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Epidemiologi Klinik

&
Evidence Based Medicine
Blok 3 FK Muhamadiyah
Oleh
Prof.DR.Dr.R.M. Suryadi Tjekyan DTM&H.MPH

EVIDENCE BASED MEDICINE


Normalitas/Abnormalitas
Diagnosis
Kekerapan
Risiko
Prognosis

EPIDEMILOGI
KLINIK
SEBAGAI
METODA

Pengobatan

CRITICAL
APPRAISAL

Pencegahan
Kausa

Perjalanan/Riwayat

alami

GOOD AND VALID EVIDENCE

Give T=the

Best to The

Patients

area penelitian
biologic onset
(patobiology)

Risk factors
(Causation)

early diagnosis
possible

usual clinical
diagnosis

Dx

End Points

sembuh
komplikasi
cacad
mati

Prognostic
Diagnostic
Factors
test
Clinical Trials
Diagnostic
Therapy
Clinical Trials
test
Clinical Trials
Prevention I
Prevention II

Screening

EPIDEMIOLOGI KLINIS
Batasan epidemiologi klinis adalah studi
mengenai variasi luaran (out come) dan
perjalanan dari penyakit pada perorangan atau

kelompok dan sebab dari variasi tersebut.


Epidemiologi Klinis Penerapan metode epidemiologi
dan biostatistika pada diagnosis, terapi dan prognosis
pasien
Evidence Based Medicine
Pendekatan pada pengelolaan
pasien yang mengaplikasikan
informasi medis dari hasil penelitian yang sahih
(The best

evidence ) Give T=the

Best to The

Patients

Evidence-based medicine (EBM) is the conscientious, explicit


and judicious use of the current best evidence in making
decisions about the care of individual patients (Sackett 1996).
EBM bertujuan memperbaiki perawatan penderita
dengan cara

Penggunaan yang efisien dan efektif alat diagnose


Penggunaan Petanda Prognostik yang baik
Penggunaan metoda terapi,rehabilitasi dan prevensi
yang efektif dan aman
Penyesuaian yang baik tepat sesuai dengan yang
dikehendaki penderita

Objectives
1. Memahami dasar dasar Evidence Based Mediccine
2. Memahami Health Service Research(Penelitian
Pelayanan Kesehatan) sebagai
bagian dari
Epidemiologi
3. Memahami batasan penyakit , sakit dan resiko
yang ditimbulkannya.
4. Memahami keadaan Normal dan Abnormalitas
5. Memahami Aplikasi klinis dari RR , RD dan
NNT(Risk Ratio,Risk Difference dan Number
Needed to treat)

APA PERANAN
EPIDEMIOLOGI KLINIK

Epidemiologi klinik merupakan metoda


dasar dari EBM Berupa aplikasi prinsip

dan metode epidemiologi pada


permasalahan yang dijumpai
dikedokteran klinik

Dasar pendekatan kuantitatif di Klinik

Pengarahan bentuk interaksi klinisi dan penderita

. Pendekatan lintas sektoral melalui


epidemiologi klinik

keilmuan dasar

pada tatanan klinik

Mengembangkan dan menetrapkan

metode

epidemiologi berdasar pengamatan klinik yang

akan menghasilkan kesimpulan yang sahih (valid)

Fokus dari epidemiologi klinik adalah


isu klinis berupa :
Normalitas

dan Abnormalitas

Diagnosis
Kekerapan/Frekuensi
Risiko

Prognosis
Pengobatan/Terapi
Pencegahan

Kausa
Perjalanan/Riwayat

alami

NORMALITAS & ABNORMALITAS

Last (1995):
a)

Keadaan yang sesuai dengan variasi yang


ada pada populasi
b) Normal adalah indikasi peluang yang
rendah untuk mendapatkan penyakit
c)

Merujuk kepada kurva normal Gauss


normal adalah bila berada dalam variasi
rata rata 2 SD

NORMAL SECARA KLINIS


Normal

keadaan yang khas pada


populasi secara umum Chol 200mg/dl

Normal

dapat dindikasikan keadaan


yang tidak memerlukan follow up
lebih lanjut ataupun intervensi

KOLESTER
Kolesterol
darah
10

Std. Dev = 33.17


Mean = 169.9
N = 50.00

0
100.0

120.0

110.0

140.0

130.0

160.0

150.0

180.0

170.0

200.0

190.0

220.0

210.0

240.0

230.0

KOLESTER

Abnormalitas bila kadar Kolesterol > rerata + 2 x SD = > 169.9 + (2 x 33.17)=236.24

Normal secara Laboratoris


Biasanya dipakai interval referensi [2 SD]
KETERBATASAN
1.

2.
3.

Asumsi data berdistribusi normal akan


tetapi tidak selalau data klinis
berdistribusi normal.
Pemilihan 2 SD adalah arbitrase
mengapa tidak dipilih 90 % atau 99 %
Tidak selalu terdapat hubungan umum
antara penyimpangan statistik dengan
penyakit di Klinik Anemia dan gejala
kliniknya ,Serum Cholesterol dan MCI

4. Interval referensi tergantung pada populasi


referensi

a) dapat terdapat orang yang sakit didalammnya


b) Tidak seluruh populasi mengikuti test
C) Umur/Sex/Ras berpengaruh terhadap interval
referensi

Interval referensi dapat tidak memprediksi


abnormalitas secara akurat
6. Limit interval referensi biasanya tidak tetap
bergantung pada jumlah individu pada ekor
kurva
5.

EBM
Started in early 90s by clinical
epidemiologists
1992
: only few articles on EBM
2000
: >1000 articles
Indonesia
: started in 1997
Workshops : Yogya (2000)
IKA FKUI (2000, 2001)
Group discussion on EBM / mailing list:
<ebm-f2000@yahoogroups.com>
(coord:
<firmanda@cabi.net.id>)

1360

1370

1200
965
1000

86
5

800
599
600

400
213
200
2
1964 -1991
2001

1993

1
0

7
5

1995

1997

1999

MEDLINE searching results of articles containing the term


Evidence-based medicine, 1964-2001; English language only
(Downloaded on Sept 6, 2001/SS)

EBM & Clinical Epidemiology


Fletcher & Fletcher: CE = The application
of epidemiologic principles in problems
encountered in clinical medicine
Sackett et al: CE = The basic science for
clinical medicine
Much resistance by experts
EBM: In principle no one disagree
All major medical journals have adopted
EBM

Why do we need evidence?

