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Prof.Dr.H.Rusdi Lamsudin, SpS
(K), M.Med.SC
Medical Doctor, UGM, 1971
Neurologist, UGM, Unair, 1978
Master of Medical Sciences, University of New Castle, Australia, 1986
PhD, UGM, 1996 Neuro-Intensive and Stroke Unit Course, Innsbruck University, Austria,
July-Oct 1997
Prof, UGM, 2000
Chairman, Indonesian Neurological Association, Yogyakarta, Chapter,
2003-2007 Chairman, Indonesian Geriatric Neurology Study Group, Indonesian
Neurological Association, 2003-2007
Dean, Faculty of Medicine Indonesian Islamic University, 2006up to
now
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Introduction
Evidence Based MedicineProf Dr dr Rusdi Lamsudin
SpS(K), M.Med.Sc
Faculty of MedicineIndonesian Islamic University
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INTRODUCTION
The role of science in medicine hasincreased dramatically in recent decades
The increase prominence of science hasimproved health care by showing thatmany widely accepted medical practicesare not only effective but, in some cases,injurious
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INTRODUCTION
Yet today, much of modern medicineremains unsupported by scientificevidence.
EBM arose from realization that healthcare interventions, no matter how
commonsense or physiologically sound,often lack benefit and sometimes evencause harm.
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INTRODUCTION
In the absence of evidence of the efficacyof many treatment, physicians traditionallyfollow the pattern of physician A, relying
on anecdotal experience and knowledgeacquired from mentors or peers to guidetheir practice
EBM encourages physicians to follow thepardigm of physician B.
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INTRODUCTION
Indicators suggest that the EBMmovement has altered medicine, ex;
One study suggest that the number ofphysicians practicing EBM has increases
One scholar underscores the importance ofthe EBM movement by declaring it a
paradigm shift in medical practice
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What is EBM
The conscientious, explicit, and judicioususe of current best evidence in makingdecisions about the care of individual
patients and populations
The integration of best research evidencewith clinical expertise and patient values
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A Definition of EBM
The conscientious, explicit,judicious use of the current best
evidence in making decisionsabout the care of individual
patients.
(Ref: Sackett et al, 1996)
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Definition of EBM (cont.)
EBM practice requires integratingpractitioner clinical expertise with best
evidence from systematic research.
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Evidence-Based Medicine
Pengambilan Keputusan Klinis
Cost-Utility
Kuali tas Pelayanan
Sehat Sakit Outcome
Sembuh
Cacat
Mati
FR
Patofisiologi
D/
R/
P/
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Intuisi
Pengalaman kl inistidak sistematis
Patofisiologis
Pencar ian bukti -bukti
dan informasi yangberasal dar i peneli-
tian yg sistematis
Pengambilan keputusan kl inis
Paradigma lama Paradigma baru
2 dekade terakhir
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Penggunaan yang tel i ti , jelas dan
bijaksana dari bukti yang terbaik
Kemapuan klinis
individual
Bukti kl inis eksternal
yang terbaik dan tersedia yang
yang berasal dari r iset
yang sistematis
I ntegrasi
EBM
A
K
U
R
Akurasi & presisi tes diagnosis
efikasi dan safety terapi, re-
habil itasi & tdnk prevensikekuatan tanda prognosis
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Definition of Level of Evidence Level I: Highest
Sources: Primary endpoint of RCT-adequate Sample Size
Meta-analysis of RCTs
Level II: IntermediateSources:
Small RCT Predefines sec.endpoint of large RCT
Level III: LowerSources:
Prospective case series
Post hoc analysis of large RCTs
Level IV: UndeterminedSources:
Small uncontrolled case series
General agreement despite lack of evidence
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Levels of Evidence
Level 1: Randomized Clinical Trials
Level 2: Head to Head Trial or
Systematic Review of Cohort Studies
Level 3: Case-Control Studies
Level 4: Case-series
Level 5: Expert Opinion
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Steps to EBM
Step 1: Define a clinical question Formulate a clinical question in PICO format from
a patient scenario
Recognize type of clinical questions
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Steps to EBM
Step 5: Communication Communicate the information to patients and to
integrate patients values and preferences in
decision-making
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Answerable Clinical Question(ACQ)
First step in applying results of clinicalresearch to patient care
Well- formulated ACQ will save time: Search for evidence will be efficient
Sensibly-honed process rather than chaotic
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4 Parts of ACQ (PICO)
P Patient and problem
I Intervention (treatment, test,
prognostic factor, etiology, etc.)
