HISTORY OF EVIDENCE BASED MEDICINE

IGNATIUS BIMA PRASETYA

EVIDENCE BASED MEDICINE?

 1990 Gordon Guyatt came with the term

“scientific medicine” but the reception was
lukewarm at best
 1991 He came again with a new name,
“Evidence Based Medicine”
 Yet it started wayyyyyy back
EARLY MEDICAL PRACTICES AND EDUCATION
 Apprenticeship system
 Based on experience
 No emphasis on books or written text
 May vary from “experts to experts”
EARLY MEDICAL PRACTICES AND EDUCATION
 MEDICINE
MEDICAL ART VS MEDICAL SCIENCE
 Exact science vs
individual creativity
 Accountable vs
unaccountable
 Objectivity vs
subjectivity
 Quantitative vs
Qualitative
 Deductive vs
Inductive
DEDUCTIVE VS INDUCTIVE
 DEDUCTIVE VS INDUCTIVE

Should be
Pancreatic Surgery should
THEORY Filled with pus excised
abscess be done!
immediately

Out of 10 patient who Out of 10 patient who

Surgery shouldn’t be
OBSERVATION Pancreatic abscess underwent surgery, didn’t undergo
done!
only 2 survived surgery, 6 survived
1854

Was born in York, Was born in

England Winterfell

Was an Was a King in The

anaesthesiologist North

Knows that he knew Didn’t even know

nothing that he knew nothing
John Snow Jon Snow
JOHN SNOW

STATISTICS!
EARLY 1900

• Flexner Report
• Med school with strict criteria and curriculum
1904 • Emphasis on biomedical science

• Physician began to represent a larger fraction of the membership on public health boards
After 1904

• Rockefeller Foundation funded “The Public Health School”

• Emphasis on environmental and social influences on health and diseases
1941
1969

 Suzanne and Robert Fletcher

 They recognized that biomedical science
often had no translational application to
clinical medicine
 They made efforts on bridging the two
 In 1982 they published a textbook, “Clinical
Epidemiology: The essentials”
1970-1980

 Alvan Feinstein
 Was a mathematician turned physician
 Started his medical career at a Rheumatic fever hospital in New York
and immediately realized that the basis used for diagnosis were purely
clinical authority instead of scientific criteria
 He successfully developed a system of classification based on
observations, resulting in the closing of the institution due to the lack
of sufficient patients
 CLINICAL EPIDEMIOLOGY

“The science of making predictions about individual patients by counting

clinical events in similar patients, using strong scientific methods for
studies of group of patients to ensure that the predictions are accurate”

Clinical epidemiology become a formal part of medical school since 1967,

With the new Department lead by Dr. David Sackett
MODERN ERA

Critical Appraisal
Safety and efficacy of boceprevir/peginterferon/ribavirin for HCV G1
compensated cirrhotics: Meta-analysis of 5 trials
Introduction

Peg-IFN Ribavirin DAA

Method

(P05101 (RESPOND-2 ), P05216

(SPRINT-2), P05514 (PROVIDE),
P05685 (Peginterferon alfa-2a
Study), dan 2415 Patients
P06086 (Anemia Management
Study)
Study Limitation
• The meta-analysis enrolled stable, well-compensated cirrhotics
(due to the requirement for platelets to be >100,000/mm3) who
may differ from cirrhotic patients in clinical practice who need to
be treated
• The design was retrospective analysis so the subgroups are not
truly randomized comparisons
• The role of IL-28B polymorphism was not well elaborated
Meta Analysis Appraisal
Validity
Valid question Yes
Inclusion of all relevant studies Yes
Appropriate inclusion criteria Yes
Valid included study design Not stated
Similar results from study to study Not stated
Meta Analysis Appraisal
• Applicability: patients with compensated cirrhosis only stands for
some little part of all HCV patients. Population with stable disease
such as the study population are even less common
COCHRANE
 Archie Cochrane
 A British researcher imprisoned during WW2
 Conducted several experiments on his fellow inmates
 Established methods to eschew biases through the promotion of
Randomized Controlled Trials
 Cochrane Collaboration, formed by Tom Chalmers, Ian Chalmers,
Murray Enkin
PROBLEM SOLVED?

Remember to always use the options with the

best results from valid studies!

Always keep in mind about applicability!

Value Based Medicine

EBM WEAKNESSES

A doctor’s work is not a simple algorithm

Human beings are complex

Some evidences were just impossible to be studied upon

No such thing as “Best Evidence”, only “Best evidence according to current

knowledge”

The term “best available evidence” may be misused for political and
economical gains
TAKE HOME MESSAGE

“Good doctors use both individual clinical expertise and the best available external
evidence and neither alone is enough. Without clinical expertise, practice risks
becoming tyrannized by external evidence, for even excellent external evidence may be
inapplicable to or inappropriate for an individual patient”

-David Sackett-