TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件

李文欽醫(yī)師實(shí)證醫(yī)學(xué)中心主任2013/11/08實(shí)證醫(yī)學(xué)與個(gè)案討論李文欽醫(yī)師實(shí)證醫(yī)學(xué)與個(gè)案討論簡(jiǎn)報(bào)大綱簡(jiǎn)述實(shí)證醫(yī)學(xué)五大步驟如何問(wèn)問(wèn)題及形成PICO的內(nèi)容資料搜尋的策略、使用資料庫(kù)及搜尋結(jié)果對(duì)資料的評(píng)讀如何落實(shí)實(shí)證醫(yī)學(xué)於個(gè)案討論簡(jiǎn)報(bào)大綱簡(jiǎn)述實(shí)證醫(yī)學(xué)五大步驟過(guò)去

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現(xiàn)在

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未來(lái)當(dāng)一個(gè)醫(yī)生該具備的的能力三日不讀書(shū)，面目可憎醫(yī)病照護(hù)教學(xué)研究過(guò)去／現(xiàn)在／未來(lái)當(dāng)一個(gè)醫(yī)生該具備的的能力三日不讀書(shū)，TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件2000年Sackett將實(shí)證醫(yī)學(xué)定義為“整合最佳研究證據(jù)、臨床經(jīng)驗(yàn)以及病患價(jià)值以達(dá)成病患最佳治療的過(guò)程”實(shí)證醫(yī)學(xué)的實(shí)行是一種終身的、自發(fā)的、以問(wèn)題為導(dǎo)向的學(xué)習(xí)過(guò)程實(shí)證醫(yī)學(xué)的重要性臨床經(jīng)驗(yàn)病患價(jià)值最佳研究證據(jù)實(shí)證醫(yī)療Sackettetal20002000年Sackett將實(shí)證醫(yī)學(xué)定義為“整合最佳研究證據(jù)實(shí)證醫(yī)學(xué)的五個(gè)步驟1.Askingananswerablequestion(提出可回答的臨床問(wèn)題)2.Trackingdownthebestevidence

(搜尋最佳實(shí)證文獻(xiàn)資料)3.Criticalappraisal

(嚴(yán)謹(jǐn)?shù)奈墨I(xiàn)評(píng)讀)4.Integratingtheappraisalwithclinicalexpertiseandpatients’preference

(將臨床專業(yè)與病人價(jià)值觀相結(jié)合)5.Evaluationtheeffectivenessandefficiencyinexecutingsteps1-4(評(píng)估改善)

實(shí)證醫(yī)學(xué)的五個(gè)步驟1.AskingananswerabAstrokepatientwhohaslongtermgoutyarthritisDoesgoutcauseahigherriskofstoke?痛風(fēng)會(huì)增加中風(fēng)的風(fēng)險(xiǎn)嗎？Astrokepatientwhohaslong找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingEBM的步驟SirAustinBradfordHill(1897-1991),EnglishepidemiologistandstatisticianHedescribedtheclinicaltrialasbeing‘a(chǎn)CAREFULLY,andETHICALLY,describedexperimentwiththeaimofansweringsomePRECISELYFRAMEDQUESTIONGreaterprecisionisrequiredintheobjectives.WeneedtohaveAdefinedpopulationDefinedendpointsRelativelyfewquestiontobeanswered.問(wèn)題要怎麼問(wèn)？找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題1.形成問(wèn)題

(ClinicalQuestion)Doesgoutcauseahigherriskofstoke?痛風(fēng)會(huì)增加中風(fēng)的風(fēng)險(xiǎn)嗎？1.形成問(wèn)題(ClinicalQuestion)Doe臨床的問(wèn)題模型(PICO)P:Patient,Population指此病人或族群的年齡層、體質(zhì)、疾病史、過(guò)去史等I:Intervention指治療、診斷、預(yù)後、成本效益分析等，為研究的主題C:Comparison指做與不做或不同處置間的比較O:Outcome指預(yù)後或與目前問(wèn)題有關(guān)的比較基準(zhǔn)臨床的問(wèn)題模型(PICO)P:Patient,Popul找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingEBM的步驟PICO1Doesgoutcauseahigherriskofstoke?PICOtype:TherapyPatient:老年人Intervention:痛風(fēng)Comparison:無(wú)痛風(fēng)Outcome:中風(fēng)的風(fēng)險(xiǎn)問(wèn)題要怎麼問(wèn)？找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題2.Trackingdownthebestevidence直接使用實(shí)證醫(yī)學(xué)資料庫(kù)(secondarydatabases)如ACPjournalclub,CochraneLibrary,UpToDate,MDConsult,PracticeGuideline找初步篩選的資料庫(kù)(primarydatabases)PubMed,OVID,Proquest未經(jīng)篩選的資料庫(kù)~如Google可搜尋實(shí)證醫(yī)學(xué)的資料庫(kù)2.Trackingdownthebestevid

