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INTRODUCTIONINTRODUCTION

EVIDENCE – BASED EVIDENCE – BASED

MEDICINEMEDICINE

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EBM

. Pendekatan th/ empiris ditinggalkan

. Start : awal 90’s di Paris oleh ahli epidemiologi klinis

. 1992 : hanya sedikit artikel EBM

. 1998 : >1000 artikel

. Indonesia : berawal pada thn 1997

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• “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”

Sackett DL et al

• Penggunaan bukti-bukti ilmiah yang terkini dan terpercaya dalam pengambilan keputusan tatalaksana pasien

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Previous practice:Previous practice:

6 yrs medicaleducation

40-50 yrsmedical practice

Problems with patients:Dx, Rx, Px

Consultant, colleaguesTextbooksHandbooks

Lecture notesClinical guidelines

CME, seminars, etcJournals

Usu. see only Results section, or even worse, Abstract section

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.. Integrasi : 1.Best research evidence - penelitian yang terpercaya dan sesuai - penelitian ilmu dasar kedokteran maupun penelitian ttg klinis, test diagnostik , prognosis dll

2. Clinical expertise - kemampuan klinis kompetensi dokter - identifikasi secara cepat tingkat kesehatan dan diagnosa , faktor resiko dan manfaat dari intervensi yang dilakukan serta pengenalan pasien dan harapan2nya

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3.Patient values

-pemahaman terhadap keunikan pilihan, perhatian

dan harapan pasien dan yang mana yang harus

diintegrasikan dalam pengambilan keputusan

saat menangani pasien

bila ke 3 elemen ini terintegrasi

dokter dan pasien diagnosa dan terapi

outcome klinis dan kwalitas hidup yang baik

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WHY EBM?WHY EBM?

11..Selalu ada bukti ilmiah terbaruSelalu ada bukti ilmiah terbaru

2.Ketidakmampuan untuk mengetahui 2.Ketidakmampuan untuk mengetahui adanya bukti ilmiah terbaruadanya bukti ilmiah terbaru

3.Setiap hari diperlukan informasi yang valid/ sah pada situasi klinis ( diagnosa, prognosa, therapi dan pencegahan)

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4.Kurangnyan informasi dari: sumber tradisional ( buku teks, tenaga ahli )

5.Terdapat peningkatan kemampuan diagnostik dan keputusan klinis dengan waktu dan pengalaman, tetapi terdapat kemunduran dalam mengup-date pengetahuan

6.Keterbatasan waktu untuk evaluasi dan pencarian informasi yang mendalam tentang hal-hal yang berhubungan dengan klinis

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Years after graduation

Relative% ofremainingknowledge

2 4 6 8 10 12

$100%

1010

DiagnosisDiagnosis(Determination of disease or problem)(Determination of disease or problem)

TreatmentTreatment(Intervention necessary to help the patient)(Intervention necessary to help the patient)

PrognosisPrognosis(Prediction of the outcome of the disease)(Prediction of the outcome of the disease)

Main area

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Steps in Practicing Steps in Practicing Evidence-Based MedicineEvidence-Based Medicine

Langkah 1: Membuat pertanyaan klinis yang baik dan dapat dipertanggungjawabkanLangkah 2: Pilih penelitian / bukti yang terbaik untuk menjawab pertanyaan Langkah 3: Nilai dengan kritis hasil penemuan Langkah 4: Integrasikan penemuan dengan keahlian klinis dan kebutuhan pasienLangkah 5: Evaluasi hasil yang diperoleh

dan temukan cara untuk meningkatkannya

Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

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Step 1: Construct Well-Built Step 1: Construct Well-Built Clinical QuestionsClinical Questions

•• ““Background” questionsBackground” questions

–– Ask for general knowledge about a Ask for general knowledge about a

disorderdisorder - - Two componentsTwo components

Root (who, what, when, where, why)Root (who, what, when, where, why)

A disorder or aspect of a disorderA disorder or aspect of a disorder

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-What is Kawasaki disease? -What is the cause? - What are symptoms & signs? -What is the treatment? -Cardiac involvement?

