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1、實證醫學簡介與實務-如何改善教學技巧-臺北醫學大學九十二學年度教師發展中心研討會http:/www.wanfang.gov.tw/ebm实证医学简介与实务Clinical Epidemiology - 臨床流行病學实证医学简介与实务 以流行病學及統計學的方法，從龐大的醫學資料中過濾出值得信賴的部份，嚴格評讀、綜合分析、將所能獲得的最佳文獻、證據(Evidence)，與醫護人員的經驗(Experience)，及病人期望(Expectation)的結合，以應用於臨床工作中。什麼是實證醫學实证医学简介与实务Triple “E” of EBMEvidenceExperienceExpectationD
2、ecision Analysis实证医学简介与实务updateknowledge知識更新browsing綜覽problemsolving問題導向primaryjournal一級雜誌secondaryjournal二級雜誌eg.JAMA,NEJMeg.EvidenceBasedMedicine,EBMreviews,讀者文摘initialquestionsearchablequestion实证医学简介与实务Search evidence实证医学简介与实务DaveSackettEvidence Cart -CEBM - Centre for Evidence Based Medicine实证医学简
3、介与实务实证医学简介与实务实证医学简介与实务工具篇教學資源实证医学简介与实务Oxford Centre for EBMhttp:/实证医学简介与实务實施實證醫學五大步驟 1. 整理出一個可以回答的問題 (Asking an answerable question) 2.尋找文獻證據 (Tracking down the best evidence) 3.嚴格評讀文獻 (Critical appraisal ) 4.應用於病人身上 (Integrating the appraisal with clinical expertise & patients preference)。 5.對過程進行稽
4、核 (Auditing performance in step 1-4)实证医学简介与实务EBM密碼QSAAQ: PECOT S: PubMedA: CATA: NNT实证医学简介与实务EBM解碼QSAAQuestion: PECOTParticipantExposureComparisonOutcomesTime Search: PubMedAppraisal: CAT critical appraisal of topicsApply: NNT Number need to treatment实证医学简介与实务洪清霖教授推薦醫學的讀者文摘实证医学简介与实务实证医学简介与实务Prefilte
5、red DATABASESCochrane Library (HINT有)Cochrane Database of Systematic Reviews (CDSR)Cochrane Controlled Trials Register (CCTR) Database of Reviews of Effectiveness (DARE)NHS Economic Evaluation Database Health Technology Assessment DatabaseCochrane Library http:/ EBM resourceTo answer focused clinica
6、l questions, the most efficient approach is to begin with a pre-filtered evidence-based medicine resource such as Best Evidence, the Cochrane Library, or Clinical Evidence 实证医学简介与实务National Guideline Clearinghouse BooleanOperators(AND,OR,NOT,*,(aorb)andc)http:/www.guideline.govScreeningforbreastcanc
7、er:recommendationsandrationale,2002filterhttp:/www.guideline.gov/search/detailedsearch.aspx操作实证医学简介与实务Search evidence实证医学简介与实务Unfiltered DATABASESMEDLINECINAHLPsycINFOERIC (Education Resources Information Center)实证医学简介与实务Searching Key Words :搜尋策略 top downRCTCase-ControlCase ReportsOpinions实证医学简介与实务C
8、an hyperbaric oxygenation accelerates the healing rate of nonischemic chronic diabetic foot ulcers?实证医学简介与实务PECOTP: nonischemic chronic diabetic foot ulcersE: Hyperbaric oxygenation acceleratesC: wound care O: the healing rateT: one month 实证医学简介与实务实证医学简介与实务实证医学简介与实务实证医学简介与实务实证医学简介与实务Text + Graph实证医学
9、简介与实务VPN(Virtual Private Network)实证医学简介与实务MEDLINEIf a search of UpToDate, Best Evidence, and the Cochrane Library does not provide a satisfactory answer to a focused clinical question, it may be time to turn to MEDLINE. the first medical literature databasesomething for everyone实证医学简介与实务StepsProblem
10、 1: You are trying to find a known paper 眾裡尋她Problem 2: You want to answer a specific question 直指核心Problem 3: You want to get general information quickly about a well defined topic綜覽主題Problem 4: Your search gives irrelevant articles去蕪存菁实证医学简介与实务Problem 5: The search gives no articles, or too few 絕處逢
11、生Problem 6: You dont know where to start searching無從下手Problem 7: Limiting a set loses important articles but does not exclude those of low methodological quality點石成金Problem 8: Medline hasnt helped另謀蹊徑Steps实证医学简介与实务Up to 63% of all availableRCTs may be missed by a search strategy limited to MEDLINE A
12、ntman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of metaanalyses of randomized control trials and recommendations of clinical experts: Treatment formyocardial infarction. JAMA. 1992;268:240-247.Beyand Medline实证医学简介与实务Other Searching Strategyhandsearchingreference lists
13、direct contact with pharmaceutical companies/researchers实证医学简介与实务PubMed甲、Help/ FAQ http:/www.ncbi.nlm.nih.gov/entrez/query/static/help/pmhelp.html乙、PubMed filter丙、Cubby操作实证医学简介与实务Search evidence实证医学简介与实务Textbooks and the InternetFinding Answers to More General Questions: Textbooks and the Internet实证
