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1、李文欽醫師實證醫學中心主任2013/11/08實證醫學與個案討論mis实证医学个案讨论会简报范例簡報大綱l簡述實證醫學五大步驟l如何問問題及形成PICO的內容l資料搜尋的策略、使用資料庫及搜尋結果l對資料的評讀l如何落實實證醫學於個案討論mis实证医学个案讨论会简报范例過去現在未來當一個醫生該具備的的能力三日不讀書，面目可憎醫病照護教學研究mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例2000年Sackett將實證醫學定義為“整合最佳研究證據、臨床經驗以及病患價值以達成病患最佳治療的過程”實證醫學的實行是一種終身的、自發的、以問題為導向的學習過程實證醫學的重要性臨床經驗病患價
2、值最佳研究證據實證醫療Sackett et al 2000mis实证医学个案讨论会简报范例實證醫學的五個步驟1. Asking an answerable question (提出可回答的臨床問題) 2. Tracking down the best evidence (搜尋最佳實證文獻資料) 3. Critical appraisal (嚴謹的文獻評讀) 4. Integrating the appraisal with clinical expertise and patients preference (將臨床專業與病人價值觀相結合)5. Evaluation the effective
3、ness and efficiency in executing steps 1-4 (評估改善) mis实证医学个案讨论会简报范例AstrokepatientwhohaslongtermgoutyarthritisDoes gout cause a higher risk of stoke?痛風會增加中風的風險嗎？mis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身上Apply將病人的問題寫成PICOAskingEBM的步驟Sir Austin Bradford Hill(1897-1991),Englishepidemiologis
4、tandstatisticianHedescribedtheclinicaltrialasbeingaCAREFULLY,andETHICALLY,describedexperimentwiththeaimofansweringsomePRECISELY FRAMED QUESTIONGreaterprecisionisrequiredintheobjectives.WeneedtohaveAdefinedpopulationDefinedendpointsRelativelyfewquestiontobeanswered.問題要怎麼問？mis实证医学个案讨论会简报范例1.形成問題(Clini
5、calQuestion)Does gout cause a higher risk of stoke?痛風會增加中風的風險嗎？mis实证医学个案讨论会简报范例臨床的問題模型(PICO)P: Patient, Population指此病人或族群的年齡層、體質、疾病史、 過去史等I: Intervention指治療、診斷、預後、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指預後或與目前問題有關的比較基準mis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身上Apply將病人的問題寫成P
6、ICOAskingEBM的步驟PICO 1 Does gout cause a higher risk of stoke?PICO type:TherapyPatient:老年人Intervention:痛風Comparison:無痛風Outcome:中風的風險問題要怎麼問？mis实证医学个案讨论会简报范例2. Tracking down the best evidence直接使用實證醫學資庫(secondary databases) 如ACP journal club, Cochrane Library, UpToDate, MD Consult, Practice Guideline找初步
7、篩選的資庫(primary databases) PubMed, OVID, Proquest未經篩選的資庫如Google可搜尋實證醫學的資料庫mis实证医学个案讨论会简报范例 如何尋找與EBM相關的館藏資源？主題切入本院一般綜合性資料庫 1. PudMed：可查出abstract 2. Ovid：可查出abstract、Fulltext 3. Proquest：可查出abstract、Fulltext 4. Clinicalkey：可查出abstract、Fulltext找實證醫學資料時可加上 Systemic Review (系統性評論)、 Meta-analysis (整合分析)、 Ra
8、ndomized Controlled Trial (隨機對照臨床試驗研究)、 Controlled Trials利用資料庫功能鍵mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例MeSHtoidentifyeverytermforexamplemis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身上Apply將病人的問題寫成PICOAskingSearchingStrategyFindingoutTheCorrectKeywor
9、ds原始關鍵字Primary Term 或MeSH Term 同義字1同義字2P(oror)andI(Goutor Hyperuricemia or)andC(oror)andO(strokeoror)mis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身上Apply將病人的問題寫成PICOAskingSearchingStrategyFindingoutTheCorrectKeywordsKeywordsfromPICOitem:(“gout”OR“hyperuricemia”)AND“stroke”MeSHtoidentifyever
10、ytermforexamplemis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身上Apply將病人的問題寫成PICOAsking善用搜尋Systematicreview關鍵字: (“gout”OR“hyperuricemia”)AND(“stroke”OR“cardiovasculardisease”)mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身上Apply將病人的問題寫成PICOAskingmis实证医学
