Introduksi EBM

8/13/2019 Introduksi EBM

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Prof.Dr.H.Rusdi Lamsudin, SpS

(K), M.Med.SC

Medical Doctor, UGM, 1971

Neurologist, UGM, Unair, 1978

Master of Medical Sciences, University of New Castle, Australia, 1986

PhD, UGM, 1996 Neuro-Intensive and Stroke Unit Course, Innsbruck University, Austria,

July-Oct 1997

Prof, UGM, 2000

Chairman, Indonesian Neurological Association, Yogyakarta, Chapter,

2003-2007 Chairman, Indonesian Geriatric Neurology Study Group, Indonesian

Neurological Association, 2003-2007

Dean, Faculty of Medicine Indonesian Islamic University, 2006up to

now


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Introduction

Evidence Based MedicineProf Dr dr Rusdi Lamsudin

SpS(K), M.Med.Sc

Faculty of MedicineIndonesian Islamic University


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INTRODUCTION

The role of science in medicine hasincreased dramatically in recent decades

The increase prominence of science hasimproved health care by showing thatmany widely accepted medical practicesare not only effective but, in some cases,injurious


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INTRODUCTION

Yet today, much of modern medicineremains unsupported by scientificevidence.

EBM arose from realization that healthcare interventions, no matter how

commonsense or physiologically sound,often lack benefit and sometimes evencause harm.


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INTRODUCTION

In the absence of evidence of the efficacyof many treatment, physicians traditionallyfollow the pattern of physician A, relying

on anecdotal experience and knowledgeacquired from mentors or peers to guidetheir practice

EBM encourages physicians to follow thepardigm of physician B.


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INTRODUCTION

Indicators suggest that the EBMmovement has altered medicine, ex;

One study suggest that the number ofphysicians practicing EBM has increases

One scholar underscores the importance ofthe EBM movement by declaring it a

paradigm shift in medical practice


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What is EBM

The conscientious, explicit, and judicioususe of current best evidence in makingdecisions about the care of individual

patients and populations

The integration of best research evidencewith clinical expertise and patient values


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A Definition of EBM

The conscientious, explicit,judicious use of the current best

evidence in making decisionsabout the care of individual

patients.

(Ref: Sackett et al, 1996)


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Definition of EBM (cont.)

EBM practice requires integratingpractitioner clinical expertise with best

evidence from systematic research.


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Evidence-Based Medicine

Pengambilan Keputusan Klinis

Cost-Utility

Kuali tas Pelayanan

Sehat Sakit Outcome

Sembuh

Cacat

Mati

FR

Patofisiologi

D/

R/

P/


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Intuisi

Pengalaman kl inistidak sistematis

Patofisiologis

Pencar ian bukti -bukti

dan informasi yangberasal dar i peneli-

tian yg sistematis

Pengambilan keputusan kl inis

Paradigma lama Paradigma baru

2 dekade terakhir


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Penggunaan yang tel i ti , jelas dan

bijaksana dari bukti yang terbaik

Kemapuan klinis

individual

Bukti kl inis eksternal

yang terbaik dan tersedia yang

yang berasal dari r iset

yang sistematis

I ntegrasi

EBM

A

K

U

R

Akurasi & presisi tes diagnosis

efikasi dan safety terapi, re-

habil itasi & tdnk prevensikekuatan tanda prognosis


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Definition of Level of Evidence Level I: Highest

Sources: Primary endpoint of RCT-adequate Sample Size

Meta-analysis of RCTs

Level II: IntermediateSources:

Small RCT Predefines sec.endpoint of large RCT

Level III: LowerSources:

Prospective case series

Post hoc analysis of large RCTs

Level IV: UndeterminedSources:

Small uncontrolled case series

General agreement despite lack of evidence


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Levels of Evidence

Level 1: Randomized Clinical Trials

Level 2: Head to Head Trial or

Systematic Review of Cohort Studies

Level 3: Case-Control Studies

Level 4: Case-series

Level 5: Expert Opinion


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Steps to EBM

Step 1: Define a clinical question Formulate a clinical question in PICO format from

a patient scenario

Recognize type of clinical questions


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Steps to EBM

Step 5: Communication Communicate the information to patients and to

integrate patients values and preferences in

decision-making


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Answerable Clinical Question(ACQ)

First step in applying results of clinicalresearch to patient care

Well- formulated ACQ will save time: Search for evidence will be efficient

Sensibly-honed process rather than chaotic


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4 Parts of ACQ (PICO)

P Patient and problem

I Intervention (treatment, test,

prognostic factor, etiology, etc.)

