Evidence-Based Medicine

-What, Why, and How-

Adaptasi dari : Iwan Dwiprahasto

Clinical Epidemiology & Biostatistics Unit (CE&BU)/
Dept Pharmacology & Toxicology
Faculty of Medicine, UGM
 Content
Introduction.

Why is EBM?

What is EBM?

Steps of EBM.

Conclusion.
2
Detroit News and Free Press. Sunday, February 6, 2000.
 Negative appendectomy Negative appendectomy

9.8

36.6
45,4
80.2

Without US With US

Puig et al, Radiology January 2003

http://www.naturalnews.c
om/medical_errors.html
experience based treatment vs medical error

Clinical skills

Medical errors

Evidence-based
knowledge

Year
Innovation, development, & diffusion of
Medical technology

Established technology
Late adopters

Early adopters Obsolete

technology
Clinical trials
Abandoned
First medical use technology

Innovation Development Diffusion Evaluation

 Obsolete vs current technology

Technology Past Present

Fever in children Cold water Warm water

Foetal heart rate Laenec stethoscope Doppler

Hipertension SBP >160 SBP>140

HNP Myelografi MRI

Radiologic contrast Ionic Non ionic

 Cox2 inhibitor, Rofecoxib: its history
No.
Year Journal Conclusion
subject

Risk of GI bleeding is much

2000 NEJM 8076
lower than NSAID

Cirkulati Risk of CVD is similar to

2001 >28, 000
on NSAID

Risk of CHD at a dose >25

2002 Lancet >200.000
mg

Risk of CHF 2.5 times

2004 Lancet >39 000
greater than NSAID

was withdrawn
Sept, 2004 VIOXX (Rofecoxib)
from the markt
It is known that medicine & all other health care areas
are rapidly changing.

No. of medical journals increased >7 times

today > 20,000 biomedical journals

As clinicians should base our decision & action on the

best possible evidence.

To keep up to date in Internal Medicine, I need to read

17 articles a day, 365 days a year 12
 Why EBM ?
Our daily need for valid information about Dx, Rx,
prognosis….etc.

The inadequacy of traditional sources for information because

they are out of date (textbook ), frequently wrong (expert ), or
too overwhelming in volume & too variable in validity (
journals ).

3. Disparity between Dx. skills & clinical judgment which

increase with experience & up to date knowledge which
decline.
 Rule 31 – Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London

5,000?
2500000 per day
Year
Per Year

2000000
Articles per
MedicalArticles

1500000
1,500
1000000 per day
Medical

95 per
500000 day

0
Biomedical MEDLINE Trials Diagnostic?
Is keeping up to date Mission
Impossible?

Bluegreenblog 2006
From Human evolution

To

Medical technology
evolution
From less accurate or inaccurate (leading to misdiagnosisa)
To more accurate technology with (still) few misdiagnosis
“Half of what you are
taught as medical
students will in 10
years have been shown
to be wrong.
And the trouble is,
none of your teachers
knows which half.”
(Dr. Sydney Burwell,
Dean of Harvard Medical School).
From experience to Evidence-based Medicine

Old paradigm New paradigm

Why did you prescribe Why antibiotics are not

antibiotics for common cold? prescribed for your patient?

Effectives, because patient Recent evidence shows that

did not come back soon after no antibiotic is required for
treatment Comon cold

Experience-based Evidence-based
medicine Medicine (EBM)
 Evidence-Based Medicine

"the conscientious, explicit, and

judicious use of current best evidence
in making clinical decisions about the
care of individual patients."

22
Evidence-Based Medicine: an integration of

clinical best
expertise research
evidence

patient values &

expectation
 Relevance: Type of Evidence

 pathophysiology,
DOE: Disease-
 pharmacology,
oriented evidence
 etiology

• mortality,
POE: Patient-
• morbidity,
oriented evidence • quality of life
 DOE Intermediate POEM
Lipid lowering Lower serum Reduced cardiac Improved all-cause
Drug cholesterol events mortality

Consuming a Lower serum Improved self Improved life

Low-fat diet cholesterol esteem expectancy

Hormon Increased Reduced risk Improved life

Replacement bone of fractures expectancy &
Therapy density quality

DOE : Disease Oriented Evidence

POIM : Patient Oriented Evidence that Matters
 Five steps to EBM
ASK
= Develop your answerable clinical question

ACQUIRE
= Efficiently find the best evidence

APPRAISE
= Critically evaluate the evidence for its validity and
usefulness

APPLY
= Use the results of the appraisal in your clinical
practice

ASSESS
= Evaluate your performance
 Three different modes of practice

“Replicating” • Fast
the practice of • Easy
experts • Ego based recommendation

“Searching • Fast
only” • If appropriate, E-B care

• E-B care,
“Searching & • time
appraising”
• resources
 5 Steps of EBM
1. Converting the need for information into answerable
Question.

2. Collect evidence to answer question

3. critically appraise that evidence for it’s validity, impact &

applicability.

4. Integrating the critical appraisal with our clinical expertise

& our pt. Unique biology, values & circumstances.

5. Evaluate our effectiveness & efficiency in steps 1-4 and

seeking ways to improve them. 28
 What is Evidence-Based Medicine?

See a patient Ask a question Seek the best

evidence

Monitor the Apply the evidence Appraise that evidence

change
1. Converting the need for information into
answerable Question.

FOREGROUND QUESTION

• Jika pada seorang penderita post

stroke diberikan aspirin, berapa besar
kemungkinan ybs dapat terhindar dari
risiko recurrent stroke dibandingkan
dengan jika tidak mendapat aspirin
2. Collect evidence to answer question

Where to search for “evidence” ?