Science
Deductive learning
Every Friday
Dr. AT is on call
Today is Friday

Therefore
Dr. AT is on call

Inductive learning
Resident A is neat
Resident B is neat
Resident C is neat
etc

Therefore:
All residents are neat

Previous practice:
6 yrs medical
education

40-50 yrs
medical practice

Usu. see only Results section,


or even worse, Abstract section

Problems with patients:


Dx, Rx, Px

Consultant, colleagues
Textbooks
Handbooks
Lecture notes
Clinical guidelines
CME, seminars, etc
Journals

What is Evidence-based
Medicine?
The conscientious, explicit, and judicious use
of current best evidence in making decisions
about the care of individual patients

Pemanfaatan bukti mutakhir yang sahih


dalam tata laksana pasien

Integration of
studies, and
preference

(1) physicians competence,


(2) valid evidence from
(3) patients

Pros

: New paradigm in medicine


Extraordinary innovations,
only 2nd to Human Genome Project
Cons : New version of an old song
Fair : Nothing wrong with EBM, but:

Be careful in searching evidence


Meta-analyses, clinical trials, and all
observational studies should be critically
appraised

Keyword for EBM:


Methodological skill to judge the validity
of study reports (Re. Andersen B:
Methodological errors in medical research,

WHY EBM?
1.New evidence are continuously
generated
2. We usually fail to get the new evidence
3. Our clinical performance deteriorates
with
time (the slippery slope)
4. Traditional CME does not improve
clinical
performance
5.EBM encourages self directed learning
process which should overcome the
above shortages

100%

Relative
% of
remaining
knowledge

10

Years after graduation

THE SLIPPERY SLOPE

12

Steps in the practice of EBM


1. Formulate clinical problems in answerable questions
2. Search the best evidence: use internet or other online database for current evidence
3. Critically appraise the evidence for VIA
Validity (was the study valid?)
Importance (were the results clinically
important?)
Applicability (could we apply to our patient?)
4. Apply the evidence to patient
5. Evaluate our performance

Main area
Diagnosis
(Determination of disease or problem)
Treatment
(Intervention necessary to help the patient)
Prognosis
(Prediction of the outcome of the disease)

Others:
Meta-analysis
Clinical guidelines
Economic analysis
Clinical decision making
Cost-effectiveness analysis
Qualitative research

(I)
Formulating clinical questions

A 2-month-old infant with large VSD


Birth weight 3.1 kg
BW 3.8 kg, HR=132, RR 68
Retractions (+)
Systolic murmur, gallop rhythm
Hepatomegaly
Dx: Large VSD, CHF, FTT
Definite Rx: early surgery
Alternative Rx: Drugs first?

Medical students:
(Background question)
What is VSD?
How to Dx?
What are symptoms & signs of
CHF
in infants with L-R
shunt?
What is the treatment?

House officers
(Foreground question)

In infants with large VSD and CHF,


would administration of digoxin or other
inotropic agent delay the need for
surgery?

Other example

In neonates born to mothers with


history of herpes simplex infection,
does the administration of IVIG
(intravenous immunoglobulin) reduce
the possibility of neonatal herpes?

Four elements of
good clinical question: PICO
The Patient or Problem
The Intervention
Comparative intervention (if
relevant)
The Outcome

Question for Diagnosis


A 11 year-old girl was evaluated for thyroid solitary
nodule. She has been complaining of pain on
palpation; other physical findings were negative.
Thyroid function showed normal results. The
physician was thinking about screening with
ultrasound.
P:
I:
C:
O:

In young women with solitary thyroid nodule and


normal thyroid function,
what is the likelihood of ultrasound
in excluding malignancy?

Harm
A 15-month-old infant was brought for MMR
vaccination. The mother inform that her daughter is
very allergic to egg. Knowing that all MMR vaccine
contain small amount of egg protein ovalbumin,
Question formulation:
P:
I:
O:

In patients allergic to egg,


does administration of MMR vaccine
cause significant allergic reaction?

II
Searching the evidence

Examples of on-line Journals /


Databases

http://bmj.com
http://adc/bmjjournals.co
m
MEDLINE/PubMed
EMBASE
MDConsult
AAP Journal Club
Cochrane Library

Berlangganan peserta diberi kartu akses

Use keywords for searching


Note:
Spelling (American / British), terminology
Follow rigidly the instructions of each website
Examples:
host vs graft reaction AND management
hemosiderosis AND thalassemia OR
thalassaemia
breast cancer OR Ca mammae AND
immunoglobulin OR IVIG

III
Appraising the evidence:
VIA

VIA
VALIDITY: In Methods section:

design, sample, sample size, eligibility criteria


(inclusion, exclusion) sampling method,
randomization method, measurements, methods
of analysis, etc

IMPORTANCE: In Results section

characteristics of subjects, drop out, analysis, p


value, confidence intervals, etc

APPLICABILITY: In Discussion section + our patients


characteristics

Example:
Critical appraisal for therapy
Were the subjects randomized?
Were all subjects received similar treatment?
Were all relevant outcomes considered?
Were all subjects randomized included in the
analysis?
Calculate CER, EER, RRR, ARR, and NNT
Were study subjects similar to our patients in terms
of prognostic factors?

Hierarchy/Level of evidence
I

a. Meta-analysis of RCT
b. Large RCT
II a. Controlled trial without randomization
b. Cohort, case control studies
III a. Cross-sectional
b. Case series, case reports

IV

Expert opinion

Impelentation of EBM practice:


How to get started
1. Teaching EBM in medical schools / PPDS
Easier than to change the already existing attitude
Most important
May be included in formal curricula or integrated in
existing activities: ward rounds, on calls, case
presentations, group discussions, journal clubs, etc

2. Workshop for teaching staff


3. Workshop for practitioners, incl. nurses

Resistance to EBM teaching


& learning

Rudimentary skill in critical appraisal /


methodological skill
Limited resources, esp. time factor
Lack of high quality evidence
Scepticism toward evidence-based
practice
Happy with current practice

Development of EBM practice

Passive diffusion model


Active dissemination model
Coordinated implementation
model:
# Patients & community
# Health administrators
# Public policy makers
# Clinical policy makers

Strategies for developing EBM


practice

Clinical guidelines
Practice development leaders
(! Environment)
Development units
Dissemination of good
practice
Networking
Research summaries
Action research

Physicians proficiency

Evidence

Patients preference

Patient with
problem

Apply
the evidence

Critically
appraise
the evidence

Formulate
in answerable
question

Search the
evidence

Sources of
evidence

Good clinical
question

Recent relevant
literature

Problem
identification

Valid, important,
applicable
evidence

Patient

Integration of
current evidence
into practice

Advantages of EBM
Encourages reading habit
Improves methodological skill (and
willingness to do research?!)
Encourages rational & up to date
management of patients
Reduces intuition & judgment in clinical
practice, but not eliminates them
Consistent with ethical and medico-legal
aspects of patient management

End result
self directed, life-long learning attitude
for high quality medical management

Conclusion
EBM is nothing more than a
framework of systematic use of
current valid study results
relevant to our patient

Remember, however
...
Medicine is the science of uncertainty
and the art of probabilities

