EBM : An Overview

dr. Agus Susiloningsih

11/26/2007 10:22 PM

Key points in this overview

What is EBM? What is best evidence mean? What is clinical expertise mean? What is patients value mean? Why EBM? What are the barrier to practice EBM? What are the steps to practice EBM? What are the kind of the clinical questions? What kind of the evidences you are looking for? What are the hierarchy/ level of evidence?

11/26/2007 10:26 PM

Key points in this overview

Where do you can find the best evidence? How can you identify the best evidence? What are the principal questions to appraise the evidence? What should you do if you cant find the best evidence?

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What is EBM?

EBM is the integration

of best research evidence with clinical expertise and patient values

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What is the best research evidence?

relevant
Bukti ilmiah dari penelitian yang relevan dengan klinis (t.u. patient-centered clinical research)

valid

Bukti terbaru yang lebih valid dapat menggantikan bukti sebelumnya. (More accurat, powerful, efficacious, safer)

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Hierarchy of evidence
Quality 1a (best) 1b 1c Type of evidence Systematic review of randomized controlled trials Individual randomized controlled trials with narrow confidence interval All or none case series (when all patients died before a new therapy was introduced, but patients receiving the new therapy now survive) Systematic review of cohort studies Individual cohort study or randomized controlled trials with <80% follow up Outcome research; ecological studies Systematic review of case-control studies Individual case-control study Case series

2a 2b 2c 3a 3b 4

5 (worst) Expert opinion

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What is Clinical expertise mean?

Kemampuan untuk mengidentifikasi dengan cepat permasalahan/ kondisi pasien serta nilai yang dipegang dan harapannya.

skill

experi ence

Pengalaman sebelumnya dalam menghadapi permasalahan pasien.

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What is patient value mean?

Preferences yang dipilih/ diinginkan

Concerns yang menjadi perhatian

expectation yang diharapkan

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Evidence-based medicine practice

Best available evidence

Clinical expertise, experience, skills and judgment EBP

Client needs, values and preferences

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WHY THE INTEREST IN EBM?

1. Our daily need for valid information about diagnosis, prognosis, therapy, and prevention (up to five times per inpatient and twice for every three outpatients). The inadequacy of traditional sources for this information because they are out of date (textbooks), frequently wrong (experts), ineffective (didactic continuing medical education), or too overwhelming in their volume and too variable in their validity for practical clinical use (medical journals).

2.

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WHY THE INTEREST IN EBM?

3.

The disparity between our diagnostic skills and clinical judgment, which increase with experience, and our up-to-date knowledge and clinical performance, which decline. Our inability to afford more than a few seconds per patient for finding and assimilating this evidence or to set aside more than half an hour per week for general reading and study.

4.

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FIVE RECENT DEVELOPMENTS

1. The development of strategies for efficiently tracking down and appraising evidence (for its validity and relevance). The creation of systematic reviews of the effects of health care (epitomized by the Cochrane Collaboration). The creation of evidence-based journals of secondary publication (which publish the 2% of clinical articles that are both valid and of immediate clinical use) and of evidencebased summary services such as Clinical Evidence.

2.

3.

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FIVE RECENT DEVELOPMENTS

4. The creation of information systems for bringing the foregoing to us in seconds. The identification and application of effective strategies for lifelong learning and for improving our clinical performance.

4.

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The 5 steps of EBP

1. Ask an answerable question
2. Access the appropriate evidence 3. Appraise the evidence

4. Apply the results to clinical practice

5. Evaluate your practice

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1. Formulasi pertanyaan (PICO)

Terjemahkan masalah klinik dalam pertanyaan terstruktur dan identifikasi konsep kunci

Patients or problem Intervention(s) Comparison(s) Outcomes

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Identify clinical questions:

central issues in clinical work Therapy or Intervention treatments to patients that - do more good than harm - are worth the efforts and costs of using them Prognosis patients likely clinical course over a time and complications of the disorder

Etiology causes or risk factors of disease

Diagnosis - possible causes of patients clinical problems

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2. Penelusuran/ pencarian bukti ilmiah

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What type of research to look for?

