TUGAS EVIDENCE BASE MEDICINE (EBM)

KEPANITERAAN KLINIK IKM-IKK

NAMA : JENNIFER FINNALIA HUSIN

NIM : 04084821820023

DOKTER MUDA IKM-IKK PERIODE 15 APRIL – 24 JUNI 2019

1. CASE 33:
The patient is a 73-year-old white woman who was admitted to the hospital with heart
failure. She is a compliant patient and seldom misses her medications. On admission, her
medications were furosemide 40 mg po qd, enalapril 20 mg po bid, simvastatin 10 mg po qd,
and aspirin 325 mg po qd. She usually functions at a NYHA class II level, but she now has
had two admissions for congestive heart failure in the past 4 months. On this admission, a
myocardial infarction has already been ruled out and she remains in sinus rhythm. She has
normal renal function with a serum creatinine of 0.7 mg/dL. The patient is particularly
concerned about staying out of the hospital because she is very active in her community,
lives alone, and has no one to care for her pets and plants. The resident asks the team if
digoxin would help shorten her hospital stay or keep her from being readmitted. You are
asked to do a PubMed search and bring the answer to morning rounds.

2. Dari Clinical Scenario dibuat:

a. Tabel P.I.C.O

P 73 years old, white woman who was admitted to the hospital with Congestive
heart failure
I Usage of digoxin
C
O Might help shorten her hospital stay or keep her from being readmitted

b. Buatlah Clinical Question

73 years old, white woman who was admitted to the hospital with Congestive heart
failure if digoxin would help shortens her hospital stay or keep her from being
readmitted?
 c. Buatlah Search Term/Search/Keyword
Old woman AND Admitted to the hospital AND Congestive Heart failure AND
myocardial infarction AND usage of Digoxin AND Shorten hospital stay OR Keep from
being readmitted.

d. Lakukan searching

e. Pastekan abstract artikel yang didapat pada lembar jawaban

ABSTRACT
BACKGROUND: Heart failure is the leading cause for hospital readmission, the
reduction of which is a priority under the Affordable Care Act. Digoxin reduces 30-day
all-cause hospital admission in chronic systolic heart failure. Whether digoxin is effective
in reducing readmission after hospitalization for acute decompensation remains unknown.
METHODS: Of the 5153 Medicare beneficiaries hospitalized for acute heart failure and
not receiving digoxin, 1054 (20%) received new discharge prescriptions for digoxin.
Propensity scores for digoxin use, estimated for each of the 5153 patients, were used to
assemble a matched cohort of 1842 (921 pairs) patients (mean age, 76 years; 56%
women; 25% African American) receiving and not receiving digoxin, who were balanced
on 55 baseline characteristics.
RESULTS: Thirty-day all-cause readmission occurred in 17% and 22% of matched
patients receiving and not receiving digoxin, respectively (hazard ratio [HR] for digoxin,
0.77; 95% confidence interval [CI], 0.63-0.95). This beneficial association was observed
only in those with ejection fraction <45% (HR 0.63; 95% CI, 0.47-0.83), but not in those
with ejection fraction _45% (HR 0.91; 95% CI, 0.60-1.37; P for interaction, .145), a
difference that persisted throughout the first 12 months postdischarge (P for interaction,
.019). HRs (95% CIs) for 12-month heart failure readmission and all-cause mortality
were 0.72 (0.61-0.86) and 0.83 (0.70-0.98), respectively.
CONCLUSIONS: In Medicare beneficiaries with systolic heart failure, a discharge
prescription of digoxin was associated with lower 30-day all-cause hospital readmission,
which was maintained at 12 months, and was not at the expense of higher mortality.
Future randomized controlled trials are needed to confirm these findings.
KEYWORDS: Digoxin; Heart failure; Hospital readmission

f. Lakukan Critical appraisal dari artikel dengan critical appraisal worksheet

VALIDITY:Are the results of the trial valid? (Internal Validity)

Yang dinilai FRISBEC
F: Patient Follow-Up
 Were all patients who entered the Yes
trial properly accounted for at its
conclusion? Losses to follow-up
should be less than 20% and
 reasons for drop-out given.
 Was follow-up long enough? Yes

R: Randomization
 Were the recruited patients Yes
representative of the target
population?
 Was the allocation (assignment) of
patients to treatment randomized Yes
and concealed?
I: Intention to Treat Analysis
 Were patients analyzed in the Yes
groups
to which they were randomized?
 Were all randomized patient data Yes
analyzed? If not, was a sensitivity or
“worst case scenario” analysis done?
S: Similar Baseline Characteristics of
Patients
 Were groups similar at the start of Yes
the
trial?
B: Blinding
 Were patients, health workers, and No
study personnel “blind” to treatment?
 If blinding was impossible, were No
blinded
raters and/or objective outcome measures
used?
E: Equal Treatment
 Aside from the experimental Yes
intervention, were the groups treated
equally?
Conflict of Interest
 Are the sources of support and Yes
other potential conflicts of interest
acknowledged and addressed?
Summary of Article’s Validity
 Notable study strengths or Yes
weaknesses
or concerns?
 How serious are the threats to Yes
validity
and in what direction could they bias the
study outcomes?
IMPORTANCY (What were the results?)

Yang dinilai/dihitung
CER 0,1
EER 0,001
RR 0,0023
RRR/RBI 0,001
ARI/ABI 0,0259
NNT 30,996
C.APPLICABILIITY
Will the results help me in caring for my patient? (ExternalValidity/Applicability)
Is my patient so different to those in the No
study that the result cannot apply?
Is the treatment feasible in my setting? Yes
Will the potenntial benefits of treatment Yes
outweigh the potential harms of treatment
for my patient?