Evidence Based Medicine

dr. Nindya Aryanty, M.Med.Ed

 Good physicians must successfully
meet many challenges
• The assimilation of a considerable volume of facts
such as elements of anatomy, hundreds of
syndromes for further pattern recognition,
dosages of drugs and pieces of legislation or
administrative rules governing medical practice.
• The acquisition of automatisms necessary for the
execution of many clinical maneuvers such as
those required to perform a physical examination
or to practice emergency medicine.
 Good physicians must successfully
meet many challenges
• The ability to effectively communicate (listening
and talking) with the patient, the patient’s family,
as well as members of the health team.
• The assessment of patient risks.
• The making of diagnosis and prognosis.
• The listing of problems and creation of a
hierarchical classification.
• The making of decisions (choices).
• The mastery of exploratory and surgical
procedures (performance).
 Good physicians must successfully
meet many challenges
• The management of patients after
intervention (follow-up and care, control of
disease course).
• The evaluation of the effectiveness and
efficiency of cure and care.
• The respect of medical, cultural and social
ethics as well as of patient values, preferences
and expectations.
• Empathy.
 Medicine – Art & Science
• Medicine is ‘the art and science of diagnosis,
treatment, and prevention of disease, and the
maintenance of good health
• To be a good physician, it is necessary to
develop the art of medicine and to master
medicine as a science
 The art of medicine requires:
• A clinician with an open mind and flexibility of
reasoning.
• The ability to establish a good relationship
with the patient.
• Manual and sensory skills.
• Clinical flair and intuition, i.e. an aptitude to
infer from previous experience, without active
and concrete recall, in order to make
appropriate decisions.
• Clinical imagination.
 The art of medicine requires:
• The capacity to persuade the patient to take
responsibility for his or her own health and to convince
the patient that the clinician will also share that
responsibility.
• The aptitude to convert serendipity into insight of
patient problems.
• The preservation and maintenance of human dignity
(this is one difference between medicine and the
advanced technical manipulation of human beings).
• The estheticism, elegance and style in the
conceptualization, execution, evaluation, and
communication of a clinical experience lived.
 The science of medicine
• is the study of the material universe or
physical reality in order to understand it
• is organized reasoning means discovery,
implementation, uses and evaluation of
evidence
• a structured and organized way of using
probability, uncertainty, and facts in
preventive medicine and clinical care to best
benefit the patient and the community
‘A doctor should never forget that he or
she is a scientist. Every diagnostic and
therapeutic decision should have a
logical basis that can be clearly
articulated to colleagues and
patients…or in court.

J.Wroblewski, 1999
The practice of good medicine relies as
well on our ability to properly explain
the reasoning which leads to our
conclusions and which is translated into
clinical orders, health programs and
policy implementation decisions, as well
as into our legal views of individuals or
situations under scrutiny.
• Some patients will accept our orders (‘take
this pill twice a day after meals!’…‘between
you and me, I would definitely operate!’)
without comment  They expect that the
physician will think and decide for them.
• Others will rightfully ask ‘why?’; Health policy
makers, planners, funding agencies,
administrators and politicians will always ask
‘why?’  give an argument (offer a set of
reasons of evidence in support of a
conclusion)
What is evidence-based medicine?
Is the process of systematically
reviewing, appraising and using
clinical research findings to aid the
delivery of optimum clinical care to
patients

(Rosenberg et al., 1995 cit Belsey, 2009)

David Sackett et al., 1990s
 EVIDENCE BASED MEDICINE IN
PRACTICE
Four steps in evidence based medicine
• Formulate a clear clinical question from a
patient's problem
• Search the literature for relevant clinical
articles
• Evaluate (critically appraise) the evidence for
its validity and usefulness
• Implement useful findings in clinical practice
 1. Setting the question
A 77 year old woman living alone is admitted
with non-rheumatic atrial fibrillation and her first
bout of mild left ventricular failure, and she
responds to digoxin and diuretics. She has a
history of well controlled hypertension. An
echocardiogram shows moderately impaired left
ventricular function. She is an active person and
anxious to maintain her independence. During
the ward round on the following day a debate
ensues about the risks and benefits of offering
her long term anticoagulation with warfarin
 1. Setting the question
• The questions that initiate evidence based medicine
can relate to diagnosis, prognosis, treatment,
iatrogenic harm, quality of care, or health economics
• Question relates to prognosis and susceptibility: "How
great is the annual risk of embolic stroke in a 77 year
old woman with non-rheumatic atrial fibrillation,
hypertension, and moderate left ventricular
enlargement if she is not given anticoagulants?"
• Question concerns treatment: "What is the risk
reduction for stroke from warfarin therapy in such a
patient, and what is the risk of harming her with this
therapy?"
 2. Finding the evidence
• The second step is a search for the best
available evidence.
• Clinicians need effective searching skills and
easy access to bibliographic databases.
So much evidence, so little time
Primary literature
How much is incorrect?