如何尋找與EBM相關(guān)的館藏資源？主題切入

本院一般綜合性資料庫(kù)

1.PudMed：可查出abstract2.Ovid：可查出abstract、Fulltext 3.Proquest：可查出abstract、Fulltext 4.Clinicalkey：可查出abstract、Fulltext找實(shí)證醫(yī)學(xué)資料時(shí)可加上

SystemicReview(系統(tǒng)性評(píng)論)、Meta-analysis(整合分析)、RandomizedControlledTrial(隨機(jī)對(duì)照臨床試驗(yàn)研究)、

ControlledTrials利用資料庫(kù)功能鍵如何尋找與EBM相關(guān)的館藏資源？主題切入TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件MeSHtoidentifyeverytermforexampleMeSHtoidentifyeverytermfo找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingSearchingStrategy

FindingoutTheCorrectKeywords原始關(guān)鍵字PrimaryTerm或MeSHTerm同義字1同義字2P(oror)andI(GoutorHyperuricemiaor)andC(oror)andO(strokeoror)找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingSearchingStrategy

FindingoutTheCorrectKeywordsKeywordsfromPICOitem:(“gout”O(jiān)R“hyperuricemia”)AND“stroke”MeSHtoidentifyeverytermforexample找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAsking善用搜尋Systematicreview˙關(guān)鍵字:(“gout”O(jiān)R“hyperuricemia”)AND(“stroke”O(jiān)R“cardiovasculardisease”)找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAsking找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題TheEvidencePyramidV.AnimalresearchV.

Invitro(testtube)researchIV.Caseseries/ReportsV.Ideas,Editorials,OpinionsIII.CaseControlStudiesII.CohortstudiesI.RandomizedControlledStudies(RCT)I.RandomizedControlledDoubleBlindStudies

Meta-analysis統(tǒng)計(jì)方法Meta-analysis

圖示結(jié)果Forestplot*Hierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobias.(LevelI~V)From:OxfordCenterforEBM研究設(shè)計(jì)與證據(jù)強(qiáng)度TheEvidencePyramidV.AnimalLevelTherapy/Prevention,Aetiology/HarmPrognosisDiagnosisDifferentialdiagnosis/symptomprevalencestudyEconomicanddecisionanalyses1aSR(withhomogeneity*)ofRCTsSR(withhomogeneity*)ofinceptioncohortstudies;CDR?validatedindifferentpopulationsSR(withhomogeneity*)ofLevel1diagnosticstudies;CDR?with1bstudiesfromdifferentclinicalcentresSR(withhomogeneity*)ofprospectivecohortstudiesSR(withhomogeneity*)ofLevel1economicstudies1bIndividualRCT(withnarrowConfidenceInterval?)Individualinceptioncohortstudywith>80%follow-up;CDR?validatedinasinglepopulationValidating**cohortstudywithgood???referencestandards;orCDR?testedwithinoneclinicalcentreProspectivecohortstudywithgoodfollow-up****Analysisbasedonclinicallysensiblecostsoralternatives;systematicreview(s)oftheevidence;andincludingmulti-waysensitivityanalyses1cAllornone§Allornonecase-seriesAbsoluteSpPinsandSnNouts??Allornonecase-seriesAbsolutebetter-valueorworse-valueanalyses????2aSR(withhomogeneity*)ofcohortstudiesSR(withhomogeneity*)ofeitherretrospectivecohortstudiesoruntreatedcontrolgroupsinRCTsSR(withhomogeneity*)ofLevel>2diagnosticstudiesSR(withhomogeneity*)of2bandbetterstudiesSR(withhomogeneity*)ofLevel>2economicstudies2bIndividualcohortstudy(includinglowqualityRCT;e.g.,<80%follow-up)Retrospectivecohortstudyorfollow-upofuntreatedcontrolpatientsinanRCT;DerivationofCDR?orvalidatedonsplit-sample§§§onlyExploratory**cohortstudywithgood???referencestandards;CDR?afterderivation,orvalidatedonlyonsplit-sample§§§ordatabasesRetrospectivecohortstudy,orpoorfollow-upAnalysisbasedonclinicallysensiblecostsoralternatives;limitedreview(s)oftheevidence,orsinglestudies;andincludingmulti-waysensitivityanalyses2c"Outcomes"Research;Ecologicalstudies"Outcomes"ResearchEcologicalstudiesAuditoroutcomesresearch3aSR(withhomogeneity*)ofcase-controlstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudies3bIndividualCase-ControlStudyNon-consecutivestudy;orwithoutconsistentlyappliedreferencestandardsNon-consecutivecohort

study,orverylimitedpopulationAnalysisbasedonlimitedalternativesorcosts,poorqualityestimatesofdata,butincludingsensitivityanalysesincorporatingclinicallysensiblevariations.4Case-series(andpoorqualitycohortandcase-controlstudies§§)Case-series(andpoorqualityprognosticcohortstudies***)Case-controlstudy,poorornon-independentreferencestandardCase-seriesorsupersededreferencestandardsAnalysiswithnosensitivityanalysis5Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedoneconomictheoryor"firstprinciples"OxfordCentreforEvidence-basedMedicine-LevelsofEvidence(March2009)