If the question is about Look for a systematic review or

Intervention/Therapy

Randomised controlled trial (RCT) Cohort Studies RCT

Diagnosis/Screening -Accuracy -Health Outcomes Prognosis

Longitudinal cohort studies

Etiology/Risk factors

RCT, cohort or case-control study

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Where to search?
The Cochrane database (www.thecochranelibrary.com) Collection of databases of high quality information about health care intervention, including systematic reviews Prepared by Cochrane collaboration a not-for-profit organisation which aims to help people make well-informed about healthcare PubMed (www.pubmed.gov) Specialised Medline search engine with built-in search filters to find high quality studies in 4 study categories: prognosis, therapy, etiology, diagnosis DynaMed (www.dynamicmedical.com) A database designed to help making clinical decision at the point of care Medline database (medline dan Dynamed dapat diakses melalui search.ebscohost.com)

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3. Telaah kritis terhadap bukti

Telaah tentang validitas, impact (besarnya efek), dan aplikabilitasnya. Worksheet/ tools yang sesuai jenis jurnal Memerlukan skill khusus

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4. Penerapan bukti ilmiah

Pengaplikasian Bukti yang terpercaya (Hasil telaah kritis) dalam praktek (pasien) Memerlukan clinical expertise dan mempertimbangkan patiens values

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5. Evaluasi Penerapan bukti ilmiah

Menilai effectiveness dan efficacy dari penerapan bukti ilmiah terpercaya Tujuan : meningkatkan kualitas pelayanan.

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Barriers to applying the best available evidence

Growing volume of research information about health care Keeping up to date Time Topic threatening if critical appraisal skills poor Basic knowledge and skills needed Evidence often poor or none Lack of evidence is anxiety provoking Cookbook medicine has its appeal

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Obstacles to practicing EBM in developing countries

Limited access to literature databases Limited access to adequate library facilities Questionable applicability of journal articles that are eventually retrieved Inexperience in small-group learning Lack of time to attend workshops Lack of role models for practicing EBM

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Key points dalam critical appraisal

Tentukan jenis jurnal (find out it in the abstract) Tentukan worksheet yang sesuai jenis jurnal Baca dengan cepat keseluruhan isi jurnal, jika sesuai dengan yang diharapkan lakukan critical appraisal secara teliti (sesuai worksheet) 3 pertanyaan mendasar dalam critical appraisal : 1. Are the results of this study valid? 2. Are the valid results of this study important? 3. Are the valid and important results of this study applicable to our patient?

11/26/2007 10:26 PM

Key points dalam critical appraisal (lanjt...)

Are the results of this study valid? Lihat di bagian pendahuluan, material (participant) and method, results (flow chart of participants) Are the valid results of this study important? Lihat di bagian hasil (tables, flow charts, figures) dan discussion Are the valid and important results of this study applicable to our patient? Lihat di bagian method-participant (inclusion criteria and exclusion criteria), bandingkan dengan setting dan kondisi pasien kita. What are our patients preference, concern dan expectation? Pertimbangkanlah keuntungan dan kerugiannya!

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Key points dalam EBM practice

Are the results of this study valid? Jika hasil tidak valid, maka ganti/ cari bukti ilmiah lain yang valid Are the valid results of this study important? Meski valid tapi jika tidak penting/ tidak ada manfaatnya bagi kepentingan klinis, ganti bukti ilmiah yang penting. Are the valid and important results of this study applicable to our patient? Meski valid dan penting, tetapi jIka tidak dapat diaplikasikan, cari bukti ilmiah yang lain yang sesuai dengan setting dan kondisi pasien kita.
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Alhamdulillaahirobbil alamin

11/26/2007 10:22 PM