EBM • Definition from center for evidence based medicine-oxford -UK: • Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients
What is evidence-based medicine (EBM)? EBM is the integration of the best research evidence with clinical expertise and patient values. • Best research evidence :accurate and unbiased answer to a question • Clinical experience means the skills we have learned during our practice + our ability to elicit our patients’ preferences and goals.
EBM • A very Important objective is to predict the outcome • However , There will be always a debate about what is the most desirable outcome, especially when individual factors are discussed as ;quality of life and value of life judgments
Evidence-based guidelines • Evidence-based guidelines (EBG) is the practice of evidence-based medicine at the organizational or institutional level. This includes the production of guidelines, policy, and regulations. This approach has also been called evidence based healthcare . Evidence-based individual decision making • Evidence-based individual decision (EBID) making is evidence-based medicine as practiced by the individual health care provider. There is concern that current evidence-based medicine focuses excessively on EBID
Generally, there are three distinct, but interdependent, areas of EBM. The first is to treat individual patients with acute or chronic pathologies by treatments supported in the most scientifically valid medical literature. Thus, medical practitioners would select treatment options for specific cases based on the best research for each patient they treat. The second area is the systematic review of medical literature to evaluate the best studies on specific topics. This process can be very human-centered, as in a journal club, or highly technical, using computer programs and information techniques such as data mining. Increased use of information technology turns large volumes of information into practical guides. Finally, evidence-based medicine can be understood as a medical "movement" in which advocates work to popularize the method and usefulness of the practice in the public, patient communities, educational institutions, and continuing education of practicing professionals. “source www.wikipedia.com”
In order to practice EBM we need to first appreciate that we don’t always know all the answers to our clinical questions. Once that fact has been appreciated, the following five skills need to be mastered.
To be able to ask a clinical question in a way that captures the essence of the “problem”< is structured< and is most likely to yield an answer. (PICO FORMAT ) • To be able to search for an answer (“the evidence”) to our question in a way that is most efficient. • To be able critically appraise the evidence. • To apply the evidence to the patient. • To monitor our own progress.
1-Asking the right questions • P : Patient • I: Intervention , Exposure • C: Comparison • O:Outcome Example: P: post partum mothers with psychoses I : ECT was used as a treatment C: Compared to another group who used antipsychotic as a treatment O: Rapid improvement of clinical symptoms
2- Searching for the Evidence The Hierarchy of Evidence ( From Top to Bottom ): • RCTs: systematic review of two or more Randomized control trails • Single RCT • A quasi experimental study without Randomization • Observational studies Case Control-Cohort) • Case report and series • Expert Opinion
Notice that : • Evidence-based medicine has demoted ex cathedra statements of the "medical expert “to the least valid form of evidence. All "experts" are now expected to reference their pronouncements to scientific studies.
2- Searching for the Evidence • Searching online Medical Literature • Boolean Operators • Searching PubMed • Tags • MESH (Medical Subject Heading) Technology
3- Critical appraisal ; is the study valid ? Is the study important? Points to remember From epidemiology and statistics: • Which study is considered the Gold standard in study designs ? • P value as a measure of significance (which is more significant 0.05 or 0.01 ) • Remember a positive or negative correlation doesn't always means a significance • Remember that : Double blind RCTs cant be used to evaluate the effects of a toxic substance ! • A Case control study is more useful for rare outcomes , while a cohort study is useful for rare exposure • Odds ratio is the measure of effect in case control studies , while relative risk is the measure of effect in cohort • An important difference between confounding and bias is that confounding is a property of real life situation while bias is an error the researcher introduces into the design of the study
Measuring Performance and implementing EBM Guidelines : can be considered a top-down approach to evidence based practice .particularly useful when there is : • A Clear evidence that intervention in is effective in a given condition • There is a wide national variation in practice • Examples from MOH ; Guidelines for ECT -Guidelines for Management of severe behavioral disturbance-Guidelines for seclusion & restraint- Guidelines for Lithium /Clozapine Use
Measuring Performance and implementing EBM Audit : • Is an attempt to measure actual clinical practice against a number of standards of good clinical care • There is evidence that audit improves adherence to clinical guidelines and also improve patients outcome. Audit Committee at MHS
Monitoring and Evaluation • Role of MHIS • The importance of Evidence Based Planning / Evidence Based Management in Mental Health .
What is a mental health information system ? A mental health information system (MHIS) is a system for collecting, processing, analyzing, disseminating and using information about a mental health service and the mental health needs of the population it serves.
What are the main stages of MHIS? • (i) Collection – gathering of data. • (ii) Processing – movement of data from the point where it can be collated and prepared for analysis. • (iii) Analysis – examination and study of the data. • (iv) Dissemination – communication of the results of the analysis. • (v) Use – application of the data to improve service delivery, planning, development and evaluation.
