Dewi Sutriani Mahalini

Divisi Neurologi Anak, Bagian /SMF IKA ,FK Unud

Email: dewi_sutriani@unud.ac.id
 CURRICULUM VITAE

Tempat/tgl lahir: Singaraja, 27 Juni 1970

Pendidikan:
1995 ~ Dokter umum
2006 ~ Spesialis Anak
2010 ~ Fellowship Bagian Neurologi Anak FKUI/RSCM Jakarta
2018 ~ DOKTOR
Institusi: Departemen Ilmu Kesehatan Anak FK UNUD/RSUP Sanglah
Divisi Neurologi Anak
Email : dewi_sutriani@unud.ac.id
 Evidence Based Medicine (EBM)

merupakan pendekatan sistematik dalam

memecahkan masalah klinis dengan
mengintegrasikan bukti bukti ilmiah
yang terbaik (RESEARCH EVIDENCE)
yang ada dengan keahlian (CLINICAL
EXPERTISE) dan manfaat pada pasien.
¨ Mengenal PICO dan manfaat menggunakan
PICO
¨ Dapat Menyusun PICO dan pertanyaan klinis,
(Clinical Questions) dan masalah penelitian
(Research Question)
¨ Menggunakan PICO sebagai strategi
searching literatur/jurnal
¨ Menggunakan “Boolean logic” sebagai
strategi searching

www.cebm.net
E S
B T
M E
P
S
STEP 1
Proses EBM dimulai dengan skenario
klinis yang memerlukan jawaban terbaik
berdasarkan bukti ilmiah yang terbaik

Salah satu tahap yang sulit dalam praktek EBM.

“Mengubah suatu masalah klinis menjadi
masalah research (ANSWERABLE QUESTION)”
 Ubah pertanyaan menjadi
“ANSWERABLE QUESTION”

Tentukan informasi yang diperlukan menjadi suatu tipe

pertanyaan tentang

Prevention
Diagnosis
Prognosis
Therapy
Causation
 Question Type of question
What should I do about this INTERVENTION/
condition/problem? THERAPY
What cause the problem ? AETIOLOGY
RISK FACTOR
Does this person have the condition/ DIAGNOSIS
problem?
Who will get the condition/problem PROGNOSIS
PREDICTION
How common is the problem? FREQUENCY
RATE
What are the type of problem? PHENOMENA
THOUGHTS
 BACKGROUND Q
ü Pertanyaan tentang
“General Knowledge”
ü Mengandung 2 komponen
pertanyaan:
1. A question root (who, what,
where, when, how, why)
2. A disorder, test, treatment,
or other aspect of
healthcare
FOREGROUND Q
ü Pertanyaan tentang
pengetahuan spesifik yang
memberikan informasi
dalam menentukan pilihan
terapi atau tindakan.
ü Mengandung 4 komponen
PENTING: P-I-C-O
"PICO" is the ACRONYM for this 4 part question
which consists of the first letters of
1. Population, patients, predicament, problem
2. Intervention, Indicator/ exposure, test, or other agent
3. Comparison intervention, exposure, test, control
4. Outcome of clinical importance, including time,
when relevant.
¨ CLINICAL PROBLEM ?

¨ CLINICAL QUESTION ?

¨ ANSWERABLE QUESTION ?

¨ RESEARCH QUESTION ?
o Anda adalah seorang dokter residen yang baru
bertugas 1 bulan di ruang rawat inap CEMPAKA
o Ada seoarang pasien perempuan berusia 15 tahun
dirawat dengan keluhan demam dan kejang. Ini
merupakan episode kejang pertama kali
o Pertanyaan apa yang timbul dalam fikiran anda sbg
dokter tentang pasien ini?
o Tuliskan pertanyaan pertanyaan yang muncul dalam
fikiran anda!!!
 Originate from
everyday clinical problem !!
¨ Setiap merawat 10 pasien kemungkinan akan timbul
masalah/pertanyaan yang memerlukan jawaban sekitar
sebanyak 1-18 buah.
¨ Analisis menunjukkan bahwa sebagian besar
pertanyaan yang tidak terjawab, akhirnya dapat
dijawab dengan mengembangkan formula pertanyaan
dan searching yang lebih baik.
 Dissect what you
want to know into its
component parts

PICO is the commonly used acronym

for forming clinical questions when
practicing EBM
A child, 8 years, hospitalized in PICU because
severe GBS and need ventilator support .
The doctor want to know, are there any other
therapy option is better or the best? Any treatment
already used such as prednisone, plasma
exchange and other.
Does IVIG therapy deliver outcome better than
other therapy?

