Evidence-based Medicine 1.1

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Evidence- based Medicine

description

Presentasi Penjelasan EBM

Transcript of Evidence-based Medicine 1.1

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Evidence-based Medicine

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DefinisiEvidence-based medicine is the integration of best research evidence with clinical expertise and patient values.

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Why do we need EBM?

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Patient Evidence-based Medicine

Better Outcome

Penelitian membuktikan bahwa pasien yang mendapatkan terapi berbasis bukti memperoleh hasil yang lebih baik dari

yang tidak mendapat.

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Antiarrhythmics

Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values.

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Bernard Lown (1979) American College of Cardiology

Heart Attack men (20–64 year olds)

Antiarrhythmics

Arrhythmia Died

Long-acting Antiarrhythmic Drug

(flecainide)

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NEJM New drug called Flecainide

Local anesthetic derivative that

suppresses arrhythmia

Heart attacks patients

Random Groupsflecainide

placebo

Premature ventricular

contractions (PVCs)

flecainide

placebo

PVCs

PVCs

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Conclusion

Flecainide reduces arrhythmias

Arrhythmias cause heart attacks

Therefore, people who have had heart attacks should be given flecainide

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Other researchers

Patients’s outcome

18 months following treatment, > 10% of

people who were given flecainide died

Despite a perfectly good mechanism for the usefulness of flecainide (reduces arrhythmias),

the drug was clearly toxic and, overall, did more harm than good

Mechanism-based Medicine

Not good enough

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Decision making in medicine

EBM

• Etiology• Diagnosis• Treatment • Prevention• Prognosis

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Ask a clinical question

Acquire the best evidence

Appraise the evidence

Apply the evidence

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Step 1: Ask a clinical question

More general• Whole condition • signs• symptoms

More specific• Diagnosis• Treatment • Prevention• Prognosis

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PQuestion formulation

ICO

Populatin or Patient or Problem

Intervention

Comparison (Intervention)

Outcomes

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Clinical scenarioMrs Whish, is a 28 y solicitor. She comes to see you today as she is

frustrated by the symptoms of her irritable bowel syndrome. She feels that they have got worse and despite trying numerous things that you

have suggested nothing has helped. She read an article in The Daily Mail suggesting that probiotic drinks help and wonders what you think?

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PICO

Adult female with IBS

Probiotic drinks

No Probiotic drinks

IBS Prevention

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Step 2: Acquire the best evidence

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Level Therapy / Prevention, Aetiology / Harm

Prognosis Diagnosis Differential diagnosis / symptom prevalence study

Economic and decision analyses

1a SR (with homogeneity*) of RCTs

SR (with homogeneity*) of inception cohort studies; CDR”  validated in different populations

SR (with homogeneity*) of Level 1 diagnostic studies; CDR”  with 1b studies from different clinical centres

SR (with homogeneity*) of prospective cohort studies

SR (with homogeneity*) of Level 1 economic studies

1b Individual RCT (with narrow Confidence Interval”¡)

Individual inception cohort study with > 80% follow-up; CDR”  validated in a single population

Validating** cohort study with good” ” ”  reference standards; or CDR”  tested within one clinical centre

Prospective cohort study with good follow-up****

Analysis based on clinically sensible costs or alternatives; systematic review(s) of the evidence; and including multi-way sensitivity analyses

1c All or none§ All or none case-series Absolute SpPins and SnNouts” “

All or none case-series Absolute better-value or worse-value analyses ” ” ” “

2a SR (with homogeneity*) of cohort studies

SR (with homogeneity*) of either retrospective cohort studies or untreated control groups in RCTs

SR (with homogeneity*) of Level >2 diagnostic studies

SR (with homogeneity*) of 2b and better studies

SR (with homogeneity*) of Level >2 economic studies

2b Individual cohort study (including low quality RCT; e.g., <80% follow-up)

Retrospective cohort study or follow-up of untreated control patients in an RCT; Derivation of CDR”  or validated on split-sample§§§ only

Exploratory** cohort study with good” ” ”  reference standards; CDR”  after derivation, or validated only on split-sample§§§ or databases

Retrospective cohort study, or poor follow-up

Analysis based on clinically sensible costs or alternatives; limited review(s) of the evidence, or single studies; and including multi-way sensitivity analyses

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Level

Therapy / Prevention, Aetiology / Harm

Prognosis Diagnosis Differential diagnosis / symptom prevalence study

Economic and decision analyses

2c “Outcomes” Research; Ecological studies

“Outcomes” Research

Ecological studies Audit or outcomes research

3a SR (with homogeneity*) of case-control studies

SR (with homogeneity*) of 3b and better studies

SR (with homogeneity*) of 3b and better studies

SR (with homogeneity*) of 3b and better studies

3b Individual Case-Control Study

Non-consecutive study; or without consistently applied reference standards

Non-consecutive cohort study, or very limited population

Analysis based on limited alternatives or costs, poor quality estimates of data, but including sensitivity analyses incorporating clinically sensible variations.

4 Case-series (and poor quality cohort and case-control studies§§)

Case-series (and poor quality prognostic cohort studies***)

Case-control study, poor or non-independent reference standard

Case-series or superseded reference standards

Analysis with no sensitivity analysis

5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”

Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”

Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”

Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”

Expert opinion without explicit critical appraisal, or based on economic theory or “first principles”

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Step 3: Appraise the evidence

Good Bad

Critical appraisal

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Step 4: Apply the evidence

Will it change the way I manage this patient?

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Journal SearchingSkenario

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PICO

Dog bitten patient

Antibiotic prophylaxis

No Antibiotic

Rabies

Clinicalevidence.bmj.com

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