EvidenceBased

Medicine
”Bringing research
evidence into practice”)

dr. TA Larasati, M.Kes

Bag Kedokteran Keluarga
FK Unila
Referensi

Textbook of family medicine;

Robert E & David P Rakel

BAB 7 dan 8

Evidence Based Medicine ;

Sharon E Strauss et all
Evidence-based
Medicine
vers
us
Opinion-based medicine
Experience-based
Power-based medicine
medicine
Hope-based medicine
Logic-based medicine
Erratic-based medicine
 Dr. Benjamin Spock:
Baby and Child Care
“I think it is preferable to accustom a baby
to sleeping on his stomach from the start of he is
willing. He may change later when he learns to
turn over”.

Later evidence indicates that prone position is an

significant risk factor for SIDS
(sudden infant death syndrome)
 Evidence-based
Medicine
Medicine-based evidence
Pragmatic research
Outcome research

Related with
morbidity, mortality, quality of life
Morbidity Patient Health
Mortality Satisfaction Status
QoL

Quality
Value =
Cost
 Diagnosis
Patient with complaint
History Physical
Simple test
Specific test: If the test (+) what is the probability
that the patient has the disease?
 Yes or no answer
 Predictive value is the most important

The spectrum of the presentations must

resemble that in practice
 Treatment
Patient with certain diagnosis: besttreatment?
Is drug X more effective than Y?
Focus on the clinical outcome, rather than its
explanation (biomolecular markers, etc)
Yes or no outcome most useful
Not in studies with “idealized” subjects
 Px with DM are frequently have
hypercholesterolemia, obese, hypertension, etc
 Prognosis
Usually in cohort studies
To inform about the fate of the patient
Absolute risk is more important than relative risk
 Absolute: Your risk of having second stroke in 1
year is 30%
 Relative: Your risk of having second stroke in 1
year is 2 times than in non-smokers (RR = 2)
 EB & 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
Centers for EBM all over the world
 Previous practice:
6 yrs medical Problems with pa
patients:
education Dx, Rx, Px

40-50 yrs Consultants,

medical practice colleagues
Textbooks
Usu. see only Results section, Handbooks
or even worse, Abstract Lecture notes
section Clinical guidelines
CME, seminars, etc
Journals
Trust me
In my experience ….
Logically
Textbook, handbook, capita selecta
 The results….
“Opinion-based medicine”
Steroid inj. In prematures to prevent RDS
Routin episiotomy
Routine circumsision
Antibiotics for flu-like syndrome
Use of immunomodulators
“Skin test” before antibiotic injection
Routine chest X-ray for pre-op
preparation
CT scan after minor head trauma , etc …
 What is
Evidence-based Medicine?
“The integration of the best research evidence
with our clinical expertise and our patient's
unique values and circumtances”
“Pemanfaatan bukti mutakhir yang sahih
dalam tata laksana pasien”
Integration of (1) physician‟s competence
(2) valid evidence from studies
(3) patient‟s preference
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 study
results should be critically appraised
Keyword for EBM
Methodological skill to judge the validity
of study reports (Re. Andersen B: Methodo-
logical errors in medical research, 1989)
 ψ  δ2lnΣ εφ

Yesss!!!
Dean, Harvard Medical School
to students:

“We believe that 50% of what

we are teaching to you now
will prove to be false 5 years
later; the problem is that we
do not know which 50%”
 WHY EBM?
1 Information overload
2 Keeping current with literature
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

2 4 6 8 10 12

Years after
graduation
THE SLIPPERY
SLOPE
 Our textbooks are
out-of-date
Fail to recommend Rx up to ten years
after it‟s been shown to be efficacious.
Continue to recommend therapy up to
ten years after it‟s been shown to be
useless.
 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?)
 Applicabilit (could we apply to our patient?)
4. Applyy 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)
Implementation 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 appraisa/l
methodological skill
Limited resources, esp. time factor
Lack of high quality evidence
Skepticism toward evidence-based practice
„Happy‟ with current practice
 Physician’s competence

Valid evidence Patient’s values

 Patient
With problem
proble

The Formulate
Apply
The EBM answer
In answerable
question
evidence Cycle

Appraise
The Search the
evidence evidence
Patient with Problem
 Di hadapan Anda, pasien An G, 2 tahun. Datang
dibawa ibunya karena diare sudah dua hari, tidak
ada muntah, atau demam.Tampak lemas.Turgor
kulit agak menurun, mukosa masih basah. An G
juga mau makan dan ingin minum terus.
Menurut ibunya, sebelumnya diganti susu yang
biasa diminum, karena tidak ada ditoko. Anda
menyimpulkan bahwwa pasien dehidrasi sedang
dan perlu rehidrasi segera dengan IV line.Tapi
Ibu pasien meminta anaknya jangan dirujuk ke
RS, diberi obat saja.
1. Formulate in answerable
questions
P : Patient, population, predicament, problem
I : Intervention, exposure, test, or other agent
C : Comparison intervention, exposure, test
etc if relevant

O : Outcome of clinical importance, including

time if relevant
1. Formulate in answerable
questions
P :
I :
C :
O :
2.Search the evidence(p29-
62)
Systems; coputerized
decision support

Summaries; Evidence based

textbook (ACP Med, CE;
www.clinicalevidence.com,
Dynamed, PIER)

Synopses of syntheses (Evidence-based

journal abstract; ACPJC, EBM, EBN, DARE)

Syntheses (Systematic reviews ; ACPJC+,

EvidenceUpdates, Cochrane)

Synopses of Studies ; Evidence based journal abstract

Studies ; original articles; MEDLINE; www,essentialevidenceplus.com)

3. Appraise the evidence

 ..\komunitas\KULIAH\kul blok\riset\EBM
2015\Harm worksheet.docx
 ..\komunitas\KULIAH\kul blok\riset\EBM
2015\Prognosis worksheet.docx
 ..\komunitas\KULIAH\kul blok\riset\EBM
2015\Therapy worksheet.docx
 ..\komunitas\KULIAH\kul blok\riset\EBM
2015\Diagnosis EBM.docx
4. Apply the evidence

 To your patient
 Patient value
 Patient circumtances
5. Evaluation

Self evaluation and reflect on our own practise

 In asking answerable questions
 In searching
 In critical appraisal
 In integrating evidence and patient value

 IS OUR PRACTICE IMPROVING?

 Criticism to EBM
EBM makes expensive medical care
EBM cannot be implemented in
developing countries
EBM is costly and time consuming
EBM ignore pathophysiology & reasoning
EBM ignore experience and clinical judgment
EB-guidelines etc interfere with professional
autonomy
 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
Strength of Evidence
(Intervention Study)
Larger
RCTs
Meta analysis
of small RCTs
Smalll randomized
trials
Strength of Evidence
(Observational Study)
Structured reviews
of observational
studies

Cohort studies

Case control studies

Case series description

 End result

Self directed, life-long learning attitude

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