/index.aspx?o=1025LevelTherapy/Prevention,P文獻(xiàn)依其研究架構(gòu)，大致分成5級(jí)實(shí)證醫(yī)學(xué)證據(jù)等級(jí)。Level1：有顯著意義的隨機(jī)對(duì)照研究報(bào)告（Randomizedcontrolledtrials,RCT）。Level2：世代研究（Cohortstudy）。Level3：病例及對(duì)照組研究（Case-controlstudy）。Level4：病例報(bào)告（Caseseries）。Level5：專家意見(jiàn)（Expertopinion）。

而當(dāng)這些實(shí)證醫(yī)學(xué)文獻(xiàn)的證據(jù)等級(jí)應(yīng)用在病人身上時(shí)，分成四個(gè)建議等級(jí)（Gradingsystemforrecommendations）臨床上就可根據(jù)此建議等級(jí)，而形成臨床指引：GradeA：根據(jù)Level1證據(jù)所做的建議。GradeB：根據(jù)Level2證據(jù)所做的建議。GradeC：根據(jù)Level3證據(jù)所做的建議。GradeD：根據(jù)Level3以下等級(jí)證據(jù)所做的建議。證據(jù)等級(jí)及建議等級(jí)

文獻(xiàn)依其研究架構(gòu)，大致分成5級(jí)實(shí)證醫(yī)學(xué)證據(jù)等級(jí)。證據(jù)等級(jí)及建TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件證據(jù)證據(jù)等級(jí)及建議強(qiáng)度建議強(qiáng)度證據(jù)等級(jí)證據(jù)證據(jù)等級(jí)及建議強(qiáng)度建議強(qiáng)度證據(jù)等級(jí)TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件LevelTherapy/Prevention,Aetiology/HarmPrognosisDiagnosisDifferentialdiagnosis/symptomprevalencestudyEconomicanddecisionanalyses1aSR(withhomogeneity*)ofRCTsSR(withhomogeneity*)ofinceptioncohortstudies;CDR?validatedindifferentpopulationsSR(withhomogeneity*)ofLevel1diagnosticstudies;CDR?with1bstudiesfromdifferentclinicalcentresSR(withhomogeneity*)ofprospectivecohortstudiesSR(withhomogeneity*)ofLevel1economicstudies1bIndividualRCT(withnarrowConfidenceInterval?)Individualinceptioncohortstudywith>80%follow-up;CDR?validatedinasinglepopulationValidating**cohortstudywithgood???referencestandards;orCDR?testedwithinoneclinicalcentreProspectivecohortstudywithgoodfollow-up****Analysisbasedonclinicallysensiblecostsoralternatives;systematicreview(s)oftheevidence;andincludingmulti-waysensitivityanalyses1cAllornone§Allornonecase-seriesAbsoluteSpPinsandSnNouts??Allornonecase-seriesAbsolutebetter-valueorworse-valueanalyses????2aSR(withhomogeneity*)ofcohortstudiesSR(withhomogeneity*)ofeitherretrospectivecohortstudiesoruntreatedcontrolgroupsinRCTsSR(withhomogeneity*)ofLevel>2diagnosticstudiesSR(withhomogeneity*)of2bandbetterstudiesSR(withhomogeneity*)ofLevel>2economicstudies2bIndividualcohortstudy(includinglowqualityRCT;e.g.,<80%follow-up)Retrospectivecohortstudyorfollow-upofuntreatedcontrolpatientsinanRCT;DerivationofCDR?orvalidatedonsplit-sample§§§onlyExploratory**cohortstudywithgood???referencestandards;CDR?afterderivation,orvalidatedonlyonsplit-sample§§§ordatabasesRetrospectivecohortstudy,orpoorfollow-upAnalysisbasedonclinicallysensiblecostsoralternatives;limitedreview(s)oftheevidence,orsinglestudies;andincludingmulti-waysensitivityanalyses2c"Outcomes"Research;Ecologicalstudies"Outcomes"ResearchEcologicalstudiesAuditoroutcomesresearch3aSR(withhomogeneity*)ofcase-controlstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudies3bIndividualCase-ControlStudyNon-consecutivestudy;orwithoutconsistentlyappliedreferencestandardsNon-consecutivecohort

study,orverylimitedpopulationAnalysisbasedonlimitedalternativesorcosts,poorqualityestimatesofdata,butincludingsensitivityanalysesincorporatingclinicallysensiblevariations.4Case-series(andpoorqualitycohortandcase-controlstudies§§)Case-series(andpoorqualityprognosticcohortstudies***)Case-controlstudy,poorornon-independentreferencestandardCase-seriesorsupersededreferencestandardsAnalysiswithnosensitivityanalysis5Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedoneconomictheoryor"firstprinciples"OxfordCentreforEvidence-basedMedicine-LevelsofEvidence(March2009)

