Ebm kuliah

EVIDENCE-BASED MEDICINEEVIDENCE-BASED MEDICINE
(EBM)(EBM)
dr Gita Sekar Prihanti MPdKeddr Gita Sekar Prihanti MPdKed
Modified from Glasziou P. Evidence-based practiceModified from Glasziou P. Evidence-based practice
(ppt). Downloaded from www.cebm.net(ppt). Downloaded from www.cebm.net

Pengertian EBM:Pengertian EBM:
““Evidence-based medicine is theEvidence-based medicine is the integrationintegration
ofof best research evidencebest research evidence withwith clinicalclinical
expertiseexpertise andand patient valuespatient values””
-- Sackett, et al 2001Sackett, et al 2001

Decision making in medicineDecision making in medicine
DiagnosisDiagnosis
TreatmentTreatment
PreventionPrevention
PrognosisPrognosis
EtiologyEtiology

Keterampilan KlinikKeterampilan Klinik
 Keterampilan dan kemampuan menilai olehKeterampilan dan kemampuan menilai oleh
dokter yang didapat dari pengalaman dandokter yang didapat dari pengalaman dan
praktik klinikpraktik klinik
 Peningkatan keterampilan terlihat melaluiPeningkatan keterampilan terlihat melalui
berbagai aspek, namun yang terutama adalahberbagai aspek, namun yang terutama adalah
semakin efektif dan efisien-nya kemampuansemakin efektif dan efisien-nya kemampuan
menegakkan diagnosis, dan kemampuan dalammenegakkan diagnosis, dan kemampuan dalam
mengidentifikasi dan mempertimbangkan nilai-mengidentifikasi dan mempertimbangkan nilai-
nilai, hak dan pendapat pasien dalamnilai, hak dan pendapat pasien dalam
pengambilan keputusan medispengambilan keputusan medis

Bukti KlinisBukti Klinis
 Penelitian yang relevan secara klinis, dapat berupaPenelitian yang relevan secara klinis, dapat berupa
penelitian ilmu-ilmu kedokteran dasar, tetapi terutamapenelitian ilmu-ilmu kedokteran dasar, tetapi terutama
dari riset-riset klinis yang berorientasi pasiendari riset-riset klinis yang berorientasi pasien
 UUji ketelitian (accuracy) dan ketepatan (precision)ji ketelitian (accuracy) dan ketepatan (precision)
sebuah metoda diagnosis (termasuk pemeriksaan fisik),sebuah metoda diagnosis (termasuk pemeriksaan fisik),
uji kekuatan suatu penanda prognosis, uji efektivitas danuji kekuatan suatu penanda prognosis, uji efektivitas dan
keamanan suatu terapi, tindakan rehabilitasi maupunkeamanan suatu terapi, tindakan rehabilitasi maupun
metoda pencegahanmetoda pencegahan
 Sebuah penemuan klinis dapat mengganti sebuah ujiSebuah penemuan klinis dapat mengganti sebuah uji
metoda diagnosis maupun terapi yang telah diterima kemetoda diagnosis maupun terapi yang telah diterima ke
metoda baru yang lebih kuat, tepat, efektif dan aman.metoda baru yang lebih kuat, tepat, efektif dan aman.

Mengapa perlu belajar &Mengapa perlu belajar &
mempraktikkan EBM?mempraktikkan EBM?
 Penelitian menemukan bahwa pasienPenelitian menemukan bahwa pasien
yang mendapatkan terapi yang berbasisyang mendapatkan terapi yang berbasis
bukti memperoleh hasil yang lebih baikbukti memperoleh hasil yang lebih baik
dari yang tidak mendapat.dari yang tidak mendapat.
 Merupakan cara up-date yang lebihMerupakan cara up-date yang lebih
efisien dibanding metoda tradisionalefisien dibanding metoda tradisional
(misal, berlangganan jurnal, ikut(misal, berlangganan jurnal, ikut
seminar).seminar).
 Perkembangan terakhir membuat EBMPerkembangan terakhir membuat EBM
lebih mungkin dipraktikkan.lebih mungkin dipraktikkan.

