EVIDENCE BASED MEDICINE

FOR GENERAL PRACTITIONER

AGUS
WIDIYATMOKO

Why do we need EBM?

Stay up to date
Medical information
changes constantly
Unlike bread our
knowledge does
not become visibly
moldy or stale we
just keep using it

Why do we need EBM?

Save LIVES!
Encainide and flecainide for ventricular arrhythmia
Well proven to decrease the number of premature ventricular
beats became widely used 1980s
BUT
Further studies showed significant INCREASE in
MORTALITY died from other cardiac complications and
dysrhythmias ( a dangerous DOE)

Thrombolytics for acute MI

CLEAR evidence of benefit in the 1970s
Not widely recommended until 1988 almost 13 yrs later
How many thousands of people died unnecessarily in the
years in between?

SHIFTING PARADIGM
Scientific/medical
information
Clinical
problems

Evidence-based Medicine

Why do we need EBM?

We want to do the right thing what is
best for our patients
Practice variations that do not make sense
...
Not to doctors
Not to patients
Not to payors
Not to policy makers

validity

Current vs future knowledge

Current

future knowledge

Innovation, development, & diffusion of

Medical technology

Established technology
Late adopters
Obsolete
technology

Early adopters

Clinical trials
Abandoned
technology

First medical use

Innovation

Development

Diffusion

Evaluation

Abandoned technology
Ticrynafen (US, Mei 79 - Mei 80): hepatocelullar
injury (> 500 reports)
Benoxaprofen (April 82-Agustus 82): kematian 61
kasus (cholestatic jaundice) di UK (BMJ)
Zomepirac (Okt 80-Maret 83): reaksi anafilaktoid (N
Engl J Med 1981): 1100 reports
Suprofen (jan 86-Mei 87): flank pain synd (> 300
reports).
Temafloxacin (US, Feb 1992) anemia hemolitik,
disfungsi ginjal, kematian

Abandoned/obsolete
technology
Biopsi paru untuk mendiagnosis pneumonia
Episiotomi untuk tindakan rutin pertolongan
persalinan
Tonsilektomi untuk tindakan operasi rutin
pada tonsilitis
Pemeriksaan USG untuk screening rutin ibu
hamil sbg upaya mencegah outcome
persalinan yang buruk
Pemeriksaan Widal untuk Typhoid

Inovasi obat anihipertensi

% pasien

Proven benefit

80

90

100

110

120

Diastolic blood pressure

130

140

Early diffusion of
anihipertensive

% pasien

benefit

80

90

100

110

120

Diastolic blood pressure

130

140

Wide utilization of
anihipertensive

% pasien

benefit

Low
efficacy

80

Low
efficacy

90

100

110

120

Diastolic blood pressure

130

140

Causes of negative Widal

absence of infection by S typhi
the carrier state
an inadequate inoculum of bacterial
antigen in the host to induce antibody
production
technical difficulty or errors in the
performance of the test
previous antibiotic treatment
variability in the preparation of commercial
antigens

Causes of positive Widal

agglutination tests
the patient being tested has typhoid fever
previous immunisation with Salmonella
antigen.
cross-reaction with non-typhoidal Salmonella.
variability and poorly standardised
commercial antigen preparation
infection with malaria or other
enterobacteriaceae
other diseases such as dengue

best-evidence resources
Dalam format yang dapat memfasiliitasi rapid
searching untuk menemukan jawaban yang tepat atas
pertanyaan-pertanyaan klinik
search engine

electronic

pocket
notebook

Portability
Easy navigation from clinical questions to
evidence-based answers.

So why not get info from textbooks

and review articles?
Texts and review articles?
Dated perhaps by several years
Often heavily biased
Author chooses article that he/she agrees with (or
has written)

May help more with background knowledge

(help me learn about disease) not foreground
(help me answer the specific clinical question for
this patient)

Where to find the best evidence

Burn your (traditional)

textbooks
Revisi, paling tidak 1 tahun sekalli
Padat Referensi yang updated
(khususnya ttg diagnosis and
management)

http://www.bmjpg.com/index.htm
http://www.acponline.co
http://cebm.jr2.ox.ac.uk/eboc/eboc.htm

