EBM - Prognosis

Heru Purwanto
Unit Epidemiologi Klinik FK Univ.Airlangga
Divisi Bedah Onkologi FK Univ.Airlangga/RSU
Dr.Soetomo
Surabaya
TYPES OF REPORTS ON PROGNOSIS

The best evidence with which to answer clinical question about prognosis would
Come from SYSTEMATIC REVIEW / META NALYSIS.

Is the evidence from this systematic review

valid ?
1.Is this a systematic review of RCT
2.Does it describe a comprehensive and
detailed search for relevant trials ?
3.Were the individual studies assessed for
validity ?
4.Were individual patient data ( or aggregate
data ) used in the analysis ?
EBM-PROGNOSIS
3-criterias to evaluate the study :

Is this evidence about prognosis valid ?

Is this valid evidence about

prognosis important ?

Can we apply this valid , important

evidence about prognosis to our patient ?
Is this evidence about prognosis
valid ?
Was a defined, representative sample of patients
assembled at a common point in the course of their
disease ?
Was follow-up of study pateints sufficiently long and
complete
Were objective outcome criteria applied in a
blind fashion ?
If subgroups with different prognoses are identified :
Was there adjustment for important prognostic
fadtors?
Was there validation in an independent group or test-
set patients?
Was a defined, representative sample of patients
assembled at a common point in the course of their
disease ?

Ideally, include the entire population who

ever lived who developed the disease.
IMPOSSIBLE.
The participants of the study are all at the
same stage.
How close ?
How the target disorder was defined. ?
How participants were assembled ?
Was follow-up of study pateints sufficiently long and
complete

Ideally every patient in the cohort would be

followed untill they fully recover or develop
one of the disease outcomes.
Some losses to follow up are both :
UNAVOIDABLE and MOSTLY UNRELATED TO
PROGNOSIS ( e.g : moving away )
Other losses losses might arise because
patients die or are too ill to continue follow
up.
Was follow-up of study pateints
sufficiently long and complete
Considering the rule 5 and20. < 5% loss
leads to little bias, > 20% loss seriously
threatens validity
Count 100 patients enter the study ( 4 died
and 16 are lost to follow up )
applied in a
blind fashion ?

Extreme outcomes are relatively easy : DEATH

FULL RECOVERY.
A Wide range of outcomes can be more
difficult to detect or to confirm.
Established specific criteria to define each
important outcome and used them.
Blinding is crucial : tend to search more
aggresive for outcomes for people with
characteristic(s) prognostic factor than people
without it.
If subgroups with different
prognoses are identified :
Was there adjustment for important
prognostic fadtors?
Was there validation in an independent
group or test-set patients?
IS THIS VALID EVIDENCE
ABOUT PROGNOSIS
IMPORTANT ?

HOW LIKELY ARE THE OUTCOMES OVER

TIME?

HOW PRECISE ARE THE PROGNOSTIC

ESTIMATES?
evidence about prognosis to our
patient ?

Is our patient so different from those in the

study that its results cannot apply ?

Will this evidence make a clinically

important impact on our conclusions about
what to offer or tell our patient ?
Have a Much time to search
the literature