11、个案讨论会简报范例TheEvidencePyramidV. Animal researchV. In vitro (test tube) researchIV. Case series/ ReportsV. Ideas, Editorials, OpinionsIII. Case Control StudiesII. Cohort studiesI. Randomized Controlled Studies (RCT)I. Randomized Controlled Double Blind Studies Meta - analysis統計方法統計方法統計方法統計方法Meta-analys
12、isMeta-analysis 圖示結果Forest plot*Hierarchy of evidence: arranges study designs by their susceptibility to bias. (Level IV)From: Oxford Center for EBM研究設計與證據強度mis实证医学个案讨论会简报范例Level Therapy/Prevention, Aetiology/HarmPrognosisDiagnosisDifferential diagnosis/symptom prevalence studyEconomic and decision
13、analyses1aSR(withhomogeneity*)ofRCTsSR(withhomogeneity*)ofinceptioncohortstudies;CDRvalidatedindifferentpopulationsSR(withhomogeneity*)ofLevel1diagnosticstudies;CDRwith1bstudiesfromdifferentclinicalcentresSR(withhomogeneity*)ofprospectivecohortstudiesSR(withhomogeneity*)ofLevel1economicstudies1bIndi
14、vidualRCT(withnarrowConfidenceInterval)Individualinceptioncohortstudywith80%follow-up;CDRvalidatedinasinglepopulationValidating*cohortstudywithgoodreferencestandards;orCDRtestedwithinoneclinicalcentreProspectivecohortstudywithgoodfollow-up*Analysisbasedonclinicallysensiblecostsoralternatives;systema
15、ticreview(s)oftheevidence;andincludingmulti-waysensitivityanalyses1cAllornoneAllornonecase-seriesAbsoluteSpPinsandSnNoutsAllornonecase-seriesAbsolutebetter-valueorworse-valueanalyses2aSR(withhomogeneity*)ofcohortstudiesSR(withhomogeneity*)ofeitherretrospectivecohortstudiesoruntreatedcontrolgroupsinR
16、CTsSR(withhomogeneity*)ofLevel2diagnosticstudiesSR(withhomogeneity*)of2bandbetterstudiesSR(withhomogeneity*)ofLevel2economicstudies2bIndividualcohortstudy(includinglowqualityRCT;e.g.,80%follow-up;CDRvalidatedinasinglepopulationValidating*cohortstudywithgoodreferencestandards;orCDRtestedwithinoneclin
17、icalcentreProspectivecohortstudywithgoodfollow-up*Analysisbasedonclinicallysensiblecostsoralternatives;systematicreview(s)oftheevidence;andincludingmulti-waysensitivityanalyses1cAllornoneAllornonecase-seriesAbsoluteSpPinsandSnNoutsAllornonecase-seriesAbsolutebetter-valueorworse-valueanalyses2aSR(wit
18、hhomogeneity*)ofcohortstudiesSR(withhomogeneity*)ofeitherretrospectivecohortstudiesoruntreatedcontrolgroupsinRCTsSR(withhomogeneity*)ofLevel2diagnosticstudiesSR(withhomogeneity*)of2bandbetterstudiesSR(withhomogeneity*)ofLevel2economicstudies2bIndividualcohortstudy(includinglowqualityRCT;e.g.,80%foll
19、ow-up)Retrospectivecohortstudyorfollow-upofuntreatedcontrolpatientsinanRCT;DerivationofCDRorvalidatedonsplit-sampleonlyExploratory*cohortstudywithgoodreferencestandards;CDRafterderivation,orvalidatedonlyonsplit-sampleordatabasesRetrospectivecohortstudy,orpoorfollow-upAnalysisbasedonclinicallysensibl