Invest in evidence databases

EBMR (EB-Medicine Review)
http://www.ovid.com
Evidence-Based Medicine,
Evidence-Based Mental Health
Evidence-Based Nursing,
Cancerlit,
Aidsline,
Bioethicsline and
MEDLINE
+ 200 fulltext journals

http://www.ncbi.nlm.nih.gov/PubMed
http://www.biomednet.comm

The EBM Process

The patient

1. Start with the patient -- a clinical problem or

question arises out of the care of the patient

2. Construct a well built clinical question derived from

the case (PICO)
The resource 3. Select the appropriate resources and conduct a
search
The evaluation 4. Appraise that evidence for its validity (closeness to
the truth) and applicability (usefulness in clinical
practice)
5. Return to the patient -- integrate that evidence with
The patient
clinical expertise, patient preferences and apply it to
practice
Self-evaluation 6. Evaluate your performance with this patient

The question

Types of Questions
Therapy/prevention Question
Prognosis Question
Diagnosis Question

Harm Question

Type of study
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

http://www.hsl.unc.edu/lm/ebm/Supplements/QuestionSupplement.htm

Question Worksheet

Who?
What?
Alternately?
Outcome?
Question?

Type of Question

Therapy
Prognosis
Diagnosis
Harm

Type of Study

But how does EBM REALLY work?

Step 1: Translate clinical scenarios into an
answerable clinical questions
TRUE STORY
My 35 yr old patient was just diagnosed with
dyspepsia
I received laboratory report and he is coming
in to see me tomorrow

What are my questions?

What do I know about DYSPEPSIA?

How common is it?

How can it be treated?
What about family history?
Etc.
These are called background questions

Foreground questions apply to that

specific patient (or population)
After meeting with patient and spouse we find
that he has seen the gastroenterologist who
recommended endoscopy but the patient is
reluctant
35 year old male patient was diagnosed with
dyspepsia wants to know whether to get a treatment.
He is concerned about death from esophageal cancer
and also risks of stomach rupture.

Focusing the Clinical Question

P
patient

Who?

How would I
describe a
group of
patients similar
to mine?

I intervention
What?

Which main
intervention
am I
considering?

comparison

outcome

Alternative
Intervention?
(if necessary)

What is the main

alternative to
compare with the
intervention?

Outcomes

What can I
hope to
accomplish? or
What could this
exposure really
affect?

Examples
P

In men with
dyspepsia
aged 35 years

Endoscopy

OMD

In children
with acute otitis
media
aged 2-4 years

Antibiotics

No treatment except
paracetamol

O
Predictive
value?
Likelihood
ratio?

No pain after
two days?

 Developing the question requires:

Some background knowledge of the condition
Understanding of the patient and what are the
outcomes that matter in this patient

Death?
Disability?
Quality of life? Anxiety, Impotence, etc.
Cost?

Hands on Part 1
Think in your practice THIS session what was
a clinical question you had?
Think of a foreground question (not just a drug dose
or drug interaction)
What diagnostic test would have been best for that patient
with abdominal pain?
What treatment would have been best for the patient with
Dementia?
What about the patient who was asking about acupuncture
for osteoarthritis?

How does EBM REALLY work?

Step 2: Translate question into effective
searches for the best evidence
Requires knowledge of medical informatics
How to search what terms to use, what
types of studies, etc.
Where to search utility of varied sources of
information
Evidence based sources, Texts, Medline,

EBM sources
EBM sources Cochrane, USPSTF,
Clinical Evidence
+ Ideally best information source hard to
argue with, will explicitly state the level of
evidence (weak to strong)
- There may not be any good evidence

Cochrane Database of
Systematic Reviews

ACP Journal Club

Daily POEMS

Database of Abstracts of
Reviews of Effectiveness

Clinical Evidence

DynaMed

How does EBM REALLY work?

Step 3: Critically appraise the evidence
Validity of the evidence
Internal study design, blinding, randomized, sample size,
appropriate statistics, etc.

Relevance of the evidence

Did they measure something pts care about?
Is population similar (enough) to mine?
Is the intervention feasible?

Importance of the evidence

Magnitude of effect or clinical significance?
P values, confidence intervals, relative risk or absolute risk
reduction

 Step 3: Critically appraise the evidence

(cont.)
Requires some knowledge of basic
epidemiology and biostatistics
Sensitivity, specificity, prevalence, likelihood ratios
Absolute risk reduction, relative risk reduction, odds
ratios, number needed to treat

Requires knowledge of study types

ASSUMING THAT IT IS A WELL DESIGNED STUDY
Appropriate sample size, randomization, stats, treatment
allocation, etc., etc.

