Pengantar Ebm 2015 New

EVIDENCE-BASED MEDICINE (EBM)Azelia Nusadewiarti, dr, MPH

Kasus (1) Salah seorang pasien yang mempunyai bayi berumur 6 bulan bertanya, perlukah bayinya mendapat imunisasi MMR mengingat saat ini banyak beredar berita bahwa MMR dapat menyebabkan sindrom autisme?

Kasus (2)Kerabat anda yang lain, yang saat ini sedang hamil 24 minggu bertanya, perlukah ia mendapatkan pemeriksaan USG apabila ia tidak ingin mengetahui jenis kelamin bayinya?

Cara-cara lampauMengerti patofisiologiCommon senseTergantung pengalaman klinisBertanya pada ahliDll (membaca)?

Pengambilan Keputusan di bidang KedokteranDiagnosisTerapi PencegahanPrognosisEtiologi

Sebagai klinisi kita butuh informasiNamun sebagian besar informasi yang kita butuhkan sulit didapatkan:Buku teks kita out of datePenyimpanan jurnal kita tidak teratur, kualitas bervariasiPara ahli sulit untuk sepakatCME tidak efektif

Era cyber-medicine, segala informasi mudah diakses oleh setiap orangMeningkatnya pendidikan pasien berakibat meningkatnya konsumerisme; pasien semakin sadar akan haknya. Mereka menginginkan penatalaksanaan penyakit yang lebih efektif, efisien, transparan dan accountableHal tsb dan juga faktor2 lain memaksa dokter meningkatkan profesionalisme; salah satu aspek penting profesionalisme adalah meningkatkan ketrampilan & pengetahuan melalui perilaku life long learning

Evidence-based MedicineThe conscientious, explicit, dan judicious use of current best evidence in making decisions about the care of individual patientsPemanfaatan bukti mutakhir yang sahih dalam tatalaksana pasien

Evidence-based MedicineIntegrating individual clinical expertise with the best available external clinical evidence from systematic research and patient preferences (Sackett et al., 2000).

Integrasi hasil-hasil penelitian dengan praktek klinisMembedakan informasi yang valid & bias

Mengapa EBM?Bukti-bukti terbaru secara terus-menerus dihasilkanKita seringkali sulit untuk mendapatkan informasi terbaruPengetahuan kita semakin lama semakin berkurangEBM mendorong self directed learning

Komponen EBMDalam mempraktikan EBM dibutuhkan integrasi:Kemampuan klinik individuDenganBerbagai bukti klinis yg terbaik & tersedia yg berasal dari penelitian yg sistematisNilai-nilai pasien

Yang dimaksud dgn bukti klinis yg terbaik & tersedia adalah berbagai riset klinik yang relevan, berasal dari:Ilmu kedokteran dasarPenelitian klinis yg Patient-centered

Berbagai bentuk bukti klinisRandomized Controlled Trials / Clinical TrialsCohort studiesCase-control studiesCross-sectional / surveyQualitative studiesSystematic ReviewClinical Practice Guidelines

DilemaYou are very ill

Which doctor do you want?William Osler, 1900Smart young doctor

Which doctor do you want?Wise & experienced smart young doctor

5 Step Evidence-Based Practice Rumuskan masalah klinis pasien Cari bukti di internet (Cochrane, PubMed/ Medline, dll) Lakukan Critical Appraisal (VIA) Terapkan bukti Evaluasi kinerja penerapan bukti

Bagaimana kita mempraktikan EBMStep 1Merubah kebutuhan akan informasi (mengenai terapi, pencegahan, diagnosis, prognosis, etiologi, dll) menjadi pertanyaan yang dapat dijawab

The PICO questions"PICO" + T (Time)(P)atient dan problem (bagaimana pasien dan masalah apa?) (I)ntervention (tes diagnostik, terapi, paparan, dsb) (C)omparison (jika relevan, misalnya gold standard, plasebo) Clinical (O)utcome (Patient- Oriented Outcome that Matters (3D), misalnya, perbaikan klinis, mortalitas, morbiditas )

BACKGROUND QUESTIONS(PERTANYAAN LATAR BELAKANG) Ketika seorang dokter memberikan pelayanan medis kepada pasien hampir selalu timbul pertanyaan di dalam pikirannya tentang diagnosis, kausa, prognosis, maupun terapi yang akan diberikan kepada pasien. Sebagian dari pertanyaan itu cukup sederhana atau merupakan pertanyaan rutin yang mudah dijawab, disebut pertanyaan latar belakang (background questions) (Sackett et al., 2000; Hawkins, 2005).

