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Critical AppraisalCritical AppraisalArtikel TerapiArtikel Terapi

Fakultas Kedokteran Universitas YARSIFakultas Kedokteran Universitas YARSI

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Practicing EBM:Practicing EBM: Five StepsFive Steps

Step 1:Step 1:convert need for information in toconvert need for information in toan answerable qestionan answerable qestion

Step !:Step !:track down t"e best evidence wit"track down t"e best evidence wit"

w"ic" to answer t"at qestionw"ic" to answer t"at qestion

Step #:Step #:criticall$ appraise t"e evidence forcriticall$ appraise t"e evidence forits validit$% impact and applicabilit$its validit$% impact and applicabilit$

Step &:Step &:integrate t"e critical appraisal wit"integrate t"e critical appraisal wit"or clinical e'pertise and patient(s niqeor clinical e'pertise and patient(s niqecircmstancescircmstances

Step ):Step ):evalate or e*ectiveness andevalate or e*ectiveness ande*icienc$ in steps 1+& and seeking wa$s toe*icienc$ in steps 1+& and seeking wa$s to

improveimprove

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,ritical Appraisal,ritical Appraisal

is the process ofis the process of s$stematicall$s$stematicall$

examining research evidence toexamining research evidence toassess itsassess itsvalidit$% resltsvalidit$% reslts andand

relevancerelevance before using it to informbefore using it to inform

a decision.a decision.

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Case Control

Study

Case Control

Study

CauseCause

Cohort Study

Cohort Study

DiseaseDisease

,ase report,ase report,ase series,ase series,ross+,ross+sectionalsectional

,ase report,ase report,ase series,ase series,ross+,ross+

sectionalsectional

Exposures &

outcomes are

measured at the

same time

Exposures &

outcomes are

measured at the

same time

DescriptiveDescriptive

Ou

tcomeOutcome

ExposureExposure

PurePurePurePure

RCTRCT

RCTRCT

SemiSemiSemiSemi

QuasiQuasi

experi-experi-mentalmental

QuasiQuasi

experi-experi-mentalmental

AnalyticAnalyticAnalyticAnalytic

OSER!AT"O#A$OSER!AT"O#A$OSER!AT"O#A$OSER!AT"O#A$

-.A/T0TAT0E 2ESEA2,3 MET345-.A/T0TAT0E 2ESEA2,3 MET345-.A/T0TAT0E 2ESEA2,3 MET345-.A/T0TAT0E 2ESEA2,3 MET345

E%PER

"E#TA$E%PER"E#TA$E%PER"E#TA$E%PER"E#TA$

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6Saat sekarang

Paparan

Paparan

Outcome

Outcome

Kohort

Kasus Kontrol

Paparan

Outcome

Potong lintang

retrospektif

prospektif

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Article Abot T"erap$Article Abot T"erap$

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Article About TherapyArticle About Therapy

0deal Std$ 5esign:0deal Std$ 5esign:

6evel 0a :6evel 0a : Meta+anal$sis of 2andomisedMeta+anal$sis of 2andomised

,ontrolled Trial,ontrolled Trial

6evel 0b :6evel 0b : 2andomised ,ontrolled Trial2andomised ,ontrolled Trial

2andomised controlled trial 72,T82andomised controlled trial 72,T8 Clinical trial where at least two treatment groups areClinical trial where at least two treatment groups are

compared. One must be a control group, e.g. receivingcompared. One must be a control group, e.g. receivingstandard care or a placebo treatment. Allocation to a groupstandard care or a placebo treatment. Allocation to a groupmust be random and unbiased.must be random and unbiased.

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!enario!enario

"asien, la!i#la!i $% tahun, obeis, penderita"asien, la!i#la!i $% tahun, obeis, penderita&eu!emia, dirawat di rumah sa!it ber!aitan&eu!emia, dirawat di rumah sa!it ber!aitanproto!ol pemberian !emoterapi yang !eempat.proto!ol pemberian !emoterapi yang !eempat.