 So much evidence, so little timeSo much evidence, so little time

PerkembanganPerkembangan
 Strategi mencari dan menilai bukti yangStrategi mencari dan menilai bukti yang
lebih efisien.lebih efisien.
 Ketersediaan jurnal-jurnal yangKetersediaan jurnal-jurnal yang evidence-evidence-
basedbased..
 DihasilkannyaDihasilkannya systematic reviewsystematic review dandan
ringkasan (ringkasan (summariessummaries).).
 Sistem informasi yang memungkinkanSistem informasi yang memungkinkan
akses ke literatur dalam hitungan detik.akses ke literatur dalam hitungan detik.

The flecainide storyThe flecainide story
 Th e history of the use of the drug fl ecainide to treatTh e history of the use of the drug fl ecainide to treat
heart attacks in the Unitedheart attacks in the United States in the 1980s is aStates in the 1980s is a
dramatic example of the gap between research anddramatic example of the gap between research and
clinical practice, and of the reliance on evidence of aclinical practice, and of the reliance on evidence of a
mechanism rather thanmechanism rather than an outcome. In 1979, thean outcome. In 1979, the
developer of the defi brillator, Bernard Lown, pointeddeveloper of the defi brillator, Bernard Lown, pointed outout
in an address to the American College of Cardiology thatin an address to the American College of Cardiology that
one of the biggestone of the biggest causes of death was heart attack,causes of death was heart attack,
particularly among young and middle-agedparticularly among young and middle-aged men (20–64-men (20–64-
year-olds). People had a heart attack, developedyear-olds). People had a heart attack, developed
arrhythmiaarrhythmia and died from the arrhythmia. He suggestedand died from the arrhythmia. He suggested
that a ‘safe and long-actingthat a ‘safe and long-acting antiarrhythmic drug thatantiarrhythmic drug that
protects against ventricular fi brillation’ would saveprotects against ventricular fi brillation’ would save
millions of lives.millions of lives.

 In response to this challenge, a paper was published inIn response to this challenge, a paper was published in
thethe New England JournalNew England Journal of Medicine introducing a newof Medicine introducing a new
drug called fl ecainide — a local anestheticdrug called fl ecainide — a local anesthetic derivativederivative
that suppresses arrhythmia. The paper described athat suppresses arrhythmia. The paper described a
study in whichstudy in which patients who had just had heart attackspatients who had just had heart attacks
were randomly assigned to groupswere randomly assigned to groups to receive either ato receive either a
placebo or flecainide and were then switched from oneplacebo or flecainide and were then switched from one
group to the other (a cross-over trial). The researchersgroup to the other (a cross-over trial). The researchers
counted the number ofcounted the number of premature ventricularpremature ventricular
contractions (PVCs) as a measure of arrhythmias. Thecontractions (PVCs) as a measure of arrhythmias. The
patients on flecainide had fewer PVCs than the patientspatients on flecainide had fewer PVCs than the patients
on placebo. Whenon placebo. When the flecainide patients were ‘crossedthe flecainide patients were ‘crossed
over’ to the placebo treatment, the PCsover’ to the placebo treatment, the PCs increased again.increased again.

 Th e conclusion was straightforward: fl ecainide reducesTh e conclusion was straightforward: fl ecainide reduces
arrhythmias,arrhythmias, arrhythmias cause heart attacks (the mechanism);arrhythmias cause heart attacks (the mechanism);
therefore, people who havetherefore, people who have had heart attacks should be given flhad heart attacks should be given fl
ecainide. After the results were published,ecainide. After the results were published, fl ecainide was approvedfl ecainide was approved
by the United States Food and Drug Administrationby the United States Food and Drug Administration and becameand became
fairly standard treatment for heart attack in the United Statesfairly standard treatment for heart attack in the United States
(although it did not catch on in Europe or Australia(although it did not catch on in Europe or Australia).).

 Almost immediately after the fi rst trials were complete,Almost immediately after the fi rst trials were complete,
however, otherhowever, other researchers had started gatheringresearchers had started gathering
information on the survival of the patientsinformation on the survival of the patients (the outcome)(the outcome)
instead of the PVC rate (the mechanism). Th is showedinstead of the PVC rate (the mechanism). Th is showed
that overthat over the 18 months following treatment, more thanthe 18 months following treatment, more than
10% of people who were given10% of people who were given flecainide died, whichflecainide died, which
was double the rate of deaths among a placebo group.was double the rate of deaths among a placebo group.
 In other words, despite a perfectly good mechanism forIn other words, despite a perfectly good mechanism for
the usefulness ofthe usefulness of fl ecainide (it reduces arrhythmias), thefl ecainide (it reduces arrhythmias), the
drug was clearly toxic and, overall, diddrug was clearly toxic and, overall, did more harm thanmore harm than
good.good.