14、医学简介与实务e- A golden gateway to health information resources 操作实证医学简介与实务实证医学简介与实务实证医学简介与实务实证医学简介与实务原文哪裡找HINT http:/www.hint.org.tw/cgi-bin/ovidweb/ovidweb.cgie journal eg. 衛生署中辦處圖書館http:/sp1.cto.doh.gov.tw/info/elibrary/elibrary.php?Alreadylogin=AE mail圖書館 操作实证医学简介与实务Try Google http:/.tw/ 甲、+ pdf 乙、+
15、docRecommend “Reference Manager” internet search操作实证医学简介与实务The extent to which beliefs are based on evidence is very much less than believers suppose.Bertrand Russell, Skeptical Essays, 1928我們所相信的事物中，證據的成分，超乎我們想像的少。实证医学简介与实务教學流程篇EBM結合結合PBeL教學教學实证医学简介与实务How to get start.Read bookLearn to do a searchD
16、isseminate evidence based clinical practice guidelines for common conditionsEBM journal clubAttend EBM workshopSponsor an annual workshop at your institutionPractice, practice practice!Teach EBM实证医学简介与实务Evidence-Based Medicine实证医学简介与实务1.整理出一個可以回答的問題 (Asking An Answerable Question)提出問題, 才有可能解決問題实证医学简
17、介与实务 1st stepCase Thinking process Study goalsHomework: PECOT实证医学简介与实务 THE 5 PARTS TO A WELL FORMULATED CLINICAL QUESTIONEach question has 5 parts that should be considered:1 1 P P P Patients/consumers/participants:atients/consumers/participants: 2 2 E E E Exposure:xposure: 3 3 C C C Comparison:ompa
18、rison: What is/are the main alternative/s to compare with the exposure?Ref:New Zealand Guidelines Group (NZGG). Handbook for the preparation of explicit evidence-based clinical practice guidelines, 2001 p16. 实证医学简介与实务 4 4 O Outcome:utcome: What is really important to the patient/consumer? What does
19、this exposure affect? Which outcomes should be considered? - intermediate or short term measures (eg lowering in cholesterol levels), mortality, morbidity and treatment complications, rates of relapse, late morbidity and readmission, return to work and physical and social functioning and other measu
20、res such as quality of life, general health status. Cost to the consumer is another outcome that should be considered. 5 5 T T T Time:ime: Over what time frame is it reasonable to expect an effect? Ref:New Zealand Guidelines Group (NZGG). Handbook for the preparation of explicit evidence-based clini
21、cal practice guidelines, 2001 p16. THE 5 PARTS TO A WELL FORMULATED CLINICAL QUESTION实证医学简介与实务教育處方实证医学简介与实务Ref:New Zealand Guidelines Group (NZGG). Handbook for the preparation of explicit evidence-based clinical practice guidelines, 2001 p46. 实证医学简介与实务2.尋找文獻證據 (Tracking down the best evidence)In th
22、e long run, were all dead. John Maynard Keynes, 1883 - 1946 http:/ 2nd stepReview the case on the websiteReview previous established flow chartsDiscuss with the clinicianAfter the discussionHomework: Cubby实证医学简介与实务3.嚴格評讀文獻 (Critical Appraisal )Are We Doing the Right Things Right ?实证医学简介与实务 3rd stepM
23、odify the flow charts, discuss with the tutorPresent study goals or new concept of diseases under EBM3 to 4 days laterHomework: My Lesson - CATmaker实证医学简介与实务-共同評讀軟體應用介面-CAT search实证医学简介与实务-共同評讀軟體應用介面-CAT example实证医学简介与实务CATmaker 实证医学简介与实务实证医学简介与实务实证医学简介与实务实证医学简介与实务bottom line財務報告上頂線(top line)是營收、底線(
24、bottom line)是利潤A companys bottom line is its net income, or the “bottom” figure on a companys income statement.The top line of a company is its gross sales, or revenue figure. 实证医学简介与实务实证医学简介与实务实证医学简介与实务The Evidence Pyramid圖片來源: 方信元 醫師演講簡報实证医学简介与实务Classification of evidence -US Agency for Health Car
25、e Policy and Research Classification (AHCPR, 1992)Evidence levelDescriptionIa:evidence from meta-analysis of randomised controlled trialsIb:evidence from at least one randomised controlled trialIIa:evidence from at least one controlled study without randomisationIIb:evidence from at least one other
26、type of quasi-experimental studyIII:evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studiesIV:evidence from expert committee reports or opinions and/or clinical experience of respected authorities实证医学简介与实务Grading of recommendation
27、s Eccles M et al.(1998) North of England Evidence Based Guideline Development Project:guideline for angiotensin converting enzyme inhibitors in primary care management of adults with symptomatic heart failure.British Medical Journal 316:1369. A directly based on category I evidence, or assigned this
