Evidence-based
medicine
Dyah Kanya Wati
INTRODUCTION
• EBM or “Kedokteran Berbasis Bukti” had been grown since early
1990.
• At 1992 only 2 articles contain EBM term.
• At 2000, increased to more than 1000 articles
• In a short time, EBM spread throughout the world, like:
As a standard for
Medical faculty and There are course about
determining health
hospital EBM
policies
EBM and Clinical
Epidemiology
• Fletcher dan fletcher → clinical epidemiology as an
application of epidemiological principles in problems
that found in clinical medicine
• Sacket→ clinical epidemiology as a basic science for
clinical medicine
Clinical epidemiology is the science, while EBM
applies the Science
Definisi EBM
• “The conscientious, explicit, and judicious use of current
best evidence in making decisions about the care of
individual patients”
In summary, EBM is a framework for applying valid
current evidence in patient management
• EBM is a intersection of 3 component:
Doctors as health care providers
Evidence of valid research
The values of the patient’s choice
Practical paradigm before
the EBM era
• Common things that are used to solve problems in
practice:
Personal experience, but not well documented
Consultation, but often seniors do not update their
knowledge.
Using logic and applying pathophysiology, whereas the
logic is still a hypothesis without empirical evidence
Textbooks, but still general and late in the update
Read journals, but did not do a critical review
Why EBM is
needed?
• Progress in medical science and technology goes very fast
• No doctor can master the progress of medical science
• Naturally, a doctor's clinical ability will decrease
• Continuous profesional education does not play much role in changing
the behavior and performance of doctors
• EBM maintain lifelong learning behavior
What makes EBM?
• Specifically, EBM is the combination of:
1. Best research evidence
2. Clinical expertise
3. Patient values
• EBM is not “book recipe”
Evidence Based Medicine Triad
Standar Kompetensi Dokter
Konsil Kedokteran Indonesia
5 Information
Management Areas
• 5.1. Main competency
• Access, manage, critically assess the validity and
applicability of information to explain problems, or make
decisions in relation to primary level health services
5.2. Graduates of the
Doctor Able to
• use information and communication technology to help
diagnose, provide therapy, preventive measures and
health promotion, as well as safeguarding, and
monitoring health statusen
• Using information and communication technology (internet) well
• Using data and scientific assessment evidence to assess its relevance
and validity
• Implement research and statistical methods to assess the validity of
scientific information
• Applying basic skills in assessing data to validate scientific
information systematically
• Improve the ability to continuously summarize and save archives
A New Paradigm
for Medical Practice
• Evidence-based medicine de-emphasizes intuition, unsystematic
clinical experience, and patho-physiologic rationale as sufficient
grounds for clinical decision making and stresses the
examination of evidence from clinical research
Steps in EBM
practice
• In evidence-based practice, if problems are found in practice, then:
1. Formulate problems in questional form that can be answered
2. Looking for the best evidence to answer the question
3. Conduct critical appraisal of the evidence found
4. Apply valid and important evidence
5. Evaluate the EBM steps taken and their impact on patients
Formulate problems
in questional form
• Complete clinical questions contain 4 elements:
1. P=patient or problem or population→ patient or patient health
problems
2. I=Intervention or Index or Indicator→ the main intervention to
patient
3. C=Comparator→ Alternative intervention
4. O=outcome → the clinical outcome expected from the intervention
Patient oriented vs
Disease oriented
• POE (patient-oriented evidence)→ related to
mortality, morbidity and quality of life.
• DOE (disease-oriented evidence)→ oriented to
pathophysiology, pathogenesis, biomolecular markers,
pharmacology, etc.
• POE is more relevant to clinical practice, and some can
be applied to patients.
