Clinical Evidence如何协助实证医学实践范例 Clinical ev.ppt

,C 陳建谷 .tw,Topics,什麼是實證醫學Evidence-Based Medicine? 實證醫學為什麼重要? 實行實證醫學的傳統方式 Clinical Evidence如何協助實證醫學實踐範例 案例情境Case Scenario,What is evidence based medicine?,“Evidence based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about individual patients”. Sackett, D. L., et al. (1996). Evidence based medicine: what it is and what it isnt. BMJ, 312(7023), 71-72.,實證醫學-遵循證據的科學。 是指對病人的診治必須基於當前可以得到的最佳臨床研究結果，結合醫生的經驗，考慮病人的實際情況，並在尊重其選擇和意願前提下，制定對病人的治療措施。,Evidence-based Medicine: How to teach and practice EBM. Straus SE, Richardson WS, Paul Glasziou, Haynes RB. Third Edition. Churchill Livingston: Edinburgh, 2005.,Evidence Based Medicine,實證醫學的重要性?,實證醫學可以讓醫護人員 發覺醫療知識尚未補足的部分 選擇最經濟有效的治療方式 最重要的是可以避免使用無效或者讓病人受到傷害的治療方式,Different levels of evidence The Haynes Pyramid,More time is needed as we go down the pyramid,Dr. Brian Haynes. Of studies, syntheses, synopses, summaries, and systems: the “5S“ evolution of information services for evidence-based healthcare decisions. Evidence-Based Medicine 2006;11:162-164.,Studies,Syntheses,Synopses,Summaries,Systems,研究,統整,精要,綜結,系統,PubMed: Studies: 原始研究文獻,Studies,Syntheses,Synopses,Summaries,Systems,研究,統整,精要,綜結,系統,Cochrane systematic reviews: Syntheses: 系統性回顧,Studies,Syntheses,Synopses,Summaries,Systems,研究,統整,精要,綜結,系統,Evidence based medicine journal: Synopses: 單篇實證文獻摘要性評述,Studies,Syntheses,Synopses,Summaries,Systems,研究,統整,精要,綜結,系統,BMJ Clinical Evidence: Summaries: 針對臨床問題結合證據的概述,What is BMJ Clinical Evidence? Helping Clinicians Put Evidence Into Practice,特點 提供650多個臨床問題和3100種的臨床療法 來源包括1000多篇來自Cochrane Library, Medline等資料庫的文章 內容由國際上專業組織的臨床工作者來撰寫的並且採取嚴格的評估方法來找尋臨床證據 提供確認的治療益處與危害 定期更新 可連結到PubMed,實證醫學的五個主要步驟,Assess Ask clinical question 提出一個可以被回答的問題 Acquire the evidence 檢索文獻資料 Appraise the evidence 嚴格評價證據的可信度和相關性 Apply the evidence 結合實際作出臨床決策,CE編輯流程與實證的結合,How BMJ Clinical Evidence relates to the steps of EBM?,“Ask clinical questions” Review planning,“Acquire the Evidence”,Appraise the evidence,“Apply the Evidence” Combined into structured summaries,1. Planning Ask clinical questions 形成臨床問題,PICO Patient 病人或問題 Intervention/Risk factor 介入或指標,某種治療檢查危險因子 Comparison 比較 Outcome 結果 (預期/避免) Type of Study (Systematic reviews? RCTs?) Quality parameters Size of study Length of follow up Loss to follow up,2. Searching Acquire the evidence.獲得證據,PubMed Medline Cochrane Reviews and many more,2. Searching Acquire the evidence. 列出參考證據來源,3. Searching 治療好處的證據然而壞處呢?,Systematic reviews 通常不會提供副作用 (Ernst 2001) RCTs 不夠大或者時間不夠長還未出現壞處 醫護人員有太多證據要評估 (Derry 2001),BMJ列出治療分類的方法,療法損益圖示,/ceweb/about/guide.jsp,各種治療方式的列表,Benefits,Harms,評估標準,不同類型的文章會有不同的評估標準，而會評估者會依據內容寫出是否採用作文參考文獻的理由 GRADE,Appraisal appraise the evidence BMJ Clinical Evidence appraisal criteria,只有17位病人sample數太小,Appraisal Selection of studies,DO YOU WANT TO INCLUDE THIS ARTICLE? YES NO IF NO, INDICATE REASON FOR EXCLUSION BELOW: Irrelevant/wrong question Not RCT Not Blinded Wrong comparison Too small Wrong intervention Wrong patient group Surrogate Outcome Less than 80% follow up Other (please specify),Appraisal BMJ Clinical Evidence makes the GRADE,What is GRADE?,Grading of Recommendations Assessment, Development and Evaluation system for grading evidence,評估證據的相關性與可靠性的標凖,What is GRADE?,Developed by international guideline developers Explicit evaluation of the importance of outcomes Explicit, comprehensive criteria for downgrading and upgrading quality of evidence ratings Clear separation between quality of evidence and strength of recommendations,What is GRADE?,一群臨床指引人員在兩千年時所創，因為醫護人員需要有一個分數表來替證據打分數才有辦法定奪，做為最終治療方式的參考證據的可信度與強度 明顯的區分證據品質與建議強度,GRADE 分類 Quality of Evidence 證據品質,High: 進一步研究會顯示結果是一樣的. Moderate: 進一步研究顯示結果可能會有變化但不大. Low: 進一步研究會顯示不同的結果. Very low: 任何效果評估都顯時不確定性太高.,GRADE categorisations Quality of Evidence,High: Further research is very unlikely to change our confidence in the estimate of effect. Moderate: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low: Any estimate of effect is very uncertain.,GRADE Strength of recommendations 建議強度,Strong 大多數病人可以使用同樣的治療方式 Weak 不同的病人得選擇不同的治療方式,GRADE Strength of recommendations,Strong desirable effects clearly outweigh undesirable effects, or the reverse Most patients will make same decision about the treatment Weak different patients will choose different approaches to treatment,CE內證據強度與品質標示方法,Summary statements rewritten Glossary links explain what GRADE scores mean Links to GRADE table from each summary statement,Glossary,GRADE Table,GRADE Table,會說明分數和解讀 連結到原始參考文獻,Scoring system 一致的評分標準,BMJ Clinical Evidence Updating Cycle,Does it stop here? 每六個月到一年更新 每天都會有新的文章上傳,BMJ Updates,與加拿大McMaster University合作 結合超過3,000位醫護人員參與 系統性的評估一百二十多種頂尖臨床期刊 可以直接到PubMed,BMJ Updates,Collaboration with McMaster University Engages over 3,000 clinicians Systematic survey of over 120 top clinical journals,Guidelines 可以看有關病症的各種國際臨床指南,Looking back Traditional Steps of Evidence Based Medicine,Assess Ask clinical question Acquire the evidence Appraise the evidence Apply the evidence,好的EBM Summary所具備的特點是?,綜觀性的搜尋所有文獻 極佳的評估程序 經常更新 能夠直接連結相關原始文獻 容易查找使用,那BMJ Clinical Evidence有符合這些特點嗎?,綜觀性的搜尋所有文獻 極佳的評估程序 經常更新 能夠直接連接相關原始文獻 容易查找使用 ?,Case Scenario:,You are an inexperienced junior hospital doctor. A 55 year old asthmatic man who has heart failure attends the out-patient clinic. Despite taking an ACE inhibitor his heart failure is inadequately controlled. You discuss the case with your senior who advises that you add an Angiotensin II reception blocker to his treatment. 你是一名年輕的臨床醫生，