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Evidence Based Medicine
DARWIN AMIR
Bgn Penyakit Saraf
RS DR. M. Djamil / Fakultas Kedokteran
Universitas AndalasPADANG
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Evidence Based Medicine
A new paradigm for the health care system
Using the current evidence in the medicalliterature to provide the best care to patients
Will give you the historical basis and
philosophical underpinning of EBM
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Medicine in the pre historic had no
concept of probability (the ancients
and the Greek, the Gods decided all
life, therefore that probability did not
enter into issues of daily life
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After Luca Piccauli (1494) defined basic
principles of algebra and multiplication
tables introduced the first statistic problem
and Girolamo Gardano (1545) introducedthe first attempt to use mathematics to
describe statistic and probability.
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Galileo expanded on this by calculating
probabilities using two dice
Thomas Gataker expounded on the meaning
of probability by noting that it was natural
laws. Huygens (1657), Leibniz (1662) and
Englishman John Graunt (1660) wrote on
norms of statistic including the relation ofpersonal choice and judgement to statistical
probability.
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John Graunt categorized the cause of death
of the London populate using statistical
sampling and predict the human lifespan.
Graunt statistic can be compared to recent
data from the US in 1993
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Table : Probability of survival, 1660 and 1993
Percentage survival to each age
Age 1660 1993
0 100% 100%
26 25% 98%
46 10% 95%
76 1% 70%
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Medical practice
Clinician helps patients by
- Diagnosing what is wrong with them- Administering treatment that does more
good than harm
- Giving them an indication of what the
future is likely to hold (prognosis)
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Evidence Based Practice
in Primary Care
The growing demand for public
accountability in health care and the
increased availability of information tousers -------- >
EBP will be central theme in general
practice and the organization of care for
many years to come
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The need for an EB approach to
decision-making in general practice
The core of GP is the relationship between
the doctor and patient.
Central aspects of this relationship is the
process of decision making (range from
simple clinical types of decision to decision
at a level about how service should beorganized
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The decisions ought to involve a negotiatedin the context of a partnership between the
health care professional and the patient and
takes account of factors such as patientneed, preferences, priorities, available
resources and evidence of the effects of
providing different forms of care
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Evidence from
Randomized
Controlled Trials
Other
Necessary
Evidence
Effects of careN e e d s
MAKING POLICIES AND
TAKING DECISIONSProfessional and providers
Service users and purchasersresearchers and funders
Resources Priorities
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Both the doctor and patient require access to
reliable and valid information ----- > to the
situation is required. EBM is the phrase used to describe such an
approach and entails (from the doctors
perspective): - the conscientious- explicit
- judicious use
GP acquire, wisdom and judgment throughtheir clinical experience
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This expertise produces clinical skills and
acumen (diligent) in detecting signs and
symptoms.
Greater understanding of individuals
(predicament, rights and preferences) in
making clinical decisions about their care.
The judgment for decision making based on the
availability of better research methods for
assessing the validity of evidence of
effectiveness through to improved techniques
for collating evidence in a systematic way
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The distinction between EBM and
Evidence Based Health Care
Evidence Based Medicine Evidence Based Health Care
Conceptual approach that
health care professionalscan use in making
decisions about the care
of individuals patients
Broader concepts that
incorporates improveapproach to understanding
patients, families and
practitioners beliefs, values
and attitudes. Takes account evidence at a
population levels
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How to get started: a five-step process for
using an evidence based approach in GP
The McMaster University EBM Resources Group have
identified a five-step approach need to follow :
1. define the problem;
2. track down the information sources you need;
3. critically appraise the information;
4. apply the information with your patients;5. evaluate how effective thisapplication of information is
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Step 1: defining the problem
Questions frequently arises, such as pros andconts of using a particular form of therapy, thevalue of having a particular diagnostic test orscreening procedure, the risk or prognosis of a
particular disease or the cost of a potentialintervention.
There is a clinical problem for which you areunsure of the evidence and to make a decisionto investigate it further.
