EBM CYCLE AND PICO QUESTION

NAJIRMAN
KETUA BAGIAN ILMU PENYAKIT DALAM FK UNAND/
RSUP Dr.M.DJAMIL
KEPALA CE-EBM FK UNAND
 What is Evidence-based Medicine?

Integration of (1) physician’s competence

(2) valid evidence from studies
(3) patient’s preference

PEMANFAATAN BUKTI MUTAKHIR YANG SAHIH

DALAM TATALAKSANA PASIEN
Evidence-based medicine (EBM)
 The process of systematically reviewing,
appraising and using clinical research findings
to aid the delivery of optimum clinical care to
patients
 What is evidence-based medicine?
The term ‘evidence-based medicine’ (EBM) was
fi rst used by a Canadian, David Sackett and his
collegues at McMaster University in Ontario,
Canada in the early 1990s
EBM as integrating the best research evidence
with clinical expertise and patient values to
achieve the best possible patient management

EBM practitioners to avoid ‘information

overload’ but, at the same time, to find and
apply the most useful information.
 WHY DO WE NEED EBM?
 There is a large information gap between research
and clinical practice
So much research is published all the time, clinicians
understandably are unaware of most of it, or do not
have the ‘tools’ to assess its quality
Researchers, on the other hand, do not understand
the information needs of clinicians and continue to
present their work in a way that is not easily
accessible to busy practitioners
Most treatment-related decisions were based on an ad
hoc selection of information from the vast and variable
quality scientific literature, on expert opinion, or,
worse of all, on trial and error
 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
 5000/ DAY
5000
4500
4000
3500
3000
2500
2000
1500 1000/ DAY
1000
500 50/DAY
0
TRIALS MEDLINE TOTAL

THE AMOUNT OF
MEDICAL RESEARCH
Archie Cochrane proposed that researchers and

practitioners should collaborate internationally to

systematically review all the best clinical trials (that is,

randomised controlled trials, or RCTs), specialty by

specialty
 STEPS IN EBM
1. Formulate an answerable question

2. Track down the best evidence of outcomes available.

3. Critically appraise the evidence (ie find out how

good it is).

4. Apply the evidence (integrate the results with clinical

expertise and patient values).

5. Evaluate the effectiveness and efficiency of the

process (to improve next time).
 PATIENT Diagnosis
Drawing conclusion
That impact on practice ENCOUNTER Therapy
Prognosis
Etiology

APPRISING EBM FORMULATING

CLINICAL
THE EVIDENCE QUESTIONS

SEARCHING
THE •Patient
•Hierarchy of evidence •Intervention
EVIDENCE
•Pre appraised resources •Comparison
•Outcome
 CLINICAL EXPERTISE

BEST PATIENT
E
RESEARCH VALUES &
B
EVIDENCE PREFERENCES
M
 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
 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
 LANGKAH PERTAMA
 Clinical question = Pertanyaan klinis
 Disusun menurut rumus : PICO
P = Population/ Who are the relevant patients?
participants

What is the management strategy, diagnostic test or

exposure that you are interested in (such as a drug,
I = Intervention
food, surgical procedure, diagnostic test or exposure
Indicator/ to a chemical)?

What is the control or alternative management

C = Comparator/ strategy, test or exposure that you will be
Control comparing the one you are interested in with?

What are the patient-relevant consequences of

O = Outcome the exposure in which we are interested?
In EBM, treatments and therapies are called
‘interventions’ and such questions are questions of
INTERVENTION

Other types of questions that may arise are as follows:

1. What causes the problem? AETIOLOGY AND RISK FACTORS

2. What is the frequency of the problem? FREQUENCY

3. Does this person have the problem? DIAGNOSIS

4. Who will get the problem? PROGNOSIS AND PREDICTION

Interventions
Interventions cover a wide range of activities from drug
treatments and other clinical therapies, to lifestyle
changes (for example, diet or exercise) and social
activities (such as an education program). Interventions
can include individual patient care or population health
activities (for example, screening for diseases
such as cervical or prostate cancer).
Example 1
A 28-year-old male presents with recurrent furunculosis
for past 8 months; these episodes have been treated with
drainage and several courses of antibiotics but keep
recurring. He asks if recurrences can be prevented. To
convert this to an answerable question, use the P I C O
method as follows :
P Population/patient = patients with recurrent furunculosis
I Intervention/indicator = prophylactic antibiotics
C Comparator/control = no treatment
O Outcome = reduction in recurrence rate of furunculosis

Question:
‘In patients with recurrent furunculosis, do prophylactic antibiotics,
compared to no treatment, reduce the recurrence rate?’
P = Population, patients, partricipants, problem
•Wanita dengan osteoartritis
I = Intervention, indicator, index
•Temberian steorid