/index.aspx?o=1025LevelTherapy/Prevention,P找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAsking˙Title:-Hyperuricemiaandriskofstroke:asystematicreviewandmeta-analysis.(2009)˙Source:ArthritisRheum.2009Jul15;61(7):885-92˙Level:2a找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題Largeepidemiologicstudieshaveshownthathyperuricemiaisassociatedwithanincreasedincidenceofcoronaryheartdisease(CHD)andincreasedmortalityinthosewith

andwithout

preexistingCHD.FangJ,AldermanMH.SerumuricacidandcardiovascularmortalitytheNHANESIepidemiologicfollow-upstudy,1971-1992.NationalHealthandNutritionExaminationSurvey.JAMA2000;283:2404.FreedmanDS,WilliamsonDF,GunterEW,ByersT.Relationofserumuricacidtomortalityandischemicheartdisease.TheNHANESIEpidemiologicFollow-upStudy.AmJEpidemiol1995;141:637.BrandFN,McGeeDL,KannelWB,etal.Hyperuricemiaasariskfactorofcoronaryheartdisease:TheFraminghamStudy.AmJEpidemiol1985;121:11.NiskanenLK,LaaksonenDE,Nyyss?nenK,etal.Uricacidlevelasariskfactorforcardiovascularandall-causemortalityinmiddle-agedmen:aprospectivecohortstudy.ArchInternMed2004;164:1546.ChoiHK,CurhanG.Independentimpactofgoutonmortalityandriskforcoronaryheartdisease.Circulation2007;116:894.LargeepidemiologicstudieshaProposedmechanisms

forsuchanincreaseinriskincludethedevelopmentofhypertension

andoxidativestress.JohnsonRJ,SegalMS,SrinivasT,etal.Essentialhypertension,progressiverenaldisease,anduricacid:apathogeneticlink?JAmSocNephrol2005;16:1909.BakerJF,KrishnanE,ChenL,SchumacherHR.Serumuricacidandcardiovasculardisease:recentdevelopments,andwheredotheyleaveus?AmJMed2005;118:816.ProposedmechanismsforsuchaItisunclearifhyperuricemiahasacausaleffector,ashasbeenmoreoftensuggested,issimplyamarkerforotherriskfactors,suchashypertension,dyslipidemia,anddiabetes.CulletonBF,LarsonMG,KannelWB,LevyD.Serumuricacidandriskforcardiovasculardiseaseanddeath:theFraminghamHeartStudy.AnnInternMed1999;131:7.WannametheeSG,ShaperAG,WhincupPH.Serumurateandtheriskofmajorcoronaryheartdiseaseevents.Heart1997;78:147.WheelerJG,JuzwishinKD,EiriksdottirG,etal.Serumuricacidandcoronaryheartdiseasein9,458incidentcasesand155,084controls:prospectivestudyandmeta-analysis.PLoSMed2005;2:e76.FeigDI,KangDH,JohnsonRJ.Uricacidandcardiovascularrisk.NEnglJMed2008;359:1811.Itisunclearifhyperuricemia文獻(xiàn)評(píng)讀三部曲文獻(xiàn)評(píng)讀最主要的三個(gè)步驟，即是VIPV：Validity/Reliability;效度/信度我們能相信這篇文章嗎?I：Importance/Impact;重要性我們相信它，但這個(gè)結(jié)論重要嗎?P：Practice/Applicability;臨床適用性如果我們相信它，這個(gè)結(jié)論可以應(yīng)用在我們所照護(hù)的病患嗎?文獻(xiàn)評(píng)讀三部曲文獻(xiàn)評(píng)讀最主要的三個(gè)步驟，即是VIP找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingAccordingto“SharonE.Strausetal,Evidence-basedmedicine:howtopracticeandteachEBM,Elsevier,2005:33-7.“ValidityImportanceApplicabilityResultsfromsecondarydatabaseResultsfromprimarydatabaseAppraisedbyexpertsNeededtobeappraisedResults(NNT)ResultsConsiderpopulationandfeasibilityConsiderpopulationandfeasibility找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題效度(Validity)：可以用RAM-bo方式審視效度研究族群是否有隨機(jī)分配(Randomized)？隨機(jī)分配的方法是否適當(dāng)(Accounted)？結(jié)果的衡量(Measurement)，

