EVIDENCE-BASED MEDICINE(EBM)

Oleh: dr. Darwin Amir, Sp.S

Bgn Ilmu Penyakit SyarafFakultas Kedokteran Universitas Andalas

Pendahuluan

• Dokter dalam pekerjaannya se-hari2 dihadapkan pd perubahan yg cepat dalam perkembangan informasi terutama yg relevan dgn masaalah medis (evidence based) dan informasi tersebut sangat bermanfaat untuk meningkatkan kualitas perawatan pasien.

• Dokter memerlukan informasi yg terbaru dan juga memerlukan keterampilan baru (learn new skills) • Undergraduate medical education, have to master:

* current information* techniques* prepare for life long learning

Apa itu EBM:EBM adalah integrasi dari bukti penelitian terbaru (best research evidence), keterampilan klinik dan masaalah yg ada pada pasien.* Research evidence ------- > clinically relevant research * Clinical expertise ------- > ability to use our clinical skills and past experience to rapidly identify* Patients values ------- > preference, concerns and expectations each patients bring to serve the patients

Research evidence

Research evidence

Patients values

Patients values

Clinical Expertise

Clinical Expertise

Evidenced Based

Medicine

Three elements of the tutorial process in PBL

Definisi:

Proses penelitian dan penggunaan informasi yg disajikan dalam literatur untuk memperbaiki perawatan pasien.

Prosesnya melibatkan:

* Dokter terlatih (mengubah “kekurangan pengetahuan” (knowledge deficit) ---- > menjadi pertanyaan klinik yg spesifik.

* Meneliti (meng-evaluasi) bahan kepustaka an yg berhubungan dengan pertanyaan

klinis,

* Berbagi informasi dengan koleganya.

EBM adalah pendekatan terhadap keputusan klinik atau “problem solving” <------- dengan menggunakan sumber informasi

Future of medicine ---- > patient care should be Evidenced Based.

Practising EBM require skills (efficient and effective literature searching), critical appraisal and the application of this finding to the clinical problem.

Basic skills of EBM

Five basic skills of EBM.

• Generating clinical questions (define the problem).

• Finding of evidence to answer the questions

• Critically appraisal the evidence.

• Applying the evidence to specific patients.

• Evaluating one’s own performance.

Generating clinical questions

• To formulate questions that are both patient-based and learner-centered (difficult).

• Well constructed clinical questions helps to direct the search for evidence and for precise answers.

Generating clinical questions

• Good clinical questions as having four elements.

1. the patient or problem.

2. the intervention (cause, prognostic

factors,treatment).

3. comparison intervention (if necessary)

4. outcomes

EBM

• Telah memperlihatkan pergeseran dalam pengambilan keputusan medis

• Secara dramatis telah memperbaiki kualitas dan mampu meningkatkan perawatan pasien.

• Tantangan bagi generasi dokter sekarang untuk belajar lebih giat.

• Manfaatkan EBM dlm pendidikan dan upayakan bagaimana mempelajarinya dan menggunakan proses untuk kepentingan profesi.

For example;Patients with acute otitis media does antibiotica therapy lead to faster resolution of symptoms compared with no intervention ?.

Mr X, aged 31 years, with chronic low back pain, ask to be referred to a chiropractor

Finding the evidence to answer the questions

Students must be aware of the hierarchy of evidence that forms an important principle in EBM.

Finding the evidence to answer the questions

Gold standard source;* carefully designed, randomised,

control trials.* systematic reviews of studies.* expert opinion.* personal experience.

Finding the evidence to answer the questions

Advances technology:* database (Medline and Cochrane

library)* acces to database and how they are

organised* mastery medical informatic system.

Critically appraising the evidence.

Once the best evidence has been found, next step is to appraise it critically for its validity and usefulness.

Mastery a fundamental knowledge of research methodology (basis for critical appraisal of the literature)

Software to help construct critical apprasial is available at the website (CAT maker at the Center of EBM).

Critically appraising the evidence.

Mastery a fundamental knowledge of research methodology (basis for critical appraisal of the literature)

Critically appraising the evidence.

Software to help construct critical

apprasial is available at the website

(CAT maker at the Center of EBM).

Applying the evidence to specific patients

Apply the answer that have been found from the literature to the patients problem.

Reminded that EBM also involves applying the traditional skills of medical training

A good understanding of pathophisiology is essential in interpreting and applying the results of clinical research to the patients

Applying the evidence to specific patients

• Reminded that EBM also involves

applying the traditional skills of medical

training

• A good understanding of pathophisiology

is essential in interpreting and applying

the results of clinical research to the patients

Pertanyaan klinik yg relevan dan spesifik mengandung 4 unsur:1). Problem / pasien yg dituju.

2). Intervensi, apakah dg alami atau disain klinik spt penyebab, faktor prognostik, pengobatan dll.

3). Perbandingan intervensi bila diperlukan.

4). Luaran (outcome) klinis atau outcome of interest.

4 elemen ini membentuk suatu singkatan yaitu PICO P= Patient,

I = Intervention, C= Comparison, O= Outcome.

Contoh: Seorang pasien wanita 46 thn dgn kolitis ulseratif selama 17 thn, mengenai kolon secara ekstensive dgn gejala yg cukup hebat. Saat ini kolitisnya kambuh, ia tdk mau di-operasi tetapi sadar akan resiko kanker yg ia dengar dan baca dari newsletter. Suaminya tlh meyakinkannya akan resiko yg akan terjadi.

P = 46 yr old women

I = Long standing ulcerative

colitis, now in remision

C = Patients without

ulcerative colitis

O = Prevention / control of

colon cancer

P = 46 ys old women with

long standing ulcerative

colitis, now in remision.

I = Mesalamine

C = Standard therapy.

O = Prevention of relaps