Presentation on theme: "Evidence Based Medicine"— Presentation transcript:
1 Evidence Based Medicine DARWIN AMIRBgn Penyakit SarafRS DR. M. Djamil / Fakultas KedokteranUniversitas AndalasPADANG
2 Evidence Based Medicine A new paradigm for the health care systemUsing the current evidence in the medical literature to provide the best care to patientsWill give you the historical basis and philosophical underpinning of EBM
3 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
4 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.
5 probabilities using two dice Thomas Gataker expounded on the meaning Galileo expanded on this by calculatingprobabilities using two diceThomas Gataker expounded on the meaningof probability by noting that it was naturallaws.Huygens (1657), Leibniz (1662) andEnglishman John Graunt (1660) wrote onnorms of statistic including the relation ofpersonal choice and judgement to statisticalprobability.
6 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
7 Table : Probability of survival, 1660 and 1993 Percentage survival to each ageAge16601993100%2625%98%4610%95%761%70%
8 Medical practice - Administering treatment that does more Clinician helps patients by- Diagnosing what is wrong with them- Administering treatment that does moregood than harm- Giving them an indication of what thefuture is likely to hold (prognosis)
9 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
10 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
11 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
12 Evidence from Randomized Controlled Trials Other Necessary Evidence N e e d sEffects of careMAKING POLICIES ANDTAKING DECISIONSProfessional and providersService users and purchasersresearchers and fundersResourcesPriorities
13 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 useGP acquire, wisdom and judgment through their clinical experience
14 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
15 The distinction between EBM and Evidence Based Health Care Evidence Based MedicineEvidence Based Health CareConceptual approach thathealth care professionalscan be used in makingdecisions about the careof individuals patientsBroader concepts thatincorporates improveapproach to understandingpatients, families andpractitioners beliefs, valuesand attitudes.Takes account evidence at apopulation levels
16 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
17 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.
18 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
19 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 valueCritical appraisal of articles is a process which involves carefully reading an article and analysing its methodology, content and conclusionDo I believe these result sufficiently that I would be prepared to adopt a similar approach or reach a similar conclusion, with my own patients ?.
20 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
21 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 thisThe practitioner is having sufficient time to apply these steps routinely in their daily practice
22 Supporting a framework for Evidence-Based Practice within general practice As professional you have the challenge and responsibilities in facing general practiceFramework 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.
23 Supporting a framework for Evidence-Based Practice within general practice Good examples are:- Cochrane library (a database of high quality systematicreview 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 evidenceA natural extension of this process is apply EB Protocols and guidelines, develop by he colleagues in clinical practice.
24 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 treatment3). 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.
25 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 inpatients whose asthma was not controlled with high dose inhaledsteroid, but even then alternative treatment might have fewer sideeffects. He decided it was time to review his prescribing oftheophylline and used the practice computer to produce a list of allhis asthmatic patients and their recent medication. He found 86patients, three of whom were taking theophylline. He was reassuredthat his use of theophylline was limited, but made an entry in therecords of each of these patients to remind him to review theirmedication when the patient next attended. Ultimately, he was ableto persuade two of these patients to discontinue theophylline, andafter 6 months the prescribing data were checked again to confirmthat these changes had persisted.
26 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?
27 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 ?)
28 Natural history of diseases (no medical intervention) Biologic onset ClinicalDiagnosis Outcome RecoveryDisabilityDeathectClinical Courses(medical intervention)
30 The strategy for making a prognosis “expert opinion”consulting the appropriate specialistlooking it up in a text book“clinical experiences”“read up”
31 Cohort study Survival analysis Case control study Case Series RecoveryDisabilityDeathEtcEarlydiagnosispossibleBiologiconsetClinicaldiagnosisOutcome
32 Summary If the concept is embraced it will improve general 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.
33 for Your Good Attention Thank Youfor Your Good Attention