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Evidence-Based Medicine
Sudigdo Sastroasmoro
(s_sudigdo@yahoo.com)
Fakultas Kedokteran Universitas
Indonesia
Evidence-based Medicine
Opinion-based medicine
Experience-based medicine
Power-based medicine
Hope-based medicine
Logic-based medicine
Erratic-based medicine
Evidence-based Medicine
Medicine-based evidence
Pragmatic research
Outcome research
Quality
Value =
Cost
Diagnosis
Patient with complaint
History
Physical
Simple test
Specific test
Yes or no answer
Predictive value is the most important
The spectrum of the presentations must
resemble that in practice
Treatment
Patient with certain diagnosis
Does drug X more effective than Y?
Focus on the outcome, rather than its
explanation (biomolecular markers)
Yes or no outcome most useful
Prognosis
Usually in cohort studies
To inform the patient 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)
EBM
Started in early 90s by clinical epidemiologists
1992 : only few articles on EBM
2000 : >1000 articles
Indonesia : started in 1997
Workshops : Yogya (2000)
IKA FKUI (2000, 2001,
etc)
Group discussion on EBM / mailing list:
<ebm-f2000@yahoogroups.com>
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
Previous Practice
6 yrs medical Problems with
education patients:
Dx, Rx, Px
Trust me
In my experience .
Logically
Textbook, handbook, capita
selecta
The results.
Opinion-based medicine
Steroid inj. in prematures to prevent RDS
Routine episiotomy
Routine circumcision
Antibitotics 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
What is
Evidence-based Medicine?
2 4 6 8 10 12
Treatment
(Intervention necessary to help the patient)
Prognosis
(Prediction of the outcome of the disease)
A 2-year old boy diagnosed presented
with 6-day high fever, conjunctival
injection without secretion, skin rash>
blood test shows leukocytosis, high
ESR, CRP +++. He was suspected to
have Kawasaki disease. The
pediatrician is aware of the use of
immunoglobulin to prevent coronary
involvement, but uncertain about the
dosage.
Medical students:
(Background question)
Background
questions
B e b r i e f a n d s p e c i f
i c
Relevance: Type of Evidence
Patient-Oriented
Evidence
Comparing DOES and POEMs
E
Antiarrhythmic Drug A PVC Drug A > DOE & POEM
Therapy On ECG mortality contradicts
Non-Randomized trials B
Level 3
Observational studies
Case series / reports C
Anecdotes, expert, Level 4
consensus
Implementation of EBM practice:
How to get started
Apply Formulate
The evidence In answerable
question
Critically
Appraise Search the
The evidence 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
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
Criticism to EBM