Evidence Based Medicine

dr. Yogi PR, SpJP, FIHA

Definition
• Evidence based medicine (EBM) is the conscientious, explicit,
judicious and reasonable use of modern, best evidence in making
decisions about the care of individual patients. EBM integrates clinical
experience and patient values with the best available research
information.

Masic I, Miokovic M, Muhamedagic B. Acta Inform Med. 2008; 16(4): 219–225.

 Evidence Based Medicine

It is a change in the way physicians practice medicine, teach

and learn, and handle research.

Clinical practice: Based on the best current evidence

(not necessarily on how it’s always been done)

Patient Care: Compassionate, patient-oriented

(less authoritarian)

Learning & Teaching: Problem-based, problem-solving

more investigative, less know-it-all-by-yesterday

Research: More stringent approach, better proof criteria

(more demanding of proof, less room for error)
“Gap” antara penelitian dan praktek klinis
• Tidak semua praktek klinik yang ada sudah melakukan sesuai bukti
keberhasilan klinis yang sudah ditemukan
Contoh : Terapi trombolitik dan aspirin diketahui menurunkan
mortalitas pada pasien STEMI sejak tahun 70, namun
memerlukan 1 Dekade hingga akhirnya terapi tsb dipakai sehari-
hari

• Tidak semua bukti teori bermanfaat dalam praktek sehari hari

Contoh : Aliskiren (direct renin inhibitor) --> altitude study harus
di stop karena efek samping yang signifikan
Bagaimana tingkat kekuatan sebuah penelitian ?
 sebagai dasar menilai keberhasilan terapi / prosedur dan
dipakai dalam praktek klinis sehari-hari
Steps in practicing EBM ?
THE FIVE BASIC STEPS OF EBM
1. Clinical Question
Patient-focused, problem-oriented
2. Find Best Evidence
Literary Search
3. Critical Appraisal
Evaluate evidence for quality and usefulness
4. Apply the Evidence
Implement useful findings in clinical practice
5. Evaluate
The information, intervention, and EBM process
EBM QUESTION: Should include multiple factors

(Examples)

P PATIENT type of patient or population

Ex: 47 yr male w/DM2 and cellulitis toe, 25 yr female w/DVT and chest pain

E EXPOSURE environmental, personal, biological

Ex: TB, tobacco, drug, diet, pregnancy or menopause, MRSA, allergy

I INTERVENTION clinical intervention

Ex: medication, procedure, test, surgery, radiation, drug, vaccine

C COMPARISON compare alternative treatment

Ex: other prior, new or existing therapy

O OUTCOME clinical outcome of interest

Ex: Reduced death rate in 5 yrs, decreased infections, fewer hospitalizations
FRAMING THE QUESTION (Example: PICO)

ELEMENT PROMPTS THE QUESTION:

Patient How would I describe a group of patients similar to mine?

Intervention What main action am I considering?
Comparison What is/are the other options?
Outcome What do I (or the patient) want to happen (or not happen)?

Example:

P: In kids under age 12 with poorly controlled asthma on metered

dose inhaled steroids…
I: would the addition of salmetrol to the current therapy
C: compared to increasing the dose of current steroid
O: lead to better control of symptoms without increasing side effects?
 Find the Best Evidence
“The Literary Search”

HINT: If your desk looks like this, it’s probably the

LAST place you should start looking!
 Find the Best Evidence
“The Literary Search”

The BEST EVIDENCE is:

External - from outside resources (researchers, experts)

Current – not out of date, most recent

High Quality - accurate, precise, effective, safe

Patient focused - applicable and appropriate for your individual

patient
FIVE STEPS TO FINDING THE BEST EVIDENCE

1. IDENTIFY NEEDS: What type of information is needed?

2. IDENTIFY RESOURCES: Types, Availability, Timeliness,Costs?
3. SEARCH & RETRIEVE: Use efficient strategies
4. REVIEW : Check quality and usefulness of info
5. INTERPRET: Help patient understand info, application
WHAT TYPE OF INFORMATION IS NEEDED?

WHAT CATEGORY IS THE QUESTION?

• Diagnosis
• Prognosis
• Therapy
• Harm
WHAT STUDY DESIGN FITS IT BEST?
There are MANY study designs!

EXPERIMENTAL TRIALS
(Answers questions of diagnosis or treatment)
Randomized Controlled Trials (RCTs)
Controlled studies
Blinded vs Open
ETC.

