EVIDENCE BASED MEDICINEapt. Chilmia Nurul Fatiha, M.Sc.

OUTLINE

✘ Cara Mencari Evidence Based Medicine (buktiberbasis klinik)✘ Penggunaan PICO dalam pencarian jurnal klinisdengan contoh kasus penyakit

“EBM is integration of best research evidence with clinical expertise and

patient values.”~ David Sackett

Components of EBM

Patient Values

Best Research Evidence Clinical Expertise

BackgroundWhy we do EBM?

Sumber Informasi

• Tersier

• Sekunder

• Primer

• Search engine

Critical appraisal

• Valid

• Reliabel

• Relevan

• Penting/signifikan secaraklinik

Tujuan /maksud

Evidence based medicine

SUMBER INFORMASI

Pustaka PRIMER

• Penyajian data interpretasilangsung olehpeneliti/penulis

• Informasi paling mutakhir & orisinil

• Scientific journal. Thesis, proceeding

• Contoh: The Lancet, NEJM, Nature, BMC Journal

Pustaka SEKUNDER

• Pihak keduamengumpulkan/evaluasiberbagai sumber primer, dikategori sesuai kebutuhan database

• Contoh:

• International pharmaceutical abstract

• Chemical abstract

• Clinical expertise abstract

Pustaka TERSIER

• Dari sumber 1 dan 2 ditrangkum

analisis/interpretasiinformasi ilmiah

• Contoh:

• Goodman & Gilman

• AHFS

• BNF

• USP

Bagaimana cara mencari evidence based medicine

1. Identifikasi secara jelas kebutuhan informasilalu klasifikasi jenis pertanyaan: Dosis? Interaksi? Pilihan obat?

2. Identifikasi sumber daya yang dimiliki Kolega/ahli: konsultasi/diskusi Textbook, journal Electronic database (Medscape, PubMed)

3. Pencarian

Searching

Strategi Pencarian

Pustaka tersier

(textbook, review artikel, compendia, e-book)

Pustaka sekunder

Pustaka primer Scientific journal

Abstract, database (Pubmed)

Proceeding, Thesis, Disertation

Pustaka tersier

Klasifikasi Pertanyaan Pustaka yang direkomendasikan

Obat pilihan/indikasi Pharmacotherapy: A Pathophysiologic ApproachAMA Drug InformationAHFS DI/USPDIApplied Therapeutics: The Clinical Use of DrugsCurrent Diagnosis and TreatmentHarrison’s: Principles of Internal MedicineDrug Fact and ComparisonPhysician Desk ReferenceGoodman – Gilman’s: The Pharmacologic Basis Therapeutic

Pustaka tersier

Klasifikasi Pertanyaan Pustaka yang direkomendasikan

Dosis/ FrekuensiPenggunaan

Drug Fact and ComparisonAHFS DI/USP DIPhysician Desk ReferenceMartindale’s: The Extra PharmacopoeiaAMA Drug InformationCurrent Diagnosis and TreatmentApplied Therapeutics: the Clinical Use of DrugsDrug Information HandbookPharmacotherapy: A Pathophysiologic ApproachPoisindex

Pustaka tersier

Klasifikasi Pertanyaan Pustaka yang direkomendasikan

Interaksi obatObat-obatObat-makananObat-parameter lab

Drug Interaction FactAHFS DI/USP DIApplied Therapeutics: The Clinical Use of DrugsHansten’s Drug InteractionMeyler’s side Effect of Drugs: An Encyclopedia of Adverse Reactions and InteractionPhysicians Desk referenceDrug in Pregnancy and LactationBasic Skill in Interpreting Laboratory Data

Pustaka Primer

✘ Pastikan detail kebutuhan informasi hingga munculpertanyaan✘ Urutkan pertanyaan dalam elemen PICO✘ “To get the right answer, you must ask the right question”

P I C OPatient/ Participant/

ProblemIntervention Comparion Outcome

In patient with (problem)

does(intervention)

or(comparison)

affect (outcome)

Component PICO

P I C O

Population

Patient

Problem

Intervention or

Exposure

Comparison Outcome

Who are the

patients?

What do we do

to them?

What do we

compare the

intervention

with?

