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Curriculum Vitae

Name: Joewono Soeroso MD, MSc PhD, Internist-Rheumatologist-Clinical


Epidemiologist
DOB : Purwokerto 1 July 1950
Educations:
MD: Diponegoro University 1977
Internist: Airlangga Unversity 1986
MSc (Clinical-Epidemiologi & Evidence Based Medicine): College of
Medicine Univ. of The Philippines Manila 1995
Rheumatologist: 1999
Fred Hutchinson Research Center, Seattle 2002
PhD: Airlangga Unversity 2004
GB Airlangga Unversity 2014
Teaching Saff at FK Unair 1991- now

INTRODUKSI
EVIDENCE BASED MEDICINE
Joewono Soeroso
Unit Epidemiologi Klinis FK Unair
Sub-Bagian Reumatologi-Lab-SMF I. Penyakit Dalam
FK Unair-RSUD Dr. Sutomo

Subject

Tutor

1.

Intro & Basics of EBM

Prof. Dr. Joewono Soeroso dr. MSc, SpPDKR

2.

Therapy & Harm

J. Eko Wahono Rahardjo dr M.Kes.,SpS


(K)

3.

Prognosis & Meta-analysis

Heru Purwanto dr M.Kes., SpB-Onk

4.

How to Find Current Best


Evidence (theory & practice)

Dr. Anang Endaryanto dr. SpA(K)

5.

Critical Appraisal Article on


Therapy (theory & practice)

Dr. Cita Rosita SP dr. SpKK(K)

6.

UTS

Critical Appraisal Paper : Screening, Risk


Factor, Diagnosis, Therapy (Groups)

7.

UAS

Individual

Act local
Think global
Do not hesitate
Do do and do.

BASIS DARI EBM

Metode Penelitian
Epidemiologi
Bio-statistika
Ekonomi klinis
Ilmu sosial

What is EBM?

Implementation of the best evidence


obtained from clinical research to
clinical practice

Other Names of EBM

Clinical epidemiology (Feinstein, 1975, Sackett 1981)


Health Technology Assessment (David Banta, 1998)
Medical Epidemiology (Greenberg, 1998)

Objective of EBM

To efficiently improving patients health


To keep up to date
To enhance quality research

(Sackett 1991, Dixon, 1997 Sackett 1999,Glasziou 2007)

EBM is a bottom-up approach, not a


cook-book approach
External evidence can inform, but never
replace clinical expertise
(Sackett et al, 1999)

Research

Better Quality of
Life

What is in the real world?


A new antibiotic for the treatment typhoid fever
patient 1

patient 2

patient 3

patient 4

patient 5

cured
Does this antibiotic work well?
not cured

What is in the real world?


Publication Bias
Research 1

Research 2

Research 3 Research 4 Research 5

Good results published


Poor results not published
AHRQ 48% medical research
were not published

What is in the real world?


The case of gastric freezing machine
In the 70s, 2500 gastric freezing
machines for treatment of gastric bleeding
were sold
Until a randomized trial showed this
machine was not better than conventional
treatment

What is in the real world?


Haynes (An Intern Med 1986; 309 :105) ; 800
research articles in 4 famous journals
valid only 19%
Reid (JAMA 1995; 274: 651 ) ; 1300 research
articles on accuracy of diagnostic tools from
valid only 6%
urine
dipstick to MRI and CT scan
Cohrane Collaboration (1996): 16,000 studies on
tx of mild hypertension valid only 22 studies

Epidemiology
the study of the distribution and
determinants of health related
events, and the application of this
study to control health problems
(Last, 1988)

Tujuan
Meningkatkan efisiensi diagnosis, terapi
dan prognosis
Tetap mengikuti perkembangan
IPTEKDOK
Meningkatkan kuantitas dan kualitas
penelitian

area penelitian
biologic onset
(patobiology)

early diagnosis
possible

usual clinical
diagnosis

Dx

Risk factors
(Causation)

End Points

sembuh
komplikasi
cacad
mati

Prognostic
Diagnostic
Screening
Factors
test
Clinical Trials
Diagnostic
Therapy
Clinical Trials
Clinical Trials
test
Prevention I
Prevention II

Critical Appraissal

Causation
Screening
Diagnosis
Therapy
Prognosis
Quality of Care (Clinical
auditing)
Economic Analysis

Summary of EBM
original articles
(we dont know the quality yet)
critical appraisal
Clinical expertise
Science
Logics
Knowledge
Experience

Valid evidence
Quantitative methods

Implement to patients (Dx, Tx , Prx)

Clinical expertise
Art
Beliefs
Judgments
Intuition

Evidence based guidelines (Pedoman Diagnosis & Terapi)


evidence based consensus

CONTOH PENERAPAN
EFISIENSI DIAGNOSIS

Studi Kasus
tk. Becak, 30 th
leukemia akut
trombosit 5.000/mm3
Sepsis kmd timbul
koma dan lateralisasi

Perlu CT
Scan?

pria 42 tahun
splenomegali-asites
bili total 2.5 mg%
albumin 1.8 mg%
globulin 4.7 mg%

Perlu
USG?

Piutang RSUD Dr. Soetomo


1.5 M / th (sebelum krismon)
22 % piutang tes penunjang

Kuantifikasi Diagnosis
Metode nilai prediktif
anamnesis & pem. fisis cermat
tahu sensitivitas (Sn) dan spesifisitas
(Sp)
tes Dx terhadap gold standard
pengolahan dalam tabel 2 x 2

Kasus I
pria 55 th, nyeri dada kiri, menjalar
merokok 2 pak /hari
T 180/110, gallop +
kolesterol 358 mg%
probabilitas (prates) menderita PJK
Perlu treadmill???

(90%)

NILAI PREDIKTIF
dari TES DIAGNOSTIK
Positive predictive value
Probabilitas untuk menderita suatu
penyakit jika hasil tes positif
Negative predictive value
Probabilitas untuk tidak menderita
suatu penyakit jika hasil tes negatif

Kasus I

Sn tredmil 60% dan Sp tredmil 91%

PJK

(angiografi koroner = gold standard)

+
tredmil

prob. pascates

540

549

360

91

451

900
probab (prates) PJK

100

540
----- =
549
91
----451

98% +8%
21%

1000

90%

98% (pascates)

Kasus II
pria 35 th, nyeri epigastrium
tidak merokok
T 120/80 ; fisik d.b.n.
lab : normal
probabilitas (prates )menderita PJK( 5 %)

Kasus II

Sn tredmil 60% dan Sp tredmil 91%

PJK
(angiografi koroner)

tredmil

30

86

= = 26% +21%
116 30/116

20

864

884

50

950

probab (prates) PJK

5%

prob. pascates

864/884 = 98% + 48%

1000

26% (pascates)

Kasus III
pria 45 th, nyeri dada kiri-tidak khas
merokok 1 pak /hari
T 120/80
lab: normal
probabilitas (prates ) PJK ( 50%)

Kasus III

Sn tredmil 60% dan Sp tredmil 91%

PJK
(angiografi koroner)

tredmil

300

45

= = 87% +37%
345 300/345

200

455

655 455/655 = 85 %, + 35%

500

500

probab (prates) PJK 50%

prob. pascates

1000
87%(pascates)

Kesimpulan
Predictive Value Method

Kasus I : probabilitas menderita PJK


dari 90% ke 98%, tidak perlu tredmil
Kasus II :probabilitas menderita PJK
dari 5% ke 26%, tidak perlu tredmil
Kasus III : probabilitas menderuta PJK
dari 50% ke 87 %,
perlu

tredmil

Cost per kasus terdiagnosis


tredmil @ Rp 100.000,
Kasus I : tidak perlu tredmil, langsung tx
Kasus II : Rp 100.000 X 1000/30 =
Rp 3.330.000/kasus
Kasus III : Rp 100.000 X 1000/300 =
Rp 333.000/kasus

Threshold Model
of Pauker & Kassirer

DONT TEST
DONT TREAT

0%

TEST & TREAT IF


THE RESULT POSITIVE

25%

TREAT

65%
PRETEST PROBABILITY

100%

Hanya kasus yangmeragukan


yang memerlukan tes diagnostik

Bacaan Wajib
Pitono Soeparto et al Epidemiologi Klinis. Seri Gramik FK Unair 1998
Sackett DLS, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology,a basic
science for clinical medicine 2nd ed. Boston/:Little,Brown Company, 1991
Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology. The
essentials.William and Wilkins 1985
Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research,
Quantitative methods, California:Life time Learning Publications, 1982
Sackett DLS Teaching Evidence Based Medicine, Churchill Living Stone, 1998
Geyman et al Evidence Based Clinical Practice, Butterworth-Heineman 2000