Refleksi

Kasus
dengan
Evidence
Based
Medicine
My students are
dismayed when I say to
them

Half of what you are

taught as medical
students will in 10 years
have been shown to be
wrong. And the trouble
is, none of your teachers
knows which half.

(Dr. Sydney Burwell,

Dean of Harvard Medical School).
I dont
know

The three most

important words
in education

(David Pencheon)
 CLINICAL SCENARIO
Youve just begun a month as the attending
physician supervising residents and
students on a hospital medicine inpatient
service. You join the team on rounds after
theyve finished admitting a patient. The
patient is a 76-year-old woman admitted
with a history of progressive dyspnea and
leg edema. She was diagnosed with
congestive heart failure 6 months ago,
when she presented with similar complaints,
and was found on examination to have
elevated neck veins, lung crackles, an S3
gallop, and pitting edema in both legs.
 CLINICAL SCENARIO
On that admission, her ECG showed
normal sinus rhythm and her transthoracic
echocardiogram showed systolic
dysfunction, with an estimated ejection
fraction of 2530%. Since then, she has
been treated with diuretics, ACE
(angiotensin-converting enzyme)
inhibitors, beta-blockers, digoxin, and
aspirin and has been hospitalized twice
with exacerbations of heart failure.
 CLINICAL SCENARIO
Now, on her third hospitalization, she is
frustrated by her continued symptoms and
worried about the future, given her
frequent exacerbations and admissions to
hospital. Her examination shows
significant edema, neck vein distension,
an S3 gallop, and an abdominal fluid wave.
Her ECG shows sinus rhythm, and her
chest radiograph shows pulmonary venous
congestion with small bilateral effusions.
 STEPS IN PRACTICING
EBM
1. Convert the need for information into
an answerable question.
2. Track down the best evidence with
which to answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our
clinical expertise and our patients
characteristics and values.
5. Evaluating our effectiveness and efficiency
in executing steps 14 and seeking ways
to improve them both for next time.
What questions you have about this
patient; specifically, what important pieces
of medical knowledge youd like to have in
order to provide better care for this patient.
OUR REACTIONS TO KNOWING
AND TO NOT KNOWING
Cognitive resonance: knowledge we
already possess
Cognitive dissonance: knowledge
we dont possess
Maladaptive reactions:
Hiding
Overreacting: anxiety, guilt or shame
Adaptive reactions:
Motivate learning
Ignorance, incompetence, obsolescence,
not knowing when we dont know
 BACKGROUND
QUESTIONS
The teams medical students asked
several questions, including:
a. What can precipitate an acute
exacerbation of congestive heart
failure?
b. How does congestive heart failure lead
to ascites?
c. What did the patient mean by If my
heart has failed, will I flunk, too?
 BACKGROUND QUESTIONS
When well formulated, background
questions usually have two
components:
1. A question root (who, what, when,
where, how, why) with a verb.
2. An aspect of the condition or thing of
interest.
 FOREGROUND
QUESTIONS
The teams house officers also asked
several questions, including:
a.Among patients presenting with an
acute exacerbation of heart failure, how
often would a thorough investigation
uncover previously unsuspected acute
ischemia as the principal (or
contributing) precipitant of the episode?
 FOREGROUND
QUESTIONS
The teams house officers also
asked several questions, including:
b. In adults with heart failure who are in
sinus rhythm, would adding warfarin to
standard therapy reduce morbidity or
mortality from thromboembolism
enough over 35 years to be worth the
harmful effects and inconveniences of
warfarin?
 FOREGROUND
QUESTIONS
The teams house officers also
asked several questions, including:
c. In patients with recurrent
exacerbations of heart failure, would
joining a local, integrated, heart failure
disease management program reduce
mortality, morbidity, or hospitalizations
enough over the next year to be worth
the extra time, money, or
inconvenience?
 FOREGROUND QUESTIONS
The house officers questions concern
specific knowledge that could directly
inform one or more foreground
clinical decisions they face with this
patient, including a broad range of
biologic, psychologic, and sociologic
issues.
 FOREGROUND QUESTIONS
When well constructed, such foreground
questions usually have four components:
1. The patient situation, population, or
problem of interest.
2. The main intervention, defined very
broadly, including an exposure, a diagnostic
test, a prognostic factor, a treatment, a
patient perception, and so forth.
3. A comparison intervention or exposure, if
relevant.
4. The clinical outcome(s) of interest,
including a time horizon if relevant.
 Question Components:
PICO

The patient or problem or

population
The intervention
Comparison with what etc.
Outcome one is concerned about
(Time horizon)
Questions: PICO

Centre for EBM: http://163.1.212.5/docs/focusquest.htm

 PICO

Patient Intervention Compariso Outcomes

or n
Problem
 Clinical question about
diagnosis

Patient Interventio Compariso Outcome

or n n s
Problem
Patient Serum Bone Diagnosi
with ferritin marrow s of iron
anemia stain for deficienc
iron y
anemia
 Clinical question about
diagnosis
In patients with anemia does serum
ferritin compared to bone marrow
stain for iron help rule in (or rule
out) a diagnosis of iron deficiency
anemia?
 Clinical question about
prognosis

