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    Evidence Based Medicine For General Practitioner: Agus Widiyatmoko

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    dewisuryandari
    This document discusses the importance and process of evidence-based medicine (EBM) for general practitioners. It explains that EBM is needed to stay up to date as medical information constantly changes, and to ensure practitioners are doing what is best for patients based on the highest quality evidence rather than outdated or biased information. The document outlines the 5 steps of EBM: developing a focused clinical question, searching for evidence, critically appraising the evidence, applying the evidence to the individual patient, and evaluating performance. It emphasizes evaluating the validity, relevance and importance of evidence found in studies of different types.

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    Evidence Based Medicine For General Practitioner: Agus Widiyatmoko

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    dewisuryandari
    37 views61 pages
    This document discusses the importance and process of evidence-based medicine (EBM) for general practitioners. It explains that EBM is needed to stay up to date as medical information constantly changes, and to ensure practitioners are doing what is best for patients based on the highest quality evidence rather than outdated or biased information. The document outlines the 5 steps of EBM: developing a focused clinical question, searching for evidence, critically appraising the evidence, applying the evidence to the individual patient, and evaluating performance. It emphasizes evaluating the validity, relevance and importance of evidence found in studies of different types.

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    This document discusses the importance and process of evidence-based medicine (EBM) for general practitioners. It explains that EBM is needed to stay up to date as medical information constantly changes, and to ensure practitioners are doing what is best for patients based on the highest quality evidence rather than outdated or biased information. The document outlines the 5 steps of EBM: developing a focused clinical question, searching for evidence, critically appraising the evidence, applying the evidence to the individual patient, and evaluating performance. It emphasizes evaluating the validity, relevance and importance of evidence found in studies of different types.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    37 views61 pages

    Evidence Based Medicine For General Practitioner: Agus Widiyatmoko

    Uploaded by

    dewisuryandari
    This document discusses the importance and process of evidence-based medicine (EBM) for general practitioners. It explains that EBM is needed to stay up to date as medical information constantly changes, and to ensure practitioners are doing what is best for patients based on the highest quality evidence rather than outdated or biased information. The document outlines the 5 steps of EBM: developing a focused clinical question, searching for evidence, critically appraising the evidence, applying the evidence to the individual patient, and evaluating performance. It emphasizes evaluating the validity, relevance and importance of evidence found in studies of different types.

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    EVIDENCE BASED MEDICINE

    FOR GENERAL PRACTITIONER

    AGUS
    WIDIYATMOKO

    Why do we need EBM?


    Stay up to date
    Medical information
    changes constantly
    Unlike bread our
    knowledge does
    not become visibly
    moldy or stale we
    just keep using it

    Why do we need EBM?


    Save LIVES!
    Encainide and flecainide for ventricular arrhythmia
    Well proven to decrease the number of premature ventricular
    beats became widely used 1980s
    BUT
    Further studies showed significant INCREASE in
    MORTALITY died from other cardiac complications and
    dysrhythmias ( a dangerous DOE)

    Thrombolytics for acute MI


    CLEAR evidence of benefit in the 1970s
    Not widely recommended until 1988 almost 13 yrs later
    How many thousands of people died unnecessarily in the
    years in between?

    SHIFTING PARADIGM
    Scientific/medical
    information
    Clinical
    problems

    Evidence-based Medicine

    Why do we need EBM?


    We want to do the right thing what is
    best for our patients
    Practice variations that do not make sense
    ...
    Not to doctors
    Not to patients
    Not to payors
    Not to policy makers

    validity

    Current vs future knowledge

    Current

    future knowledge

    Innovation, development, & diffusion of


    Medical technology

    Established technology
    Late adopters
    Obsolete
    technology

    Early adopters

    Clinical trials
    Abandoned
    technology

    First medical use

    Innovation

    Development

    Diffusion

    Evaluation

    Abandoned technology
    Ticrynafen (US, Mei 79 - Mei 80): hepatocelullar
    injury (> 500 reports)
    Benoxaprofen (April 82-Agustus 82): kematian 61
    kasus (cholestatic jaundice) di UK (BMJ)
    Zomepirac (Okt 80-Maret 83): reaksi anafilaktoid (N
    Engl J Med 1981): 1100 reports
    Suprofen (jan 86-Mei 87): flank pain synd (> 300
    reports).
    Temafloxacin (US, Feb 1992) anemia hemolitik,
    disfungsi ginjal, kematian