C = Comparison
•Tanpa steroid PERTANYAAN KLINIS
Pada wanita dengan osteoartritis,
O = Outcome apakah pemberian steroid,
•Mengurangi nyeri dibanding tanpa steroid, dapat
mengurangi keluhan nyeri?
P = Population, patients, partricipants, problem
•Pasien dengan tumor tiroid

I = Intervention, indicator, index

•pemeriksaan USG
PERTANYAAN KLINIS
C = Comparison
Pada pasien dengan
•biopsi tiroid
tumor tiroid, apakah
O = Outcome pemeriksaan USG lebih
•menentukan keganasan sensitif, dibanding
dengan biopsi, untuk
menegakkan diagnosis
keganasan?
P = Population, patients, partricipants, problem
•Manula dengan batuk kronik berulang
I = Intervention, indicator, index
•fisioterapi
PERTANYAAN KLINIS
C = Comparison Pada manula dengan
•tanpa fisio terapi batuk berulang, apakah
fisioterapi dapat
O = Outcome empercepat
•mempercepat kesembuhan kesembuhan?
P = Population, patients, partricipants, problem
•Pasien lupus eritematosus sistemik

I = Intervention, indicator, index

•riwayat gagal jantung

C = Comparison PERTANYAAN KLINIS

•tanpa riwayat gagal jantung
Pada pasien LES apakah
O = Outcome terdapatnya riwayat
•memperburuk prognosis gagal jantung
memperburuk
prognosis?
 AETIOLOGY AND RISK FACTORS
Example 1
George has come in 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 low but want to give him a
more precise answer.

P Population/patient = adult males

I Intervention/indicator = vasectomy
C Comparator/control = no vasectomy
OOutcome = testicular cancer
Question:

‘In men, does having a vasectomy (compared to

not having one) increase the risk of getting

testicular cancer in the future?’

 FREQUENCY OR RATE

Questions of frequency (prevalence) are about how many

people in the population have a disease or health problem,
such as what is the frequency of hearing problems in
infants or the prevalence of Alzheimer’s disease in the over
70s. If the question also includes a time period, such as for
cases of influenza in winter versus summer, it becomes a
question of rate (incidence).
Example 1

Mabel is a 6-week-old baby at her routine follow-up. She

was born prematurely at 35 weeks. You want to tell the
parents about her chances of developing hearing problems.

P = infants Question:
‘In infants born prematurely,
I = premature compared to those born at full
term, what will the prevalence
C = full-term of sensorial deafness be?’

O = sensorial deafness
APLIKASI EBM DALAM PELAYANAN
KESEHATAN
Evidence Physician

Patients EBM
Type of Clinical Questions for the Ideal Type of Study

Type of Question Ideal Type of Study

Therapy RCT > Cohort Study > Case Control
Diagnosis: Prospective, blind controlled trial
comparison to gold standard
Prognosis Cohort Study > Case Control > Case
Series/Case Report
Etiology/Harm RCT > Cohort Study > Case Control
Levels of Evidence: Study Type / Evidence Hierarchy
 JENIS DISAIN PENELITIAN

 CROSS SECTIONAL/ POTONG LINTANG

 CASE CONTROL

 COHORT

 CLINICAL TRIAL/ EXPERIMENTAL

Level bukti (level of evidence) untuk efek terapi
Level Desain/ jenis studi
Level I  RCT berkualitas tinggi dengan perbedaan yang secara statistik
signifikan, atau perbedaan yang secara statistik tidak signifikan
tetapi dengan Confidence Interval sempit
 Kajian sistematis dari RCT level I (dan hasil studi homogen)
Level II  RCT dengan kualitas lebih rendah (misalnya, follow-up <80%,
tanpa pembutaan, atau randomisasi tidak sempurna)
 Studi prospektif dengan pembanding
 Kajian sistematis dari studi level II atau studi level I dengan
hasil-hasil inkonsisten
Level III  Studi kasus kontrol
 Studi retrospektif dengan pembanding
 Kajian sistematis dari studi level III
Level IV  Case series
Level V  Pendapat pakar
Sumber: deVries dan Berlet, 2010
SEARCHING
Kapankah perlu dibuat pertanyaan
klinis ?
Pertanyaan klinis perlu dibuat bila:
• penting untuk kesembuhan pasien
• diperkirakan akan ditemukan jawabannya
• sering dijumpai dalam praktik
• menarik untuk kita
• ada kemungkinan berkaitan dengan isu
medikolegal

PANDUAN PRAKTEK KLINIK

LOGO