Meta-analysis of RCTs > RCT > Cohort > Case

Control > Case Series > Case Report

Hierarchy of studies

Step 3 Critical appraisal of

medical literature
This is often confused with EBM
they are not the same thing

This is often the toughest part of EBM

Skipped by many doctors suffering from
photonumerophobia
The fear that ones fear of numbers and statistics will
come to light

This is where most attempts come to a halt

Not enough time and expertise

EBM Databases
Systematic Literature Searches

Cochrane Library (OVID)

BMJ Clinical Evidence

Systematic Literature Surveillance

ACP Journal Club (OVID)

DARE
DynaMed
Medical InfoRetriever

Drilling for the Best Information

Cochrane Library
Clinical Evidence
Clinical Inquiries
Specialty-specific

Usefulness

POEMs

ACP Journal Club

Textbooks, Up-toDate, 5-Minute
Clinical Consult
Journals/
Medline
PubMed

Need to read the key

Levels of Evidence
Level 1: Highest
Level 2:
Level 3:
Level 4:
Level 5: Lowestbut still evidence

Read the key

Levels of Recommendation (USPSTF)
A Highest Strongly recommended (PAP smears)
B Recommended (Mammograms age 40+)
C no recommendation for or against (too close a
balance between harm/benefit) (osteoporosis
screening below age 60)
D Recommend AGAINST (ovarian cancer)
I insufficient evidence to make any recommendation
for or against (Prostate cancer screening)

Other guidelines
A good evidence
B fair evidence
C based on expert opinion and/or
consensus
X evidence of harm

Essential principle
Be ready to surrender to a
higher level of evidence when it
becomes available
Do not become entrenched in what has been
done for years
A bad idea done by a LOT of people for a LONG time,
is still a bad idea

Evidence based information,

recommendations, reviews
Not all that claims to be evidence based, is really EBM
Should include explicit statements about search methods,
findings, appraisal and level of evidence (or strength of
recommendation)

High quality sources

Cochrane, AHRQ, USPSTF, ACP Journal Club, Clinical
Evidence, InfoRetriever

Questionable sources
Developed by BOGSAT methodology
Bunch Of Guys Sitting Around a Table
Sometimes called consensus, argument may be won based on
volume and stamina

How does EBM REALLY work?

Step 4: Implement information into
practice
Integrate information with patients values and
preferences
Patient-centered care

How does EBM REALLY work?

Step 4: Implement information into practice
Integrate information with patients values and
preferences
Patient-centered care
Demographics, age, socioeconomics, fear, etc.

Evidence may point to surgery as better treatment but

patient refuses
This does NOT mean EBM is out the window
Your job is to understand the magnitude of benefit and the
level of evidence
Then translate into useable information for the patient

 As patient participates in care decisions, you

are practicing TRUE evidence based
medicine

OK I am convinced, how can I start to

practice evidence based medicine?
Step 1 Ask the questions
Use your clinical experiences to find 1-2 case
scenarios every day that translate into clinical
questions
Ask your student to help he/she may REALLY appreciate
that you explicitly tried to help find a REAL answer that would
help an actual patient

PICO population intervention comparison outcome

 Use your growing clinical skills but do not

be swayed by YUCKs
Your Unsubstantiated Clinical Knowledge
(and experience)
Regularly seek to find the best available
evidence to guide you
Especially review common topics, you may be
getting stale without realizing it

 Step 2 Search for the evidence

When searching for background
information
Critically appraise your texts for known
problems/biases
Date of publication, references, source

Try to use systematic review articles

Explicit statements of how and where they
searched, and statements of strength of
recommendation of level of evidence

 Step 2 searching (continued)

Locate and regularly use YODAs
Your Own Data Analyzer
Let others do hard work for you
It is their full-time job, do you really have the time and expertise to do
better?

Try InfoRetriever and Clinical Evidence a few times a week

Save your questions on a card and find answers over lunch or end of
the day
Look at the Cochrane reports first
BUT even those may be dated!

 Step 3 Critical Appraisal

Do not fall for three common myths
Newer article, by bigger name, and a famous journal,
does NOT mean it is better

Use three quick tips

Is it relevant first?, dont get overwhelmed by the stats, was it
from YODA?

PRACTICE CRITICAL APPRAISAL of original

research if you do not use it, you will lose it
I often let headlines drive this then I need to know NOW

 Step 4 Integrate into patient care

Take your findings back to your patients
Sometimes this may be 2 minutes later or 2 weeks
later
Discuss how to integrate this into care of your
patient
Tell the patient that you have been looking up the latest
information and they will appreciate it!

 Step 5 Self evaluation how did you do?

Learn to improve your . . .

Framing of the question

Search terms
Search locations
Critical appraisal skills
Patient understanding
Patient centered approach

Questions?