Position Statement 12: Evidence-Based Healthcare
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Policy Position
Mental Health America is dedicated to accelerating the translation of scientific knowledge to practice and policy implementation. This focus on evidence-based healthcare spans the development, evaluation, translation, dissemination and implementation of both scientific and practical knowledge about mental health disorders and their treatment.
Mental Health America believes that scientific evidence is vital to the development of an informed decision-making partnership between consumers and providers. Evidence-based healthcare must balance scientific knowledge, clinical expertise and experience, and consumer and family values to inform healthcare delivery and decision-making. To ensure this balance, processes for determining relevant evidence and for applying such findings to practice and policy must be transparent and driven by consumer and family perspectives and values. Mental Health America opposes processes and policies that emanate from cost containment objectives. Moreover, our organization opposes the misuse of the concept of evidence-based practice as a justification for denial of coverage, reimbursement or access to care.
Mental Health America believes that a common standard must be developed for determining what constitutes an evidence-based practice. Currently, such standards are defined by professional and governmental entities with such variation that confusion exists about which practices ought to prevail.[1] In defining this standard, Mental Health America supports the role of all levels of evidence –including randomized clinical trials, quasi-experimental studies, observational studies and expert consensus –in creating the evidence base for an intervention or service.
Mental Health America believes that greater investment must be made in long-term research that demonstrates not only the efficacy of treatments and services but also their effectiveness in real-world settings that account for the breadth of experience and the unique and varied health status and diversity of the larger population. Such research should focus on outcomes that are relevant to consumers and families. To that end, consumer and family input and involvement must drive both research design and development so that the evolving evidence base represents the values, goals and priority health outcomes they seek. Furthermore, research findings should be published in layperson language so the general public can understand and utilize the information in their healthcare decision-making.[2]
Mental Health America believes that cultural competency is an essential element of evidence-based healthcare. The unique cultural perspectives and outcomes relevant to diverse populations need to be incorporated at all levels of evidence development and implementation. It is vital that “evidence-based”policy, practice or service changes not be implemented with ethnic and cultural groups when there is inadequate research and evaluation about effectiveness and appropriateness for those groups.
Background
The boundaries of scientific research are stretching and revealing new
understanding and options for treating many chronic illnesses, including
mental health disorders. Even as emerging science gives us information about
how and why mental illnesses affect individuals, and about genetic biomarkers
that may better guide treatment choices, it also reveals the absence of universally
effective treatments and practices. In addition, the findings from
the Institute of Medicine illustrate that it takes nearly two decades for
such knowledge to translate into effective practice and policy that can influence
treatment choices for an individual.[3]
Evidence-based medicine and evidence-based practice –often used synonymously –are
not new concepts in the healthcare field and arose in academic circles and
among public and private payers as a cornerstone for quality improvement and
improved healthcare decision-making. Several factors contribute to the growing
emphasis on “evidence,”including the pressure to address escalating
healthcare costs while addressing the needs of the uninsured and quality-focused
health system trends such as pay-for-performance and program and treatment
outcome measurement.
The terminology has been introduced into the mental health context more recently. Prominent reports from the Surgeon General[4], the President’s New Freedom Commission on Mental Health[5] and the Institute of Medicine[6] all underscore the importance of narrowing the gap between research and implementation of evidence-based practices. Consequently, government agencies, private-sector health plans, academic research centers and industrial stakeholders are dedicating enormous resources to evaluating current science and practice, disseminating information about best and promising practices and technologies, and guiding the implementation and replication of such evidence-based approaches to healthcare.[7]
Although the term “evidence-based”is more widely recognized, there remains some confusion over the lack of a common definition. This is a vital factor in determining how evidence is developed and applied in the real-world healthcare context. For example, some experts identify “evidence-based practices,”as “interventions for which there is scientific evidence consistently showing that they improve client outcomes.”[8] Another widely cited definition of evidence-based medicine is “the integration of best research evidence with clinical expertise and patient values.”[9] More narrowly drawn definitions may lead to an overemphasis on scientific proof and the exclusion of important perspectives from both clinicians and, most important, from people in recovery from mental illnesses.
Opportunities & Challenges
A stronger focus on evidence base presents an opportunity to improve the quality of mental health care, empower consumers and families to seek and demand continually improving care and services and ensure consistently better and meaningful outcomes for consumers and families. In addition, there is the opportunity to redeploy mental health system resources on outcome-driven programs and practices and to incorporate the recovery paradigm into the services and supports that consumers receive.
For example, the Substance Abuse and Mental Health Services Administration (SAMHSA)’s Center for Mental Health Services and the Robert Wood Johnson Foundation are currently funding a multi-phase initiative on evidence-based practices for mental health. This project has yielded standardized guidelines and training materials to assist states and programs in implementing five evidence-based practices: assertive community treatment (ACT), supported employment, integrated treatment for co-occurring mental health and substance abuse disorders, family psychoeducation and illness self-management.[10] Building on emerging evidence about cost-effectiveness, outcomes and workforce enhancement, a toolkit addressing peer-provided services is forthcoming. Although not part of the toolkit initiative, SAMHSA also recognizes three heavily researched evidence-based practices for children: therapeutic foster care, multi-systemic therapy (MST) and positive behavioral interventions and supports. According to the National Association of State Mental Health Program Directors (NASMHPD), as of 2002, at least 47 states were implementing one or more of the five practices using the toolkits.[11]
There are several challenges to the effective realization of evidence-based
healthcare.