'o!ter#muda !esulitan memasang'o!ter#muda !esulitan memasang peripheralperipheralvenous cannulasvenous cannulasuntu! pemberian !emoterapi,untu! pemberian !emoterapi,sehingga beberapa !ali gagal. "asien men(adisehingga beberapa !ali gagal. "asien men(adi!eta!utan, dan hal ini memicu a!tivitas saraf!eta!utan, dan hal ini memicu a!tivitas sarafsimpatis yang menga!ibat!an vaso!onstri!sisimpatis yang menga!ibat!an vaso!onstri!si

perifer.perifer.'o!ter#muda a!hirnya ber!onsultasi !epada do!ter'o!ter#muda a!hirnya ber!onsultasi !epada do!ter!onsultan untu! mengatasi hal tersebut.!onsultan untu! mengatasi hal tersebut.

'o!ter#!onsultan menyaran!an menghangat!an'o!ter#!onsultan menyaran!an menghangat!antangan dan lengan bawah pasien terlebih dahulutangan dan lengan bawah pasien terlebih dahulu

sebelum memasangsebelum memasang peripheral venous cannulasperipheral venous cannulas..

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Focsing AnswerableFocsing Answerable

-estions-estionsPoplatioPoplatio

nn0nterventio0nterventio

n orn orE'posreE'posre

AlternativeAlternative0nterventio0nterventio

n orn or

E'posreE'posre

4tcomes4tcomes

PasienPasiendengandenganpen$litpen$litpemasanpemasan

gangankanlkanl

venavenaperiferperifer

Peng"angatPeng"angatan tanganan tangandan lengandan lenganbawa"bawa"

++ TingkatTingkatkeber"asilakeber"asilannpemasangapemasanga

n kanln kanlpada venapada venaperiferperifertangantangan

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)sers* +uides)sers* +uides

for an Article About Therapyfor an Article About Therapy

0909 Are t"e reslts of t"e std$Are t"e reslts of t"e std$

validvalid

009009 ;"at were t"e reslts;"at were t"e reslts

00090009;ill t"e reslts "elp me in;ill t"e reslts "elp me in

caring forcaring for m$ patientsm$ patients

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0909 Are t"e reslts of t"e std$ validAre t"e reslts of t"e std$ valid

"rimary +uides"rimary +uides-as the assignment of patients to treatments randomied/-as the assignment of patients to treatments randomied/

-ere all patients who entered the trial properly accounted for and-ere all patients who entered the trial properly accounted for andattributed at its conclusion/attributed at its conclusion/

# -as followup complete/# -as followup complete/

# -ere patients analyed in the groups to which they were# -ere patients analyed in the groups to which they wererandomied/randomied/

econdary +uidesecondary +uides-ere patients, health wor!ers, and study personnel 0blind0 to-ere patients, health wor!ers, and study personnel 0blind0 totreatment/treatment/

-ere the groups similar at the start of the trial/-ere the groups similar at the start of the trial/

Aside from the experimental intervention, were the groups treatedAside from the experimental intervention, were the groups treatedeually/eually/

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"rimary +uides"rimary +uides-as the assignment of patients to treatments-as the assignment of patients to treatmentsrandomied/randomied/

2andomisation"rocess of allocating individuals to the alternative

treatments in a clinical trial, avoiding bias.hould produce groups which are similar, except for

the treatment of interest.

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"rimary +uides"rimary +uides-ere all patients who entered the trial properly-ere all patients who entered the trial properly

accounted for and attributed at its conclusion/accounted for and attributed at its conclusion/

# -as follow up complete/# -as follow up complete/

0ntention+to+treat anal$sis 70TT8 All patients allocated to one arm of a 2CT are

analysed in that arm, whether or not theycompleted the prescribed treatment3regimen.

