Evidence based medicine

By dr. Balgis MSc.

CM FM.
 The science of medicine
is continuously changing
if we do not adapt to
this change, the
following might happen;
a. We may have not give
our patient effective
treatments
b. We may have wasted
precious resources.
 Old model of decision making
• The traditional model of medical education
depended on learning collection facts,
principles and rules of thumbs that would
serve individual for a professional life.
• The method; passive dissemination of
information (didactic lecture in large
session halls)
• The “ Professor” or the “ Expert” become
the standard source of information for
decision making
• Problem can be answered by asking
colleagues and local expert, reading text
books ( out of date by the time they are
published), or browsing journals (but which
journal should you look at)
New model of medical decision making
There is now a strong trend towards
the view that medical education should
be lifelong, oriented towards problem
solving and based on the principle that;
1. Clinical experience is important but
observations must be recorded
systematically and without bias
2. Regular reference must be made to
original literature
3. The results of studies must be
critically examined using rules of
evidence before applying it to practice
Evidence-Based Medicine
Definition

“the conscientious,
explicit and judicious
use of current best
evidence in making
decisions about the care
of the individual
patient”
 WHY EBM?
1. New evidence are continuously generated
2. We usually fail to get the new evidence
3. Our clinical performance deteriorates with
time (“the slippery slope”)
4. Traditional CME does not improve clinical
performance
5. EBM encourages self directed learning
process which should overcome the above
shortages

SS/EBM/MRU/02-04
 Dr Sydney Burwell, Dean of Harvard
Medical School

 “My students are dismayed when I

say to them “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.”

SS/EBM/MRU/02-04
 100%

Relative $
% of
remaining
knowledge

2 4 6 8 10 12

Years after graduation

THE SLIPPERY SLOPE

SS/EBM/MRU/02-04
• EBM seeks to de-emphasize intuition,
unsystematic clinical experience, and
pathophysiologic rationale and
stresses the examination of evidence
from clinical research
The practice of EBM requires the integration of
 individual clinical expertise and patient values

with the
 best available external clinical evidence from
systematic research.
    
Best Clinical Evidence

Clinical Patient’s Needs/

Experience Preferences
 What evidence-based
medicine is:
• Good doctors use both individual clinical
expertise and the best available external
evidence, and neither alone is enough.
– Without the former, practice risks becoming
evidence-tyrannised, for even excellent
external evidence may be inapplicable or
inappropriate for an individual patient.
– Without the latter, practice risks becoming
rapidly out of date, to the detriment of
patients and patient-care.
 Evidence-based medicine is
not “cook-book” medicine:
• Patients cannot go through a ‘treatment
tunnel’ assuming the same management is
appropriate and the same outcomes important
to each (patient’s unique biology and values)
• External clinical evidence can inform, but can
never replace, individual clinical expertise
• Your clinical accumen decides whether the
external evidence applies to the individual
patient at all and, if so, how it should be
integrated into a clinical decision.
Evidence-based medicine is
not “cost-cutting” medicine:
• The aim is to give most benefit to
each individual patient
• To apply the most efficacious
interventions which will maximise
their function, quality, and quantity of
life
• may raise rather than lower the cost
of their care.
 EBM is neither old-hat nor
impossible to practice:
• The former argument falls before the evidence:
– of striking variations in the integration of
patient values into our clinical behaviour
– of striking variations in the rates with which
clinicians provide interventions of established
benefit and uselessness to their patients.
– in the inability of clinicians to keep abreast
of important medical advances reported in
primary journals
The patient 1. Start with the patient -- a clinical problem or question
arises out of the care of the patient

The question 2. Construct a well built clinical question derived from the
case  and classify it into one category

The resource 3. Select the appropriate resource(s) and conduct a search

The evaluation 4. Appraise that evidence for its validity (closeness to the
truth) , importance and applicability (usefulness in clinical
practice)
The patient 5. Return to the patient – Make a clinical dicesion to apply
or not to apply the result of the study /integrate that
evidence with clinical expertise, patient factors to carry out
the dicesion
Self-evaluation 6. Evaluate your performance with this patient
 Types of Questions
Diagnosis Question
Therapy
/prevention Question
A question concerning
the ability of a test to
A question concerning the effectiveness predict the likelihood of a disease
of a treatment or preventative measure

A question concerning outcome of

Harm Question
A patient with a particular condition

A question concerning the likelihood

Prognosis Question
of a therapeutic intervention to cause harm
 Information sources - where to search?

