循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件

Evidence-BasedMedicine

循證醫(yī)學(xué)楊學(xué)寧XueningYang,MD廣東省人民醫(yī)院廣東省肺癌研究所廣東省循證醫(yī)學(xué)科研中心循證醫(yī)學(xué)雜志社Evidence-BasedMedicine

循證醫(yī)學(xué)楊1Evidence-basedPractice(EBP)ModelsTraditionalpracticeModel(×)Model1:UsethehighestqualityinformationtoguideclinicaldecisionsModel2:Search,evaluate,andmakeavailablespecialtyspecificbestavailableevidenceModel3:CreateoriginalresearchorsystematicreviewsEvidence-basedPractice(EBP)M2EBMPractice-Fivesteps

PatientHistoryandPE……QuestionAskingAnswerableClinicalQuestions.SearchSearchingforthebestcurrentevidence.AppraiseCritically-appraisingtheevidence.Application:Integratingtheevidencewithourexpertiseandourpatient’suniquebiologyandvaluesAuditEvaluatingourperformanceEBMPractice-FivestepsPa3Step1AskingAnswerableClinicalQuestionsSetting:64residents

at2NewHavenhospitalsMethod:Interviewedafter401consultationsQuestionsAsked280questions(2per3patients)Pursuedananswerfor80questions(29%)NotpursuedbecauseLackoftimeForgotthequestionSourcesofanswersTextbooks(31%),articles(21%),consultants(17%)Green,AmJMed2000Step1AskingAnswerableClini4Step1AskingAnswerableClinicalQuestionsMostofourquestionsareneveransweredWhenanswered,theinformationislikelytobeneitherthebestnorup-to-dateStep1AskingAnswerableClini5Step1AskingAnswerableClinicalQuestionsEBMstartswithaclearclinicalquestionWell-builtclinicalquestionsguidethewholeEBMprocessTypeofquestion?Causation/etiology

InterventionDiagnosisPrognosisTypeofStudy?Whatwouldbethebeststudydesigninordertoanswerthequestion?studydesignsshouldlimitbiasStep1AskingAnswerableClini6Step1AskingAnswerableClinicalQuestionsQuestioncomponents:PICOWhattypesofParticipants?WhattypesofInterventions?WhattypesofComparison?WhattypesofOutcomes?Step1AskingAnswerableClini7Step1AskingAnswerableClinicalQuestionsWhattypesofparticipants?DiseaseorconditionofinterestPotentialco-morbiditySettingDemographicfactorsTaskofclinicalproblemStep1AskingAnswerableClini8Step1AskingAnswerableClinicalQuestionsWhattypesofintervention?TypesoftreatmentTypeofdiagnostictestTypeofcausativeagentTypeofprognosticfactorStep1AskingAnswerableClini9Step1AskingAnswerableClinicalQuestionsWhattypesofoutcomes?Forcausation,outcomeisdiseaseFordiagnostictest,outcomeindiseaseofinterestFortreatmentincludealloutcomesimportanttopeoplemakingdecisionstodefinesuccessoftherapyForprognosis,outcomeisthechosenendpointofthediseaseStep1AskingAnswerableClini10Step1AskingAnswerableClinicalQuestionsBroadornarrowquestionsBroadDogefinitibimprovesurvivalinlungadenocarcinoma?NarrowDogefinitibimprovesurvivalinfemallungadenocarcinomarefractorytofirst-linechemo?Step1AskingAnswerableClini11Step1AskingAnswerableClinicalQuestionsCausationPeople-Exposure-Comparison-OutcomesDoesheavysmokerhavehigherincidenceoflungcancer?Prognosis:People-Exposure-Comparison-OutcomesIslungadenocarcinomawithhighlevelofCEAaremorelikelytohaverecurrentdisease?Step1AskingAnswerableClini12Step2SearchingforthebestcurrentevidenceTextbookAnnuallyrevisedUsehighlevelevidencesWithreferenceGuidelinesCochraneLibraryMedlineStep2Searchingforthebest13NationalGuidelineClearinghouse(/)Step2NationalGuidelineClearinghou14Toomuch?即使是小的問(wèn)題也有相關(guān)指南Step2Toomuch?即使是小的問(wèn)題也有相關(guān)指南Step215Step2Step216CochraneLibraryAdvantagehighestqualityevidencewe’lleverhaveontheeffectivenessofhealthcareDisadvantagenotyetmanysystemicreviewsnecessarilyomitsthenewesttreatmentStep2CochraneLibraryAdvantageStep17EBPModelsTraditionalpracticeModel(×)Model1:UsethehighestqualityinformationtoguideclinicaldecisionsModel2:Search,evaluate,andmakeavailablespecialtyspecificLevel1informationModel3:CreateoriginalresearchorsystematicreviewsStep2EBPModelsTraditionalpractice18PubMed/MEDLINE/PubmedStep2PubMed/MEDLINEhttp://www.ncbi19Medline-PubMedAdvantageexhaustiveness,flexibilityofsearchingjournalcoverage,currency(on-lineversions)widespreadavailabilityandsupportDisadvantagehavetodoyourownqualityfilteringputtingtogethergoodsearchesisdifficultgapsincoverage(medical,geographicalandlinguistic)Step2Medline-PubMedAdvantageStep220Step2Step221Step2Step222Step2Step223Step2Step224Step2Step225Step2SearchingforthebestcurrentevidenceForprimaryliteratureNotjustabstract!TrytogetFull-textStep2Searchingforthebest26Step3Critically-appraisingtheevidenceValid?Designandmethodology:logical?SampleExperimentorMeasure:carriedoutinasoundwayandConvincible？Follow-uprate?Analysis

