introek-ebm 2015_@ - copy
TRANSCRIPT
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Curriculum Vitae
Name: Joewono Soeroso MD, MSc PhD, Internist-Rheumatologist-ClinicalEpiemiologist
D!" : Purwo#erto $ Jul% $&'(
Eucations:
) MD: Diponegoro *ni+ersit% $&
) Internist: irlangga *n+ersit% $&./
) MSc 0Clinical-Epiemiologi 1 E+ience "ase Meicine2: College o3Meicine *ni+4 o3 5he Philippines Manila $&&'
) Rheumatologist: $&&&
) 6re 7utchinson Research Center, Seattle 8((8) PhD: irlangga *n+ersit% 8((9
) " irlangga *n+ersit% 8($9
5eaching Sa33 at 6; *nair $&&$- now
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INTRODUKSI
EVIDENCE BASED MEDICINEJoewono SoerosoUnit Epidemiologi Klinis FK Unir
S!"#Bgin Re!mtologi#$"#SMF I% &en'(it DlmFK Unir#RSUD Dr% S!tomo
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Subject Tutor
1. Intro & Basics of EBM Prof. Dr. Joewono Soeroso dr. MSc, SpPD!"
#. $%erap & 'arm J. E(o )a%ono "a%ard*o dr M.!es.,SpS+!
-. Pronosis & Metaanalsis 'eru Purwanto dr M.!es., SpB/n(
0. 'ow to ind Current BestE2idence +t%eor & practice
Dr. 3nan Endaranto dr. Sp3+!
4. Critical 3ppraisal 3rticle on
$%erap +t%eor & practice
Dr. Cita "osita SP dr. Sp!!+!
5. 6$S Critical 3ppraisal Paper 7 Screenin, "is(actor, Dianosis, $%erap +8roups
9. 63S Indi2idual
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)A*t lo*l
)T+in( glo"l
) Do not +esitte
) Do , do nd do%
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B3SIS D3"I EBM
: Metode Penelitian
: Epidemioloi
: Biostatisti(a
: E(onomi (linis
: Ilmu sosial
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Implementation of the best evidenceImplementation of the best evidenceobtained from clinical research toobtained from clinical research to
clinical practiceclinical practice
What is EBM?What is EBM?
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Other Names of EBMOther Names of EBM
Clinical epidemioloClinical epidemiolo +einstein, 1;94, Sac(ett 1;
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/=*ecti2e of EBM
: $o efficientl impro2in patients> %ealt%$o efficientl impro2in patients> %ealt%
: $o (eep up to date$o (eep up to date: $o en%ance ?ualit researc%$o en%ance ?ualit researc%+Sac(ett 1;;1, Di@on, 1;;9 Sac(ett 1;;;+Sac(ett 1;;1, Di@on, 1;;9 Sac(ett 1;;;,8lasAiou #9,8lasAiou #9
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EBM is a =ottomup approac%, not aEBM is a =ottomup approac%, not a
coo(=oo( approac%coo(=oo( approac%
E@ternal e2idence can inform, =ut ne2erE@ternal e2idence can inform, =ut ne2er
replace clinical e@pertisereplace clinical e@pertise +Sac(ett et al, 1;;;+Sac(ett et al, 1;;;
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Reser*+
Better -!lit' o.$i.e
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/+t is in t+e rel world0
*!red
not *!red
A new nti"ioti* .or t+e tretment t'p+oid .e1er
Does t+is nti"ioti* wor( well0
ptient 2 ptient 3 ptient 4 ptient 5 ptient 6
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/+t is in t+e rel world0
7ood res!lts p!"lis+ed
&oor res!ltsnot p!"lis+ed
&!"li*tion Bis
Reser*+ 2 Reser*+ 6Reser*+ 5Reser*+ 4Reser*+ 3
A8R- 59: medi*l reser*+were not p!"lis+ed
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/+t is in t+e rel world0
T+e *se o. gstri* .ree;ing m*+ine
) In t+e s? 36== gstri* .ree;ing
m*+ines .or tretment o. gstri* "leeding
were sold
) Until rndomi;ed tril s+owed t+is
m*+ine ws not "etter t+n *on1entionl
tretment
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1lid onl' @:
) Reid JAMA 1995; 274: 651 24== reser*+rti*les on **!r*' o. dignosti* tools .rom
!rinedipsti*( to MRI nd CT s*n
/+t is in t+e rel world0
) Co+rne Coll"ortion 2@ 2@?=== st!dies on t o. mild +'pertension 1lid onl' 33 st!dies
) 8'nes An Intern Med 1986; 309 :105 9== reser*+ rti*les in 5 .mo!s Go!rnls 1lid onl' 2:
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Epidemiolog't+e st!d' o. t+e distri"!tion nd
determinnts o. +elt+ relted
e1ents? nd t+e ppli*tion o. t+is
st!d' to *ontrol +elt+ pro"lems
$st? 299
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Mening(t(n eHsiensi dignosis? terpidn prognosisTetp mengi(!ti per(em"ngnI&TEKDOKMening(t(n (!ntits dn (!litspenelitin
T!G!n
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biologic onset
(patobiology)
Prognostic
FactorsDiagnostic
test
+Dx
early diagnosis
possible
usual clinical
diagnosis sembuhkomplikasi
cacadmatiRisk factors
(Causation)Screening
Clinical Trials
Preention !
area penelitian
"Clinical Trials
T#erapyClinical Trials
Preention !!
