Evidence Based Medicine

DARWIN AMIR
Bgn Penyakit Saraf
RS DR. M. Djamil / Fakultas Kedokteran
Universitas Andalas
PADANG

Evidence Based Medicine

A new paradigm for the health care system

Using the current evidence in the medical

literature to provide the best care to patients

Will give you the historical basis and

philosophical underpinning of EBM

 Medicine in the pre historic had no

concept of probability (the ancients and

the Greek) the Gods decided all life,
therefore that probability did not enter
into issues of daily life

 After Luca Piccauli (1494) defined basic

principles of algebra and multiplication

tables introduced the first statistic problem
and Girolamo Gardano (1545) introduced
the first attempt to use mathematics to
describe statistic and probability.

Galileo expanded on this by calculating

probabilities using two dice
Thomas Gataker expounded on the meaning
of probability by noting that it was natural
laws.
Huygens (1657), Leibniz (1662) and
Englishman John Graunt (1660) wrote on
norms of statistic including the relation of
personal choice and judgement to statistical
probability.

 John Graunt categorized the cause of death

of the London populate using statistical

sampling and predict the human lifespan.
Graunt statistic can be compared to recent

data from the US in 1993

Table : Probability of survival, 1660 and 1993

Percentage survival to each age
Age

1660

1993

100%

100%

26

25%

98%

46

10%

95%

76

1%

70%

Medical practice

Clinician helps patients by

- Diagnosing what is wrong with them
- Administering treatment that does more
good than harm
- Giving them an indication of what the
future is likely to hold (prognosis)

Evidence Based Practice

in Primary Care
The growing demand for public

accountability in health care and the

increased availability of information to
users -------- >
EBP will be central theme in general

practice and the organization of care for

many years to come

The need for an EB approach to

decision-making in general practice

The core of GP is the relationship between

the doctor and patient.

Central aspects of this relationship is the

process of decision making (range from
simple clinical types of decision to decision
at a level about how service should be
organized

 The decisions ought to involve a negotiated

in the context of a partnership between the

health care professional and the patient and
takes account of factors such as patient
need, preferences, priorities, available
resources and evidence of the effects of
providing different forms of care

Evidence from
Randomized
Controlled Trials

Needs

Other
Necessary
Evidence

Effects of care

MAKING POLICIES AND

TAKING DECISIONS
Professional and providers
Service users and purchasers
researchers and funders

Resources

Priorities

Both the doctor and patient require access

to reliable and valid information ----- > to
the situation is required.
EBM is the phrase used to describe such an
approach and entails (from the doctors
perspective): - the conscientious
- explicit
- judicious use
GP acquire, wisdom and judgment through
their clinical experience

This expertise produces clinical skills and

acumen (diligent) in detecting signs and
symptoms.

Greater understanding of individuals

(predicament, rights and preferences) in
making clinical decisions about their care.

The judgment for decision making based on the

availability of better research methods for
assessing the validity of evidence of
effectiveness through to improved techniques
for collating evidence in a systematic way

The distinction between EBM and

Evidence Based Health Care
Evidence Based Medicine

Conceptual approach that

Evidence Based Health Care

Broader concepts that

incorporates improve
approach to understanding
patients, families and
practitioners beliefs, values
and attitudes.

Takes account evidence at a

population levels

health care professionals

can be used in making
decisions about the care
of individuals patients

How to get started: a five-step process for

using an evidence based approach in GP

The McMaster University EBM Resources Group have

identified a five-step approach need to follow :
1. define the problem;
2. track down the information sources you need;
3. critically appraise the information;
4. apply the information with your patients;
5. evaluate how effective this application of information is

Step 1: defining the problem

Questions frequently arises, such as pros and
conts of using a particular form of therapy, the
value of having a particular diagnostic test or
screening procedure, the risk or prognosis of a
particular disease or the cost of a potential
intervention.
There is a clinical problem for which you are
unsure of the evidence and to make a decision
to investigate it further.