Every day clinical problem

Clinical Problem PICO Answerable question
The doctor want to P=child with severe GBS 1. In child with severe
know, are there any GBS, does IVIG
other therapy option is I /C = therapy deliver survival
better for child 1. Plasma rate better than plasma
hospitalized with GBS exchange exchange therapy?
& need ventilator 2. Prednisone 2. In child with severe
supports? 3. IVIG GBS, does IVIG
O= therapy deliver
1. Survive/Death sequalae less than
Does IVIG therapy 2. Sequalae plasma exchange
deliver outcome better 3. LOS in PICU therapy?
than other therapy? 4. Outcome scoring 3. In child with severe
5. Recovery GBS, does IVIG
6. Etc. therapy deliver
sequalae less than
Prednisone ?
 Population The patient or problem in question
P
Problem Who are the relevant people in relation to
clinical problem?
Intervention The intervention/test/exposure of
I interest.
Indicator
Index test Management strategy, exposure or test to
find out about relation to clinical problem
Comparator Comparison interventions
C
Control Alternative/control strategy, exposure or
test for comparison
Outcome The outcome of interest
O What are you most concerned about
happening or stopping happening
¨ CLEAR ‒ harus jelas
¨ DIRECTLY‒ langsung
¨ FOCUS - terfokus pada masalah
¨ ANSWERABLE ‒ dapat jawaban
dengan searching literature/
journal.
Anda bekerja sbg dokter anak di sebuah rumah sakit.
seorang anak laki laki diantar ke rumah sakit karena diare. Anda
masih bingung memilih terapi. Salah satunya obat probiotik.

Anda ingin mengetahui mana yang lebih bermanfaat untuk

pasien apakah kombinasi probiotics & pre-biotics efektif dalam
mengurangi lama diare dibandingkan dengan hanya
menggunakan probiotik saja. Dari sudut harga sangat berbeda

jauh.
 Patient Children with acute diarrhea
P Population

Intervention Probiotic + Prebiotic therapy

I
Comparison Probiotic only
C
Outcome Decrease duration of diarrhea
O
question In children with acute diarrhea, whether
? giving combination probiotics+prebiotics
more effective compared with probiotic for
decreasing duration of diarrhea
q Who are you interested in?
q How would you describe the patients
or population of interest?
Patients or population
Which is referred to the specific group the
patient or population belong to ?
¨ Diabetes mellitus type 1
¨ Infant with acute diarrhea
¨ Adult with chronic kidney disease
¨ Epilepsy in adult/children/ neonates
¨ Low birth weight infant
¨ Children with dermatitis atopic
¨ Pregnant woman
¨ Patient epilepsy with phenobarbital
¨ Cause
¨ Risk Factor
¨ Prognostic Factor
¨ Treatment/intervention
Intervention
Which is the kind of treatment or
procedure we want to know its efficacy ?.
 RISK FACTOR PROGNOSTIC FACTOR

¨ Family with epilepsy ¨ Control of blood

¨ Social economy pressure
¨ Low protein intake ¨ HbA1C
¨ Obese ¨ Hb concentration
¨ Less exercise ¨ Regular exercise
¨ Age ¨ MRI result
¨ High blood pressure ¨ CRP
¨ HDL/LDL ratio
 INTERVENTION TREATMENT

¨ Plasma exchange ¨ Amphicillin

¨ V-P shunt ¨ Carbamazepin
¨ Certain Procedure ¨ Paracetamol
¨ Elastic bandage ¨ Ibuprofen
¨ Elastic stocking ¨ High protein intake
¨ Catheterization ¨ Hiperosmoler fluid
¨ What is the alternative to the
intervention?
¨ May not always be necessary

Comparison
Which is the standard treatment
for comparing the effect of
Intervention ?
¨ What do I hope to accomplish?
¨ What could this exposure really affect?

