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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
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

Best research Clinical
evidence Expertise
Six Steps in EBM
1. The Patient
2. The Question
3. The Resource
4. The Evaluation
5. The Application
6. 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
M- Matters
POEMs vs. DOEs

Disease- Patient-Oriented
Oriented Evidence that
Example Evidence Matters Comment
POEM study
Antiarrhythmic Drug X PVCs Drug X increases contradicts DOE
Therapy on ECG mortality study

Antihypertensive Antihypertensive Antihypertensive POEM agrees

therapy therapy BP therapy mortality with DOE
DOE exists, but
PSA screening ? whether PSA the important
Prostate detects prostate screening POEM is
Screening cancer early mortality unknown

PVC = premature ventricular contraction, also

known as ectopic heartbeat, extrasystole
PSA test= prostate specific antigen test
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
Therapy Question - A question concerning the effectiveness of a treatment or
preventative measure
Prognosis Question - A question concerning outcome of a patient with a
particular condition
Diagnosis Question - A question concerning the ability of a test to predict the
likelihood of a disease
Harm Question - A question concerning the likelihood of a therapeutic
intervention to cause harm
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
Applicability (applicable to your patient) --- external
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

Systematic Review

Randomized Controlled Trial

Cohort studies

Case Control studies

Case Series/Case Reports

Animal research
This is often referred to as the "evidence pyramid". It is used to illustrate the
evolution of the literature.
The base of the pyramid is where information usually starts with an idea or
laboratory research. As these ideas turn into drugs and diagnostic tools they are
tested in laboratories models, then in animals, and finally in humans. The human
testing may begin with volunteers and go through several phases of clinical trials
before the drug or diagnostic tool can be authorized for use within the general
population. Randomized controlled trials are then done to further test the
effectiveness and efficacy of a drug or therapy. As you move up the pyramid the
amount of available literature decreases, but increases in its relevance to the
clinical setting.
Meta-Analysis takes the systematic review (see below) a step further by using
statistical techniques to combine the results of several studies as if they were one
large study.
Systematic Reviews usually focus on a clinical topic and answer a specific
question. Extensive literature searches are conducted to identify studies with
sound methodology. The studies are reviewed, assessed, and summarized
according to the predetermined criteria of the review question.
Randomized Controlled Trials are carefully planned projects that study the effect
of a therapy or test on real patients. They include methodologies that reduce the
potential for bias and that allow for comparison between intervention groups and
control groups (no intervention). Evidence for questions of diagnosis is found in
prospective trials which compare tests with a reference or "gold standard" test.
Cohort Studies take a large population and follow patients who have a specific condition
or receive a particular treatment over time and compare them with another group that
is similar but has not been affected by the condition being studied. Cohort studies are
not as reliable as randomized controlled studies, since the two groups may differ in
ways other than in the variable under study.
Case Control Studies are studies in which patients who already have a specific
condition are compared with people who do not. These types of studies are often less
reliable than randomized controlled trials and cohort studies because showing a
statistical relationship does not mean than one factor necessarily caused the other.
Case Series consist of collections of reports on the treatment of individual patients.
Case Report is a report on a single patient. Because they are reports of cases and use
no control groups with which to compare outcomes, they have no statistical validity .

Practice Guidelines are systematically developed statements to assist practitioner and

patient make decisions about appropriate health care for specific clinical
circumstances. Guidelines review and evaluate the evidence and then make explicit
recommendations for practice.
The pyramid serves as a guideline to the hierarchy of evidence available. You may
not always find the best level of evidence to answer your question. In the absence of
the best evidence, you then need to consider moving down the pyramid to other
types of studies.
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