即是否依照盲法(blind)及客觀(objective)二要素操作治療意圖分析(Intention-to-treatanalysis,ITT)隨機(jī)試驗(yàn)的一種分析方法所有被分配在治療組/對(duì)照組的病人無(wú)論是否完成該項(xiàng)治療/安慰劑都應(yīng)該被放進(jìn)治療組/對(duì)照組(原分派組別)中做分析文獻(xiàn)評(píng)讀三部曲效度(Validity)：可以用RAM-bo方式審視效度文獻(xiàn)重要性(Importance/Impact)：研究結(jié)果是什麼?研究結(jié)果如何被估計(jì)?經(jīng)過(guò)多久的時(shí)間?文獻(xiàn)結(jié)果的評(píng)估方式：勝算比(oddsratio)代表生物學(xué)上的影響。相對(duì)危險(xiǎn)(relativerisk)、絕對(duì)危險(xiǎn)降低度(absoluteriskreduction)、相對(duì)危險(xiǎn)降低度(relativeriskreduction)、益一需治數(shù)(NNT,numberneededtotreat):為預(yù)防一個(gè)不良結(jié)果或使一個(gè)病人達(dá)實(shí)驗(yàn)所求之有益結(jié)果所需治療的病人數(shù)NNT=1/ARR文獻(xiàn)評(píng)讀三部曲重要性(Importance/Impact)：文獻(xiàn)評(píng)讀三部曲可行性(Practical,Applicability?)：臨床實(shí)用性如何？1.應(yīng)考量病患的生物因素(biologicalissues):

---同樣的治療應(yīng)用在不同的病患族群是否有不同反應(yīng)?

--我們的病人與研究中的病人是否非常不同，以致無(wú)法應(yīng)用在研究結(jié)果？2.其他的社會(huì)經(jīng)濟(jì)因素（socialandeconomicissues）的考量:

--這個(gè)治療適用於我們的診療環(huán)境嗎？病患的配合度如何？

--醫(yī)療提供者的配合度及能力如何？3.流行病學(xué)因素(epidemiologicalissues）的考量:

--我們的病人是否有其他共病狀況，可能改變治療的結(jié)果？影響有多大？

--病人可能從治療中得到什麼好處或壞處？

--經(jīng)由治療而減少的不良後果是否比不治療有明顯的差別？文獻(xiàn)評(píng)讀三部曲可行性(Practical,Applicability幫助文獻(xiàn)評(píng)讀的工具幫助文獻(xiàn)評(píng)讀的工具依所搜尋文獻(xiàn)類別，評(píng)讀所問(wèn)的問(wèn)題依所搜尋文獻(xiàn)類別，評(píng)讀所問(wèn)的問(wèn)題4.將臨床專業(yè)與病人價(jià)值觀相結(jié)合您的病人是否與研究中的病人差別很大，以至於無(wú)法適用該研究結(jié)果？族群/地域/文化差異您期望您的病人從研究結(jié)果中獲得多大的好處？還有哪些替代方案？研究結(jié)果適用於您的病人嗎？4.將臨床專業(yè)與病人價(jià)值觀相結(jié)合您的病人是否與研究中的病人5.評(píng)估執(zhí)行效果及改善過(guò)程您是否開(kāi)始使用實(shí)證手法搜尋最佳證據(jù)？您搜尋及評(píng)讀證據(jù)的速度有多快？您有能力將這些證據(jù)應(yīng)用在適當(dāng)?shù)牟∪松砩蠁幔磕欠褚姥@些新證據(jù)來(lái)改變您的診療習(xí)慣？5.評(píng)估執(zhí)行效果及改善過(guò)程您是否開(kāi)始使用實(shí)證手法搜尋最佳證據(jù)如何落實(shí)實(shí)證醫(yī)學(xué)於個(gè)案討論會(huì)?如何落實(shí)實(shí)證醫(yī)學(xué)於個(gè)案討論會(huì)?如何落實(shí)實(shí)證醫(yī)學(xué)於個(gè)案討論會(huì)1.由討論的個(gè)案找尋問(wèn)題(形成PICO)2.進(jìn)行文獻(xiàn)搜尋(PUBMed,Cochrane,Ovid……)3.進(jìn)行文獻(xiàn)評(píng)讀(Evidencelevel,Recommendgrade)會(huì)議中報(bào)告文章重點(diǎn)與結(jié)論4.所搜尋的文獻(xiàn)值得應(yīng)用到本病人身上嗎?如何落實(shí)實(shí)證醫(yī)學(xué)於個(gè)案討論會(huì)1.由討論的個(gè)案找尋問(wèn)題(形成實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)順序Casereport(個(gè)案報(bào)告)提出問(wèn)題，建立PICO格式文獻(xiàn)搜尋(所使用關(guān)鍵字、資料庫(kù))所搜尋到文獻(xiàn)的題目、出處、及文獻(xiàn)的證據(jù)等級(jí)5.報(bào)告文獻(xiàn)的重點(diǎn)與結(jié)論6.是否可應(yīng)用到我們的病人身上實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)順序Casereport(個(gè)案報(bào)告)˙Clinicalquestion:Doesgoutcauseahigherriskofstoke?

