Najirman
Kelompok studi Clinical Epdemiology and Evidence Based medicine (CEEBM) FK Unand
Ketua SubBagian Reumatologi, Bagian Ilmu Penyakit Dalam FK Unand/
RSUP Dr.M.Djamil
PENDAHULUAN
Seorang pasien laki-laki berumur 51 tahun datang berobat pada seorang
dokter dengan keluhan nyeri dada. 2 minggu sebelumnya dia mersa
sehat-sehat saja, sampai kemudian dia merasa sesak bila berjalan dan
mendaki, Sesak akan hilang bila berhenti selama 2-3 menit. Sesak juga
akan muncul bila berolah raga. Kebiasaan merokok sebungkus perhari
dan juga menderita darah tinggi. Selama ini tidak pernah berobat, karena
tidak
ada
keluhan.
Akan tetapi
akhir-akhir
ini
dia
mencemaskan
pemeriksaan
tambahan
sebelum
mengambil
suatu
keputusan
pengalaman
sendiri.
Informasi
yang
kita
inginkan
tentu
EBM
awal
diperkenalkannya
EBM,
hanya
beberapa
jurnal
yang
menerapkan prinsip EBM, akan tetapi sejak tahun 2000, sudah lebih dari
1000 jurnal yang menerapkan prinsip EBM.
LANGKAH-LANGKAH DALAM EBM
Untuk mencari bukti sahih yang diperlukan dalam suatu jurnal, ada
beberapa langkah yang harus dilakukan :
1. Memformulasikan suatu pertanyaan
Sebelum membuat pertanyaan, seorang dokter haruslah terlebih
dahulu memahami apa masalah yang dihadapinya, kemudian baru
membuat suatu pertanyaan. Pertanyaan klinis dibuat bila:
Setelah itu kita ketik apa yang ingin kita cari dari jurnal, misal SLE,
setelah itu klik search, sehingga akan tampak tampilan seperti tampak
pada gambar dibawah ini
Importance
Hasil suatu penelitian yang kita peroleh dari suatu jurnal belum tentu
sesuai dengan yang kita inginkan. Untuk itu hal yang perlu kita
perhatikan
adalah
keadaan
pasien
kita
sama
atau
mendekati
Aplicability
Yakni menerapkan hasil yang didapat dari jurnal untuk diaplikasi pada
pasien/ kasus yang dihadapi. Untuk melakukan hal tersebut yang
penting harus diketahui adalah bahwa apa yang didapat di jurnal
haruslah keadaannya sama dengan kondisi pasien yang akan kita
tangani.
4. Mengintegrasikan bukti yang didapat dengan pengalaman
klinis terhadap pasien
Setelah kita dapat apa yang kita inginkan, maka langkah berikutnya
adalah menerapkan hasil tersebut terhadap pasien yang ditangani. Ini
dilakukan dengan mengkombinasikan hal yang kita dapat dari sutu
jurnal dengan pengalaman yang tealh kita punyai sehingga kita
menatalaksanan pasien secara optimal
5. Mengevaluasi aplikasi tersebut untuk perbaikan dimasa depan.
Pada tahap ini setiap penerapan yang kita lakukan terhadap pasien
yang kita peroleh dari hasil penelusran di jurnal haruslah kita evaluasi,
apakah masih bermanfaat ataukah sudah tidak sesuai lagi dengan
kondisi pasien saat ini. Hal ini disebabkan karena ilmu kedokteran itu
terus berkembang dan banyak penelitian baru yang dapat dilihat di
internet setiap saat.
tetapi untuk mendapatkan hasil terbaik dari suatu jurnal, tergantung juga
jenis
pertanyaan
yang
kita
ajukan
atau
tergantung
pada
jenis
menggunakannya
untuk
menentukan
pilihan
dalam
suatu
2a. A Aside from the allocated treatment, were groups treated equally?
What is best?
Apart from the intervention the patients in the different
groups should be treated the same, eg., additional
treatments or tests.
