EVIDENCE-BASED THERAPY

FOR EMERGENCY CASES

IN THE ERA OF
CONTROVERSIAL THERAPY
Presented in the Seminar on
Clinical Updates on Emergency Medicine,
Banjarmasin, 16 September 2018

Alfi Yasmina
 DAILY PRACTICE

Clinical questions

Where to look for the

answers?

Textbook Experts/Seniors

CME Medical journals

 Time

Diagnostic skills

Clinical judgment

Up-to-date
knowledge

Up-to-date clinical
performance
Tsugawa et al. (BMJ 2017;357:j1797)
•30 days mortality rate:
– Doctors < 40 yrs: 10,8% (10,7-10,9)
– Doctors 40-49 yrs: 11,1% (11,0-11,3)
– Doctors 50-59 yrs: 11,3% (11,1-11,5)
– Doctors ≥ 60 yrs: 12,1% (11,6-12,5)
 Information Overload

• Doubling time of medical knowledge:

– In 1950: 50 years
– In 1980: 7 years
– In 2010: 3.5 years
– In 2020: 73 days (projected)
(Densen, 2011).
• New articles in Pubmed:
– In 2003: 593.740
– In 2016: 1,255,875
 Evidence

• POEM = Patient Oriented Evidence that Matters

– addresses a clinical problem or clinical question that
primary care physicians will encounter in their practice
– uses patient-oriented outcomes (symptom severity,
symptom duration, mortality, hospital length of stay, cost,
healing rate, complications)
– has the potential to change our practice if the results are
valid and applicable
• DOE = Disease-Oriented Evidence
– common in the medical literature
– often brought to our attention by pharmaceutical
representatives
– often misleading and generally should be considered
premature.
 When POEMs exist, forget the DOEs.
• Sebuah studi uji klinis acak terkontrol
menunjukkan bahwa memasang
perban penutup mata pada abrasi
kornea dapat mengurangi nyeri dan
mempercepat penyembuhan dibanding
tanpa pemasangan perban.
• Studi awal menunjukkan bahwa
finasterid meningkatkan kecepatan
aliran urine. Uji klinis acak lanjutan
menunjukkan bahwa skor gejala
(gejala kencing tidak lampias) tidak
berbeda bermakna jika dibandingkan
dengan plasebo.
 POEM DOE

Common Read these! Dangerous

Uncommon Read if you have time. Worthless

Medical
Billers &
Coders
(2014)
 Fraud research/articles

• Retracted from Pubmed:

– 2004-2013: 2343 articles
– Mostly original articles and case reports
• Reasons
– Honest error, plagiarism, duplicates,
fabricated data, author dispute, ethical
issues
(Singh et al., 2014)
• “Most published research findings are
false” – Ioannidis (2005)
 What do we need?

• A way of getting clinical/medical

information for answering our clinical
questions that is:
– Relevant with our daily clinical practice
– Valid and reliable
– Quick and timely
– Recent/updated
– Easy to access
– Not costly
 CONCEPT

• Evidence-based medicine:
– “the conscientious, explicit, and judicious
use of current best evidence in making
decisions about the care of individual
patients” (Sackett, 1996)
• Evidence + clinical expertise + patient
values
– Applicable
– Not obsolete
 Reduce HARM on patients
Best available evidence, modified by patient preferences/circumstances, is
applied to improve the quality of clinical judgments (MCEG, 1997)
 CONCEPT

• Best available evidence:

– Clinically relevant
– Quick and easy to access
– Reliable, valid & accurate
• Clinical expertise:
– Ability to use clinical skills & past experience to:
• Diagnose and manage patients
• Identify risk & benefit of management
• Identify patients’ values/expectations
• Integrate evidence with patient values
• Patient preferences:
– Unique values, concerns, expectations
 5 STEPS IN EBM

Asking an answerable question

Searching for best evidence

Critically appraising the evidence for validity,

impact & applicability

Integrating results of critical appraisal with

clinical expertise and patient values to
incorporate them to practice

Evaluating performance
 5 STEPS IN EBM

Asking an answerable question

Searching for best evidence

Critically appraising the evidence for validity,

impact & applicability

Integrating results of critical appraisal with

clinical expertise and patient values to
incorporate them to practice

Evaluating performance
 Asking Answerable Questions

• Background questions
– A question root (who, what, when, etc.)
with a verb
– A disorder, test, treatment, or other aspect
of healthcare
• Foreground questions
– PICO
 Asking Answerable Questions

