3. keputusan klinis & evidence based medicine

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  • 8/14/2019 3. Keputusan Klinis & Evidence Based Medicine

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    Syahrul

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    Evidence-based medicine

    (EBM)

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    Evidence-based medicine (EBM) orevidence-basedpractice (EBP) aims to apply the best availableevidence gained from the scientific method toclinical decision making . It seeks to assess the strength of evidence of the risksand benefits of treatments (including lack oftreatment) and diagnostic tests. Evidence quality can range from meta-analyses andsystematic reviews of double-blind , placebo-controlled clinical trials at the top end, down toconventional wisdom at the bottom.

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    http://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidencehttp://en.wikipedia.org/wiki/Scientific_methodhttp://en.wikipedia.org/wiki/Decision_makinghttp://en.wikipedia.org/wiki/Therapyhttp://en.wikipedia.org/wiki/Meta-analyseshttp://en.wikipedia.org/wiki/Systematic_reviewshttp://en.wikipedia.org/wiki/Double-blindhttp://en.wikipedia.org/wiki/Placebo-controlledhttp://en.wikipedia.org/wiki/Placebo-controlledhttp://en.wikipedia.org/wiki/Clinical_trialshttp://en.wikipedia.org/wiki/Conventional_wisdomhttp://en.wikipedia.org/wiki/Conventional_wisdomhttp://en.wikipedia.org/wiki/Clinical_trialshttp://en.wikipedia.org/wiki/Placebo-controlledhttp://en.wikipedia.org/wiki/Placebo-controlledhttp://en.wikipedia.org/wiki/Placebo-controlledhttp://en.wikipedia.org/wiki/Double-blindhttp://en.wikipedia.org/wiki/Double-blindhttp://en.wikipedia.org/wiki/Double-blindhttp://en.wikipedia.org/wiki/Systematic_reviewshttp://en.wikipedia.org/wiki/Meta-analyseshttp://en.wikipedia.org/wiki/Meta-analyseshttp://en.wikipedia.org/wiki/Meta-analyseshttp://en.wikipedia.org/wiki/Therapyhttp://en.wikipedia.org/wiki/Decision_makinghttp://en.wikipedia.org/wiki/Scientific_methodhttp://en.wikipedia.org/wiki/Evidencehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practicehttp://en.wikipedia.org/wiki/Evidence-based_practice
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    EBM/EBP recognizes that many aspects ofhealth care depend on individual factors such asquality- and value-of-life judgments, which areonly partially subject to scientific methods.EBP, however, seeks to clarify those parts ofmedical practice that are in principle subject toscientific methods and to apply these methodsto ensure the best prediction of outcomes inmedical treatment, even as debate continuesabout which outcomes are desirable.

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    http://en.wikipedia.org/wiki/Quality_of_lifehttp://en.wikipedia.org/wiki/Value_of_lifehttp://en.wikipedia.org/wiki/Predictionhttp://en.wikipedia.org/wiki/Predictionhttp://en.wikipedia.org/wiki/Value_of_lifehttp://en.wikipedia.org/wiki/Value_of_lifehttp://en.wikipedia.org/wiki/Value_of_lifehttp://en.wikipedia.org/wiki/Value_of_lifehttp://en.wikipedia.org/wiki/Value_of_lifehttp://en.wikipedia.org/wiki/Quality_of_lifehttp://en.wikipedia.org/wiki/Quality_of_life
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    Evidence-based medicine categorizes different typesof clinical evidence and rates or grades themaccording to the strength of their freedom from thevarious biases that beset medical research. For

    example, the strongest evidence for therapeuticintervention s is provided by systematic review ofrandomized , triple-blind , placebo-controlled trials with allocation concealment and complete follow-upinvolving a homogeneous patient population andmedical condition. In contrast, patient testimonials,case reports, and even expert opinion have little valueas proof because of the placebo effect, the biasesinherent in observation and reporting of cases,difficulties in ascertaining who is an expert, and more.

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    http://en.wikipedia.org/wiki/Randomized_trialhttp://en.wikipedia.org/wiki/Triple-blindhttp://en.wikipedia.org/wiki/Placebo-controlled_studieshttp://en.wikipedia.org/wiki/Randomized_trialhttp://en.wikipedia.org/wiki/Triple-blindhttp://en.wikipedia.org/wiki/Placebo-controlled_studieshttp://en.wikipedia.org/wiki/Placebo-controlled_studieshttp://en.wikipedia.org/wiki/Placebo-controlled_studieshttp://en.wikipedia.org/wiki/Placebo-controlled_studieshttp://en.wikipedia.org/wiki/Triple-blindhttp://en.wikipedia.org/wiki/Triple-blindhttp://en.wikipedia.org/wiki/Triple-blindhttp://en.wikipedia.org/wiki/Randomized_trial
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    Systems to stratify evidence by quality have been developed,such as this one by the U.S. Preventive Services Task Force forranking evidence about the effectiveness of treatments orscreening .

    Level I: Evidence obtained fr om at least one properly designedrandomized controlled trial .Level II-1: Evidence obta ined from well-designed controlled trialswithout randomization .Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center orresearch group.Level II-3: Evidence obtained from multiple time series with or withoutthe intervention. Dramatic results in uncontrolled trials might also beregarded as this type of evidence.Level III: Opinions of respected authorities, based on clinical experience,

    descriptive studies, or reports of expert committees.14/11/2013 6

    http://en.wikipedia.org/wiki/US_Preventive_Services_Task_Forcehttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Randomizationhttp://en.wikipedia.org/wiki/Randomizationhttp://en.wikipedia.org/wiki/Case-controlhttp://en.wikipedia.org/wiki/Cohort_studyhttp://en.wikipedia.org/wiki/Case-controlhttp://en.wikipedia.org/wiki/Case-controlhttp://en.wikipedia.org/wiki/Case-controlhttp://en.wikipedia.org/wiki/Case-controlhttp://en.wikipedia.org/wiki/Case-controlhttp://en.wikipedia.org/wiki/Cohort_studyhttp://en.wikipedia.org/wiki/Randomizationhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/US_Preventive_Services_Task_Force
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    The UK National Health Service uses a similar system with categorieslabeled A, B, C, and D. The above Levels are only appropriate for treatmentor interventions; different types of research are required for assessingdiagnostic accuracy or natural history and prognosis, and hence different"levels" are required. For example, the Oxford Centre for Evidence-based

    Medicine suggests levels of evidence (LOE) according to the study designsand critical appraisal of prevention, diagnosis, prognosis, therapy, andharm studies.