Different aspects of clinical questions

Etiology how to identify causes for


disease

Differential diagnosis how to rank

possible causes by likelihood, seriousness


& treatability

Diagnostic tests how to select and

interpret diagnostic tests (either to rule in or


rule out), need to consider accuracy,
precision, acceptability, expense, safety etc

Prognosis how to estimate patients likely


clinical course and complications over time

Therapy how to select treatments that do

more good than harm and are worth efforts


& costs

Prevention/screening how to identify &


modify risk factors for disease/diagnose
disease early

Four elements of a well constructed clinical


question: PICO

P
I
C
O

: Patient or Problem
: Intervention
: Comparative intervention
: Outcome

Four elements of a well constructed clinical


question: PICO

How would I
describe a
group of
patients
like mine?
B e

Which main
intervention
am I
considering?
b r i e f

What is the
What can I
alternative
hope
to compare
from this
with the
intervention?
intervention?
a n d s p e c i f i c

Example 1:

Female, 28 years, known to have SLE,


shortness of breath on exertion, swollen
ankles at end of day
Previous pericardial effusion, uncomplicated
MI, taking ibuprofen for painful knees
No chest pain, fever, cough or sputum
BP 145/85 mmHg, HR regular 88 bpm
Elevated neck veins, fluid in lungs & third
heart sound but no murmurs

Etiology
P

..does giving compared


In young
ibuprofen
with no
female with
ibuprofen
SLE & history
of cardiac
involvement

O
lead to
increased
likelihood of
heart failure?

Differential diagnosis
P

In SLE
.with pre- .and taking .which one
patients
existing
and taking Is more likely
with new
Cardiac
NSAID
explanation?
onset
Involvement
heart failure

Prognosis
P

In young
female
SLE

does
devment of
heart failure

.compared lead to
with no heart increased
mortality?
failure

Therapy
P
In SLE
patient on
ibuprofen
with
heart
failure

I
would
removal of
NSAID
and
addition
of diuretic

C
versus
NSAID
removal plus
diuretic plus
ACE inhibitor

O
alleviate
heart
failure?

Prevention
P
In SLE
patients
with
heart failure

I
.would
long-term
ACE
Inhibitor

C
compared
with no
ACE
inhibitor

O
prevent
recurrence
& improve
quality
of life

Example (2)
Female, 73 years, shortness of breath on

exertion, swollen ankles at end of day


previous uncomplicated MI, no betablockers, taking ibuprofen for painful knees
no chest pain, fever, cough or sputum
BP 145/85mmHg, HR regular 88bpm
elevated neck veins, fluid in lungs & third
heart sound but no murmurs

Etiology
P

In elderly
female with
CHD

..does giving compared


ibuprofen
with no
ibuprofen

O
lead to
increased
likelihood of
heart failure?

Differential diagnosis
P

In patients .with prewith new


existing
onset
CHD
heart failure

.and taking .which one


and taking Is more likely
NSAID
explanation?

Example: Prognosis

In elderly
does
.compared lead to
female
development with no heart increased
patients of heart failure
mortality?
failure
with CHD

Example: Therapy
P
In CHD on
ibuprofen
with
heart
failure

I
would
removal of
NSAID
and
addition
of diuretic

C
versus
NSAID
removal of
diuretic plus
ACE inhibitor

O
alleviate
heart
failure?

Prevention
P
In patients
with
heart failure

I
.would
long-term
ACE
Inhibitor

C
compared
with no
ACE
inhibitor

O
prevent
recurrence
& Improve
quality
of life

Problem 1 - Diagnostic test


Male, 38 years, complaining of stomach pains

(again)
previously responsive to antacids
you suspect H. pylori and suggest referring for
endoscopy
after describing what is involved, patient is not
keen and asks if there is another test
you agree to find out about sensitivity and
specificity of non-invasive tests

Diagnosis
P
in patients
(men?) with
recurrent
stomach
complaints
responsive to
antacids

is noncompared
invasive
with
diagnostic test endoscopy

(breath test)

O
as sensitive
and specific at
identifying H.
pylori status

Problem 2 - Prevention
male, 28 years, with symptoms
suggestive of influenza
illness has caused misery, resulted in
time off work (self-employed)
aware that elderly are vaccinated, wants
to know if it can benefit him next year
you decide to look for evidence on
efficacy of vaccine among young, healthy
adults

Prevention
P

In healthy
adults

is influenza
immunization

compared effective in
with no
reducing
immunization
incidence
of flu

Problem 3 - Therapy
Infant, 13 months, experienced 2
attacks of febrile convulsions
Variable recommendations on the use of
maintenance anticonvulsants
Not sure whether to give or not in order to
prevent further attacks

Therapy
P
In infants
with
repeat
febrile con
vulsion ..

I
.. is anticonvulsant
drugs

compared
with
no drugs

better
control
further
seizure

Problem 4 - Prognosis
Female, 46 years, had ulcerative colitis for 11

years, in remission at present


extensive involvement of colon, severe
symptoms at times
not keen on surgery, but has read about
possible increased risk of cancer
you agree to find out what the risk might be

Prognosis
P

In middleaged
women

with history
of ulcerative
colitis

cf no
colitis

what is
the risk of
developing
Ca

Concluding remark
In patient with
X and X, would the
administration of
Y or Y, decrease the
likelihood of
developing
so and so?

HYPOTHESIS TESTING
&
ESTIMATION
(P value & Confidence Interval)

Sample is assumed to be representative


to the population.
In research: measurement are always done in the sample,
the results will be applied to population.

P
S

P
S

Target population

Accessible
population

Intended
Sample
Actual
study subjects

Usu. based on practical


purposes

Target population
(Demographic & clinical)

Accessible
population
(+ time, place)

Appropriate
sampling
technique
Actual
study
subjects
Subjects
completed
the study

Intended
Sample

[Non-response, drop outs,


withdrawals, loss to follow-up]

[Subjects selected
for study]

External validity II:


Does AP represent TP?

Target population

Accessible
population
[External validity I:
Does IS represent AP?}
Actual
study
subjects

Intended
Sample

[Internal validity: does


ASS represent IS?]

USE LOGIC / COMMON SENSE


The provided worksheets are only one of the approaches
in critical appraisal
Complete appraisals should include all aspects of
research methods
Do not forget 7 points to establish cause-effect
relationship (Bradford Hill)
Correct temporal relationship
Dose dependent
Strong association
Consistency within the study (subgroup)
Coherence
Similarity to other studies
Biologically plausible

Sampling
Investigation

Results

Inference

P value
Confidence intervals!!!