 Unfortunately, because the initial studies had beenUnfortunately, because the initial studies had been
widely published in medicalwidely published in medical texts, it was a long timetexts, it was a long time
before doctors caught up with the subsequent databefore doctors caught up with the subsequent data
showing poor outcomes, which did not attract as muchshowing poor outcomes, which did not attract as much
attention. Meanwhile,attention. Meanwhile, by 1989, about 200,000 peopleby 1989, about 200,000 people
were being treated with fl ecainide in thewere being treated with fl ecainide in the United States.United States.
Based on the trial evidence, this would have caused tensBased on the trial evidence, this would have caused tens
ofof thousands of additional heart attack deaths due to thethousands of additional heart attack deaths due to the
use of fl ecainide.use of fl ecainide. Although there was publishedAlthough there was published
information, doctors were systematically killinginformation, doctors were systematically killing peoplepeople
with fl ecainide because they did not know about thewith fl ecainide because they did not know about the
good-qualitygood-quality outcome-based research.outcome-based research.

What does the flecainideWhat does the flecainide
example tell us?example tell us?
 In the flecainide example, the initial research was widelyIn the flecainide example, the initial research was widely
disseminated becausedisseminated because it was based on a traditionalit was based on a traditional
mechanistic approach to medicine, and becausemechanistic approach to medicine, and because it offit off
ered a ‘cure’. Th e subsequent outcomes research mayered a ‘cure’. Th e subsequent outcomes research may
not have beennot have been widely disseminated because it waswidely disseminated because it was
counterintuitive and negative in termscounterintuitive and negative in terms of a potentialof a potential
treatment. Doctors continued to prescribe fl ecainidetreatment. Doctors continued to prescribe fl ecainide
becausebecause they believed that it worked. Th ey did not knowthey believed that it worked. Th ey did not know
that they needed to look forthat they needed to look for additional information.additional information.

 Seorang ibu datang membawa anaknyaSeorang ibu datang membawa anaknya
yang berumur 1,5 tahun dengan keluhanyang berumur 1,5 tahun dengan keluhan
pilek dan batuk sejak dua hari yang lalu.pilek dan batuk sejak dua hari yang lalu.
Dahak keluar saat muntah, bening.Dahak keluar saat muntah, bening.
 Pada pemeriksaan didapatkan suhuPada pemeriksaan didapatkan suhu
37,937,9oo
C, FP 24x/menit, rongga hidungC, FP 24x/menit, rongga hidung
hiperemis dan terdapat sekret encer danhiperemis dan terdapat sekret encer dan
bening. Tenggorokan tidak hiperemis,bening. Tenggorokan tidak hiperemis,
paru tidak ada kelainan.paru tidak ada kelainan.

Terapi?Terapi?
 Decongestan?Decongestan?
 Antihistamin?Antihistamin?
 Antipiretik?Antipiretik?
 Edukasi?Edukasi?

The Antihistamine-decongestant combination
(ADC) was equivalent to placebo in providing
temporary relief of Upper Respiratory Infection
symptoms in preschool children. However, the
ADC did have significantly greater sedative
effects than did placebo.
Clemens CJ, Taylor JA, Almquist JR, Quinn HC, Mehta A,
Naylor GS.Is an antihistamine-decongestant combination
effective in temporarily relieving symptoms of the common
cold in preschool children? J Pediatr. 1997 Mar;130(3):463-6

FDA Experts Urge Ban on ColdFDA Experts Urge Ban on Cold
Medicines for Young ChildrenMedicines for Young Children
September 29, 2007 08:40:15 PM PSTSeptember 29, 2007 08:40:15 PM PST
By Steven ReinbergBy Steven Reinberg
HealthDay ReporterHealthDay Reporter
 An FDA review of records filed with the agencyAn FDA review of records filed with the agency
between 1969 and September 2006 found 54between 1969 and September 2006 found 54
reports of deaths in children associated withreports of deaths in children associated with
decongestant medicines made withdecongestant medicines made with
pseudoephedrine, phenylephrine or ephedrine. Itpseudoephedrine, phenylephrine or ephedrine. It
also found 69 reports of deaths associated withalso found 69 reports of deaths associated with
antihistamine medicines containingantihistamine medicines containing
diphenhydramine, brompheniramine ordiphenhydramine, brompheniramine or
chlorpheniramine, the AP said.chlorpheniramine, the AP said.

