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Evidence-Based Practice in Chile PAPER Constanza Caneo1 and Jorge Calderón2

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Evidence-Based Practice in Chile PAPER Constanza Caneo1 and Jorge Calderón2 THEMATIC Evidence-based practice in Chile PAPER Constanza Caneo1 and Jorge Calderón2 1Adult Psychiatrist, Liaison stability, there are several problems regarding Psychiatry Unit, Pontificia Over the past few decades, the emergence of the provision of healthcare in Chile. The national Universidad Católica de Chile, evidence-based practice medicine (EBP) has Santiago, Chile public health system provides services for 72.2% allowed a change in the integration of 2Adult Psychiatrist, Head Liaison of the population. The Ministry of Health over- fi knowledge with policy making and health Psychiatry Unit, Ponti cia sees the design, coordination and execution of Universidad Católica de Chile, service development, and Chile has been Santiago, Chile. Email: jcaldep@ health services in the public sector; however, influenced by EBP with no exemption. In this gmail.com its involvement in the private sector is rather paper, we will describe the impact of the EBP restricted, which considerably reduces the impact Conflicts of interest. CC collabo- model at different levels of the Chilean health rates without economical incen- of EBP in this sector (Chilean Ministry of Health, system, including the development of national tives with Epistemonikos in the 2014). depression study group. None of clinical guidelines, medical training and in- the authors have or ever had An example of the impact of a mixed planning work in any government institu- patient involvement in health awareness. tion. None of the authors have model in Chile is shown in the results of a study collaborated in the development conducted by Araya et al (2006). The study of GES Guidelines. Both authors showed that differences in access to healthcare have worked in the public sector. Over the past few decades, medical teaching and Currently, both authors work in a is dependent upon the type of system used private sector health provider and practice around the world has been considerably (private/public) rather than due to the severity of in a private academic institution. modified by the expansion of the evidence-based None of the authors received the illness. The most graphic finding was that pri- economical incentives for the medicine (EBM) model developed by David vate sector patients were three times more likely development of this paper. None et al Sackett (Guyatt, 1991; Sackett , 1996)asit than those in the public sector to have a consult- of the authors have formal or fl informal relationships or have has in uenced research, medical school teaching ation in mental health over a 6-month period, receive monetary incentives from curriculums and health service development. fl any pharmaceutical company. JC an association that was not in uenced by disability has actively collaborated in the Nowadays, along with skills with an emphasis on or mental health illness severity (Araya et al, development of a Mental Health empathy, assertive communication and provision Law in Chile. 2006). This implies that there is a great need for of emotional comfort for patients, incorporating the design and application of a health policy doi:10.1192/bji.2017.20 recent research into clinical practice has become that applies to the whole population, throughout essential. The focus on improving skills such as the country. © The Authors 2018. This is an efficient searching of information, comprehensive Open Access article, distributed In 2006, as a way to palliate differences in under the terms of the Creative reading, and critical appraisal of neurosciences access to adequate healthcare and to equalise ser- Commons Attribution- represents the link that combines the knowledge NonCommercial-NoDerivatives vice provision, the Ministry of Health developed licence (http://creativecommons. generated from EBM with the development the National Guidelines for Clinical Practice GES org/licenses/by-nc-nd/4.0/), which of healthcare policies and health services, and permits non-commercial re-use, (Garantías Explícitas de Salud or Explicit distribution, and reproduction in this is known as evidence-based practice (EBP) Guaranteed Access to Health). any medium, provided the ori- (Tanenbaum, 2005). The guidelines are mandatory by law and ginal work is unaltered and is The EBP paradigm implies that every decision properly cited. The written per- every physician practising medicine within the mission of Cambridge University must be supported by the best current evidence, Chilean territory must respect the minimum stan- Press must be obtained for com- a process relevant and necessary for standardisa- mercial re-use or in order to cre- dards suggested in the guidelines for diagnosis, ate a derivative work. tion and the