Clinical importance vs. statistical significance


Cholesterol level,
mg/dl
300

220

Standard, n= 5000

Clinical
Experimental, n=5000
300

t=

df = 9998

218

p = 0.0023
Statistical

Clinical importance vs. statistical significance


Yes

No

Standard

10

New

Absolute risk reduction = 30%

Clinical

Fischer exact test: p = 0.212

Statistical

Statistic and Parameter

An observed value drawn from the sample is


called a statistic (cf. statistics, the science)
The corresponding value in population is called a
parameter
We measure, analyze, etc statistics and translate
them as parameters

Examples of statistics:

Proportion
Percentage
Mean
Median
Mode
Difference in
proportion/mean

OR
RR
Sensitivity
Specificity
Kappa
LR
NNT

There are 2 ways in infering statistic


into parameter
Hypothesis testing p value
Estimation: Confidence interval (CI)

P Value & CI tell the same concept in different


ways

P value

Determines the probability that the


observed results are caused solely by
chance (probability to obtain the observed
results if Ho were true)

Confidence Interval

Estimates the range of values


(parameter) in the population using a
statistic in the sample (as point estimate)

Most commonly used CI:

CI 90% corresponds to p 0.10


CI 95% corresponds to p 0.05
CI 99% corresponds to p 0.01
Note:
p value only for analytical studies
CI for descriptive and analytical studies

How to calculate CI
General Formula:
CI = p Z x SE

p = point of estimate, a value drawn from


sample (a statistic)
Z = standard normal deviate for , if =
0.05 Z = 1.96 (~ 95% CI)

Example 1
100 FK-Unsri students 60 females (p=0.6)
What is the proportion of females in Indonesian
FK students? (assuming FKUnsri represents FK
in Indonesia)

Example 1

SE(p)CI pq
n
95%CI 0.61.96 0.6x0.4
100
0.61.96x0.5
10
0.6 0.1 0.5;0.7

Examples 3: CI of difference between


proportions (p1-p2)

50 patients with drug A, 30 cured (p1=0.6)


50 patients with drug B, 40 cured (p2=0.8)
95%CI(p p ) (p p ) 1.96xSE(p p )
1
2
1
2
1
2

SE(p1 p 2 )

p1q1 p1q2

n2
n2

(0.6 0.4) (0.8 0.2)


0 .4

0.09
50
50
50
95%CI(p1 p 2 ) (0.2 0.9); (0.2 0.09) 0.11; 0.29

Example 4: CI for difference between


2 means
Mean systolic BP:
50 smokers
50 non-smokers
x1-x2
95% CI(x1-x2)
SE(x1-x2)

= 146.4 (SD 18.5) mmHg


= 140.4 (SD 16.8) mmHg
= 6.0 mmHg
= (x1-x2) 1.96 x SE (x1-x2)
= S x V(1/n1 + 1/n2)

Example 4: CI for difference between


2 means

(n1 1)s12 (n2 1)s 2 2


(n1 n2 2)

(49 18.6) 49 16.2


17.7
98

1
1
SE(x 1 x 2 ) 17.7

3.53
50 50
95%CI 6.0 (1.96X3.53) 1.0;13.0

Other commonly supplied CI

Relative risk
Odds ratio
Sensitivity, specificity
Likelihood ratio
Relative risk reduction
Number needed to treat

(RR)
(OR)
(Se, Sp)
(LR)
(RRR)
(NNT)

In contrast to CI for proportion, mean, diff.


between proportions/means, where the
values of CI are symmetrical around point
estimate, CIs for RR, OR, LR, NNT are
asymmetrical because the calculations
involve logarithm

Examples

RR
OR
NNT

= 5.6
= 12.8
= 12

(95% CI = 1.2 ; 23.7)


(95% CI = 3.6 ; 44,2)
(95% CI = 9 ; 26)

If p value <0.05, then 95% CI:


exclude 0 (for difference), because if A=B
then A-B = 0 p>0.05
exclude 1 (for ratio), because if A=B then A/B
= 1, p>0.05
For small number of subjects, computer
calculated CI may not meet this rule due to
correction for continuity automatically done by
the computer

Concluding remarks

p values (hypothesis testing) gives you the


probability that the result is merely caused
by chance, it does not give the magnitude
and direction of the difference
Confidence interval (estimation) indicates
estimate of value in the population given
one result in the sample, it gives the
magnitude and direction of the difference

Concluding remarks

p value alone tends to equate statistical


significance and clinical importance
CI avoids this confusion because it
provides estimate of clinical values and
exclude statistical significance
whenever applicable, supply CI
especially for the main results of study
in critical appraisal of study results, focus
should be on CI rather than on p value.

Concluding remarks

In appraising study results, focus


should be on confidence intervals
rather than on p values.

Diagnosis
Nilai Uji Diagnostik tergantung dari
Keterandalan (reliability),
Kesahihannya (validity)
Relevansinya

Peniliaian hasil suatu diagnostik diekpresikan kedalam


bentuk satuan nilai

1. Sensitivitas/Sensitivity
2. Spesifisitas
3. Nilai Prediksi Positif
4. Nilai Prediksi Negatif
4. Likelihood ratio +
5. Likelihood ratio
( Likelihood ratio = Ratio kemungkinan )

SENSITIVITAS adalah suatu kemampuan dari suatu tes


yang memberikan hasil
positif dalam suatu grup
perorangan dengan suatu penyakit (Positif asli).
Sensitivitas =
Pr (tes + / Dx +) = a/a+c
Probabilitas Test Positif +gold Standard positif
SPESIFISITAS adalah kemampuan dari suatu tes yang memberikan hasil
negatif dalam suatu grup perorangan tanpa suatu penyakit (Negatif asli).
Spesifisitas
=
Pr (tes - / Dx -) = d/b+d
Probabilitas test negatif +gold standard negatif

Nilai prediksi positif atau nama lainnya Positive Predictive Value


/Posterior Probability of Positive Value adalah peluang orang yang
disaring sebagai positif akan mempunyai penyakit yang diskrining =
a/(a+b).
Nilai prediksi negatif adalah Peluang orang yang disaring sebagai
negatif tidak akan mempunyai penyakit yang diskrining = d /(c+d)

Likelihood Ratio

Likelihood ratio positif adalah : Peluang mendapatkan hasil


positif pada kelompok penyakit dibandingkan peluang
mendapatkan hasil positif pada grup bukan penyakit.

