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Jurnal Reading

Ferial Hadipoetro Idris


Ditujukan pada S.Ked pra
kepaniteraan/ Kepaniteraan umum
2 Maret 2014 & 16 Juni 2014 & 12
Oktober 2014

Rujukan
Douglas Badenoch and Carl Heneghan,
Evidence based tool kit, BMJ Books,2002
Materi pelatihan EBM Workshop, Centre
for clinical epidemiology & EBM,
RSCM/FKUI, 2013.

Kenapa belajar jurnal reading?


1. Untuk Menjawab
pertanyaan pasien
berdasarkan bukti
(EBM=Evidence Based
Medicine)
2. Untuk mampu memilih
jurnal yang baik
3. Untuk mampu
mengkritisi jurnal
4. Untuk mampu menulis
jurnal yang baik

Apa EBM?
Integrasi bukti penelitian
terbaik dengan
keahlian klinis dan
nilai2 (patient value)

Bukti penelitian

Keahlian klinis

EBM

Nilai2 pasien

Bagaimana menjawab pertanyaan


pasien berdasarkan bukti?
1.

2.
3.
4.
5.
6.

Susun pertanyaan pasien


dengan kaidah PICO
(etiologi, diagnosis, terapi,
prognosis)
Searching, finding the
evidence
Kritisi jurnal
Hasil Integrasikan dengan
keahlian dan nilai2 pasien
Buat keputusan bersama
dengan pasien
Evaluasi efektifitas dan
efisiensi

PICO
Evaluasi
Efektifitas
Efisiensi

searching

Kritisi jurnal
Integrasi
hasil dari jurnal,
kahlian dan
nilai pasien

Bagaimana Membuat PICO


Etiology/ Harm
P= Patient
Or Problem
Or
Population:
among/In

I=
C=Compariso Outcome:
Intervention
n : versus,
Effect, result
or indicator or compare
index test or
exposur:
Does, would

In healthy
children

Exposed in
utero to
cocaine

Compare to
children not
exposed

Have
increased
incidence of
learning
disabilities at
6 years

Bagaimana Membuat PICO


Diagnosis
P= Patient
Or Problem
Or
Population:
among/In

I=
C=Compariso Outcome:
Interventionor n : versus,
Effect, result
indicator or
compare
index test or
exposur:
Does, would

In an
otherwise
healthy 7
year old boy
with sore
throat

How does the Compare to


In diagnosing
clinical exam throat culture pharyngitis?

Bagaimana Membuat PICO


Treatment/ Therapy/ Intervention ?
P= Patient
Or Problem
Or
Population:
among/In

I=
C=Compariso Outcome:
Interventionor n : versus,
Effect, result
indicator or
compare
index test or
exposur:
Does, would

In Child with
frequent
febrile
sizures

Would
Compare to
anticonvulsan no treatment
t therapy

Result in
seizure
reduction?

Bagaimana Membuat PICO


Prognosis?
P= Patient
Or Problem
Or
Population:
among/In

I=
C=Compariso Outcome:
Interventionor n : versus,
Effect, result
indicator or
compare
index test or
exposur:
Does, would

In patient
Does the
Better than To predict
with sepsis level of
C reactive in hospital
procalcitoni protein
mortality?
n

Searching, finding the evidence


Cari Jurnal: sumber primer
resource

Alamat internet

Iuran tahunan

Google scholar

http://scholar.google.com.br/

gratis

Medline-pubmed

www.ncbi.nml.nih.gov/PUBMED
Terbesar di dunia

gratis

emedicine

www.emedicine.com

gratis

medscape

www.medscape.com

gratis

Medical matrix

www.medmatrix.org/index.asp

gratis

Clinical practice
guideline

www.guideline.gov

gratis

www.cma.caa/cpgs

gratis

Searching, finding the evidence


Cari Jurnal: sumber sekunder/short cut/hasil
telaah kritis/ sudah diolah
resource

Alamat internet

CATs on the web

Bandolier: www.jr2.ox.ac.uk/Bandolier
TRIP: www.tripdatabase.com
Best evidence:

Secondary
jurnals

ACP jurnal club


Evidence-Based Medicine

The cochrane
libary

Iuran tahunan

Langkah searching
1.
2.
3.

Buat pertanyaan : PICO


Keluarkan kata kunci dan cari synonim
Hubungkan ke search engine atau data base: generic:
Pubmed, Google, Yahoo
specialized: TRIP, SUM search
1. Ketik kata kunci di search box:
1.1 (population OR synonym 1 OR)AND
1.2 (intervention OR synonym 1 OR..)And
1.3 (comparison OR synonym 1 OR..)And
1.4 (outcome OR synonym 1 OR..) And
1.5 Filter/limit (for best study)

Bagaimana Cara Membaca Jurnal?


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Judul tulisan
Nama Penulis
Nama/no/edisi jurnal
Abstract
Latar belakang
Tujuan
Method
Hasil
Diskusi
Kesimpulan

Kritisi Jurnal
Therapi
1. Is the study valid? 2. Are the result important?
1.1 Was there clearly define research question? PICO
1.2 Were the group randomised? (RCT= Randomized control
trial)
1.3 Were all patient accounted all? Drop out rate <80%,
length of study:enough outcome to be manifest, intention
to treat (all patient randomized to be analysed even if it
is not complete the treatment they actually got)
1.4 Were the research participant blinded? Double blind
randomization ( clinican and patient do not know)
1.5 Equal treatment: no co intervention to one group
1.6 Did randomization produce comparable group at the start
of the trial? Uji homogenitas.