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““Foreground” questionsForeground” questions

–– Ask for specific knowledge about Ask for specific knowledge about managing patients with a disordermanaging patients with a disorder

-Have four essential component In a child with Kawasaki disease, will repeated echo examination necessary for early detection of cardiac involvement? (Dx)

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Formulate a focused clinical Formulate a focused clinical questionquestion

P- PatientP- Patient

I- InterventionI- Intervention

C- ComparisonC- Comparison

O- OutcomeO- Outcome

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Asking answerable clinical Asking answerable clinical questions (CEBM- Oxford)questions (CEBM- Oxford)

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Step 2: Locate the Best EvidenceStep 2: Locate the Best Evidence

•• Sources of information and evidence may include:Sources of information and evidence may include:

–– ColleaguesColleagues

–– TextbooksTextbooks

–– Journals (e.g., evidence-based)Journals (e.g., evidence-based)

–– Systematic reviewsSystematic reviews

–– GuidelinesGuidelines

–– Electronic databasesElectronic databases

•• Where to start searching may depend on:Where to start searching may depend on:

–– Available timeAvailable time

–– Available databasesAvailable databases

–– Foreground versus background knowledge requiredForeground versus background knowledge requiredSackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

.

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Evidence PyramidEvidence Pyramid

Meta-Analysis Meta-Analysis

Systematic Review Systematic Review

Randomized Controlled Trial Randomized Controlled Trial

Cohort studies Cohort studies

Case Control studies Case Control studies

Case Series/Case Reports Case Series/Case Reports

Animal researchAnimal research

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Levels of EvidenceLevels of EvidenceLevel of Level of

EvidenceEvidenceType of StudyType of Study

1a1a Systematic reviews of randomized clinical Systematic reviews of randomized clinical trials (RCTs)trials (RCTs)

1b1b Individual RCTsIndividual RCTs

2a2a Systematic reviews of cohort studiesSystematic reviews of cohort studies

2b2b Individual cohort studies and low-quality Individual cohort studies and low-quality RCTsRCTs

3a3a Systematic reviews of case-controlled studiesSystematic reviews of case-controlled studies

3b3b Individual case-controlled studiesIndividual case-controlled studies

44 Case series and poor-quality cohort and case-Case series and poor-quality cohort and case-control studiescontrol studies

55 Expert opinion based on clinical experienceExpert opinion based on clinical experience

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Levels of EvidenceLevels of Evidence

Level 1: Highest: Level 1: Highest:

Level 2: Level 2:

Level 3:Level 3:

Level 4:Level 4:

Level 5: Lowest—but still evidenceLevel 5: Lowest—but still evidence

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Step 3: Critically Appraise Step 3: Critically Appraise the Evidence the Evidence

VALIDITY: In Methods section:

-design, sample, sample size, eligibility criteria (inclusion, exclusion) sampling method, randomization method, intervention,measurements, methods of analysis, etcCan I trust this information?

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IMPORTANCE: In Results section-characteristics of subjects, drop out, analysis, p value, confidence intervals, etc

Are the valid results of the study important?

APPLICABILITY: In Discussion section + our patient’s characteristics, local setting

Can the results be applied to my patient?

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Step 4: Integrate Findings Step 4: Integrate Findings With Clinical Expertise With Clinical Expertise

and Patient Needsand Patient Needs

CriticalAppraisal

ClinicalDecision

ClinicalExpertise

Patient

Adapted from: Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

► Preferences

► Concerns

► Expectations

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Step 5: Evaluate Performance Step 5: Evaluate Performance and Seek Ways to Improveand Seek Ways to Improve

Step 1

Step 2Step 4

Step 3

Step 5

Am I asking well-Am I asking well-formulated clinical formulated clinical questions? questions?

Am I searching at all? Do I Am I searching at all? Do I know the best sources of know the best sources of current external evidence?current external evidence?

Am I critically appraising Am I critically appraising external evidence?external evidence?Am I integrating my Am I integrating my critical appraisal into my critical appraisal into my practice?practice?

Examples of Self-Evaluation Questions:

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Limitations of EBMLimitations of EBM

Kurangnya bukti bukti (penelitian )ilmiah Kurangnya bukti bukti (penelitian )ilmiah Sumber biaya membatasi tipe dan ruang lingkup Sumber biaya membatasi tipe dan ruang lingkup penelitianpenelitianAkses ke sumber informasi terbatas Akses ke sumber informasi terbatas

(pada situasi klinik )(pada situasi klinik )Tidak adekuatnya contoh penelitian yang ada untuk Tidak adekuatnya contoh penelitian yang ada untuk menilai kompleksitas yang terdapat dala sistem menilai kompleksitas yang terdapat dala sistem kehidupan kehidupan Kurangnya keterampilan untuk memanfaatkan sumber Kurangnya keterampilan untuk memanfaatkan sumber informasi yang adaainformasi yang adaaKesulitan dalam menerapkan bukti ilmiah tsb dalam Kesulitan dalam menerapkan bukti ilmiah tsb dalam menangani pasienmenangani pasien

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