PENGANTAR EVIDENCE-

PENGANTAR EVIDENCE-
BASED MEDICINE (EBM)
BASED MEDICINE (EBM)
Indah S. Widyahening
Indah S. Widyahening
Modified from Glasziou P. Evidence-based practice Modified from Glasziou P. Evidence-based practice
(ppt). Downloaded from www.cebm.net (ppt). Downloaded from www.cebm.net
UNIVERSITAS INDONESIA
UNIVERSITAS INDONESIA
Pengertian EBM:
Pengertian EBM:

Evidence-based medicine is the

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


-
-
Sackett, et al 2001
Sackett, et al 2001
Decision making in medicine
Decision making in medicine

Diagnosis
Diagnosis

Treatment
Treatment

Prevention
Prevention

Prognosis
Prognosis

Etiology
Etiology
Keterampilan Klinik
Keterampilan Klinik

Keterampilan dan kemampuan menilai oleh

Keterampilan dan kemampuan menilai oleh
dokter yang didapat dari pengalaman dan
dokter yang didapat dari pengalaman dan
praktik klinik
praktik klinik

Peningkatan keterampilan terlihat melalui

Peningkatan keterampilan terlihat melalui
berbagai aspek, namun yang terutama adalah
berbagai aspek, namun yang terutama adalah
semakin efektif dan efisien-nya kemampuan
semakin efektif dan efisien-nya kemampuan
menegakkan diagnosis, dan kemampuan dalam
menegakkan diagnosis, dan kemampuan dalam
mengidentifikasi dan mempertimbangkan nilai-
mengidentifikasi dan mempertimbangkan nilai-
nilai, hak dan pendapat pasien dalam
nilai, hak dan pendapat pasien dalam
pengambilan keputusan medis
pengambilan keputusan medis
Bukti Klinis
Bukti Klinis

Penelitian yang relevan secara klinis, dapat berupa

Penelitian yang relevan secara klinis, dapat berupa
penelitian ilmu-ilmu kedokteran dasar, tetapi terutama
penelitian ilmu-ilmu kedokteran dasar, tetapi terutama
dari riset-riset klinis yang berorientasi pasien
dari riset-riset klinis yang berorientasi pasien

Berupa uji ketelitian (accuracy) dan ketepatan (precision)

Berupa uji ketelitian (accuracy) dan ketepatan (precision)
sebuah metoda diagnosis (termasuk pemeriksaan fisik),
sebuah metoda diagnosis (termasuk pemeriksaan fisik),
uji kekuatan suatu penanda prognosis, uji efektivitas dan
uji kekuatan suatu penanda prognosis, uji efektivitas dan
keamanan suatu terapi, tindakan rehabilitasi maupun
keamanan suatu terapi, tindakan rehabilitasi maupun
metoda pencegahan
metoda pencegahan

Sebuah penemuan klinis dapat mengganti sebuah uji

Sebuah penemuan klinis dapat mengganti sebuah uji
metoda diagnosis maupun terapi yang telah diterima ke
metoda diagnosis maupun terapi yang telah diterima ke
metoda baru yang lebih kuat, tepat, efektif dan aman.
metoda baru yang lebih kuat, tepat, efektif dan aman.
Mengapa perlu belajar &
Mengapa perlu belajar &
memprak!kkan EBM"
memprak!kkan EBM"

Penel!!an menemukan ba#$a pa%!en

Penel!!an menemukan ba#$a pa%!en
&ang men'apakan erap! &ang berba%!%
&ang men'apakan erap! &ang berba%!%
buk! memper(le# #a%!l &ang leb!# ba!k
buk! memper(le# #a%!l &ang leb!# ba!k
'ar! &ang !'ak men'apa)
'ar! &ang !'ak men'apa)

Merupakan *ara up-'ae &ang leb!#

Merupakan *ara up-'ae &ang leb!#
e+!%!en '!ban'!ng me('a ra'!%!(nal
e+!%!en '!ban'!ng me('a ra'!%!(nal
(m!%al, berlangganan jurnal, !ku
(m!%al, berlangganan jurnal, !ku
%em!nar))
%em!nar))

Perkembangan erak#!r membua EBM

Perkembangan erak#!r membua EBM
leb!# mungk!n '!prak!kkan)
leb!# mungk!n '!prak!kkan)
Perkembangan
Perkembangan

Sraeg! men*ar! 'an men!la! buk! &ang

Sraeg! men*ar! 'an men!la! buk! &ang
leb!# e+!%!en)
leb!# e+!%!en)