Diagnostic
test
$nd Points
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) C!stion
) S*reening
) Dignosis
)T+erp') &rognosis
) -!lit' o. Cre Clini*l!diting
) E*onomi* Anl'sis
Criti*l Apprissl
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original articlesoriginal articles(we dont know the !alit" "et#(we dont know the !alit" "et#
$alid evidence$alid evidence
critical appraisalcritical appraisal
Implement to patientsImplement to patients ((%&' & ' )r%&' & ' )r
EEvidence based g!idelines ()vidence based g!idelines ()edomanedoman %%iagnosis *iagnosis * erapierapi##
evidence based consens!sevidence based consens!s
+linical e&pertise+linical e&pertise
,cience,cience-.ogics.ogics-/nowledge/nowledge-E&perienceE&perience
+linical e&pertise+linical e&pertise
0rt0rt-BeliefsBeliefs-1!dgments1!dgments-Int!itionInt!ition
,!mmar",!mmar"of EBMof EBM
2!antitative methods2!antitative methods
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CONTO8 &ENERA&ANEFISIENSI DIA7NOSIS
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) t(% Be*(? 4= t+
) le!(emi (!t
) trom"osit 6%===mm4
) Sepsis (md tim"!l
(omdn lterlissi
)&erl! CTS*n0
St!di Ks!s
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) pri 53 t+!n
) splenomegli#sites
) "ili totl 3%6 mg:
) l"!min 2%9 mg:
glo"!lin 5%< mg:
)&erl!US70
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&i!tng RSUD Dr% Soetomo
) 2%6 M t+ se"el!m (rismon
) 33 : pi!tng tes pen!nGng
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Metode nili predi(ti.
)nmnesis pem% Hsis cermat) t+! sensiti1its Sn dn spesiHsits
Sp
tes D ter+dp gold standard) pengol+n dlm tabel 2 x 2
K!ntiH(si Dignosis
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) pri 66 t+? n'eri dd (iri? menGlr
) mero(o( 3 p( +ri
) T 29=22=? gllop
) (olesterol 469 mg:
) pro""ilits prtes menderit &JK
)&erl! tredmill000
Ks!s I
(90%)
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%!&'! PR$D!T!F
dari T$S D!'%*ST!Positie predictie alue
Probabilitas untuk enderita suatu
penyakit,ika#asil tes positif
%egatie predictie alue
Probabilitas untuk tidak enderita
suatu penyakit,ika#asil tes negatif
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asus!
tredil
P-(angiografi koroner . gold standard)
prob/ pascates+
+
0
0
540
1000
360
9
91
549
451
123
00000
124
.
probab (prates) P- (pascates)
+8%98%
98%
900 100
Sn tredil 536dan Sp tredil 476
90%
47
00000
217
21%
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) pri 46 t+? n'eri epigstri!m
) tid( mero(o(
) T 23=9= Hsi( d%"%n%) l" norml
) pro""ilits prtes menderit &JK
Kasus II
( 5 %)
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KasusII
tredmil
PJK(angiografi oroner!
"ro#$ "asates+
+
0
0
30
1000
20
86
864
116 30&116
884 864&884 ' 98% + 48%
'
"ro#a# ("rates! PJK ("asates!
+21%' 26%
26%
50 950
Sn tredil 536dan Sp tredil 476
5 %
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) pri 56 t+? n'eri dd (iri#tid( (+s
) mero(o( 2 p( +ri
) T 23=9=) l" norml
) pro""ilits prtes &JK
Kasus III
( 50%)
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KasusIII
tredmil
PJK(angiografi oroner!
"ro#$ "asates+
+
0
0
300
1000
200
45
455
345 300&345
655 455&655 ' 85 % + 35%
'
"ro#a# ("rates! PJK ("asates!
+3)%' 8)%
8)%
500 500
Sn tredil 536dan Sp tredil 476
50%
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) Ks!s I pro""ilits menderit &JK
dri =: (e 9:? tid( perl! tredmil
) Ks!s IIpro""ilits menderit &JK
dri 6: (e 3@:? tid( perl! tredmil
) Ks!s III pro""ilits mender!t &JK
dri6=: (e 9< :?
Kesimp!ln
&redi*ti1e Vl!e Met+od
perl!tredmil
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tredil 8 Rp 733/3339
asus ! : tidak perlu tredil9 langsung tx
asus !!: Rp 733/333 ; 7333
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T#res#old >odel
of Pauker ? assirer
1
DONT TEST
DONT TREAT
TEST & TREAT IF
THE RESULT POSITIVE TREATTREAT
PRETEST PROBABILITY
#4 54
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)8n' (s!s 'ng
'ng memerl!(n tes dignosti(
meragukan
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Pitono Soeparto et al Epiemiologi ;linis4 Seri rami# 6; *nair $&&.
Sac#ett D: