pengenalan ebm kbk

8/10/2019 Pengenalan EBM KBK

1/14

Pengenalan

Evidence Based Medicine

6 yrs medical

education

40-50 yrs

medical practice

Problems with patients:

Dx, Rx, Px

Consultant,

colleagues

Textbooks

HandbooksLecture notes

Clinical guidelines

CME, seminars, etc

Journals

Usu. see only Results section,

or even worse,Abstract section

Previous practice:


2/14

What is Evidence-based

Medicine?

The conscientious, explicit, and judicious use ofcurrent best evidence in making decisions about

the care of individual patients

Pemanfaatan bukti mutakhir yang sahih dalamtata laksana pasien

Integration of (1) physicians competence(2) valid evidence from studies

(3) patients preference

Basis of Evidence-based care involvesthe integration of the best research

evidence with clinical expertise and

patient values.

Patients Needs/

PreferencesClinical

Experience

Best Clinical Evidence


3/14

EBM Usefulness

Instead of routinely reviewing the contents

of dozens of journals for interesting

articles, EBM suggests that you target

your reading to issues related to specific

patient problems as encountered.

This makes EBM a life-long self-directed

and problem-based learning process.

1. Formulate clinical problems in answerable questions

2. Search the best evidence: use internet or other on-

line database for current evidence

3. Critically appraise the evidence for

Validity (was the study valid?)

Importance (were the results clinically important?)

Applicability (could we apply to our patient?)

4. Apply the evidence to patient

5. Evaluate our performance

Steps in EBM practice

VIA


4/14

EBM Process

Patient

Encounter

Formulating the

Clinical Question

Searching the

Evidence

Apprais ing the

Evidence

Diagnosis

Therapy

Prognosis

Etiology

PatientInterventionComparisonOutcome

Hierarchy of evidencePre appraised resources

Drawing conclusion

That impact on practiceDOESPOEM

(Lang, 2000)

Types of Questions

Background Questions

General or background knowledge about the

disease, condition (anatomy, physiology,

pathophysiology, diagnosis, treatment, prognosis,

or basic management)

Have 2 parts:

First: Question root who, what, where, when, why, how

Second: disorder, condition, therapy, etc. of interest

Ex: what population is most at risk for hepatitis?


5/14

Background Questions

Textbooks answer background questions, they

contain collected & synthesized wisdom for

topics that do not change often.

Not all topics are covered, easy to use, relatively

inexpensive and can be opinion-based rather

than evidence-based, written by experts in their

fields.

Foreground Questions

Asked for speci fic knowledge about

managing patients with a disorder

Have 4 parts:

Patient or problem - P

Intervention - I

Comparison of intervention - C Outcomes - O


6/14


7/14

The components: I

The intervention / topic of interest (e.g.cause, change in practice etc.) e.g. Use of guava juice (as a drink)

Might want to specify how much / how often

For complex interventions may need to givespecific detail / consideration to thedescription

What exactly am I considering?

The components:C

The comparison or alternative (not

applicable to all questions) e.g.

Anti -biotic therapy?

Nothing?

Fluids alone?

What alternatives actions might I try?


8/14

The components:O

The outcome e.g.

Cure

Duration of disease

prevention

Death

Side effects

Pain (reduced)

Wellbeing

What am I hoping to accomplish (what

outcomes might reasonably be affected)?

The 4 part clinical question

1. Population

2. Intervention

3. Comparison

4. Outcome

In Dengue Hemorrhagic Fever

patients does guava juice increase theplatelet count when compared to no

treatment


9/14

Novice Expert

Searcher Searcher

At all stages you ask both kinds of

questions, but as experience increases

the foreground questions increase.

It is essential that you understand thebackground question before attempting to

answer the foreground ones.

Background

Information

Foreground

Information

CLINICAL EXPERTISE

Medical

School

Practice

Medical

School

CME

FOREGROUNDBACKGROUNDClinical

Skills

Formal

Education

NEW CLINICAL (EBM

PARADIGM) EXPERIENCE

PAST CLINICAL

EXPERIENCE

Roots

Disorder

Pa

tient

Intervention

Co

mparison

Outcome


10/14

What makes a clinical question

well built? Question should be directly relevant to the

problem at hand.

Question should be phrased to facilitatesearching for a precise answer.

Asking a well-built question, like many clinicalskills, needs practice.

After constructing the PICO analysis,

determine the category of the question.

There are the four categories of EBMquestions

Categories of EBM Questions


11/14

Treatment

result in seizure

reduction?

compared to no

treatment

would

anticonvulsant

therapy

In a child with

frequent febrile

seizures

OutcomeComparisonIntervention

Patient /

Problem /

Population

Diagnosis

in diagnosing

GAS infection?

compare to

throat culture

how does the

clinical exam

In an otherwise

healthy 7-year-

old boy with

sore throat


Patient /

Problem /

Population


12/14

Prognosis

in predicting

Alzheimers

later in life?

-is IQ an

important

prognostic

factor

In children with

Down

syndrome,


Patient /

Problem /

Population

Etiology / Harm

have increased

incidence of

learning

disabilities atage six years?

compared to

children not

exposed

exposed in

utero to

cocaine,

controlling for

confounding

factors, do

otherwisehealthy children


Patient /

Problem /

Population


13/14

Relevance: POEs and DOEs

DOE = Disease oriented evidence Ologies (path-, etiol-, pathophys-)

ie Med school

POE = Patient oriented evidence Morbidity, mortality or quality of life

Something a patient would care about withoutexplanation

Highest quality evidence

Comparing

DOEs and POEs2

ExamplesDisease-OrientedEvidence

Patient-OrientedEvidence that

MattersComment

AntiarrhythmicTherapy, HRT

Drug X PVCs onECG

Drug X increasesmortality

POEM studycontradictsDOE study

Anti-HTNtherapy Antihypertensivetherapy BP Antihypertensivetherapy mortality POEM agreeswith DOE

Prostate

Screening

PSA screeningdetects prostatecancer early

? whether PSAscreening mortality

DOE exists, butthe POEM isunknown


14/14

Defining the Question

Q : Is ciprofloxacin more effective than

cotrimoxazole for urinary tract infection ?

P : urinary tract infection

I : ciprofloxacin

C (if any) : cotrimoxazole

O : healing

My dad is 70 years old - should hisdoctor order a PSA?

Patient: In asymptomatic older men

Intervention: does PSA testing

Outcome: lower the morbidity or

mortality of prostate cancer?

pengenalan ebm kbk

Documents