EBM prognostic2

EBM prognostic

Skenario klinis• Seorang ODHA laki-laki berusia 38 tahun datang ke klinik

VCT untuk berkonsultasi tentang diagnosis TB yang baru saja dia dapatkan dari dokter berikut OAT yang telah diberikan. Dia ingin menanyakan apakah kondisi ini dapat memperpendek umurnya.

• Dari data didapatkan pasien tinggal bersama orang tuanya yang penuh kasih sayang.

• Nilai CD4 pasien terakhir 240 cell/mm3• Pasien belum pernah mendapat OAT sebelumnya• Dokter ingin tahu seberapa besar OAT yang diberikan pada

ODHA dapat mempengaruhi umurnya

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Practice of EBM• Step 1: Converting the need for information (about prevention,

diagnosis, prognosis, therapy, causation, etc.) into an answerable question

• Step 2: Tracking down the best evidence with which to answer that question

• Step 3: Critically appraise that evidence for the validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice)

• Step 4: Integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values, and circumstances

• Step 5: Evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time

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Clinical question about prognosis

Patient or Problem

Intervention Comparison Outcomes

Pasien usia 38 tahun dengan diagnosis HIV-TB

DOTS - mortality

Pertanyaan klinis

• Apakah pemberian OAT dengan DOTS pada pasien HIV-TB dapat memperlambat kematiannya?

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Practice of EBM• Step 1: Converting the need for information (about prevention,

diagnosis, prognosis, therapy, causation, etc.) into an answerable question

• Step 2: Tracking down the best evidence with which to answer that question

• Step 3: Critically appraise that evidence for the validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice)

• Step 4: Integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values, and circumstances

• Step 5: Evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time

Search Strategy

Medline database:http://www.ncbi.nlm.nih.gov/pubmed/

• Using the Clinical Queries function of PubMed:– Key words:

• “natural history” AND• “HIV”

– Clinical Study Categories: “prognosis”– Scope: “Narrow”

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Searching the Evidence

• Natural History and Factors Associated with Early and Delayed Mortality in HIV-Infected Patients Treated of Tuberculosis under Directly Observed Treatment Short-Course Strategy : A Prospective Cohort Study in India

• Alvarez-Uria G, Naik PK, Pakam R, Bachu L, Midde M.• Interdisciplinary Perspectives on Infectious Diseases

Volume 2012, ArticleI D 502012, 9 pages

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Practice of EBM• Step 1: Converting the need for information (about prevention,

diagnosis, prognosis, therapy, causation, etc.) into an answerable question

• Step 2: Tracking down the best evidence with which to answer that question

• Step 3: Critically appraise that evidence for the validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice)

• Step 4: Integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values, and circumstances

• Step 5: Evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time

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Clinical domain

Question Epidemiological study type

Diagnosis How accurate are tests used to diagnose disease?

Cross-sectional study

Prognosis What are the consequences of having a disease?

Cohort (longitudinal) study

Therapy How does treatment change the course of disease?

RCT (or systematic review of RCTs)

Harm (Etiology/causation)

What conditions lead to disease?

Cohort or case-control study

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Is this evidence about prognosis valid?1. Was a defined, representative

sample of patients assembled at a common point in the course of their disease?

– Penelitian ini merupakan studi cohort prospektif

– dengan konsekutif sampling

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Is this evidence about prognosis valid?

2. Was follow-up of study patients sufficiently long and complete? Apakah follow up dilakukan secara lama dan komplit

– Follow-up terhadap 1000 pasien dilakukan selama 24 bulan dengan kematian kumulatif sebanyak 388 pasien

– Pada penelitian ini tidak dijelaskan berapa sampel pasien dan jumlah pasien yang masih hidup pada akhir pengamatan

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Is this evidence about prognosis valid?

3. Were objective outcome criteria applied in a “blind” fashion? – Pada penelitian ini , total mortality dan penyebab

kematian dijelaskan– Cause of death was ascertained by hospital notes, death

reports dari VFHCS database– Penilaian outcome kematian tidak dijelaskan apakah

blinded karena tidak perlu metode blinded dalam Dx kematian

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Is this evidence about prognosis valid?4. If subgroups with different prognoses are identified:• Was there adjustment for important prognostic factors?

• Was there validation in an independent group of “test-set” patients?

• Tidak ada test-set pasien dalam penelitian ini

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Is this valid evidence about prognosis important?

1. How likely are the outcomes over time?2. How precise are the prognostic estimates?

– From our study, we found that, at a median follow-up of 10.4 bulan , mortality was 38.8%

– Pasien dibagi menjadi 2 kelompok: penilaian follow-up mortality dalam 3 bulan pertama dan setelah 3 bulan.

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Can we apply this valid, important evidence about prognosis to our patient?

1. Is our patient so different from those in the study that its results cannot apply?

– tidak2. Will this evidence make a clinically important

impact on our conclusions about what to offer or tell our patient?

– ya

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Practice of EBM• Step 1: Converting the need for information (about prevention,

diagnosis, prognosis, therapy, causation, etc.) into an answerable question

• Step 2: Tracking down the best evidence with which to answer that question

• Step 3: Critically appraise that evidence for the validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice)

• Step 4: Integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values, and circumstances

• Step 5: Evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time

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Resolution of the CaseSesuai umur pasien (38th) maka kondisi ini dapat

meningkatkan risiko kematian sebesar 1,24x dibanding pasien usia < 35th dalam 3 bulan pertama pengobatan

Sesuai dengan nilai CD4 terakhir (240cell/mm3), maka kondisi ini dapat meningkatkan risiko kematian sebesar 1,2x dibandingan pasien dengan nilai CD4 diatas > 250cell/mm3 dalam 3 bulan pertama pengobatan

Setelah menjalani pengobatan > 3bulan, risiko kematian akibat TB menjadi tidak bermakna