Proporsi hasil positif grup penyakit

= a/ a+b

Proporsi hasil positif grup bukan penyakit

= b/b+d

Likelihood Ratio Positif = ( a / a+ b ) : (b / b + d)

Likelihood ratio negatif adalah : Peluang mendapatkan hasil


negatif pada kelompok penyakit dibandingkan peluang
mendapatkan hasil negatif pada grup bukan penyakit

Proporsi hasil negatif grup penyakit

= c/a+c

Proporsi hasil negatif grup bukan penyakit

= d/b+d

Likelihood Ratio Negatif adalah = (c/ a+c ) : d / ( b+d)

Likehood Ratio Positif


Likelihood Ratio dari Test =--------------------------------- = Odd RatioLikelihood Ratio Negatif

Prevalen = (a+c)/(a+b+c+d)

Tes
Penyaringan

Penyakit
Total
+

a
(positif asli)

Total

(positif palsu)

a+b
(total tes positif)

(negatif palsu)

d
(negatif asli)

c+d
(total tes negatif)

a+c
(total
penyakit)

b+d
(total bukan
penyakit)

a+b+c+d
(total keseluruhan)

Sensitivitas = ( a / ( a + c )
Spesifisitas = (d/ ( b + d )
Akurasi
= (a+d)/(a+b+c+d )

Nilai Prediksi Positif = a/ ( a+ b)


Nilai Prediksi Negatif = d/( c+ d)

Likelihood Ratio Positif = ( a / a+ b ) : (b / b + d)


Likelihood Ratio Negatif adalah = (c/ a+c ) : d / ( b+d)

Infark miokard
Kreatinin kinase

Total

Ya

Tidak

Positif (>80 IU)

215

16

231

Negatif (<80 IU)

15

114

129

Total

230

130

360

Sensitivitas
Spesifisitas

=
=

NPP
NPN

215/231 x 100
114/129 x 100

=
=

215/230 x 100
114/130 x 100

= 93,5%
= 87,7%
= 93,1 %
= 88,4 %

Pre test prevalen = ( 230/360) = 63.89 %

LR + = ( proporsi + grup pneyakit / Proporsi +Goup bukan penyakit


LR + = 0,9348/0,1231 = 7,5938
LR - = ( proporsi - grup pneyakit / Proporsi -Goup bukan penyakit
LR - = 0.0652/0,8769 = 0,0743

Infark miokard
Likelihood
Rasio

Kreatinin kinase
Ya

Proporsi

Positif > 80 IU

215

215/231 = 0,9348

Negatif < 80 IU

15

15/231 = 0,0652

Total

230

Tidak Proporsi

16 (16/130 = 0,1231)

0,9348/0,1231 = 7,5938

114 (114/130= 0,8769)

0.0652/0,8769 = 0,0743

130

360

LR TEST = LR+/LR- = 7,5938/0,0743 = 102,2 ----odd ratio

1. Likelihood ratio test didefinisikan sebagai


rasio dari Likelihood Ratio Positif
dibandingkan dengan Likelihood ratio negatif
2. Makin tinggi Likelihood ratio test makin
effisien kemampuan deskrimasi dari test
skrining/Daignostik
LR TEST = LR+/LR- = 7,5938/0,0743 = 102,2

Nilai likelihood ratio dari skrining adalah sama dengan odd ratio.

Hanya kasus
yang memerlukan tes diagnostik

pria 55 th, nyeri dada kiri, menjalar


merokok 2 pak /hari
T 180/110, gallop +
kolesterol 358 mg%

probabilitas (prates) menderita PJK 90 %


Perlu treadmill???

Sn tredmil 60% dan Sp tredmil 91%

PJK

+8%

(angiografi koroner = gold standard)

+
tredmil

prob. pascates

540

549

360

91

451

900
probab (prates) PJK
(pascates)

100

540
----- =
549

1000

90%
98%

98%

probabilitas
menderita PJK
dari 90% ke
98%, tidak
perlu tredmil

pria 45 th, nyeri dada kiritidak khas

merokok 1 pak /hari


T 120/80

lab: normal
probabilitas (prates ) PJK 50 %

Sn tredmil 60% dan Sp tredmil 91%

PJK

(angiografi koroner)

tredmil

prob. pascates

+
+

300

45

345

200

455

655

500

950

probab (prates) PJK


(pascates)

87%

+37%

1000
50%

300
----- =
345

87%

probabilitas
menderita PJK dari
50% ke 87 %,
Perlu tredmil

Pre test validity

General structure :
2 X 2 table

Predictor
Test
positive
Predictor
Test
negative

Target disorder
Positive
(disease)
True positive
TP
a
False negative
FN
c

Target disorder
Negative
(normal)
False positive
FP
b
True negative
TN
d

Sensitivity, specificity, predictive values, likelihood ratios, ROC

Critical appraisal
Use worksheet
Use supporting softwares

CAT

Maker
Save in CAT Banks

Indonesian research report CAT


Bank??

Is this evidence about a diagnostic test valid?

Was there an independent, blind comparison


with a reference (gold) standard of
diagnosis?
Was the diagnostic test evaluated in an
appropriate spectrum of patients (like those
in whom we would use it in practice)?
Was the reference standard applied
regardless of the diagnostic test result?
Was the test (or cluster of tests) validated in
a second, independent group of patients?

validity

Does this (valid) evidence


demonstrate an important ability of
this test to accurately distinguish
patients who do and dont have a
specific disorder?
Sensitivity
Specificity
Likelihood ratios

SnNOut
SpPIn

Disease
(+)

Disease
(-)

Totals

Test (+)

a+b

Test (-)

c+d

b+d

a+b
+c+d

d/b+d

Specificity

Totals
Sensitivity

a+c
a/a+c

Probability of positive test result


in patients with the disease

Probability of negative test result


in patients without the disease

SnNout
Diagnostic test with a very high sensitivity ,
a negative result effectively rules out the
diagnosis

SpPin
Diagnostic test with a very high specificity ,
a positive result effectively rules in the
diagnosis

Disease
(+)

Disease
(-)

Totals

a/a+b Test (+)

a+b

d/c+d Test (-)

c+d

a+c

b+d

a+b
+c+d

Totals

Positive predictive value


Probability of having disease in positive test group
Negative predictive value
Probability of not having disease in negative test group

Sensitivity=a/a+c=90%
Specificity =d/b+d=85%
Pos predictive value=a/a+b=73%
Neg predictive value=d/c+d=95%
Outcome

Iron deficiency anemia

Totals

Present

Absent

(+)
<65 mmol/L

731
a

270
b

1001
a+b

(-)
>65 mmol/L

78
c

1500
d

1578
c+d

1770
b+d

2579
a+b+
c+d

Predictor
Diag
nostic
test
result
(Serum
ferritin)

LR + = se/(1-sp)=90/15=6

Totals

809
a+c

Prevalence= (a+c)/(a+b+c+d)= 32%

Odds = ratio of two probabilities


Odds = p/1-p
Probability = odds/1+odds
Likelihood ratio (+):
Prop (+) result in people with the disease
Prop (+) result in people w/out the disease
Pretest Odds X LR = Posttest Odds

(1-Se)/Sp= -

+ = Se/(1-Sp)

Likelihood ratio

do not
test

do not
test

get on with treatment

Test

do not
treat

.10

Test
.20

.30

.40

.50

.60

.70

.80

pretest probability

posttest probability

PreTest odds x LR

pretest probability

.90

Pretest
probability

Likelihood ratio

Posttest
probability

Accuracy of the test

The accuracy of the test


depends on how well the
test separates the group
being tested into those with
and without the disease in
question
Accuracy is measured by the
area under the ROC curve.
An area of 1 represents a
perfect test; an area of 0.5
represents a worthless test
(AUC)

0.90-1.00
0.80-0.90
0.70-0.80
0.60-0.70
0.50-0.60

=
=
=
=
=

excellent (A)
good (B)
fair (C)
poor (D)
fail (F)

Questions to answer in applying a valid


diagnostic test to an individual patient

Is the diagnostic test available, affordable, accurate,


and precise in our setting?
Can we generate a clinically sensible estimate of our
patients pre-test probability?

