E vidence
Download
1 / 64

E vidence - PowerPoint PPT Presentation


  • 172 Views
  • Uploaded on

Sudigdo Sastroasmoro ([email protected]) Medical School University of Indonesia. E vidence. B ased . M edicine . (”Bringing research evidence into practice”). Dr. Benjamin Spock: Baby and Child Care.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' E vidence' - huyen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
E vidence

Sudigdo Sastroasmoro

([email protected])

Medical School University of Indonesia

E vidence

B ased

M edicine

(”Bringing research evidence

into practice”)


Dr benjamin spock baby and child care
Dr. Benjamin Spock:Baby and Child Care

“I think it is preferable to accustom a baby to sleeping on his stomach from the start of he is willing. He may change later when he learns to turn over”.

Later evidence indicates that prone position is a

an significant risk factor for SIDS

(sudden infant death syndrome)


EBM & Clinical Epidemiology

  • Fletcher & Fletcher: CE = The application of

    epidemiologic principles in problems encountered in clinical medicine

  • Sackett et al: CE = The basic science for clinical medicine

  • Much resistance by experts

  • EBM: In principle – no one disagree

  • All major medical journals have adopted EBM

  • Centers for EBM all over the world


Previous practice
Previous practice:

Problems with patients:

Dx, Rx, Px

6 yrs medical

education

40-50 yrs

medical practice

Consultants, colleagues

Textbooks

Handbooks

Lecture notes

Clinical guidelines

CME, seminars, etc

Journals

Usu. see only Resultssection,

or even worse, Abstract section


  • Trust me

  • In my experience ….

  • Logically

  • Textbook, handbook, capita selecta


What is evidence based medicine
What is Evidence-based Medicine?

  • “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”

  • “Pemanfaatan bukti mutakhir yang sahih dalam tata laksana pasien”

  • Integration of (1) physician’s competence (2) valid evidence from studies (3) patient’spreference


  • Pros : “New paradigm in medicine”

  • “Extraordinary innovations, only 2nd to Human Genome Project”

  • Cons : New version of an old song

  • ‘Fair’ : Nothing wrong with EBM, but:

    • Be careful in searching evidence

    • Meta-analyses, clinical trials, etc. should be critically appraised

  • Keyword for EBM:

    • Methodological skill to judge the validity

    • of study reports (Re. Andersen B: Methodological errors in medical research, 1989)


  • “Hierarchy of Lies”

    Statistics

    Damn lies.....

    Lies.....

    (Mark Twain)


    Why ebm
    WHY EBM?

    1. Information overload

    • Keeping current with literature

    • Our clinical performance deteriorates with time (“the slippery slope”)

      4. Traditional CME does not improve clinical

      performance

      5. EBM encourages self directed learning process which should overcome the above shortages


    The fact……..

    • >25,000 periodical (journals)

    • 6,000,000 articles annually

    • 17,000 biomedical books annually

    • 3000 recognized diseases

    • 1500 therapeutic regimens (+250 annually)


    The flora and fauna of the medical jungle

    Original Research

    Academic Reviews

    Decision/Cost Analysis

    Medical Cookbooks (Practice Guidelines)

    Translation Journals

    CME

    Clinical Experience

    Experts

    Newsletters and Survey Services

    Pharmaceutical Representatives

    Computer sources

    Audiotapes

    Qualitative Research

    The Flora and Fauna of the Medical Jungle


    Our textbooks are out of date
    Our textbooks areout-of-date

    • Fail to recommend Rx up to ten years after it’s been shown to be efficacious.

    • Continue to recommend therapy up to ten years after it’s been shown to be useless.


    The inevitable consequence
    The inevitable consequence:

    • On average, the clinically-important knowledge of physicians deteriorates rapidly after we complete our training.


    100%

    $

    Relative

    % of

    remaining

    knowledge

    2 4 6 8 10 12

    Years after graduation

    THE SLIPPERY SLOPE


    Steps in EBM practice

    • Formulate clinical problems in answerable questions

    • Searchthebestevidence: use internet or other on-

    • line database for current evidence

      3. Critically appraise the evidence for

      • Validity (was the study valid?)