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Step 2: tracking down the information
sources needed
Medical literature which can assist in providing
answers to the question raised in clinical practice
is broadly scattered; journals, family medicine
journals and government reports
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Step 3: critically appraising the information
Decided which journal articles to read. It isimportant to read them carefully as not allpublished is of equal value
Critical appraisal of articles is a process which
involves carefully reading an article andanalysing its methodology, content andconclusion
Do I believe these result sufficiently that I wouldbe prepared to adopt a similar approach or reach asimilar conclusion, with my own patients ?.
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Step 4: applying the information with your patients
How to apply the information obtained to theparticular circumstances of your patients ?. This is
a probably the most crucial step in the process.
Whether there are any methodological issuesraised about the evidence which might prompt
you to reject it outright.
This process requires a partnership between thedoctor and patient. If at the end of the process the
decision is made be a mutual and conscientious
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Step 5: evaluating how effective it is.
Evaluate the effect of the evidence as applied tospecific patients.
The expected benefits that arose from using aparticular item of evidence were consistent with
the observed benefits. It may well generate the need for further
research to identify why some patients have not
responded in the expected manner and what bedone to rectify this
The practitioner is having sufficient time toapply these steps routinely in their daily practice
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Supporting a framework for Evidence-Based
Practice within general practice
As professional you have the challenge andresponsibilities in facing general practice
Framework needs to be built around ensuring thatthe evidence required to inform decision-makingis available, accessible, acceptable and applied byGP.
Emerged internationally which aim to producesystematic summaries with trying to practiceEBP.
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Supporting a framework for Evidence-
Based Practice within general practice
Good examples are:- Cochrane library (a database of high quality systematic
review of health care)
- AGP Journal Club.- BMJ and Lancet.
At a more local level, there are a growing number ofnetworks being amongs general practitioner of searching
for and appraising evidence A natural extension of this process is o apply EB
Protocols and guidelines, develop by he colleagues inclinical practice.
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The relevant clinical questions in yourpatients must contain 4 element:
1). The patients problem.2). Intervention, which by research methodology,
diagnostic test and the treatment
3). If needed with intervention comparable.4). Clinical outcome or outcome of interest.
The 4 element to form the terminology i.e. PICO
P= Patient,I = Intervention,
C= Comparison,
O= Outcome.
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Use of theophylline in asthmaFollowing the publication for the management of asthma in adults,
dr. A noted the statement that thephylline might have a role in
patients whose asthma was not controlled with high dose inhaled
steroid, but even then alternative treatment might have fewer side
effects. He decided it was time to review his prescribing of
theophylline and used the practice computer to produce a list of all
his asthmatic patients and their recent medication. He found 86
patients, three of whom were taking theophylline. He was reassured
that his use of theophylline was limited, but made an entry in the
records of each of these patients to remind him to review their
medication when the patient next attended. Ultimately, he was able
to persuade two of these patients to discontinue theophylline, and
after 6 months the prescribing data were checked again to confirm
that these changes had persisted.
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Prognosis
- What are the consequences of having the disease
Is it dangerous ?
Could I die of itHow long will I be able to continue my
present actives ?
Will it ever go away altogether?
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The prognosis question
A qualitative aspect
(which outcomes could happen?)
A quantitative aspect
(how likely are they to happen ?)
A temporal aspect(over what time period ?)
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Natural history of diseases
(no medical intervention)
Biologic onset Clinical
Diagnosis Outcome Recovery
DisabilityDeath
ect
Clinical Courses
(medical intervention)
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Risk Factors
BiologiconsetClinical
Diagnosis
Recovery
DisabilityDeath
Etc
Outcome
Prognostic factorsDemographic variableDisease specific variable
Co-morbid factor
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The strategy for making a prognosis
expert opinion
consulting the appropriate specialist
looking it up in a text book
clinical experiences
read up
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Cohort studySurvival analysis
Case control studyCase Series
Biologic
onset
Early
diagnosis
possible
Clinical
diagnosis
Outcome
Recovery
Disability
Death
Etc
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Summary
If the concept is embraced it will improvegeneral practice
Will make the GP an even more rewardingdiscipline within which to practice.
Will support shared decision making withusers. It is the ideal model of makingdecisions within the medical encounter.
EBM / EBP will help maintain the central roleof general practice in health care.
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