Eviden BAsed Medicine For PBL

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Evidence Based Medicine

DARWIN AMIR

Bgn Penyakit Saraf

RS DR. M. Djamil / Fakultas Kedokteran

Universitas AndalasPADANG


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Evidence Based Medicine

A new paradigm for the health care system

Using the current evidence in the medicalliterature to provide the best care to patients

Will give you the historical basis and

philosophical underpinning of EBM


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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


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After Luca Piccauli (1494) defined basic

principles of algebra and multiplication

tables introduced the first statistic problem

and Girolamo Gardano (1545) introducedthe first attempt to use mathematics to

describe statistic and probability.


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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 ofpersonal choice and judgement to statistical

probability.


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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


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Table : Probability of survival, 1660 and 1993

Percentage survival to each age

Age 1660 1993

0 100% 100%

26 25% 98%

46 10% 95%

76 1% 70%


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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)


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Evidence Based Practice

in Primary Care

The growing demand for public

accountability in health care and the

increased availability of information tousers -------- >

EBP will be central theme in general

practice and the organization of care for

many years to come


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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 beorganized


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The decisions ought to involve a negotiatedin the context of a partnership between the

health care professional and the patient and

takes account of factors such as patientneed, preferences, priorities, available

resources and evidence of the effects of

providing different forms of care


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Evidence from

Randomized

Controlled Trials

Other

Necessary

Evidence

Effects of careN e e d s

MAKING POLICIES AND

TAKING DECISIONSProfessional and providers

Service users and purchasersresearchers and funders

Resources Priorities


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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 throughtheir clinical experience


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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


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The distinction between EBM and

Evidence Based Health Care

Evidence Based Medicine Evidence Based Health Care

Conceptual approach that

health care professionalscan use in making

decisions about the care

of individuals patients

Broader concepts that

incorporates improveapproach to understanding

patients, families and

practitioners beliefs, values

and attitudes. Takes account evidence at a

population levels


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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 thisapplication of information is


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Step 1: defining the problem

Questions frequently arises, such as pros andconts of using a particular form of therapy, thevalue of having a particular diagnostic test orscreening procedure, the risk or prognosis of a

particular disease or the cost of a potentialintervention.

There is a clinical problem for which you areunsure of the evidence and to make a decisionto investigate it further.


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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


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Step 3: critically appraising the information

Decided which journal articles to read. It isimportant to read them carefully as not allpublished is of equal value

Critical appraisal of articles is a process which

involves carefully reading an article andanalysing its methodology, content andconclusion

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


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Step 4: applying the information with your patients

How to apply the information obtained to theparticular circumstances of your patients ?. This is

a probably the most crucial step in the process.

Whether there are any methodological issuesraised about the evidence which might prompt

you to reject it outright.

This process requires a partnership between thedoctor and patient. If at the end of the process the

decision is made be a mutual and conscientious


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Step 5: evaluating how effective it is.

Evaluate the effect of the evidence as applied tospecific patients.

The expected benefits that arose from using aparticular 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 bedone to rectify this

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


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Supporting a framework for Evidence-Based

Practice within general practice

As professional you have the challenge andresponsibilities in facing general practice

Framework needs to be built around ensuring thatthe evidence required to inform decision-makingis available, accessible, acceptable and applied byGP.

Emerged internationally which aim to producesystematic summaries with trying to practiceEBP.


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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 ofnetworks being amongs general practitioner of searching

for and appraising evidence A natural extension of this process is o apply EB

Protocols and guidelines, develop by he colleagues inclinical practice.


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The relevant clinical questions in yourpatients 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.


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Use of theophylline in asthmaFollowing 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.


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Prognosis

- What are the consequences of having the disease

Is it dangerous ?

Could I die of itHow long will I be able to continue my

present actives ?

Will it ever go away altogether?


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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 ?)


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Natural history of diseases

(no medical intervention)

Biologic onset Clinical

Diagnosis Outcome Recovery

DisabilityDeath

ect

Clinical Courses

(medical intervention)


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Risk Factors

BiologiconsetClinical

Diagnosis

Recovery

DisabilityDeath

Etc

Outcome

Prognostic factorsDemographic variableDisease specific variable

Co-morbid factor


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The strategy for making a prognosis

expert opinion

consulting the appropriate specialist

looking it up in a text book

clinical experiences

read up


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Cohort studySurvival analysis

Case control studyCase Series

Biologic

onset

Early

diagnosis

possible

Clinical

diagnosis

Outcome

Recovery

Disability

Death

Etc


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Summary

If the concept is embraced it will improvegeneral practice

Will make the GP an even more rewardingdiscipline within which to practice.

Will support shared decision making withusers. It is the ideal model of makingdecisions within the medical encounter.

EBM / EBP will help maintain the central roleof general practice in health care.


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