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INTRODUKSI
EVIDENCE BASED MEDICINE
Joewono Soeroso
Unit Epidemiologi Klinis FK Unair
Sub-Bagian Reumatologi-Lab-SMF I. Penyakit Dalam
FK Unair-RSUD Dr. Sutomo
Subject
Tutor
1.
2.
3.
4.
5.
6.
UTS
7.
UAS
Individual
Act local
Think global
Do not hesitate
Do do and do.
Metode Penelitian
Epidemiologi
Bio-statistika
Ekonomi klinis
Ilmu sosial
What is EBM?
Objective of EBM
Research
Better Quality of
Life
patient 2
patient 3
patient 4
patient 5
cured
Does this antibiotic work well?
not cured
Research 2
Epidemiology
the study of the distribution and
determinants of health related
events, and the application of this
study to control health problems
(Last, 1988)
Tujuan
Meningkatkan efisiensi diagnosis, terapi
dan prognosis
Tetap mengikuti perkembangan
IPTEKDOK
Meningkatkan kuantitas dan kualitas
penelitian
area penelitian
biologic onset
(patobiology)
early diagnosis
possible
usual clinical
diagnosis
Dx
Risk factors
(Causation)
End Points
sembuh
komplikasi
cacad
mati
Prognostic
Diagnostic
Screening
Factors
test
Clinical Trials
Diagnostic
Therapy
Clinical Trials
Clinical Trials
test
Prevention I
Prevention II
Critical Appraissal
Causation
Screening
Diagnosis
Therapy
Prognosis
Quality of Care (Clinical
auditing)
Economic Analysis
Summary of EBM
original articles
(we dont know the quality yet)
critical appraisal
Clinical expertise
Science
Logics
Knowledge
Experience
Valid evidence
Quantitative methods
Clinical expertise
Art
Beliefs
Judgments
Intuition
CONTOH PENERAPAN
EFISIENSI DIAGNOSIS
Studi Kasus
tk. Becak, 30 th
leukemia akut
trombosit 5.000/mm3
Sepsis kmd timbul
koma dan lateralisasi
Perlu CT
Scan?
pria 42 tahun
splenomegali-asites
bili total 2.5 mg%
albumin 1.8 mg%
globulin 4.7 mg%
Perlu
USG?
Kuantifikasi Diagnosis
Metode nilai prediktif
anamnesis & pem. fisis cermat
tahu sensitivitas (Sn) dan spesifisitas
(Sp)
tes Dx terhadap gold standard
pengolahan dalam tabel 2 x 2
Kasus I
pria 55 th, nyeri dada kiri, menjalar
merokok 2 pak /hari
T 180/110, gallop +
kolesterol 358 mg%
probabilitas (prates) menderita PJK
Perlu treadmill???
(90%)
NILAI PREDIKTIF
dari TES DIAGNOSTIK
Positive predictive value
Probabilitas untuk menderita suatu
penyakit jika hasil tes positif
Negative predictive value
Probabilitas untuk tidak menderita
suatu penyakit jika hasil tes negatif
Kasus I
PJK
+
tredmil
prob. pascates
540
549
360
91
451
900
probab (prates) PJK
100
540
----- =
549
91
----451
98% +8%
21%
1000
90%
98% (pascates)
Kasus II
pria 35 th, nyeri epigastrium
tidak merokok
T 120/80 ; fisik d.b.n.
lab : normal
probabilitas (prates )menderita PJK( 5 %)
Kasus II
PJK
(angiografi koroner)
tredmil
30
86
= = 26% +21%
116 30/116
20
864
884
50
950
5%
prob. pascates
1000
26% (pascates)
Kasus III
pria 45 th, nyeri dada kiri-tidak khas
merokok 1 pak /hari
T 120/80
lab: normal
probabilitas (prates ) PJK ( 50%)
Kasus III
PJK
(angiografi koroner)
tredmil
300
45
= = 87% +37%
345 300/345
200
455
500
500
prob. pascates
1000
87%(pascates)
Kesimpulan
Predictive Value Method
tredmil
Threshold Model
of Pauker & Kassirer
DONT TEST
DONT TREAT
0%
25%
TREAT
65%
PRETEST PROBABILITY
100%
Bacaan Wajib
Pitono Soeparto et al Epidemiologi Klinis. Seri Gramik FK Unair 1998
Sackett DLS, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology,a basic
science for clinical medicine 2nd ed. Boston/:Little,Brown Company, 1991
Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology. The
essentials.William and Wilkins 1985
Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research,
Quantitative methods, California:Life time Learning Publications, 1982
Sackett DLS Teaching Evidence Based Medicine, Churchill Living Stone, 1998
Geyman et al Evidence Based Clinical Practice, Butterworth-Heineman 2000