      • Importance (were the results clinically important?)

      • Applicability (could we apply to our patient?)

  • 4. Apply the evidence to patient

  • 5. Evaluate our performance

  • VIA


    Main area

    Diagnosis(Determination of disease or problem) Treatment(Intervention necessary to help the patient)Prognosis(Prediction of the outcome of the disease)


    Others:

    Meta-analysisClinical guidelinesEconomic analysis Clinical decision makingCost-effectiveness analysisQualitative research


    I formulating clinical questions
    (I)Formulating clinical questions


    • A 2-month old infant with large VSD

    • Birth weight 3.1 kg

    • Weight 3.8 kg, HR=132, RR 68

    • Retractions (+)

    • Systolic murmur, gallop rhythm

    • Hepatomegaly

    • Dx: Large VSD, Heart failure, Failure to thrive

    • Definite Rx: early surgery

    • Alternative Rx: Drugs first?


    Medical students background question
    Medical students:(Background question)

    • What is VSD?

    • How to Dx?

    • What are symptoms & signs of CHF in infants with L-R shunt?

    • What is the treatment?


    House officers foreground question
    House officers(Foreground question)

    • In infants with large VSD and CHF, would administration of digoxin or other inotropic agent delay the need for surgery?


    Foreground

    questions

    Background

    questions

    Experience with condition


    Other example
    Other example

    • In neonates born to mothers with history of herpes simplex infection, does the administration of IVIG (intravenous immunoglobulin) reduce the possibility of neonatal herpes?


    Other example1

    In women with history of eclampsia, would administration of low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Other example


    Examples of clinical questions in practice
    Examples of clinical questions in practice low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?


    Example etiology
    Example: Etiology low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    P I C O

    …a risk factor for the developmnt HMD?

    “In

    premature

    infants …

    …is mode

    of delivery…


    Example diagnosis
    Example: Diagnosis low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    P I C O

    “In patients

    with suspected

    malaria

    …effectively

    establish

    diagnosis?

    …comparedwith microscope

    exam

    …can

    rapid test


    Example therapy
    Example: Therapy low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    P I C O

    will early

    IV

    Immuno-globulin

    (IVIG)

    “For px

    with Stevens

    Johnson

    syndrome

    …when

    compared

    with

    no IVIG

    …prevent

    severe

    complica-

    tions?


    Example prognosis
    Example: Prognosis low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    P I C O

    …worsen

    the

    prognosis?

    “For px

    with SLE

    …would

    history

    of

    heart failure

    …compared

    with no

    history

    of HF


    Four elements of good clinical question pico
    Four elements of low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?good clinical question:PICO

    The Patient or Problem

    The Intervention

    Comparative intervention

    The Outcome

    Domain

    Determinants

    Outcome


    Four elements of a well constructed clinical question pico
    Four elements of a well constructed clinical question: PICO low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    P I C O

    The main

    intervention

    considered

    The

    alternative

    to compare

    with the

    intervention

    Outcome

    expected

    from this

    intervention?

    Description

    of patient

    or problem

    B e b r i e f a n d s p e c i f i c


    Remember 1
    Remember (1) low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    • Not all clinical questions contain 4 elements, depending on the nature of the condition being asked.

    • Examples:

      • In post-menopausal women on hormone replacement therapy, does addition of vitamin X reduce the likelihood of developing hip fracture? (PIO)

      • In patients with thalassemia HbE disease, what is the prevalence of single gene mutation? (PO)


    Remember 2
    Remember (2) low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    • In the PICO context, Intervention does not necessarily mean TREATMENTor PREVENTION, but may be:

      • A diagnostic test (for diagnosis)

        • In a patient with solitary thyroid nodule, does ultrasound exam, compared with needle biopsy, differentiate malignant from benign tumor?

      • A risk factor (for etiology, prognosis)

        • Is poor fiber diet a risk factor for the development of colo-rectal cancer?