28、 grading by the developers, for explicit and documented reasonsB directly based on category II evidence, or assigned this grading by the developers, for explicit and documented reasonsC directly based on category III evidence, or assigned this grading by the developers, for explicit and documented r
29、easonsD directly based on category IV evidence, or assigned this grading by the developers, for explicit and documented reasons实证医学简介与实务萬芳醫院實證醫學推展歷程91.04.24 於臺北醫學大學MY TMU 開立實證 醫學看版，建立知識學習的介面 。实证医学简介与实务http:/my.tmu.edu.tw/实证医学简介与实务实证医学简介与实务实证医学简介与实务延伸學習Centre for EBM 牛津實證醫學中心http:/Critical Appraisal
30、Skills Programme (CASP)英國國家健康保險之嚴格評讀技巧計劃http:/www.phru.nhs.uk/casp/casp.htm实证医学简介与实务4.應用於病人身上 (Integrating the Appraisal with Clinical Expertise & Patients Preference)Information must be translated into action. 实证医学简介与实务EBM-Decision Support ATP-III guidelineDecision Support SystemSupport other knowl
31、edge domain userComputer Human InterfaceEfficiencyFriendly GUIQuality control实证医学简介与实务实证医学简介与实务5.對過程進行稽核 (Auditing performance in step 1-4)实证医学简介与实务Hierarchy of Outcome Measures实证医学简介与实务实证医学简介与实务Background:Evidence-based medicine (EBM) is a part of many medical school and residency curricula worldwi
32、de, but there is little research into the most effective methods to teach these skills. -Baum K. The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice. Med Educ Online 2003;8:4. 实证医学简介与实务Purpose:To evaluate whether a cou
33、rse on EBM utilizing adult learning principals leads to both immediate and short-term attitudinal, confidence, and behavioral change.-Baum K. The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice. Med Educ Online 2003;8:
34、4. 实证医学简介与实务Methods:73 Internal Medicine and Internal Medicine/Pediatric residents attended a half-day seminar on EBM. Participants completed pre- and post-course 5-point Likert questionnaires, and set two personal goals for integrating EBM into their daily practice.We performed nonparametric two -s
35、ample Wilcoxon Rank-Sum tests to compare responses.We also elicited the self-reported success of the residents in meeting their goals one-month post-course.-Baum K. The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.
36、Med Educ Online 2003;8:4. 实证医学简介与实务-Baum K. The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice. Med Educ Online 2003;8:4. 实证医学简介与实务Results:Attitudes about EBM improved (3.5 pre-course vs. 3.7 post-course), as well as
37、self-reported EBM skills (3.0 vs. 3.3). 72% of residents reported having met at least one of their two goals for the integration of EBM into their practice.-Baum K. The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.
38、Med Educ Online 2003;8:4. 实证医学简介与实务-Baum K. The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice. Med Educ Online 2003;8:4. 实证医学简介与实务-Baum K. The impact of an evidence-based medicine workshop on residents attitudes towa
39、rds and self-reported ability in evidence-based practice. Med Educ Online 2003;8:4. 实证医学简介与实务-Baum K. The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice. Med Educ Online 2003;8:4. 实证医学简介与实务Conclusions:An EBM workshop
40、based upon adult learning principles was successful in meeting multiple educational goals. The links between andragogy, learners internal drive for behavior change, and successful EBM education should be further explored.-Baum K. The impact of an evidence-based medicine workshop on residents attitud
41、es towards and self-reported ability in evidence-based practice. Med Educ Online 2003;8:4. 实证医学简介与实务執行成果（九）執行成果（九）課程問卷調查結果課程問卷調查結果實證醫學實證醫學態度態度前後測差異前後測差異 实证医学简介与实务執行成果（十）執行成果（十）課程問卷調查結果課程問卷調查結果實證醫學實證醫學技巧技巧前後測差異前後測差異 实证医学简介与实务延伸學習Oxford Centre for EBMhttp:/ Centre for health evidencehttp:/ How to read
42、 a paper: the Medline database http:/ Zealand Guidelines Group (NZGG). Handbook for the preparation of explicit evidence-based clinical practice guidelines, 2001. http:/www.nzgg.org.nz/development/documents/nzgg_guideline_handbook.pdfThe Users Guides to Evidence-based Medicine, JAMA. (2000;283(14):1875-1879). 操作实证医学简介与实务陳杰峰醫師陳杰峰醫師實證醫學中心http:/www.wanfang.gov.tw/ebm敬請指教敬請指教!实证医学简介与实务实证医学简介与实务
