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Jurnal ReadingFerial Hadipoetro IdrisDitujukan pada S.Ked pra kepaniteraan/ Kepaniteraan umum 2 Maret 2014 & 16 Juni 2014 & 12 Oktober 2014
RujukanDouglas Badenoch and Carl Heneghan, Evidence based tool kit, BMJ Books,2002Materi pelatihan EBM Workshop, Centre for clinical epidemiology & EBM, RSCM/FKUI, 2013.
Kenapa belajar jurnal reading?Untuk Menjawab pertanyaan pasien berdasarkan bukti (EBM=Evidence Based Medicine)Untuk mampu memilih jurnal yang baikUntuk mampu mengkritisi jurnalUntuk mampu menulis jurnal yang baik
Apa EBM?Integrasi bukti penelitian terbaik dengan keahlian klinis dan nilai2 (patient value)EBMBukti penelitianKeahlian klinisNilai2 pasien
Bagaimana menjawab pertanyaan pasien berdasarkan bukti?Susun pertanyaan pasien dengan kaidah PICO (etiologi, diagnosis, terapi, prognosis) Searching, finding the evidence Kritisi jurnalHasil Integrasikan dengan keahlian dan nilai2 pasien Buat keputusan bersama dengan pasienEvaluasi efektifitas dan efisiensi PICOKritisi jurnal
Bagaimana Membuat PICO Etiology/ Harm
P= PatientOr ProblemOr Population: among/In I= Intervention or indicator or index test or exposur: Does, wouldC=Comparison : versus, compareOutcome:Effect, resultIn healthy childrenExposed in utero to cocaineCompare to children not exposedHave increased incidence of learning disabilities at 6 years
Bagaimana Membuat PICO Diagnosis
P= PatientOr ProblemOr Population: among/In I= Interventionor indicator or index test or exposur: Does, wouldC=Comparison : versus, compareOutcome:Effect, resultIn an otherwise healthy 7 year old boy with sore throatHow does the clinical examCompare to throat cultureIn diagnosing pharyngitis?
Bagaimana Membuat PICO Treatment/ Therapy/ Intervention ?
P= PatientOr ProblemOr Population: among/In I= Interventionor indicator or index test or exposur: Does, wouldC=Comparison : versus, compareOutcome:Effect, resultIn Child with frequent febrile sizuresWould anticonvulsant therapyCompare to no treatmentResult in seizure reduction?
Bagaimana Membuat PICO Prognosis?
P= PatientOr ProblemOr Population: among/In I= Interventionor indicator or index test or exposur: Does, wouldC=Comparison : versus, compareOutcome:Effect, resultIn patient with sepsisDoes the level of procalcitoninBetter than C reactive proteinTo predict in hospital mortality?
Searching, finding the evidenceCari Jurnal: sumber primer
resourceAlamat internetIuran tahunanGoogle scholarhttp://scholar.google.com.br/gratisMedline-pubmedwww.ncbi.nml.nih.gov/PUBMEDTerbesar di dunia gratisemedicinewww.emedicine.comgratismedscapewww.medscape.comgratisMedical matrixwww.medmatrix.org/index.aspgratisClinical practice guidelinewww.guideline.govgratiswww.cma.caa/cpgsgratis
Searching, finding the evidenceCari Jurnal: sumber sekunder/short cut/hasil telaah kritis/ sudah diolah
resourceAlamat internetIuran tahunanCATs on the webBandolier: www.jr2.ox.ac.uk/Bandolier TRIP: www.tripdatabase.comBest evidence:Secondary jurnalsACP jurnal clubEvidence-Based MedicineThe cochrane libary
Langkah searchingBuat pertanyaan : PICOKeluarkan kata kunci dan cari synonimHubungkan ke search engine atau data base: generic: Pubmed, Google, Yahoo specialized: TRIP, SUM searchKetik kata kunci di search box:1.1 (population OR synonym 1 OR)AND1.2 (intervention OR synonym 1 OR..)And1.3 (comparison OR synonym 1 OR..)And1.4 (outcome OR synonym 1 OR..) And1.5 Filter/limit (for best study)
Bagaimana Cara Membaca Jurnal?
