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EVIDENCE-BASED MEDICINE

OVERVIEW
& CRITICAL APRAISAL

Andaru Dahesihdewi, dr., M,Kes., SpPK-K


Clinical Epidemiology and Biostatistics Unit UGM
EVIDENCE BASED MEDICINE (EBM)
The conscientious, explicit, and judicious use of
current best evidence in making decisions about
the care of individual patients
The practice of EBM means integrating individual
clinical expertise with the best available clinical
evidence from systematic research

1. CLINICAL EXPERTISE
2. BEST RESEARCH EVIDENCE
3. PATIENTS VALUES & EXPECTATION
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How to practice EBM
See
a patient

Ask a question Seek the best evidence

Monitor Appraise
Implementation
the change the evidence

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1. A. CLINICAL QUESTION
Background question
Foreground question

P I C O
PATIENT/
INTERVENTION COMPARISON OUTCOMES
PROBLEM

KLINIS
ICT TB
KP BAKU EMAS AKURASI Dx
Pasien dws UGM
1. B. CLINICAL QUESTION
Background question
Foreground question

P I C O
PATIENT/
INTERVENTION COMPARISON OUTCOMES
PROBLEM

BATUK
TERAPI TANPA LAMA SAKIT/
AKUT
ANTIBIOTIKA ANTIBIOTIKA KEPARAHAN
Pasien anak UGM
1. C. CLINICAL QUESTION
Background question
Foreground question

P I C O
PATIENT/
INTERVENTION COMPARISON OUTCOMES
PROBLEM

TERAPI
ASMA TANPA
STEROID MOON FACE
Pasien anak STEROID
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2. SEARCH "evidence"

Where to find the best evidence

Burn your (traditional) textbooks Invest in evidence databases

Revisi, paling tidak 1 tahun EBMR (EB-Medicine Review)


sekali Evidence-Based Medicine,
Padat Referensi yang Evidence-Based Nursing,
updated (khususnya ttg Cancerlit,
diagnosis dan Aidsline,
management) MEDLINE
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3. Telaah kritis
Satu tahap dalam proses praktek klinis yang berbasis
bukti
Penilaian obyektif terhadap informasi ilmiah yang
bermanfaat
Cara sistematik menilai validitas metodologi, hasil dan
manfaat dari artikel hasil penelitian yang dipublikasikan

Dapat membantu menetapkan bahwa hasil suatu


penelitian cukup baik untuk digunakan dalam pembuatan
keputusan
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Pedoman Telaah Kritis

Dikembangkan oleh Bagian Epidemiologi dan Biostatistika


Universitas McMaster, 1981
Untuk artikel uji diagnosis, terapi/ pencegahan, prognosis,
analisis keputusan klinis, CPGs, Pelaporan variasi dalam
keluaran dari pelayanan kesehatan, Clinical utilization review,
kualitas hidup terkait dg kesehatan, analisis ekonomi.

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Level of Evidence
Level Evidence

Ia Meta-analisis (RCT)

Ib RCT
Clinical study with comparison,
IIa without randomisation
IIb Quasi-experimental study

III Descriptive study: comparative study,


correlation study, case study
Expert committee report, opinion,
IV
Clinical experiences

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Derajat Evidence
Derajat Jenis Evidence

Ia

Ib

IIa

IIb

III

IV

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Derajat Evidence
Derajat Jenis Evidence

Ia

Ib

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CRITICAL APPRAISAL

DIAGNOSTIC THERAPY PROGNOSTIC HARM

USERSGUIDE http://www.cche.net

1. Is this study important and valid?


2. Whats the result?
3. Does this study apply to my patient population
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Pedoman telaah kritis
Uji diagnosis

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Pedoman
standar publikasi
Uji diagnosis

STARD CHECKLIST

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Are the result of the study valid?

Petunjuk primer :
A

Standar referensi
Uji diagnostik pembandingan
(gold standard)

Independen
Dibutakan

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KAJIAN KRITIS ARTIKEL DIAGNOSIS

Are the result of the study valid?

Spektrum pasien sesuai dengan yang ditemukan


dalam praktek

Seluruh spektrum pasien


dari yang ringan sampai
yang berat

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KAJIAN KRITIS ARTIKEL DIAGNOSIS

Are the result of the study valid?