• Expert opinion • Library

• Synthesis journals
• Textbooks • Medical journals
• The Cochrane • Grey literature
 Search for the Best Evidence
• Review articles
• Community/professional standards
• Systematic reviews
• Original results
 “Best Available Clinical Evidence”
• Therapy
– Double-blind, placebo-controlled, randomized clinical trial
• Diagnosis
– Independent, blind comparison with a reference standard
• Prognosis
– Representative and well-defined prospective cohort of patients
at a similar point in the course of disease

• See Centre for Health Evidence

Type of Question Suggested best type of Study

Therapy RCT>cohort > case control > case series

Diagnosis Prospective, blind comparison to a gold standard
Etiology/Harm RCT > cohort > case control > case series
Prognosis Cohort study > case control > case series
Prevention RCT>cohort study > case control > case series
Clinical Exam Prospective, blind comparison to gold standard
Cost Economic analysis
Evidence Pyramid

Meta-Analysis

Systematic Review

Randomized Controlled Trial

Cohort studies

Case Control studies

Case Series/Case Reports

Animal research
 Levels of Evidence
• Level 1: Randomized Clinical Trials
• Level 2: Head to Head Trial or
Systematic Review of Cohort Studies
• Level 3: Case-Control Studies
• Level 4: Case-series
• Level 5: Expert Opinion
 Levels of Evidences
(I-1) a well done systematic review of 2 or more RCTs
(I-2) a RCT
(II-1) a cohort study
(II-2) a case-control study
(II-3) a dramatic uncontrolled experiment
(III) respected authorities, expert committees, etc..
(IV) ...someone once told me....
– http://www.phru.org/casp/
– See also AAFP
Conducting an efficient computer-
aided literature search
• Physicians as primer clinical decision makers have
significant impact on the cost and quality of care.
• The current information explosion in medicine makes
it progressively more difficult for physicians to
access the information necessary to make intelligent
and cost effective clinical decisions
• What is needed is a new model of medical knowledge
acquisition that emphasizes the important of
knowledge seeking skills and the ability of widely
available computer technology to augment the
physician cognitive potential.
• As example the use of computer technology to
support the physician’s need for medical knowledge is
the retrieval of information from a wide variety of on
line medical database such as MEDLINE
 MEDLINE

• Is the largest database of publication in health-related topics

and most widely used medical bibliographic available in the
market
• Covering years since 1966
• It is being maintained by US National Library of Medicine
• Indexing journals only
• ± International coverage
• It covers more than 4800 journal derived from 70 countries
around the world and 75% of the articles are in english.
 From the guru of EBM -
‘MEDLINE is the best general source of
current best evidence at present because of
its breadth and constant maintenance. Thus,
it is important to evidence-based practice
that clinicians develop and hone MEDLINE
searching skills and acquire local access.’

Evidence-based Medicine: how to practice & teach

EBM - Sackett D L et al 1998
 Clinical scenario
• Patients usually come in to the clinic for problems.
Unfortunately these problem are vague and sometimes not
clearly stated.
• To state the problem clearly, you must bear in mind that
there are only three important elements that the patient
want to know
1. What their disease are
2. What treatment they should
be given
3. What is the result to expect
It is essential for medical and health
practitioners to have the correct
information before knowledge can be
created or translated.
• Before attempting to
search for the evidence
in the literature,
construct a well-built or
clearly structured
question that could be
broken into the
following four parts
Three important elements in clinical
research are baically
• PICO analysis):
• PIO analysis):
• P - Patient/Population
• P - Patient/Population • I - Intervention
• I - Intervention • C – Comparison
• O - Outcome • O - Outcome

Some time the researcher

can add Method
 The Boolean Principle
• The venn diagram depicts 3 sets
• Which are designated as setA, set B,
set C
• Each set has contents which are
referred to elements
• The element consist of some numbers.
• Note that the different sets
haveoverlapping elements
• Boolean logic can be used to express the
relationships between the various sets in
this diagram, or to identify specific
elements.
• This achieved using connectives ”AND”
or “OR”. The union between set A and
Set B can be expressed in Boolean logic
as
A OR B
in the diagram, this would be
represented by elements 1,2,3,4,5 and 6
 OR is MORE
• The union between set A and
Set B can be expressed in
Boolean logic as
A OR B
in the diagram, this would be
represented by elements
1,2,3,4,5 and 6
BOOLEAN LOGIC
OR

