finding current best evidence

8/13/2019 Finding Current Best Evidence

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FINDING

CURRENTBEST EVIDENCE

Dr. Retno Asti WerdhaniDept. Ilmu KedokteranKomunitas FKUI



Knowledge Deterioratesin Time

knowledge

of current

best care

. ..

. . .... ....... ....

....

... ...

..

r = -0.54

p<0.001

years since

graduation



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



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.



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



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.



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

http://www.ovid.com/

http://update.cochrane.co.uk/

http://www.ncbi.nlm.nih.gov/pubmed

http://www.biomednet.com/

http://www.biomednet.com/

http://www.ncbi.nlm.nih.gov/pubmed

http://update.cochrane.co.uk/

http://www.ovid.com/



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

http://www.annals.org/

http://www.acponline.org/

http://pedsccm.wustl.edu/EBJournal_club.html


http://www.jfponline.com/

http://www.jfponline.com/



http://www.acponline.org/

http://www.annals.org/



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

http://bmj.bmjjournals.com/

http://content.nejm.org/

http://hiru.mcmaster.ca/

http://bmjupdates.mcmaster.ca/index.asp


http://www.freemedicaljournal.com/

http://www.guidelines.gov/

http://www.guidelines.gov/

http://www.freemedicaljournal.com/



http://hiru.mcmaster.ca/

http://content.nejm.org/

http://bmj.bmjjournals.com/



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



Making answerable questionP : Patient and/or Problem

I : Intervention

(C) : Comparation in intervention (if relevant)

O : Outcome

(M) : Methods



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.



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



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



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.



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.



SUMMARY KEEP ON ASKING

KEEP ON SEARCHING

KEEP ON LEARNING

THAT WILL MAKE YOU A BETTER-

IMPROVED MEDICAL PRACTITIONER



Take Home Messages ??

finding current best evidence

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