PICOtype:TherapyPatient:OldpatientIntervention:GoutComparison:WithoutgoutOutcome:Riskofstroke˙Clinicalquestion:PICOtype˙Title:Hyperuricemiaandriskofstroke:asystematicreviewandmeta-analysis.(2009)˙Source:ArthritisRheum.2009Jul15;61(7):885-92˙Level:2a˙Title:TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件科別選定與討論頻率1.科別:內(nèi)、外、婦、兒、皮膚科藥劑、護(hù)理、(檢驗(yàn)、放射)2.頻率:每月一次3.會(huì)議主題設(shè)定:實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)4.請(qǐng)科部主任定期檢視結(jié)果與統(tǒng)計(jì)科別選定與討論頻率1.科別:內(nèi)、外、婦、兒、皮膚科TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件ThankYouForYourAttention!ThankYouForYourAttention!李文欽醫(yī)師實(shí)證醫(yī)學(xué)中心主任2013/11/08實(shí)證醫(yī)學(xué)與個(gè)案討論李文欽醫(yī)師實(shí)證醫(yī)學(xué)與個(gè)案討論簡(jiǎn)報(bào)大綱簡(jiǎn)述實(shí)證醫(yī)學(xué)五大步驟如何問(wèn)問(wèn)題及形成PICO的內(nèi)容資料搜尋的策略、使用資料庫(kù)及搜尋結(jié)果對(duì)資料的評(píng)讀如何落實(shí)實(shí)證醫(yī)學(xué)於個(gè)案討論簡(jiǎn)報(bào)大綱簡(jiǎn)述實(shí)證醫(yī)學(xué)五大步驟過(guò)去

／

現(xiàn)在

／

未來(lái)當(dāng)一個(gè)醫(yī)生該具備的的能力三日不讀書(shū)，面目可憎醫(yī)病照護(hù)教學(xué)研究過(guò)去／現(xiàn)在／未來(lái)當(dāng)一個(gè)醫(yī)生該具備的的能力三日不讀書(shū)，TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件2000年Sackett將實(shí)證醫(yī)學(xué)定義為“整合最佳研究證據(jù)、臨床經(jīng)驗(yàn)以及病患價(jià)值以達(dá)成病患最佳治療的過(guò)程”實(shí)證醫(yī)學(xué)的實(shí)行是一種終身的、自發(fā)的、以問(wèn)題為導(dǎo)向的學(xué)習(xí)過(guò)程實(shí)證醫(yī)學(xué)的重要性臨床經(jīng)驗(yàn)病患價(jià)值最佳研究證據(jù)實(shí)證醫(yī)療Sackettetal20002000年Sackett將實(shí)證醫(yī)學(xué)定義為“整合最佳研究證據(jù)實(shí)證醫(yī)學(xué)的五個(gè)步驟1.Askingananswerablequestion(提出可回答的臨床問(wèn)題)2.Trackingdownthebestevidence

(搜尋最佳實(shí)證文獻(xiàn)資料)3.Criticalappraisal

(嚴(yán)謹(jǐn)?shù)奈墨I(xiàn)評(píng)讀)4.Integratingtheappraisalwithclinicalexpertiseandpatients’preference

(將臨床專業(yè)與病人價(jià)值觀相結(jié)合)5.Evaluationtheeffectivenessandefficiencyinexecutingsteps1-4(評(píng)估改善)

實(shí)證醫(yī)學(xué)的五個(gè)步驟1.AskingananswerabAstrokepatientwhohaslongtermgoutyarthritisDoesgoutcauseahigherriskofstoke?痛風(fēng)會(huì)增加中風(fēng)的風(fēng)險(xiǎn)嗎？Astrokepatientwhohaslong找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingEBM的步驟SirAustinBradfordHill(1897-1991),EnglishepidemiologistandstatisticianHedescribedtheclinicaltrialasbeing‘a(chǎn)CAREFULLY,andETHICALLY,describedexperimentwiththeaimofansweringsomePRECISELYFRAMEDQUESTIONGreaterprecisionisrequiredintheobjectives.WeneedtohaveAdefinedpopulationDefinedendpointsRelativelyfewquestiontobeanswered.問(wèn)題要怎麼問(wèn)？找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題1.形成問(wèn)題