Pengelolaan informasiPengelolaan informasi
“Push” and “Pull”“Push” and “Pull” methodsmethods
 ““Push” – mengingatkan informasi baruPush” – mengingatkan informasi baru
““Just in Case” learningJust in Case” learning
HANYA untuk informasi yang penting, terbaruHANYA untuk informasi yang penting, terbaru
dan benar (valid)dan benar (valid)
 ““Pull” – mengakses informasi saatPull” – mengakses informasi saat
dibutuhkandibutuhkan
““Just in Time” learningJust in Time” learning
Diterapkan setiap saat ada pertanyaanDiterapkan setiap saat ada pertanyaan
EBM Steps: Question; search; appraise; applyEBM Steps: Question; search; appraise; apply

““Just-in-case” learningJust-in-case” learning
Berlangganan jurnal-jurnal tertentu yangBerlangganan jurnal-jurnal tertentu yang
berisikan informasi yang paling penting &berisikan informasi yang paling penting &
sangat relevan dengan praktik sehari-harisangat relevan dengan praktik sehari-hari
 Evidence-based MedicineEvidence-based Medicine
http://http://www.evidence-basedmedicine.comwww.evidence-basedmedicine.com
 Clinical EvidenceClinical Evidence
http://www.clinicalevidence.comhttp://www.clinicalevidence.com

““Just in time” learningJust in time” learning
Kebutuhan akan informasiKebutuhan akan informasi
Sebagai dokter kita selalu perlu informasi,Sebagai dokter kita selalu perlu informasi,
 Sebagian besar pertanyaan kita TIDAKSebagian besar pertanyaan kita TIDAK
terjawabterjawab
 Terjawab namun bukan informasi terbaikTerjawab namun bukan informasi terbaik
atau terbaruatau terbaru

Textbooks sudah ketinggalanTextbooks sudah ketinggalan
Journals tidak tertata baik danJournals tidak tertata baik dan
kualitas bervariasikualitas bervariasi
Para ahli sulit sepakatPara ahli sulit sepakat
CME/CPD tidak efektifCME/CPD tidak efektif
Hambatan memperoleh informasiHambatan memperoleh informasi

 Some evidence based cases.docSome evidence based cases.doc

Pertanyaan anda?Pertanyaan anda?
 Tulis satu masalah kesehatan/kedokteranTulis satu masalah kesehatan/kedokteran
yang anda ingin jawabyang anda ingin jawab
 Critical question?Critical question?
 Apakah anda menjawabnya? Bagaimana?Apakah anda menjawabnya? Bagaimana?

Information “pull”Information “pull”
Steps in EBM processSteps in EBM process
1.1. Menyusun pertanyaan yang dapat dijawabMenyusun pertanyaan yang dapat dijawab
2.2. Mencari bukti terbaikMencari bukti terbaik
3.3. Telaah kritis (critical appraisal) bukti yangTelaah kritis (critical appraisal) bukti yang
didapatdidapat
4.4. Integrasi dengan keterampilan klinis danIntegrasi dengan keterampilan klinis dan
nilai-nilai pasiennilai-nilai pasien

EBP Step 1:EBP Step 1: Menyusun pertanyaan yang dapatMenyusun pertanyaan yang dapat
dijawabdijawab
Pertanyaan yang baikPertanyaan yang baik
merupakan tulang punggungmerupakan tulang punggung
dalam penerapan EBM. Perludalam penerapan EBM. Perlu
latihan untuk dapat menyusunlatihan untuk dapat menyusun
pertanyaan yang terformulasipertanyaan yang terformulasi
dengan baik.dengan baik.

Bentuk pertanyaan sangatBentuk pertanyaan sangat
tergantung padatergantung pada
pengalaman.pengalaman.
GENERAL KNOWLEDGE
SPECIFIC KNOWLEDGE
TIPE
PERTANY
AAN
PENGALAMAN KLINIS

