Download - Finding Current Best Evidence
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 1/20
FINDING
CURRENTBEST EVIDENCE
Dr. Retno Asti WerdhaniDept. Ilmu KedokteranKomunitas FKUI
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 2/20
Knowledge Deterioratesin Time
knowledge
of current
best care
. ..
. . .... ....... ....
....
... ...
..
r = -0.54
p<0.001
years since
graduation
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 3/20
INTRODUCTION ‘Half of what you are taught will in 10 years have been shown to be wrong. Andthe trouble is, none of your teachersknows which half’ (Sydney Burwell, MD.Dean of Harvard Medical School, 1956)
Keeping up to date with current bestevidence for the care of our patients ischallenging
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 4/20
INTRODUCTION ‘Best evidence’ resources are built
according to an explicit process that
values research according to itsscientific merit and clinical relevance
Search engine : electronic or pocket
notebook Easy navigation from clinical question
to evidence-based answers.
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 5/20
Where to find the best evidence?
(Traditional) textbook :
- Useful for pathophysiology of clinicalproblems
- Not to use for establishing the cause,
diagnosis, prognosis, prevention ortreatment of a disorder
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 6/20
Where to find the best evidence? Textbook to be dependable in the modern era :
Revised frequently (at least once a year)
Heavily referenced (at least about diagnosis
and management) Evidence in support
Citation or web-linked textbooks isencouraging, but none of these providessystematically critically appraised evidence.
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 7/20
Invest in evidence databases Evidence-based Medicine Review
(EBMR) www.ovid.com
Cochrane Libraryhttp://update.cochrane.co.uk
US National Library of Medicinehttp://www.ncbi.nlm.nih.gov/pubmed
http://www.biomednet.com
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 8/20
Invest in evidence databases- Internal Medicine
www.annals.org
http://www.acponline.org - Pediatric
http://pedsccm.wustl.edu/EBJournal_cl
ub.html - Family Practice
http://www.jfponline.com
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 9/20
Invest in evidence databases- http://bmj.bmjjournals.com/
- http://content.nejm.org/
- http://hiru.mcmaster.ca - http://bmjupdates.mcmaster.ca/index.a
sp
- www.freemedicaljournal.com
- http://www.guidelines.gov
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 10/20
How to control the evidence that
finds you ? Trade in your (traditional journalsubscription
Invest in evidence-based journals andonline services
ACP Journal Club summarize the bestevidence from high-quality studiesselected from all the journals ofrelevance to our clinical interest(general)
Applicable clinical decision
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 11/20
Making answerable questionP : Patient and/or Problem
I : Intervention
(C) : Comparation in intervention (if relevant)
O : Outcome
(M) : Methods
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 12/20
What’s the best evidence
for each domain? 1. Therapy/Prevention
Double blind randomized controlled trialSystematic review with meta-analysis;
Prospective controlled study.
2. Etiology/Cause/HarmRCTs or systematic reviews are the beststudy designs;Case-control studies are usually the bestavailable; but sometimes a case study is theonly evidence available.
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 13/20
What’s the best evidence
for each domain? 3. Diagnosis
Prospective cohort studies, with blind
comparison to the gold standard
4. Prognosis
Systematic review of homogeneouscohort studies
Cohort study
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 14/20
Levels of Evidence
1. Systematic review with meta-analysis of highquality randomized controlled trials with low
heterogeneity.2. Well-designed Randomized Controlled Trial(preferably double-blind)
3. Systematic review of observational studies.
4. Well-designed observational studies(prospective are considered to be stronger orless potentially biased than retrospective)
5. Unsystematic clinical reports: case study,case series
6. Authority, population studies, bench studies
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 15/20
CasesUrinary Tract Disorders
A 35-year old woman sees you for asecond episode of dysuria and fever.For the first episode 3 months ago, shewas seen and treated by another GPwith a course of co-trimoxazole for 7
days. She was well after that until theday before when the symptomsreturned.
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 16/20
CasesHepatitis B Carrier
Mr Tan is a 35-year-old engineermarried with a 6 year-old son. He hasbeen diagnosed as a Hepatitis B carrier2 months ago while trying to donateblood. His son has had hepatitis
immunization at birth. He has come tosee you for advice.
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 17/20
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 18/20
SUMMARY KEEP ON ASKING
KEEP ON SEARCHING
KEEP ON LEARNING
THAT WILL MAKE YOU A BETTER-
IMPROVED MEDICAL PRACTITIONER
8/13/2019 Finding Current Best Evidence
http://slidepdf.com/reader/full/finding-current-best-evidence 19/20
Take Home Messages ??