C Comparison (if necessary)
O - Outcome
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4 Domains of EBM
Treatment
Diagnosis
Prognosis
Causation/Etiology
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Diagnosis
PIn an otherwise healthy 7-year-old boywith sore throat,
I - how does the clinical exam
C compare to throat culture
Oin diagnosing GAS infection?
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Prognosis
P - In children with Down syndrome,
I - is IQ an important prognostic factor
C
O in predicting Alzheimers later in life?
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Etiology/Harm
P controlling for confounding factors, dootherwise healthy children
I - exposed in utero to cocaine,
C compared to children not exposed
O have increased incidence of learningdisabilities at age six years?
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Principles of EBM
So what is best evidence?
Highest quality
Lowest quality
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Level BLimited (2-3)
population riskstrata evaluated
Class I
Recommen-dationthat procedure or
treatment isuseful/ effective
Limited evidencefrom single
randomized trialor non-
randomizedstudies
Class IIa
Recommen-dationin favor of
treatment orprocedure being
useful/ effective
Some conflictingevidence from
single randomizedtrial or non-randomized
studies
Class IIb
Recommen-dationsusefulness/
efficacy less wellestablished
Greater conflictingevidence from
single randomizedtrial or non-randomized
studies
Class III
Recommen-dationthat procedure or
treatment notuseful/effective
and may beharmful
Limited evidencefrom single
randomized trialor non-
randomizedstudies
Applying Classification of
Recommendations and Level of
Evidence
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Applying Classification of
Recommendations and Level of
Evidence
Level C
Very limited (1-2)population riskstrata evaluated
Class I
Recommen-dationthat procedureor treatment is
useful/ effective
Only expertopinion, casestudies, or
standard-of-care
Class IIa
Recommendation infavor of treatment
or procedure
beinguseful/effective
Only divergingexpert opinion,case studies, orstandard-of-care
Class IIb
Recommen-dationsusefulness/
efficacy less well
established
Only divergingexpert opinion,case studies, orstandard-of-care
Class III
Recommendationthat procedure or
treatment not
useful/effectiveand may be
harmful
Only expert opinion,case studies, orstandard-of-care
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EBM in Basic Medical Education
Semester I Programme ( 20 weeks) General education
Contents
Module 1: Critical thinking and skill learning: includingEBM
Module 2: effective skill communication and empathy
Module 3: Awareness of community and environment
Module 4:Human being as a bio-psycho-socio-cultural
entity
Module 5: the Indonesian health priority
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EBM in Basic Medical Education
Semester II - VII Integrated
Block (ex. UII: 20 block)
EBMon block Ex: EBMin Cardiovascular (lecture dan tutorial)
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EBM in Basic Medical Education
Semester VIIIXII Clerkship
EBM in clerkship
Journal reading Clinical decision making
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Guidelines
National Guideline Clearinghouse
Primary Care Clinical Practice Guidelines
Agency/Association sitesAAFP
APA
AAP
http://www.guideline.gov/http://hhttp//medicine.ucsf.edu/resources/guidelines/http://www.aafp.org/x19449.xmlhttp://www.psych.org/psych_pract/treatg/pg/prac_guide.cfmhttp://www.aap.org/policy/paramtoc.htmlhttp://www.aap.org/policy/paramtoc.htmlhttp://www.psych.org/psych_pract/treatg/pg/prac_guide.cfmhttp://www.aafp.org/x19449.xmlhttp://hhttp//medicine.ucsf.edu/resources/guidelines/http://www.guideline.gov/8/13/2019 Introduksi EBM
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Clinical Practice Guidelines
CPGs and EBM are closely related. ManyCPGs. are evidence-based and facilitatethe practice of EBM by serving as
codification of best evidence whenwritten
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Purpose-specific resources
