INTRODUCTION

EVIDENCE BASED MEDICINE

EBM
th/ empiris ditinggalkan . Start : awal 90s di Paris oleh ahli epidemiologi klinis . 1992 : hanya sedikit artikel EBM . 1998 : >1000 artikel . Indonesia : berawal pada thn 1997
. Pendekatan

 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:
6 yrs medical education Problems with patients: Dx, Rx, Px

40-50 yrs medical practice

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

Consultant, colleagues Textbooks Handbooks Lecture notes Clinical guidelines CME, seminars, etc Journals
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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

WHY EBM?
1.Selalu ada bukti ilmiah terbaru

2.Ketidakmampuan untuk mengetahui adanya bukti ilmiah terbaru 3.Setiap hari diperlukan informasi yang valid/ sah pada situasi klinis ( diagnosa, prognosa, therapi dan pencegahan)

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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100% Relative % of remaining knowledge

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12

Years after graduation

Main area
Diagnosis (Determination of disease or problem) Treatment (Intervention necessary to help the patient) Prognosis (Prediction of the outcome of the disease)
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Steps in Practicing Evidence-Based Medicine

Langkah 1: Membuat pertanyaan klinis yang baik dan dapat dipertanggungjawabkan Langkah 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 pasien Langkah 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 Clinical Questions

Background questions
Ask for general knowledge about a disorder - Two components
Root (who, what, when, where, why) A 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 questions
Ask for specific knowledge about managing 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 question

P- Patient
I- Intervention C- Comparison

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

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Step 2: Locate the Best Evidence

Sources of information and evidence may include: Colleagues Textbooks Journals (e.g., evidence-based) Systematic reviews Guidelines Electronic databases Where to start searching may depend on: Available time Available databases Foreground versus background knowledge required
Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.
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Evidence Pyramid
Meta-Analysis Systematic Review Randomized Controlled Trial

Cohort studies Case Control studies

Case Series/Case Reports Animal research
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Levels of Evidence
Level of Type of Study Evidence 1a Systematic reviews of randomized clinical trials (RCTs) 1b Individual RCTs 2a 2b 3a Systematic reviews of cohort studies Individual cohort studies and low-quality RCTs Systematic reviews of case-controlled studies

3b
4 5

Individual case-controlled studies

Case series and poor-quality cohort and casecontrol studies Expert opinion based on clinical experience
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Levels of Evidence
Level 1: Highest: Level 2: Level 3: Level 4: Level 5: Lowestbut still evidence

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Step 3: Critically Appraise the Evidence

VALIDITY: In Methods section: -design, sample, sample size, eligibility criteria (inclusion, exclusion) sampling method, randomization method, intervention,measurements, methods of analysis, etc Can 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 patients characteristics, local setting Can the results be applied to my patient?

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Step 4: Integrate Findings With Clinical Expertise and Patient Needs

Critical Appraisal Patient

Clinical Decision

Preferences Concerns Expectations

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

Clinical Expertise
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Step 5: Evaluate Performance and Seek Ways to Improve

Examples of Self-Evaluation Questions:
Step 5
Step 1

Step 4

Step 2

Step 3

Am I asking wellformulated clinical questions? Am I searching at all? Do I know the best sources of current external evidence? Am I critically appraising external evidence?
Am I integrating my critical appraisal into my practice?
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Limitations of EBM
Kurangnya bukti bukti (penelitian )ilmiah Sumber biaya membatasi tipe dan ruang lingkup penelitian Akses ke sumber informasi terbatas (pada situasi klinik ) Tidak adekuatnya contoh penelitian yang ada untuk menilai kompleksitas yang terdapat dala sistem kehidupan Kurangnya keterampilan untuk memanfaatkan sumber informasi yang adaa Kesulitan dalam menerapkan bukti ilmiah tsb dalam menangani pasien
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