      • A condition in the patient himself (for prognosis)

        • In patient with SLE, would the history of cardiac failure, compared with no failure, worsen the long-term prognosis?


    Relevance type of evidence
    Relevance: Type of Evidence low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    POE: Patient-oriented evidence

    mortality, morbidity, quality of life

    DOE: Disease-oriented evidence

    pathophysiology, pharmacology, etiology


    Comparing does and poems
    Comparing DOEs and POEMs low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Example

    DOE

    POEM

    Comment

    DOE & POEM

    contradicts

    Drug A >

    mortality

    Antiarrhythmic

    Therapy

    Drug A  PVC

    On ECG

    Drug X 

    mortality

    POEM agrees

    With DOE

    Antihypertens.

    Therapy

    Drug X  BP

    PSA screening

    detects prostate

    Ca. early

    ? whether PSA

    screening 

    mortality

    Prostate

    screening

    DOE exists, but

    POEM unknown


    Ii searching the evidence

    II low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?Searching the evidence


    Examples of on line journals databases
    Examples of on-line Journals / Databases low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    • http://bmj.com

    • http://adc/bmjjournals.com

    • MEDLINE/PubMed

    • EMBASE

    • MDConsult

    • AAP Journal Club

    • Cochrane Library


    Use keywords for searching low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Note:

    • Spelling (American / British), terminology

    • Follow rigidly the instructions of each website

      Examples:

    • “Host vs graft reaction” AND management

    • hemosiderosis AND thalassemia OR thalassaemia

    • “breast cancer” OR “Ca mammae” AND immunoglobulin OR IVIG


    Iii appraising the evidence via

    III low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?Appraising the evidence:VIA


    VIA low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Validity:In Methods section:

    • design, sample, sample size, eligibility criteria (inclusion, exclusion), sampling method, randomization method, intervention, measurements, methods of analysis, etc

      Importance:In Results section

    • characteristics of subjects, drop out, analysis, p value, confidence intervals, etc

      Applicability:In Discussion section + our patient’s characteristics, local setting


    Validity other approach rammbo
    Validity - other approach: low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?RAMMbo

    • Recruitment: sampling methods, eligibility criteria, sample size

    • Allocation: randomization? concealment?

    • Maintenance: many drop outs?

    • Measurement

      • blinded – RCT, Dx test

      • objective – validity & reliability

    Can be applied for all designs with necessary

    Adjustment according to nature of the design


    Example: low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Critical appraisal for therapy

    • Were the subjects randomized?

    • Were all subjects received similar treatment?

    • Were all relevant outcomes considered?

    • Were all subjects randomized included in the analysis?

    • Calculate CER, EER, RRR, ARR, and NNT

    • Were study subjects similar to our patients in terms of prognostic factors?


    Hierarchy of evidence

    Rec low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Weight of

    Scientific

    Scrutiny

    A

    Level 1

    Level 2

    B

    Level 3

    C

    Level 4

    Hierarchy of evidence

    Meta-analysis of RCT

    Large RCT

    Small RCT

    Non-Randomized trials

    Observational studies

    Case series / reports

    Anecdotes, expert, consensus


    Implementation of ebm practice how to get started

    Implementation of EBM practice: low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?How to get started

    1. Teaching EBM in medical schools / PPDS

    Easier than to change the already existing attitude

    Most important

    May be included in formal curricula or integrated in

    existing activities: ward rounds, on calls, case

    presentations, group discussions, journal clubs, etc

    2. Workshop for teaching staff

    3. Workshop for practitioners, incl. nurses


    Resistance to ebm teaching learning

    Resistance to EBM teaching low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?& learning

    Rudimentary skill in critical appraisal / methodological skill

    Limited resources, esp. time factor

    Lack of high quality evidence

    Skepticism toward evidence-based practice

    ‘Happy’ with current practice


    Development of ebm practice

    Development of EBM practice low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Passive diffusion model

    Active dissemination model

    Coordinated implementation model:

    Patients & community

    Health administrators

    Public policy makers

    Clinical policy makers


    Summing up .... low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?