Step 2: tracking down the information

sources needed

Medical literature which can assist in providing

answers to the question raised in clinical practice
is broadly scattered; journals, family medicine
journals and government reports

Step 3: critically appraising the information

Decided which journal articles to read. It is
important to read them carefully as not all
published is of equal value
Critical appraisal of articles is a process which
involves carefully reading an article and
analysing its methodology, content and
conclusion
Do I believe these result sufficiently that I would
be prepared to adopt a similar approach or reach
a similar conclusion, with my own patients ?.

Step 4: applying the information with your patients

How to apply the information obtained to the

particular circumstances of your patients ?. This is
a probably the most crucial step in the process.

Whether there are any methodological issues

raised about the evidence which might prompt
you to reject it outright.

This process requires a partnership between the

doctor and patient. If at the end of the process the
decision is made be a mutual and conscientious

Step 5: evaluating how effective it is.

Evaluate the effect of the evidence as applied to
specific patients.
The expected benefits that arose from using a
particular item of evidence were consistent with
the observed benefits.
It may well generate the need for further
research to identify why some patients have not
responded in the expected manner and what be
done to rectify this
The practitioner is having sufficient time to
apply these steps routinely in their daily practice

Supporting a framework for Evidence-Based

Practice within general practice

As professional you have the challenge and

responsibilities in facing general practice

Framework needs to be built around ensuring that

the evidence required to inform decision-making
is available, accessible, acceptable and applied by
GP.

Emerged internationally which aim to produce

systematic summaries with trying to practice
EBP.

Supporting a framework for EvidenceBased Practice within general practice

Good examples are:

- Cochrane library (a database of high quality systematic
review of health care)
- AGP Journal Club.
- BMJ and Lancet.
At a more local level, there are a growing number of
networks being amongs general practitioner of searching
for and appraising evidence
A natural extension of this process is apply EB Protocols
and guidelines, develop by he colleagues in clinical
practice.

The relevant clinical questions in your

patients must contain 4 element:
1). The patients problem.
2). Intervention, which by research methodology,
diagnostic test and the treatment
3). If needed with intervention comparable.
4). Clinical outcome or outcome of interest.
The 4 element to form the terminology i.e. PICO

Use of theophylline in asthma

Following the publication for the management of asthma in adults,
dr. A noted the statement that thephylline might have a role in
patients whose asthma was not controlled with high dose inhaled
steroid, but even then alternative treatment might have fewer side
effects. He decided it was time to review his prescribing of
theophylline and used the practice computer to produce a list of all
his asthmatic patients and their recent medication. He found 86
patients, three of whom were taking theophylline. He was reassured
that his use of theophylline was limited, but made an entry in the
records of each of these patients to remind him to review their
medication when the patient next attended. Ultimately, he was able
to persuade two of these patients to discontinue theophylline, and
after 6 months the prescribing data were checked again to confirm
that these changes had persisted.

Prognosis
- What are the consequences of having the disease
Is it dangerous ?
Could I die of it
How long will I be able to continue my

present actives ?
Will it ever go away altogether?

The prognosis question

A qualitative aspect
(which outcomes could happen?)

A quantitative aspect
(how likely are they to happen ?)

A temporal aspect
(over what time period ?)

Natural history of diseases

(no medical intervention)
Biologic onset Clinical
Diagnosis Outcome Recovery
Disability
Death
ect

Clinical Courses
(medical intervention)

Risk Factors

Biologic
onset

Clinical
Diagnosis

Outcome

Recovery
Disability
Death
Etc

Demographic variable
Prognostic factorsDisease specific variab
Co-morbid factor

The strategy for making a prognosis

expert opinion
consulting the appropriate specialist
looking it up in a text book
clinical experiences
read up

Cohort study
Survival analysis
Case control study
Case Series

Biologic
onset

Early
diagnosis
possible

Clinical
diagnosis

Outcome

Recovery
Disability
Death
Etc

Summary

If the concept is embraced it will improve

general practice
Will make the GP an even more rewarding
discipline within which to practice.
Will support shared decision making with
users. It is the ideal model of making
decisions within the medical encounter.
EBM / EBP will help maintain the central role
of general practice in health care.