Evidence-Based Medicine

Hai orang-orang yang beriman, jika datang

kepadamu orang fasik membawa suatu
berita, maka periksalah (kebenarannya)
dengan teliti, agar kamu tidak menimpakan
suatu musibah kepada suatu kaum tanpa
mengetahui keadaannya yang menyebabkan
kamu menyesal atas perbuatanmu itu. (Al-
Hujurat: 6)
Objectives
Background
Role
Definiton and Aim
Components
Steps
Level Evidence
Main Area Introduction(diagnosis, therapy, prognosis, harm)
Two fundamental questions
What is the purpose of medicine?
How do I decide what to do?

You have to know where youre going before deciding how to get
there
What is the purpose of medicine?
Patient care
Public health
Research

Improving the quality of

patients lives
What is evidence-based medicine?
Evidence based medicine is the conscientious, explicit, and judicious
use of current best evidence in making decisions about the care
of individual patients.

Sackett, et al. BMJ 1996;312:71-72

 Practice Pradigms
Old paradigm New paradigm

Unsystematic clinical Systematic clinical

experience experience

Pathophysiology Pathophysiology
necessary but not
sufficient

Content expertise & Rules of evidence

authoritarianism
backgorund
EBM is relatively new. The term EBM
became more widely used in the early
1990s, and was later formally defined by
Sackett et al. in 1996.
The practice of evidence based medicine
means integrating individual clinical
expertise with the best available external
clinical evidence from systematic research
Role
finding evidence and using that evidence to make clinical
decisions
A cornerstone of EBM is the hierarchical system of
classifying evidence.
This hierarchy is known as the levels of evidence. Physicians
are encouraged to find the highest level of evidence to answer
clinical questions.
Definiton
"Evidence-based medicine is the integration of
best research evidence with clinical expertise
and patient values."

Sackett, D. L. (2000). Evidence-based medicine: How to

practice and teach EBM(2nd ed.). Edinburgh; New York:
Churchill Livingstone.
 Clinical expertise: the clinicians cumulated
experience, education, and clinical skills

Patient values: The patient brings to the encounter his or

her own personal and unique concerns, expectiations, and
values.

Best Research Evidence: usually found in clinically

relevant research that has been conducted using sound
methodology
 Evidence-Based Medicine (EBM)
Evidence-Based Practice (EBP)
Evidence-Based Clinical Practice (EBCP)
Evidence-Based Health Care (EBHC)
Evidence-Based Nursing (EBN)

Sacketts definition refers to all of these;

EBP and EBHC are more universally used.
EBP:
1. Assess the patient
2. Ask the question
3. Acquire the evidence
4. Appraise the evidence
5. Apply: talk with the
patient
(from Introduction to Evidence Based
Practice tutorial)
EBM:
1. Ask focused question
2. Find the evidence
3. Appraise the evidence
4. Make a decision
5. Evaluate performance
(from Centre for Evidence Based Medicine
www.cebm.net)
Levels of evidence
Level Type of evidence

I Evidence obtained from at least one randomised controlled trial or

from meta-analysis of randomised controlled trials

II Evidence obtained from at least one well-designed controlled study

without randomisation

III Evidence obtained from well-designed non-experimental

descriptive studies, such as comparative studies, correlation studies
and case control studies

IV Evidence obtained from expert committee reports or opinions

and/or clinical experience of respected authorities
Forming a question
Identify key patient problem
Phrased to facilitate finding an answer
What treatment might be considered
Alternative treatments to consider
Outcome to avoid or promote
PICO
P= Patient or problem
I = Intervention, prognostic factor,
or exposure
C=Comparison
O=Outcomes
(T)=Type of Study
Exercises: PICO scenarios
Types of Studies
Case series and Case Reports
Case control studies
Cohort studies
Randomized, controlled clinical trials
Systematic Reviews
Meta-analysis
Case series and Case reports
Collections of reports on the treatment of
individual patients or a report on a single
patient.
No control groups with which to compare
outcomes, so limited statistical validity.
Case control studies

Patients who already have a specific condition are compared

with people without the condition. Researcher looks back to
identify factors or exposures possibly associated with the
condition, often relying on medical records and patient recall.
Less reliable because showing a statistical relationship does
not mean than one factor necessarily caused the other.
Starts with patients who already have the outcome
and looks backwards to possible exposures.
Cohort studies
Take a large population who are already taking a particular
treatment or have an exposure, follow them forward over
time, and then compare for outcomes with a similar group
that has not been affected by the treatment or exposure.
Observational and not as reliable as randomized controlled
studies, since the two groups may differ in ways other than in
the variable under study.
Starts with the exposure and follows patients
forward to an outcome.
Randomized, controlled clinical trials

Carefully planned projects that introduce a treatment or

exposure to study its effect on patients.
Include methodologies that reduce the potential for bias
(randomization and blinding) and allow for comparison
between intervention and control groups.
Is an experiment and can provide sound evidence of cause
and effect.
Randomly assigns exposures and then follows
patients forward to an outcome.
Systematic Reviews

Usually focus on a clinical topic and answer a specific

question. An extensive literature search is conducted to
identify studies with sound methodology. The studies are
reviewed, assessed, and the results summarized
according to the predetermined criteria of the review
question.
Meta-analysis

Thoroughly examines a number of valid studies on a topic

and combines the results using accepted statistical
methodology to report the results as if it were one large
study.
The Cochrane Collaboration has done a lot of work in the
areas of systematic reviews and meta-analysis.
 Research Design

Diagnostic tests Cross sectional study

Prognosis Cohort study

Therapy RCT

Patients Preferences Qualitative research

BMJ 1997;315:1636