This paper: Yes No Unclear
Comment:
2b. A Were all patients who entered the trial accounted for? and were
they analysed in the groups to which they were randomised?
What is best?
Losses to follow-up should be minimal preferably less
than 20%. However, if few patients have the outcome of
interest, then even small losses to follow-up can bias the
results. Patients should also be analysed in the groups to
which they were randomised intention-to-treat analysis.
This paper: Yes No Unclear
Comment:
The relative risk tells us how many times more likely it is that
an event will occur in the treatment group relative to the control
group. An RR of 1 means that there is no difference between the
two groups thus, the treatment had no effect. An RR < 1 means
that the treatment decreases the risk of the outcome. An RR > 1
means that the treatment increased the risk of the outcome.
2a. A Aside from the allocated treatment, were groups treated equally?
What is best?
Apart from the intervention the patients in the different
groups should be treated the same, eg., additional
treatments or tests.
No
Unclear
2b. A Were all patients who entered the trial accounted for? and were
they analysed in the groups to which they were randomised?
What is best?
Losses to follow-up should be minimal preferably less
than 20%. However, if few patients have the outcome of
interest, then even small losses to follow-up can bias the
results. Patients should also be analysed in the groups to
which they were randomised intention-to-treat analysis.
This paper: Yes No Unclear
Comment:
The relative risk tells us how many times more likely it is that
an event will occur in the treatment group relative to the control
group. An RR of 1 means that there is no difference between the
two groups thus, the treatment had no effect. An RR < 1 means
that the treatment decreases the risk of the outcome. An RR > 1
means that the treatment increased the risk of the outcome.
to
follow-up
people
for
an
appropriate
period
of
time
(dependent on disease in question)
to see if they are truly negative.
This paper: Yes No Unclear
Comment:
Was there an independent, blind comparison between the index test and
an appropriate reference ('gold') standard of diagnosis?
Where do I find the information?
What is best?
There are two issues here. First the The Methods section should have a
description
of
the
reference
reference
standard
should
be standard used and if you are unsure
appropriate - as close to the 'truth' of whether or not this is an
reference standard you
as possible. Sometimes there may appropriate
may need to do some background
not be a single reference test that is searching in the area.
suitable and a combination of tests
The Methods section should also
may be used to indicate the describe who conducted the two
tests and whether each was
presence of disease.
independently
and
Second, the reference standard and conducted
blinded to the results of the other.
the index test being assessed
should be applied to each patient
independently and blindly. Those
who interpreted the results of one
test should not be aware of the
results of the other test.
This paper: Yes No Unclear
Comment:
Sensitivity (Sn) = the proportion of The sensitivity tells us how well the
people with the condition who have test identifies people with the
a positive test result.
condition. A highly sensitive test will
not miss many people.
The sensitivity tells us how well the
test identifies people with the In our example, the Sn = 240/250 =
condition. A highly sensitive test will 0.96
not miss many people.
10 people (4%) with dementia were
In our example, the Sn = 240/250 = falsely identified as not having it.
0.96
This means the test is fairly good at
identifying
people
with
the
condition.
Specificity (Sp) = the proportion of The specificity tells us how well the
people without the condition who test identifies people without the
have a negative test result.
condition. A highly specific test will
not falsely identify many people as
The specificity tells us how well the having the condition.
test identifies people without the
condition. A highly specific test will In our example, the Sp = 600/750 =
not falsely identify many people as 0.80
having the condition.
150 people (20%) without dementia
In our example, the Sp = 600/750 = were falsely identified as having it.
0.80
This means the test is only
moderately good at identifying
people without the condition.
Positive Predictive Value (PPV) = the This measure tells us how well the
proportion of people with a positive test performs in this population. It is
test who have the condition
dependent on the accuracy of the
test (primarily specificity) and the
In our example, the PPV = 240/390 prevalence of the condition.
= 0.62
Of the 390 people who had a
positive test result, 62% will actually
have dementia.
Negative Predictive Value (NPV) =
the proportion of people with a
negative test who do not have the
condition.
the
It is
the
the
What is best?
Methods
section
should