Petunjuk sekunder :

Hasil uji Dx yg diteliti mempengaruhi keputusan


untuk mengerjakan standar referensi?
Hasil (-) Gold standard

Hasil (+) Gold standard

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KAJIAN KRITIS ARTIKEL DIAGNOSIS

Are the result of the study valid?

Cara melakukan uji Dx dideskripsikan, dapat


direplikasi?

Lihat bagian metodologi

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KAJIAN KRITIS ARTIKEL DIAGNOSIS

What were the result?

Are likelihood ratios for the test results


presented or data necessary for their
calculation provided?

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KAJIAN KRITIS ARTIKEL DIAGNOSIS

APA HASILNYA?
Gold standard

Hasil (+) Hasil (-)

Uji Hasil (+) a b N1


diag-
nostik Hasil (-) c d N2

N3 N4 N

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SIGNIFICANT ?
CLINICAL OR STATISTICAL ?

DIAGNOSTIC
Sensitivity
Spesivicity p value ; CI

Predictive value
Likelihood ratio

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DIAGNOSIS WORKSHEET

CITATION :

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ABSTRACT

DIAGNOSTIC TEST

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Are the result of the study valid?

A Independent
Blind
Reference standard
Diagnostic test comparison
(gold standard)

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Independent & Blind ?
METHOD

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Are the result of the study
valid?

Was there an independent, blind comparison


with a reference standard of diagnosis ?

YES, .
On page was described

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Are the result of the study valid?

All spectrum of patients


from mild to severe

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Are the result of the study
valid?

Did the patient sample include an appropriate


spectrum of patients to whom the diagnostic
test will be applied in clinical practice?

YES,
All patients with dengue symtomps & signs were
included

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Are the result of the study
valid?

Did the result of the test being evaluated influence


the decision to perform the reference standard?
Related to independently of study method

Were the method for performing the test described


in sufficient detail to permit replication?

METHOD ?
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Details of
methods

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What were the result?

Are likelihood ratios for the test results


presented or data necessary for their
calculation provided?

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GOLD
Result? STANDARD

162

38

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result?

162

38

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ACUTE I DENGUE INF ?
ELISA

(+) (-)

(+) 10 14 24
Rapid Dengue
Test
PanBio (-) 41 135 176

51 149 200

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ACUTE II DENGUE INF ?
ELISA

(+) (-)

(+) 25 31 56
Rapid Dengue
Test
PanBio (-) 19 125 144

44 156 200

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Dx Performance ?
Acute I Inf. Acute II Inf.

Sensitivity (%) = 10/51 =19.6 25/44 = 56,8


Spesifisity (%) = 135/149 = 90,6 125/156 = 80,1
LR+ = 19,6/9,4 = 2,1 56,8/19,9= 2,9
LR- = 80,4/90,6= 0,89 43,2/80,1= 0,54
PPV (%) = 10/24 = 41.7 25/56 = 44,6
NPV (%) = 135/176 = 76.7 125/144 = 86,8
Pretest probability (%) 51/200 = 25,5 44/200 = 22
Pretest odds: 25,5/74,5= 0.34 22/78 = 0,28
Post-test odds: (+) 0,71 ; (-) 0.3 (+)0,81 ; (-)0,15
Post-test probability(%) (+)41.5 ; (-)23.1 (+)44,75 ; (-)13,0

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KAJIAN KRITIS ARTIKEL DIAGNOSIS

APAKAH HASILNYA DAPAT MEMBANTU PASIEN SAYA?

Reprodusibel dan interpretasi memuaskan


dlm setting saya?
Dapat diterapkan pada pasien saya?

kriteria inklusi dan eksklusi, setting praktek

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Nomogram

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KAJIAN KRITIS ARTIKEL DIAGNOSIS

Likelihood ratio

>10 atau < 0,1, menghasilkan perubahan yg besar


dari pre dan post test probability sering
konklusif
5-10 dan 0.1-0.2, perubahan sedang
2-5 daan 0,5-0,2, perubahan kecil (kadang-kadang
penting)
1-2 dan 0,5-1, mengubah probability kecil sekali
(dan jarang penting)
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KAJIAN KRITIS ARTIKEL DIAGNOSIS

Test-treatment tresholds

Do not Do not
test
Test, & treat on test
the basis of the
tests results
Do not Get on with
treat treatment

0 .10 .20 .30 .40 .50 .60 .70 .80 .90


A B
Prevalence (pre-test probability) of target disoreder

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TO BE CONTINUE

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