MERUMUSKAN PERTANYAAN KLINISContoh pertanyaan klinis yang mudah dijawab/ background questions: Bagaimana cara mendiagnosis tuberkulosis paru? Apakah gejala dan tanda yang terbanyak dijumpai tentang malaria? Bagaimana cara hiperkolesterolemia meningkatkan risiko pasien untuk mengalami infark otot jantung? Apakah penyebab hiperbilirubinemia? Apakah kontra-indikasi pemberian kortikosteroid?

MERUMUSKAN PERTANYAAN KLINISFOREGROUND QUESTIONS. Banyak pertanyaan klinis lainnya yang sulit dijawab, yang tidak memadai untuk dijawab hanya berdasarkan pengalaman, membaca buku teks, atau mengikuti seminar. Pertanyaan yang sulit dijawab disebut pertanyaan latar depan (foreground questions) (Sackett et al., 2000; Hawkins, 2005). Pertanyaan latar depan bertujuan untuk memperoleh informasi spesifik yang dibutuhkan untuk membuat keputusan klinis.

MERUMUSKAN PERTANYAAN KLINISContoh pertanyaan klinis yang sulit dijawab/ foreground questions:

Apakah vaksin MMR (mumps, measles, rubella) menyebabkan autisme pada anak, sehingga sebaiknya tidak diberikan kepada anak? (Halsey et al., 2001)

MERUMUSKAN PERTANYAAN KLINISPertanyaan latar depan tentang keakuratan diagnosis, kebenaran kausa, keakuratan prognosis, efektivitas dan kerugian terapi, tidak memadai dan tidak dibenarkan jika diperoleh jawabnya hanya berdasarkan mengikuti seminar, membaca tinjauan pustaka dan buku teks. Pertanyaan latar depan memerlukan upaya yang lebih sistematis untuk

MERUMUSKAN PERTANYAAN KLINISPertanyaan latar depan memerlukan upaya yang lebih sistematis untuk menjawabnya, dengan menggunakan bukti-bukti dari sumber database hasil riset yang otoritatif dan terpercaya kebenarannya. Jawaban yang benar atas pertanyaan latar depan memerlukan keterampilan dokter untuk menilai kritis kualitas bukti hasil riset.

MERUMUSKAN PERTANYAAN KLINISBukti-bukti terbaik dan terkini untuk menjawab pertanyaan latar depan diperoleh dari aneka sumber data base hasil riset yang bisa diakses melalui web, misalnya : PIER, ACP Journal, Cochrane Library (www.nelh.nhs.uk/cochrane.asp), Evidence Based Medicine (www.ebm.bmjjournals.com/), Bandolier (www.ebandolier. com/), dan perpustakaan elektronik/e-library, misalnya, PubMed (www.pubmed.gov), National Electronic Library for Health (www.nelh.nhs.uk/).

Online Medical Information Resources

Resource Internet Address Annual Cost Google Scholar http://scholar.google.com Free Medline Pubmed www.ncbi.nlm.nih.gov/pubmed Free eMedicine www.emedicine.com Free Medscape www.medscape.com Free Medical Matrix www.medmatrix.org Free Clinical Practice www.guidelines.gov Free Guidelines www.cma.caa/cpgs Free MD Consult www.mdconsult.com USD 200 UpToDate www.uptodate.com USD 495 Best Evidence www.acponline.org USD 85

CLINICAL EXPERTISE

Bagaimana kita mempraktikan EBMStep 2Mencari bukti-bukti klinis yang terbaik dalam menjawabnya

Computer literature search

PubMed and MEDLINE

PubMed: A service of the National Center for Biotechnology Information (NCBI) of National Library of Medicine that provides access to over 22 million citations and abstracts from MEDLINE and additional life sciences journals. PubMed includes links to many sites providing full text articles and other related resoucesMEDLINE: The U.S. National Library of Medicines (NLM) premier bibliographic database MEDLINE contains citations and abstracts from life sciences journals and NOT full-text articles Source: currently, citations from approximately 5,600 worldwide journals in 39 languages; 60 languages for older journals

Searching in Pubmed: Step-by-Step Formulate a focused PICO question. Define keywords. Identify the type of article that is most likely to answer your question: therapy, diagnosis, harm, etc. Identify the design that is most likely to answer your question: RCT, cohort, cross sectional, case control, etc. Always try to find systematic reviews. Use MeSH or Thesaurus or text words for searching Combine concepts with Boolean operators (AND/OR/NOT). Limiting to age, sex, language, year of publication, etc. Evaluate search results. Use "Related Articles" link option.