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"rimary +uides"rimary +uides-ere all patients who entered the trial properly-ere all patients who entered the trial properlyaccounted for and attributed at its conclusion/accounted for and attributed at its conclusion/

# -ere patients analyed in the groups to which# -ere patients analyed in the groups to whichthey werethey were randomied/ randomied/

0ntention+to+treat anal$sis 70TT8

All patients allocated to one arm of a 2CT areanalysed in that arm, whether or not they completedthe prescribed treatment3regimen.

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econdary +uidesecondary +uides-ere patients, health wor!ers, and study personnel 0blind0 to treat-ere patients, health wor!ers, and study personnel 0blind0 to treatment/ment/

Blinding

The process of ensuring that participants or researchers 4single#blind5or participants and researchers 4double#blind5 are unaware of whichtreatment group participants have been randomised to, reducing

thepossibility of bias in the results.
http://www.cche.net/usersguides/therapy.asphttp://www.cche.net/usersguides/therapy.asphttp://www.cche.net/usersguides/therapy.asphttp://www.cche.net/usersguides/therapy.asphttp://www.cche.net/usersguides/therapy.asphttp://www.cche.net/usersguides/therapy.asp

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validvalid

econdary +uidesecondary +uides

-ere the groups similar at the start of the-ere the groups similar at the start of thetrial/trial/

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validvalid

econdary +uidesecondary +uides

Aside from the experimental intervention,Aside from the experimental intervention,were the groups treated eually/were the groups treated eually/

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009 ;"at were t"e reslts009 ;"at were t"e reslts

6ow large was the treatment e7ect/6ow large was the treatment e7ect/


http://www.cche.net/usersguides/therapy.asphttp://www.cche.net/usersguides/therapy.asphttp://www.cche.net/usersguides/therapy.asp

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&

)>

#

1&

# ? )> @=

1& ? )> @

!@ = ? ! @>%!1

@ 1 + >%!1 @

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882 9 $:882 9 $:

2isi!o !egagalan pemasangan !anul vena perifer pada2isi!o !egagalan pemasangan !anul vena perifer pada!elompo! perla!uan3intervensi adalah sebesar $:!elompo! perla!uan3intervensi adalah sebesar $:

C82 9 ;

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222 9 =>:222 9 =>:Tinda!an local-warmingmenurun!an risi!o relatifter(adinya !egagalan pemasangan !anul vena perifersebesar =>:

A22 9 ;;:A22 9 ;;:

"enurunan risi!o absolut !egagalan pemasangan !anul"enurunan risi!o absolut !egagalan pemasangan !anulvena perifer dengan tinda!anvena perifer dengan tinda!an local-warminglocal-warming adalahadalahsebesar ;;:sebesar ;;:

??T 9 @,@??T 9 @,@Bumlah pasien yang perlu dila!u!an tinda!an local-warminguntu! menghindari ter(adinya satu !egagalanpemasangan !anul vena perifer adalah sebanya! @,@pasien

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1>>+C) @)

1>> +

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882 9 :882 9 :

2isi!o !egagalan pemasangan !anul vena perifer pada2isi!o !egagalan pemasangan !anul vena perifer pada!elompo! perla!uan3intervensi adalah sebesar :!elompo! perla!uan3intervensi adalah sebesar :

C82 9 1=:C82 9 1=:

2isi!o !egagalan pemasangan !anul vena perifer pada2isi!o !egagalan pemasangan !anul vena perifer pada!elompo! tanpa#perla!uan3 !ontrol adalah sebesar 1=:!elompo! tanpa#perla!uan3 !ontrol adalah sebesar 1=:

22 9 %,;>22 9 %,;>"asien yang mendapat tinda!a"asien yang mendapat tinda!alocal-warminglocal-warming memili!imemili!irisi!o ter(adinya !egagalan pemasangan !anul venarisi!o ter(adinya !egagalan pemasangan !anul venaperifer sebesar %,;> !ali dibanding!an pasien yangperifer sebesar %,;> !ali dibanding!an pasien yangtida! mendapat!an perla!uantida! mendapat!an perla!uan

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222 9 =1:222 9 =1:Tinda!an local-warmingmenurun!an risi!o relatifter(adinya !egagalan pemasangan !anul vena perifersebesar =1:

