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Evidencebased Medicine An Overview

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KPS/SPS IDAI Jakarta. IKA Unair Surabaya. Unibraw Malang. USU Medan ... EMBASE. MDConsult. AAP Journal Club. Cochrane Library. SS/EBM/MRU/02-04. Note: ... – PowerPoint PPT presentation

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Title: Evidencebased Medicine An Overview


1
Evidence-based Medicine An Overview
Sudigdo Sastroasmoro (sudigdo_s_at_yahoo.com) Medica
l Research Unit, Medical School University of
Indonesia
2
  • Younger staff IKA (1)
  • Younger staff IKA (2)
  • Senior staff IKA
  • PPDS IKA
  • PPDS IKA
  • RSAB-HK
  • SMF-RSCM
  • Unud-Denpasar
  • Undip-Semarang
  • KPS/SPS IDAI Jakarta
  • IKA Unair Surabaya
  • Unibraw Malang
  • USU Medan
  • Unand Padang
  • Unilam Banjarmasin
  • Interntl Class, FMUI
  • Unsri Palembang
  • Raker IKA-Lido
  • Raker Kolegium-Ancol
  • 21. RSUD Bantul
  • 22. PPDS IKA
  • 23. International Class FMUI
  • 24. Student Center FMUI
  • 25. Iluni
  • 26. Clin governance Fatmawati
  • 27. HTA-Depkes
  • 28. MMR-UGM
  • 29. Mediva
  • 30. Guidelines Cardiology
  • 31. Alternative medicine
  • 32. PHTDI Semarang
  • 33. Foreign Health Manpower
  • 34. Dermato-venereology RSCM
  • 35. TIA Jakarta
  • 36. PIT Peralmuni
  • 37. PIT Ikabi
  • 38. PIT PAPDI
  • 39. Faculty of Dentistry UI

3
EBM
  • Started in early 90s by clinical epidemiologists
  • 1992 only few articles on EBM
  • 2000 gt1000 articles
  • Indonesia started in 1997
  • Workshops Yogya (2000)

    IKA FKUI (2000, 2001, etc)
  • Group discussion on EBM / mailing list
  • ltebm-f2000_at_yahoogroups.comgt
  • (Moderator firmanda_at_cabi.net.idgt)

4
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5
EBM Clinical Epidemiology
  • Fletcher Fletcher CE The application of
  • epidemiologic principles in problems
    encountered in clinical medicine
  • Sackett et al CE The basic science for
    clinical medicine
  • Much resistance by experts
  • EBM In principle no one disagree
  • All major medical journals have adopted EBM
  • Centers for EBM all over the world

6
Previous practice
Problems with patients Dx, Rx, Px
6 yrs medical education
40-50 yrs medical practice
Consultant, colleagues Textbooks Handbooks Lecture
notes Clinical guidelines CME, seminars,
etc Journals
Usu. see only Results section, or even worse,
Abstract section
7
What is Evidence-based Medicine?
  • The conscientious, explicit, and judicious use
    of current best evidence in making decisions
    about the care of individual patients
  • Pemanfaatan bukti mutakhir yang sahih dalam tata
    laksana pasien
  • Integration of (1) physicians competence (2)
    valid evidence from studies (3) patients
    preference

8
  • Pros New paradigm in medicine
  • Extraordinary innovations,
  • only 2nd to Human Genome Project
  • Cons New version of an old song
  • Fair Nothing wrong with EBM, but
  • Be careful in searching evidence
  • Meta-analyses, clinical trials, and all study
    results should be critically appraised
  • Keyword for EBM
  • Methodological skill to judge the validity
  • of study reports (Re. Andersen B
    Methodological errors in medical research, 1989)

9
When doctors meet numbers .....
10
There are two most difficult things to understand
woman
and ....
11
Hierarchy of Lies
Statistics
Damn lies.....
Lies.....
(Mark Twain)
12
A roadside merchant was asked how he could
sell rabbit sandwiches so cheap. "Well," he
explained, "I have to put some horse-meat in
too. But I mix them 5050. One horse, one
rabbit." (Darrel Huff, How to Lie with
Statistics)
A statistician can have his head in an oven and
his feet in ice, and he will say that on the
average he feels fine.
13
Ways of Reaching The Truth
  • Faith The seductive approach
  • Trust me
  • In my experience