ConclusionEthical?Importance?Clinicalsignificance？Cost-effective？Applicable?Willtheresultshelplocally?Step3Critically-appraisingt27Step3Critically-appraisingtheevidenceQuickscreeningbytitle,abstractandrelatemessageAuthorsWell-known？Pastrecord？Creditable？InstituteCompetencetodothisstudy？Well-known？SpecialtyHasorhadpublishedincorejournals?Yourpractice？Valuable？GoforFull-textDiscrimination？Rational？EBM？Step3Critically-appraisingt28Step3Critically-appraisingtheevidence

TypeofQuestionSuggestedbesttypeofStudyTherapyRCT>cohort>casecontrol>caseseriesDiagnosisProspective,blindcomparisontoagoldstandardEtiology/HarmRCT>cohort>casecontrol>caseseriesPrognosisCohortstudy>casecontrol>caseseriesPreventionRCT>cohortstudy>casecontrol>caseseriesClinicalExamProspective,blindcomparisontogoldstandardCostEconomicanalysisRightmethodsiscrucialStep3Critically-appraisingt29TheEvidencePyramidHierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobiasPrimaryResearch

Experimental

observationalSecondaryResearchForquantitativestudiesForqualitativestudiesNoconsensusabouttherelativerigourofdifferentmethodsSystematicreviewTheEvidencePyramidHierarchy30Step3Critically-appraisingtheevidencePhaseIIIRCTheadtoheadComparesurvivalAdequatesamplesizeStep3Critically-appraisingt31Step3Critically-appraisingtheevidenceMeasureObjective：Labtest，RadiologySubjective：pain，symptomsEndpointalternative：relieveofsymptom,shrinkoftumorGoldStandard：prolongsurvivalStep3Critically-appraisingt32Step3Critically-appraisingtheevidenceConclusionBasedonthedata?New?Updated?ComparewithotherstudyAnd,Whatnext?Step3Critically-appraisingt33Step3Critically-appraisingtheevidenceAttention!Don’ttrustitjustbecauseitisfromabigboss,meta-analysis,RCT,orguideline.Evidenceshouldbeinconsistencewithknownmedicalscience(physiology,pathology,pharmacology,etc）UsageofscientificlanguageisnotnecessarilymeanscientificbasedScientificmethodscreditStep3Critically-appraisingt34NotalltheevidencesarethesameimportanceHollingworth&Jarvik,Radiology2007;244:31-38Flowchartofcost-effectivenessateachlevelofTAhierarchyTechnicalPerformanceDiagnosticPerformanceDiagnosticImpactTherapeuticImpactImpactonHealthNotalltheevidencesarethe35循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件36Step4ApplicationIntegratingtheevidencewithourexpertiseandourpatient’suniquebiologyandvaluesYourquestionYourpatientYourexpertiseYourhospitalHowto……Step4ApplicationIntegrating37Step5EvaluatingourperformanceFollow-upEvaluateThepatientsbenefit……?Next…………Oragainanother5stepsCollectdataandwriteanarticleStep5Evaluatingourperforma38EBPModelsTraditionalpracticeModel(×)Model1:UsethehighestqualityinformationtoguideclinicaldecisionsModel2:Search,evaluate,andmakeavailablespecialtyspecificbestavailableevidenceModel3:CreateoriginalresearchorsystematicreviewsEBPModelsTraditionalpractice39SelectiveEBPMaynotneedtocarryoutall5steps1.AskingAnswerableClinicalQuestions.X2.Searchingforthebestcurrentevidence.X3.Critically-appraisingtheevidence.4.Application:Integratingtheevidencewithourexpertiseandourpatient’suniquebiologyandvalues5.EvaluatingourperformanceSelectiveEBPMaynotneedtoc40SelectiveEBP3differentmodesofEBPSearching&appraisingprovidesE-Bcare,butisexpensiveintimeandresourcesSearchingonlymuch,quicker,andifcarriedoutamongE-Bresources,canprovideE-BcareReplicatingthepracticeofexpertsquickest,butmaynotdistinguishevidence-basedfromego-basedrecommendationsSelectiveEBP3differentmodes41SelectiveEBPEvenfullyEBM-trainedcliniciansworkinall3modesSearching&appraisingfortheproblemsIencounterdaily.SearchingonlyforproblemsIencounteronceamonth.ReplicatingforproblemsIencounteronceadecade(andcrossingmyfingers!).SelectiveEBPEvenfullyEBM-tr42Case1Male,ZSUProfessor，62yearsoldSmallcelllungcancer,limiteddisease,chemofor6cycleswithcompleteresponseMedicaloncologist：prophylacticcranialirradiation（PCI）notimporvesurvival,andwithAE！Radio-oncologist：PCIimprovesurvival,andtolerableQuestion:Why?ShouldthepatientbegivePCI?Improvesurvival?Howmuch?Sideeffect？When?How?Case1Male,ZSUProfessor，62ye43TextbookPublish20061.ChanceofSCLCbrainmet：50%-80%for2years2.1995，aMETA-analysis：SCLCwithCR,PCIimprove3yearsurvival15%-21%，butnotanalysisthecomplication3.Reducebrainmetfrom30%→5%☆Conclusion：SCLCwithCR,PCIisrecommendafter2cyclesofchemoComplications?case1TextbookPublish2006case144Guideline&SRNCCNLungcancerandProphylacticcranialirradiation12002TheCochraneLibrary,Issue2Prophylacticcranialirradiationsignificantlyimprovessurvivalanddisease-freesurvivalforpatientswithsmallcelllungcancerincompleteremission.

case1Guideline&SRNCCNcase145循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件46循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件47例1例148FromSecondarySourcePCIshouldstartearlyafterchemocomplications：notRCT2studyreportnodifferenceinmentalorneurologicaldisorder,butonlystudypartofthestudypatients，40%and60%（1995，1997）N=300N=314InoneRCT（N=46）,reportamentaldisorder（1997）case1FromSecondarySourcePCIshoul49PUBMED"CranialIrradiation"[MESH]ANDlungneoplasms[mh]("CranialIrradiation/adverseeffects"[MESH]OR"CranialIrradiation/mortality"[MESH])ANDlungneoplasms[mh]☆25papers，3papersafter2006，onrelatepaper（level5）例1PUBMED"CranialIrradiation"[ME50PUBMED2009,JCOpeer-reviewComplicationsMentalandneurologicalIncreasebyconcurrentchemoirradiationIncreaseindoselevel≥40Gy，nomorethan30Gy，recommend20GySupportPCIinSCLClimiteddiseasewithchemoCR.例1PUBMED2009,JCOpeer-review例151Conclusion&DecisionPCIreducebrainmet,improvesurvivalWhenRT<30GY,rarecomplicationsMorebenefitthanharmRecommendation：PCI，rightnowcase1Conclusion&DecisionPCIreduc52EventsLikeThis……

