Evidence Based MedicineEvidence Based Medicine

DARWIN AMIRDARWIN AMIRBgn Penyakit SarafBgn Penyakit Saraf

RS DR. M. Djamil / Fakultas Kedokteran RS DR. M. Djamil / Fakultas Kedokteran

Universitas AndalasUniversitas Andalas

PADANGPADANG

Evidence Based MedicineEvidence Based Medicine

A new paradigm for the health care systemA new paradigm for the health care system

Using the current evidence in the medical Using the current evidence in the medical literature to provide the best care to patientsliterature to provide the best care to patients

Will give you the historical basis and Will give you the historical basis and philosophical underpinning of EBMphilosophical underpinning of EBM

Medicine in the pre historic had no Medicine in the pre historic had no

concept of probability (the ancients and concept of probability (the ancients and

the Greek) the Gods decided all life, the Greek) the Gods decided all life,

therefore that probability did not enter therefore that probability did not enter

into issues of daily life into issues of daily life

After Luca Piccauli (1494) defined basic After Luca Piccauli (1494) defined basic

principles of algebra and multiplication principles of algebra and multiplication

tables introduced the first statistic problem tables introduced the first statistic problem

and Girolamo Gardano (1545) introduced and Girolamo Gardano (1545) introduced

the first attempt to use mathematics to the first attempt to use mathematics to

describe statistic and probability.describe statistic and probability.

Galileo expanded on this by calculating Galileo expanded on this by calculating probabilities using two dice probabilities using two dice Thomas Gataker expounded on the meaning Thomas Gataker expounded on the meaning of probability by noting that it was natural of probability by noting that it was natural laws.laws. Huygens (1657), Leibniz (1662) and Huygens (1657), Leibniz (1662) and Englishman John Graunt (1660) wrote on Englishman John Graunt (1660) wrote on norms of statistic including the relation of norms of statistic including the relation of personal choice and judgement to statistical personal choice and judgement to statistical probability.probability.

John Graunt categorized the cause of death John Graunt categorized the cause of death

of the London populate using statistical of the London populate using statistical

sampling and predict the human lifespan. sampling and predict the human lifespan.

Graunt statistic can be compared to recent Graunt statistic can be compared to recent

data from the US in 1993 data from the US in 1993

Table : Probability of survival, 1660 and 1993

Percentage survival to each age

AgeAge 16601660 19931993

00 100%100% 100%100%

2626 25%25% 98%98%

4646 10%10% 95%95%

7676 1%1% 70%70%

Medical practiceMedical practice

Clinician helps patients byClinician helps patients by - Diagnosing what is wrong with them- Diagnosing what is wrong with them

- Administering treatment that does more - Administering treatment that does more

good than harmgood than harm

- Giving them an indication of what the - Giving them an indication of what the

future is likely to hold (prognosis)future is likely to hold (prognosis)

Evidence Based Practice Evidence Based Practice in Primary Carein Primary Care

The growing demand for public The growing demand for public accountability in health care and the accountability in health care and the increased availability of information to increased availability of information to users -------- > users -------- >

EBP will be central theme in general EBP will be central theme in general practice and the organization of care for practice and the organization of care for many years to come many years to come

The need for an EB approach to The need for an EB approach to decision-making in general practice decision-making in general practice

The core of GP is the relationship between The core of GP is the relationship between the doctor and patient. the doctor and patient.

Central aspects of this relationship is the Central aspects of this relationship is the process of decision making (range from process of decision making (range from simple clinical types of decision to decision simple clinical types of decision to decision at a level about how service should be at a level about how service should be organizedorganized

The decisions ought to involve a negotiated The decisions ought to involve a negotiated in the context of a partnership between the in the context of a partnership between the health care professional and the patient and health care professional and the patient and takes account of factors such as patient takes account of factors such as patient need, preferences, priorities, available need, preferences, priorities, available resources and evidence of the effects of resources and evidence of the effects of providing different forms of care providing different forms of care

Evidence fromRandomized

Controlled Trials

Other Necessary Evidence

Effects of care N e e d s

MAKING POLICIES AND TAKING DECISIONSProfessional and providers

Service users and purchasers researchers and funders

Resources Priorities

Both the doctor and patient require access Both the doctor and patient require access to reliable and valid information ----- > to to reliable and valid information ----- > to the situation is required.the situation is required.

EBM is the phrase used to describe such an EBM is the phrase used to describe such an approach and entails (from the doctors approach and entails (from the doctors perspective): - the conscientiousperspective): - the conscientious

- explicit- explicit

- judicious use - judicious use GP acquire, wisdom and judgment through GP acquire, wisdom and judgment through

their clinical experience their clinical experience

This expertise produces clinical skills and This expertise produces clinical skills and acumen (diligent) in detecting signs and acumen (diligent) in detecting signs and symptoms. symptoms.

Greater understanding of individuals Greater understanding of individuals (“predicament”, rights and preferences) in (“predicament”, rights and preferences) in making clinical decisions about their care.making clinical decisions about their care.

The judgment for decision making based on the The judgment for decision making based on the availability of better research methods for availability of better research methods for assessing the validity of evidence of assessing the validity of evidence of effectiveness through to improved techniques effectiveness through to improved techniques for collating evidence in a systematic way for collating evidence in a systematic way

The distinction between EBM and The distinction between EBM and Evidence Based Health Care Evidence Based Health Care

Evidence Based MedicineEvidence Based Medicine Evidence Based Health CareEvidence Based Health Care

Conceptual approach that Conceptual approach that health care professionals health care professionals can be used in making can be used in making decisions about the care decisions about the care of individuals patientsof individuals patients

Broader concepts that Broader concepts that incorporates improve incorporates improve approach to understanding approach to understanding patients, families and patients, families and practitioners beliefs, values practitioners beliefs, values and attitudes. and attitudes.

Takes account evidence at a Takes account evidence at a population levels population levels

How to get started: a five-step process for How to get started: a five-step process for using an evidence based approach in GP using an evidence based approach in GP

The McMaster University EBM Resources Group have The McMaster University EBM Resources Group have identified a five-step approach need to follow :identified a five-step approach need to follow :

1. define the problem;1. define the problem;

2. track down the information sources you need;2. track down the information sources you need;

3. critically appraise the information;3. critically appraise the information;

4. apply the information with your patients;4. apply the information with your patients;

5. evaluate how effective this application of information is 5. evaluate how effective this application of information is

Step 1: defining the problemStep 1: defining the problem

Questions frequently arises, such as pros and Questions frequently arises, such as pros and conts of using a particular form of therapy, the conts of using a particular form of therapy, the value of having a particular diagnostic test or value of having a particular diagnostic test or screening procedure, the risk or prognosis of a screening procedure, the risk or prognosis of a particular disease or the cost of a potential particular disease or the cost of a potential intervention. intervention.

There is a clinical problem for which you are There is a clinical problem for which you are unsure of the evidence and to make a decision unsure of the evidence and to make a decision to investigate it further.to investigate it further.

Step 2: tracking down the information Step 2: tracking down the information sources needed sources needed

Medical literature which can assist in providing Medical literature which can assist in providing answers to the question raised in clinical practice answers to the question raised in clinical practice is broadly scattered; journals, family medicine is broadly scattered; journals, family medicine journals and government reports journals and government reports

Step 3: critically appraising the informationStep 3: critically appraising the information

Decided which journal articles to read. It is Decided which journal articles to read. It is important to read them carefully as not all important to read them carefully as not all published is of equal valuepublished is of equal value

Critical appraisal of articles is a process which Critical appraisal of articles is a process which involves carefully reading an article and involves carefully reading an article and analysing its methodology, content and analysing its methodology, content and conclusionconclusion

Do I believe these result sufficiently that I would Do I believe these result sufficiently that I would be prepared to adopt a similar approach or reach be prepared to adopt a similar approach or reach a similar conclusion, with my own patients ?. a similar conclusion, with my own patients ?.

Step 4: applying the information with your patientsStep 4: applying the information with your patients

How to apply the information obtained to the How to apply the information obtained to the particular circumstances of your patients ?. This is particular circumstances of your patients ?. This is a probably the most crucial step in the process. a probably the most crucial step in the process.

Whether there are any methodological issues Whether there are any methodological issues raised about the evidence which might prompt raised about the evidence which might prompt you to reject it outright. you to reject it outright.

This process requires a partnership between the This process requires a partnership between the doctor and patient. If at the end of the process the doctor and patient. If at the end of the process the decision is made be a mutual and conscientiousdecision is made be a mutual and conscientious

Step 5: evaluating how effective it is. Step 5: evaluating how effective it is.

Evaluate the effect of the evidence as applied to Evaluate the effect of the evidence as applied to specific patients. specific patients.

The expected benefits that arose from using a The expected benefits that arose from using a particular item of evidence were consistent with particular item of evidence were consistent with the observed benefits.the observed benefits.

It may well generate the need for further It may well generate the need for further research to identify why some patients have not research to identify why some patients have not responded in the expected manner and what be responded in the expected manner and what be done to rectify this done to rectify this

The practitioner is having sufficient time to The practitioner is having sufficient time to apply these steps routinely in their daily practice apply these steps routinely in their daily practice

Supporting a framework for Evidence-Based Supporting a framework for Evidence-Based Practice within general practicePractice within general practice

As professional you have the challenge and As professional you have the challenge and responsibilities in facing general practiceresponsibilities in facing general practice

Framework needs to be built around ensuring that Framework needs to be built around ensuring that the evidence required to inform decision-making the evidence required to inform decision-making is available, accessible, acceptable and applied by is available, accessible, acceptable and applied by GP.GP.