assurance of a better provision of treatment and follow-up of the specified diseases. healthcare for patients, considering the available These guidelines are evidence based and are gen- resources and the sustainability for the planned erated from recommendations by an expert panel fi treatment over time. In Chile, the lack of suf - elected by the Ministry of Health. The panel cient infrastructure and the need to import reviews the collected information using strategies knowledge for clinical decision making because from EBM search and evidence assessment – of scarce locally conducted research has limited such as the Grading of Recommendations, Assess- the implementation of EBP. Despite these limita- ments, Development and Evaluation (GRADE) fl tions, the EBP model has in uenced several areas system developed by the Cochrane Collaboration in Chilean medicine, ranging from medical train- – and classifies the quality of evidence of a certain ing programs to the development of national recommendation alongside a visual summary of guidelines (see Fig. 1). clinically relevant findings (Subsecretaría de Salud Pública, 2014). Development of national guidelines A good example of national guideline develop- Chile has a population of 18 million inhabitants, ment is the National Depression Detection and with an income per capita of around US$ Treatment Program, which was developed in 20 000, a Gini coefficient of 0.51 and a life expect- 2004 following a national disease-burden study ancy of 82 years. Despite economic growth and that identified depression as an urgent matter 58 BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 3 AUGUST 2018 Downloaded from https://www.cambridge.org/core. 24 Sep 2021 at 04:06:11, subject to the Cambridge Core terms of use. Education Evidence & research Scarce locally conducted experimental EBM in Medical school studies curriculum Limited financial support for research Local Diplomas and medical (predominantly from governmental continue education programs institutions) of EBM Imported evidence: Journal clubs No epidemiological surveillance Two fold translational process: language & cultural validation plus applicability assessment Diverse understanding of “evidence”: implications in translation of evidence and guideline implementation Clinical practice Weak input for policy making & national guideline development Patient level Clinician level National level Individual level: Easy access to internet and Resources: National Guidelines: Values and patient’s expectations: update information Quality accreditation processes by standardized minimal High access to internet and Epistemonikos international & national agencies (Joint interventions for illnesses mobile technology Commission International. Chilean Ministry of covered by GES: Free access to clinical guidelines Scholarships for national and Health). Only hospitals of the private sector Depression, Bipolar Cultural aspects of health international continuing undergo accreditation process by disorder, Schizophrenia, Immigration status education, postgraduate international agencies Alcohol & drug use studies and felowship Limited infrastructure disorders. Developed by group level: programs Holistic medicine and traditional medicine Governmental Institutions. Human Rights Observatory for people inclusion in the national health system with severe mental illness (Mapuche Medicine) NGOs to support people with mental illness Law reformations lead by patients (Ricarte Soto’s Law) Legislation: absence of mental health law. Private sector: easier and earlier access to health care. Patient need oriented. Lack of hierarchy structure. Easy access to specialists. Not GP center. Better work quality for physicians, better pay. Public sector: longer wait lists, GP center model. Public health oriented system. Better inclusion of psychosocial teams in the system. Better follow up of complex patients. Poor work quality for physicians, underpaid Fig. 1 Influence of the EBP model at different levels of the Chilean health and medical education systems. for the Ministry of Health. The program was suc- Currently there are four clinical guidelines rele- cessfully scaled up nationally after a pilot study vant for psychiatry: depression, schizophrenia, bipo- and became one of the 80 medical conditions cov- lar disorder and alcohol and substance abuse, which ered by GES (Araya et al, 2012). The diagnostic are updated every 5–6 years. Unfortunately, these procedures, pharmacological and psychological evidence-based guidelines lack a systematic assess- treatment, and clinical follow-up suggested by ment for implementation fidelity and patient satis- the guidelines are covered by health insurance faction is not considered (González-Valderrama in both public and private healthcare sectors, et al, 2015). Moreover, there is no available database including coverage for electroconvulsive therapy
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