From personal experience, prevalence statistics,


practice databases, or primary studies

Are the study patients similar to our own?

Is it unlikely that the disease possibilities or


probabilities have changed since this evidence was
gathered?
Will the resulting post-test probabilities affect our
management and help our patient?

Could it move us across a test-treatment


threshold?

Would our patient be a willing partner in carrying


it out?

Would the consequences of the test help our


patient reach his or her goals in all this?

Guides for deciding whether a


screening or early diagnostic
maneuver does more good than
harm:
1.

2.
3.

4.

Does early diagnosis really lead to


improved survival, or quality of life, or
both?
Are the early diagnosed patients willing
partners in the treatment strategy?
Is the time and energy it will take us to
confirm the diagnosis and provide
(lifelong) care well spent?
Do the frequency and severity of the
target disorder warrant this degree of
effort and expenditure?

Ukuran Ukuran Resiko


Absolute Risk
Risk Difference
Relative Risk
Adjusted Relative Risk
Attributable Risk
Population Attributable Risk
Absolute Risk Reduction (ARR)
Relative Risk Reduction (RRR)
Numbers Needed to Treat (NNT)
Numbers Needed to Harm (NNH)

Apakah A berhubungan dengan B?


Exposure
Treatment
Program
Process
Characteristic
Behavior

Effect
Death
Outcome
Cost
Disease

Risk Difference= R.D.


Perbedaan Resiko

Risk difference= IE - IC

(incidence terpapar) - (incidence tidak


terpapar)

Contoh
Intervensi : Fosamax; Controls: Placebo
Outcome: Fraktur Klinis
IE = 11.9 per 100; IC = 14.7 per 100
Risk difference = 11.9-14.7 = -2.8 per
100

Relative Risk (RR)

RR = IE/IC

(incidence

in exposed) / (incidence in
non-exposed)

Contoh:
Intervensi: Fosamax; Controls: Placebo
Outcome: Fraktur Klinis
IE = 11.9 per 100; IC = 14.7 per 100
RR = 11.9/14.7 = 0.81

Interpretasi dari Relative Risk


Insiden kelompok terpapar dan tidak
terpapar(Tidak ada Hubungan)

RR = 1

RR > 1

Insiden kelompok terpapar lebih besar


dari kelompok tidak terpapar.

RR < 1

Insiden kelompok terpapar lebih kecil


dari kelompok tidak
terpapar.(Protektif)

Rumus Relatif Risk


Outcome
Yes

No

Total

Yes

a+b

No

c+d

Exposure

Relative risk = incidence in exposed


incidence in nonexposed

Hitunglah Resiko relatif


Heart Disease
Yes

Yes

No

40

360

400

200

1400

1600

Regular
Exercise
No

RR

= I(e)
I(ne)

Interpretation:

a/(a+b)
c/(c+d)

Penelitian Kasus Kontrol

Hip Fracture
(cases)

Received
Health
Promo
a

Did Not
Receive
Health
Promo
c

No
Hip Fracture
(controls)

Received
Health
Promo
b

Did Not
Receive
Health
Promo
d

Penelitian Kasus Kontrol


Hip Fx
(cases)

No Hip Fx
(controls)

Promo

No Promo

Total

a+c

b+d

Odds Ratio (OR) or Relative Odds (RO) =


Odds that a case was exposed
Odds that a control was exposed

ad
bc

Hitunglah Odd Ratio


Hip Fx

No
Hip Fx

Promo

100

200

No Promo

900

800

Odds Ratio =

Interpretation:

Hitunglah Odd Ratio


CHD

Smokers

Non-Smokers

Total
Odds Ratio

Interpretation:

Cases

Controls

120

170

80

230

200

400

Adjusted Risk
Resiko yang disesuaikan

Kegunaan

Untuk dapat dibandingkan

Memperhitungan perbedaan Co-Variate


yang ada dalam group yang diteliti

Metoda Penyesuaian/Adjustment
Standarisasi
Mantel Haenszel
Log-linear models

risk models
odds models
rate models
incidence-time models

Latihan dan Miokard Infark


Miokard infark

Jumlah

Latihan
Postif

Negatif

Positif

170

80

250

Negatif

80

170

250

250

250

500

Odd ratio

(170x170): (80x80) = 4.52

Measures of exposure effect [95% CI]


Risk ratio
:
Odds ratio
:
Risk difference
:
Proportional attributable risk
:
Population proportional attr. risk :

2.13
4.52
0.36
0.53
0.36

[1.74,
[3.10,
[0.28,
[0.43,
[0.27,

2.59]
6.58]
0.44]
0.61]
0.44]

1.
2.

3.
4.

5.

6.

Umur kelompok MI, 80% orang berusia diatas 50 tahun dan hanya 20 %
pada kelompok Non MI termasuk kelompok usia > 50 tahun tersebut .
Apakah perbedaan usia pada dua kelompok dapat menjelaskan hubungan ini
atau sepenuhnya resiko 4.52 kali tersebut hanya dipengaruhi oleh faktor
tidak olah raga/latihan dan tidak dipengaruhi oleh umur
Harus dibuktikan dulu bahwa umur bukan confounder
Bila umur adalah confounder maka dipertanyakan berapa sebenarnya resiko
terjadinya MI yang memang disebabkan oleh faktor tidak latihan/olahraga
sebaliknya
Umur bukan confounder maka berarti resiko terjadinya MI pada kelompok
yang tidak berolahraga memang 4.52 kali dibandingkan dengan yang
berolahraga atau dengan kata lain insiden MI pada kelompok berolahraga
dibandingkan tidak berolah raga adalah 1 : 4.52 dimana setiap 100 pasien MI
kelompok yang berolaharaga maka didalam populasi terdapat 452 kasus MI
kelompok individu yang tidak berolah raga.
Subjek studi menjadi dua kelompok yaitu usia
6.1. dibawah 50 tahun
6.2. lebih dari 50 tahun
6.3. Dilihat hubungan antara latihan dan kejadian MI pada masing-masing
kelompok usia.