Emerged internationally which aim to produce Emerged internationally which aim to produce systematic summaries with trying to practice systematic summaries with trying to practice EBP. EBP.

Supporting a framework for Evidence-Supporting a framework for Evidence-Based Practice within general practiceBased Practice within general practice

Good examples are: Good examples are: - Cochrane library (a database of high quality systematic - Cochrane library (a database of high quality systematic

review of health care)review of health care)- AGP Journal Club. - AGP Journal Club.

- BMJ and Lancet. - BMJ and Lancet. At a more local level, there are a growing number of At a more local level, there are a growing number of

networks being amongs general practitioner of searching networks being amongs general practitioner of searching for and appraising evidencefor and appraising evidence

A natural extension of this process is apply EB Protocols A natural extension of this process is apply EB Protocols and guidelines, develop by he colleagues in clinical and guidelines, develop by he colleagues in clinical practice. practice.

The relevant clinical questions in your patients 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.

Use of theophylline in asthmaUse of theophylline in asthmaFollowing the publication for the management of asthma in adults,Following the publication for the management of asthma in adults,dr. A noted the statement that thephylline might have a role indr. A noted the statement that thephylline might have a role inpatients whose asthma was not controlled with high dose inhaledpatients whose asthma was not controlled with high dose inhaledsteroid, but even then alternative treatment might have fewer sidesteroid, but even then alternative treatment might have fewer sideeffects. He decided it was time to review his prescribing ofeffects. He decided it was time to review his prescribing oftheophylline and used the practice computer to produce a list of alltheophylline and used the practice computer to produce a list of allhis asthmatic patients and their recent medication. He found 86his asthmatic patients and their recent medication. He found 86patients, three of whom were taking theophylline. He was reassuredpatients, three of whom were taking theophylline. He was reassuredthat his use of theophylline was limited, but made an entry in thethat his use of theophylline was limited, but made an entry in therecords of each of these patients to remind him to review theirrecords of each of these patients to remind him to review theirmedication when the patient next attended. Ultimately, he was ablemedication when the patient next attended. Ultimately, he was ableto persuade two of these patients to discontinue theophylline, andto persuade two of these patients to discontinue theophylline, andafter 6 months the prescribing data were checked again to confirmafter 6 months the prescribing data were checked again to confirmthat these changes had persisted. that these changes had persisted.

•PrognosisPrognosis- What are the consequences of having the disease- What are the consequences of having the disease

Is it dangerous ?Is it dangerous ?Could I die of itCould I die of itHow long will I be able to continue my How long will I be able to continue my

present actives ?present actives ?Will it ever go away altogether?Will it ever go away altogether?

The prognosis questionThe prognosis question

A qualitative aspectA qualitative aspect

(which outcomes could happen?)(which outcomes could happen?)

A quantitative aspectA quantitative aspect

(how likely are they to happen ?)(how likely are they to happen ?)

A temporal aspectA temporal aspect

(over what time period ?)(over what time period ?)

Natural history of diseases Natural history of diseases (no medical intervention)(no medical intervention)

Biologic onset Clinical Diagnosis Outcome Recovery

Disability Death ect

Clinical Courses(medical intervention)

Risk Factors

Biologiconset

ClinicalDiagnosis

RecoveryDisabilityDeathEtc

Outcome

Prognostic factorsDemographic variableDisease specific variablesCo-morbid factor

The strategy for making a prognosisThe strategy for making a prognosis

““expert opinion”expert opinion”consulting the appropriate specialistconsulting the appropriate specialistlooking it up in a text booklooking it up in a text book

““clinical experiences”clinical experiences”

““read up”read up”

Cohort studyCohort studySurvival analysisSurvival analysis

Case control studyCase control studyCase SeriesCase Series

Biologiconset

Earlydiagnosispossible

Clinicaldiagnosis

Outcome

RecoveryDisability

DeathEtc

Summary Summary If the concept is embraced it will improve If the concept is embraced it will improve

general practicegeneral practice

◊ ◊ Will make the GP an even more rewarding Will make the GP an even more rewarding discipline within which to practice.discipline within which to practice.

◊ ◊ Will support shared decision making with Will support shared decision making with users. It is the ideal model of making users. It is the ideal model of making decisions within the medical encounter.decisions within the medical encounter.

◊ ◊ EBM / EBP will help maintain the central role EBM / EBP will help maintain the central role of general practice in health care.of general practice in health care.