Using the question to guideUsing the question to guide
searchingsearching
 Scenario -Scenario - A 64 year old obese male who has tried manyA 64 year old obese male who has tried many
ways to lose weight presents with a newspaper article aboutways to lose weight presents with a newspaper article about
“fat-blazer” – Chitosan. He asks for your advice.“fat-blazer” – Chitosan. He asks for your advice.
 QuestionQuestion
 PPopulationopulation
 IIndicator (intervention, test, etc)ndicator (intervention, test, etc)
 CComparatoromparator
 OOutcomeutcome

searchingsearching
 PPopulation – in obese patientsopulation – in obese patients
 IIndicator (intervention, test, etc) – does chitosanndicator (intervention, test, etc) – does chitosan
 CComparator – compared to placeboomparator – compared to placebo
 OOutcome – decrease weightutcome – decrease weight
1. Underline the key terms
2. Number the order of importance from 1-4
3. Think of alternate spellings, synonyms, & truncations

searchingsearching
 PPopulation –opulation – obes* OR overweightobes* OR overweight
 IIndicator (intervention, test, etc) – doesndicator (intervention, test, etc) – does chitosanchitosan
 CComparator – compared toomparator – compared to placeboplacebo
 OOutcome – decreaseutcome – decrease weight OR kilogram*weight OR kilogram*
1. Underline the key terms
2. Number the order of importance from 1-4
3. Think of alternate spellings, synonyms, & truncations
1
2
3
4

InterventionsInterventions
 Jean is a 55-year-old woman who quiteJean is a 55-year-old woman who quite
often crosses the Atlantic to visit heroften crosses the Atlantic to visit her
elderly mother. She tends to get swollenelderly mother. She tends to get swollen
legs on these fl ights and is worriedlegs on these fl ights and is worried aboutabout
her risk of developing deep veinher risk of developing deep vein
thrombosis (DVT), because she has readthrombosis (DVT), because she has read
quite a bit about this in the newspapersquite a bit about this in the newspapers
lately. She asks you if she should wearlately. She asks you if she should wear
elastic stockings on her next trip to reduceelastic stockings on her next trip to reduce
her risk of this.her risk of this.

Aetiology and risk factorsAetiology and risk factors
 George has come to your surgery toGeorge has come to your surgery to
discuss the possibility of getting adiscuss the possibility of getting a
vasectomy. He says he has heardvasectomy. He says he has heard
something about vasectomy causing ansomething about vasectomy causing an
increase in testicular cancer later in life.increase in testicular cancer later in life.
You know that the risk of this is veryYou know that the risk of this is very lowlow
but want to give him a more precisebut want to give him a more precise
answer.answer.

Question:
‘In men, does having a vasectomy (compared with not having one),
increase the risk of getting testicular cancer in the future?’

DiagnosisDiagnosis
 Julie is pregnant for the second time. She had her fi rstJulie is pregnant for the second time. She had her fi rst
baby when she was 33baby when she was 33 and had amniocentesis to fi ndand had amniocentesis to fi nd
out if the baby had Down syndrome. The testout if the baby had Down syndrome. The test waswas
negative but it was not a good experience, because shenegative but it was not a good experience, because she
did not get thedid not get the result until she was 18 weeks pregnant.result until she was 18 weeks pregnant.
She is now 35 and 1 month pregnant,She is now 35 and 1 month pregnant, and asks if sheand asks if she
can have a test that would give her an earlier result. Th ecan have a test that would give her an earlier result. Th e
locallocal hospital off ers serum biochemistry plus nuchalhospital off ers serum biochemistry plus nuchal
translucency ultrasoundtranslucency ultrasound screening as a fi rst trimesterscreening as a fi rst trimester
test for Down syndrome. You wonder if thistest for Down syndrome. You wonder if this combinationcombination
of tests is as reliable as conventional amniocentesis.of tests is as reliable as conventional amniocentesis.

 Question:Question:
 ‘‘For pregnant women, is nuchal translucency ultrasoundFor pregnant women, is nuchal translucency ultrasound
screening plus serumscreening plus serum biochemistry testing in the fi rstbiochemistry testing in the fi rst
trimester as accurate (ie with equal or bettertrimester as accurate (ie with equal or better sensitivitysensitivity
and specifi city) as conventional amniocentesis forand specifi city) as conventional amniocentesis for
diagnosing Downdiagnosing Down syndrome?’syndrome?’

Prognosis (prediction)Prognosis (prediction)
 Childhood seizures are common and frightening for theChildhood seizures are common and frightening for the
parents, and theparents, and the decision to initiate prophylacticdecision to initiate prophylactic
treatment after a fi rst fi t is a difficult one.treatment after a fi rst fi t is a difficult one. To helpTo help
parents make their decision, you need to explain the riskparents make their decision, you need to explain the risk
of furtherof further occurrences following a single seizure ofoccurrences following a single seizure of
unknown cause.unknown cause.

