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Introduction to

Evidence-Based Medicine
Dr. Bhisma Murti, MPH, MSc, PhD
Insiitute for Health Economics and Policies (IHEPS, Bagian
Ilmu Kesehatan Masyarakat,
Fakultas Kedokteran, Universitas Sebelas Maret

What is Evidence-Based
Medicine?
The integration of individual clinical
expertise with the best available clinical
evidence from systematic research.
David L Sackett, W Scott Richardson, William
Rosenberg, R Brian Haynes Evidence Based Medicine-How to Practice and Teach EBM, 1996

The Elements of EBM


Patient Concerns,
Values and Expectation

EBM
Best research
evidence

Clinical
Expertise

Six Steps in EBM


1.
2.
3.
4.
5.
6.

The Patient
The Question
The Resource
The Evaluation
The Application
The Self-Evaluation

The Patient
Start from a clinical problem or question arising out of the
patients concern and the care of the patient
It is the patients problem that matters, not the disease
So focus on the patients problem!

POEMs

vs.

DOEs

P- Patient

D- Disease

O- Oriented

O- Oriented

E Evidence

E- Evidence

that
M- Matters

POEMs

Example
Antiarrhythmic
Therapy

DiseaseOriented
Evidence

vs.

DOEs

Patient-Oriented
Evidence that
Matters

Drug X PVCs Drug X increases


on ECG
mortality

Comment
POEM study
contradicts DOE
study

Antihypertensive Antihypertensive Antihypertensive


POEM agrees
therapy
therapy BP
therapy mortality with DOE

Prostate
Screening

PSA screening
detects prostate
cancer early

? whether PSA
screening
mortality

PVC = premature ventricular contraction, also


known as ectopic heartbeat, extrasystole
PSA test= prostate specific antigen test

DOE exists, but


the important
POEM is
unknown

The Question
Construct a well built clinical question derived from the
case, i.e. the patients problem

Types of Questions
Therapy/ prevention Question
Prognosis Question
Diagnosis Question
Harm Question
Etc.

Questions: PICO

The Resource
Select the appropriate resource(s) and conduct a search

The Evaluation
Appraise that evidence for:
Validity (closeness to the truth) --- internal validity
Importance (clinical significance in magnitude and
length)
Applicability (applicable to your patient) --- external
validity

Suggested Best Type of Study


Type of Question

Suggested best type of Study

Therapy

RCT>cohort > case control > case series

Diagnosis

Prospective, blind comparison to a gold standard

Etiology/Harm

RCT > cohort > case control > case series

Prognosis

Cohort study > case control > case series

Prevention

RCT>cohort study > case control > case series

Clinical Exam

Prospective, blind comparison to gold standard

Cost

Economic analysis

Evidence Pyramid for


Therapy Question
Meta-Analysis
Systematic Review
Randomized Controlled Trial
Cohort studies
Case Control studies
Case Series/Case Reports
Animal research

The Application
Return to the patient -- integrate that evidence with clinical
expertise, patient preferences and apply it to practice

The Self-Evaluation
Evaluate your performance with this patient