Textbooks ? Electronic evidence databases

• Pubmed
• MEDLINE
• Cochrane
• EBMR (EB-Medicine
• Diagnosis Review)
• Terapi • Evidence-Based Medicine,
• Prognosis
• Evidence-Based Nursing,
• Survival
• Cancerlit, Aidsline,
 Colleagues

Conferences

In the past Med Reps

Textbooks
Source of Medical
Information Patients

Now & in the Critically appraised

future journals
3. critically appraise that evidence for it’s validity, impact &
applicability.

USERS’ GUIDE

Diagnosis Terapi Prognosis Harm

http://www.cche.net
4. Integrating the critical appraisal with our clinical expertise
& our pt. Unique biology, values & circumstances.

Patient’s value and expectation

5. Evaluate our effectiveness & efficiency in steps
1-4 and seeking ways to improve them.

Stop treatment

Switch therapy

Refer
 Kategori Evidence

Meta analisis & Syst Rev

Ia
Ib
Randomized Controlled Trial

Non-Randomized Trial
IIa
IIb
Quasi Experimental

Observational study
III
IV
Expert opinion, clinical experience

Uji pra-klinik

Uji in vitro
ASKING ANSWERABLE
CLINICAL QUESTION
 What is Evidence-Based Medicine?

See a patient Ask a question Seek the best

evidence

Monitor the Apply the evidence Appraise that evidence

change
 Clinical questions

Background question Foreground question

Any medical/clinical
PICO
question

What, why, when, Patient, Intervention,

where, How Comparison, Outcome
Background Question

What are treatments for dyslipidemia?

What are risk factors for stroke?

What is best treatment for pneumonia?

What is the etiology of Diabetes Mellitus?

What makes blood pressure increase?

 Foreground Questions

P • = Patient Population or Problem

I • =Intervention

C • =Comparison

O • =Outcome
 Therapy
“In patients with an acute MI, are
antiarrhythmic drugs more effective than
standard therapy in preventing sudden
cardiac death?”

P • = Acute myocardial infarction

I • = Antiarrhythmic drugs

C • = Standard therapy

O • = Sudden cardiac death

 Diagnosis

P • In 7 year old child with sore throat,

I • Does clinical findings

C • Compare to culture of pharyngeal swab

• More sensitive in detecting Streptococcus

O beta hemoliticus Group A?
 Harm

P • In patients with osteoarthritis

I • Does the use of meloxicam

C • Compare to piroxicam

O • Result in less gastric bleeding?

 SYSTEMATIC REVIEW

“cough,” “bronchitis,” “sputum,” and

“respiratory tract infections.”

RCT, semua bahasa, mulai 1966 s/d 1998

• Antibiotic TIDAK LEBIH BAIK daripada plasebo

jika resolusi batuk dinilai pada hari 7-11 RR= 0.85
(95% CI 0.73 to 1.00)
• Antibiotic TIDAK BERPENGARUH terhadap
penyembuhan (RR= 0.62; 95%CI:0.36 to 1.09)

• Efek samping antibiotika: 19% (12-36%)

• RR= 1,9 (95CI:1,19-3,21)
HOW TO FIND CURRENT
BEST EVIDENCE
 What is Evidence-Based Medicine?

See a patient Ask a question Seek the best

evidence

Monitor the Apply the evidence Appraise that evidence

change
 WHERE TO
I. Evidence-Based Resources:
SEARCH
1. Evidence-Based Systematic Review Databases
2. Secondary journals
3. EBM textbooks and guidelines
4. Medline/electronic databases
II. Selected Comprehensive Web-Based EBD
Resources
1. Netting the Evidence
2. Centre For Evidence Based Medicine
3. Evidence-Based Medicine Resource Center
4. Online Guide to Critical Appraisal

III. Biomedical Journals

IV. Expert/colleagues opinion

 1. Evidence-Based Systematic Review Databases

The Cochrane Library:

• Best source for structured, systematic reviews
• Explicit search & quality criteria (free abstracts)

Database of Abstracts of Reviews of Effectiveness

(DARE)
• Structured abstracts of systematic reviews meeting
highest quality standards
• A (free) part of the Cochrane Library
Evidence-Based Medicine Reviews (EBMR) integrates
the above with secondary journal content:
•ACP Journal Club / Best Evidence
•Medline searching and some full-text journals.
 2. Secondary Journals

• Evidence-Based “secondary journals” provides

structured abstract
• Selected from high quality publications
• Initial resources for finding evidence on clinical
conditions

• E.g.’s-
• Evidence-Based Medicine, ACP Journal Club (free)
• Specialty-specific resources: Evidence-Based Pharmacy,
Evidence-based psychiatry
• Bandolier (free) b: Ringkasan dari bukti-bukti ilmiah
 3. EBM Textbooks and Guidelines

Clinical practice guidelines (EB-CPG)

• Berst resource of clinical practice with strength of evidence
• Resources of CPG:
• National Guideline Clearinghouse (free)
• Guide to Clinical Preventative Services (free)
• Consider whether it is applicable for your daily practice

Evidence-based textbooks
• Clinical Evidence is the best (explicit protocols)
• Good exceptions: UpToDate, Scientific American Medicine (the
latter now available via WebMD), Evidence-Based On Call
 4. Medline / Electronic Databases
• PubMed: ncbi.nlm.nih.gov/pmc (free)
• highwire.stanford.edu (free)
• freemedicaljournals.com (free)
• Freebooks4doctors.com (free)