Question:Question:
‘In children who have had one seizure of unknown cause‘In children who have had one seizure of unknown cause
(either associated(either associated with a fever or not), what is the long-termwith a fever or not), what is the long-term
risk of further seizures?’risk of further seizures?’

Frequency or rateFrequency or rate
 Mabel is a six-week-old baby at herMabel is a six-week-old baby at her
routine follow-up. She was bornroutine follow-up. She was born
prematurely at 35 weeks. Her parents askprematurely at 35 weeks. Her parents ask
about her chances of developingabout her chances of developing hearinghearing
problems, as friends of theirs had aproblems, as friends of theirs had a
premature baby with deafness thatpremature baby with deafness that waswas
detected late.detected late.

PhenomenaPhenomena
 Mary is a mother who is concerned about herMary is a mother who is concerned about her
three-year-old child. He has athree-year-old child. He has a fever. After youfever. After you
have examined him, you conclude that hehave examined him, you conclude that he
probably has a viralprobably has a viral infection. Mary asks, ‘Butinfection. Mary asks, ‘But
what if he has a fever again during the night,what if he has a fever again during the night,
doctor?’doctor?’ You want to understand her principalYou want to understand her principal
underlying concerns so that you canunderlying concerns so that you can reassurereassure
her.her.

Question:
‘For mothers of children with a fever, what are the principal concerns?’

EBP Step 2:EBP Step 2: Mencari bukti terbaikMencari bukti terbaik
What study designs should you be looking for?

Where to searchWhere to search
 PubMed :PubMed : http://www.pubmed.govhttp://www.pubmed.gov
 The Cochrane Library :The Cochrane Library :
http://www.cochrane.orghttp://www.cochrane.org
 Clinical Evidence :Clinical Evidence :
http://www.clinicalevidence.comhttp://www.clinicalevidence.com
 Other useful places to searchOther useful places to search ::
http://www.embase.comhttp://www.embase.com

The question guides the searchThe question guides the search

The Evidence Pyramid
Systems
Summaries
Synopses
Syntheses
Studies - RCT, cohort, case-control
single original studies
Internet Findings
Clinical Decision-Making Tools
Connected to the Electronic Medical Record
Evidence-based textbooks
BMJ Clinical Evidence,
TRIP, InfoPOEMS, PIER
Evidence-based
journal abstracts
ACP Journal Club
Systematic reviews
Cochrane, DARE
PubMed Clinical Queries
Original journal
articles
MEDLINE (PubMed)
EMBASE
Google, Google Scholar
Dogpile, Ixquick
ACP Journal Club Nov- Dec 2006;145(3):A8-9

* Means any other
lettersAND means both
terms required
Check the question
type
Check the emphasis

Stepwise searchingStepwise searching
 Search with #1 PICO itemSearch with #1 PICO item
ChitosanChitosan
Then go to “Clinical Queries”Then go to “Clinical Queries”
Chitosan (again)Chitosan (again)
 Add #2 PICO itemAdd #2 PICO item
Chitosan AND (obes* OR overweight)Chitosan AND (obes* OR overweight)

Combining terms withCombining terms with
Boolean operators – ANDBoolean operators – AND
chitosanoverweight
overweight AND chitosan - has both terms
IN CAPITALS

Combining terms withCombining terms with
Boolean operators – ORBoolean operators – OR
obeseoverweight
overweight OR obese - has either term

BooBoo-le-ans*-le-ans*
 AND = both termsAND = both terms
 OR = either termOR = either term
 NOT = not this termNOT = not this term
 (ADJacent, NEAR, … = AND + close)(ADJacent, NEAR, … = AND + close)
* George Boole (a man) is claimed to have invented “logic”

Where to the brackets go?Where to the brackets go?
 If yIf you wantou want
 cheesecheese AND fruitAND fruit
 Which do youWhich do you ask forask for??
 (cheese(cheese AND appleAND apple)) OR pearOR pear OR melonOR melon
 cheesecheese ANDAND ((apple OR pearapple OR pear OR melon)OR melon)
 What does PubMed doWhat does PubMed do ifif bothboth AND and OR?AND and OR?
 CheeseCheese AND apple OR pearAND apple OR pear
 ((Look at DETAILS tabLook at DETAILS tab))