Adjusted odd ratio tidak sama dengan Crude Odd Ratio


Umur adalah Confounding

1.

cOR/aOR > 0,15

2.

cOR/aOR < 0,87

CONFOUNDER POTENSIAL

Adjusted RR
Myocardial Infarction
Yes
No

Total

Education
High School

100

1700

1800

60

1140

1200

130

2570

2700

1-4 years

105

110

5-9 years

10

120

130

10 + years

15

45

60

160

2840

3000

College

Oral Contraception
Never

Total

Adjusted RR
Myocardial Infarction
Crude
Adjusted*
95% C.I.
RR
RR
Education
High School

1.11

--

--

--

--

--

1-4 years

0.98

1.0

(0.9-1.1)

5-9 years

1.60

1.3

(0.9-1.7)

10 + years

5.20

4.1

(2.1-6.1)

College

Oral Contraception
Never

*Adjusted for educational status

Absolute Risk Reduction (ARR)

Absolute Risk Reduction (ARR) adalah


perbedaan angka kejadian antara
kelompok kontrol dan kelompok
perlakuan(control group (CER) dan
exposure group (EER): ARR = CER - EER.

Perlakuan: Fosamax
Controls: Placebo
Outcome: Fraktur Klinis
CER = 14.7 per 100; EER = 11.9 per 100
ARR = 14.7-11.9 = 2.8 per 100

Number needed to treat= NNT


NNT Adalah penderita yang harus diobati
untuk mengurangi 1 tambahan outcome yang
jelek (death, stroke, etc.).
Perhitungan: NNT = 1/ARR = 1/(2.8%)
=35.7 = 36 penderita untuk mengurangi 1
kematian atau efek jelek lainnya

NNHs Adalah jumlah penderita yang harus


ditambahkan untuk menimbulkan 1 effek
buruk (side effect, etc.)

TERAPI / PENGOBATAN
memilih terapi yang terbaik untuk penderita

1. Menentukan tujuan terapi apakah kuratif, paliatif


atau hanya menghilangkan gejala,
2. Memilih terapi yang spesifik apakah memang
penderita membutuhkan terapi, apakah terdapat
bukti, asal sumber bukti tersebut yang menyatakan
bahwa terapi tersebut adalah terapi yang spesifik
untuk mencapai tujuan terapi.
3. Menentukan target terapi agar dapat ditentukan
kapan menghentikan pengobatan, kapan mengganti
dengan obat lain

PERMASALAHAN KLINIS PASIEN


Patient/Problem

Intervention

FORMULASI PERTANYAN KLINIS YANG DAPAT DIJAWAB

PICO

Comparison Intervention

SOFTWARE

PENELUSURAN ARTIKEL YANG RELEVAN


LIBRARY SEARCHING

PEMILIHAN ARTIKEL YANG RELEVAN

TELAAH KRITIS
ARTIKEL/CRITICAL
APPRAISAL

Outcome

LIST OF ARTIKEL

KUMPULAN ARTIKEL RELEVAN

APPLYING EVIDENCE/PENERAPAN BUKTI

HIPERTENSI DENGAN TD DIASTOLIK 110 mmHg

1. Tujuan terapi : Untuk mencegah kerusakan


target organ seperti otak, mata, jantung,
ginjal, pembuluh darah besar yang dapat
menimbulkan kecacatan ataupun kematian
dikemudian hari.

2.Pilihan terapi : Obat anti hipertensi


berdasarkan uji klinik tersamar ganda.
3. Target terapi : menurunkan tekanan darah
diastolik dibawah 90 mmHg

PENENTUAN ARTIKEL YANG COCOK UNTUK RUJUKAN TERAPI

1. Apakah artikel yang dibaca relevan------- baca Abstraknya

1.1.

1.2.

1.3.

Telaah abstract:
Apakah hasil studi cocok dengan dengan kita butuhkan bila ya
lanjutkan bila tidak stop jangan dibaca.
Apakah permasalahan yang disajikan sering dijumpai pada praktek
anda sehari hari di RS dan intervensi yang dilakukan laik untuk
dilakukan bila ya lanjutkan bila tidak stop
Apakah informasi yang didapat dari artikel tersebut dapat
membawa perubahan pada cara perawatan pasien ditempat anda `
pada saat ini. Bila ya lanjutkan bila tidak stop

BiLA ARTIKEL SUDAH RELEVAN MAKA DAPAT DILANJUTKAN


KE TAHAP TELAAH KRITIS SELANJUTNYA

VALIDITAS ARTIKEL YANG DIBACA

1. Apakah subjek penelitian di alokasikan secara random bila ya


lanjutkan bilaTidak stop atau dapat dikatakan tidak valid
2. Apakah subjek yang diteliti tidak mempunyai kesamaan dengan
dengan Subjek ditempat anda bila ya stop bila tidak lanjutkan (tidak
aplikabel)
3. Apakah subjek penelitian secara keseluruhan termasuk didalam
kesimpulan Penelitian
3.1. Apakah follow up lengkap
3.2. Apakah subjek dianalisa sesuai pada random alokasinya
Beri penjelasan
4. Apakah jenis penelitian single/double/triple blind
5. Apakah jumlah kelompok kontrol dan dan perlakuan sama
6. Apakah hasil penelitian bermakna dan bila yang dilakukan negatif trial
apakah power of test cukup besar
Untuk tidak terjebak maka bila akan memakai evidence Based Medicine gunakan
Cat Nipper yang secara langsung mengarahkan ke literature yang cocok hanya
tinggal melakukan Telaah Kritis
PUSTAKA YANG KONVENSIONAL TIDAK BANYAK MENOLONG ATAU KADANG
KARENA TERPAKSA TIMBUL SALAH ARAH

Resume pertanyaan telaah kritis Terapi

1. Apakah alokasi subyek penelitian ke kelompok terapi atau kontrol


betul-betul secara acak? (Validitas)
2. Apakah semua keluaran (outcome) dilaporkan ? (Applicability)
3. Apakah lokasi studi menyerupai lokasi anda bekerja atau tidak ?
(Applicability)
4. Apakah kemaknaan statistik maupun klinis dipertimbangkan atau
dilaporkan ? (Validitas dan kegunaan (applicabillity).
5. Apakah tindakan terapi yang dilakukan dapat dilakukan ditempat
anda bekerja atau tidak ? (Applicability)
6. Apakah semua subyek penelitian diperhitungkan dalam kesimpulan
(Validitas)

Apakah kemaknaan statistik maupun klinis dipertimbangkan atau


dilaporkan ? (Validitas dan kegunaan (applicabillity).
ADVERSE EVENT RATE
STATUS PENDERITA
PLACEBO

ACTIVE Rx

Kerusakan organ sasaran


sebelumnya

.22

0,8

Tanpa kerusakan organ sebelumnya

.10

.04

Parameter

Adverse event rates

Relative Risk
Reduction (RRR)

Placebo
P

Active Rx
A

(P A) = RRR
P

Prior target organ damage

.22

.08

.22 0.8= 64
.22

No prior target

.10

0.4

.10 0.4 = 60
.10

Patients status at entry

Parameter

Adverse event rates

Ukuran Resiko

Patients status at
entry

Placebo
P

Active Rx
A

RRR

Absolute Risk
Reduction

Prior target organ


damage

.22

.08

64%

.22 - .08 = 14

No prior organ
damage

.10

0.4

60%

.10 - .04 = .06

1.