Four elements of a well constructed clinical question: PICO

PICODescription of patient or problem The main intervention considered The alternative to compare with the intervention Outcome expected from this intervention?

PICO Questions CLINICAL SCENARIO On ICU round, you and your colleagues, found a septic shock patients just admitted due to a severe pneumonia. In this setting, it was reported that case fatality rate patients with severe sepsis is more than 50%. Someone told you that steroid might be beneficial in this kind of patient, but another one said the opposite. PICO?

PICO Questions STRUCTURE Patient, Population, (Clinical) Problem Intervention (or Indicator or Index test) Comparison Outcome

Be brief and specific!

PICO Questions REPRHASE CLINICAL SCENARIO INTO PICO QUESTIONS

P - Population/patients In septic shock patients, I - Intervention/indicator does corticosteroid administration C - Comparator compared to no corticosteroid O - Outcome will reduce mortality?

Type of Article and Best study design

Question Best Study Design Intervention Randomised controlled trial (RCT)Etiology and Risk Factor RCT Cohort study Case-control study Frequency and rate Cohort study Cross-sectional study Diagnosis Cross-sectional study with random or consecutive sample Prognosis and prediction Cohort/survival study

CLINICAL QUERIES

MeSH Medline Subject Headings (MeSH terms) are assigned to each article Provide consistent way to retrieve articles MeSH a controlled vocabulary organised in a tree structure Index = like chapter headings in a text book Major Subject Headings (eg Leg) Subject Headings (eg knee) Subheadings (eg cruciate ligament) Each new paper is tagged by NLM librarians using MeSH terms representing the key things about each study (eg rct ligament surgery)

Searching in Pubmed: Step-by-Step Formulate a focused PICO question. Define keywords. Identify the type of article that is most likely to answer your question: therapy, diagnosis, harm, etc. Identify the design that is most likely to answer your question: RCT, cohort, cross sectional, case control, etc. Always try to find systematic reviews. Use MeSH or Thesaurus or text words for searching Combine concepts with Boolean operators (AND/OR/NOT). Limiting to age, sex, language, year of publication, etc. Evaluate search results. Use "Related Articles" link option.

What are your clinical questions?A 35 year old man says his brother recently died of a ruptured cerebral aneurysm. He is worried about whether he might have one and what the chances are that it would rupture.

Boolean Operators

AND

OR

NOT

Strategy of using Boolean operators: first increase sensitivity, then specificity One keyword concerning the patient Another keyword concerning the patient #1 OR #2 One keyword concerning the intervention Another keyword concerning the intervention #4 OR #5 One keyword concerning the outcome Another keyword concerning the outcome #7 OR #8 #3 AND #6 AND #9

Answerable question - PICO P - Population/patients In septic shock patients, I - Intervention/indicator does corticosteroid administration C - Comparator compared to no corticosteroid O - Outcome will reduce mortality?

Corticosteroid Example Break

Break the question into the following components

Population/ Problem Intervention Comparison Outcome

Septic shock OR

Sepsis OR

Severe infection Corticosteroid therapy OR

SteroidOR

Prednisone OR

MethylprednisoloneNo corticosteroid Mortality OR

Survival OR

Death

Risk FactorsCause(s)SymptomsSigns, TestsPrognosisTreatment EffectPast current futureTypes of question: strokeFrequency

Cohort Study

Survey

Inception Cohort Study

Treatments

Randomised Trial

The best evidence for different types of question

LevelTreatmentPrognosisDiagnosisIIIRandomised trialInception CohortCross sectionalIII

The best evidence for different types of question

LevelTreatmentPrognosisDiagnosisISystematic Review of Systematic Review of Systematic Review of IIRandomised trialInception CohortCross sectionalIII

Finding the best evidence for the question type: use Methods Filters

Basic Principles DiagnosisSensitivity, specificity Prevalence, prior probability, predictive values Likelihood ratios Dichotomous scale, cutoff points (continuous scale) Positive (true and false), negative (true & false) ROC (receiver operator characteristic) curve

Importance of treatmentMagnitude of the treatment effect p value Relative Risk Reduction (RRR) Relative Risk Increase (RRI) Absolute Risk Reduction (ARR) Absolute Risk Increase (ARI) Number Needed to Treat (NNT) Number needed to harm (NNH) 2. How precise is the treatment effect construct Confidence Interval (CI)

How likely are the outcomes over time?