C Comparison (if necessary)

O - Outcome


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4 Domains of EBM

Treatment

Diagnosis

Prognosis

Causation/Etiology


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Diagnosis

PIn an otherwise healthy 7-year-old boywith sore throat,

I - how does the clinical exam

C compare to throat culture

Oin diagnosing GAS infection?


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Prognosis

P - In children with Down syndrome,

I - is IQ an important prognostic factor

C

O in predicting Alzheimers later in life?


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Etiology/Harm

P controlling for confounding factors, dootherwise healthy children

I - exposed in utero to cocaine,

C compared to children not exposed

O have increased incidence of learningdisabilities at age six years?


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Principles of EBM

So what is best evidence?

Highest quality

Lowest quality


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Level BLimited (2-3)

population riskstrata evaluated

Class I

Recommen-dationthat procedure or

treatment isuseful/ effective

Limited evidencefrom single

randomized trialor non-

randomizedstudies

Class IIa

Recommen-dationin favor of

treatment orprocedure being

useful/ effective

Some conflictingevidence from

single randomizedtrial or non-randomized

studies

Class IIb

Recommen-dationsusefulness/

efficacy less wellestablished

Greater conflictingevidence from

single randomizedtrial or non-randomized

studies

Class III

Recommen-dationthat procedure or

treatment notuseful/effective

and may beharmful

Limited evidencefrom single

randomized trialor non-

randomizedstudies

Applying Classification of

Recommendations and Level of

Evidence


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Applying Classification of

Recommendations and Level of

Evidence

Level C

Very limited (1-2)population riskstrata evaluated

Class I

Recommen-dationthat procedureor treatment is

useful/ effective

Only expertopinion, casestudies, or

standard-of-care

Class IIa

Recommendation infavor of treatment

or procedure

beinguseful/effective

Only divergingexpert opinion,case studies, orstandard-of-care

Class IIb

Recommen-dationsusefulness/

efficacy less well

established

Only divergingexpert opinion,case studies, orstandard-of-care

Class III

Recommendationthat procedure or

treatment not

useful/effectiveand may be

harmful

Only expert opinion,case studies, orstandard-of-care


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EBM in Basic Medical Education

Semester I Programme ( 20 weeks) General education

Contents

Module 1: Critical thinking and skill learning: includingEBM

Module 2: effective skill communication and empathy

Module 3: Awareness of community and environment

Module 4:Human being as a bio-psycho-socio-cultural

entity

Module 5: the Indonesian health priority


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Semester II - VII Integrated

Block (ex. UII: 20 block)

EBMon block Ex: EBMin Cardiovascular (lecture dan tutorial)


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Semester VIIIXII Clerkship

EBM in clerkship

Journal reading Clinical decision making


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Guidelines

National Guideline Clearinghouse

Primary Care Clinical Practice Guidelines

Agency/Association sitesAAFP

APA

AAP
http://www.guideline.gov/http://hhttp//medicine.ucsf.edu/resources/guidelines/http://www.aafp.org/x19449.xmlhttp://www.psych.org/psych_pract/treatg/pg/prac_guide.cfmhttp://www.aap.org/policy/paramtoc.htmlhttp://www.aap.org/policy/paramtoc.htmlhttp://www.psych.org/psych_pract/treatg/pg/prac_guide.cfmhttp://www.aafp.org/x19449.xmlhttp://hhttp//medicine.ucsf.edu/resources/guidelines/http://www.guideline.gov/


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Clinical Practice Guidelines

