practice of colleagues Field studies not using normative patient-derived feedback Awareness that it is a proof of concept study and hurdles can be expected Having included a selective sample of GDPs who were already open to new approaches, information and changes

Table 3. Quotes from the focus groups and forms.

Process evaluation Field Study
Theme 1: recruitment of GDPs
Quote 1	‘The people that did not participate gave as main reason that they already have a high work and administrative load, so they do not want to take more work on board.’
Quote 2	‘People that did not want to participate were mainly concerned about the project taking too much time.’
Quote 3	‘The question I got from them is ‘What do I get out from it?’
Theme 2: communication with GDPs
Quote 4	‘Occasionally we arranged a visit to the practice for setting up data collection and to help with logging in onto the iPads.’
Quote 5	‘I tried to keep the emails to a minimum and when I sent out an email to the GDPs I tried to set up the email so that no reply was required from them; so more one-way email.’
Theme 3: ADG meetings
Steward
Quote 6	‘One couldn’t just go off at a tangent – it was well managed. I was particularly impressed with Mr. X’s commitment, especially if we had problems accessing the data. And when I couldn’t attend one of the sessions due to illness, we made a telephone appointment and we looked at the data on the computer and assessed it over the phone. We spoke for an hour.’
Quote 7	‘As dental care personnel we are not used to meeting people who have a positive attitude to us, we are normally met (and I’ve said before) with suspicion. All legislation around us is based on mistrust, where you suspected to have the most evil intentions, and it was really nice to have one like Mr. X, who was neutral and positive.’
Quote 8	‘With themes and sub-themes identified the entire coding framework was established and was sense-checked and checked for comprehensiveness by all authors, before being used as the framework for subsequently directed analysis of the additional data material.’
Logistics
Quote 9	‘Had to do several doodles. Because of holidays it took for some a long time to get back to me and in the meantime the others would have planned things on the selected date.’
Quote 10	‘As for myself, I had to cancel once, which was a shame, because you need to follow up on what has been talked about last time, otherwise you do not know what was agreed upon, but of course this is your own fault.’
Experiences
Quote 11	‘Then that also helps for later. So yes, I think that … There are no big differences, but you do actually look in a mirror and think: hey, I am already doing this. And that’s nice to get back, because you get an empowerment and therefore you do it a bit more often and it sticks. But, then there also things when you start thinking: hey, but here I’m not doing anything. And this is also nice to ask yourself. This is also nice to tell. In that sense it has added something.’
Quote 12	‘Both aspects: You have someone who explains this more in depth, but more importantly you do it together with colleagues and you talk about it which you otherwise would not do in that way.’
Quote 13	‘I feel that we have all been very open and honest about what has been good and bad at home, where we come from, I think we did not have any barriers. We could talk about things, which you are not so proud of, or not good at. It has been easy and safe (a confident feeling)’
Quote 14	‘the positive thing is that you get to talk to other people and particularly about attitudes to prophylaxis, a theme there has been a lot of emphasis on, and get some tips from other dentists Next, it is like attending a course, to come here and learn how other people solve our problems.’
Theme 4: App
Questionnaire
Quote 15	‘I started every time to say to the patients that nobody is going to recognise that you filled in the questionnaire, it is completely anonymous. I cannot see what you have written, I think it was also important for them that even I cannot see it, and that their answers are pooled with others, and, well, then it was OK.’
Quote 16	‘Yes, it was probably better to differentiate the questions instead of having a whole bunch of questions, for example, take 10 questions about periodontitis or gingivitis, and then 10 questions about something else …. We should not give all questions to all patients or groups.’
Quote 17	‘An English questionnaire would be convenient for those that do not speak Dutch very well.’
Data collection
Quote 18	‘Mostly the low number was due to staff problems. They find it difficult to get the staff to do this for them. The staff is not capable or not willing to participate.’
Quote 19	‘The staff in practices with high numbers of questionnaires collected were already used to collecting this sort of information.’
Quote 20	‘Last time we had the goal to improve data collection. One of the problems was that dentists with many children in their practice started the questionnaire, but half way they got distracted by the children. In the meantime the iPad had locked itself and the questionnaire had stopped.’
Quote 21	‘For example, at the physiotherapist, quality research is also annually. Then they look at patient satisfaction and everything. And then you just get a link by e-mail. So, they ask it in advance: would you like to…? And then they ask your e-mail address and then they send it.’
Quote 22	‘I also found it inappropriate after, for example, an extraction. To ask for it. I thought: they want to go home, and then to push those questionnaires under their noses, I thought: that’s going too far.’
Quote 23	‘The technique is too modern, our older patients had problems with this.’
Quote 24	‘It is not about increasing the absolute numbers of complete questionnaires, but to break a little into the bias, that only good-looking, young men get the iPad, because the assistant or receptionist can sit next to them and help fill in, to give a stupid argument.’
Quote 25	‘For the patients it went very well, surprisingly, even with the older patients. Some of them had problems in the beginning, perhaps they couldn’t proceed because the key was blocked by another finger. But when it works, they cope surprisingly well. But if it doesn’t work, the staff need to help them.’
Feedback data
Quote 26	‘It is definitely interesting to get the feedback from the questions, you get information on your own clinic and your own actions and this is my primary interest.’
Quote 27	‘I really think that’s the disadvantage of this research. That’s it, it’s comparing apples and oranges. Yes you’re asking something but is it really like that or is that patient not intelligent enough? Does he not understand, is he intelligent enough, did he not receive this information?’
Quote 28	‘I only use the mirror data so that I don’t end up being an outlier in comparison to my peers, and to prevent having to explain myself to the insurer.’
Theme 5: claims data
Quote 29	‘Yes, I don’t think it says anything about all practices. There are plenty of practices that just declare something, anything.’
Quote 30	‘And it interests me, not only in my area, but throughout Europe. What’s happening here, what’s happening in Germany, what’s happening compared to other countries?’
Theme 6: dashboard
Usage
Quote 31	‘So, that is really nice to get back. You become aware that it is also important to take some time to explain what you actually do with that patient. Yes, I really liked that.’
Quote 32	‘I'm a little disappointed because I think I had done much more to explain the things which my patients surprisingly did not understand, but my results remained the same.’
Quote 33	‘I simply haven’t got the time. Or I have the time, but I haven’t used it, because other things were more important to me- My task is really more – not to use that dashboard and so on, but to manage that the iPad works and is used and data is collected.’
Functionality
Quote 34	‘Personally I thought it was much too complex. You would have to sit there for hours to understand what can be compared and how to do it. God, I was already happy when I was logged on and it looked as if these were my numbers.’
Quote 35	‘Your e-mailbox will be spammed dead.’
Theme 7: overall opinion of the Field studies
Quote 36	‘For me, the question is, what is the aim of this European study? Are those who are implementing the study interested in me, with my feedback and where I stand compared to other dentists? Or is it about something else?’
Quote 37	‘I think they don’t quite understand the purpose of the research.’
Quote 38	‘I think it's … how do you say it? Because, I think we were already somewhat aware of how important this actually is, that is why we said yes to participate. And I don’t know if every colleague would be open to this approach.’
Theme 8: perceived results
Quote 39	‘I think I have made some changes in my behaviour in some areas, but it cannot be seen back in my figures and results’
Quote 40	‘I always ask: are you healthy? Do you take medication? Do you have allergies? But apparently that was not enough to make people realise that you are asking whether there are medical changes. So you literally have to ask: are there medical changes since your last visit? No. Are you completely healthy? Yes. Nothing changed? And yet those numbers are more or less the same. They still don’t always realise that you are asking for the medical condition.’
Quote 41	‘And they need to have the feeling that it was their own idea, and if it’s an expensive toothbrush, it’s the manufacturers responsibility. It has to do with self-responsibility, because if something doesn’t work, they like to push the blame onto someone.’
Quote 42	‘It also helps you. Because sometimes it is difficult within a group practice to say something to the other. But when there is a result from the app, then you have an opening to really talk about it.’
Theme 9: GDPs views on oral healthcare
Quote 43	‘Look, a patient in the practice is basically satisfied otherwise they would leave. But actually you just want to know when are you satisfied? And if you are not satisfied where can I improve? What matters to them?’
Quote 44	‘But they can’t check dental things and judge if it’s actually good.’

