Evidence based medicine
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Evidence Based Medicine. DARWIN AMIR Bgn Penyakit Saraf RS DR. M. Djamil / Fakultas Kedokteran Universitas Andalas PADANG. Evidence Based Medicine. A new paradigm for the health care system Using the current evidence in the medical literature to provide the best care to patients

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Evidence Based Medicine

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Evidence based medicine

Evidence Based Medicine

DARWIN AMIR

Bgn Penyakit Saraf

RS DR. M. Djamil / Fakultas Kedokteran

Universitas Andalas

PADANG


Evidence based medicine1

Evidence Based Medicine

  • A new paradigm for the health care system

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

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


Evidence based medicine

  • Medicine in the pre historic had no concept of probability (the ancients and the Greek) the Gods decided all life, therefore that probability did not enter into issues of daily life


Evidence based medicine

  • After Luca Piccauli (1494) defined basic principles of algebra and multiplication tables introduced the first statistic problem and Girolamo Gardano (1545) introduced the first attempt to use mathematics to describe statistic and probability.


Evidence based medicine

  • Galileo expanded on this by calculating

    probabilities using two dice

  • Thomas Gataker expounded on the meaning

    of probability by noting that it was natural

    laws.

  • Huygens (1657), Leibniz (1662) and

    Englishman John Graunt (1660) wrote on

    norms of statistic including the relation of

    personal choice and judgement to statistical

    probability.


Evidence based medicine

  • John Graunt categorized the cause of death of the London populate using statistical sampling and predict the human lifespan.

  • Graunt statistic can be compared to recent data from the US in 1993


Evidence based medicine

Table : Probability of survival, 1660 and 1993

Percentage survival to each age


Medical practice

Medical practice

Clinician helps patients by

- Diagnosing what is wrong with them

- Administering treatment that does more

good than harm

- Giving them an indication of what the

future is likely to hold (prognosis)


Evidence based practice in primary care

Evidence Based Practice in Primary Care

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

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


The need for an eb approach to decision making in general practice

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

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

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


Evidence based medicine

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


Evidence based medicine

Other

Necessary

Evidence

Evidence from

Randomized

Controlled Trials

N e e d s

Effects of care

MAKING POLICIES AND

TAKING DECISIONS

Professional and providers

Service users and purchasers

researchers and funders

Resources

Priorities


Evidence based medicine

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

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

    - explicit

    - judicious use

  • GP acquire, wisdom and judgment through their clinical experience


Evidence based medicine

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

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

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


The distinction between ebm and evidence based health care

The distinction between EBM and Evidence Based Health Care


How to get started a five step process for using an evidence based approach in gp

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

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

    1. define the problem;

    2. track down the information sources you need;

    3. critically appraise the information;

    4. apply the information with your patients;

    5. evaluate how effective this application of information is


Step 1 defining the problem

Step 1: defining the problem

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

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


Step 2 tracking down the information sources needed

Step 2: tracking down the information sources needed

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


Step 3 critically appraising the information

Step 3: critically appraising the information

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

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

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


Step 4 applying the information with your patients

Step 4: applying the information with your patients

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

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

  • This process requires a partnership between the doctor and patient. If at the end of the process the decision 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 specific patients.

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

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

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


Supporting a framework for evidence based practice within general practice

Supporting a framework for Evidence-Based Practice within general practice

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

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

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


Supporting a framework for evidence based practice within general practice1

Supporting a framework for Evidence-Based Practice within general practice

  • Good examples are:

    - Cochrane library (a database of high quality systematic

    review of health care)

    - AGP Journal Club.

    - BMJ and Lancet.

  • At a more local level, there are a growing number of networks being amongs general practitioner of searching for and appraising evidence

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


Evidence based medicine

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.


Evidence based medicine

Use of theophylline in asthma

Following the publication for the management of asthma in adults,

dr. A noted the statement that thephylline might have a role in

patients whose asthma was not controlled with high dose inhaled

steroid, but even then alternative treatment might have fewer side

effects. He decided it was time to review his prescribing of

theophylline and used the practice computer to produce a list of all

his asthmatic patients and their recent medication. He found 86

patients, three of whom were taking theophylline. He was reassured

that his use of theophylline was limited, but made an entry in the

records of each of these patients to remind him to review their

medication when the patient next attended. Ultimately, he was able

to persuade two of these patients to discontinue theophylline, and

after 6 months the prescribing data were checked again to confirm

that these changes had persisted.


Prognosis what are the consequences of having the disease

Prognosis- What are the consequences of having the disease

Is it dangerous ?

Could I die of it

How long will I be able to continue my present actives ?

Will it ever go away altogether?


The prognosis question

The prognosis question

A qualitative aspect

(which outcomes could happen?)

A quantitative aspect

(how likely are they to happen ?)

A temporal aspect

(over what time period ?)


Natural history of diseases no medical intervention

Natural history of diseases (no medical intervention)

Biologic onset   Clinical

Diagnosis  Outcome  Recovery

Disability

Death

ect

Clinical Courses

(medical intervention)


Evidence based medicine

Risk Factors

Recovery

Disability

Death

Etc

Biologic

onset

Clinical

Diagnosis

Outcome

Demographic variable

Disease specific variables

Co-morbid factor

Prognostic factors


The strategy for making a prognosis

The strategy for making a prognosis

“expert opinion”

consulting the appropriate specialist

looking it up in a text book

“clinical experiences”

“read up”


Cohort study survival analysis case control study case series

Cohort studySurvival analysisCase control studyCase Series

Recovery

Disability

Death

Etc

Early

diagnosis

possible

Biologic

onset

Outcome

Clinical

diagnosis


Summary

Summary

  • If the concept is embraced it will improve general practice

    ◊ Will make the GP an even more rewarding

    discipline within which to practice.

    ◊ Will support shared decision making with

    users. It is the ideal model of making

    decisions within the medical encounter.

    ◊ EBM / EBP will help maintain the central role

    of general practice in health care.


Evidence based medicine

Thank You

for Your Good Attention


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