OBSERVATIONAL STUDIES
Descriptive reports
Retrospective studies
Cohort studies
Case Control
ETC.
EXAMPLE

Randomized Controlled Trials (RCT)

“Gold Standard” of research

Ideal experimental design - Best design for TREATMENT questions

Must identify objective of treatment

(Ex: cure, prevent complication, palliation, reassurance)

Still not always the right intervention for individual patient at that particular time and
place
What type of evidence best addresses the question, problem or issue?
CLINICAL PRACTICE APPROPRIATE DESIGN FOR CLINICAL RESEARCH

Diagnosis, Dx testing Cross-sectional study – not randomized trial

Prognosis Follow-up studies of patients evaluated at same early point of illness

Therapy, treatment RCT or Systematic review of multiple RCTs must be used

Avoid non-experimental approaches to avoid false conclusions about efficacy

Exceptions:
When treatment may be successful in an otherwise fatal condition
When no studies are available (rare conditions, new treatments, etc.)

Harm RCT, Cohort, Case-control

OTHER INFORMATIONAL
Explore hypothesis Qualitative research
History-taking Case control study
Individual trial & error n of 1 trial
Following clinical course Cohort study
Recordkeeping Systematic registry-based (computer supported) research
Quality of Care research Individual peer review, Process Evaluation

MISCELLANEOUS Basic Science, Genetics, Immunology, etc.

LITERARY SEARCH: NEXT STEP
IDENTIFY YOUR RESOURCES

Colleagues
Consultation, Discussion
(Caution: Response may be an outdated “This is what we do”)

Paper resources
books, reports, journals

Electronic databases

Health Literature Services

specialized librarians, staff

Review services, Abstract Services, etc.

SEARCH AND RETREIVE THE BEST EVIDENCE

Learn and Practice various SEARCH STRATEGIES:

• To find useful information quickly
• To eliminate irrelevant, inappropriate or weak information
Try to develop the habit of learning as you go;
Not just in lengthy formal sessions!
LITERARY SEARCH STRATEGY

ASK FOR HELP!

SPECIALIZED PERSONNEL
• track down information, textbooks, articles,
guidelines
• may provide electronic search support or training

EXAMPLES
• Medical Librarians
• Medical Informatics Specialists
• Specially trained staff member
LITERARY RESOURCES

• TEXTBOOKS (caution – most obsolete!)

• Traditional
• Evidence Based

• JOURNALS (may be outdated)

• REVIEW ARTICLES (summaries, abstracts)

• SYSTEMATIC REVIEWS (prepared in systematic, rigorous

manner) Ex: Cochrane Collection

• META-ANALYSIS

• CLINICAL PRACTICE GUIDELINES

Summarized and easily digestible information
ELECTRONIC RESOURCES, DATABASES, INTERNET

Bibliographic Database
Example: Medline, PubMed

Medical Information Services: Medscape, HDCN

Review Services
Subjective
Systematic Reviews
Meta-analysis

Examples:
• Cochrane,
• Best Evidence,
• Up to Date
MORE GREAT INTERNET RESOURCES

Websites
cyberNephrology, National Kidney Foundation. NIDDK,
American Heart Association, American Cancer Society.
National Institutes of Health, etc

Listserve Discussion Groups

CyberNephrology, C-span, etc.

Specialty Electronic Databases

Psyclit
CancerLit
CINAHL
(allied health and nursing journals)
Etc
MEDLINE
WHAT IS IT?

Searchable database of medical information compiled by National Library of

Medicine in US 1966-present

Catalogs articles from approx 4000 world journals (of estimated 12-15k total)

SEARCH METHODS

Any word or words (title, abstract, content, author name, institution, etc.)

Medical Subject Heading (MeSH) terms

A restricted thesaurus of medical titles

Articles categorized by most specific possible MeSH heading

COCHRANE LIBRARY

Cochrane Database of Systematic Reviews

-systematically compiled reviews of intervention

Cochrane Controlled Trials Register

-citations of controlled trials identified anywhere in the world

Cochrane Review Methodology Database

-methodological papers relating to systematic reviews

Etc.
GUIDELINES RECOMMENDATION
 EBM in Medical Education
Message to medical educators from Trisha Greenhalgh, MD,
co-author of Evidence Based Health Care Workbook:

“An important challenge for medical educators… is to

recognize that the competent student (and clinician!) is one
who knows how to cope with an immense and rapidly
changing body of knowledge and not one who excels in
recalling the traditional or memorizing the ephemeral.

The deans of medical and nursing schools must develop an

infrastructure that allows problem-based, self-directed
learning methods to develop within the didactic, lecture-
based curricula, which have seen no fundamental changes
for two centuries or more.”