Table 4. Average evaluation ADG-meetings by GDPs.

Experiences GDPs	n/N (%)
The objectives of the Field Study were clearly defined
Strongly agree/agree	103/114 (90)
Neutral	8/114 (7)
Strongly disagree/disagree	3/114 (3)
The moderator was well prepared
Strongly agree/agree	111/113 (98)
Neutral	1/113 (1)
Strongly disagree/disagree	1/113 (1)
The moderator was well organized
Strongly agree/agree	109/113 (96)
Neutral	3/113 (3)
Strongly disagree/disagree	1/113 (1)
The Dashboard was a helpful tool during the meeting 1.
Strongly agree/agree	54/74 (73)
Neutral	15/74 (20)
Strongly disagree/disagree	5/74 (7)
This group meeting 1 experience will be useful in my work.
Strongly agree/agree	57/67 (85)
Neutral	8/67 (12)
Strongly disagree/disagree	2/67 (3)
The time allotted for the set-up meeting was sufficient.
Strongly agree/agree	96/113 (85)
Neutral	14/113 (12)
Strongly disagree/disagree	3/113 (3)

Table 5. Action points derived during the ADG meetings.

Action points	Corresponding measure
Ask patients which toothpaste they use.	Use of fluoride toothpaste
Discuss care options with the patients.	Shared decision making
Provide more prevention to patients.	Fluoride treatment in the last 24 months
Ask patients what they think about the appearance of their teeth.	Satisfied with appearance of teeth
Tell patients that their soft tissues are checked.	Oral mucosa screening (cancer screening)