2.

Bila didapat RRR 50% menunjukkan pasti bermakna klinis, akan


tetapi sering kali juga RRR 25% dianggap sebagi bermakna
klinis.
Absolute Risk Reduction (ARR) yaitu dengan mengukur dengan
penurunan probabilitas dengan kelompok kontrol (plasebo)
dengan kelompok perlakuan (Active Tx )

KAUSA

kausa = etiologi, patogenesis atau


mekanisme
Kausa memandu pendekatan klinik
untuk prevensi, diagnosis dan
pengobatan.
banyak faktor yang menyebabkan kausa
dinamakan web of causation (fletcher
RH, 1988)

Tidaklah mungkin untuk membuktikan


hubungan kausal SECARA PASTI

Hubungan kausa dan efek untuk


manusia harus ditetapkan pada manusia
yang utuh

ASOSIASI

peluang (kesalahan acak)


bias (kesalahan sistematik)
efek kausa
efek-efek (perancu)
kausa efek (kausa dan efek)
(Hulley SB, 1988)

ASOSIASI
SEMU

ASOSIASI
MURNI

1.STRATIFIKASI MANTENHAENZEL
2.LOGISTIK REGRESSION

OXIDATIF
LDL
KOLESTEROL
TINGGI

1.COVARIAT

2.CONFOUNDING

ASOSIASI
MURNI

M.C.I
1.UMUR
2.ROKOK
3.OVERWEIGHT
4.OLAHRAGA
5.GENETIK
6.STRESS
7.HIPERTENSI
8.PERILAKU MAKAN

ASOSIASI
SEMU

ASOSIASI SEMU

meniadakan asosiasi semu oleh karena


bias (kesalahan sistematik)
Fase

desain

Tentukan

kesesuaian antara subyek,


prediktor, dan keluaran

Fase

analisis

Mengumpulkan

data tambahan untuk


mengantisipasi bias potensial
Menguji konsistensinya dengan studi lainnya

asosiasi murni bukan kausa efek

efek kausa

Fase desain

Rencanakan studi longitudinal


Dapatkan data urutan riwayat dari
variabel

Fase analisis

Pertimbangkan kecocokan biologisnya

PROGNOSIS

Prognosis

adalah suatu prediksi


penyakit mulai dari awal penyakitnya

perjalanan

Perbedaan antara uji prognostik dengan uji


diagnostik
uji diagnostik memprediksi adanya suatu penyakit
uji prognostik memprediksi keluaran dari suatu
penyakit (Hulley SB.1998).

PERBEDAAN
RESIKO DAN PROGNOSIS
1. Resiko memprediksi kejadian-kejadian probabilitas
yang
rendah,
sedangkan
prognosis
menggambarkan kejadian yang relatif sering.
(KEJADIAN)

2. Untuk resiko dihitung permulaan terjadinya sakit.


Sedang
untuk
prognosis
dihitung
ragam
konsekuensi dari penyakit. (KELUARAN)
3.

Faktor bertambahnya risiko bisa sama atau


berbeda dengan yang menandai Progonosis
(FAKTOR)

Timbul
Penyakit

Tanpa
Penyakit

resiko

Faktor
Resiko

Keluaran
penyakit

Prognosis

Faktor
Prognostis

Kematian
Kecacatan
Kekambuhan
dll

PERMASALAHAN KLINIS PASIEN


Di- Bagian Bedah RSMH telah banyak dilakukan tindakan terhadap
fraktur tibia dengan memakai IM Nailing akan tetapi pada medical
rekord didapatkan beberapa penderita yang harus di-operasi ulang
karena tulang tibia yang patah tidak menyatu anda sebagai seorang
residen diinstruksikan untuk mengguanakan evidence Based
Medicine untuk menalaah masalah ini

FORMULASI PERTANYAN KLINIS YANG DAPAT DIJAWAB

P.I.C.O

Progonostik faktor apa yang berhubungan dengan peningkatan


resiko re-operasi sesudah tindakan terapi operatif fraktur tibia

Search Article with software/lacak artikel dengan perangkat lunak

Pilih tibial fracture (MeSH) and Shaft

Sudah dipilihkan sebanyak 24 artikel sekaligus oleh Software yang


Biasanya dengan pilihan terbaik pada urutan pertama

BhandariM.TornettaP. 3rd, Sprague S, Najibi S.Petrisor b.Griffith.L Predictor


of reoperation following operative management of fractures of the tibial
shaft

Critical appraisal

Applying evidence

PEKERJAAN RUMAH KELOMPOK BAGIAN BEDAH KERJAKAN


PERMASALAHAN
REOPERASI SHAFT TIBIAL FRACTUREUNTUK DIPRESENTASIKAN
PADA SEMINAR EPIDEMIOLOGI KLINIK DAN EVIDENCEBASED
MEDICINE

DENGAN MELAKUKAN TELAAAH KRITIS ARTIKEL

BhandariM.TornettaP. 3rd, Sprague S, Najibi S.Petrisor b.Griffith.L Predictor


of reoperation following operative management of fractures of the tibial
shaft

PERMASALAHAAN BOLEH DIRUBAH MINTA PETUNJUK PENGAJAR


PROGNOSTIC

Angka kejadian yang dipakai untuk menggambarkan prognosis


Angka Kematian/KEJADIAN

Batasan (dalam persen)

- Kesintasan hidup lima tahun


(five year survival)

Pasien yang hidup selama 5 tahun yang dimulai


dari
beberapa
titik
dalam
perjalanan
penyakitnya.

-Kasus kematian (case fatality)

Pasien yang mati karena penyakitnya.

- Respons

Pasien yang menunjukkan adanya sesuatu


kemajuan sesudah mendapatkan intervensi

- Remisi

Pasien yang masuk dalam tahap


penyakitnya tidak lagi dapat dideteksi

- Kekambuhan

Pasien yang kambuh penyakitnya


sesuatu interval bebas penyaakit.

yang

sesudah

Worksheet for Using an Article About Prognosis

Prevensi

: apakah dengan
intervensi penyakit dapat dicegah,
apakah deteksi dini dan
pengobatan dapat memperbaiki
perjalanan penyakit.
Kausa : kondisi apa yang
menimbulkan penyakit ? apa
mekanisme patogenetik