Kp 1.1.3.4 Dan 1.1.3.6 Ebm Pico 5dt6g

EBM CYCLE AND PICO QUESTION

NAJIRMAN KETUA BAGIAN ILMU PENYAKIT DALAM FK UNAND/ RSUP Dr.M.DJAMIL KEPALA CE-EBM FK UNAND

What is Evidence-based Medicine? Integration of

(1) physician’s competence (2) valid evidence from studies (3) patient’s preference

PEMANFAATAN BUKTI MUTAKHIR YANG SAHIH DALAM TATALAKSANA PASIEN

Evidence-based medicine (EBM)  The process of systematically reviewing,

appraising and using clinical research findings to aid the delivery of optimum clinical care to

patients

What is evidence-based medicine? The term ‘evidence-based medicine’ (EBM) was fi rst used by a Canadian, David Sackett and his collegues at McMaster University in Ontario, Canada in the early 1990s EBM as integrating the best research evidence with clinical expertise and patient values to achieve the best possible patient management EBM practitioners to avoid ‘information overload’ but, at the same time, to find and apply the most useful information.

WHY DO WE NEED EBM?  There is a large information gap between research and clinical practice

So much research is published all the time, clinicians understandably are unaware of most of it, or do not have the ‘tools’ to assess its quality Researchers, on the other hand, do not understand the information needs of clinicians and continue to present their work in a way that is not easily accessible to busy practitioners Most treatment-related decisions were based on an ad hoc selection of information from the vast and variable quality scientific literature, on expert opinion, or, worse of all, on trial and error

WHY EBM? 1. Information overload 2. Keeping current with literature 3. Our clinical performance deteriorates with time (“the slippery slope”) 4. Traditional CME does not improve clinical performance 5. EBM encourages self directed learning process which should overcome the above shortages

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1000/ DAY

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50/DAY

0 TRIALS

MEDLINE

TOTAL

THE AMOUNT OF MEDICAL RESEARCH

Archie Cochrane proposed that researchers and practitioners should collaborate internationally to systematically review all the best clinical trials (that is, randomised controlled trials, or RCTs), specialty by specialty

STEPS IN EBM 1. Formulate an answerable question 2. Track down the best evidence of outcomes available.

3. Critically appraise the evidence (ie find out how good it is). 4. Apply the evidence (integrate the results with clinical expertise and patient values). 5. Evaluate the effectiveness and efficiency of the process (to improve next time).

Drawing conclusion That impact on practice

APPRISING THE EVIDENCE

•Hierarchy of evidence •Pre appraised resources

PATIENT ENCOUNTER

EBM

SEARCHING THE EVIDENCE

Diagnosis Therapy Prognosis Etiology

FORMULATING CLINICAL QUESTIONS

•Patient •Intervention •Comparison •Outcome

CLINICAL EXPERTISE

BEST RESEARCH EVIDENCE

E

PATIENT

B

VALUES &

M

PREFERENCES

STEPS IN EBM PRACTICE 1.

Formulate clinical problems in answerable questions

2.

Search the best evidence: use internet or other online 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

LANGKAH PERTAMA

 Clinical question = Pertanyaan klinis  Disusun menurut rumus : PICO

P = Population/ participants

Who are the relevant patients?

I = Intervention Indicator/

What is the management strategy, diagnostic test or exposure that you are interested in (such as a drug, food, surgical procedure, diagnostic test or exposure to a chemical)?

C = Comparator/ Control

What is the control or alternative management strategy, test or exposure that you will be comparing the one you are interested in with?

O = Outcome

What are the patient-relevant consequences of the exposure in which we are interested?

In EBM, treatments and therapies are called ‘interventions’ and such questions are questions of INTERVENTION Other types of questions that may arise are as follows: 1. What causes the problem? AETIOLOGY AND RISK FACTORS 2. What is the frequency of the problem? FREQUENCY 3. Does this person have the problem? DIAGNOSIS 4. Who will get the problem? PROGNOSIS AND PREDICTION

Interventions Interventions cover a wide range of activities from drug treatments and other clinical therapies, to lifestyle changes (for example, diet or exercise) and social activities (such as an education program). Interventions can include individual patient care or population health activities (for example, screening for diseases such as cervical or prostate cancer).

Example 1 A 28-year-old male presents with recurrent furunculosis for past 8 months; these episodes have been treated with drainage and several courses of antibiotics but keep recurring. He asks if recurrences can be prevented. To convert this to an answerable question, use the P I C O method as follows : P I C O

Population/patient = patients with recurrent furunculosis Intervention/indicator = prophylactic antibiotics Comparator/control = no treatment Outcome = reduction in recurrence rate of furunculosis

Question: ‘In patients with recurrent furunculosis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate?’

