EBM prognostic

Skenario klinis
Seorang ODHA laki-laki berusia 38 tahun datang ke
klinik VCT untuk berkonsultasi tentang diagnosis TB
yang baru saja dia dapatkan dari dokter berikut OAT
yang telah diberikan. Dia ingin menanyakan apakah
kondisi ini dapat memperpendek umurnya.
Dari data didapatkan pasien tinggal bersama orang
tuanya yang penuh kasih sayang.
Nilai CD4 pasien terakhir 240 cell/mm3
Pasien belum pernah mendapat OAT sebelumnya
Dokter ingin tahu seberapa besar OAT yang diberikan
pada ODHA dapat mempengaruhi umurnya

Practice of EBM
Step 1: Converting the need for information (about prevention,
diagnosis, prognosis, therapy, causation, etc.) into an
answerable question
Step 2: Tracking down the best evidence with which to answer
that question
Step 3: Critically appraise that evidence for the validity
(closeness to the truth), impact (size of the effect), and
applicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinical
expertise and with our patients unique biology, values, and
circumstances
Step 5: Evaluating our effectiveness and efficiency in executing
steps 1-4 and seeking ways to improve them both for next time

Clinical question about prognosis

Patient or Intervention
Problem

Comparison

Outcomes

Pasien
DOTS
usia 38
tahun
dengan
diagnosi
s HIV-TB

mortality

Pertanyaan klinis
Apakah pemberian OAT dengan DOTS pada
pasien HIV-TB dapat memperlambat
kematiannya?

Practice of EBM
Step 1: Converting the need for information (about prevention,
diagnosis, prognosis, therapy, causation, etc.) into an
answerable question
Step 2: Tracking down the best evidence with which to answer
that question
Step 3: Critically appraise that evidence for the validity
(closeness to the truth), impact (size of the effect), and
applicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinical
expertise and with our patients unique biology, values, and
circumstances
Step 5: Evaluating our effectiveness and efficiency in executing
steps 1-4 and seeking ways to improve them both for next time

Search Strategy
Medline database:
http://www.ncbi.nlm.nih.gov/pubmed/
Using the Clinical Queries function of
PubMed:
Key words:
natural history AND
HIV

Clinical Study Categories: prognosis

Scope: Narrow

Searching the Evidence

Natural History and Factors Associated with Early
and Delayed Mortality in HIV-Infected Patients
Treated of Tuberculosis under Directly Observed
Treatment Short-Course Strategy : A Prospective
Cohort Study in India
Alvarez-Uria G, Naik PK, Pakam R, Bachu L, Midde
M.
Interdisciplinary Perspectives on Infectious
Diseases Volume 2012, ArticleI D 502012, 9 pages

Practice of EBM
Step 1: Converting the need for information (about prevention,
diagnosis, prognosis, therapy, causation, etc.) into an
answerable question
Step 2: Tracking down the best evidence with which to answer
that question
Step 3: Critically appraise that evidence for the validity
(closeness to the truth), impact (size of the effect), and
applicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinical
expertise and with our patients unique biology, values, and
circumstances
Step 5: Evaluating our effectiveness and efficiency in executing
steps 1-4 and seeking ways to improve them both for next time

Clinical
domain

Question

Epidemiological
study type

Diagnosis How accurate are tests

Cross-sectional
used to diagnose disease? study

Prognosis What are the

consequences of having a
disease?
Therapy
How does treatment
change the course of
disease?
Harm
What conditions lead to
(Etiology/ disease?
causation)

Cohort
(longitudinal)
study
RCT (or
systematic review
of RCTs)
Cohort or casecontrol study
10

Is this evidence about prognosis valid?

1.

Was a defined, representative

sample of patients assembled
at a common point in the
course of their disease?

Penelitian ini merupakan

studi cohort prospektif

dengan konsekutif
sampling

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Is this evidence about prognosis valid?

2. Was follow-up of study patients sufficiently
long and complete? Apakah follow up
dilakukan secara lama dan komplit
Follow-up terhadap 1000 pasien dilakukan
selama 24 bulan dengan kematian kumulatif
sebanyak 388 pasien
Pada penelitian ini tidak dijelaskan berapa
sampel pasien dan jumlah pasien yang masih
hidup pada akhir pengamatan
12

Is this evidence about prognosis valid?

3. Were objective outcome criteria applied in a blind

fashion?
Pada penelitian ini , total mortality dan penyebab
kematian dijelaskan
Cause of death was ascertained by hospital notes, death
reports dari VFHCS database
Penilaian outcome kematian tidak dijelaskan apakah
blinded karena tidak perlu metode blinded dalam Dx
kematian
13

Is this evidence about prognosis valid?

4.

If subgroups with different prognoses are identified:

Was there adjustment for important prognostic factors?

14

 Was there validation in an independent group

of test-set patients?
Tidak ada test-set pasien dalam penelitian ini

Is this valid evidence about prognosis

important?
1. How likely are the outcomes over time?
2. How precise are the prognostic estimates?

From our study, we found that, at a median follow-up of

10.4 bulan , mortality was 38.8%
Pasien dibagi menjadi 2 kelompok: penilaian follow-up
mortality dalam 3 bulan pertama dan setelah 3 bulan.

16

Can we apply this valid, important

evidence about prognosis to our patient?
1. Is our patient so different from those in the
study that its results cannot apply?

tidak

2. Will this evidence make a clinically important

impact on our conclusions about what to
offer or tell our patient?

ya
21

Practice of EBM
Step 1: Converting the need for information (about prevention,
diagnosis, prognosis, therapy, causation, etc.) into an
answerable question
Step 2: Tracking down the best evidence with which to answer
that question
Step 3: Critically appraise that evidence for the validity
(closeness to the truth), impact (size of the effect), and
applicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinical
expertise and with our patients unique biology, values, and
circumstances
Step 5: Evaluating our effectiveness and efficiency in executing
steps 1-4 and seeking ways to improve them both for next time

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Resolution of the Case

Sesuai umur pasien (38th) maka kondisi ini dapat
meningkatkan risiko kematian sebesar 1,24x dibanding
pasien usia < 35th dalam 3 bulan pertama pengobatan
Sesuai dengan nilai CD4 terakhir (240cell/mm3), maka kondisi
ini dapat meningkatkan risiko kematian sebesar 1,2x
dibandingan pasien dengan nilai CD4 diatas > 250cell/mm3
dalam 3 bulan pertama pengobatan
Setelah menjalani pengobatan > 3bulan, risiko kematian
akibat TB menjadi tidak bermakna
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