-eer%e'!aan jurnal-jurnal &ang

-eer%e'!aan jurnal-jurnal &ang
e.!'en*e-ba%e'
e.!'en*e-ba%e'
)
)

D!#a%!lkann&a
D!#a%!lkann&a
%&%ema!* re.!e$
%&%ema!* re.!e$
'an
'an
r!ngka%an (
r!ngka%an (
%ummar!e%
%ummar!e%
))
))

S!%em !n+(rma%! &ang memungk!nkan

S!%em !n+(rma%! &ang memungk!nkan
ak%e% ke l!eraur 'alam #!ungan 'e!k)
ak%e% ke l!eraur 'alam #!ungan 'e!k)
Informasi di bidang kedokteran
Informasi di bidang kedokteran
0
500000
1000000
1500000
2000000
2500000
Trials MEDLINE BioMedical
M
e
d
i
c
a
l

A
r
t
i
c
l
e
s

p
e
r

t
a
h
u
n
5,000?
per hari
1,400
per hari
55 per
hari

Seorang ibu datang membawa anaknya

Seorang ibu datang membawa anaknya
yang berumur 1,5 tahun dengan keluhan
yang berumur 1,5 tahun dengan keluhan
pilek dan batuk sejak dua hari yang lalu.
pilek dan batuk sejak dua hari yang lalu.
Dahak keluar saat muntah, bening.
Dahak keluar saat muntah, bening.

Pada pemeriksaan didapatkan suhu

Pada pemeriksaan didapatkan suhu
37,9
37,9
o o
C, FP 24x/menit, rongga hidung
C, FP 24x/menit, rongga hidung
hiperemis dan terdapat sekret encer dan
hiperemis dan terdapat sekret encer dan
bening. Tenggorokan tidak hiperemis,
bening. Tenggorokan tidak hiperemis,
paru tidak ada kelainan.
paru tidak ada kelainan.
Terapi?
Terapi?

Decongestan?
Decongestan?

Antihistamin?
Antihistamin?

Antipiretik?
Antipiretik?

Edukasi?
Edukasi?
The Antihistamine-decongestant combination
(ADC) was equivalent to placebo in providing
temporary relief of Upper Respiratory Infection
symptoms in preschool children. However, the
ADC did have significantly greater sedative
effects than did placebo.

Clemens CJ, Taylor JA, Almquist JR, Quinn HC, Mehta A,
Naylor GS.Is an antihistamine-decongestant combination
effective in temporarily relieving symptoms of the common
cold in preschool children? J Pediatr. 1997 Mar;130(3):463-6
FDA Experts Urge Ban on Cold
FDA Experts Urge Ban on Cold
Medicines for Young Children
Medicines for Young Children
September 29, 2007 08:40:15 PM PST September 29, 2007 08:40:15 PM PST
By Steven Reinberg By Steven Reinberg
HealthDay Reporter HealthDay Reporter

An FDA review of records filed with the agency

An FDA review of records filed with the agency
between 1969 and September 2006 found 54
between 1969 and September 2006 found 54
reports of deaths in children associated with
reports of deaths in children associated with
decongestant medicines made with
decongestant medicines made with
pseudoephedrine, phenylephrine or ephedrine. It
pseudoephedrine, phenylephrine or ephedrine. It
also found 69 reports of deaths associated with
also found 69 reports of deaths associated with
antihistamine medicines containing
antihistamine medicines containing
diphenhydramine, brompheniramine or
diphenhydramine, brompheniramine or
chlorpheniramine, the AP said.
chlorpheniramine, the AP said.
Pengelolaan informasi
Pengelolaan informasi
Push and Pull
Push and Pull
methods
methods

Push mengingatkan informasi baru

Push mengingatkan informasi baru

Just in Case learning

Just in Case learning

HANYA untuk informasi yang penting, terbaru

HANYA untuk informasi yang penting, terbaru
dan benar (valid)
dan benar (valid)

Pull mengakses informasi saat

Pull mengakses informasi saat
dibutuhkan
dibutuhkan

Just in Time learning

Just in Time learning

Diterapkan setiap saat ada pertanyaan

Diterapkan setiap saat ada pertanyaan

EBM Steps: Question; search; appraise; apply

EBM Steps: Question; search; appraise; apply

Just-in-case learning
Just-in-case learning
Berlangganan jurnal-jurnal tertentu yang
Berlangganan jurnal-jurnal tertentu yang
berisikan informasi yang paling penting &
berisikan informasi yang paling penting &
sangat relevan dengan praktik sehari-hari
sangat relevan dengan praktik sehari-hari