14
Ways of Reaching The Truth
  • It makes sense logical
  • The Inductive Approach
  • Based on pathophysiology
  • It ought to work
  • These ought to, but dont
  • External fetal monitoring
  • Right heart catheterization

15
Ways of Reaching The TruthA Medical Paradigm
Shift
  • Evidence-Based Medicine
  • The Deductive Approach
  • Based on outcomes research
  • Putting it all back together
  • Demonstration that it does or doesnt work

16
WHY EBM?
  • 1. New evidence are continuously generated
  • 2. We usually fail to get the new evidence
  • 3. Our clinical performance deteriorates with
    time (the slippery slope)
  • 4. Traditional CME does not improve clinical
  • performance
  • 5. EBM encourages self directed learning
    process which should overcome the above
    shortages

17
Dean, Harvard Medical School to students
  • We believe that 50 of what we are teaching to
    you now will prove to be false 5 years later the
    problem is that we do not know
  • which 50

18
100

Relative of remaining knowledge
2 4 6 8
10 12
Years after graduation
THE SLIPPERY SLOPE
19
Steps in EBM practice
  • Formulate clinical problems in answerable
    questions
  • Search the best evidence use internet or other
    on-
  • line database for current evidence
  • 3. Critically appraise the evidence for
  • Validity (was the study valid?)
  • Importance (were the results clinically
    important?)
  • Applicability (could we apply to our patient?)
  • 4. Apply the evidence to patient
  • 5. Evaluate our performance

VIA
20
Main area
Diagnosis(Determination of disease or
problem) Treatment(Intervention necessary to
help the patient)Prognosis(Prediction of the
outcome of the disease)
21
Others
Meta-analysisClinical guidelinesEconomic
analysis Clinical decision makingCost-effectiven
ess analysisQualitative research
22
(I)Formulating clinical questions
23
  • A 3 year old boy with prolonged fever, skin rash,
    stomatitis, conjunctivitis, submandibular lymph
    node enlargement
  • Good nutritional status
  • Normal vital signs
  • Increased BSR, increased pletelet count
  • Dx suspected Kawasaki disease
  • Consider aspirin, immunoglobulin

24
Medical students(Background question)
  • What is Kawasaki disease?
  • What is the cause?
  • What are symptoms signs?
  • What is the treatment?
  • Cardiac involvement?

25
House officers(Foreground question)
  • In a child with Kawasaki disease, will repeated
    echo examination necessary for early detection of
    cardiac involvement? (Dx)
  • In a child with Kawasaki disease in acute phase,
    does administration of Intravenous immunoglobulin
    decrease the likelihood of developing coronary
    involvement? (Rx)
  • In a child with Kawasaki disease without coronary
    involvement in acute stage, does administration
    of long-term aspirin reduce the possibility of
    delayed coronary involvement? (Px)

26
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27
Other example
  • In neonates born to mothers with history of
    herpes simplex infection, does the administration
    of IVIG (intravenous immunoglobulin) reduce the
    possibility of neonatal herpes?

28
Four elements of good clinical question PICO
  • The Patient or Problem
  • The Intervention
  • Comparative intervention (if relevant)
  • The Outcome

29
Four elements of a well constructed clinical
question PICO
30
IISearching the evidence
31
Examples of on-line Journals / Databases
  • http//bmj.com
  • http//adc/bmjjournals.com
  • MEDLINE/PubMed
  • EMBASE
  • MDConsult
  • AAP Journal Club
  • Cochrane Library

32
Use keywords for searching
  • Note
  • Spelling (American / British), terminology
  • Follow rigidly the instructions of each website
  • Examples
  • Host vs graft reaction AND management
  • hemosiderosis AND thalassemia OR thalassaemia
  • breast cancer OR Ca mammae AND immunoglobulin
    OR IVIG

