E vidence B ased M edicine

(Bringing research evidence into practice)

PREVIOUS PRACTICE :
6 yrs medical education 40-50 yrs medical practice Problems with patients: Dx, Rx, Px Consultants, Colleagues Textbooks Handbooks Lecture notes Clinical guidelines CME, seminars, etc Journals

Usu. see only Results section, or even worse, Abstract section

Trust me In my experience . Logically Textbook, handbook, capita selecta

WHAT IS EVIDENCE BASED MEDICINE ?

Pemanfaatan bukti mutakhir yang sahih dalam tata laksana pasien Integration of (1) physicians competence (2) valid evidence from studies (3) patients preference

WHY EBM ?
1. 2. 3. 4. Information overload Keeping current with literature Our clinical performance deteriorates with time Traditional CME does not improve clinical performance 5. EBM encourages self directed learning process which should overcome the above shortages

Our textbooks are out-of-date

Fail to recommend Rx up to ten years after its been shown to be efficacious

Continue to recommend therapy up to ten years after its been shown to be useless

Patient With problem

Apply The evidence

The EBM Cycle

Formulate In answerable question

Critically Appraise The evidence

Search the evidence

STEPS IN EBM PRACTICE

1. Formulate clinical problems in answerable questions 2. Search the best evidence: use internet or other online database for current evidence 3. Critically appraise the evidence for VIA Validity (was the study valid?) Importance (were the results clinically important?) Applicability (could we apply to our patient?) 4. Apply the evidence to patient 5. Evaluate our performance

MAIN AREA
Diagnosis
(Determination of disease or problem)

Treatment
(Intervention necessary to help the patient)

Prognosis
(Prediction of the outcome of the disease)

(I) Formulating clinical questions

Four elements of a well constructed clinical question: PICO

P
Description of patient or problem

I
The main intervention considered

C
The alternative to compare with the intervention

O
Outcome expected from this intervention?

B e

b r i e f

a n d

s p e c i f i c

II Searching the evidence

Examples of on-line Journals / Databases

http://bmj.bmjjournals.com MEDLINE/PubMed EMBASE MDConsult AAP Journal Club Cochrane Library

TUGAS PBL

III Appraising the evidence: VIA

VIA
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 patients characteristics, local setting

Example: Critical appraisal for therapy

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 NNT Were study subjects similar to our patients in terms of prognostic factors?

Hierarchy of evidence
Rec
Weight of Scientific Scrutiny

Meta-analysis of RCT

Level 1

Large RCT
Small RCT
Level 2

Non-Randomized trials
Observational studies Case series / reports Anecdotes, expert, consensus
Level 4

B
Level 3