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A Presentation that promotes Evidence-Based Psychiatry and informed clinical decision making in the daily practice of Psychiatry. Prepared by Dr Yasser Amer and Dr Maged Elesely

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  1. 1. Saudi Psychiatric Association
  2. 2. Saudi Psychiatric Association
  3. 3. Learning Objectives 1. Concepts and Definitions: EBM, CPGs 2. Why do we need CPGs ? 3. Who needs CPGs ? 4. How to find CPGs on the Web? 5. How do we react to CPGs? CPGs Development, Adaptation, Dissemination and Implementation
  4. 4. Concepts & Definitions
  5. 5. Two Different Approaches to Evidence-Based Psychiatry Practice Clinical Practice Guidelines (CPGs) •“Top-down” approach • Tell clinicians how to practice • Favored by health care systems Evidence-Based Medicine (EBM) •“Bottom-up” approach • Teach clinicians how to find answers • Favored by medical educators
  6. 6. EBP definition The integration of best research evidence with clinical expertise and patient values Sackett et al 2000 EVIDENCE – BASED PSYCHIATRY
  7. 7. EBM Method Assess Ask clinical Questions your patient (PICO) Acquire the Appraise best evidence the evidence Apply evidence to patient care
  8. 8. EBM Resources • Cochrane library http://www.cochrane.org/ A lot of ready appraised studies that answer PICO questions (High quality SRs and RCTs). • Clinical Evidence - BMJ: http://clinicalevidence.bmj.com/x/index.html
  9. 9. Clinical Practice Guidelines (CPGs) Definition: (old) “Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Institute of Medicine 1990). Increasing international interest in the development and implementation of CPGs.
  10. 10. CPGs New Definition CPGs are “Statements that include Recommendations intended to optimize patient care that are informed by a Systematic Review of evidence and an assessment of the benefits and harms of alternative care options”. Committee on Standards for Developing Trustworthy CPGs (IOM-AHRQ) 2011
  11. 11. Rationale for CPGs • Worldwide concerns about:▫ Unexplained variations in clinical practice ▫ Rising health care costs ▫ Exponential growth of information ???? • Aim of CPGs:▫ To facilitate more consistent, effective and efficient practice and improve health outcomes for patients
  12. 12. Clinical Care GAP Best Practice
  13. 13. • Doctors • Nurses • Decision makers • Patients • Public
  14. 14. How to Find CPGs?
  15. 15. Producers Finders
  16. 16. • Specialized Psychiatry societies:• American Psychiatry Association • American Academy of Child & Adolescent Psychiatry • Canadian Network for Mood & Anxiety Treatments • The Maudsley Hospital, NHS, UK • National CPGs agencies:  NICE - UK SIGN - UK
  17. 17. American Psychiatric Association
  19. 19. 15 Current CPGs
  20. 20. The Maudsley Hospital
  21. 21. CPG Producers: National Agencies SIGN Scottish Intercollegiate Guidelines Network www.sign.ac.uk 12 CPGs
  22. 22. CPG Producers: National Agencies NICE National Institute for Health & Clinical Excellence www.nice.org.uk
  23. 23. 132 CPGs
  24. 24. CPGs Finders 1- National Guidelines Clearinghouse (NGC) 2- Guidelines International Network (G-I-N) 3- DynaMed database 4- PubMed/MedLine 5- Google/ Google Scholar:
  25. 25. 408 CPGs National Guideline Clearinghouse (NGC) www.guidelines.gov
  26. 26. Guidelines International Network (G-I-N) www.g-i-n.net EBHC-KT Chair, King Saud University Org. Member since 2009 (3rd Member from MENA Countries)
  27. 27. Shaikh Bahamdan’s Research Chair for Evidence-Based Health Care & Knowledge Translation Member of G-I-N since Oct. 2009 Free access to International CPG Library of G-I-N
  28. 28. http://c.ksu.edu.sa/ebhc
  29. 29. http://ebhc.ksu.edu.sa/gin/index.html
  30. 30. DynaMed https://dynamed.ebscohost.com/
  31. 31. PubMed US National Library of Medicine National Institutes of Health (NIH)
  32. 32. Some CPGs are only retrievable by “Googling” them!