Kritisi Jurnal
Terapi
2. Are the result important:
2.1 p value: < 0.01= there is a less than 1 in 100
probability of the result occuring by chance, p
value < 0.05= less then 1 in 20 probability by
chance.
2.2 quantifying the risk and benefit and harm: RRR
(relative risk reduction), ARR (Absolut Risk
Reduction), NNT (Number Needed to treat), CI
(Confidence Interval), RR (Relative Risk)

Kritisi Jurnal
terapi
2. 2. quantifying the risk and
benefit and harm:
CER=control event rate=a/
(a+c)
EER=Experiment event
rate=b/(b+d)
RRR=Relative risk
reduction= (CEREER)/CER
ARR=Absolut Rate
Reduction=CER-EER
NNT=Number needed to
treat=1/ARR

control experi
ment
event

No
event

Kritisi Jurnal
terapi
ARR are more
clinically relevant
measure to use than
RRR, because RRR
1
factor out the baseline
risk, so that small
difference in risk can
seem significant when 2
compare to small
baseline risk

CE EE AR RR
R
R
R
R
0.36

0.34

0.02

0.056

0.036

0.034

0.002

0.056

Kritisi Jurnal
Terapi
NNT= Number Needed
to Treat=the most
useful measure of
benefit= the absolut
number of patients
who need to be
treated to prevent one
bad outcome=1/ARR

Mortality in patient
surviving MCI for at
least 3 days with left
ventricular ejection
fraction <40%

RRR=
Relative
Risk
Reductio
n

ARR=
Absolut
e Risk
Reducti
on

NTT=Nu
mber
Needed
to treat

Palcebo
control
event
rate
=CER

Catropil
experime
nt control
rate=
EER

(CEEREER)/CE
R

CEREER

1/ARR

275/1116
=0.2464

228/115=
0.2045

(0.24640.2045)/0
.2464=0.
17

0.24640.2054=0
.0419

1/0.0419
=24

Kritisi Jurnal
terapi
CI= are used to represent sampling error.
95% CI= there is a 95% chance that the population
is true value lies between the two limit.
95% CI on the ARR=
/1.96x{(CERx(1-CER)/#control patients } +
{(EERx(1-EER)/# experiment patients } If CI
crosses the line of no difference (the point at
which benefit becomes a harm), then we
conclude that the result are not statistically
significant.

Kritisi Jurnal
terapi
RR=Relative Risk Ratio=EER/CER
RR<1=less risk of the event in the
experimental group

Kritisi Jurnal
Diagnosis
1. Is the study valid? 2. Are the result important?
1.1 Was there is clearly defined question? PICO
1.2 Was the presence or absence of the target
disorder confirmed with a validated test (gold
or reference standard)
1.3 was the test evaluated or an apropiate
spectrum of patient
1.4 Was the reference standard applied to all
patients
1.5 Is it clear the test was carried out?
1.6 Is the test result reproduceable?

Kritisi Jurnal
diagnosis
2. Are the result importance
2.1 sensitivity=
a/(a+c)
2.2 spesicity=
d/(b+d)
2.3 Positive predictive value=a/(a+b)
2.4 Negative predictive value=d/(c+d)
2.5 prevalence=pre test probability=(a+c)/
(a+b+c+d)
2.6 Likelihood ratio for a positive test
result= sens/(1-spec)
2.7 likelihood ratio for a negative test
result=(1-sens)/spec
2.8 pre test odds= prevalence/(1prevalence)
2.9 post test odds=pre test oddsx
likelihood pos
2.10 post test probability=post test odss/
(post test odds+1)

disease
present

Disease
absent

Diag a
test 26
+

b
69

a+b
95

Diag c
test - 46

d
249

c+d
295

total

b+d
318

A+b+c+d

a+c
72

390

Kritisi Jurnal Prognosis


1.

Is this prognosis study valid? 2. Are the result


important?
1.1 was a define representative sample of patients
assembled at a common (usually early) point in the
course of of the disease
1.2 Was the follow up study long enough
1.3 Were the objective criteria applied in a blind fashion
1.4 If subgroup with different prognosis are identified, was
there adjustment for important prognostic factors and
validation in an independenttest set patient?

Kritisi jurnal
prognosis
2. Are the result of the study importance?
2.1 How likely are the outcomes overtime?
1-5 years survival
Median time ( e.g. the length of follow up by
which 50% of patient have died)
Event curve, survival curve
2.2 How percise is this prognostic estimate?
95% CI

Kritisi jurnal Etiologi


1.Apakah Valid? 2. Apakah importan?
1.1 Apakah ada sampel pasien yang
representatif dan didefinisikan secara jelas
pada titik yang sama pada perjalanan
penyakit.
1.2 Apakah penelitian followup cukup panjang
1.3 apakah digunakan kriteria outcome yang
objektif dan tidak berbias

Kritisi jurnal Etiologi


1.4 apakah ada penyesuaian terhadap
faktor progonosis yang penting
Apakah hasil penelitian penting?
Bagaimana outcomenya
Seberapa tepat estimasi etiologi

Kritisi Jurnal Systematic


review/Meta analisis
Introduction: any controversies in the literature,
PICO
Methods: how the individual studies searched
(medline, Embase, Cinahl, unpublished in the
cochrane central: www.clinicaltrial.gov) and
selected, how to appraise, how to combine?
Jadad score
Results: flow diagram, summarized the effect:
forest plot, metaanalisis
Discussion and conclussion