(ClinicalQuestion)Doesgoutcauseahigherriskofstoke?痛風(fēng)會(huì)增加中風(fēng)的風(fēng)險(xiǎn)嗎？1.形成問(wèn)題(ClinicalQuestion)Doe臨床的問(wèn)題模型(PICO)P:Patient,Population指此病人或族群的年齡層、體質(zhì)、疾病史、過(guò)去史等I:Intervention指治療、診斷、預(yù)後、成本效益分析等，為研究的主題C:Comparison指做與不做或不同處置間的比較O:Outcome指預(yù)後或與目前問(wèn)題有關(guān)的比較基準(zhǔn)臨床的問(wèn)題模型(PICO)P:Patient,Popul找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingEBM的步驟PICO1Doesgoutcauseahigherriskofstoke?PICOtype:TherapyPatient:老年人Intervention:痛風(fēng)Comparison:無(wú)痛風(fēng)Outcome:中風(fēng)的風(fēng)險(xiǎn)問(wèn)題要怎麼問(wèn)？找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題2.Trackingdownthebestevidence直接使用實(shí)證醫(yī)學(xué)資料庫(kù)(secondarydatabases)如ACPjournalclub,CochraneLibrary,UpToDate,MDConsult,PracticeGuideline找初步篩選的資料庫(kù)(primarydatabases)PubMed,OVID,Proquest未經(jīng)篩選的資料庫(kù)~如Google可搜尋實(shí)證醫(yī)學(xué)的資料庫(kù)2.Trackingdownthebestevid

如何尋找與EBM相關(guān)的館藏資源？主題切入

本院一般綜合性資料庫(kù)

1.PudMed：可查出abstract2.Ovid：可查出abstract、Fulltext 3.Proquest：可查出abstract、Fulltext 4.Clinicalkey：可查出abstract、Fulltext找實(shí)證醫(yī)學(xué)資料時(shí)可加上

SystemicReview(系統(tǒng)性評(píng)論)、Meta-analysis(整合分析)、RandomizedControlledTrial(隨機(jī)對(duì)照臨床試驗(yàn)研究)、

ControlledTrials利用資料庫(kù)功能鍵如何尋找與EBM相關(guān)的館藏資源？主題切入TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件MeSHtoidentifyeverytermforexampleMeSHtoidentifyeverytermfo找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingSearchingStrategy

FindingoutTheCorrectKeywords原始關(guān)鍵字PrimaryTerm或MeSHTerm同義字1同義字2P(oror)andI(GoutorHyperuricemiaor)andC(oror)andO(strokeoror)找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAskingSearchingStrategy

FindingoutTheCorrectKeywordsKeywordsfromPICOitem:(“gout”O(jiān)R“hyperuricemia”)AND“stroke”MeSHtoidentifyeverytermforexample找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAsking善用搜尋Systematicreview˙關(guān)鍵字:(“gout”O(jiān)R“hyperuricemia”)AND(“stroke”O(jiān)R“cardiovasculardisease”)找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件找資料來(lái)回答問(wèn)題Acquire嚴(yán)格評(píng)讀文獻(xiàn)Appraisal是否可應(yīng)用到病人身上Apply將病人的問(wèn)題寫(xiě)成PICOAsking找資料來(lái)回答問(wèn)題嚴(yán)格評(píng)讀文獻(xiàn)是否可應(yīng)用到病人身上將病人的問(wèn)題TheEvidencePyramidV.AnimalresearchV.

Invitro(testtube)researchIV.Caseseries/ReportsV.Ideas,Editorials,OpinionsIII.CaseControlStudiesII.CohortstudiesI.RandomizedControlledStudies(RCT)I.RandomizedControlledDoubleBlindStudies