20、ecostsoralternatives;limitedreview(s)oftheevidence,orsinglestudies;andincludingmulti-waysensitivityanalyses2cOutcomesResearch;EcologicalstudiesOutcomesResearchEcologicalstudiesAuditoroutcomesresearch3aSR(withhomogeneity*)ofcase-controlstudiesSR(withhomogeneity*)of3bandbetterstudiesSR(withhomogeneity
21、*)of3bandbetterstudiesSR(withhomogeneity*)of3bandbetterstudies3bIndividualCase-ControlStudyNon-consecutivestudy;orwithoutconsistentlyappliedreferencestandardsNon-consecutivecohortstudy,orverylimitedpopulationAnalysisbasedonlimitedalternativesorcosts,poorqualityestimatesofdata,butincludingsensitivity
22、analysesincorporatingclinicallysensiblevariations.4Case-series(andpoorqualitycohortandcase-controlstudies)Case-series(andpoorqualityprognosticcohortstudies*)Case-controlstudy,poorornon-independentreferencestandardCase-seriesorsupersededreferencestandardsAnalysiswithnosensitivityanalysis5Expertopinio
23、nwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexplicitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexpl
24、icitcriticalappraisal,orbasedonphysiology,benchresearchorfirstprinciplesExpertopinionwithoutexplicitcriticalappraisal,orbasedoneconomictheoryorfirstprinciplesOxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009) http:/=1025mis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身
25、上Apply將病人的問題寫成PICOAskingTitle: - Hyperuricemia and risk of stroke: a systematic review and meta-analysis.(2009)Source:ArthritisRheum.2009Jul15;61(7):885-92Level:2amis实证医学个案讨论会简报范例Largeepidemiologicstudieshaveshownthathyperuricemiaisassociatedwithanincreasedincidenceofcoronary heart disease (CHD) and
26、increased mortality inthosewithandwithoutpreexistingCHD.FangJ,AldermanMH.SerumuricacidandcardiovascularmortalitytheNHANESIepidemiologicfollow-upstudy,1971-1992.NationalHealthandNutritionExaminationSurvey.JAMA2000;283:2404.FreedmanDS,WilliamsonDF,GunterEW,ByersT.Relationofserumuricacidtomortalityandi
27、schemicheartdisease.TheNHANESIEpidemiologicFollow-upStudy.AmJEpidemiol1995;141:637.BrandFN,McGeeDL,KannelWB,etal.Hyperuricemiaasariskfactorofcoronaryheartdisease:TheFraminghamStudy.AmJEpidemiol1985;121:11.NiskanenLK,LaaksonenDE,NyyssnenK,etal.Uricacidlevelasariskfactorforcardiovascularandall-causemo
28、rtalityinmiddle-agedmen:aprospectivecohortstudy.ArchInternMed2004;164:1546.ChoiHK,CurhanG.Independentimpactofgoutonmortalityandriskforcoronaryheartdisease.Circulation2007;116:894.mis实证医学个案讨论会简报范例Proposed mechanisms forsuchanincreaseinriskincludethedevelopment of hypertension andoxidative stress.John
29、sonRJ,SegalMS,SrinivasT,etal.Essentialhypertension,progressiverenaldisease,anduricacid:apathogeneticlink?JAmSocNephrol2005;16:1909.BakerJF,KrishnanE,ChenL,SchumacherHR.Serumuricacidandcardiovasculardisease:recentdevelopments,andwheredotheyleaveus?AmJMed2005;118:816.mis实证医学个案讨论会简报范例Itisunclearifhyper
30、uricemiahasacausal effect or,ashasbeenmoreoftensuggested,issimply a marker forotherriskfactors,suchashypertension,dyslipidemia,anddiabetes.CulletonBF,LarsonMG,KannelWB,LevyD.Serumuricacidandriskforcardiovasculardiseaseanddeath:theFraminghamHeartStudy.AnnInternMed1999;131:7.WannametheeSG,ShaperAG,Whi