Judul tulisanNama PenulisNama/no/edisi jurnalAbstractLatar belakangTujuanMethodHasilDiskusiKesimpulan
Kritisi JurnalTerapi2. Are the result important:2.1 p value: < 0.01= there is a less than 1 in 100 probability of the result occuring by chance, p value < 0.05= less then 1 in 20 probability by chance.2.2 quantifying the risk and benefit and harm: RRR (relative risk reduction), ARR (Absolut Risk Reduction), NNT (Number Needed to treat), CI (Confidence Interval), RR (Relative Risk)
Kritisi Jurnalterapi2. 2. quantifying the risk and benefit and harm:CER=control event rate=a/(a+c)EER=Experiment event rate=b/(b+d)RRR=Relative risk reduction= (CER-EER)/CERARR=Absolut Rate Reduction=CER-EERNNT=Number needed to treat=1/ARR
controlexperimenteventabNo eventcd
Kritisi JurnalterapiARR are more clinically relevant measure to use than RRR, because RRR factor out the baseline risk, so that small difference in risk can seem significant when compare to small baseline risk
CEREERARRRRR10.360.340.020.05620.0360.0340.0020.056
Kritisi JurnalTerapiNNT= Number Needed to Treat=the most useful measure of benefit= the absolut number of patients who need to be treated to prevent one bad outcome=1/ARR
Mortality in patient surviving MCI for at least 3 days with left ventricular ejection fraction
Kritisi Jurnal terapiCI= are used to represent sampling error.95% CI= there is a 95% chance that the population is true value lies between the two limit.95% CI on the ARR=/1.96x{(CERx(1-CER)/#control patients } + {(EERx(1-EER)/# experiment patients } If CI crosses the line of no difference (the point at which benefit becomes a harm), then we conclude that the result are not statistically significant.
Kritisi JurnalDiagnosisIs the study valid? 2. Are the result important?1.1 Was there is clearly defined question? PICO1.2 Was the presence or absence of the target disorder confirmed with a validated test (gold or reference standard)1.3 was the test evaluated or an apropiate spectrum of patient1.4 Was the reference standard applied to all patients1.5 Is it clear the test was carried out?1.6 Is the test result reproduceable?
Kritisi Jurnaldiagnosis2. Are the result importance2.1 sensitivity= a/(a+c)2.2 spesicity=d/(b+d)2.3 Positive predictive value=a/(a+b)2.4 Negative predictive value=d/(c+d)2.5 prevalence=pre test probability=(a+c)/(a+b+c+d)2.6 Likelihood ratio for a positive test result= sens/(1-spec)2.7 likelihood ratio for a negative test result=(1-sens)/spec2.8 pre test odds= prevalence/(1-prevalence)2.9 post test odds=pre test oddsx likelihood pos2.10 post test probability=post test odss/(post test odds+1)
disease presentDisease absentDiag test +a26b 69a+b 95Diag test -c 46d 249c+d 295totala+c 72b+d 318A+b+c+d390
Kritisi Jurnal PrognosisIs this prognosis study valid? 2. Are the result important?1.1 was a define representative sample of patients assembled at a common (usually early) point in the course of of the disease1.2 Was the follow up study long enough1.3 Were the objective criteria applied in a blind fashion1.4 If subgroup with different prognosis are identified, was there adjustment for important prognostic factors and validation in an independenttest set patient?
Kritisi jurnal prognosis2. Are the result of the study importance?2.1 How likely are the outcomes overtime?1-5 years survivalMedian time ( e.g. the length of follow up by which 50% of patient have died)Event curve, survival curve 2.2 How percise is this prognostic estimate? 95% CI
Kritisi jurnal Etiologi1.Apakah Valid? 2. Apakah importan?1.1 Apakah ada sampel pasien yang representatif dan didefinisikan secara jelas pada titik yang sama pada perjalanan penyakit.1.2 Apakah penelitian followup cukup panjang1.3 apakah digunakan kriteria outcome yang objektif dan tidak berbias
Kritisi jurnal Etiologi1.4 apakah ada penyesuaian terhadap faktor progonosis yang pentingApakah hasil penelitian penting?Bagaimana outcomenyaSeberapa tepat estimasi etiologi
Kritisi Jurnal Systematic review/Meta analisisIntroduction: any controversies in the literature, PICOMethods: how the individual studies searched (medline, Embase, Cinahl, unpublished in the cochrane central: www.clinicaltrial.gov) and selected, how to appraise, how to combine? Jadad scoreResults: flow diagram, summarized the effect: forest plot, metaanalisisDiscussion and conclussion
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