As the private and public market rush to embrace anything labeled “evidence-based,”one
concern is that policymakers and administrators will inappropriately use evidence-based
findings solely as a cost containment tool and, in the process, stifle the
program innovation and growth of new technologies, therapies and practices.
Of highest concern is the potential for using narrowly defined evidence-based
practices to the exclusion of other treatments or programs for which a rigorous
evidence base has not been developed. Such efforts ultimately will restrict
both choice and quality of care for the consumer.
Consumers of mental health services are particularly concerned that existing evidence-based practices were developed and evaluated in the absence of the recovery paradigm and therefore have little real-world relevance to their quest for a full life in the community. Moreover, the existing research base is ill-fitted to address the values surrounding recovery, including individualized care, holistic care and peer support. Clinical research design –particularly the “gold standard”of randomized controlled trials –do not effectively measure important outcomes, such as quality of life, employment, relationships, and the impact of side effects of different treatments. Realities of the individual consumer (age, gender, ethnicity, co-occurring disorders, and treatment goals and preferences) often are not captured as part of this research. It should be noted that more recent practical trials are designed with an eye toward improving the collection of such information, but it will take time to build this more relevant body of evidence.
A related concern is the dearth of research focused on response differences by people of different age, gender, race and ethnicity. Evaluations of existing scientific evidence by the Agency for Healthcare Research and Quality (AHRQ) and other entities demonstrate the limitations of clinical trials in terms of adequate participation by patients of across age, gender, and racial and ethnic minorities. This affects the ability to generalize science-based findings to real-world treatment practices. From a practice and policy perspective, drawing short-term conclusions based on limited evidence may have the unintended consequence of exacerbating health care disparities.
Policy and program barriers to implementation of evidence-based practices in the mental health care system are a reality in every community. Such barriers include organizational structure, limitations on financing, unique state regulation and licensing issues, the lack of clear guidelines and models for implementation, workforce shortages and lack of sufficient training resources, technology deficits and resistance to change.
Call To Action
Mental Health America envisions a healthcare system that ensures accessible,
high-quality care for all people regardless of treatment setting, disability,
racial or ethnic background, and income. The growing emphasis on evidence
development and the determination of evidence-based practices holds the promise
of moving the healthcare system toward our vision. And yet, current debate
and decision making also have the potential to generate policies and practices
that curtail innovation and overlook promising treatment approaches that are
on the threshold of being “evidence-based.”It is therefore essential
that stakeholders in the mental health community become familiar with the terminology
and proliferation of initiatives that focus on evidence-based healthcare. In
addition, consumers, families, clinicians, and providers must work to identify
and promote key questions for future research that are relevant to the consumer
and address issues with respect to differences in age, gender, health status,
race and ethnicity. Finally, stakeholders must advocate for the following principles
in achieving evidence-based healthcare:
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Transparency. The process to evaluate evidence and develop evidence-based programs, interventions, treatments and policies should be open to the public and include stakeholders in the decision making process. Consumers and families should have active and meaningful roles on review, evaluation and governing bodies that make decisions about how to apply evidence in practice and policy. In addition, clear and complete research findings should be communicated to consumers and families, and tools and practices should be developed to aid consumers in how to use such information in their dialogue with caregivers.
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Individualized Care. Scientific and practical evidence can aid in determining what is the best intervention to optimize an individual’s care, but such evidence alone cannot guarantee the right choice for every individual. Therefore, it is important that reimbursement and coverage policies reflect the need for individualized care and maintain flexibility for clinicians and individuals to access a range of treatments and services. In addition, it is important to advocate for wider investment in practical clinical trials and other research methods that generate evidence applicable to real-world treatment settings.
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Consumer-relevant Outcomes. The inclusion of consumers and families in the discussion and determination of clinical trials and other research is also important because they can articulate what research is most relevant to their quality of life and health outcomes. Current research is heavily focused on symptom management rather than on more relevant quality outcomes such as ability to work, independent living and social connectedness. More important, inclusion of people affected by mental illness can ensure that evidence-based healthcare is grounded in the recovery paradigm.[12]
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Quality First. Safety and finding the right treatment for the individual should be the top goal of an evidence-based healthcare system. Treatment costs are relevant to the discussion but must be weighed in the system context –total care costs for an individual across services and settings –rather than as unit costs. In the context of clinical decision making, cost should be evaluated by providers and consumers after a careful weighing and discussion of benefits and risks and a dialogue that emphasizes choice across a range of therapeutic options.
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Fidelity. Adherence to program standards and principles is important to ensure reliable outcomes. Ongoing fidelity measurement is especially important in programs or practices that have been altered to suit the geographic, ethnic or cultural needs of those being served. While exact implementation may not be possible or desirable, providers need to document the changes being made and rigorously measure the outcomes and the effects of the changes. Policymakers should take fidelity issues into consideration when crafting policies so that they are flexible and appropriate.
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Cultural and Linguistic Competence. Mental health research has too often excluded diverse populations, which has created an even wider gap between research and practice for racial and ethnic minorities.[13] Similar issues arise in the application of research findings to different groups based on age, gender and sexual orientation. Cultural competence must be integrated into all evidence-based practices and at all stages of implementation. Research should be designed and developed by and with input and participation from members of specific cultural and ethnic populations. Practices should be adapted, whenever appropriate, to the cultural and linguistic groups being served. Outcomes of evidence-based practices should be evaluated in terms of culture-specific and culturally relevant outcomes.
Effective Period
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Page last updated: 09/20/2007