Evidence Based Medicine

DARWIN AMIRBgn Penyakit SarafRS DR. M. Djamil / Fakultas Kedokteran Universitas AndalasPADANG

Evidence Based MedicineA new paradigm for the health care system

Using the current evidence in the medical literature to provide the best care to patients

Will give you the historical basis and philosophical underpinning of EBM

Medicine in the pre historic had no concept of probability (the ancients and the Greek) the Gods decided all life, therefore that probability did not enter into issues of daily life

After Luca Piccauli (1494) defined basic principles of algebra and multiplication tables introduced the first statistic problem and Girolamo Gardano (1545) introduced the first attempt to use mathematics to describe statistic and probability.

Galileo expanded on this by calculating probabilities using two dice

Thomas Gataker expounded on the meaning of probability by noting that it was natural laws.

Huygens (1657), Leibniz (1662) and Englishman John Graunt (1660) wrote on norms of statistic including the relation of personal choice and judgement to statistical probability.

John Graunt categorized the cause of death of the London populate using statistical sampling and predict the human lifespan.

Graunt statistic can be compared to recent data from the US in 1993

Table : Probability of survival, 1660 and 1993Percentage survival to each age

Medical practice Clinician helps patients by - Diagnosing what is wrong with them - Administering treatment that does more good than harm - Giving them an indication of what the future is likely to hold (prognosis)

Evidence Based Practice in Primary CareThe growing demand for public accountability in health care and the increased availability of information to users -------- >

EBP will be central theme in general practice and the organization of care for many years to come

The need for an EB approach to decision-making in general practice The core of GP is the relationship between the doctor and patient.

Central aspects of this relationship is the process of decision making (range from simple clinical types of decision to decision at a level about how service should be organized

The decisions ought to involve a negotiated in the context of a partnership between the health care professional and the patient and takes account of factors such as patient need, preferences, priorities, available resources and evidence of the effects of providing different forms of care

Evidence fromRandomized Controlled Trials Other Necessary Evidence Effects of care N e e d sMAKING POLICIES AND TAKING DECISIONSProfessional and providers Service users and purchasers researchers and fundersResourcesPriorities

Both the doctor and patient require access to reliable and valid information ----- > to the situation is required.EBM is the phrase used to describe such an approach and entails (from the doctors perspective): - the conscientious - explicit - judicious use GP acquire, wisdom and judgment through their clinical experience

This expertise produces clinical skills and acumen (diligent) in detecting signs and symptoms.

Greater understanding of individuals (predicament, rights and preferences) in making clinical decisions about their care.

The judgment for decision making based on the availability of better research methods for assessing the validity of evidence of effectiveness through to improved techniques for collating evidence in a systematic way

The distinction between EBM and Evidence Based Health Care

How to get started: a five-step process for using an evidence based approach in GP The McMaster University EBM Resources Group have identified a five-step approach need to follow :1. define the problem;2. track down the information sources you need;3. critically appraise the information;4. apply the information with your patients;5. evaluate how effective this application of information is

Step 1: defining the problemQuestions frequently arises, such as pros and conts of using a particular form of therapy, the value of having a particular diagnostic test or screening procedure, the risk or prognosis of a particular disease or the cost of a potential intervention. There is a clinical problem for which you are unsure of the evidence and to make a decision to investigate it further.

Step 2: tracking down the information sources neededMedical literature which can assist in providing answers to the question raised in clinical practice is broadly scattered; journals, family medicine journals and government reports

Step 3: critically appraising the informationDecided which journal articles to read. It is important to read them carefully as not all published is of equal valueCritical appraisal of articles is a process which involves carefully reading an article and analysing its methodology, content and conclusionDo I believe these result sufficiently that I would be prepared to adopt a similar approach or reach a similar conclusion, with my own patients ?.

Step 4: applying the information with your patientsHow to apply the information obtained to the particular circumstances of your patients ?. This is a probably the most crucial step in the process.

Whether there are any methodological issues raised about the evidence which might prompt you to reject it outright.

This process requires a partnership between the doctor and patient. If at the end of the process the decision is made be a mutual and conscientious

Step 5: evaluating how effective it is. Evaluate the effect of the evidence as applied to specific patients. The expected benefits that arose from using a particular item of evidence were consistent with the observed benefits.It may well generate the need for further research to identify why some patients have not responded in the expected manner and what be done to rectify this The practitioner is having sufficient time to apply these steps routinely in their daily practice

Supporting a framework for Evidence-Based Practice within general practiceAs professional you have the challenge and responsibilities in facing general practice

Framework needs to be built around ensuring that the evidence required to inform decision-making is available, accessible, acceptable and applied by GP.

Emerged internationally which aim to produce systematic summaries with trying to practice EBP.

Supporting a framework for Evidence-Based Practice within general practiceGood examples are: - Cochrane library (a database of high quality systematic review of health care)- AGP Journal Club. - BMJ and Lancet. At a more local level, there are a growing number of networks being amongs general practitioner of searching for and appraising evidenceA natural extension of this process is apply EB Protocols and guidelines, develop by he colleagues in clinical practice.

The relevant clinical questions in your patients must contain 4 element: 1). The patients problem. 2). Intervention, which by research methodology, diagnostic test and the treatment 3). If needed with intervention comparable. 4). Clinical outcome or outcome of interest. The 4 element to form the terminology i.e. PICO P= Patient, I = Intervention, C= Comparison, O= Outcome.

Use of theophylline in asthmaFollowing the publication for the management of asthma in adults,dr. A noted the statement that thephylline might have a role inpatients whose asthma was not controlled with high dose inhaledsteroid, but even then alternative treatment might have fewer sideeffects. He decided it was time to review his prescribing oftheophylline and used the practice computer to produce a list of allhis asthmatic patients and their recent medication. He found 86patients, three of whom were taking theophylline. He was reassuredthat his use of theophylline was limited, but made an entry in therecords of each of these patients to remind him to review theirmedication when the patient next attended. Ultimately, he was ableto persuade two of these patients to discontinue theophylline, andafter 6 months the prescribing data were checked again to confirmthat these changes had persisted.

Prognosis- What are the consequences of having the diseaseIs it dangerous ?Could I die of itHow long will I be able to continue my present actives ?Will it ever go away altogether?

The prognosis question A qualitative aspect(which outcomes could happen?)

A quantitative aspect(how likely are they to happen ?)

A temporal aspect(over what time period ?)

Natural history of diseases (no medical intervention)Biologic onset Clinical Diagnosis Outcome Recovery Disability Death ectClinical Courses(medical intervention)

Risk FactorsBiologiconsetClinicalDiagnosisRecoveryDisabilityDeathEtcOutcomePrognostic factorsDemographic variableDisease specific variablesCo-morbid factor

The strategy for making a prognosisexpert opinionconsulting the appropriate specialistlooking it up in a text book

clinical experiences

read up

Cohort studySurvival analysisCase control studyCase SeriesBiologiconsetEarlydiagnosispossibleClinicaldiagnosisOutcomeRecoveryDisabilityDeathEtc

Summary If the concept is embraced it will improve general practice

Will make the GP an even more rewarding discipline within which to practice.

Will support shared decision making with users. It is the ideal model of making decisions within the medical encounter.

EBM / EBP will help maintain the central role of general practice in health care.