    Abandoned/obsolete
    technology
    Biopsi paru untuk mendiagnosis pneumonia
    Episiotomi untuk tindakan rutin pertolongan
    persalinan
    Tonsilektomi untuk tindakan operasi rutin
    pada tonsilitis
    Pemeriksaan USG untuk screening rutin ibu
    hamil sbg upaya mencegah outcome
    persalinan yang buruk
    Pemeriksaan Widal untuk Typhoid

    Inovasi obat anihipertensi

    % pasien

    Proven benefit

    80

    90

    100

    110

    120

    Diastolic blood pressure

    130

    140

    Early diffusion of
    anihipertensive

    % pasien

    benefit

    80

    90

    100

    110

    120

    Diastolic blood pressure

    130

    140

    Wide utilization of
    anihipertensive

    % pasien

    benefit

    Low
    efficacy

    80

    Low
    efficacy

    90

    100

    110

    120

    Diastolic blood pressure

    130

    140

    Causes of negative Widal


    absence of infection by S typhi
    the carrier state
    an inadequate inoculum of bacterial
    antigen in the host to induce antibody
    production
    technical difficulty or errors in the
    performance of the test
    previous antibiotic treatment
    variability in the preparation of commercial
    antigens

    Causes of positive Widal


    agglutination tests
    the patient being tested has typhoid fever
    previous immunisation with Salmonella
    antigen.
    cross-reaction with non-typhoidal Salmonella.
    variability and poorly standardised
    commercial antigen preparation
    infection with malaria or other
    enterobacteriaceae
    other diseases such as dengue

    best-evidence resources
    Dalam format yang dapat memfasiliitasi rapid
    searching untuk menemukan jawaban yang tepat atas
    pertanyaan-pertanyaan klinik
    search engine

    electronic

    pocket
    notebook

    Portability
    Easy navigation from clinical questions to
    evidence-based answers.

    So why not get info from textbooks


    and review articles?
    Texts and review articles?
    Dated perhaps by several years
    Often heavily biased
    Author chooses article that he/she agrees with (or
    has written)

    May help more with background knowledge


    (help me learn about disease) not foreground
    (help me answer the specific clinical question for
    this patient)

    Where to find the best evidence

    Burn your (traditional)


    textbooks
    Revisi, paling tidak 1 tahun sekalli
    Padat Referensi yang updated
    (khususnya ttg diagnosis and
    management)

    http://www.bmjpg.com/index.htm
    http://www.acponline.co
    http://cebm.jr2.ox.ac.uk/eboc/eboc.htm

    Invest in evidence databases


    EBMR (EB-Medicine Review)
    http://www.ovid.com
    Evidence-Based Medicine,
    Evidence-Based Mental Health
    Evidence-Based Nursing,
    Cancerlit,
    Aidsline,
    Bioethicsline and
    MEDLINE
    + 200 fulltext journals

    http://www.ncbi.nlm.nih.gov/PubMed
    http://www.biomednet.comm

    The EBM Process


    The patient

    1. Start with the patient -- a clinical problem or


    question arises out of the care of the patient

    2. Construct a well built clinical question derived from


    the case (PICO)
    The resource 3. Select the appropriate resources and conduct a
    search
    The evaluation 4. Appraise that evidence for its validity (closeness to
    the truth) and applicability (usefulness in clinical
    practice)
    5. Return to the patient -- integrate that evidence with
    The patient
    clinical expertise, patient preferences and apply it to
    practice
    Self-evaluation 6. Evaluate your performance with this patient

    The question

    Types of Questions
    Therapy/prevention Question
    Prognosis Question
    Diagnosis Question

    Harm Question

    Type of study
    Type of Question

    Suggested best type of Study

    Therapy

    RCT>cohort > case control > case series

    Diagnosis

    Prospective, blind comparison to a gold standard

    Etiology/Harm

    RCT > cohort > case control > case series

    Prognosis

    Cohort study > case control > case series

    Prevention

    RCT>cohort study > case control > case series

    Clinical Exam

    Prospective, blind comparison to gold standard

    Cost

    Economic analysis

    http://www.hsl.unc.edu/lm/ebm/Supplements/QuestionSupplement.htm

    Question Worksheet

    Who?
    What?
    Alternately?
    Outcome?
    Question?

    Type of Question

    Therapy
    Prognosis
    Diagnosis
    Harm

    Type of Study

    But how does EBM REALLY work?


