Evidence Based Medicine

DR. dr. Zafrullah Khany Jasa SpAn.KNA

• Evidence-Based Medicine (EBM)
• Evidence-Based Practice (EBP)
• Evidence-Based Clinical Practice (EBCP)
• Evidence-Based Health Care (EBHC)
• Evidence-Based Nursing (EBN)
I am here to learn EBM because ….

1. I am working in clinical practice

2. I am working on evidence resources
(reviews, guidelines, reports , …)
3. I will help others use evidence
4. I plan to teach EBM
5. My boss told me I had to attend
 Evidence-Based Medicine (EMB)
• Adalah integrasi hasil-hasil penelitian terbaru dengan
subyek pasien dan kejadian klinik dalam membuat
keputusan klinik .
• EBM merupakan hasil-hasil penelitian terbaru yang
merupakan integrasi antara pengalaman klinik,
pengetahuan patofisiologi dan keputusan terhadap
kesehatan pasien.
• Atau
• merupakan integrasi kejadian untuk menentukan
terapi atau penatalaksanaan suatu penyakit.
• Dengan melihat pada penelitian-penelitian
kedokteran dan literatur-literatur (individual
atau group), sehingga dapat membantu dokter
– Menentukan diagnosis yang tepat,
– Memilih rencana pemeriksaan terbaru,
– Memilih terapi terbaru
– Memilih metode pencegahan penyakit terbaru.
Evidence Based Medicine

Medical Decision
Patient
Values

Clinical Research
Expertise Evidence
• Selama ini jenis penelitian terbaik adalah :
– Randomised clinical trials
– Meta-analysis

• Bukti-bukti klinik biasanya ditulis dalam suatu

journal dan dokumen-dokumen, sehingga
memudahkan seorang dokter atau klinisi untuk
memanfaatkanya.
• Menggunakan tehnik EMB berskala besar dengan
pengelompokan pada penyakit yang sama dapat
digunakan untuk pembuatan suatu “ practice
guidelines” atau konsensus.

• Manfaat “practice guideline” oleh para klinisi

digunakan untuk menentukan :
– Diagnostik.
– Terapi.
 EBM Klinik

• Merupakan bukti penelitian terbaru

– untuk memutuskan tentang penatalaksaan pasien-
pasien secara individu.
– untuk memperbaiki dan mengevaluasi perawatan
pada pasien.

• Digunakan sebagai ”gold standart/ standar

baku/standar emas “ untuk praktisi klinik dan
guideline therapi.
Sumber EBM Klinik

• Sistematic reviews dari literatur

kedokteran.
• Large Randomised controlled trials
( efikasi terapi)
• Large prospective studies (pemantauan
waktu).
–  Bukti penelitian test diagnostik dan terapi.
 Klasifikasi EBM

• 1. Evidence-Base guideline.
– EBM praktis pada tingkat organisasi atau
institusi dalam bentuk guideline, pedoman, dan
aturan

• 2.Evidence-Base individual decision

making.
– EBM praktis pada individual.
 Manfaat EBM Klinik

• Practice guideline atau Evidence-base medicine

guidelines.
1. Membantu menurunkan mortalitas atau
kematian pasien.
2. Memperbaiki derajat kesehatan dan
perawatan.
3. Mengevaluasi dan merencanakan terapi.
4. Memilih pola hidup dan perawatan kesehatan
terbaik.
Contoh EBM klinik
– Clinical Guidelines” The Evidence Base for
Tight Blood Pressure Control in the
Management of Type 2 Diabetes Mellitus “
– Petunjuk Praktis “ Pengelolaan Diabetes
Mellitus Tipe 2” oleh PERKENI 2002.
– Konsensus “Pengelolaan dan Pencegahan
Diabetes Mellitus Tipe 2 di Indonesia “ oleh
PERKENI 2006
– JNC VII for hipertension.
 FIVE STEPS TO FINDING THE BEST EVIDENCE

1. IDENTIFY NEEDS : What type of information is needed?

2. IDENTIFY RESOURCES : Types, Availability, Timeliness,
Costs?
3. SEARCH & RETRIEVE : Use efficient strategi
4. REVIEW : Check quality and usefulness of info
5. INTERPRET : Help patient understand info, application
EBP:
1. Assess the patient Steps
2. Ask the question
3. Acquire the evidence
4. Appraise the evidence EBM:
5. Apply: talk with the 1. Ask focused question
patient 2. Find the evidence
3. Appraise the evidence
4. Make a decision
5. Evaluate performance
 Forming a question