P = Population, patients, partricipants, problem •Wanita dengan osteoartritis I = Intervention, indicator, index •Temberian steorid C = Comparison •Tanpa steroid

PERTANYAAN KLINIS Pada wanita dengan osteoartritis, O = Outcome apakah pemberian steroid, •Mengurangi nyeri dibanding tanpa steroid, dapat mengurangi keluhan nyeri?

P = Population, patients, partricipants, problem •Pasien dengan tumor tiroid I = Intervention, indicator, index •pemeriksaan USG C = Comparison •biopsi tiroid O = Outcome •menentukan keganasan

PERTANYAAN KLINIS Pada pasien dengan tumor tiroid, apakah pemeriksaan USG lebih sensitif, dibanding dengan biopsi, untuk menegakkan diagnosis keganasan?

P = Population, patients, partricipants, problem •Manula dengan batuk kronik berulang I = Intervention, indicator, index •fisioterapi

PERTANYAAN KLINIS Pada manula dengan C = Comparison batuk berulang, apakah •tanpa fisio terapi fisioterapi dapat O = Outcome empercepat •mempercepat kesembuhan kesembuhan?

P = Population, patients, partricipants, problem •Pasien lupus eritematosus sistemik I = Intervention, indicator, index •riwayat gagal jantung C = Comparison •tanpa riwayat gagal jantung O = Outcome •memperburuk prognosis

PERTANYAAN KLINIS Pada pasien LES apakah terdapatnya riwayat gagal jantung memperburuk prognosis?

AETIOLOGY AND RISK FACTORS Example 1 George has come in to your surgery to discuss the possibility of getting a vasectomy. He says he has heard something about vasectomy causing an increase in testicular cancer later in life.

You know that the risk of this is low but want to give him a more precise answer.

P Population/patient = adult males I Intervention/indicator = vasectomy C Comparator/control = no vasectomy OOutcome = testicular cancer

Question: ‘In men, does having a vasectomy (compared to not having one) increase the risk of getting testicular cancer in the future?’

FREQUENCY OR RATE Questions of frequency (prevalence) are about how many

people in the population have a disease or health problem, such as what is the frequency of hearing problems in infants or the prevalence of Alzheimer’s disease in the over 70s. If the question also includes a time period, such as for cases of influenza in winter versus summer, it becomes a question of rate (incidence).

Example 1 Mabel is a 6-week-old baby at her routine follow-up. She was born prematurely at 35 weeks. You want to tell the parents about her chances of developing hearing problems. P = infants I = premature C = full-term

Question: ‘In infants born prematurely, compared to those born at full term, what will the prevalence of sensorial deafness be?’

O = sensorial deafness

APLIKASI EBM DALAM PELAYANAN KESEHATAN

Evidence

Physician

Patients

EBM

Type of Clinical Questions for the Ideal Type of Study

Type of Question Ideal Type of Study

Therapy

RCT > Cohort Study > Case Control

Diagnosis:

Prospective, blind controlled trial comparison to gold standard

Prognosis

Cohort Study > Case Control > Case Series/Case Report

Etiology/Harm

RCT > Cohort Study > Case Control

Levels of Evidence: Study Type / Evidence Hierarchy

JENIS DISAIN PENELITIAN  CROSS SECTIONAL/ POTONG LINTANG  CASE CONTROL  COHORT

 CLINICAL TRIAL/ EXPERIMENTAL

Level bukti (level of evidence) untuk efek terapi Level Desain/ jenis studi Level I  RCT berkualitas tinggi dengan perbedaan yang secara statistik signifikan, atau perbedaan yang secara statistik tidak signifikan tetapi dengan Confidence Interval sempit  Kajian sistematis dari RCT level I (dan hasil studi homogen) Level II  RCT dengan kualitas lebih rendah (misalnya, follow-up <80%, tanpa pembutaan, atau randomisasi tidak sempurna)  Studi prospektif dengan pembanding  Kajian sistematis dari studi level II atau studi level I dengan hasil-hasil inkonsisten Level III  Studi kasus kontrol  Studi retrospektif dengan pembanding  Kajian sistematis dari studi level III Level IV  Case series Level V  Pendapat pakar Sumber: deVries dan Berlet, 2010

SEARCHING

Kapankah perlu dibuat pertanyaan klinis ? Pertanyaan klinis perlu dibuat bila: • penting untuk kesembuhan pasien • diperkirakan akan ditemukan jawabannya • sering dijumpai dalam praktik • menarik untuk kita • ada kemungkinan berkaitan dengan isu medikolegal PANDUAN PRAKTEK KLINIK

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