E

vidence
B
ased
M edicine
(Bringing research evidence into
practice)

PREVIOUS
PRACTICE :
6 yrs
medical
education
40-50 yrs
medical
practice

Usu. see only Results

section,
or even worse, Abstract
section

Problems with
patients:
Dx, Rx, Px
Consultants,
Colleagues
Textbooks
Handbooks
Lecture notes
Clinical
guidelines
CME, seminars,
etc
Journals

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

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out-of-date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

Critically
Appraise
The evidence

The
EBM
Cycle

Formulate
In answerable
question

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

B e

I
The main
intervention
considered

b r i e f

The
alternative
to compare
with the
intervention
a n d
i c

Outcome
expected
from this
intervention?

s p e c i f

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
Non-Randomized
trials

Level 2

B
Level 3

Observational studies
Case series / reports
Anecdotes, expert,
consensus

Level 4