PowerPoint Presentation

Saudi Psychiatric Association

Saudi Psychiatric Association

Learning ObjectivesConcepts and Definitions: EBM, CPGsWhy do we need CPGs ?Who needs CPGs ?How to find CPGs on the Web?How do we react to CPGs?CPGs Development, Adaptation, Dissemination and Implementation

Concepts & DefinitionsEBM?..EBP?...CPG?

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

EBP definitionThe integration of best research evidence with clinical expertise and patient valuesSackett et al 2000

EVIDENCE BASED PSYCHIATRY

8

Acquire the best evidenceAppraise the evidenceApplyevidence to patient careAssess your patientAsk clinical Questions(PICO)

EBM Method

9Alternative to next slide

EBM ResourcesCochrane libraryhttp://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

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.

Clinical Practice Guidelines (CPGs)

CPGs New DefinitionCPGs 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

WHY do we need CPGs?

Rationale for CPGs

Worldwide concerns about:-Unexplained variations in clinical practiceRising health care costsExponential growth of information ????

Aim of CPGs:-To facilitate more consistent, effective and efficient practice and improve health outcomes for patients

Evidence-Based CPGsClinical Care GAP

Current Practice

Best Practice

Guidelines

WHO needs CPGs?

Stakeholders

DoctorsNursesDecision makersPatientsPublic

CPGs on the Web

How to Find CPGs?

CPGs on the Web

CPGs ProducersSpecialized Psychiatry societies:- American Psychiatry AssociationAmerican Academy of Child & Adolescent PsychiatryCanadian Network for Mood & Anxiety TreatmentsThe Maudsley Hospital, NHS, UKNational CPGs agencies:- NICE - UK SIGN - UK

American Psychiatric Association

AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

15 Current CPGs

The Maudsley Hospital

SIGNScottish Intercollegiate Guidelines Networkwww.sign.ac.uk

CPG Producers:National Agencies12 CPGs

CPG Producers:National Agencies

NICENational Institute for Health & Clinical Excellencewww.nice.org.uk

132 CPGs

CPGs Finders

1- National Guidelines Clearinghouse (NGC)2- Guidelines International Network (G-I-N) 3- DynaMed database4- PubMed/MedLine5- Google/ Google Scholar:

CPG Finders National Guideline Clearinghouse (NGC)www.guidelines.gov

408 CPGs

CPG FindersGuidelines International Network (G-I-N)www.g-i-n.net EBHC-KT Chair, King Saud UniversityOrg. Member since 2009 (3rd Member from MENA Countries)

Shaikh Bahamdans Research Chair for Evidence-Based Health Care & Knowledge TranslationMember of G-I-N since Oct. 2009Free access to International CPG Library of G-I-N

http://c.ksu.edu.sa/ebhc

http://ebhc.ksu.edu.sa/gin/index.html

DynaMedhttps://dynamed.ebscohost.com/

CPG FindersPubMedUS National Library of MedicineNational Institutes of Health (NIH)

Some CPGs are only retrievable by Googling them!

Extensive search for BAD CPGsInternational (13) 2004-2011USA (8) 2004-2011UK (4) 2005-2013Canadian (12) 2004-2013Review articles (evidence) (28) 2007-2013

How do we react to CPGs?

CPGs ?

Strength/ LevelEVIDENCE PYRAMID

Evidence Pyramid

SRRCTCohortCase controlCase seriesCase reportExpert opinion

I

II

III

IV

ABCLevels of EvidenceGrades of Recommendations

TopicTeamContentSearchFOUNDNOT FOUNDAppraiseDevelopAppraiseAdopt or AdaptDissemination - ImplementationEvaluate impact

Guideline AdaptationIs 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/

CPG Scope: PIPOH ModelPatient (& disease characteristics)Intervention(s)Professionals (Target users)Outcomes (purpose of the CPGs)Healthcare settings (& context)

= Health/ Clinical/ Key Questions

How to assess of the quality of any CPG ?

Assess guideline quality

ADAPTE TOOL 9 AGREE II Instrument

23 items in 6 domains 7 point response scale Domain scores Recommendations

23 Items in 6 DomainsUSERS MANUAL page 7

DOMAINSNo. of Items1Scope & Purpose32Stakeholder Involvement33Rigour of Development (Methodology)84Clarity & Presentation45Applicability36Editorial Independence2

AGREE Enterprise website http://www.agreetrust.org/

If CPGs are to have a positive impact on patient care outcomes they must be implemented into daily clinical practice

Implementing Guidelines

CPGs Are Not RulesExpect 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 .

Clinical ScenarioAn 82 year-old female with dementia is admitted to the Black Lion Hospital for recurrent falls. She is found to have Alzheimers 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?

Acknowledgments Prof. Dr. Lubna Al-AnsaryProfessor, Consultant, Family MedicineHolder, Shaikh Bahamdan EBHC-KT ChairHead, CPGs Committee, University HospitalsKing Saud UniversityMember, G-I-N Board of TrusteesCo-chair, G-I-N Adaptation Working GroupProf. Dr. Eman Abahussein Professor, Consultant, PsychiatryHead, Psychiatry CPGs SubcommitteeCollege of Medicine & King Khalid University HospitalKing Saud UniversityDr. Yasser S. AmerPediatrician - Healthcare InformaticianCPGs General Coordinator, QMD, CPGs Committee,King Saud University Hospitals (KKUH/KAUH)Member, G-I-N Adaptation Working Group/Steering Committee

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