CPGs and EBM are closely related. ManyCPGs. are evidence-based and facilitatethe practice of EBM by serving as

codification of best evidence whenwritten


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Purpose-specific resources

CDC Travel

Drug information resources

Patient Education handouts

Diagnostic TestingARUP

Medical Search engines

Textbooks

Journals
http://www.aruplab.com/guides/clt/default.htmhttp://www.aruplab.com/guides/clt/default.htm


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EBM Databases

Systematic Literature Searches Cochrane Library (OVID)

Clinical Evidence

Systematic Literature Surveillance ACP Journal Club (OVID) DARE

DynaMed

Medical InfoRetriever

EMB Search Engine TRIP Database
http://www.clinicalevidence.com/ceweb/conditions/index.jsphttp://nhscrd.york.ac.uk/darehp.htmhttp://www.ceres.uwcm.ac.uk/section.cfm?section=triphttp://www.ceres.uwcm.ac.uk/section.cfm?section=triphttp://nhscrd.york.ac.uk/darehp.htmhttp://www.clinicalevidence.com/ceweb/conditions/index.jsp


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Today

National Guidelines Clearinghouse (AHRQ)

Cochrane

ACP Journal Club Dynamed

First Consult

InfoRetriever


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Cochrane Library

The current resource with the highestmethodological rigor

For each clinical question, all of the English

literature meticulously searched forrandomized trials

Large systematic reviews with valid methods+ collaborative effort

Conclusions are based on all the evidencefrom valid randomized trials
http://www.update-software.com/history/clibhist.htmhttp://www.update-software.com/history/clibhist.htm


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Cochrane Library

Included in OVID subscription

Limitations

limited to English

only addresses questions amenable to randomizedtrials

most of medicine has not been studied enoughtoallow for conclusions

$235/year or abstracts only
http://www.update-software.com/cochrane/abstract.htmhttp://www.update-software.com/cochrane/abstract.htm


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ACP Journal Club

About 100 journals systematically surveyed

Highest-validity articles abstracted

Structured abstracts to guide critical appraisal

Clinical commentary

Included in our OVID subscription
http://www.acpjc.org/shared/purpose_and_procedure.htmhttp://www.acpjc.org/shared/purpose_and_procedure.htm


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ACP Journal Club

Limitations individual article summaries may not account for thebig picture

may have to read multiple items

No control over what is covered $78/year ?
http://www.acpjc.org/index.html


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DynaMed

Designed as entry point to information

Textbooks and Medline not efficient

Intuitive clinical organization

Brief summarized information presented

Links and references if more detailsneeded

ICD-9 codes and links to patientinformation handouts


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DynaMed format

Description

Etiology

Increased Risks

Associated Conditions Complications

History (cc, HPI, etc.)

Physical

Diagnostic (including Ruleout, Tests to order)

Prognosis

Treatment

Prevention

Screening References

Patient Information


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DynaMed Sources

18 primary journalse.g. BMJ, JAMA,Lancet, NEJM, Pediatrics

12 secondary literature sourcese.g.

Alternative Therapies, ACP Journal Club,Cochrane Library, InfoPOEMs

4 drug info sourcese.g. The Medical

Letter, FDA MedWatch


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DynaMed

Limitations

variable quality

areas with a lot of research can get hard to

navigate

$200/year or effort
http://www.dynamicmedical.com/


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First Consult/PDxMD

By MDConsult

Differential Diagnosis

Disease Information

Patient Education Handouts


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PDxMD


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Medical InfoRetriever

104 journals surveyed for Evidence-BasedPractice Newsletter

Over 1300 article synopses/ POEMS

Cochrane abstracts

Selected evidence-based guidelines

Basic drug info Clinical calculators/prediction rules


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InfoRetriever

Comes in web, desktop and PDA versions

Limitations

individual article summaries may not account for the

big picture may have to read multiple items

$249/year

Optimized for use with Internet Explorer 5.x or

Netscape 6.x
http://www.infopoems.com/


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Conclusion

If and when EBM effectuates as paradigmshift in medicine, that is, as more andmore physicians move toward making

decisions based on high-grade scientificevidence rather than custom.

Be A lifelong Learner with Evidence BasedMedicine

Introduksi EBM

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