Evidence Base Medicine Fakultas Kedokteran Universitas Kristen Krida Wacana (UKRIDA) Jl.Arjuna Utara no.

6, Jakarta 11510 Marco 10-2010-095 marcorahardja@hotmail.com 4 September 2013

STAGES FROM THE STRONGEST TO THE WEAKEST

MetaAnalysis Systematic Review Randomized Controlled Trial Cohort studies Case Control studies Case Series/Case Reports Animal research/Laboratory studie

Meta-analysis is a method to perform in-depth analysis of a topic from several valid research which combined so that resembles a large research. Systematic Reviews is done by performing a review of literatures that focuses on a topic to answer a question. The literatures will be analyzed and the results will be summarized.

Randomized controlled clinical trials shortened as RCT is a research method that uses real patient sample which divided into two groups, which are control group and the treated group. Both groups should be treated equally. Stratify patients into control or treatment group should be done randomly or blinding to reduce

possibility of subjectivity. Commonly used for journals therapy. Cohort Studies is an observational research that typically ahead observed against two groups (control and treatment). Case Control Studies is a study comparing a group of patients whom suffering from certain diseases with patients who are not. Case series and Case reports is a report case from patient.

EBM GENERALLY BASED ON JOURNAL. THE SUGGESTED JOURNAL ARE Type of Questions Sugested Journal Therapy Diagnosis Etiology/Harm Prognosis Prevention Clinical Exam Cost RCT>cohort > case control > case series prospective, blind comparison to a gold standard RCT > cohort > case control > case series cohort study > case control > case series RCT>cohort study > case control > case series prospective, blind comparison to gold standard economic analysis

QUICK AND EFFISIENT TIPS FOR JOURNAL SEARCHING To find out about how to choose the best diagnostic or Diagnosis how to interprete results of a diagnostic tools, take a look at To find out about how to choose a treatment which has Treatment bigger benefits instead of the danger , take a look at To find out about how to estimate the outcome of patient's Prognosis desease or possible complications that occur, take a look at To find out about the causes of a disease or danger of a Harm/etiology substance on the incidence of the disease, take a look at HOW TO CRITICIZED A JOURNAL HARM OR ETIOLOGY There are three basic questions we need to consider about each journal that we will use as EBM : 1. Is the Journal valid ? (Trustworthy) 2. Is the Journal essential ? (Significant results) 3. Is the Journal applicable for our clinical practice ? 1. Is the Journal valid ? To answer whether the journal is valid, some of these questions answered with YES (there is information about such things in the journals that we used)

2. Is control group patients and the experiment clearly identified the inclusion and exclusion? Are both group of patient (control and treatment) have the same characteristics?

If the treatment group are hypertensive patients for all categories (1st grade and 2nd grade) The patient controls has to be the same with hypertensive patients for all categories. Take a look at METHOD 3. Is the control group patients and experiment group get the same treatment? If the control group has the blood pressure checked on, experiment group also has to be checked. Take a look at METHOD 4. Is the duration of observation long enough? Are the amount of patients complete from the beginning until the end of research? Long or short is seen from how the deseases runs, how long the medicines take effect, etc. If the medicine effect within 3 months after the regular consumption, and the research is done less than 3 months, Of course it's not long enough.It is stated complete if the number of drop out participants either the control or experiment group less than 20% of the first amount the beginning Take a look at METHOD and RESULT 5. Is the exposure preceded the result? For journals that look about the effect something harmful to the body if eaten should be seen that the exposure preceded the harm caused. EXAMPLE: if you want to see if smoking can cause lung cancer it must be proved before a smoker once many years ago and then suffered from lung cancer. Try searching section and RESULT METHOD 6. Is the risk also increased with the increasing the amount exposure dose which suspected harmful? Example: The more amount cigarettes per day, the bigger risk of getting lung cancer Take a look at METHOD and RESULT So it can be concluded that a journal is discuss whether something is harmful for the body or is it resulted something that can effect / risky within the body (ETIOLOGY) Valid if : 1. Same characteristic between group sample and experiment. 2. Same treatment between group sample and experiment. . research.

3. Observed long enough and the number of research participants drop-out <20%)

complete (amount

4. Precedes exposure effect 5. Risk increases with increasing amount or exposure Take a look at METHOD and RESULTH for valid section WHAT IS EVIDENCE BASE MEDICINE ( EBM ) ? EBM is a technique that is used for decision making in managing patients with integrating three factors:

Skills and clinical expertise of a doctor The interests of patients Scientific evidence that can be justified

In other words, EBM is a way to help a doctor when making a decision while treating patients in accordance with the needs of the patient and the clinical expertise of a doctor based on scientific evidence WHY EBM ? EBM is needed for the rapidly development of health department and there's a lot of scientific evidence. The best treatment now is not necessarily the best for the next few years. Meanwhile not all the new scientific knowledge that could be hundreds we need. Therefore we need EBM which is using scientific approach to the sourcing of information as required for individual doctor who triggered the problems faced by patients with adjusted clinical experience and the ability of the doctor. EBM also taught doctor about judging is the journal can be trusted and used. STEPS TO DO EBM ? 1. Patient Start from the patient, which can be :

Clinical problem which patient has Questions were raised by our patients in relation to their illness treatment

2.

Question

Make the questions from first problem

3.

Source

Begin searching through the internet journal sources to answer the question

4.

Evaluation

Evaluate is journals that we get quite valid,

important and applicable

5.

Patient

Applied the findings based on the scientific evidence to the patient by considering the interests or needs of the patient and doctor clinical skills

6.

Evaluation

Evaluate the results of the patient treatment

HOW TO MAKE QUESTIONS A good question should contains 4 things PICO (patient, intervention , comparison, outcome) Patient As to what is our patient's characteristics (important points only). Could be included:

Relating or matters relevant to the patient's disease, such as age, gender or ethnicity.

matters concerning the problem, disease, or condition of the patient

Intervention Prognosis exposure

Contains terms related to intervention given to patients. Is it about prescribe a a medicine? Is it about the diagnostic test? Is it about asking the patients prognosis? Is it about asking about asking what causes the disease of patient?

Comparison

It doesnt necesseraly has the comparison. The comparison could be with placebo or other medicine or other therapeutic measures

Outcome

Expectations you want from these interventions, such as

Is it a symptom reduction? Is it reduction from the side effects? Is it a function or quality of life improvements? Is it a reduction in amount days of hospitalized?

Example of Question

A woman Mrs. Susi, 28 years 36 weeks pregnant G1P0A0 consult to doctor about ways to give birth. Mrs. Susi's sister had an experience in vacuum because of exhaustion of pushing. And she had sewn a lot while giving birth. Now her son is 6 years old and

suffering from epilepsy. Mrs. Susi heard about a technique that uses forceps. She asked which one is more secure to mother and baby.

The keyword of the questions that may be asked are:

Patient : giving birth, prolonged second stage Intervention : vacuum Comparison : forcep Outcome : secure for mother and baby

The question would be : For the handling of giving birthd prolonged second stage which is more safe for mothers and babies between vacuum and forceps?