SanlubabyformulamilkpowdercontaminatewithmelamineJul.16,2008甘肅省衛(wèi)生廳接電話報(bào)告，稱今年該院收治的嬰兒患腎結(jié)石病例明顯增多，近幾個(gè)月已達(dá)十幾例，經(jīng)了解均食用了三鹿牌配方奶粉。Sept.11,2008新華社報(bào)道：“高度懷疑”三鹿公司生產(chǎn)的三鹿牌嬰幼兒配方奶粉受到三聚氰胺污染。case2EventsLikeThis……

Sanlubaby53SanlubabyformulamilkpowdercontaminatewithmelamineSept.17,2008國(guó)務(wù)院有關(guān)部門(mén)負(fù)責(zé)人和科學(xué)家國(guó)家質(zhì)檢總局局長(zhǎng)李長(zhǎng)江：……共檢驗(yàn)了109家企業(yè)的491批次產(chǎn)品，有22家企業(yè)的69個(gè)批次的產(chǎn)品檢出了三聚氰胺，檢出不合格產(chǎn)品的企業(yè)約為20％……需要指出的是，這次被檢出含有三聚氰胺產(chǎn)品的企業(yè)，不是所有批次的嬰幼兒奶粉都有問(wèn)題，比如，伊利、蒙牛、雅士利、施恩等企業(yè)被抽檢的產(chǎn)品有幾十個(gè)批次，但有問(wèn)題的只有幾個(gè)批次。case2Sanlubabyformulamilkpowder54Sanlubabyformulamilkpowdercontaminatewithmelamine衛(wèi)生部陳竺部長(zhǎng)：三聚氰胺……主要對(duì)膀胱和腎臟有影響，引發(fā)動(dòng)物膀胱炎、膀胱結(jié)石、腎臟炎癥等，但沒(méi)有發(fā)現(xiàn)對(duì)人類有致癌作用。嬰幼兒食用……出現(xiàn)不明原因的哭鬧、嘔吐、發(fā)熱、尿液混濁、血尿、少尿或無(wú)尿等癥狀，應(yīng)立即就近到醫(yī)療機(jī)構(gòu)篩查就診。食用含有三聚氰胺的其他品牌嬰幼兒奶粉，只有出現(xiàn)上述癥狀時(shí)，才需要立即到醫(yī)院篩查就診。從2008年9月12日至17日8時(shí)，各地報(bào)告臨床診斷患兒一共有6244例。其中，4917例患兒癥狀輕微，生命體征穩(wěn)定，正在進(jìn)行院外隨訪治療或已經(jīng)治愈。現(xiàn)仍留院觀察治療患兒有1327人。所有臨床診斷病歷中，有158人發(fā)生過(guò)急性腎功能衰竭，占總病例數(shù)的2.5%。經(jīng)有效治療，目前158例重癥患兒當(dāng)中，已經(jīng)有94人病情平穩(wěn)或已經(jīng)治愈出院。此外，回顧性的調(diào)查發(fā)現(xiàn)有3例死亡病例，其中甘肅省有2名，浙江有1名，不包括在剛才提到的6244名診斷病例之中。case2Sanlubabyformulamilkpowder55循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件56循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件57循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件58循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件59TheEvidencePyramidHierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobiasPrimaryResearch

Experimental

observationalSecondaryResearchForquantitativestudiesForqualitativestudiesNoconsensusabouttherelativerigourofdifferentmethodsSystematicreviewTheEvidencePyramidHierarchy60SanlubabyformulamilkpowdercontaminatewithmelamineCelloranimalisnoequaltohumanButthereareanycorelation?Noevidencedoesnotmeannoharm!Howshouldweact?Sanlubabyformulamilkpowder61SummaryEBMisaLifelonglearningmodellifelong,self-directed,problem-basedlearningKnow-howinfinding,appraising,andapplyingevidenceSummaryEBMisaLifelonglearn62FurtherReadingonEvidenceBasedMedicineFurtherReadingonEvidenceBa63Evidence-BasedMedicine

