EBM

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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

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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.

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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

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• 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

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• 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

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• In order to practice EBM we need to first
  appreciate that we dont always know all the
  answers to our clinical questions. Once that fact
  has been appreciated, the following five skills
  need to be mastered.

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• To be able to ask a clinical question in a way
  that captures the essence of the problemlt is
  structuredlt 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.

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1-Asking the right questions

• P Patient
• I Intervention , Exposure
• C Comparison
• OOutcome
• 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

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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

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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.

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2- Searching for the Evidence

• Searching online Medical Literature
• Boolean Operators
• Searching PubMed
• Tags
• MESH (Medical Subject Heading) Technology

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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

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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

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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

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• Monitoring and Evaluation
• Role of MHIS
• The importance of Evidence Based Planning /
  Evidence Based Management in Mental Health .

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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.

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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.

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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

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• 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

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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.

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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

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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 )examplenumber 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

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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.

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• 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.

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• 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

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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

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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

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Useful websites for EBM

• WWW.COCHRANE.ORG
• WWW.CEBM.NET
• WWW.EBMNY.ORG

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• Thank You
• Dr. Fahmy Bahgat, ABPsych.
• Manger Mental Health Information Center,MHS,MOHP