• Identify key patient problem

• Phrased to facilitate finding an answer
• What treatment might be considered
• Alternative treatments to consider
• Outcome to avoid or promote
 PICO
P = Patient or problem
I = Intervention, prognostic factor, or
exposure
C = Comparison
O = Outcomes
(T)= Type of Study
 Types of Studies
• Case series and Case Reports
• Case control studies
• Cohort studies
• Randomized, controlled clinical trials
• Systematic Reviews
• Meta-analysis
Evidence Based Medicine

PATIENT

PHYSICIAN INFORMATION

It starts with the patient

and ends with the patient!
 EBM IN DEVELOPING COUNTRIES

LIMITED RESOURCES
May help to eliminate unnecessary or poor quality screening
tests (ie: resting EKG to screen for CAD = high false negative
and false positive rates)

LIMITED DRUG REGULATION

Approval for drug marketing easy - promotes insurgence of
new drugs for questionable indications, limited
effectiveness, false claims, inflated prices based on ad
response (include “more expensive is better”)
EBM IN DEVELOPING COUNTRIES

LIMITED CAPACITY FOR CME

Drug companies - may sponsor meetings that are little more
than captive marketing sessions or biased education sessions
(drug education vs promo)

Result may be push for more expensive, less effective

treatments (ie push for CCB’s over BB’s) - calc channel
blockers over Beta Blockers
EBM IN DEVELOPING COUNTRIES

LIMITED ACCESS TO LITERATURE DATABASES

Desktop computer with CD ROM reader and modem ($900)

Electricity
1 yr subscription to MedLine on CD ROM (?500)
Internet connection $25/mt

Convince administrators of expense:

Publicly cite how searches help with lectures, research and
patient care management decisions

Get equipment from drug companies

(usually strings attached)
EBM IN DEVELOPING COUNTRIES

LIMITED ACCESS TO ADEQUATE LIBRARY FACIILITIES

ALMOST INEVITABLE IN DEVELOPING COUNTRIES

Identify resources via search, but then unable to retrieve articles!

A top EBM practitioner (Philippines) recommends:

1. Top 3 medical libraries in your country
2. Multinational drug company libraries
3. Friends and colleagues - including in other countries
 WHAT IS THE BASIS OF YOUR MEDICAL
PRACTICE ?
A. Training, clinical experience and consultation with
other professionals

B. Convincing evidence (non-experimental) from

articles, case reports, product literature, etc.

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis Reports
Kualifikasi EBM Klinik

1. U.S. Preventive Services Task Force

2. U. K. National Health Service (level of
evidence [LOE])
 1 .U.S. Preventive Services Task Force
• Level I:
– Designed randomized controlled trial.
• Level II-1:
– Designed controllled trial tanpa random
• Level II-2:
– Studi cohort atau case-control analytic.
• Level II-3:
– Multiple time series dengan atau tanpa intervensi.
• Level III:
– Pendapat ahli, penelitian klinik dasar, studi
descriptive atau laporan kasus.
Kategori dari rekomendasi
( US. Preventive Services Task Force)
• Level A:
– Suatu penelitian yang memberikan manfaat klinik lebih baik
dengan resiko sedikit.
• Level B:
– Suatu penelitian yang memberikan manfaat klinik sedikit lebih
baik dengan resiko sedikit
• Level C:
– Suatu penelitian yang memberikan manfaat klinik sedikit, dimana
perbandingan antara manfaat dan resiko sama.
• Level D:
– Suatu penelitian yang memberikan resiko klinik lebih berat.
• Level I:
– Suatu penelitian yang tidak mempunyai bukti cukup, kualitas
jelek atau banyak pertentangan.
2. UK National Health Service
( level of evidence [LOE])

• Pembagaian berdasarkan pendekatan prevention, diagnosis,

prognosis dan therapy.
• Level A:
– Consistent Randomised Controlled Clinical Trial, Cohort
study, keputusan klinik berdasarkan validitas pada
populasi yang berbeda.
• Level B:
– Consistent Retrospective Cohort,Explonatory Cohort,
Ecological Study,,Outcomes Research, Case-control
Study, atau extrapolasi dari studi level A.
• Level C:
– Case-series Study atau extrapolasi dari studi level B
• Level D:
– Opini tanpa critical appraisal atau berdasarkan
patophysiologi.
Is keeping up to date Mission Impossible?

TERIMA KASIH