循證醫(yī)學(xué)楊學(xué)寧XueningYang,MD廣東省人民醫(yī)院廣東省肺癌研究所廣東省循證醫(yī)學(xué)科研中心循證醫(yī)學(xué)雜志社Evidence-BasedMedicine

循證醫(yī)學(xué)楊64Evidence-basedPractice(EBP)ModelsTraditionalpracticeModel(×)Model1:UsethehighestqualityinformationtoguideclinicaldecisionsModel2:Search,evaluate,andmakeavailablespecialtyspecificbestavailableevidenceModel3:CreateoriginalresearchorsystematicreviewsEvidence-basedPractice(EBP)M65EBMPractice-Fivesteps

PatientHistoryandPE……QuestionAskingAnswerableClinicalQuestions.SearchSearchingforthebestcurrentevidence.AppraiseCritically-appraisingtheevidence.Application:Integratingtheevidencewithourexpertiseandourpatient’suniquebiologyandvaluesAuditEvaluatingourperformanceEBMPractice-FivestepsPa66Step1AskingAnswerableClinicalQuestionsSetting:64residents

at2NewHavenhospitalsMethod:Interviewedafter401consultationsQuestionsAsked280questions(2per3patients)Pursuedananswerfor80questions(29%)NotpursuedbecauseLackoftimeForgotthequestionSourcesofanswersTextbooks(31%),articles(21%),consultants(17%)Green,AmJMed2000Step1AskingAnswerableClini67Step1AskingAnswerableClinicalQuestionsMostofourquestionsareneveransweredWhenanswered,theinformationislikelytobeneitherthebestnorup-to-dateStep1AskingAnswerableClini68Step1AskingAnswerableClinicalQuestionsEBMstartswithaclearclinicalquestionWell-builtclinicalquestionsguidethewholeEBMprocessTypeofquestion?Causation/etiology