Meta-analysis統(tǒng)計(jì)方法Meta-analysis

圖示結(jié)果Forestplot*Hierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobias.(LevelI~V)From:OxfordCenterforEBM研究設(shè)計(jì)與證據(jù)強(qiáng)度TheEvidencePyramidV.AnimalLevelTherapy/Prevention,Aetiology/HarmPrognosisDiagnosisDifferentialdiagnosis/symptomprevalencestudyEconomicanddecisionanalyses1aSR(withhomogeneity*)ofRCTsSR(withhomogeneity*)ofinceptioncohortstudies;CDR?validatedindifferentpopulationsSR(withhomogeneity*)ofLevel1diagnosticstudies;CDR?with1bstudiesfromdifferentclinicalcentresSR(withhomogeneity*)ofprospectivecohortstudiesSR(withhomogeneity*)ofLevel1economicstudies1bIndividualRCT(withnarrowConfidenceInterval?)Individualinceptioncohortstudywith>80%follow-up;CDR?validatedinasinglepopulationValidating**cohortstudywithgood???referencestandards;orCDR?testedwithinoneclinicalcentreProspectivecohortstudywithgoodfollow-up****Analysisbasedonclinicallysensiblecostsoralternatives;systematicreview(s)oftheevidence;andincludingmulti-waysensitivityanalyses1cAllornone§Allornonecase-seriesAbsoluteSpPinsandSnNouts??Allornonecase-seriesAbsolutebetter-valueorworse-valueanalyses????2aSR(withhomogeneity*)ofcohortstudiesSR(withhomogeneity*)ofeitherretrospectivecohortstudiesoruntreatedcontrolgroupsinRCTsSR(withhomogeneity*)ofLevel>2diagnosticstudiesSR(withhomogeneity*)of2bandbetterstudiesSR(withhomogeneity*)ofLevel>2economicstudies2bIndividualcohortstudy(includinglowqualityRCT;e.g.,<80%follow-up)Retrospectivecohortstudyorfollow-upofuntreatedcontrolpatientsinanRCT;DerivationofCDR?orvalidatedonsplit-sample§§§onlyExploratory**cohortstudywithgood???referencestandards;CDR?afterderivation,orvalidatedonlyonsplit-sample§§§ordatabasesRetrospectivecohortstudy,orpoorfollow-upAnalysisbasedonclinicallysensiblecostsoralternatives;limitedreview(s)oftheevidence,orsinglestudies;andincludingmulti-waysensitivityanalyses2c"Outcomes"Research;Ecologicalstudies"Outcomes"ResearchEcologicalstudiesAuditoroutcomesresearch3aSR(withhomogeneity*)ofcase-controlstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudies3bIndividualCase-ControlStudyNon-consecutivestudy;orwithoutconsistentlyappliedreferencestandardsNon-consecutivecohort

study,orverylimitedpopulationAnalysisbasedonlimitedalternativesorcosts,poorqualityestimatesofdata,butincludingsensitivityanalysesincorporatingclinicallysensiblevariations.4Case-series(andpoorqualitycohortandcase-controlstudies§§)Case-series(andpoorqualityprognosticcohortstudies***)Case-controlstudy,poorornon-independentreferencestandardCase-seriesorsupersededreferencestandardsAnalysiswithnosensitivityanalysis5Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchor"firstprinciples"Expertopinionwithoutexplicitcriticalappraisal,orbasedoneconomictheoryor"firstprinciples"OxfordCentreforEvidence-basedMedicine-LevelsofEvidence(March2009)

/index.aspx?o=1025LevelTherapy/Prevention,P文獻(xiàn)依其研究架構(gòu)，大致分成5級(jí)實(shí)證醫(yī)學(xué)證據(jù)等級(jí)。Level1：有顯著意義的隨機(jī)對(duì)照研究報(bào)告（Randomizedcontrolledtrials,RCT）。Level2：世代研究（Cohortstudy）。Level3：病例及對(duì)照組研究（Case-controlstudy）。Level4：病例報(bào)告（Caseseries）。Level5：專家意見(jiàn)（Expertopinion）。

而當(dāng)這些實(shí)證醫(yī)學(xué)文獻(xiàn)的證據(jù)等級(jí)應(yīng)用在病人身上時(shí)，分成四個(gè)建議等級(jí)（Gradingsystemforrecommendations）臨床上就可根據(jù)此建議等級(jí)，而形成臨床指引：GradeA：根據(jù)Level1證據(jù)所做的建議。GradeB：根據(jù)Level2證據(jù)所做的建議。GradeC：根據(jù)Level3證據(jù)所做的建議。GradeD：根據(jù)Level3以下等級(jí)證據(jù)所做的建議。證據(jù)等級(jí)及建議等級(jí)

文獻(xiàn)依其研究架構(gòu)，大致分成5級(jí)實(shí)證醫(yī)學(xué)證據(jù)等級(jí)。證據(jù)等級(jí)及建TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件證據(jù)證據(jù)等級(jí)及建議強(qiáng)度建議強(qiáng)度證據(jù)等級(jí)證據(jù)證據(jù)等級(jí)及建議強(qiáng)度建議強(qiáng)度證據(jù)等級(jí)TMIS實(shí)證醫(yī)學(xué)個(gè)案討論會(huì)簡(jiǎn)報(bào)范例課件LevelTherapy/Prevention,Aetiology/HarmPrognosisDiagnosisDifferentialdiagnosis/symptomprevalencestudyEconomicanddecisionanalyses1aSR(withhomogeneity*)ofRCTsSR(withhomogeneity*)ofinceptioncohortstudies;CDR?validatedindifferentpopulationsSR(withhomogeneity*)ofLevel1diagnosticstudies;CDR?with1bstudiesfromdifferentclinicalcentresSR(withhomogeneity*)ofprospectivecohortstudiesSR(withhomogeneity*)ofLevel1economicstudies1bIndividualRCT(withnarrowConfidenceInterval?)Individualinceptioncohortstudywith>80%follow-up;CDR?validatedinasinglepopulationValidating**cohortstudywithgood???r