Look for the best evidence to
answer clinical questions
• The best search can use the internett:
Database
Electronic textbook
Journal
www.pubmed.com
www.cochrane.org
www.clinicalevidence.com
www.highwire.org
Critical review of evidence
• Three things that must be explored: VIA
1. Validity: whether methodologically valid?
RAMMbo (Recruitement, Allocation, Maintenance, Measurement-blinded
and objective)
a. Recruitement→Were subjects randomly selected or consecutive
sampling?
b. Allocation→ whether the subject allocation is done randomly?
c. Maintenance→ Are all subjects treated equally? Is there a drop out?
d. Measurement-blinded and objective→ Are outcome measurements done
in a disguised or objective manner?
Critical review of
evidence….cont
2. Importance: is it clinically important?
Seen in the results section. Pay attention to subject
characteristics, mean, mean difference, proportion, relative
risk, odds ratio with confidence intervals.
3. Applicability
Pay attention to the discussion section, as well:
Characteristics of patients faced
Are there drugs, facilities, expertise, costs, etc. for the
application of evidence?
Are there social, cultural, religious values in the application
of evidence?
Apply evidence to patients
• Not all valid evidence can be applied to patients (maybe
the patient's characteristics are different, there may be
no tools or expertise available, the patient may not
agree)
Doctor's
competence
Valid Patients
Evidence value
Evaluate result
• Informal evaluation by reviewing the results of EBM
practices in each patient
• Or formally by evaluate
input (facilities and infrastructure needed),
process (search for evidence, speed and accuracy of
reviewing), and
outcome (clinical results)
Rank of evidence
• In the implementation of EBM there are hierarchy of
evidence strength, for example evidence for therapy:
Rank 1
a. Systematic review (RS) of randomized clinical trials
b. Randomized clinical trials and large samples
c. All or none
Rank 2
a. Systematic review of cohort studies
b. Cohort Study
Rank 3
a. Systematic review of case control studies
b. Case control study
Rank 4
a. Case series
b. Other observational studies
Rank 5
a. Expert opinion, consensus
Why doctors are unwilling
to learn and apply EBM?
• Lacking ability of senior practitioners to do
methodologies, so it is less comfortable to conduct
critical studies
• Limited resources, especially time
• Often there is no good quality evidence
• Some practitioners are skeptic to evidence-based
medical practice
• Feeling satisfied with previous practices
Criticism to EBM
1. EBM makes health care expensive
2. EBM cannot be applied in developing countries
3. EBM requires resources, including time
4. EBM only relies on clinical evidence to deny pathophysiology and logic
5. EBM denies clinical experience and clinical assessment
6. EBM violates professional autonomy
EBM BASED ON VALUE? EBM CASE REPORT?
EBM advantages
• Improve reading habits
• Improve research methodology skills
• Ensure current and rational patient practice and
management
• Reduces intuition and clinical judgment, but does not
eliminate it
• Consent with the ethical aspects and medicolegal
• EBM can, and must be the main basis in government
policy in the health sector
Central issues in clinical work,
where clinical questions
often arise
Diagnostic tests: how to select and interpret diagnostic tests, in order to
confirm or exclude a diagnosis, based on considering their precision, accuracy,
acceptability, expense, safety, etc.
Central issues in clinical work,
where clinical questions
often arise
Therapy: how to select treatments to offer our
patients that do more good than harm and that
are worth the efforts and costs of using them
Prevention: how to reduce the chance of disease
by identifying and modifying risk factors and how
to diagnose disease early by screening
Central issues in clinical work,
where clinical questions
often arise
Prognosis: how to estimate our patient’s likely clinical course
over time and anticipate likely complications of the disorder
Cohort Study
Survival analysis
Case control study
Early
Biologic Clinical
diagnosis Outcome
onset diagnosis
possible
Recovery
Disability
Death
etc
Natural course of disease
Clinical
Trial
CONCLUSION
• The EBM practice cycle requires that in dealing with
practical problems take steps such as: Formulate problems in
questional form that can be answered
1. Looking for the best evidence to answer the question
2. Conduct critical appraisal of the evidence found
3. Apply valid and important evidence
4. Evaluate the EBM steps taken and their impact on
patients
EBM is a framework for using the results of current, valid,
important research and can be applied systematically
Terimakasih