HEART DISEASES HYPERTENSION

2. The Intersect of sets A and B can
be expreseed as
A AND B
in the diagram, this would be
repsented by elements 2 and 3.
 Note that unions / OR tend to
increase the number of elements
included, while Intersects / AND
tend to do the opposite
 BOOLEAN LOGIC
• AND

HEART HYPER
AND TENSION
DISEASES

Query:    I'm interested in the relationship between heart disease and

hypertension
 BOOLEAN LOGIC
Eliminate certain terms
from search

• NOT
Not
CONGENITAL
HEART HEART
DISEASES DISEASES

Query:    I want to see information about heart disease , but

I want to avoid about congenital heart disease
• To make things more exciting, brackets “()” can help us
use unions and intersects in the same expression for
example:
( A AND B) OR C
would refer to elements 2,3,4,6 and 7 but the similar
expressions
A AND (B OR C)
would refer to elements 2,3, and 4.
 Combining words
• As well as using the boolean
operators to combine words, there
are other ways of connecting search
terms to narrow down your results.
This is a highly effective way of
making your results more specific and
relevant and most databases offer
this in one form or another, so look
out for it.
 Phrase searching
• A technique that narrows your search
down by searching for an exact phrase or
sentence.
• It is particularly useful when searching for
a title or a quotation. Usually speech marks
are used to connect the words together.
For example “Towards a healthier
Scotland” will find results which contain
that phrase. Some search tools may use
(brackets) or 'single quote marks' rather
than speech marks
Truncation / wildcard searching

• These search techniques used to retrieve

information on similar words or all
variations of a word.
• Truncation symbols vary from database to
database, so check what is used.
; common symbols include *, ?, #.
 Truncation / wildcard searching
• In truncation the end of the word is replaced. For
example physiother* will retrieve physiotherapy,
physiotherapeutic, physiotherapist and so on.
• In wildcard searching, letters from inside the word are
replaced. For example wom*n with retrieve the terms
woman and women.
 Focusing a search
• There are many ways to focus your search and all
search tools offer different ways of doing this.
Check the help facilities if the options are not
immediately obvious. Some of the ways of limiting
your search are as follows:
• Age groups
• Language
• Year of publication
• Place
• Publication type
• Human/animal
 Still too much?
• Use the most specific subject
headings
• Use focus
• Use subheadings
• Use AND
• Use limits
• Restrict textword searching to title
 Or too little?
• Use OR
• Use explode
• Use All Subheadings
• Don’t use focus
• Consider synonyms, alternative
spellings or truncation
 Or too little?
• Use OR
• Use explode
• Use All Subheadings
• Don’t use focus
• Consider synonyms, alternative
spellings or truncation
 Clinical Scenario
• Supposing a patient with hypecholesterolemia came
into your clinic and asks for an anti-cholesterol
drug because he wants to avoid sudden death.
• How you formulate the problem
Types of questions

• If you stated your

problem as” among
patients with
hypercholesterolemia
will anti-cholesterol
drug prevent sudden
death’
 The key concepts
• 1. hypercholesterolemia
• 2. Anti-cholesterol OR statin
• 3 sudden death
 Type these word in the MEDLINE
• Term Articles
1. Hypercholesterolemia 34.089
2. Anti-cholesterol OR statin 12.343
3. Sudden death 102.367

Naturally, I don’t have time to read thousands of articles! So I

limit my serach further to
4. #1 AND #2 AND #3 1.835
Still a lot of articles to read, so I added some limiters like
focusing only on randomized controlled trials
5. Randomized controlled trial 6.098
6. #4 AND #5 12
I scanned the titles and come up with one study to read and
confident that this study is the most recent, up todate
and relevant
• Buat kalimat tanya kmd klasifikasikan
dlm 1 kategori apakah terapi atau
diagnostik atau yang lain nya
• Buat PIO /PICO dan kata kunci
• Tentukan jenis penelitian terbaik
untuk setiap kategori
• Kmd mencari artikel / bukri ilmiah
terbaik melalui Pubmed, cochrane dll
• Gunakan logic booleaan dan limit scr
bijaksana dlm pencariaan artikel