Outcome
Which is the intended outcome we
expected to have by our intervention ?
q Length of stay
q Duration of diarrhea
q Duration of fever
q Accuracy
q Life expected
q Survival rate
 Clinical
PROBLEM

Jean is a 55 year-old woman

who quite often trip with a long flights
She tends to get swollen legs on these flights and is
worried about her risk of developing deep vein
thrombosis (DVT), because she has read quite a bit
about this in the newspaper lately. She asks you if
she should wear elastic stockings on her next trip to
reduce her risk of this.
P population = Passengers on long haul flight

I intervention = Wearing elastic compression

stockings

C comparator = No elastic stockings

O outcome = Development of DVT

In passengers on long-haul flights, does
wearing elastic compression stockings,
compared with not wearing elastic
stockings, prevent DVT?
George has come to your surgery to discuss
the possibility of getting a vasectomy.
He says he has heard something about
vasectomy causing an increase in testicular
cancer later in life.
You know that the risk of this is very low but
want to give him a more precise answer
Develop a ‘clinical research question’ using PICO

P population= adult male

I intervention = vasectomy

C comparator= No vasectomy

O outcome = testicular cancer

In men, does having a vasectomy (compared
with not having one), increase the risk of
getting testicular cancer in the future?
Mrs. Smith has acute lower back pain. She has
never had such pain before and is convinced
that it must be caused by something really
serious. You take a history and examine her but
find no indicators of a more serious, but she is
still not convinced.

Develop a clinical research question using

PICO to help reassure Mrs. Smith.
P = adults with lower back pain

O = more serious condition

Question :

In adults with lower back pain, what is the

frequency that the pain may reflect a more serious
condition (such as tumour or infection)?
¨ Creates a clear focused question !
¨ Defines the important outcomes !
¨ Structures your search !
¨ Saves you time!
¨ UBAH clinical problem MENJADI
answerable question
¨ Kunci sukses dalam searching:

KONVERSI “clinical problem” menjadi

“answerable question” yang jelas, secara
ideal dalam kerangka format PICO
¨ Enter the word of interest and combine
with : “AND”, “OR”, “NOT”
¨ Eq.
1. Hypertention
2. Therapy
3. 1 AND 2
Hypertension AND therapy
When do we use OR ? When do we use AND ?

¨ Combining synonyms, ¨ To combine different

spelling variants, concepts
acronyms,
related terms of each
concept
¨ Interested in retrieving
documents which
discuss one /more
items of interest
 children OR child OR infant OR
Patient pediatrics OR paediatrics

Intervention/ phenobarbital OR phenobarbitone OR

Exposure luminal

Comparison VPA OR valproic acid OR depakene

Outcome controled seizure

 children OR child OR infant OR pediatrics OR
Patient paediatrics
AND
Seizure OR convulsion
AND
phenobarbital OR phenobarbitone OR luminal
Intervention/
AND
Exposure
VPA OR valproic acid OR depakene
Comparison
AND

Outcome controled seizure

Search strategy using keyword
(1) Viral bronchiolitis
(2) Corticosteroids OR steroids OR
glucocorticoids OR prednisolone OR
dexamethasone
(3) Clinical score OR hospital stay
(4) (1) AND (2) AND (3).
Boolian
Logic
FILTER BY
Jumlah artikel
yang semakin
sedikit
FILTER BY
Formulate an answerable question
Tuliskan semua pertanyaan pada setiap masalah klinis.
Yang dihadapi (CLINICAL PROBLEM)

Identifikasi permasalahan berdasarkan tipe

pertanyaan
¨ Intervention
¨ Etiology
¨ Diagnosis
¨ Prognosis/prediction
¨ Frequency/rate
¨ Phenomenon
Susun research question menggunakan format PICO

P population =

I intervention =

C comparator =

O outcome =

ANSWERABLE QUESTION
RESEARCH QUESTION
 Click

Quick start
guide

Clinical
Queries
Question
type
 Least
biased
Meta-analisis
Analytical
Systematic review

Randomized Control Trial

Cohort study

Case Control Study

descriptive
Cross sectioal studies /
most Case Series/case Report
biased
Boolian
Logic
Jumlah artikel
yang semakin
sedikit
 Source Subjects
Population Subject

Intervension
Study Group
Comparator

Outcome Result
Question Best study design
Intervention RCT
Etiology/Risk factors RCT
Cohort Study
Case Control Study
Frequency & Rate Cohort Study
Cross Sectional Study
Diagnosis Cross Sectional Study

Prognosis & Prediction Cohort/Survival study

 EVERY DAY
CLINICAL PROBLEM PICO
A child, 8 years, P= Child with severe GBS
hospitalized in PICU
because severe GBS, I = IIG
C= (1) Plasma exchange
need ventilator support
(2) Prednison
The doctor want to know,
are there any other therapy O= (1) survive/death
option is better ? (2) sequele
Does IVIG therapy deliver (3) LOS in PICU
outcome better than other (4) outcome scoring
therapy? (5) Recovery
(6) etc