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.
“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)
epidemiologic principles in problems encountered in clinical medicine
Problems with patients:
Dx, Rx, Px
6 yrs medical
CME, seminars, etc
Usu. see only Resultssection,
or even worse, Abstract section
1. Information overload
4. Traditional CME does not improve clinical
5. EBM encourages self directed learning process which should overcome the above shortages
Medical Cookbooks (Practice Guidelines)
Newsletters and Survey Services
Qualitative ResearchThe Flora and Fauna of the Medical Jungle
2 4 6 8 10 12
Years after graduation
THE SLIPPERY SLOPE
3. Critically appraise the evidence for
Diagnosis(Determination of disease or problem) Treatment(Intervention necessary to help the patient)Prognosis(Prediction of the outcome of the disease)
Meta-analysisClinical guidelinesEconomic analysis Clinical decision makingCost-effectiveness analysisQualitative research
Experience with condition
In women with history of eclampsia, would administration of low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?Other example
P I C O
…a risk factor for the developmnt HMD?
P I C O
P I C O
P I C O
The Patient or Problem
P I C O
B e b r i e f a n d s p e c i f i c
POE: Patient-oriented evidence
mortality, morbidity, quality of life
DOE: Disease-oriented evidence
pathophysiology, pharmacology, etiology
DOE & POEM
Drug A >
Drug A PVC
Drug X BP
? whether PSA
DOE exists, but
Use keywords for searching low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?
VIA low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?
Validity:In Methods section:
Importance:In Results section
Applicability:In Discussion section + our patient’s characteristics, local setting
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
Rec low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?
Level 4Hierarchy of evidence
Meta-analysis of RCT
Case series / reports
Anecdotes, expert, consensus
1. Teaching EBM in medical schools / PPDS
Easier than to change the already existing attitude
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
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
Passive diffusion model
Active dissemination model
Coordinated implementation model:
Patients & community
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?
Appropriate low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?
[Non-response, drop outs,
withdrawals, loss to follow-up]
Usu. Based on practical
Your patient is here!
EBM makes expensive medical care
EBM cannot be implemented in
EBM is costly and time consuming
EBM ignores pathophysiology & reasoning
EBM ignore experience and clinical judgment
EB-guidelines etc interfere with professional
“It takes too long.”
“Possibly a limitation to my clinical freedom.”
“It questions my professional autonomy.”
End result low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?
Self directed, life-long learning attitude
for high quality patient care
EBM is nothing more than a
framework of systematic use of
current valid study results
relevant to our patient
In God we trust low-dose aspirin (compared with no aspirin) during pregnancy prevent eclampsia?
All others must have evidence
Medicine is the science of uncertainty
and the art of probabilities