EBM Evidence-Based Medicine

Riyani W/Zwasta M, YARSI-EBM-11-12

Apa yg akan dilakukan thd PASIEN..??

Bagaimana membuat keputusan klinik..??

Tanya ahli..?? Text book..?? Penelitian ..??

basis for clinical decisions

My students are dismayed when I say to them Half of what you are taught as medical students will in 10 years have been shown to be wrong. And the trouble is, none of your teachers knows which half.
(Dr. Sydney Burwell, Dean of Harvard Medical School).

The inevitable consequence

On average, the clinically-important knowledge of physicians deteriorates rapidly after we complete our training.

Contoh KASUS
Seorang anak, usia Sekolah Dasar, menderita NYERI TENGGOROKAN dan demam, kemungkinan akibat infeksi. Dokter di Poliklinik mengatakan bahwa anak tersebut harus diberikan obat-ANTIBIOTIK golongan PENISILIN supaya cepat sembuh.

Pasien
Ditanya Diperiksa Didiagnosis Diobati Dll Ilmu berkembang

ILMIAH

Tepat - bertanggungjawab

Tidak ada hukum bagi yang tidak-tahu, namun diwajibkan untuk mencari tahu

jujur & bertanggung-jawab

The Slippery Slope

knowledge of current best care

. ..
. . ........ ...

r = -0.54 p<0.001

... ... .... .. ....

years since graduation

Why we need EBM ?

1. our daily need for valid information
2. the inadequacy of traditional sources for this information because they are out-of-date (textbooks ), frequently wrong (experts ), ineffective or too overwhelming in their volume and too variable in their validity for practical clinical use (medical journals). 3. the disparity between our diagnostic skills/clinical judgment, which increase with experience, and our up-todate knowledge which decline. 4. our inability to afford more than a few minutes per patient for finding and assimilating this evidence or to set aside more than few hours per week for general reading and study

Knowledge Explosion
Insufficient use of available research Less than 20% of medicine is evidence based 6000 pages published/day

How do we make clinical decisions? (keputusan klinis)

Toss coins------ gambler Guess------ think about "Do no harm." ----/kerugian (Hippocrates)

Ask colleagues ---- TS, dll

Text books?------ dekat perpustakaan Browse journals ----- terpencil..??

Searching bibliographic databases

Evidence-Based Medicine
Sackett et al (1996) defined Evidence Based Medicine as

The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external; clinical evidence from systematic research".

What evidence-based medicine is:

The practice of EBM is the integration of individual clinical expertise with the best available external clinical evidence from systematic research and patients values and expectations

EBM - What is it?

Clinical Expertise

Research Evidence

Patient Preferences

Rules of Evidence

All evidence is not created equal. Evidence alone never makes clinical decisions. Values always influence decisions.

What is EBM?
The process of systematically finding, appraising and using contemporaneous research findings as a basis for clinical decisions.

Practicing EBM: Five Steps

Step 1: convert need for information in to an answerable question Step 2: track down the best evidence with which to answer that question Step 3: critically appraise the evidence for its validity, impact and applicability Step 4: integrate the critical appraisal with our clinical expertise and patients unique circumstances Step 5: evaluate our effectiveness and efficiency in steps 1-4 and seeking ways to improve

Its practice requires:

1. Asking 2. Acquiring

3. Appraising
4. Applying

5. Assessing

What Questions Do Clinicians Ask at the Point of Care?

Physicians reported
1 question / 4 patients ( day) 15 questions / 25 patients per day

2/3 clinical questions unanswered. Are the unanswered questions important?

50% of the answers direct impact on patient care.

Primary care doctors

2 questions / 3 patient Questions relation 33 % ~ treatment 25 % ~ diagnosis 15 % ~ pharmaco therapeutics.

WHY BOTHER FORMULATING QUESTIONS CLEARLY?

Answerable Clinical Questions: 1. Help focus our scarce learning time on evidence that is directly relevant to our patients clinical needs. 2. Help us focus our scarce learning time on evidence that directly addresses our particular knowledge needs, or those of our learners.

3. Suggest high-yield search strategies

4. Suggest the forms that useful answers

might take 5. When sending or receiving a patient in referral, they can help us to communicate more clearly with our colleagues 6. When teaching, ACQ help our learners to better understand the content of what we teach, while also modeling some adaptive processes for lifelong learning.

7. When our questions get answered, our

knowledge grows, our curiosity is reinforced, our cognitive resonance is restored, and we can become better, faster, and happier clinicians.

Type of Questions
Evidence based practice requires that clinicians make use of the best research they can find to help them in decision-making. To find that research efficiently, the clinician must ask a welldesigned clinical question with all the elements that will lead to finding relevant research literature. The first step in doing this is to determine the type of question: background or foreground. The type of question helps to determine the resource to access to answer the question.