Reporting Systems , Information Systems , research projects • Reporting system ; data flow from top to bottom ,(e.g. local areas to central governments) and hardly any data return to those who collected them in first place • Research Projects : a stand alone project , that focus on a particular issue (e.g. epidemiology) such information is too detailed or too specific to be used in an information system • Information System ; sustainable methods of gathering , analyzing disseminating and using information that are built into the workings of a metal health service , they are designed and implemented by those who continue to participate in the mental health services , its panning , management, delivery , and evaluation
At your clinical facility is there any difference between MHIS (Mental Health information system )& HMIS(Hospital Management information system )? . • Most of the time the answer would be …Yes.. Why ? • Define : EMR : Electronic Medical Record
What types of information should be collected? • To help MHIS planners make these decisions, it is necessary to distinguish between the different types of information needed: • Episode-level information is required to manage an individual episode of service contact; • Case-level information is required to care for an individual service user; • Facility-level information is required to manage the specific service facility (whether the facility is a specialist institution, a mental health ward in a general hospital, a community mental health team, or a primary health care (PHC) clinic); and • Systems-level information is required to develop a policy and a plan for the mental health system as a whole.
Using indicators • MHIS use a number of well-defined indicators. Indicators are measures which: (i) summarize information relevant to a particular phenomenon; (ii) can be used to indicate a given situation; and (iii) can therefore be used to measure change. • In the context of mental health care, indicators are measures that summarize information relevant to the mental health service and the population that it serves. As an important way of measuring change in a system, they are an essential tool in an MHIS. • It is necessary to make a distinction between indicators and raw data (or data elements). What distinguishes indicators from raw data is that indicators are aggregates of the minimum data that have a denominator. Both indicators and minimal data have value for information systems. At a case-level transaction data). At a system level, data need to be converted into indicators to enable overall service planning and policy evaluation. • Indicators can be used to measure various aspects of the mental health system: • Needs 2.Inputs 3. Processes 4.Outcomes
Examples for indicators : • Needs : the population for mental health Care ( percentage of population that belongs to vulnerable groups ) • Input: the resources that are put into the mental health are system (e.g. human resources finances medication )example:number of mental health professionals per 100.000 population • Processes : activities of the service (e.g.annual number of admissions to mental hospitals per 100 000 population ) • Outcomes: the effect of the service on the mental health of the population being served (e.g. reduction of symptoms , percentage of discharges) • For more examples review the monthly indicators from MHIC on the website for MHS
What are the benefits of an MHIS? • An MHIS is a planning service delivery tool to improve effectiveness, efficiency and equity. • As a planning tool: →It can offer a way of providing accurate, consistent information about a mental health service. →It helps improve coherency of planning; rational planning is not possible without accurate information. →It is an essential tool in policy implementation and evaluation. Without accurate information, policy-makers cannot assess whether policy objectives are being achieved. • As a service delivery tool: →It can assist service providers by recording and monitoring the needs of individual service users. →It provides a means of reporting the interventions that are used, and can thus be linked to the ongoing improvement of service quality.
Effectiveness:By including indicators explicitly determined by the policy framework of the mental health service, the MHIS provides information on whether and to what extent the stated aims and objectives of the service are being met. For example, if a policy objective is to integrate mental health services into primary health care, the MHIS can be used to assess the extent to which this is in fact happening. Similarly, by monitoring the clinical interventions that are being used, service providers can continually assess their effectiveness. • Efficiency:By providing the means to assess input, process and outcome components, the MHIS provides some measures on how well resources are being used. Importantly, information can be used to secure appropriate levels of funding for the mental health service. • Equity:By explicitly measuring need and coverage, the MHIS addresses a central challenge facing the mental health service: providing equitable care with scarce resources. The MHIS can improve accountability both within the organization as well as to people with mental disorders, their families and advocacy groups.
For full list of indicators and follow up on system updates for the Mental Health Information system for MOH • Please check the website for MHS : • www.mhsecretariat.com
Qualitative studies • Qualitative studies are usually used to measure benefits or attitudes in situations where quantitative research would be less meaningful or impractical. Results are usually presented as text without numbers or figures in a way which is intended to preserve the richness of the data in its rightful context. • example, ‘What are the attitude of patients with borderline PD to their diagnosis?’ might be answered better by describing what the patients actually said than by performing a survey and summarizing attitudes on a scale with medians and inter-quartile ranges. • Example : Focus Groups
References • Oxford Hand Book of Psychiatry , 1st Edition • Core Psychiatry , 2nd Edition • WHO Mental Health Policy and Service guidance package ; Mental Health Information Systems • World Wide Web
Useful websites for EBM • WWW.COCHRANE.ORG • WWW.CEBM.NET • WWW.EBMNY.ORG
Thank You Dr. Fahmy Bahgat, ABPsych. Manger Mental Health Information Center,MHS,MOHP