General structure of searchGeneral structure of search
 ((PPopulation OR synonym 1 OR …) ANDopulation OR synonym 1 OR …) AND
 ((IIntervention OR synonym 1 OR …) ANDntervention OR synonym 1 OR …) AND
 ((CComparator OR synonym 1 OR …) ANDomparator OR synonym 1 OR …) AND
 ((OOutcome OR synonym 1 OR …)utcome OR synonym 1 OR …) ANDAND
 FILTER (FILTER (for best study typefor best study type))
(look at Haynes filters in “this table”)(look at Haynes filters in “this table”)

ShortcutsShortcuts
 Meta-search enginesMeta-search engines
 www.tripdatabase.comwww.tripdatabase.com
 SumsearchSumsearch
 Start 2nd Explorer window, enterStart 2nd Explorer window, enter
 www.www.tripdatabasetripdatabase.com.com
 And repeat your searches (based on your carefulAnd repeat your searches (based on your careful
records!)records!)

More Tips on Effective SearchingMore Tips on Effective Searching
 Decide the TYPE of question (Rx, Dx, Px, …)Decide the TYPE of question (Rx, Dx, Px, …)
 Chose the right database for the type ofChose the right database for the type of
question, e.g.,question, e.g.,
 Intervention:Intervention: Cochrane Library, PubMed, …Cochrane Library, PubMed, …
 Diagnostic:Diagnostic: PubMed: Clinical QueriesPubMed: Clinical Queries
 Prognosis, Etiology:Prognosis, Etiology: PubMed: Clinical QueriesPubMed: Clinical Queries

 Searching tips and tacticsSearching tips and tactics

 In looking for synonyms, you should considerIn looking for synonyms, you should consider
both textwords and keywords inboth textwords and keywords in the databasethe database
you are searching.you are searching.
 The MEDLINE keyword system, which is knownThe MEDLINE keyword system, which is known
as MeSH (Medical Subject Heading), has a treeas MeSH (Medical Subject Heading), has a tree
structure that covers a broadstructure that covers a broad set of synonymsset of synonyms
very quickly.very quickly.
 The ‘explode’ (exp) feature of the tree structureThe ‘explode’ (exp) feature of the tree structure
allows you to capture an entire subtree of MeSHallows you to capture an entire subtree of MeSH
terms within a single word.terms within a single word.

Thus for the colorectal cancer term in the aboveThus for the colorectal cancer term in the above
search, the appropriate MeSHsearch, the appropriate MeSH term might be:term might be:

 The term ‘screen*’ is shorthand for wordsThe term ‘screen*’ is shorthand for words
beginning with screen, for example,beginning with screen, for example,
screen, screened, screening. (Note: thescreen, screened, screening. (Note: the
‘wildcard’ symbol varies between‘wildcard’ symbol varies between systems,systems,
eg it may be an asterisk [*], or colon [:].)eg it may be an asterisk [*], or colon [:].)

How to use PubMedHow to use PubMed
http://www.ncbi.nlm.nih.gov/entrez/query.fcgihttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi

Searching ‘warm-up’Searching ‘warm-up’
 Step 1: Create a search strategyStep 1: Create a search strategy
 Scenario: A 64-year-old obese male whoScenario: A 64-year-old obese male who
has tried many ways to lose weighthas tried many ways to lose weight
presents with a newspaper article aboutpresents with a newspaper article about
‘fat-blazer’ (chitosan). He asks for your‘fat-blazer’ (chitosan). He asks for your
advice.advice.

 Question: In obsese patients, doesQuestion: In obsese patients, does
chitosan, compared with a placebo,chitosan, compared with a placebo,
decreasedecrease weight?weight?

Step 2: Convert this question to a searchStep 2: Convert this question to a search
strategystrategy
 To do this, fi rst do 3 things:To do this, fi rst do 3 things:
1. Underline the key terms.1. Underline the key terms.
2. Number in order of importance from 1 to2. Number in order of importance from 1 to
4.4.
3. Th ink of alternative spellings, synonyms3. Th ink of alternative spellings, synonyms
and truncations.and truncations.

Next, run through the following exercise:Next, run through the following exercise:
1. Open your browser (eg Explorer) and go to1. Open your browser (eg Explorer) and go to
http://www.pubmed.govhttp://www.pubmed.gov
2. Type in the term we chose as (1): ‘chitosan’.2. Type in the term we chose as (1): ‘chitosan’.
Write down the number ofWrite down the number of results you found....results you found....
3. Select Clinical Queries (left-hand menu)3. Select Clinical Queries (left-hand menu)
4. Select the Th erapy category (which is the4. Select the Th erapy category (which is the
default) and search on ‘chitosan’again. Writedefault) and search on ‘chitosan’again. Write
down the number of results you now founddown the number of results you now found
………..………..