    Step 1: Translate clinical scenarios into an
    answerable clinical questions
    TRUE STORY
    My 35 yr old patient was just diagnosed with
    dyspepsia
    I received laboratory report and he is coming
    in to see me tomorrow

    What are my questions?


    What do I know about DYSPEPSIA?

    How common is it?


    How can it be treated?
    What about family history?
    Etc.
    These are called background questions

    Foreground questions apply to that


    specific patient (or population)
    After meeting with patient and spouse we find
    that he has seen the gastroenterologist who
    recommended endoscopy but the patient is
    reluctant
    35 year old male patient was diagnosed with
    dyspepsia wants to know whether to get a treatment.
    He is concerned about death from esophageal cancer
    and also risks of stomach rupture.

    Focusing the Clinical Question


    P
    patient

    Who?

    How would I
    describe a
    group of
    patients similar
    to mine?

    I intervention
    What?

    Which main
    intervention
    am I
    considering?

    comparison

    outcome

    Alternative
    Intervention?
    (if necessary)

    What is the main


    alternative to
    compare with the
    intervention?

    Outcomes

    What can I
    hope to
    accomplish? or
    What could this
    exposure really
    affect?

    Examples
    P

    In men with
    dyspepsia
    aged 35 years

    Endoscopy

    OMD

    In children
    with acute otitis
    media
    aged 2-4 years

    Antibiotics

    No treatment except
    paracetamol

    O
    Predictive
    value?
    Likelihood
    ratio?

    No pain after
    two days?

    Developing the question requires:


    Some background knowledge of the condition
    Understanding of the patient and what are the
    outcomes that matter in this patient

    Death?
    Disability?
    Quality of life? Anxiety, Impotence, etc.
    Cost?

    Hands on Part 1
    Think in your practice THIS session what was
    a clinical question you had?
    Think of a foreground question (not just a drug dose
    or drug interaction)
    What diagnostic test would have been best for that patient
    with abdominal pain?
    What treatment would have been best for the patient with
    Dementia?
    What about the patient who was asking about acupuncture
    for osteoarthritis?

    How does EBM REALLY work?


    Step 2: Translate question into effective
    searches for the best evidence
    Requires knowledge of medical informatics
    How to search what terms to use, what
    types of studies, etc.
    Where to search utility of varied sources of
    information
    Evidence based sources, Texts, Medline,

    EBM sources
    EBM sources Cochrane, USPSTF,
    Clinical Evidence
    + Ideally best information source hard to
    argue with, will explicitly state the level of
    evidence (weak to strong)
    - There may not be any good evidence

    Cochrane Database of
    Systematic Reviews

    ACP Journal Club

    Daily POEMS

    Database of Abstracts of
    Reviews of Effectiveness

    Clinical Evidence

    DynaMed

    How does EBM REALLY work?


    Step 3: Critically appraise the evidence
    Validity of the evidence
    Internal study design, blinding, randomized, sample size,
    appropriate statistics, etc.

    Relevance of the evidence


    Did they measure something pts care about?
    Is population similar (enough) to mine?
    Is the intervention feasible?

    Importance of the evidence


    Magnitude of effect or clinical significance?
    P values, confidence intervals, relative risk or absolute risk
    reduction

    Step 3: Critically appraise the evidence


    (cont.)
    Requires some knowledge of basic
    epidemiology and biostatistics
    Sensitivity, specificity, prevalence, likelihood ratios
    Absolute risk reduction, relative risk reduction, odds
    ratios, number needed to treat

    Requires knowledge of study types


    ASSUMING THAT IT IS A WELL DESIGNED STUDY
    Appropriate sample size, randomization, stats, treatment
    allocation, etc., etc.

    Meta-analysis of RCTs > RCT > Cohort > Case


    Control > Case Series > Case Report

    Hierarchy of studies

    Step 3 Critical appraisal of


    medical literature
    This is often confused with EBM
    they are not the same thing

    This is often the toughest part of EBM


    Skipped by many doctors suffering from
    photonumerophobia
    The fear that ones fear of numbers and statistics will
    come to light

    This is where most attempts come to a halt


    Not enough time and expertise

    EBM Databases
    Systematic Literature Searches

    Cochrane Library (OVID)


    BMJ Clinical Evidence

    Systematic Literature Surveillance

    ACP Journal Club (OVID)


    DARE
    DynaMed
    Medical InfoRetriever

    Drilling for the Best Information

    Cochrane Library
    Clinical Evidence
    Clinical Inquiries
    Specialty-specific

