Critical Appraisal

Therapy&Etiology
Sasaran Belajar

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Evidence-based Medicine (EBM)
• integrating individual clinical expertise with the
best available external clinical evidence from
systematic research to achieve the best
possible patient management (David Sackett,
1990)
• improve the quality of the information on
which health care decisions are based
• avoid ‘information overload’
• find and apply the most useful information
•  Evidence-based Practice (EBP)
EBP --- Why do we need it?
• gap between what we know from research
and what we do in clinical practice
• research  some valid and some invalid 
clinicians understandably are unaware of
most of it / do not have the ‘tools’ to assess
its quality
• most treatment-related decisions were not
based on a systematic review of clinical
research
Steps in
EBP
1. Formulate an answerable question
2. Track down the best evidence of
outcomes available
3. Critically appraise the evidence (find
out how good it is and what it means)
4. Apply the evidence (integrate the
results with clinical expertise and
patient values)
Step 1 : Formulate an answerable question
• Admit that you don’t know
• Use the “PICO” principle
Jean is a 55-year-old woman who quite
often crosses the Atlantic to visit her
elderly mother. She tends to get swollen
legs on these flights and is worried about
her risk of developing deep vein
thrombosis (DVT), because she has read
quite a bit about this in the newspapers
lately. She asks you if she should wear
elastic stockings on her next trip to
reduce her risk of this
Question :
‘In passengers on long-haul flights, does
wearing elastic compression stockings,
compared with not wearing elastic
stockings, prevent DVT?’
Step 2 : Track down the best evidence of
outcomes available
Step 3 : Critically appraise the evidence

a. Is the PICO of the study close enough to

the PICO of your question?
b. How well was the study done?
internal validity --- how well the research
methods prevented the results from being
affected by bias and confounding factors
To find out how well bias and confounding factors
were avoided in a health care study, check each stage
of the study to see how well bias has been
eliminated/how ‘fairly’ the study has been done :
• How fairly were the subjects recruited (the ‘P’)?
• How fairly were the subjects allocated to groups
(the ‘I’ and ‘C’)?
• How fairly were the study groups maintained
through equal management and follow-up of
subjects (the ‘I’ and ‘C’)?
• How fairly were the outcomes measured (the ‘O’)?
c. What do the results mean?

Binary/dichotomous

Outcome
measure

Continuous

• Are the results real and relevant?

 P-values (hypothesis testing)
 CI/confident intervals (estimation)
Outcome measure for binary outcomes
Critical Appraisal
Worksheet
Terapi-CEBM
Terapi-Ktclearinghouse
Etiologi
Catmaker
Step 4 : Apply the evidence
External validity  the questions that you should ask
before you decide to apply the results of the study to
your patient are :
• Is the treatment or test feasible in my setting?
• What else do I need to apply this evidence?
• What alternatives are available?
• Is my patient so different to those in the study that
the results cannot apply at all?
• Will the potential benefits of treatment outweigh
the potential harms of treatment for my patient?
• What does my patient think about it?
Step 5 : Integrate the evidence with our
clinical expertise and our patient’s
characteristics and values.
Step 6 : Evaluating our effectiveness and
efficiency in executing steps 1–4
and seeking ways to improve them
both for next time.
Skenario 1
Seorang pasien laki-laki usia 70 tahun didiagnosis
mengalami stenosis karotis. Dokter menjelaskan
bahwa kondisi tersebut dapat menyebabkan stroke
tipe sumbatan apabila tidak ditangani dengan baik.
Dokter menyarankan untuk dilakukan tindakan
pembedahan namun pasien dan keluarga menolak
mengingat pertimbangan efek samping tindakan
pembedahan yang telah dikemukakan oleh dokter.
1 minggu kemudian keluarga pasien datang dengan
membawa artikel yang menyebutkan bahwa untuk
seseorang yang mengalami stenosis karotis memiliki
alternatif tindakan yaitu pemasangan cincin pada
pembuluh darahnya. Keluarga pasien menanyakan
kepada dokter apakah artikel tersebut dapat
dipercaya dan diterapkan.
Skenario 2
Seorang wanita usia 40 tahun yang didiagnosis
meningioma datang untuk control pasca pembedahan.
Menurut pasien, dokter yang terdahulu menjelaskan
bahwa faktor yang berperan terhadap terjadinya
meningioma adalah penggunaan KB hormonal. Namun
pasien mengaku tidak pernah menggunakan KB
hormonal. Pasien menanyakan adakah faktor lain pada
dirinya sehingga terkena meningioma.
Lakukan telaah kritis
- Susun PICO dari skenario
- Susun pertanyaan klinik dari PICO
tersebut
- Susun PICO dari jurnal yang telah
disediakan
- Telaah kritis sesuai worksheet
- Tarik kesimpulan