Evidence Based Medicine

Didik Setiawan, PhD., Apt

- Faculty of Pharmacy,
- Center for Health Economic Studies,
Universitas Muhammadiyah Purwokerto, Purwokerto, Indonesia
Why do we need Evidence Based Medicine
Daily need for valid information about
diagnosis, prognosis, therapy and prevention

• Five times per inpatient • Limitation to find and

• Twice for every three assimilate the evidence
outpatients required for each patients
Inadequacy of traditional sources for this
information

textbooks • out of date

expert • frequently wrong

didactic CPE • ineffective

• too. overwhelming in their volume and too

medical journal variable in their validity for practical use
Disparity between skills and clinical
judgement and total performance

Skills and judgement

Performance

Total performance

Up-to-date knowledge

Time
How to Practice EBM

Converting the need of information into an answerable clinical

question

Tracking down the best evidence (searching and cleaning)

Critically appraise the evidence for its validity, impact, and

applicability
Integrating the critical appraisal with clinical expertise and patients
biology, value and circumstances
evaluate the effectiveness in executing steps 1-4 and seeking ways
to improve them for next time
How clinician incorporate the evidence into
their practice?

•at least the first four steps are carried out

Doing •suitable for every day cases where we need to be very sure about what we are doing
•unstable angina or thromboembolism

•search are restricted to evidence that. have allready undergone critical appraisal by others (skip
step 3)
Using •suitable for less often cases
•aspirin overdose

•the decision of respected opinion leaders are followed (skip step 2 and 3)
Replicating •for very infrequent cases
•graft-host disease in transplant recipient
Some questions about EBM in practice

• What is EBM (understanding)

• How do they practice EBM
• If the skills are possessed byt the clinician, can it be done in real-
time practice?
Stages between knowledge and practice

skilled
initial reminder
communicating
awareness systems
with patients

skill and
appraisal
ability in
and
the new
acceptance
technique
Limitation, mainly because of
misunderstanding and misconception

• It will ignore patient’s value and preferences

• Promote cookbook approach
• EBM will hijacked by manager to promote cost-cutting services
Take home messages

develop new skills in seeking and

appraising evidence

apply these skills within the

time constrain of our clinical
practice
Step 1: Asking Answerable Clinical Questions
Case

• A 75-yo mas is seen in our office after being discharged from hospital 2
weeks previously. Durign this admission he underwent a carotid
endarterectomy after suffering a transient ischemic attact (TIA), and being
diagnosed with significant carotid stenosis. His hospital stay was
uncomplicated and his discharge medications included metoprolol 50mg
twice daily for hypertension and aspirin 81mg daily. Today he has brought us
an article from the internet describing the benefits of statins for stroke
prevention and he wonders what this medication is and if he should take it.
Our note from his last visit showed that his total cholesterol was 5mmol/dL,
HDL was 2.0mmol/dL, and LDL was 2mmol/dL. His examination was
unremarkable
• What question do you have about this patients?
Background and Foreground Questions

Background ask for general knowledge about a condition or thing

two essential components: (1) A root questions (who, what where, when, how, why) and a
verb; (2) A disorder, test, treatment or other aspect of health-care

Ex: How does heart failure cause ascites?

Foreground Ask for specific knowledge to inform decision or actions

Patients/Problems, intervention or Exposure, Comparison (if relevant), Clinical Outcomes

(if relevant)

ex: In adults with heart failure, who are in sinus rhythm, would adding warfarin to
standard therapy reduce morbidity and mortality from thromboembolism enough over 3-5
years to be wirth warfarin's harmful effects and inconvenients
Examine your PICO
Proportion of BG and FG question over time

Foreground

Background

A B C
Central issues in cllinical work (source of
clinical questions)

Clinical findings • How to properly gather and interpret findings from the history and physical examination

Etiology • How to identify causes of risk factors for disease (including iatrogenic harms)

Clinical
manifestation of
• knowing how often and when a disease causes its clinical manifestations and how to use
disease this knowledge in classifying our patients' illness

Differential • When considering the possible causes of our patient's clinical problems, how to select
diagnosis those that are likely, serious, and responsive to treatment

• how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis,
Diagnostic tests
based on considering their precission, accuracy, acceptability, safety, expenses etc
Central issues in cllinical work (source of
clinical questions)

• How to estimate our patient's likely clinical course over time and anticipate likely
Prognosis complications of the disorder

• How to select treatments to offer our patients that do more good than harm abd
Therapy that are worth the efforts and costs of using them

• How to reduce the chance of disease by identifying and modifying risk factors and
Prevention how to diagnose disease early by screening

Experience • How to empathize with our patients situation, appreciate the meaning the find in
and meaning the experience, and understand how this meaning influences their healing