    Usefulness

    POEMs

    ACP Journal Club


    Textbooks, Up-toDate, 5-Minute
    Clinical Consult
    Journals/
    Medline
    PubMed

    Need to read the key


    Levels of Evidence
    Level 1: Highest
    Level 2:
    Level 3:
    Level 4:
    Level 5: Lowestbut still evidence

    Read the key


    Levels of Recommendation (USPSTF)
    A Highest Strongly recommended (PAP smears)
    B Recommended (Mammograms age 40+)
    C no recommendation for or against (too close a
    balance between harm/benefit) (osteoporosis
    screening below age 60)
    D Recommend AGAINST (ovarian cancer)
    I insufficient evidence to make any recommendation
    for or against (Prostate cancer screening)

    Other guidelines
    A good evidence
    B fair evidence
    C based on expert opinion and/or
    consensus
    X evidence of harm

    Essential principle
    Be ready to surrender to a
    higher level of evidence when it
    becomes available
    Do not become entrenched in what has been
    done for years
    A bad idea done by a LOT of people for a LONG time,
    is still a bad idea

    Evidence based information,


    recommendations, reviews
    Not all that claims to be evidence based, is really EBM
    Should include explicit statements about search methods,
    findings, appraisal and level of evidence (or strength of
    recommendation)

    High quality sources


    Cochrane, AHRQ, USPSTF, ACP Journal Club, Clinical
    Evidence, InfoRetriever

    Questionable sources
    Developed by BOGSAT methodology
    Bunch Of Guys Sitting Around a Table
    Sometimes called consensus, argument may be won based on
    volume and stamina

    How does EBM REALLY work?


    Step 4: Implement information into
    practice
    Integrate information with patients values and
    preferences
    Patient-centered care

    How does EBM REALLY work?


    Step 4: Implement information into practice
    Integrate information with patients values and
    preferences
    Patient-centered care
    Demographics, age, socioeconomics, fear, etc.

    Evidence may point to surgery as better treatment but


    patient refuses
    This does NOT mean EBM is out the window
    Your job is to understand the magnitude of benefit and the
    level of evidence
    Then translate into useable information for the patient

    As patient participates in care decisions, you


    are practicing TRUE evidence based
    medicine

    OK I am convinced, how can I start to


    practice evidence based medicine?
    Step 1 Ask the questions
    Use your clinical experiences to find 1-2 case
    scenarios every day that translate into clinical
    questions
    Ask your student to help he/she may REALLY appreciate
    that you explicitly tried to help find a REAL answer that would
    help an actual patient

    PICO population intervention comparison outcome

    Use your growing clinical skills but do not


    be swayed by YUCKs
    Your Unsubstantiated Clinical Knowledge
    (and experience)
    Regularly seek to find the best available
    evidence to guide you
    Especially review common topics, you may be
    getting stale without realizing it

    Step 2 Search for the evidence


    When searching for background
    information
    Critically appraise your texts for known
    problems/biases
    Date of publication, references, source

    Try to use systematic review articles


    Explicit statements of how and where they
    searched, and statements of strength of
    recommendation of level of evidence

    Step 2 searching (continued)


    Locate and regularly use YODAs
    Your Own Data Analyzer
    Let others do hard work for you
    It is their full-time job, do you really have the time and expertise to do
    better?

    Try InfoRetriever and Clinical Evidence a few times a week


    Save your questions on a card and find answers over lunch or end of
    the day
    Look at the Cochrane reports first
    BUT even those may be dated!

    Step 3 Critical Appraisal


    Do not fall for three common myths
    Newer article, by bigger name, and a famous journal,
    does NOT mean it is better

    Use three quick tips


    Is it relevant first?, dont get overwhelmed by the stats, was it
    from YODA?

    PRACTICE CRITICAL APPRAISAL of original


    research if you do not use it, you will lose it
    I often let headlines drive this then I need to know NOW

    Step 4 Integrate into patient care


    Take your findings back to your patients
    Sometimes this may be 2 minutes later or 2 weeks
    later
    Discuss how to integrate this into care of your
    patient
    Tell the patient that you have been looking up the latest
    information and they will appreciate it!

    Step 5 Self evaluation how did you do?


    Learn to improve your . . .

    Framing of the question


    Search terms
    Search locations
    Critical appraisal skills
    Patient understanding
    Patient centered approach

    Questions?

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