E vidence

(”Bringing research evidence into practice”)

B ased

M edicine

6 yrs medical

education

40-50 yrsmedical practice

Problems with patients:

Dx, Rx, Px

Consultants, ColleaguesTextbooksHandbooks

Lecture notesClinical

guidelinesCME, seminars,

etcJournals

Usu. see only Results section,

or even worse, Abstract section

PREVIOUS PRACTICE :

Trust meIn my experience ….LogicallyTextbook, handbook, capita selecta

“Pemanfaatan bukti mutakhir yang sahih dalam tata laksana pasien”

Integration of (1) physician’s competence(2) valid evidence from studies(3) patient’s preference

WHAT IS EVIDENCE BASED MEDICINE ?

1. Information overload

2. Keeping current with literature

3. Our clinical performance deteriorates with time

4. Traditional CME does not improve clinical performance

5. EBM encourages self directed learning process which should overcome the above shortages

WHY EBM ?

Our textbooks are

out-of-date

Fail to recommend Rx up to ten years after it’s been shown to be efficacious

Continue to recommend therapy up to ten years after it’s been shown to be useless

TheEBMCycle

PatientWith problem

FormulateIn answerable

question

Search theevidence

Critically Appraise

The evidence

ApplyThe evidence

1. Formulate clinical problems in answerable questions2. Search the best evidence: use internet or other on-

line database for current evidence 3. Critically appraise the evidence for

Validity (was the study valid?) Importance (were the results clinically

important?) Applicability (could we apply to our

patient?)4. Apply the evidence to patient5. Evaluate our performance

VIA

STEPS IN EBM PRACTICE

Diagnosis(Determination of disease or problem)

Treatment(Intervention necessary to help the patient)

Prognosis(Prediction of the outcome of the disease)

MAIN AREA

(I)Formulating clinical questions

Four elements of a well constructed clinical question: PICO

P I C O

The maininterventionconsidered

The alternativeto compare

with theintervention

Outcomeexpected from this

intervention?

Descriptionof patient

or problem

B e b r i e f a n d s p e c i f i c

IISearching the evidence

Examples of on-line Journals / Databases

http://bmj.bmjjournals.comMEDLINE/PubMedEMBASEMDConsultAAP Journal ClubCochrane Library

IIIAppraising the evidence: VIA

TUGAS PBL

Validity : In Methods section:

design, sample, sample size, eligibility criteria (inclusion, exclusion), sampling method, randomization method, intervention, measurements, methods of analysis, etc

Importance : In Results section

characteristics of subjects, drop out, analysis, p value, confidence intervals, etc

Applicability : In Discussion section + our patient’s characteristics, local setting

VIA

Were the subjects randomized?Were all subjects received similar treatment?Were all relevant outcomes considered?Were all subjects randomized included in the analysis?Calculate CER, EER, RRR, ARR, and NNTWere study subjects similar to our patients in terms of prognostic factors?

Example: Critical appraisal for therapy

Hierarchy of evidence

Meta-analysis of RCT

Large RCT

Small RCT

Non-Randomized trials

Observational studies

Case series / reports

Anecdotes, expert, consensus

Level 1

Level 2

Level 3

Level 4

A

B

C

Rec

Weight ofScientific Scrutiny