A22 9 1;:A22 9 1;:

"enurunan risi!o absolut !egagalan pemasangan !anul"enurunan risi!o absolut !egagalan pemasangan !anulvena perifer dengan tinda!anvena perifer dengan tinda!an local-warminglocal-warming adalahadalahsebesar 1;:sebesar 1;:

??T 9

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Dangan "an$a meli"at:Dangan "an$a meli"at:

22 72elative 2isk8% ata22 72elative 2isk8% ata222 72elative 2isk 2edction8222 72elative 2isk 2edction8

Per"atikan nilai:Per"atikan nilai:A22 7Absolte 2isk 2edction8% ataA22 7Absolte 2isk 2edction8% ata

//T 7/mber /eeded to Treat8//T 7/mber /eeded to Treat8

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Dmla" SampelDmla" Sampel 1>>1>> 1>>>1>>>

4tcome brk tanpa terapi4tcome brk tanpa terapi !>!> !>!>

4tcome brk dengan terapi4tcome brk dengan terapi

1)1)

1)1)

2isiko tanpa terapi 7,E282isiko tanpa terapi 7,E28 >%!>%! >%>!>%>!

2isiko dengan terapi 7EE282isiko dengan terapi 7EE28 >%1)>%1) >%>1)>%>1)

2elative 2isk 72282elative 2isk 7228 >%%%%%!)>%!) >%!)>%!)Absolte 2isk 2edction 7A228Absolte 2isk 2edction 7A228 >%>)>%>) >%>>)>%>>)

/mber /eeded to Treat 7//T8/mber /eeded to Treat 7//T8 !>!> !>>!>>

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009 ;"at were t"e reslts009 ;"at were t"e reslts

6ow precise was the estimate of the treatment e7ec6ow precise was the estimate of the treatment e7ec

t/t/

,ondence interval

Dor whatever e7ect being measures 4e.g. 22, 222,A22, ?TT5 the conEdence interval is the range ofvalues within which the FtrueG value in thepopulation is found. +enerally expressed as a >:conEdence interval, i.e. you can be >: conEdent

that the population value lies within those limits.



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&

)>

#

1&

# ? )> @=

1& ? )> @!

@ = ? ! @>%!1

@ 1 + >%!1 @

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1>>+C) @)

1>> +

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0009 ;ill t"e reslts "elp me in caring for0009 ;ill t"e reslts "elp me in caring for

m$ patientsm$ patients

Can the results be applied to my patient care/Can the results be applied to my patient care/

-ere all clinically important outcomes-ere all clinically important outcomes

considered/considered/

Are the li!ely treatment beneEts worth theAre the li!ely treatment beneEts worth the

potential harms and costs/potential harms and costs/



+ d) * + id

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0009 ;ill t"e reslts "elp me in caring0009 ;ill t"e reslts "elp me in caring

for m$ patientsfor m$ patients

Can the results be applied to my patientCan the results be applied to my patient

care/care/

# !ara!teristi! pasien# !ara!teristi! pasien

# !ara!teristi! perla!uan# !ara!teristi! perla!uan



) * + id) * + id

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-ere all clinically important outcomes-ere all clinically important outcomes

considered/considered/



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) * + id) * + id

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Are the li!ely treatment beneEts worth theAre the li!ely treatment beneEts worth the

potential harms and costs/potential harms and costs/



) * + id) * + id

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&

)>

#

1&

# ? )> @=

1& ? )> @

!@ = ? ! @>%!1

@ 1 + >%!1 @

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,4/S42T,4/S42T

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E'planation G ElaborationE'planation G Elaboration

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d) * + id

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0009 ;ill t"e reslts "elp me in0009 ;ill t"e reslts "elp me in

caring for m$ patientscaring for m$ patients

-ill patients be better o7 as a result-ill patients be better o7 as a result

of the test/of the test/

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Terima KasihTerima Kasih

therapy (4)

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