Académique Documents
Professionnel Documents
Culture Documents
Medicine
(Bringing research evidence
into practice)
Sudigdo Sastroasmoro
Clinical Epidemiology and Evidence-based Medicine Unit
FMUI CMH, Jakarta
SS/EBM/IKA-UDIP-2010
Evidence-based Medicine
Medicine-based evidence
Pragmatic research
Outcome research
Related with
morbidity, mortality, quality of life
SS/EBM/IKA-UDIP-2010
Morbidity
Mortality
QoL
Value
SS/EBM/IKA-UDIP-2010
Patient
Satisfaction
Quality
=
Cost
Health
Status
Diagnosis
SS/EBM/IKA-UDIP-2010
Treatment
Patient with certain diagnosis: best
treatment?
Is drug X more effective than Y?
Focus on the clinical outcome, rather than
its explanation (biomolecular markers, etc)
Yes or no outcome most useful
Not in studies with idealized subjects
Px with DM are frequently have
hypercholesterolemia, obese, hypertension, etc
SS/EBM/IKA-UDIP-2010
Prognosis
Usually in cohort studies
To inform about the fate of the patient
Absolute risk is more important than relative
risk
Absolute: Your risk of having second stroke in 1 year
is 30%
Relative: Your risk of having second stroke in 1 year
is 2 times than in non-smokers (RR = 2)
SS/EBM/IKA-UDIP-2010
Pros
SS/EBM/IKA-UDIP-2010
Previous practice:
6 yrs medical
education
40-50 yrs
medical practice
SS/EBM/IKA-UDIP-2010
Consultants,
colleagues
Textbooks
Handbooks
Lecture notes
Clinical guidelines
CME, seminars, etc
Journals
Trust me
In my experience .
Logically
Textbook, handbook, capita selecta
SS/EBM/IKA-UDIP-2010
The results.
Opinion-based medicine
Steroid inj. in prematures to prevent RDS
Routine episiotomy
Routine circumcision
Antibiotics for flu-like syndrome
Use of immunomodulators
Skin test before antibiotic injection
Routine chest X-ray for pre-op preparation
CT scan after minor head trauma
etc
SS/EBM/IKA-UDIP-2010
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
WHY EBM?
1 Information overload
2 Keeping current with literature
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
SS/EBM/IKA-UDIP-2010
100%
10
12
SS/EBM/IKA-UDIP-2010
Main area
Diagnosis
(Determination of disease or problem)
Treatment
(Intervention necessary to help the patient)
Prognosis
(Prediction of the outcome of the disease)
SS/EBM/IKA-UDIP-2010
(I)
Formulating clinical questions
SS/EBM/IKA-UDIP-2010
SS/EBM/IKA-UDIP-2010
Medical students:
(Background question)
SS/EBM/IKA-UDIP-2010
House officers
(Foreground question)
In a child with KD, would immunoglobulin
treatment, compared with no
immunoglobulin, reduce the chance to
develop coronary complication?
SS/EBM/IKA-UDIP-2010
Foreground
questions
Background
questions
Experience with condition
SS/EBM/IKA-UDIP-2010
Other examples
In women with history of eclampsia, would
administration of low-dose aspirin during
pregnancy prevent eclampsia? (Prevention)
In young women with solitary thyroid nodule,
can USG, compared with biopsy, differentiate
between benign from malignant? (Diagnosis)
Four elements of
good clinical question: PICO
SS/EBM/IKA-UDIP-2010
B e
SS/EBM/IKA-UDIP-2010
b r i e f
The
Outcome
alternative
expected
to compare
from this
with the
intervention?
intervention
a n d
s p e c i f i c
Asking prevalence PO
How many percent of patients with TIA who
subsequently develop stroke?
SS/EBM/IKA-UDIP-2010
SS/EBM/IKA-UDIP-2010
POEM
Patient-Oriented
Evidence
SS/EBM/IKA-UDIP-2010
DOE
Antiarrhythmic
Therapy
Antihypertens.
Therapy
Prostate
screening
SS/EBM/IKA-UDIP-2010
POEM
Comment
Drug A PVC
On ECG
Drug A >
mortality
Drug X BP
Drug X
mortality
PSA screening
detects prostate
Ca. early
? whether PSA
screening
mortality
POEM agrees
With DOE
II
Searching the evidence
SS/EBM/IKA-UDIP-2010
III
Appraising the evidence:
VIA
SS/EBM/IKA-UDIP-2010
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
SS/EBM/IKA-UDIP-2010
Example:
Critical appraisal for therapy
Hierarchy of evidence
Weight of
Scientific
Scrutiny
Meta-analysis of RCT
Level 1
Large RCT
Small RCT
Level 2
Non-Randomized trials
Observational studies
Level 3
SS/EBM/IKA-UDIP-2010
Rec
SS/EBM/IKA-UDIP-2010
Patient
With problem
The
EBM
Cycle
Apply
The
evidence
Appraise
The
evidence
SS/EBM/IKA-UDIP-2010
Formulate
In answerable
question
Search the
evidence
Criticism to EBM
EBM makes expensive medical care
EBM cannot be implemented in developing
countries
EBM is costly and time consuming
EBM ignore pathophysiology & reasoning
EBM ignore experience and clinical judgment
EB-guidelines etc interfere with professional
autonomy
SS/EBM/IKA-UDIP-2010
Criticism to EBM
EBM makes expensive medical care
Cf:
Routine antibiotics for ARTI & diarrhea
Liberal indication for C-section
Unnecessary sophisticated procedures /
exams
Unnecessary / harmful treatment:
steroid for recurrent cough
SS/EBM/IKA-UDIP-2010
Criticism to EBM
EBM cannot be implemented in
developing countries
By definition EBM is implemented if it is
implementable (patients preference and
local condition) for the benefit of the
patients and the community
SS/EBM/IKA-UDIP-2010
Criticism to EBM
EBM is costly and time consuming
EBM does requires facilities at the cost
of quality medical care!
Cost benefit ratio should be assessed in
individual and community levels
SS/EBM/IKA-UDIP-2010
Criticism to EBM
EBM ignores pathophysiology & reasoning
EBM encourages clinical reasoning in the
light of valid and important evidence
Pathophysiology and reasoning should be
seen as hypothesis and should end-up in
empirical evidence
SS/EBM/IKA-UDIP-2010
Criticism to EBM
EBM ignore experience and clinical judgment
Personal experience and clinical judgment are
by no means can be eliminated
EBM encourage detailed and systematic
documentation of experience and judgment
Subjective experience should be, whenever
possible, translated into more objective
measures
SS/EBM/IKA-UDIP-2010
Criticism to EBM
EB-guidelines interfere with professional autonomy
Professional conduct (competence, altruism,
openness, collegiality, ethics) is encouraged in
EBM
Every physician should develop their own
practice attitude based on his/her professionalism, valid evidence, and patients values
Development of clinical guidelines and other
standards of care should be seen as a guide and
implemented according to clinical setting
SS/EBM/IKA-UDIP-2010
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
SS/EBM/IKA-UDIP-2010
End result
Self directed, life-long learning attitude
for high quality patient care
SS/EBM/IKA-UDIP-2010
Conclusion
EBM is nothing more than a
framework of systematic use of
current valid study results
relevant to our patient
SS/EBM/IKA-UDIP-2010