Type of Questions
"Background"
questions ask for general knowledge about a condition or thing. Answering the background question:
excellent review article respected evidenced-based textbook.

"Foreground"
questions ask for specific knowledge to inform clinical decisions or actions. Answering the foreground question.
Primary source : journal Secondary source : Cochrane

When in need of an overview on clinical presentation of a disease, standard therapies, diagnostic tools, etc. consult a textbook.

Background Questions
Ask for general knowledge about a disease or disease process
Have two essential components:
A question root (who, what, when, etc.) with a verb A disorder, test, treatment, or other aspect of healthcare

Example:
What causes migraines? How often should women over the age of 40 have a mammogram?

The background question is usually asked because of the need for basic information. It is not normally asked because of a need to make a clinical decision about a specific patient.

Foreground questions
Ask for specific knowledge about managing patients with a disease Have 3 or 4 essential components
Patient and/or problem Indicator / Intervention Comparative intervention (optional, include if relevant) Clinical outcome

Example:
In young children with acute otitis media, is short-term antibiotic therapy as effective as long term antibiotic therapy?

EBM Process

Secondary sources (shortcut)

CATs on the web
Bandolier: www.jr2.ox.ac.uk/Bandolier TRIP: www.tripdatabase.com

Best evidence: Secondary journals

ACP Journal Club Evidence-Based Medicine

The Cochrane library

Contoh KASUS
Seorang anak, usia Sekolah Dasar, menderita NYERI TENGGOROKAN dan demam, kemungkinan akibat infeksi. Dokter di Poliklinik mengatakan bahwa anak tersebut harus diberikan obat-ANTIBIOTIK golongan PENISILIN supaya cepat sembuh.

LANGKAH KE-1 EBM Menyusun Pertanyaan Klinis

PICO
PICO is a mnemonic used to describe the four elements of a good clinical foreground question

P Patient I Indicator/Intervention C Comparison O Outcome

P=Population/Patient/Problem
How would you describe a group of patients similar to yours? What are the most important characteristics of the patient? This may include the primary problem, disease, or coexisting conditions. Sometimes the sex, age or race of a patient might be relevant to the diagnosis or treatment of a disease.

I=Indicator/Intervention; E=Exposure
Which main intervention, prognostic factor, or exposure are you considering? What do you want to do for the patient? Prescribe a drug? Order a test? Order surgery? What factor may influence the prognosis of the patient? (eg. Age/Coexisting problems) What was the patient exposed to? (eg.
Asbestos/cigarett smoke)

Comparison
What is the main alternative to compare with the intervention? Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests? Your clinical question does not always need a specific comparison.

Outcome
What can you hope to accomplish, measure, improve or affect? What are you trying to do for the patient? Relieve or eliminate the symptoms? Reduce the number of adverse events? Improve function or test scores?

Question Categories
Diagnosis - How to select a diagnostic test or how to interpret the results of a particular test. Therapy - Which treatment is the most effective, or what is an effective treatment given a particular condition. Harm or Etiology - Are there harmful effects of a particular treatment or exposure or risk factor Prognosis - What is the patient's likely course of disease given the characteristic

PICO & Applicability

Type of Question: Suggested best type of study: Diagnosis prospective, blind comparison to a gold standard Therapy Prognosis Harm/Etiology Prevention Clinical Exam Cost Benefit RCT > cohort > case control > case series cohort study > case control > case series RCT > cohort > case control > case series RCT > cohort study > case control > case series prospective, blind comparison to gold standard economic analysis

Type of studies

Hierarchy of study designs:

Systematic review Meta-analysis RCT (DB/SB) Cohort study Case controlled study Cross sectional study Case series

Kategori Evidence

Ia Meta analisis & Syst Rev Ib Randomized Controlled Trial IIa Non-Randomized Trial IIb Quasi Experimental III Observational study IV Expert opinion, clinical experience Uji pra-klinik Uji in vitro

GUIDE TO PICO APPLICABILITY

PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

PICO TYPE OF QUESTION TYPE OF STUDY/METHODOLOGY

Case - 1
Your next patient is a 72yearold woman with osteoarthritis of the knees and moderate hypertension, accompanied by her daughter, a lab tech from the hospital. The daughter wants you to give her mother a prescription for one of the new COX2 inhibitors. She has heard that they cause less GI bleeding.

Fill in the column

PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

PICO TYPE OF QUESTION TYPE OF STUDY/METHODOLOGY

Case - 1
PATIENT/PROBLEM 72 year old woman with osteoarthritis of the knee and moderate hypertension PICO
In a 72 year old woman with osteoarthritis of the knee, can COX2 Inhibitor use decrease the risk of GI bleeding compared with other NSAIDs?