    Formulate low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    In answerable

    question

    Apply

    The evidence

    Critically

    Appraise

    The evidence

    Search the

    evidence

    Patient

    With problem

    The

    EBM

    Cycle


    Appropriate low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    sampling

    technique

    Actual

    study

    subjects

    Subjects

    completed

    the study

    [Non-response, drop outs,

    withdrawals, loss to follow-up]

    Usu. Based on practical

    purposes

    Target population

    (Domain)

    Accessible

    population

    (time, place)

    (demographic, clinical)

    Your patient is here!

    Intended

    Sample

    [Subjects selected

    for study]


    Criticism to ebm
    Criticism to EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    • EBM makes expensive medical care

    • EBM cannot be implemented in developing countries

    • EBM is costly and time consuming

    • EBM ignore pathophysiology & reasoning

    • EBM ignore experience and clinical judgment

    • EB-guidelines etc interfere with professional autonomy


    Criticism to ebm1
    Criticism to EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    EBM makes expensive medical care

    Cf:

    • Routine antibiotics for ARTI & diarrhea

    • Liberal indication for C-section

    • Unnecessary sophisticated procedures / exams

    • Unnecessary / harmful treatment: steroid for recurrent cough


    Criticism to ebm2
    Criticism to EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    EBM cannot be implemented in

    developing countries

    • By definition EBM is implemented if it is implementable (patient’s preference and local condition) – for the benefit of the patients and the community


    Criticism to ebm3
    Criticism to EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    EBM is costly and time consuming

    • EBM does requires facilities at the cost of quality medical care!

    • Cost benefit ratio should be assessed in individual and community levels


    Criticism to ebm4
    Criticism to EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    EBM ignores pathophysiology & reasoning

    • EBM encourages clinical reasoning in the light of valid and important evidence

    • Pathophysiology and reasoning should be seen as hypothesis and should end-up in empirical evidence


    Criticism to ebm5
    Criticism to EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    EBM ignore experience and clinical judgment

    • Personal experience and clinical judgment are by no means can be eliminated

    • EBM encourage detailed and systematic documentation of experience and judgment

    • Subjective experience should be, whenever possible, translated into more objective measures


    Criticism to ebm6
    Criticism to EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    EB-guidelines etc interfere with professional

    autonomy

    • Professional conduct (competence, altruism, openness, collegiality, ethics) is encouraged in EBM

    • Every physician should develop their own practice attitude based on his/her profess-ionalism, valid evidence, and patient’s values

    • Development of clinical guidelines and other standards of care should be seen as a guide and implemented according to clinical setting


    Barriers to the implementation of evidence based medicine
    Barriers to the implementation of Evidence-Based Medicine low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    “It takes too long.”

    “Possibly a limitation to my clinical freedom.”

    “It questions my professional autonomy.”


    Advantages of ebm
    Advantages of EBM low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    • Encourages reading habit

    • Improves methodological skill (and willingness to do research?!)

    • Encourages rational & up to date management of patients

    • Reduces intuition & judgment in clinical practice, but not eliminates them

    • Consistent with ethical and medico-legal aspects of patient management


    End result low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Self directed, life-long learning attitude

    for high quality patient care


    Conclusion

    Conclusion low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    EBM is nothing more than a

    framework of systematic use of

    current valid study results

    relevant to our patient


    • Evidence-based Cardiology low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    • Evidence-based Pediatrics

    • Evidence-based Ob-Gyn

    • Evidence-based Dentistry

    • Evidence-based Nursing

    • Evidence-based Health Policy

    • Evidence-based Health Technology Assessment

    • Evidence-based Decision Making

    • Evidence-based Health Performance Indicators

    • Evidence-based Clinical Audit

    • Evidence-based Risk Management …….

    • Evidence-based Everything!!!


    In God we trust low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    All others must have evidence


    Remember however

    Remember, however …... low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?

    Medicine is the science of uncertainty

    and the art of probabilities


    ad