 Why has this decreased? It is because of the ‘fiWhy has this decreased? It is because of the ‘fi
lter’ that PubMed uses to focuslter’ that PubMed uses to focus on clinical trialson clinical trials
(to see the actual fi lter click on the ‘fi lter table’(to see the actual fi lter click on the ‘fi lter table’
on the Clinicalon the Clinical Queries page).Queries page).
 5. Try adding ‘AND another stage’, ie type in5. Try adding ‘AND another stage’, ie type in
chitosan AND (obes* ORchitosan AND (obes* OR overweight) — noteoverweight) — note
that you need brackets around your OR search.that you need brackets around your OR search.
ThisThis should reduce the number of articles evenshould reduce the number of articles even
further and certainly down to afurther and certainly down to a manageablemanageable
number.number.

 Search #1: chitosanSearch #1: chitosan
 Search #2: obes* OR overweightSearch #2: obes* OR overweight
 Search #3: weight OR kilogram*Search #3: weight OR kilogram*
 Search #4: placeboSearch #4: placebo
 Search #5: #1 AND #2 AND #3 AND #4Search #5: #1 AND #2 AND #3 AND #4
 However, you might have found that the first 1 orHowever, you might have found that the first 1 or
2 search terms were enough2 search terms were enough to narrow down theto narrow down the
search to around 20 titles.search to around 20 titles.

““Just in Time” learningJust in Time” learning
The EBMThe EBM AlternativeAlternative ApproachApproach
 Fokus pada problem pasien yang dihadapi saat iniFokus pada problem pasien yang dihadapi saat ini
(“just in time” education)(“just in time” education)
 RelevanRelevan dengan praktikdengan praktik
 Mudah diingatMudah diingat
 Up to dateUp to date
 Belajar untuk memperoleh informasi terkini yangBelajar untuk memperoleh informasi terkini yang
terbaikterbaik

Hambatan EBMHambatan EBM
1.1. Kebiasaan untuk bertanya dan mencariKebiasaan untuk bertanya dan mencari
2.2. Keterampilan menemukan, menelaahKeterampilan menemukan, menelaah
(appraisal) dan menerapkan “evidence”(appraisal) dan menerapkan “evidence”
3.3. Sumber informasi sangat banyakSumber informasi sangat banyak
4.4. Keterbatasan waktuKeterbatasan waktu

KesimpulanKesimpulan
 Benarkah terdapat “banjir” informasi?Benarkah terdapat “banjir” informasi?
 Ya – 5,000 artikel per hariYa – 5,000 artikel per hari
 Apakah CME membantu?Apakah CME membantu?
 SedikitSedikit
 Dapatkah EBM (patient-centered learning)Dapatkah EBM (patient-centered learning)
membantu?membantu?
 Ya, karena metode yang dipergunakan lebihYa, karena metode yang dipergunakan lebih
efektif dari CMEefektif dari CME
 Apakah hambatannya?Apakah hambatannya?
 Sumber-sumber bukti, keterampilan, perilakuSumber-sumber bukti, keterampilan, perilaku
mencarimencari

Bagaimana praktiknya?Bagaimana praktiknya?
 Penemuan bukti untuk mendukung salahPenemuan bukti untuk mendukung salah
satu pengambilan keputusan klinis setiapsatu pengambilan keputusan klinis setiap
pasien andapasien anda khususnya rawat inapkhususnya rawat inap..
 Penemuan bukti untuk mendukung salahPenemuan bukti untuk mendukung salah
satu pengambilan keputusan salah satusatu pengambilan keputusan salah satu
pasien anda per satu hari praktik.pasien anda per satu hari praktik.
 Mendorong rekan kerja anda mengikutiMendorong rekan kerja anda mengikuti
yang anda kerjakan.yang anda kerjakan.
 Bekerja sebagai tim dalam menemukanBekerja sebagai tim dalam menemukan
jawaban yang berbasis bukti.jawaban yang berbasis bukti.

 Keep on AskingKeep on Asking
 Keep on SearchingKeep on Searching
 Keep on LearningKeep on Learning

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