• How to keep up-to-date, improve our clinical and other skills, and run better, more
Improvement efficient, clinical care system
Step 2: How to find current best evidence
4S
principle

Compare the 4S approach

with your current practice
MEDLINE (PubMed)

• MeSH Term and text word (tw)

• Boolean Logic
• Thesaurus
Text word
[tw]
Example for systematic review

• ("Economics"[Mesh] OR "Economic*"[tw] OR "Cost-Benefit

Analysis"[Mesh] OR "Cost Effectiveness Analysis"[tw]OR "Cost-
Effectiveness Analysis"[tw] OR "Economic Evaluation*"[tw] OR "Cost
Utility Analysis"[tw] OR "Cost-Utility Analyses"[tw]) AND
("Papillomavirus Vaccines"[Mesh] OR "Papillomavirus Vaccines"[tw]
OR "Human Papillomavirus Vaccines"[tw] OR "Human Papilloma
Virus Vaccines"[tw])
Boolean Logic

http://www.electronics-micros.com/img/electronics/venn-logic1.jpg
Step 3: Critical Appraisal

Diagnosys, Prognosys, Therapy, Harm

Case

• A 75-yo mas is seen in our office after being discharged from hospital 2
weeks previously. Durign this admission he underwent a carotid
endarterectomy after suffering a transient ischemic attact (TIA), and being
diagnosed with significant carotid stenosis. His hospital stay was
uncomplicated and his discharge medications included metoprolol 50mg
twice daily for hypertension and aspirin 81mg daily. Today he has brought
us an article from the internet describing the benefits of statins for stroke
prevention and he wonders what this medication is and if he should take it.
Our note from his last visit showed that his total cholesterol was
5mmol/dL, HDL was 2.0mmol/dL, and LDL was 2mmol/dL. His examination
was unremarkable
• What kind of study do you want to find?
Evaluate the Evidence

Go to:
www.cebm.net
> Resources
> EBM Tools
> Critical Appraisal Tools
> Find the Worksheet
> Use the worksheet
Let’s use the RCTs worksheet
 Step 4: Integrating the Critical Appraisal with clinical
expertise and patient’s biology, value and preferences
The questions that you should ask before you decide to
apply the results of the study to your patient are:

• Is my patient so different to those in the study that the results

cannot apply?
• Is the treatment feasible in my setting?
• Will the potential benefits of treatment outweigh the potential
harms of treatment for my patient?
Step 5: Evaluation
Self evaluation in asking answerable
questions

• Am I asking any clinical questions at all?

• Am I asking well-formulated questions (2 background and at least
three foreground questions)
• Am I using a “map” to locate my knowledge gaps and articulate
questions?
• Can I get myself “unstuck” when asking questions?
• Do I have a working method to save my questions for later
answering?
Self evaluation in finding the best external
evidence
• Am I searching at all?
• Do I know the best sources of current evidence for my clinical discipline?
• Have I achieved immediate access to searching hardware, software, and
the best evidence for my clinical discipline?
• Am I finding useful external evidence from a widening array of sources?
• Am I becoming more efficient in my searching?
• Am I using truncation, booleans, MeSH headings, thesaurus, limiters, and
intelegent free text when searching MEDLINE?
• How do my searches compared to with those of research librarians or
other respected colleagues who have a passion for providing best current
patient care?
A self evaluation in critically appraising the
evidence for its validity and potential usefulness

• Am I critically appraising external evidence at all?

• Are the critical appraisal guides becoming easier for me to apply?
• Am I becoming more accurate and efficient in applying some of
the critical appraisal measures (such as likelihood ratios, NNTs,
and the like)?
• Am I creating any appraisal summaries?
A self evalluation in integrating the critical
appraisal with clinical expertise and applying the
result in clinical practice
• Am I integrating my critical appraisals into my practice at all?
• Am I becoming more accurate and efficient in adjusting some of
the critical appraisal. Measures to fit my individual patients (pre-
test probabilities, NNTs etc)
• Can I explain (and resolve) disagreement about management
decision in terms of this integration?
Self evaluation of changing practice
behaviour

• When new evidence suggests a change in practice, am I identifying

barriers to this change?
• Have I carried out any check, such as audits of my diagnostic,
therapeutics, or other EBM performances?
Assignment

• Cardiovascular • Background Q
• Diabetes • Foreground Q
• Lipid disorder • Search Term (MeSH term + tw;
• Infectious disease Boolean logic, thesaurus)
• Cancer • 1 RCT
• respiratory • Appraise using appraisal
worksheet for RCTs
Didik Setiawan, PhD., Apt

Email: d.didiksetiawan@gmail.com
Phone/WA: +62 81 226 700 119
www.ches.ump.ac.id