% of outcome of interest at a particular point in time (1 or 5 year survival rates) Median time to the outcome (e.g. the length of follow-up by which 50% of patients have died) Event curves (e.g. survival curves) that illustrate, at each point in time, the proportion of the original study sample who have not yet had a specified outcome.

Step 3Penilaian secara kritis (critical appraisal) bukti2 tersebut berdasarkan validitas, impact, and applicability (manfaatnya terhadap praktik klinik kita)

The Users Guides on Medical LiteratureBagaimana kita mempraktikan EBM

Struktur users guidesApakah hasil penelitian valid? (Validity)Bagaimana hasilnya? (Importance)Akankah hasil tersebut membantu saya dalam menyelesaikan masalah pasien? (Applicability)

Searching: finding good answers?

Rapid Critical AppraisalIts peer-reviewed, therefore it must be OK?

Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar LondonMedical Articles Per Year

Perhatikan kekuatan bukti hasil penelitian ketika melakukan Critical Appraisal

Hirarki Kekuatan Bukti

Step 4Mengintegrasikan hasil evaluasi kritis dengan ketrampilan klinis kita dan dgn keadaan biologis, nilai-nilai dan situasi pasien kita yang unikBagaimana kita mempraktikan EBM

Step 5Mengevaluasi efektivitas dan efisiensi kita dalam melaksanakan langkah 1-4 dan terus berusaha mencari jalan meningkatkan kemampuan kitaBagaimana kita mempraktikan EBM

Conflicting Results--Whats the truth?Guideline 1Article 1Article 2Guideline 2CMEExpert Textbook

Evidence-based CardiologyEvidence-based PediatricsEvidence-based Ob-GynEvidence-based Dentistry Evidence-based Nursing Evidence-based Health PolicyEvidence-based Health Technology AssessmentEvidence-based Decision MakingEvidence-based Health Performance IndicatorsEvidence-based Clinical AuditEvidence-based Risk Management .Evidence-based Everything!!!

Half of what you are taught as medical students will in 10 years have been shown to be wrong. And the trouble is, none of your teachers knows which half.

(Dr. Sydney Burwell, Dean of Harvard Medical School, 1956)

Primary Care (WHO)EssentialPracticalScientifically soundSocially acceptable methods and technologyAccessible to individuals and familiesAffordable

Advantages of EBMEncourages reading habitImproves methodological skill (and willingness to do research?!)Encourages rational & up to date management of patientsReduces intuition & judgment in clinical practice, but not eliminates themConsistent with ethical and medico-legal aspects of patient management

End result

End resultself directed, life-long learning attitudefor high quality medical management

Misused evidenceA pediatrician has just read a meta-analysis that asthmatic attack is more likely to develop if a asthmatic baby is given egg white as compared to yolk. One day a mother told the pediatrician that her baby will wheeze immediately if given egg yolk but no problem when given egg white. The pediatrician responded: No, you are wrong. Valid level I evidence indicate that white egg is far more allergenic than egg yolk. From now on you have to give your baby the yolk instead of the white.

Remember, however ...Medicine is the science of uncertaintyand the art of probabilities

Terima kasihAll Evidence is notcreated equal!!

*************PRESENTATION ONE*Introduction to Evidence-Based Practice*PRESENTATION ONE*Introduction to Evidence-Based Practice*PRESENTATION ONE*Introduction to Evidence-Based Practice****PRESENTATION ONE*Introduction to Evidence-Based Practice*PRESENTATION ONE*Introduction to Evidence-Based Practice*PRESENTATION ONE*Introduction to Evidence-Based Practice*PRESENTATION ONE*Introduction to Evidence-Based Practice*PRESENTATION ONE*Introduction to Evidence-Based Practice***PRESENTATION ONE*Introduction to Evidence-Based Practice**PRESENTATION ONE*Introduction to Evidence-Based Practice**PRESENTATION ONE*Introduction to Evidence-Based Practice**************