Patient Intervention Comparison Outcomes

or
Proble
m
A 45- Mitral valve No mitral Cardio-
year- prolapse prolapse vascular
old with mitral and morbidity
woman regurgitatio regurgitatio and
n n mortality
 Clinical question about
prognosis
In a 45-year-old woman what is the
risk following mitral prolapse with
mitral regurgitation compared to
without mitral prolapse with mitral
regurgitation of subsequent
cardiovascular morbidity and
mortality?
 Clinical question about
therapy
Patient Interventi Compariso Outcome
or on n s
Problem
A 75- Statins Placebo Stroke
year-old
man
with
significa
nt
carotid
stenosis
 Clinical question about
therapy
In 75-year-old man with significant
carotid stenosis does statins
compared to placebo reduce the
risk of stroke?
 Clinical question about
harm

Patient Interventi Comparis Outcomes

or Problem on on
A 45-year-old Caffein No Urge
woman caffeine incontinen
during a ce
routine
health
maintenance
visit
 Clinical question about
harm
In a 45-year-old woman does
caffeine consumption compared to
no caffeine consumption increase
the risk of urge incontinence?
Central issues in clinical work,
where clinical questions often
arise
1. Clinical findings: how to properly gather and
interpret findings from the history and physical
examination.
2. Etiology: how to identify causes or risk factors for
disease (including iatrogenic harms).
3. Clinical manifestations of disease: knowing
how often and when a disease causes its clinical
manifestations and how to use this knowledge in
classifying our patients illnesses.
4. Differential diagnosis: when considering the
possible causes of our patients clinical problems,
how to select those that are likely, serious, and
responsive to treatment.
Central issues in clinical work,
where clinical questions often
arise
5. Diagnostic tests: how to select and interpret
diagnostic tests, in order to confirm or exclude a
diagnosis, based on considering their precision,
accuracy, acceptability, safety, expense, etc.
6. Prognosis: how to estimate our patients likely
clinical course over time and anticipate likely
complications of the disorder.
7. Therapy: how to select treatments to offer our
patients that do more good than harm and that
are worth the efforts and costs of using them.
Central issues in clinical work,
where clinical questions often
arise
8. Prevention: how to reduce the chance of
disease by identifying and modifying risk factors
and how to diagnose disease early by screening.
9. Experience and meaning: how to empathize
with our patients situations, appreciate the
meaning they find in the experience, and
understand how this meaning influences their
healing.
10.Improvement: how to keep up-to-date, improve
our clinical and other skills, and run a better,
more efficient, clinical care system.
Steps in Practicing EBM

1. Convert the need for information into

an answerable question.
2. Track down the best evidence with
which to answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients
characteristics and values.
Steps in Practicing EBM

1. Convert the need for information into

an answerable question.
2. Track down the best evidence with
which to answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients
characteristics and values.
Question Components: PICO

The patient or problem or population

The intervention
Comparison with what etc.
Outcome one is concerned about
 PICO
Patient Interventi Comparis Outcomes
or on on
Problem
Hysterecto Vaginal Abdominal Operation time,
my for hysterecto hysterecto intra-operative
benign my my complication,
disease short term
outcomes,
recovery from
surgery,
negative and
positive long
term outcomes
 Clinical Question
What is the most appropriate surgical
approach to hysterectomy in benign
disease?
 Steps in Practicing EBM

1. Convert the need for information into

an answerable question.
2. Track down the best evidence with
which to answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients
characteristics and values.
Straus S, Haynes RB. Managing evidence-based knowledge:
the need for reliable, relevant and readable resources. CMAJ
2009;180(9):942-945.
 The Evidence: Systems
Lefebvre G, Allaire C, Jeffrey J, Vilos
G. Hysterectomy. SOGC Clinical
Practice Guidelines, No. 109, January
2002. J Obstet Gynaecol Can
2002;24(1):3748.
109E-CPG-January2002.pdf
 The Evidence:
Summaries
Berghella V (Editor). Obstetric
Evidence Based Guidelines. London:
Informa, 2007.
Obstetric Evidence Based
Guidelines.pdf
The Evidence: Synopsis

Vaginal hysterectomy for large

fibroids had reduced operating time
and hospital stay compared to
abdominal hysterectomy. Evidence-
Based Obstetrics & Gynecology,
2004;6(1):19-21.
1561.pdf
The Evidence: Synthesis
Johnson N, Barlow D, Lethaby A,
Tavender E, Curr E, Garry R. Surgical
approach to hysterectomy for benign
gynaecological disease. Cochrane
Database of Systematic Reviews
2006, Issue 2. Art. No.: CD003677.
DOI:
10.1002/14651858.CD003677.pub3.
CD003677
 The Evidence: Studies
Silva-Filho AL, Werneck RA, de
Magalhes RS, Belo AV, Triginelli SA.
Abdominal vs vaginal hysterectomy:
a comparative study of the
postoperative quality of life and
satisfaction. Arch Gynecol Obstet.
2006 Apr;274(1):21-4.
21-24.pdf
 Steps in Practicing EBM

1. Convert the need for information into

an answerable question.
2. Track down the best evidence with
which to answer that question.
3. Critically appraise the evidence for its
validity, impact, and applicability.
4. Integrate the evidence with our clinical
expertise and our patients
characteristics and values.