What happen?

What is the

problem?

What are they

exposed to?

What is the

outcome?

PICO: component of searchable question

Patient population/disease The patient population or disease of interest- Age- Gender- Ethnicity- With certain disorder (eg. Hepatitis)

Intervention The intervention or range of intervention of interest- Exposure of disease- Risk behavior (eg. Smoking)- Prognostic factor A

Comparison The intervention or range of intervention of interest- No disease- Absense of risk behavior (eg. Non-Smoking)- Prognostic factor B

Outcome Outcome of interest- Risk of disease- Accuracy of diagnosis

The Best Evidence to Answer Clinical Question

Tipe Pertanyaan Suggested best type of study

Therapy RCT>Cohort>Case control>Case series

Etiology RCT>Cohort>Case control>Case series

Prevention RCT>Cohort>Case control>Case series

Diagnosis Prospective, blind comparison to gold standard

Prognosis RCT>Cohort>Case control>Case series

Cost Economic analysis

Hierarchy of Evidence

Hierarchy of EvidenceMA

SR of RCT (1a)

RCT (1b)

Systematic review of cohort studies (2a)

Cohort study (2b)

Case control study (3)

Case series (4)

Case Report, Expert opinion (5)

"Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009)". Centre for Evidence-

Based Medicine. 2009-06-11.

Meta analysis

✘ A statistical technique in which the results of numerous studies are mathematically combined in order to improve the reliability of the results

✘Meta analyses and systematic reviews are different

Meta-analyses

Combination of results of several RCTs or other types of evidence

Meta analyses includes a statistical combination of the results

Considered to be highest-level evidence if conducted properly

Relies on enough RCTs being available

Example meta analysis

Systematic Review

A summary of medical literature that use well defined methods to systematically search, critically appraise, and synthesize on specific issue or question

Example systematic review

Randomized Control Trial (RCT)

✘ Uji klinik dengan subyek uji manusia✘ Randomized …? Control …?✘Partisipan (subyek uji), pemberi

perlakuan, pengukur (pengamat)

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Randomized Control trials

Treatment group and control group

Random assignment to group

May involve “blinding” of participants and researcher

Used for therapeutic or diagnostic interventions

Some interventions unsuitable for RCTs

Expensive

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Example of RCT29

Cohort studies

Two groups of people followed over time

One group has received an intervention or exposure (eg. smoking)

Groups otherwise closely matched

Groups followed over time

Can be used for causation, diagnostic, harms, and therapeutic studies

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Cohort study

✘ Hubungan antara penyebab (paparan) dengan penyakit✘Membandingkan kelompok terpapardengan yang tidak terpapar berdasarkanstatus penyakit

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Example of cohort study33

Example of cohort study34

Case-control studies

Used mainly for causation studies

Patient with outcome matched to control

Investigations made into possible causes in both patients

Maybe only option in rare conditions

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Case control study

✘Hubungan paparan (penyebab) dengan penyakit✘Membandingkan kelompok kasus dan control status paparan

37

Example case control study

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Case series

✘Serangkaian kasus✘Tidak ada perbandingan kasus dengan non kasus -tidak bias memberi bukti kausal

39

Example case series

40

Example of case series

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Case Report

✘Laporan dari 1 kasus yang menimpa pasien✘Tanpa membandingkan dengan kontrol

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Example case report

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Example of case report

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What type of clinical research is this?

✘Two groups of doctors, one group smokers, the other non-smokers are followed over the study of 20 years to see which group are more likely to develop lung cancer

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What type of clinical research is this?

✘Two groups of patients are studied, one group given physiotherapy for low back pain, the other given advice only. Patients are randomly assigned to either group and followed up after six months.

What type of clinical research is this?

✘One hundred sets of twins, where on had developed melanoma and the other had not, were studied for possible causation factors

Critical Aprraisal

4. Appraise the evidence

✘ Are the result valid?

✘What are the result? Is it important?

✘Can we apply the results to patients?

4. Appraise the evidence

✘V: validity; method of the study✘I: important: result of the study✘A: applicable, result of the study is applicable to our daily patients

THANKS!Any questions?You can find me at✘ IG @chilmia✘ cnfatiha@gmail.com