    Level A: Consistent Randomised Controlled Clinical Trial , cohort study , all ornone (see note below), clinical decision rule validated in different populations.Level B: Consistent Retrospe ctive Cohort, Explo ratory Cohort, Ecological

    Study, Outcomes Research, case-control study ; or extrapolations from level Astudies.Level C:Case-series study or extrapolations from level B studies.Level D: Expert opinion without explicit critical appraisal, or based onphysiology , bench research or first principles.

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    http://en.wikipedia.org/wiki/National_Health_Servicehttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Cohort_studyhttp://en.wikipedia.org/wiki/Case-control_studyhttp://en.wikipedia.org/wiki/Case-control_studyhttp://en.wikipedia.org/wiki/Case-series_studyhttp://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Case-series_studyhttp://en.wikipedia.org/wiki/Case-series_studyhttp://en.wikipedia.org/wiki/Case-series_studyhttp://en.wikipedia.org/wiki/Case-control_studyhttp://en.wikipedia.org/wiki/Case-control_studyhttp://en.wikipedia.org/wiki/Case-control_studyhttp://en.wikipedia.org/wiki/Cohort_studyhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/National_Health_Service
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    In guidelines and other publications, recommendation for a clinical serviceis classified by the balance of risk versus benefit of the service and thelevel of evidence on which this informatio n is based.The U.S. Preventive Services Task Force uses.

    Level A: Good scientific evidence suggests that the benefits of the clinical

    service substantially outweigh the potential risks. Clinicians should discuss theservice with eligible patients.Level B: At least fair scientific evidence suggests that the benefits of the clinicalservice outweighs the potential risks. Clinicians should discuss the service witheligible patients.Level C: At least fair scientific evidence suggests that there are benefits

    provided by the clinical service, but the balance between benefits and risks aretoo close for making general recommendations. Clinicians need not offer itunless there are individual considerations.Level D: At least fair scientific evidence suggests that the risks of the clinicalservice outweighs potential benefits. Clinicians should not routinely offer theservice to asymptomatic patients.

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    http://en.wikipedia.org/wiki/US_Preventive_Services_Task_Forcehttp://en.wikipedia.org/wiki/US_Preventive_Services_Task_Forcehttp://en.wikipedia.org/wiki/US_Preventive_Services_Task_Force
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    -

    KeputusanMedis

    Keputusanetis

    Pilar Keputusan Klinis sehari2Biomedik

    Info-medik

    Indikasimedik

    pilihan pasienkualitas hidup

    fitur kontekstual

    Mindset non medisStruktur Psiko-Sosio-budaya14/11/2013 11

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    SISI SEHAT ORANG SEHATSISI SEHAT ORANG SAKIT

    WELLNESS

    BIOKULTURALINFOMEDIK

    Kedokt sosial

    Sisi sakitOrang sakitKedokt Klinis

    sinergi

    kesmas

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    Jamu = tidak ilmiah

    Mbok jamu = kasta rendah BENARKAH ??14/11/2013 13

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    Ethical decision = infomedical model= biocultural model

    Non- biomedical aspect of medicine 124 US medical schools offer & require some course of work

    in bioethics Most FM : bioethics replaced psychiatry, social (behavioral)

    sciences & community medicine (Renee C Fox, 1999)

    Beliefs, values, & norms = basic to our society, itscultural tradition and its collective conscience

    PATIENTS VALUE ON Evidence Based Medicine !!!

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    Physicians competence

    Valid evidence Patients valuesPATIENTS PREFERENCE

    FROM STUDIES

    JAMU DIPAKAI & BERMANFAAT

    (Riskesdas 2010)

    EVIDENCE BASED MEDICINE modifikasi Sudigdo S

    HOLISTIC

    inter - subyektivitas (bukan obyektivitas)

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    Suami minta Dokter melakukan euthanasiaterhadap istrinya yan g koma Komisi Etik RSharus menjawab

    Apa & bagaimana jawaban yg benar ?Pasien pulang paksa benar /salah ?

    Sebagai bahan pembelajaran sensitivitas etik mhsw FK ?

    Dokter peneliti membawa virus H5N1 ke luarnegeri & memuat data publikasinya ke Genebank

    ia terkenal tetapi negara & masyarakat tak ikut

    diuntungkan OK atau tdk ?14/11/2013 16

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    Dr. Hebat & Tergopoh-gopoh spt ini, benar atau tidak ?14/11/2013 17

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    Dalam situasi penderitaan ada mahlukpenolong yg altruis (hipocratesian) dan dapat

    dipercaya tahap prudensialMenolong dari kewajiban individual diuniversalkan sbg perintah kewajiban (Kantian)

    tahap deontologikHikmah bhw pasien = unik, utuh, jatidirinya hrsdihargai krn bermartabat tahap reflektif

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    Kalau yang ini 1 dari ratusan

    korban tsunami, lumpur panas ?? (di luar RS >>)

    KONTEKS :BENAR/SALAH ?

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