31、ncupPH.Serumurateandtheriskofmajorcoronaryheartdiseaseevents.Heart1997;78:147.WheelerJG,JuzwishinKD,EiriksdottirG,etal.Serumuricacidandcoronaryheartdiseasein9,458incidentcasesand155,084controls:prospectivestudyandmeta-analysis.PLoSMed2005;2:e76.FeigDI,KangDH,JohnsonRJ.Uricacidandcardiovascularrisk.N
32、EnglJMed2008;359:1811.mis实证医学个案讨论会简报范例文獻評讀三部曲文獻評讀最主要的三個步驟，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，但這個結論重要嗎?P：Practice/Applicability;臨床適用性如果我們相信它，這個結論可以應用在我們所照護的病患嗎?mis实证医学个案讨论会简报范例找資料來回答問題Acquire嚴格評讀文獻Appraisal是否可應用到病人身上Apply將病人的問題寫成PICOAskingAccordingto“SharonE.Stra
33、usetal,Evidence-basedmedicine:howtopracticeandteachEBM,Elsevier,2005:33-7.“ValidityImportanceApplicabilityResultsfromsecondarydatabaseResultsfromprimarydatabaseAppraisedbyexpertsNeededtobeappraisedResults(NNT)ResultsConsiderpopulationandfeasibilityConsiderpopulationandfeasibilitymis实证医学个案讨论会简报范例效度(V
34、alidity)：可以用RAM-bo方式審視效度研究族群是否有隨機分配(Randomized)？ 隨機分配的方法是否適當(Accounted)？ 結果的衡量(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-treat analysis, ITT)隨機試驗的一種分析方法所有被分配在治療組/對照組的病人無論是否完成該項 治療/安慰劑都應該被放進治療組/對照組(原分派組別) 中做分析文獻評讀三部曲mis实证医学个案讨论会简报范例重要性(Importance/Impact)：研究結果是什麼?研究結果如何被估計?經
35、過多久的時間?文獻結果的評估方式：勝算比(odds ratio) 代表生物學上的影響。相對危險(relative risk)、絕對危險降低度(absolute risk reduction)、相對危險降低度 (relative risk reduction)、益一需治數(NNT, number needed to treat): 為預防一個不良結果或使一個病人達實驗所求之有益結果所需治療的病人數NNT=1/ARR文獻評讀三部曲mis实证医学个案讨论会简报范例可行性(Practical , Applicability ?)：臨床實用性如何？1.應考量病患的生物因素(biological issu
36、es): - 同樣的治療應用在不同的病患族群是否有不同反應?-我們的病人與研究中的病人是否非常不同，以致無法應用在研究結果？2.其他的社會經濟因素（social and economic issues）的考量:-這個治療適用於我們的診療環境嗎？病患的配合度如何？-醫療提供者的配合度及能力如何？3.流行病學因素(epidemiological issues）的考量:-我們的病人是否有其他共病狀況，可能改變治療的結果？影響有多大？-病人可能從治療中得到什麼好處或壞處？-經由治療而減少的不良後果是否比不治療有明顯的差別？文獻評讀三部曲mis实证医学个案讨论会简报范例幫助文獻評讀的工具mis实证医学个
37、案讨论会简报范例依所搜尋文獻類別，評讀所問的問題mis实证医学个案讨论会简报范例4.將臨床專業與病人價值觀相結合您的病人是否與研究中的病人差別很大，以至於無法適用該研究結果？族群/地域/文化差異您期望您的病人從研究結果中獲得多大的好處？還有哪些替代方案？研究結果適用於您的病人嗎？mis实证医学个案讨论会简报范例5.評估執行效果及改善過程您是否開始使用實證手法搜尋最佳證據？您搜尋及評讀證據的速度有多快？您有能力將這些證據應用在適當的病人身上嗎？您是否依循這些新證據來改變您的診療習慣？mis实证医学个案讨论会简报范例 如何落實實證醫學於個案討論會?mis实证医学个案讨论会简报范例如何落實實證醫學於
38、個案討論會1.由討論的個案找尋問題(形成PICO)2. 進行文獻搜尋 (PUB Med, Cochrane, Ovid)3. 進行文獻評讀 (Evidence level, Recommend grade) 會議中報告文章重點與結論4.所搜尋的文獻值得應用到本病人身上嗎?mis实证医学个案讨论会简报范例實證醫學個案討論會順序1.Case report (個案報告)2.提出問題，建立 PICO格式3.文獻搜尋 (所使用關鍵字、資料庫)4.所搜尋到文獻的題目、出處、及文獻5. 的證據等級 6.5. 報告文獻的重點與結論7.6. 是否可應用到我們的病人身上 mis实证医学个案讨论会简报范例Clini
39、calquestion: Does gout cause a higher risk of stoke?PICO type:TherapyPatient:Old patientIntervention:GoutComparison:Without goutOutcome:Risk of strokemis实证医学个案讨论会简报范例Title: Hyperuricemia and risk of stroke: a systematic review and meta-analysis.(2009)Source:ArthritisRheum.2009Jul15;61(7):885-92Level:2amis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例科別選定與討論頻率1.科別:內、外、婦、兒、皮膚科藥劑、護理、(檢驗、放射)2.頻率:每月一次3.會議主題設定:實證醫學個案討論會4.請科部主任定期檢視結果與統計mis实证医学个案讨论会简报范例mis实证医学个案讨论会简报范例Thank You For Your Attention!mis实证医学个案讨论会简报范例