Foreground questions: PICO

• Patient/Population: identification of clinical
characteristics of patients that might affect
the problem and relevant in practice
• Intervention/Exposure: description on
therapy, test or screening program
(diagnosis), exposure to a causal agent/risk
factor (etiology)
• Comparison: comparison of the intervention
• Outcome: outcome of the intervention
• Apa penyebab migren?
• Kapan seorang wanita harus di-Pap Smear?
• Apa obat untuk asma bronchiale?
• Pada pasien dengan bronchitis akut, apakah
pemberian antibiotik menurunkan produksi
sputum dan mengurangi batuk
dibandingkan tanpa pemberian antibiotik?
• Pada pasien dengan osteoarthitis, apakah
pemberian kondroitin dan glukosamin sama
efektifnya dengan NSAID dalam mengurangi
nyeri sendi?
• Pada pasien lanjut usia dengan hipertensi,
apakah ACEI menurunkan mortalitas dan
infark miokard dibandingkan diuretik tiazid?
 Asking Answerable Questions

• The PICO model can be used to ask

answerable questions on:
– Etiology/Risk factor
– Diagnosis
– Prognosis
– Therapy
– Cost-effectiveness
– Quality of life
 5 STEPS IN EBM

Asking an answerable question

Searching for best evidence

Critically appraising the evidence for validity,

impact & applicability

Integrating results of critical appraisal with

clinical expertise and patient values to
incorporate them to practice

Evaluating performance
 Where to look for evidence?

• Secondary sources:
– Guidelines: NICE, NGC, CMA,
associations (ESC, AHA, ADA, NCEP,
JNC, Perki)
– Evidence-based summary: BMJ Clinical
evidence, EBM online
– Systematic reviews: Cochrane library
• Primary sources:
– Pubmed/Medline, EMBASE, CINAHL
– Google Scholar
 5 STEPS IN EBM

Asking an answerable question

Searching for best evidence

Critically appraising the evidence for validity,

impact & applicability

Integrating results of critical appraisal with

clinical expertise and patient values to
incorporate them to practice

Evaluating performance
 Critical Appraisal

• 3 important issues:
– Is it valid? (Validity)
– Are the results clinically important?
(Impact)
– Is it relevant to my clinical practice?
(Applicablity)
 Critical Appraisal

• Is it valid?
– Was the research problem defined clearly? (PICO)
– Were the patients randomized to the treatments, and was
the randomization method described in detail?
– Were the subjects (and the researchers) blinded?
– Did the randomization create similar treatment groups at
the beginning of the study?
– Were all patients considered in the analysis? Was
“intention-to-treat” analysis used?
– Were all treatment groups similarly treated since the
beginning to end of the study?
– Was the follow-up sufficiently long and complete?
 Critical Appraisal

• Are the results clinically important?

– What is the effect size of the treatments?
• ARR, RRR, NNT, RR
– How precise is the treatment effect
estimations? (95%CI)
 Critical Appraisal

• Is it relevant to my clinical practice?

– Ae the patients in the study similar with my
patient? (age, comorbidity, compliance)
– What is the effect size in my patient?
• NNT = 1/(PEER x RRR)
– Is the intervention/treatment realistic in my
clinical practice?
– Does the control reflect my daily clinical
practice?
– Are all important clinical outcome considered?
– Is the benefit of the treatment is favourable for
the harm and cost?
– What are our patient’s values & expectations of
both the outcome and treatment?
 Critical Appraisal

• Substitute/surrogate outcomes:
– Bronkodilator menghasilkan peningkatan
kecil tetapi bermakna pada forced expired
volume pasien dengan COPD
– Vasodilator meningkatkan cardiac output
pada pasien gagal jantung
– Obat hipolipidemik memperbaiki profil
lipid
 Critical Appraisal

• Patient-important outcomes
– Bronkodilator menurunkan sesak nafas
selama aktivitas sehari-hari
– Vasodilator mencegah MRS karena gagal
jantung
– Obat hipolipidemik menurunkan risiko
infark miokard
 Incorporating evidence to practice

Doing Step 1-5

Using Step 1-2, 4-5

Replicating Step 1, 4-5

 5 STEPS IN EBM

Asking an answerable question

Searching for best evidence

Critically appraising the evidence for validity,

impact & applicability

Integrating results of critical appraisal with

clinical expertise and patient values to
incorporate them to practice

Evaluating performance
 Is it doable in a busy clinical practice?

• Survey in UK GP (Sackett et al., 1977):

– “Using” mode
• 72% using EB summaries generated by others
• 84% using EB practice guidelines or protocols
• Real-time use:
– Clinical round in a busy inpatient ward
(Sackett et al., 1998)
– Clinical round in delivery ward
(Deshpande et al., 2003)
Is it feasible for managing emergency cases?

• “Using” or “replicating” mode

• Implementation of evidence-based
guidelines/protocols (Wright et al., 2008)
• Clinical pathways (Jabbour et al., 2013)
• The use of physician scorecard (Wright et
al., 2008)
• Organizational culture for developing an
evidence-based practice (Kirk et al., 2016)