Correction of
errors

Much of it is correct

The Knowledge Filter

(H.H. Bauer, 1995)
 2. Finding the evidence
• For this patient, the searches were conducted with Medline
and the Knowledge Finder searching software.
• "Atrial fibrillation" and "cerebrovascular disorders" were
entered as major medical subject headings and
"randomised controlled trial" as a publication type selected
from the "dictionaries“ menu.
• The search was performed twice, once with "prognosis"
entered as a freetext search parameter and a second time
with "therapy" included. The years 1990-4 were searched
and 10 articles were identified, of which eight seemed to
contain the relevant nformation (two on prognosis and six
reporting randomised trials of therapy). Five were available
in the library.
 3. Appraising the evidence
• The third step is to evaluate, or appraise, the
evidence for its validity and clinical usefulness.
• Crucial step  clinician decide whether an
article can be relied on to give useful guidance
 CRITICAL APPRAISAL
 Terms
• Critical appraisal : a method of assessing and
interpreting the evidence by systematically
considering its validity, result and relevance to
the area of work considered
• Case report : descriptions of individual patient
• Care series : descriptions of a series of patients
• Case control study : A study in which a group of
patients with a specific outcome are matched
with a group of matched controls without the
outcome and information is obtained about their
past exposure to a factor under investigation
 Terms
• Case control study

50-60 years old Smoke (+)

men
Lung cancer (+)
Smoke (-)

50-60 years old

Smoke (+)
men
Lung cancer (-)
Smoke (-)
 Terms
• Cohort study : A study in which data are obtained from
matched groups who have been either exposed or not
exposed (controls) to a new technology, prognostic
factor or risk factor. There are two study designs:

• prospective the cohorts are identified at a point in

time (such as time of birth, residence at a specific
location, exposure to a particular risk factor) and
followed forward in time to record health outcomes
• retrospective the cohorts are defined at a point of
time in the past and information is collected on
subsequent outcomes
 Terms
• Cohort

Lung cancer(+)
20 years old men
Smoke (+)
Lung cancer(-)

Lung cancer(+)
20 years old men
Smoke(-)
Lung cancer(-)
 Terms
• Randomized control trial

50 women received
prenatal & postnatal
lactation instruction from
100 lactation consultant Incidence &
pregnant duration of
women breastfeeding
50 women received
standard care  were not
seen by lactation
consultant
 Terms
• Systematic review : The process of
systematically locating, appraising and
synthesising evidence from scientific studies in
order to obtain a reliable overview

• Meta analysis : Results from several studies,

identified in a systematic review, are
combined and summarised quantitatively
 3. Appraising the evidence
• The two articles on prognosis fulfil criteria for validity and
applicability and reveal that our particular patient faces an 18%
annual risk of stroke if left untreated.
• Applying criteria given in the Users' guides to the medical literature:
how to use an article about therapy or prevention, we decided that
the articles we have pulled provide valid and applicable evidence.
• We used them to obtain the relative risk reduction of stroke due to
treatment with warfarin, which is 70%.
• The annual risk of stroke for our patient without treatment was
used, in conjunction with relative risk reduction obtained from the
prognosis articles, to calculate the absolute risk reduction (ARR) of
stroke attributable to anticoagulation with warfarin. This figure,
which is 0.13, was then used to calculate the "number needed to
treat" (NNT=1/ARR) with warfarin to save one stroke.
 3. Appraising the evidence
• Thus treating eight patients (1/0.13) for one year
will prevent one stroke.
• The annual rate of major haemorrhage in
patients receiving warfarin is 1%, so one patient
in every hundred taking warfarin will experience
a major bleed each year, and we therefore can
expect to prevent about 13 strokes in patients
such as ours with warfarin for every major bleed
we will cause through such treatment
 4. Acting on the evidence
• Having identified evidence that is both valid
and relevant, clinicians can either implement
it directly in a patient's care or use it to
develop team protocols or even hospital
guidelines
Therapy (case study : dog bite)
Therapy (case study : dog bite)
 Harm
(mortality associated with oral contraceptive use)

Rovina, a 25 years-old woman, attends an

obstetric clinic to seek an advice on
contraception. She has read a magazine article
describing a near-fatal pulmonary embolus in
a 35 year-old smoker who took a
contraceptive pill. She is anxious about her
own risk of major complication but also keen
to use a non-barrier method of contraceptive
if possible
 References
• Belsey J, 2009, What is evidence-based medicine?, Hayward
Medical Communication
• Greenhalgh T & Donald A, 2000, Evidence-based healthcare
workbook : understanding research, London : BMJ Publishing group
• Glasziou P, Del Mar C, Salisbury J, 2007, Evidence-based practice
workbook, USA: Blackwell Publishing
• Greenhalgh T, Donald A, 2000, Evidence Based Health Care
orkbook: understanding research, London: BMJ
• Guyatt G, Rennie D, Meade M, Cook D, 2002, user’s guide to the
medical literature: a manual for evidence-based clinical practice,
the American Medical Association
• Jenicek M, 2005, Foundations Of Evidence-based Medicine, USA:
The Parthenon Publishing Group Inc.