CDC Travel
Drug information resources
Patient Education handouts
Diagnostic TestingARUP
Medical Search engines
Textbooks
Journals
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EBM Databases
Systematic Literature Searches Cochrane Library (OVID)
Clinical Evidence
Systematic Literature Surveillance ACP Journal Club (OVID) DARE
DynaMed
Medical InfoRetriever
EMB Search Engine TRIP Database
http://www.clinicalevidence.com/ceweb/conditions/index.jsphttp://nhscrd.york.ac.uk/darehp.htmhttp://www.ceres.uwcm.ac.uk/section.cfm?section=triphttp://www.ceres.uwcm.ac.uk/section.cfm?section=triphttp://nhscrd.york.ac.uk/darehp.htmhttp://www.clinicalevidence.com/ceweb/conditions/index.jsp8/13/2019 Introduksi EBM
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Today
National Guidelines Clearinghouse (AHRQ)
Cochrane
ACP Journal Club Dynamed
First Consult
InfoRetriever
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Cochrane Library
The current resource with the highestmethodological rigor
For each clinical question, all of the English
literature meticulously searched forrandomized trials
Large systematic reviews with valid methods+ collaborative effort
Conclusions are based on all the evidencefrom valid randomized trials
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Cochrane Library
Included in OVID subscription
Limitations
limited to English
only addresses questions amenable to randomizedtrials
most of medicine has not been studied enoughtoallow for conclusions
$235/year or abstracts only
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ACP Journal Club
About 100 journals systematically surveyed
Highest-validity articles abstracted
Structured abstracts to guide critical appraisal
Clinical commentary
Included in our OVID subscription
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ACP Journal Club
Limitations individual article summaries may not account for thebig picture
may have to read multiple items
No control over what is covered $78/year ?
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DynaMed
Designed as entry point to information
Textbooks and Medline not efficient
Intuitive clinical organization
Brief summarized information presented
Links and references if more detailsneeded
ICD-9 codes and links to patientinformation handouts
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DynaMed format
Description
Etiology
Increased Risks
Associated Conditions Complications
History (cc, HPI, etc.)
Physical
Diagnostic (including Ruleout, Tests to order)
Prognosis
Treatment
Prevention
Screening References
Patient Information
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DynaMed Sources
18 primary journalse.g. BMJ, JAMA,Lancet, NEJM, Pediatrics
12 secondary literature sourcese.g.
Alternative Therapies, ACP Journal Club,Cochrane Library, InfoPOEMs
4 drug info sourcese.g. The Medical
Letter, FDA MedWatch
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DynaMed
Limitations
variable quality
areas with a lot of research can get hard to
navigate
$200/year or effort
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First Consult/PDxMD
By MDConsult
Differential Diagnosis
Disease Information
Patient Education Handouts
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PDxMD
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Medical InfoRetriever
104 journals surveyed for Evidence-BasedPractice Newsletter
Over 1300 article synopses/ POEMS
Cochrane abstracts
Selected evidence-based guidelines
Basic drug info Clinical calculators/prediction rules
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InfoRetriever
Comes in web, desktop and PDA versions
Limitations
individual article summaries may not account for the
big picture may have to read multiple items
$249/year
Optimized for use with Internet Explorer 5.x or
Netscape 6.x
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Conclusion
If and when EBM effectuates as paradigmshift in medicine, that is, as more andmore physicians move toward making
decisions based on high-grade scientificevidence rather than custom.
Be A lifelong Learner with Evidence BasedMedicine