33
The Flora and Fauna of the Medical Jungle
  • Original Research
  • Academic Reviews
  • Decision/Cost Analysis
  • Medical Cookbooks (Practice Guidelines)
  • Translation Journals
  • CME
  • Clinical Experience
  • Experts
  • Newsletters and Survey Services
  • Pharmaceutical Representatives
  • Computer sources
  • Audiotapes
  • Qualitative Research

34
Original Research is at the center of our
information jungle
35
IIIAppraising the evidenceVIA
36
VIA
  • VALIDITY In Methods section
  • design, sample, sample size, eligibility
    criteria (inclusion, exclusion) sampling
    method, randomization method, intervention,
    measurements, methods of analysis, etc
  • IMPORTANCE In Results section
  • characteristics of subjects, drop out,
    analysis, p value, confidence intervals, etc
  • APPLICABILITY In Discussion section our
    patients characteristics, local setting

37
Example Critical appraisal for therapy
  • Were the subjects randomized?
  • Were all subjects received similar treatment?
  • Were all relevant outcomes considered?
  • Were all subjects randomized included in the
    analysis?
  • Calculate CER, EER, RRR, ARR, and NNT
  • Were study subjects similar to our patients in
    terms of prognostic factors?

38
Hierarchy of evidence
Meta-analysis of RCT Large RCT Small
RCT Non-Randomized trials Observational
studies Case series / reports Anecdotes,
expert, consensus
39
Implementation of EBM practiceHow to get
started
  • 1. Teaching EBM in medical schools / PPDS
  • Easier than to change the already existing
    attitude
  • Most important
  • May be included in formal curricula or
    integrated in
  • existing activities ward rounds, on calls,
    case
  • presentations, group discussions, journal
    clubs, etc
  • 2. Workshop for teaching staff
  • 3. Workshop for practitioners, incl. nurses

40
Resistance to EBM teaching learning
  • Rudimentary skill in critical appraisal /
  • methodological skill
  • Limited resources, esp. time factor
  • Lack of high quality evidence
  • Skepticism toward evidence-based practice
  • Happy with current practice

41
Development of EBM practice
  • Passive diffusion model
  • Active dissemination model
  • Coordinated implementation model
  • Patients community
  • Health administrators
  • Public policy makers
  • Clinical policy makers

42
Strategies for developing EBM practice
  • Clinical guidelines
  • Practice development leaders
  • (! Environment)
  • Development units
  • Dissemination of good practice
  • Networking
  • Research summaries
  • Action research

43
Summing up ....
44
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45
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46
Advantages of EBM
  • Encourages reading habit
  • Improves methodological skill (and willingness to
    do research?!)
  • Encourages rational up to date management of
    patients
  • Reduces intuition judgment in clinical
    practice, but not eliminates them
  • Consistent with ethical and medico-legal aspects
    of patient management

47
End result
self directed, life-long learning attitude for
high quality medical management
48
Components of professionalism
49
CME
50
Conclusion
  • EBM is nothing more than a
  • framework of systematic use of
  • current valid study results
  • relevant to our patient

51
  • Evidence-based Cardiology
  • Evidence-based Pediatrics
  • Evidence-based Ob-Gyn
  • Evidence-based Dentistry
  • Evidence-based Nursing
  • Evidence-based Health Policy
  • Evidence-based Health Technology Assessment
  • Evidence-based Decision Making
  • Evidence-based Health Performance Indicators
  • Evidence-based Clinical Audit
  • Evidence-based Risk Management .
  • Evidence-based Everything!!!

52
Remember, however ...
  • Medicine is the science of uncertainty
  • and the art of probabilities

53
A pediatrician has just read a meta-analysis
that asthmatic attack is more likely to develop
if a asthmatic baby is given egg white as
compared to yolk. One day a mother told the
pediatrician that her baby will wheeze
immediately if given egg yolk but no problem when
given egg white. The pediatrician responded No,
you are wrong. Valid level I evidence indicate
that white egg is far more allergenic than egg
yolk. From now on you have to give your baby the
yolk instead of the white.
Misused evidence
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