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E

vidence
B
ased
M edicine

(Bringing research evidence into


practice)
HISTORY

Started in early 90s by clinical epidemiologists


1992 : only few articles on EBM
2000 : >1000 articles
Indonesia : started in 1997
PREVIOUS
PRACTICE :
6 yrs Problems with
medical patients:
education Dx, Rx, Px

40-50 yrs Consultants,


medical Colleagues
practice Textbooks
Handbooks
Lecture notes
Clinical
Usu. see only Results guidelines
section, CME, seminars,
or even worse, Abstract etc
section Journals
Trust me
In my experience .
Logically
Textbook, handbook, capita selecta
WHAT IS EVIDENCE BASED
MEDICINE ?

Pemanfaatan bukti mutakhir yang


sahih dalam tata laksana pasien

Integration of (1) physicians


competence (2) valid
evidence from studies (3)
patients preference
WHY
EBM ?
1. Information overload
2. Keeping current with literature
3. Our clinical performance deteriorates with time
4. Traditional CME does not improve clinical
performance
5. EBM encourages self directed learning process which
should overcome the above shortages
The fact..
>25,000 periodicals (journals)
6,000,000 articles annually
17,000 biomedical books annually
3000 recognized diseases
1500 therapeutic regimens (+250 annually)
textbooks
are
out-of-date

Fail to recommend Rx up to ten years after its been


shown to be efficacious
Continue to recommend therapy up to ten years after
its been shown to be useless
Patient
With problem

The
Apply EBM Formulate
The evidence Cycle In answerable
question

Critically
Appraise Search the
The evidence evidence
STEPS IN EBM
PRACTICE
1. Formulate clinical problems in answerable questions
2. Search the best evidence: use internet or other on-
line 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)
(I)
Formulating clinical
questions
Four elements of a well
constructed clinical
question: PICO

P I C O

Description The main The Outcome


of patient intervention alternative expected
or problem considered to compare from this
with the intervention?
intervention

B e b r i e f a n d s p e c i f
i c
II
Searching the evidence
Examples of on-line
Journals / Databases
http://bmj.bmjjournals.com
MEDLINE/PubMed
EMBASE
MDConsult
AAP Journal Club
Cochrane Library
TUGAS
PBL

III
Appraising the evidence: VIA
VIA
Validity : In Methods section:
design, sample, sample size, eligibility criteria
(inclusion, exclusion), sampling method,
randomization method, intervention, 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, local setting
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 of evidence
Rec
Weight of
Meta-analysis of RCT Level 1 A
Scientific
Scrutiny
Large RCT
Small RCT Level 2
B
Non-Randomized
trials
Level 3
Observational studies
Case series / reports C
Level 4
Anecdotes, expert,
consensus

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