Introduction to Evidence-Based Medicine

Dr. Bhisma Murti, MPH, MSc, PhD

Insiitute for Health Economics and Policies (IHEPS, Bagian Ilmu Kesehatan Masyarakat, Fakultas Kedokteran, Universitas Sebelas Maret

What is Evidence-Based Medicine?

The integration of individual clinical expertise with the best available clinical evidence from systematic research.
David L Sackett, W Scott Richardson, William Rosenberg, R Brian Haynes Evidence Based Medicine-How to Practice and Teach EBM, 1996

The Elements of EBM

Patient Concerns, Values and Expectation

EBM Best research evidence

Clinical Expertise

Six Steps in EBM

1. 2. 3. 4. 5. 6. The Patient The Question The Resource The Evaluation The Application The Self-Evaluation

The Patient
Start from a clinical problem or question arising out of the patients concern and the care of the patient It is the patients problem that matters, not the disease So focus on the patients problem!

POEMs
P- Patient O- Oriented

vs.

DOEs
D- Disease O- Oriented

E Evidence
that

E- Evidence

M- Matters

POEMs
DiseaseOriented Evidence

vs.

DOEs

Example
Antiarrhythmic Therapy

Patient-Oriented Evidence that Matters

Comment
POEM study contradicts DOE study

Drug X PVCs Drug X increases on ECG mortality

POEM agrees Antihypertensive Antihypertensive Antihypertensive therapy BP therapy mortality with DOE therapy PSA screening detects prostate cancer early ? whether PSA screening mortality DOE exists, but the important POEM is unknown

Prostate Screening

PVC = premature ventricular contraction, also known as ectopic heartbeat, extrasystole PSA test= prostate specific antigen test

The Question
Construct a well built clinical question derived from the case, i.e. the patients problem

Types of Questions
Therapy/ prevention Question Prognosis Question Diagnosis Question Harm Question Etc.

Questions: PICO

The Resource
Select the appropriate resource(s) and conduct a search

The Evaluation
Appraise that evidence for: Validity (closeness to the truth) --- internal validity Importance (clinical significance in magnitude and length) Applicability (applicable to your patient) --- external validity

Suggested Best Type of Study

Type of Question Therapy Diagnosis Etiology/Harm Prognosis Prevention Clinical Exam Cost Suggested best type of Study RCT>cohort > case control > case series Prospective, blind comparison to a gold standard RCT > cohort > case control > case series Cohort study > case control > case series RCT>cohort study > case control > case series Prospective, blind comparison to gold standard Economic analysis

Evidence Pyramid for Therapy Question

Meta-Analysis

Systematic Review
Randomized Controlled Trial

Cohort studies Case Control studies

Case Series/Case Reports Animal research

The Application
Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice

The Self-Evaluation
Evaluate your performance with this patient