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Evidence-Based Medicine
(”Bringing research evidence into practice”)
Sudigdo Sastroasmoro
(s_sudigdo@yahoo.com)
Fakultas Kedokteran Universitas Indonesia
Evidence-based Medicine
• Opinion-based medicine
• Experience-based medicine
• Power-based medicine
• Hope-based medicine
• Logic-based medicine
• Erratic-based medicine
Evidence-based Medicine
• Medicine-based evidence
• Pragmatic research
• Outcome research
Quality
Value =
Cost
Diagnosis
• Patient with complaint
• History
• Physical
• Simple test
• Specific test
Yes or no answer
Predictive value is the most important
The spectrum of the presentations must
resemble that in practice
Treatment
• Patient with certain diagnosis
• Does drug X more effective than Y?
• Focus on the outcome, rather than its
explanation (biomolecular markers)
• Yes or no outcome most useful
Prognosis
• Usually in cohort studies
• To inform the patient about the fate of the
patient
• Absolute risk is more important than relative
risk
– Absolute: Your risk of having second stroke in 1 year is
30%
– Relative: Your risk of having second stroke in 1 year is 2
times than in non-smokers (RR = 2)
EBM
• Started in early 90’s by clinical
epidemiologists
• 1992 : only few articles on EBM
• 2000 : >1000 articles
• Indonesia : started in 1997
• Workshops : Yogya (2000)
IKA FKUI (2000, 2001, etc)
• Group discussion on EBM / mailing list:
<ebm-f2000@yahoogroups.com>
EBM & Clinical Epidemiology
• Trust me
• In my experience ….
• Logically
• Textbook, handbook, capita selecta
The results….
“Opinion-based medicine”
• Steroid inj. in prematures to prevent RDS
• Routine episiotomy
• Routine circumcision
• Antibitotics for flu-like syndrome
• Use of immunomodulators
• “Skin test” before antibiotic injection
• Routine chest X-ray for pre-op preparation
• CT scan after minor head trauma
• etc ……
What is
Evidence-based Medicine?
• “The conscientious, explicit, and judicious use of
current best evidence in making decisions about
the care of individual patients”
• “Pemanfaatan bukti mutakhir yang sahih dalam
tata laksana pasien”
• Integration of (1) physician’s competence
(2) valid evidence from studies
(3) patient’s preference
• Pros : “New paradigm in medicine”
• “Extraordinary innovations,
• only 2nd to Human Genome Project”
• Cons : New version of an old song
• ‘Fair’ : Nothing wrong with EBM, but:
• Be careful in searching evidence
• Meta-analyses, clinical trials, and all study
results should be critically appraised
• Keyword for EBM:
• Methodological skill to judge the validity of study
reports (Re. Andersen B: Methodo-logical errors in
medical research, 1989)
100%
THE SLIPPERY SLOPE
Relative $
% of
remaining
knowledge
2 4 6 8 10 12
Treatment
(Intervention necessary to help the patient)
Prognosis
(Prediction of the outcome of the disease)
• A 2-year old boy diagnosed presented with 6-
day high fever, conjunctival injection without
secretion, skin rash> blood test shows
leukocytosis, high ESR, CRP +++. He was
suspected to have Kawasaki disease. The
pediatrician is aware of the use of
immunoglobulin to prevent coronary
involvement, but uncertain about the dosage.
Medical students:
(Background question)
Background
questions
B e b r i e f a n d s p e c i f i c
Relevance: Type of Evidence
• Patient-Oriented
• Evidence
Comparing DOES and POEMs
Non-Randomized trials B
Observational studies Level 3
Patient’s values
Valid evidence
Patient
With problem
Apply Formulate
The evidence In answerable
question
Critically
Appraise Search the
The evidence evidence
Criticism to EBM
• EBM makes expensive medical care
• EBM cannot be implemented in developing
countries
• EBM is costly and time consuming
• EBM ignore pathophysiology & reasoning
• EBM ignore experience and clinical judgment
• EB-guidelines etc interfere with professional
autonomy
Criticism to EBM
EBM makes expensive medical care
Cf:
– Routine antibiotics for ARTI & diarrhea
– Liberal indication for C-section
– Unnecessary sophisticated procedures
/ exams
– Unnecessary / harmful treatment:
steroid for recurrent cough
Criticism to EBM