INTRODUCTION

EVIDENCE BASED
MEDICINE

EBM
. Pendekatan

th/ empiris ditinggalkan

. Start
: awal 90s di Paris oleh
ahli epidemiologi klinis
. 1992
: hanya sedikit artikel EBM
. 1998
: >1000 artikel
. Indonesia : berawal pada thn 1997

 The conscientious, explicit, and

judicious use of current best evidence in
making decisions about the care of
individual patients
Sackett DL et al

Penggunaan bukti-bukti ilmiah yang

terkini dan terpercaya dalam
pengambilan keputusan tatalaksana
pasien
3

Previous practice:
6 yrs medical
education

40-50 yrs
medical practice

Usu. see only Results section,

or even worse, Abstract section

Problems with patients:

Dx, Rx, Px

Consultant,
colleagues
Textbooks
Handbooks
Lecture notes
Clinical guidelines
CME, seminars, etc
Journals
4

.. Integrasi :
1.Best research evidence
- penelitian yang terpercaya dan sesuai
- penelitian ilmu dasar kedokteran maupun
penelitian ttg klinis, test diagnostik , prognosis dll
2. Clinical expertise
- kemampuan klinis kompetensi dokter
- identifikasi secara cepat tingkat kesehatan dan
diagnosa , faktor resiko dan manfaat dari
intervensi yang dilakukan serta pengenalan
pasien dan harapan2nya
5

3.Patient values
-pemahaman terhadap keunikan pilihan, perhatian
dan harapan pasien dan yang mana yang harus
diintegrasikan dalam pengambilan keputusan
saat menangani pasien

bila ke 3 elemen ini terintegrasi

dokter dan pasien diagnosa dan terapi
outcome klinis dan kwalitas hidup yang baik
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WHY EBM?
1.Selalu ada bukti ilmiah terbaru
2.Ketidakmampuan untuk mengetahui
adanya bukti ilmiah terbaru
3.Setiap hari diperlukan informasi yang
valid/ sah pada situasi klinis ( diagnosa,
prognosa, therapi dan pencegahan)

4.Kurangnyan informasi dari: sumber

tradisional ( buku teks, tenaga ahli )
5.Terdapat peningkatan kemampuan diagnostik
dan keputusan klinis dengan waktu dan
pengalaman, tetapi terdapat kemunduran
dalam mengup-date pengetahuan
6.Keterbatasan waktu untuk evaluasi dan
pencarian informasi yang mendalam
tentang hal-hal yang berhubungan dengan
klinis
8

100%

Relative
% of
remaining
knowledge

10

12

Years after graduation

9

Main area
Diagnosis
(Determination of disease or problem)
Treatment
(Intervention necessary to help the patient)
Prognosis
(Prediction of the outcome of the disease)
10

Steps in Practicing
Evidence-Based Medicine
Langkah 1: Membuat pertanyaan klinis yang baik dan
dapat dipertanggungjawabkan
Langkah 2: Pilih penelitian / bukti yang terbaik untuk
menjawab pertanyaan
Langkah 3: Nilai dengan kritis hasil penemuan
Langkah 4: Integrasikan penemuan dengan keahlian
klinis dan kebutuhan pasien
Langkah 5: Evaluasi hasil yang diperoleh
dan temukan cara untuk meningkatkannya
Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed.
Churchill Livingstone; 2000.

11

Step 1: Construct Well-Built

Clinical Questions
Background questions
Ask for general knowledge about a
disorder
- Two components
Root (who, what, when, where, why)
A disorder or aspect of a disorder

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-What is Kawasaki disease?

-What is the cause?
- What are symptoms & signs?
-What is the treatment?
-Cardiac involvement?

13

Foreground questions
Ask for specific knowledge about
managing patients with a disorder
-Have four essential component
In a child with Kawasaki disease, will repeated echo
examination necessary for early detection of cardiac
involvement? (Dx)

14

Formulate a focused clinical

question
P- Patient
I- Intervention
C- Comparison
O- Outcome
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Asking answerable clinical

questions (CEBM- Oxford)

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Step 2: Locate the Best Evidence

Sources of information and evidence may include:
Colleagues
Textbooks
Journals (e.g., evidence-based)
Systematic reviews
Guidelines
Electronic databases
Where to start searching may depend on:
Available time
Available databases
Foreground versus background knowledge required
Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed.
Churchill Livingstone; 2000.
17

Evidence Pyramid
Meta-Analysis
Systematic Review
Randomized Controlled Trial
Cohort studies
Case Control studies
Case Series/Case Reports
Animal research
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Levels of Evidence
Level of
Type of Study
Evidence
1a
Systematic reviews of randomized clinical
trials (RCTs)
1b
Individual RCTs
2a

Systematic reviews of cohort studies

2b

Individual cohort studies and low-quality RCTs

3a

Systematic reviews of case-controlled studies

3b

Individual case-controlled studies

4
5

Case series and poor-quality cohort and casecontrol studies

Expert opinion based on clinical experience
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Levels of Evidence
Level 1: Highest:
Level 2:
Level 3:
Level 4:
Level 5: Lowestbut still evidence

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Step 3: Critically Appraise

the Evidence
VALIDITY: In Methods section:
-design, sample, sample size, eligibility criteria
(inclusion, exclusion) sampling method, randomization
method, intervention,measurements,
methods of analysis, etc
Can I trust this information?

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IMPORTANCE: In Results section

-characteristics of subjects, drop out,
analysis, p value, confidence intervals, etc
Are the valid results of the study important?
APPLICABILITY: In Discussion section + our
patients characteristics, local setting
Can the results be applied to my patient?

22

Step 4: Integrate Findings

With Clinical Expertise
and Patient Needs
Critical
Appraisal

Patient

Clinical
Decision

Preferences
Concerns
Expectations

Clinical
Expertise

Adapted from: Sackett DL et al. Evidence-Based

Medicine: How to Practice and Teach EBM. 2nd ed.
Churchill Livingstone; 2000.

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Step 5: Evaluate Performance

and Seek Ways to Improve
Examples of Self-Evaluation
Questions:
Step 5

Step 1

Step 4

Step 2

Step 3

Am I asking wellformulated clinical

questions?
Am I searching at all? Do I
know the best sources of
current external evidence?
Am I critically appraising
external evidence?
Am I integrating my
critical appraisal into my
practice?
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Limitations of EBM
Kurangnya bukti bukti (penelitian )ilmiah
Sumber biaya membatasi tipe dan ruang lingkup
penelitian
Akses ke sumber informasi terbatas
(pada situasi klinik )
Tidak adekuatnya contoh penelitian yang ada untuk
menilai kompleksitas yang terdapat dala sistem
kehidupan
Kurangnya keterampilan untuk memanfaatkan sumber
informasi yang adaa
Kesulitan dalam menerapkan bukti ilmiah tsb dalam
menangani pasien
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