Evidence-Based Medicine Lecture 3 Kanar Hidayat 2016-2017

What is “evidence-based medicine?” Introductory question for participants: “How would you define evidence-based medicine?”

Two essential questions… What is the purpose of medicine? How do I decide what to do? You have to know where you’re going before deciding how to get there… in medicine physicians must work with patients to decide on both overarching goals, and on the best way to reach those goals. In both travel and medicine, you have to know where you’re going before deciding how to get there.

What is the purpose of medicine? Patient care Public health Research Improving the quality of patients’ lives… While medicine has many facets, including direct patient care, public health, and research endeavors, the common goal of all medical ventures is improving the quality of patients’ lives. This common underlying goal can serve as the “destination” to guide all medical journeys and endeavors, regardless of which facet or field of medicine is the stage for the patient’s medical journey.

What is evidence-based medicine? Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Sackett, et al. BMJ 1996;312:71-72 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789163/ This characterization highlights the three important parts of evidence-based medical practice: the patient, the evidence, and careful application of generalized evidence to the individual patient. Konshiakas judeshias Wise))Consiankas( honest, faithfull), judeshias

Evidence-based medicine Cost-effective Better Health care EBM and traditional medicine both take evidence into account, but EBM needs better evidence One of the main achievements of EBM has been the development of systematic reviews and meta- analyses

How do I decide what to do? How do I make decisions? Dogma: “Natural is best” Tradition: “We’ve always done it that way” Convention: “Everyone does it this way” Evidence-Based: “Evidence supports this way” Some decisions are guided by dogma, or an a-priori set of beliefs (eg, “natural is best.”). Some decisions are guided by tradition (eg, “we’ve always done it that way”), relying on the collective wisdom of the ages. Some decisions are guided by convention (eg, “everyone else does it that way”), relying on the collective wisdom of colleagues. An evidence-based approach makes decisions based on critical evaluation and reflection (eg, “the evidence supports doing it this way”).

How do I decide what to do? The answer is according to EBM: use of current best evidence!

Evidence types in EBM Meta-Analysis Randomized Controlled Trial Systematic reviews

Randomized Controlled Trial

Meta-Analysis

Systematic reviews

Types of review articles Reviews that are not systematic traditional narrative reviews'

Lecture 4 Kanar Hidayat 2016-2017 Level of Evidence Lecture 4 Kanar Hidayat 2016-2017

Definition: The National Cancer Institute defines levels of evidence as "A ranking system used to describe the strength of the results measured in a clinical trial or research study. The design of the study (such as a case report for an individual patient or a randomized double-blinded controlled clinical trial) and the endpoints measured (such as survival or quality of life) affect the strength of the evidence.

Evidence Pyramid Systematic reviews and meta-analysis are situated at the top of what is known as the “Evidence Pyramid” (see figure below). As you move up the pyramid the amount of available literature on a given topic decreases, but the relevancy and quality of that literature increases. Systematic reviews and meta-analysis are considered to be the highest quality evidence on a research topic because their study design reduces bias and produces more reliable findings. However, you may not always be able to find (or need to find) the highest level of evidence to answer your research question. In the absence of the best evidence, you then need to consider moving down the pyramid

Meta-analysis Combines the results of different studies Estimate an average or common effect. The highest level for evidence based medicine!

Systematic Reviews Identify all relevant published and unpublished evidence Select studies or reports for inclusion evaluate the quality of each study or report Synthesize the findings from individual studies or reports in an unbiased way Interpret the findings and present a balanced and impartial summary of the findings with due consideration of any fault in the evidence. Bias= baiased = prejudge Impartial= natural assess= judge

Randomized control trails RCT is a type of scientific(medical) experiment, where the people being studied are randomly allocated one or other of the different treatments under study. The RCT is often considered the gold standard for a clinical trial. RCTs are often used to test the efficacy or effectiveness of various types of medical intervention and may provide information about adverse effects, such as drug reactions. Intervention = mee bemoeien

Cohort studies a type of medical research used to investigate the causes of disease, founding links between risk factors and health outcomes. Cohort studies are usually forward- looking Retrospective cohort study; means to take a look back at events that already have taken place

Cohort studies Cohort =unit

Case-control studies a case-control study is always retrospective because it starts with an outcome then traces back to investigate exposures. Is designed to help determine if an exposure is associated with an outcome.

Using Pubmed