Evidence-based Medicine
Evidence-based Medicine
http://
http://
www.evidence-basedmedicine.com
www.evidence-basedmedicine.com

Clinical Evidence
Clinical Evidence
http://www.clinicalevidence.com
http://www.clinicalevidence.com

Just in time learning

Just in time learning
Kebutuhan akan informasi
Kebutuhan akan informasi
Sebagai dokter kita selalu perlu informasi,
Sebagai dokter kita selalu perlu informasi,

Sebagian besar pertanyaan kita TIDAK

Sebagian besar pertanyaan kita TIDAK
terjawab
terjawab

Terjawab namun bukan informasi terbaik

Terjawab namun bukan informasi terbaik
atau terbaru
atau terbaru

Textbooks sudah ketinggalan

Textbooks sudah ketinggalan

Journals tidak tertata baik dan

Journals tidak tertata baik dan
kualitas bervariasi
kualitas bervariasi

Para ahli sulit sepakat

Para ahli sulit sepakat

CME/CPD tidak efektif

CME/CPD tidak efektif
Hambatan memperoleh informasi
Hambatan memperoleh informasi
Pertanyaan anda?
Pertanyaan anda?

Tulis satu masalah kesehatan/kedokteran

Tulis satu masalah kesehatan/kedokteran
yang anda ingin jawab
yang anda ingin jawab

Critical question?
Critical question?

Apakah anda menjawabnya? Bagaimana?

Apakah anda menjawabnya? Bagaimana?
Information pull
Information pull
Steps in EBM process
Steps in EBM process

Menyusun pertanyaan yang dapat dijawab

Menyusun pertanyaan yang dapat dijawab

Mencari bukti terbaik

Mencari bukti terbaik

Telaah kritis (critical appraisal) bukti yang

Telaah kritis (critical appraisal) bukti yang
didapat
didapat

Integrasi dengan keterampilan klinis dan

Integrasi dengan keterampilan klinis dan
nilai-nilai pasien
nilai-nilai pasien
Peran&aan &ang ba!k
Peran&aan &ang ba!k
merupakan ulang punggung
merupakan ulang punggung
'alam penerapan EBM) Perlu
'alam penerapan EBM) Perlu
la!#an unuk 'apa
la!#an unuk 'apa
men&u%un peran&aan &ang
men&u%un peran&aan &ang
er+(rmula%! 'engan ba!k)
er+(rmula%! 'engan ba!k)
Benuk peran&aan %anga
Benuk peran&aan %anga
erganung pa'a
erganung pa'a
pengalaman)
pengalaman)
GENERAL KNOWLEDGE
SPECIFIC KNOWLEDGE
TIPE
PERTANY
AAN
PENGALAMAN KLINIS
Using the question to guide
Using the question to guide
searching
searching

Scenario -
Scenario - A 64 year old obese male who has tried many A 64 year old obese male who has tried many
ways to lose weight presents with a newspaper article about ways to lose weight presents with a newspaper article about
fat-blazer Chitosan. He asks for your advice. fat-blazer Chitosan. He asks for your advice.

Question
Question

P
P
opulation
opulation

I
I
ndicator (intervention, test, etc)
ndicator (intervention, test, etc)

C
C
omparator
omparator

O
O
utcome
utcome

Using the question to guide
Using the question to guide
searching
searching

Scenario -
Scenario - A 64 year old obese male who has tried many A 64 year old obese male who has tried many
ways to lose weight presents with a newspaper article about ways to lose weight presents with a newspaper article about
fat-blazer Chitosan. He asks for your advice. fat-blazer Chitosan. He asks for your advice.

Question
Question

P
P
opulation in obese patients
opulation in obese patients

I
I
ndicator (intervention, test, etc) does chitosan
ndicator (intervention, test, etc) does chitosan

C
C
omparator compared to placebo
omparator compared to placebo

O
O
utcome decrease weight
utcome decrease weight

Underline the key terms

Number the order of importance from 1-4

Think of alternate spellings, synonyms, & truncations

Using the question to guide
Using the question to guide
searching
searching

Scenario -
Scenario - A 64 year old obese male who has tried many A 64 year old obese male who has tried many
ways to lose weight presents with a newspaper article about ways to lose weight presents with a newspaper article about
fat-blazer Chitosan. He asks for your advice. fat-blazer Chitosan. He asks for your advice.

Question
Question

P
P
opulation
opulation
obes* OR overweight
obes* OR overweight

I
I
ndicator (intervention, test, etc) does
ndicator (intervention, test, etc) does
chitosan
chitosan

C
C
omparator compared to
omparator compared to
placebo
placebo

O
O
utcome decrease
utcome decrease
weight OR kilogram*
weight OR kilogram*

Underline the key terms

Number the order of importance from 1-4

Think of alternate spellings, synonyms, & truncations

1
2
3
4
T
T
he
he
best
best
evidence
evidence
depends on the
depends on the
type of question
type of question
1. 1.
What are the phenomena/problems?
What are the phenomena/problems?

Observation (e.g., qualitative research)

Observation (e.g., qualitative research)
G
What is frequency of the problem? (
What is frequency of the problem? (
FREQUENCY
FREQUENCY
)
)

Random (or consecutive) sample

Random (or consecutive) sample
G
Does this person have
Does this person have
the problem? (
the problem? (
DIAGNOSIS
DIAGNOSIS
)
)

Random (or consecutive) sample with Gold Standard

Random (or consecutive) sample with Gold Standard
G
Who will get the problem? (
Who will get the problem? (
PROGNOSIS
PROGNOSIS
)
)

Follow-up of inception cohort

Follow-up of inception cohort
G
How can we alleviate the problem?
How can we alleviate the problem?
(
(
INTERVENTION
INTERVENTION
/THERAPY
/THERAPY
)
)

Randomised controlled trial

Randomised controlled trial
The Evidence Pyramid
Systems
Summaries
Synopses
Syntheses
Studies - RCT, cohort, case-control
single original studies
Internet Findings
Clinical Decision-Making Tools
Connected to the Electronic Medical Record
Evidence-based textbooks
BMJ Clinical Evidence,
TRIP, InfoPOEMS, PIER
Evidence-based
journal abstracts
ACP Journal Club
Systematic reviews
Cochrane, DARE
PubMed Clinical Queries
Original journal
articles
MEDLINE (PubMed)
EMBASE
Google, Google Scholar
Dogpile, Ixquick
ACP Journal Club Nov- Dec 2006;145(3):A8-9
* Means any other
letters
AND means both
terms required
Check the question
type
Check the emphasis
Stepwise searching
Stepwise searching

Search with #1 PICO item

Search with #1 PICO item

Chitosan
Chitosan

Then go to Clinical Queries

Then go to Clinical Queries

Chitosan (again)
Chitosan (again)

Add #2 PICO item

Add #2 PICO item

Chitosan AND (obes* OR overweight)

Chitosan AND (obes* OR overweight)
Combining terms with
Combining terms with
Boolean operators AND
Boolean operators AND
chitosan
overweight
overweight AND chitosan - has both terms
IN CAPITALS
Combining terms with
Combining terms with
Boolean operators OR
Boolean operators OR
obese
overweight
overweight OR obese - has either term
Boo
Boo
-le-ans*
-le-ans*

AND = both terms

AND = both terms

OR = either term
OR = either term

NOT = not this term

NOT = not this term

(ADJacent, NEAR, = AND + close)

(ADJacent, NEAR, = AND + close)
* George Boole (a man) is claimed to have invented logic
Where to the brackets go?
Where to the brackets go?

If y
If y
ou want
ou want

cheese
cheese
AND fruit
AND fruit

Which do you
Which do you
ask for
ask for
?
?

(cheese
(cheese
AND apple
AND apple
)
)
OR pear
OR pear
OR melon
OR melon

cheese
cheese
AND
AND
(
(
apple OR pear
apple OR pear
OR melon)
OR melon)

What does PubMed do

What does PubMed do
if
if
both
both
AND and OR?
AND and OR?

Cheese
Cheese
AND apple OR pear
AND apple OR pear

(
(
Look at DETAILS tab
Look at DETAILS tab
)
)
General structure of search
General structure of search

(
(
P
P
opulation OR synonym 1 OR ) AND
opulation OR synonym 1 OR ) AND

(
(
I
I
ntervention OR synonym 1 OR ) AND
ntervention OR synonym 1 OR ) AND

(
(
C
C
omparator OR synonym 1 OR ) AND
omparator OR synonym 1 OR ) AND

(
(
O
O
utcome OR synonym 1 OR )
utcome OR synonym 1 OR )
AND
AND

FILTER (
FILTER (
for best study type
for best study type
)
)
(look at Haynes filters in this table)
(look at Haynes filters in this table)
Search Cascade
Shortcuts
Shortcuts

Meta-search engines
Meta-search engines

www.tripdatabase.com
www.tripdatabase.com

Sumsearch
Sumsearch

Start 2nd Explorer window, enter

Start 2nd Explorer window, enter

www.
www.
tripdatabase
tripdatabase
.com
.com

And repeat your searches (based on your careful

And repeat your searches (based on your careful
records!)
records!)
More Tips on Effective Searching
More Tips on Effective Searching

Decide the TYPE of question (Rx, Dx, Px, )

Decide the TYPE of question (Rx, Dx, Px, )

Chose the right database for the type of

Chose the right database for the type of
question, e.g.,
question, e.g.,

Intervention:
Intervention:
Cochrane Library, PubMed,
Cochrane Library, PubMed,

Diagnostic:
Diagnostic:
PubMed: Clinical Queries
PubMed: Clinical Queries

Prognosis, Etiology:
Prognosis, Etiology:
PubMed: Clinical Queries
PubMed: Clinical Queries

Just in Time learning

Just in Time learning
The EBM
The EBM
Alternative
Alternative
Approach
Approach

Fokus pada problem pasien yang dihadapi saat ini

Fokus pada problem pasien yang dihadapi saat ini
(just in time education)
(just in time education)

Relevan Relevan dengan praktik dengan praktik

Mudah diingat Mudah diingat

Up to date Up to date

Belajar untuk memperoleh informasi terkini yang

Belajar untuk memperoleh informasi terkini yang
terbaik
terbaik
Hambatan EBM
Hambatan EBM
1.
1.
Kebiasaan untuk bertanya dan mencari
Kebiasaan untuk bertanya dan mencari
2.
2.
Keterampilan menemukan, menelaah
Keterampilan menemukan, menelaah
(appraisal) dan menerapkan evidence
(appraisal) dan menerapkan evidence
3.
3.
Sumber informasi sangat banyak
Sumber informasi sangat banyak
4.
4.
Keterbatasan waktu
Keterbatasan waktu
Kesimpulan
Kesimpulan

Benarkah terdapat banjir informasi?

Benarkah terdapat banjir informasi?

Ya 5,000 artikel per hari

Ya 5,000 artikel per hari

Apakah CME membantu?

Apakah CME membantu?

Sedikit
Sedikit

Dapatkah EBM (patient-centered learning)

Dapatkah EBM (patient-centered learning)
membantu?
membantu?

Ya, karena metode yang dipergunakan lebih

Ya, karena metode yang dipergunakan lebih
efektif dari CME
efektif dari CME

Apakah hambatannya?
Apakah hambatannya?

Sumber-sumber bukti, keterampilan, perilaku

Sumber-sumber bukti, keterampilan, perilaku
mencari
mencari
Baga!mana prak!kn&a"
Baga!mana prak!kn&a"

Penemuan buk! unuk men'ukung

Penemuan buk! unuk men'ukung
%ala# %au pengamb!lan kepuu%an
%ala# %au pengamb!lan kepuu%an
kl!n!% %e!ap pa%!en ra$a !nap an'a)
kl!n!% %e!ap pa%!en ra$a !nap an'a)

Penemuan buk! unuk men'ukung

Penemuan buk! unuk men'ukung
%ala# %au pengamb!lan kepuu%an
%ala# %au pengamb!lan kepuu%an
%ala# %au pa%!en an'a per %au #ar!
%ala# %au pa%!en an'a per %au #ar!
prak!k)
prak!k)

Men'(r(ng rekan kerja an'a meng!ku!

Men'(r(ng rekan kerja an'a meng!ku!
&ang an'a kerjakan)
&ang an'a kerjakan)

Bekerja %ebaga! !m 'alam menemukan

Bekerja %ebaga! !m 'alam menemukan
ja$aban &ang berba%!% buk!)
ja$aban &ang berba%!% buk!)

Half of what you are taught as medical

Half of what you are taught as medical
students will in 10 years have been shown
students will in 10 years have been shown
to be wrong. And the trouble is, none of
to be wrong. And the trouble is, none of
your teachers knows which half.
your teachers knows which half.
(Dr. Sydney Burwell, Dean of Harvard
(Dr. Sydney Burwell, Dean of Harvard
Medical School, 1956)
Medical School, 1956)

Keep on Asking
Keep on Asking

Keep on Searching
Keep on Searching

Keep on Learning
Keep on Learning