  33. 33. Extensive search for BAD CPGs • • • • • International (13) 2004-2011 USA (8) 2004-2011 UK (4) 2005-2013 Canadian (12) 2004-2013 Review articles (evidence) (28) 2007-2013
  34. 34. Adapt Develop Adopt Read CPGs ?
  35. 35. Strength/ Level Evidence Recomm. EVIDENCE PYRAMID
  36. 36. I SR A RCT II Cohort Case control B III Case series Case report IV Expert opinion C Grades of Recommendations Levels of Evidence Evidence Pyramid
  37. 37. Topic Team Content Search FOUND NOT FOUND Appraise Develop Adopt or Adapt Appraise Dissemination - Implementation Evaluate impact
  38. 38. Guideline Adaptation • Is the systematic approach to the endorsement and/or modification of a guideline(s) produced in one cultural and organizational setting for application in a different context. Adaptation may be used as an alternative to de novo guideline development, e.g., for customizing (an) existing guideline(s) to suit the local context. • http://www.adapte.org/
  39. 39. ©Copyright ADAPTE 2007
  40. 40. CPG Scope: PIPOH Model Patient (& disease characteristics) Intervention(s) Professionals (Target users) Outcomes (purpose of the CPGs) Healthcare settings (& context) = Health/ Clinical/ Key Questions
  41. 41. How to assess of the quality of any CPG ?
  42. 42. Assess guideline quality ADAPTE TOOL 9 AGREE II Instrument 23 items in 6 domains 7 point response scale Domain scores Recommendations
  43. 43. 23 Items in 6 Domains USER’S MANUAL page 7 No. of Items DOMAINS 1 Scope & Purpose 3 2 Stakeholder Involvement 3 3 8 4 Rigour of Development (Methodology) Clarity & Presentation 5 Applicability 3 6 Editorial Independence 2 4
  44. 44. AGREE Enterprise website http://www.agreetrust.org/
  45. 45. Implementing Guidelines If CPGs are to have a positive impact on patient care outcomes they must be implemented into daily clinical practice
  46. 46. CPGs Are Not Rules • Expect the vast majority of practice to fall within CPGs (80 % - 90 % Rule) • Deviation from CPGs is allowed for specific patients with specific circumstances. • When such deviation occurs an individual clinician is expected to explain the rationale. • Strong evidence (Level 1 & 2) are expected to be followed. • Weaker evidence (Level 3 & 4) can be handled differently .
  47. 47. Clinical Scenario An 82 year-old female with dementia is admitted to the Black Lion Hospital for recurrent falls. She is found to have Alzheimer’s dementia and she is on no medications. The patient has never learned to read or write so a Mini Mental Status Examination was not possible. The diagnosis was made on clinical grounds with collateral from her family. However, she is agitated at night. Her family is against antipsychotic medication and the team has asked if there are any other classes of medication that are helpful for agitation. She will return to her family in the countryside once this problem is addressed and the family cannot manage her otherwise. The treating team questions the role of antidepressants in treating behavioural symptoms in dementia patients and would like to know if there is support for a specific antidepressant in this case?
  48. 48. Best Evidence Evidence-Based Psychiatry Traditional CPGs Textbooks (Recommendati ons + Evidence) Evidence PIPOH PICO (CPG Websites) (EBM Websites) Journals Experts
  49. 49. Best evidence Patient values My Clinical Experience Evidence-Based (Best Practice) Psychiatry
  50. 50. Acknowledgments • Prof. Dr. Lubna Al-Ansary Professor, Consultant, Family Medicine Holder, Shaikh Bahamdan EBHC-KT Chair Head, CPGs Committee, University Hospitals King Saud University Member, G-I-N Board of Trustees Co-chair, G-I-N Adaptation Working Group • Prof. Dr. Eman Abahussein Professor, Consultant, Psychiatry Head, Psychiatry CPGs Subcommittee College of Medicine & King Khalid University Hospital King Saud University • Dr. Yasser S. Amer Pediatrician - Healthcare Informatician CPGs General Coordinator, QMD, CPGs Committee, King Saud University Hospitals (KKUH/KAUH) Member, G-I-N Adaptation Working Group/Steering Committee
  51. 51. Thank you for Listening ! 