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Hardisman, MD, MHID, PhD Faculty of Medicine Andalas University Padang West Sumatera

"...the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." The integration of best research evidence with clinical expertise and patient values.

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Integrated

with clinical expertise

expertise in performing the history and physical examination knowledge of the patient, the family, and the community which creates a context for therapeutic decision-making a relationship with the patient informed by his or her beliefs and values practical knowledge of the availability of resources in the community

EBPH

is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of communities and populations in the domain of health protection, disease prevention, health maintenance and improvement. Jenicek (1997)

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EBPH

is the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems and appropriate use of program planning models. Brownson (1999)

First

described in 1992 A new approach to teaching medicine A revolution in medical practice Other evidence-based approaches: ethics, psychotherapy, occupational therapy, dentistry, nursing, and librarianship

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Jenicek

(1997) published a review discussing epidemiology, EBM, EBPH Epidemiology described as the foundation of both EBM and EBPH EBPH unique in using complex interventions with multiple community and societal issues

Overwhelming

size of the literature Inadequacy of textbooks Difficulty synthesizing evidence and translating into practice Increased number of RCTs Available computerized databases Reproducible evidence strategies

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De-emphasizes

patient values Doesnt account for individual variation Devalues clinical judgment Leads to therapeutic nihilism

Convert

the need for info. into an answerable question Track down the best evidence Critically appraise that evidence Integrate the appraisal with ones clinical expertise and the individual patient Evaluate

Sackett DL. EBM: how to practice and teach EBM. Churchill Livingstone 2000

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Develop

an initial statement of the issue Search the scientific literature and organize information Quantify the issue using sources of existing data Develop and prioritize program options; implement interventions Evaluate the program or policy

Convert

the need for info. into an answerable question Track down the best evidence Critically appraise that evidence Integrate the appraisal with ones clinical expertise and the individual patient Evaluate

Sackett 2000

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State

the scientific question of interest Identify the relevant evidence Determine what information is needed to answer the scientific question Determine the best course of action considering the patient or population Evaluate process and outcome

Kohatsu et al. Am J Prev Med 2004;27:417-21

Mission: an international organisation that aims to help people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions.

www.cochrane.org

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"Without

clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients."

Textbooks

YES / NOT ? Always out of date Recommendations often not referenced Textbook for Evidence References

Clinical Evidence

www.clinicalevidence.com www.samed.com

Scientific American Medicine

Harrisons Textbook of Internal Medicine www.harrisonsonline.com www.eboncall.co.uk/content.jsp.htm

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EBM

Journals Bandolier www.jr2.ox.ac.uk/bandolier Evidence Based Medicine www.acponline.org/journals/ebm/ebmme nu.htm

EBM

Databases Cochrane Database of Systematic Reviews / Cochrane Library Medline

Free online access thru PubMed www.ncbi.nlm.nih.gov/entrez/

SUMSearch
Merck Manual. Medline National Guideline Clearinghouse from the Agency for Health Care Policy and Research (AHCPR) Database of Abstract of Reviews of Effectiveness (DARE) www.sumsearch.uthscsa.edu

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Sensitivity =A/ (A+C) Specificity = D / (B+D) Pos Predictive Value = = A/ (A+B) Neg Predictive Value = = C / (C+D) Prevalence = A / (A+B+C+D)
Disease

Present

Absent

Test Pos

Test Neg

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Diagnostic Diabetes Mellitus Based on Gold Standard Random Blood Glucose Test Pos Test Neg

Present 90 10

Absent 55 45 145 55

100

100

200

12

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13

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Disease

Risk + -

Present (+) A C

Absent (-) B D

A+B C+D
Total

A+C

B+D

* Note: (A+B) = (C+D)

Risk

of Exposed Group= A/ (A+B) of Un-Exposed= C/ (C+D) Risk = R. Exposed / R.Un-Exposed

Risk

Relative

14

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Lung Cancer

Smoking Smoking None

Present (+) 20 2

Absent (-) 80 98 100 100

22

178

200

15

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Disease

Risk + -

Present (+) A C

Absent (-) B D
A+B C+D

A+C
* Note: (A+C) = (B+D)

B+D

Total

16

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OR

(Odd Ratio) = (A x D) / (B x C)

Lung Cancer

Smoking Smoking None

Present (+) 95 5

Absent (-) 85 15 180 20

100

100

200

17

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Is

the evidence valid? Is evidence important? Does the evidence apply to our patient/ our cases?

Thank You

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