INDICATOR COX2 Inhibitor

COMPARISON Other NSAIDS

OUTCOME Less Gastrointestinal bleeding

TYPE OF QUESTION
Therapy/Treatment

TYPE OF STUDY/METHODOLOGY
Systematic Review/Meta Analysis of DoubleBlind Randomized Controlled Trials

Case - 2
You see a 70 year old man in your outpatient clinic 3 months after he was discharged from your service with an ischemic stroke. He is in sinus rhythm, has mild residual leftsided weakness but is otherwise well. His only medication is ASA and he has no allergies. He recently saw an article on the BMJ website describing the risk of seizure after a stroke and is concerned that this will happen to him.

Fill in the column

PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

PICO TYPE OF QUESTION TYPE OF STUDY/METHODOLOGY

Case - 2
PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

70 years old man

Stroke

Seizure

PICO In a 70 year old man does a history of stroke increase his risk for seizure? TYPE OF QUESTION Prognosis TYPE OF STUDY/METHODOLOGY Cohort study

Case - 3
You admit a 75 year old woman with communityacquired pneumonia. She responds nicely to appropriate antibiotics but her hemoglobin remains at 10 g/dl with an MCV of 80. Her peripheral blood smear shows hypochromia, she is otherwise well and is on no incriminating medications. You contact her family physician and find out that her Hgbwas 10,5 g/dl about 6 months ago. She has never been investigated for anaemia. A ferritinhas been ordered and comes back at 10 mmol/l. You admit to yourself that you're unsure how to interpret a ferritinresult and aren't sure how precise and accurate it is.

Fill in the column

PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

PICO TYPE OF QUESTION TYPE OF STUDY/METHODOLOGY

Case - 3
PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

Elderly woman with anemia

Ferritin

Iron deficiency anemia

PICO
In an elderly woman with hypochromic, microcytic anemia, can a low ferritin diagnose iron deficiency anemia?

TYPE OF QUESTION
Diagnosis TYPE OF STUDY/METHODOLOGY

Controlled Studies; Systematic Review/Meta Analysis of Controlled Studies

LATIHAN/TUGAS
Seorang anak, usia Sekolah Dasar, menderita NYERI TENGGOROKAN dan demam, kemungkinan akibat infeksi. Dokter di Poliklinik mengatakan bahwa anak tersebut harus diberikan obat ANTIBIOTIK golongan PENISILIN supaya cepat sembuh.

Latihan
PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

Anak penderita nyeri tenggorokan

Antibiotik golongan penisilin

Tanpa antibiotik (plasebo)

Sembuh

PICO
Apakah antibiotika golongan PENISILIN bermanfaat untuk mengobati anak yang menderita NYERI TENGGOROKAN akibat infeksi?

TYPE OF QUESTION
Therapy TYPE OF STUDY/METHODOLOGY

Systematic Review/Meta Analysis of DoubleBlind Randomized Controlled Trials

KATA KUNCI / Key words

Anak Nyeri Tenggorokan Penisilin = child = sore throat = penicillin

LANGKAH KE-2 EBM Mencari Bukti Ilmiah

Types of Information Databases

Primary sources
PubMed, MedLine Require more work to validate Cochrane, Best Evidence, InfoPoems Already reviewed- less work to validate Limited amount of information studied

Secondary sources

http://www.nlm.nih.gov

http://highwire.stanford.edu

http://www.bmj.com

http://www.cochrane.org

http://ebm.bmjjournals.com

http://guideline.gov

Pertanyaan: Apakah antibiotika golongan PENISILIN bermanfaat untuk mengobati anak yang menderita NYERI TENGGOROKAN akibat infeksi?

Jawab:

Berdasarkan penelitian dari: Sjoerd Zwart, Maroeska M Rovers, Ruut A de Melker and Arno W Hoes Yang dimuat di majalah / jurnal: bmj.com 2003;327:1324
Dengan judul: Penicillin for acute sore throat in children: randomised, double blind trial

STATEMENTS OF EVIDENCE
Ia Ib IIa

Evidence obtained from meta-analysis of randomized controlled trials. Evidence obtained from at least one randomized controlled trial. Evidence obtained from at least one well-designed controlled study without randomization. Evidence obtained from at least one other type of well-designed quasiexperimental study. Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

IIb

III

IV

Monitoring & evaluasi Implementasi SPM

Monitoring terhadap sistem mikro pelayanan klinis Self assessment: menggunakan check list Peer-review: menggunakan check-list

Terima Kasih semoga bermanfaat

riyani.wikaningrum@yarsi.ac.id