InterventionDiagnosisPrognosisTypeofStudy?Whatwouldbethebeststudydesigninordertoanswerthequestion?studydesignsshouldlimitbiasStep1AskingAnswerableClini69Step1AskingAnswerableClinicalQuestionsQuestioncomponents:PICOWhattypesofParticipants?WhattypesofInterventions?WhattypesofComparison?WhattypesofOutcomes?Step1AskingAnswerableClini70Step1AskingAnswerableClinicalQuestionsWhattypesofparticipants?DiseaseorconditionofinterestPotentialco-morbiditySettingDemographicfactorsTaskofclinicalproblemStep1AskingAnswerableClini71Step1AskingAnswerableClinicalQuestionsWhattypesofintervention?TypesoftreatmentTypeofdiagnostictestTypeofcausativeagentTypeofprognosticfactorStep1AskingAnswerableClini72Step1AskingAnswerableClinicalQuestionsWhattypesofoutcomes?Forcausation,outcomeisdiseaseFordiagnostictest,outcomeindiseaseofinterestFortreatmentincludealloutcomesimportanttopeoplemakingdecisionstodefinesuccessoftherapyForprognosis,outcomeisthechosenendpointofthediseaseStep1AskingAnswerableClini73Step1AskingAnswerableClinicalQuestionsBroadornarrowquestionsBroadDogefinitibimprovesurvivalinlungadenocarcinoma?NarrowDogefinitibimprovesurvivalinfemallungadenocarcinomarefractorytofirst-linechemo?Step1AskingAnswerableClini74Step1AskingAnswerableClinicalQuestionsCausationPeople-Exposure-Comparison-OutcomesDoesheavysmokerhavehigherincidenceoflungcancer?Prognosis:People-Exposure-Comparison-OutcomesIslungadenocarcinomawithhighlevelofCEAaremorelikelytohaverecurrentdisease?Step1AskingAnswerableClini75Step2SearchingforthebestcurrentevidenceTextbookAnnuallyrevisedUsehighlevelevidencesWithreferenceGuidelinesCochraneLibraryMedlineStep2Searchingforthebest76NationalGuidelineClearinghouse(/)Step2NationalGuidelineClearinghou77Toomuch?即使是小的問(wèn)題也有相關(guān)指南Step2Toomuch?即使是小的問(wèn)題也有相關(guān)指南Step278Step2Step279CochraneLibraryAdvantagehighestqualityevidencewe’lleverhaveontheeffectivenessofhealthcareDisadvantagenotyetmanysystemicreviewsnecessarilyomitsthenewesttreatmentStep2CochraneLibraryAdvantageStep80EBPModelsTraditionalpracticeModel(×)Model1:UsethehighestqualityinformationtoguideclinicaldecisionsModel2:Search,evaluate,andmakeavailablespecialtyspecificLevel1informationModel3:CreateoriginalresearchorsystematicreviewsStep2EBPModelsTraditionalpractice81PubMed/MEDLINE/PubmedStep2PubMed/MEDLINEhttp://www.ncbi82Medline-PubMedAdvantageexhaustiveness,flexibilityofsearchingjournalcoverage,currency(on-lineversions)widespreadavailabilityandsupportDisadvantagehavetodoyourownqualityfilteringputtingtogethergoodsearchesisdifficultgapsincoverage(medical,geographicalandlinguistic)Step2Medline-PubMedAdvantageStep283Step2Step284Step2Step285Step2Step286Step2Step287Step2Step288Step2SearchingforthebestcurrentevidenceForprimaryliteratureNotjustabstract!TrytogetFull-textStep2Searchingforthebest89Step3Critically-appraisingtheevidenceValid?Designandmethodology:logical?SampleExperimentorMeasure:carriedoutinasoundwayandConvincible？Follow-uprate?Analysis

ConclusionEthical?Importance?Clinicalsignificance？Cost-effective？Applicable?Willtheresultshelplocally?Step3Critically-appraisingt90Step3Critically-appraisingtheevidenceQuickscreeningbytitle,abstractandrelatemessageAuthorsWell-known？Pastrecord？Creditable？InstituteCompetencetodothisstudy？Well-known？SpecialtyHasorhadpublishedincorejournals?Yourpractice？Valuable？GoforFull-textDiscrimination？Rational？EBM？Step3Critically-appraisingt91Step3Critically-appraisingtheevidence

TypeofQuestionSuggestedbesttypeofStudyTherapyRCT>cohort>casecontrol>caseseriesDiagnosisProspective,blindcomparisontoagoldstandardEtiology/HarmRCT>cohort>casecontrol>caseseriesPrognosisCohortstudy>casecontrol>caseseriesPreventionRCT>cohortstudy>casecontrol>caseseriesClinicalExamProspective,blindcomparisontogoldstandardCostEconomicanalysisRightmethodsiscrucialStep3Critically-appraisingt92TheEvidencePyramidHierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobiasPrimaryResearch

Experimental

observationalSecondaryResearchForquantitativestudiesForqualitativestudiesNoconsensusabouttherelativerigourofdifferentmethodsSystematicreviewTheEvidencePyramidHierarchy93Step3Critically-appraisingtheevidencePhaseIIIRCTheadtoheadComparesurvivalAdequatesamplesizeStep3Critically-appraisingt94Step3Critically-appraisingtheevidenceMeasureObjective：Labtest，RadiologySubjective：pain，symptomsEndpointalternative：relieveofsymptom,shrinkoftumorGoldStandard：prolongsurvivalStep3Critically-appraisingt95Step3Critically-appraisingtheevidenceConclusionBasedonthedata?New?Updated?ComparewithotherstudyAnd,Whatnext?Step3Critically-appraisingt96Step3Critically-appraisingtheevidenceAttention!Don’ttrustitjustbecauseitisfromabigboss,meta-analysis,RCT,orguideline.Evidenceshouldbeinconsistencewithknownmedicalscience(physiology,pathology,pharmacology,etc）UsageofscientificlanguageisnotnecessarilymeanscientificbasedScientificmethodscreditStep3Critically-appraisingt97NotalltheevidencesarethesameimportanceHollingworth&Jarvik,Radiology2007;244:31-38Flowchartofcost-effectivenessateachlevelofTAhierarchyTechnicalPerformanceDiagnosticPerformanceDiagnosticImpactTherapeuticImpactImpactonHealthNotalltheevidencesarethe98循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件99Step4ApplicationIntegratingtheevidencewithourexpertiseandourpatient’suniquebiologyandvaluesYourquestionYourpatientYourexpertiseYourhospitalHowto……Step4ApplicationIntegrating100Step5EvaluatingourperformanceFollow-upEvaluateThepatientsbenefit……?Next…………Oragainanother5stepsCollectdataandwriteanarticleStep5Evaluatingourperforma101EBPModelsTraditionalpracticeModel(×)Model1:UsethehighestqualityinformationtoguideclinicaldecisionsModel2:Search,evaluate,andmakeavailablespecialtyspecificbestavailableevidenceModel3:CreateoriginalresearchorsystematicreviewsEBPModelsTraditionalpractice102SelectiveEBPMaynotneedtocarryoutall5steps1.AskingAnswerableClinicalQuestions.X2.Searchingforthebestcurrentevidence.X3.Critically-appraisingtheevidence.4.Application:Integratingtheevidencewithourexpertiseandourpatient’suniquebiologyandvalues5.EvaluatingourperformanceSelectiveEBPMaynotneedtoc103SelectiveEBP3differentmodesofEBPSearching&appraisingprovidesE-Bcare,butisexpensiveintimeandresourcesSearchingonlymuch,quicker,andifcarriedoutamongE-Bresources,canprovideE-BcareReplicatingthepracticeofexpertsquickest,butmaynotdistinguishevidence-basedfromego-basedrecommendationsSelectiveEBP3differentmodes104SelectiveEBPEvenfullyEBM-trainedcliniciansworkinall3modesSearching&appraisingfortheproblemsIencounterdaily.SearchingonlyforproblemsIencounteronceamonth.ReplicatingforproblemsIencounteronceadecade(andcrossingmyfingers!).SelectiveEBPEvenfullyEBM-tr105Case1Male,ZSUProfessor，62yearsoldSmallcelllungcancer,limiteddisease,chemofor6cycleswithcompleteresponseMedicaloncologist：prophylacticcranialirradiation（PCI）notimporvesurvival,andwithAE！Radio-oncologist：PCIimprovesurvival,andtolerableQuestion:Why?ShouldthepatientbegivePCI?Improvesurvival?Howmuch?Sideeffect？When?How?Case1Male,ZSUProfessor，62ye106TextbookPublish20061.ChanceofSCLCbrainmet：50%-80%for2years2.1995，aMETA-analysis：SCLCwithCR,PCIimprove3yearsurvival15%-21%，butnotanalysisthecomplication3.Reducebrainmetfrom30%→5%☆Conclusion：SCLCwithCR,PCIisrecommendafter2cyclesofchemoComplications?case1TextbookPublish2006case1107Guideline&SRNCCNLungcancerandProphylacticcranialirradiation12002TheCochraneLibrary,Issue2Prophylacticcranialirradiationsignificantlyimprovessurvivalanddisease-freesurvivalforpatientswithsmallcelllungcancerincompleteremission.

case1Guideline&SRNCCNcase1108循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件109循證醫(yī)學(xué)EvidenceBasedClinicalPracticeZSUFS課件110例1例1111FromSecondarySourcePCIshouldstartearlyafterchemocomplications：notRCT2studyreportnodifferenceinmentalorneurologicaldisorder,butonlystudypartofthestudypatients，40%and60%（1995，1997）N=300N=314InoneRCT（N=46）,reportamentaldisorder（1997）case1FromSecondarySourcePCIshoul112PUBMED"CranialIrradiation"[MESH]ANDlungneoplasms[