实证医学简介与实务课件

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ClinicalEpidemiology-臨床流行病學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initialquestionsearchablequestionSearchevidenceDaveSackettEvidenceCart-CEBM-CentreforEvidenceBasedMedicine工具篇教學資源OxfordCentreforEBM

EBM密碼QSAAQ:PECOTS:PubMedA:CATA:NNTEBM解碼QSAAQuestion:PECOTParticipantExposureComparisonOutcomesTimeSearch:PubMedAppraisal:CATcriticalappraisaloftopicsApply:NNTNumberneedtotreatment洪清霖教授推薦醫學的讀者文摘PrefilteredDATABASESCochraneLibrary(HINT有)CochraneDatabaseofSystematicReviews(CDSR)CochraneControlledTrialsRegister(CCTR)DatabaseofReviewsofEffectiveness(DARE)NHSEconomicEvaluationDatabaseHealthTechnologyAssessmentDatabaseCochraneLibrary

EMBASE操作操作"pre-filtered"EBMresourceToanswerfocusedclinicalquestions,themostefficientapproachistobeginwitha"pre-filtered"evidence-basedmedicineresourcesuchasBestEvidence,theCochraneLibrary,orClinicalEvidenceNationalGuidelineClearinghouse

BooleanOperators(AND,OR,NOT,*,(aorb)andc)Screeningforbreastcancer:recommendationsandrationale,2002filter

操作UnfilteredDATABASESMEDLINECINAHLPsycINFOERIC(EducationResourcesInformationCenter)SearchingKeyWords:搜尋策略topdownRCTCase-ControlCaseReportsOpinionsCanhyperbaricoxygenationacceleratesthehealingrateofnonischemicchronicdiabeticfootulcers?Text+GraphVPN(VirtualPrivateNetwork)MEDLINEIfasearchofUpToDate,BestEvidence,andtheCochraneLibrarydoesnotprovideasatisfactoryanswertoafocusedclinicalquestion,itmaybetimetoturntoMEDLINE.

thefirstmedicalliteraturedatabasesomethingforeveryoneStepsProblem1:Youaretryingtofindaknownpaper眾裡尋她Problem2:Youwanttoansweraspecificquestion直指核心Problem3:Youwanttogetgeneralinformation

quicklyaboutawelldefinedtopic綜覽主題Problem4:Yoursearchgivesirrelevantarticles去蕪存菁Problem5:Thesearchgivesnoarticles,ortoofew絕處逢生Problem6:Youdon‘tknowwheretostartsearching無從下手Problem7:Limitingasetlosesimportant

articlesbutdoesnotexcludethose

oflowmethodologicalquality點石成金Problem8:Medlinehasn'thelped另謀蹊徑StepsUpto63%ofallavailable

RCTsmaybemissedbyasearchstrategylimitedtoMEDLINEAntmanEM,LauJ,KupelnickB,MostellerF,ChalmersTC.Acomparisonofresultsofmetaanalysesofrandomizedcontroltrialsandrecommendationsofclinicalexperts:Treatmentformyocardialinfarction.JAMA.1992;268:240-247.BeyandMedline……OtherSearchingStrategyhandsearchingreferencelistsdirectcontactwithpharmaceuticalcompanies/researchersPubMed甲、Help/FAQ

乙、PubMedfilter

丙、Cubby操作SearchevidenceTextbooksandtheInternetFindingAnswerstoMoreGeneralQuestions:TextbooksandtheInternete-bookMEDLINEplus:Agoldengatewaytohealthinformationresources

操作原文哪裡找HINT

ejournaleg.衛生署中辦處圖書館Email圖書館

操作TryGoogle

甲、+pdf

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Recommend“ReferenceManager”internetsearch操作"Theextenttowhichbeliefsarebasedonevidenceis

verymuchlessthanbelieverssuppose."BertrandRussell,SkepticalEssays,1928我們所相信的事物中，證據的成分，超乎我們想像的少。教學流程篇EBM結合PBeL教學Howtogetstart….ReadbookLearntodoasearchDisseminateevidencebasedclinicalpracticeguidelinesforcommonconditionsEBMjournalclubAttendEBMworkshopSponsoranannualworkshopatyourinstitutionPractice,practicepractice!!TeachEBMEvidence-BasedMedicine1.整理出一個可以回答的問題

(AskingAnAnswerableQuestion)提出問題,才有可能解決問題1ststepCaseThinkingprocessStudygoalsHomework:PECOT

THE5PARTSTOAWELLFORMULATEDCLINICALQUESTIONEachquestionhas5partsthatshouldbeconsidered:1Patients/consumers/participants:

2Exposure:

3Comparison:Whatis/arethemainalternative/stocomparewiththeexposure?Ref:NewZealandGuidelinesGroup(NZGG).Handbookforthepreparationofexplicitevidence-basedclinicalpracticeguidelines,2001p16.

4Outcome:Whatisreallyimportanttothepatient/consumer?Whatdoesthisexposureaffect?Whichoutcomesshouldbeconsidered?-intermediateorshorttermmeasures(egloweringincholesterollevels),mortality,morbidityandtreatmentcomplications,ratesofrelapse,latemorbidityandreadmission,returntoworkandphysicalandsocialfunctioningandothermeasuressuchasqualityoflife,generalhealthstatus.Costtotheconsumerisanotheroutcomethatshouldbeconsidered.

5Time:Overwhattimeframeisitreasonabletoexpectaneffect?Ref:NewZealandGuidelinesGroup(NZGG).Handbookforthepreparationofexplicitevidence-basedclinicalpracticeguidelines,2001p16.

THE5PARTSTOAWELLFORMULATEDCLINICALQUESTION教育處方Ref:NewZealandGuidelinesGroup(NZGG).Handbookforthepreparationofexplicitevidence-basedclinicalpracticeguidelines,2001p46.

2.尋找文獻證據

(Trackingdownthebestevidence)Inthelongrun,we'realldead.

JohnMaynardKeynes,1883-1946

2ndstepReviewthecaseonthewebsiteReviewpreviousestablished

flowchartsDiscusswiththeclinicianAfterthediscussionHomework:Cubby3.嚴格評讀文獻

(CriticalAppraisal

)AreWeDoingtheRightThingsRight?3rdstepModifytheflowcharts,discusswiththetutorPresentstudygoalsornewconceptofdiseasesunderEBM3to4dayslaterHomework:MyLesson-CATmaker--共同評讀軟體應用介面--CATsearch--共同評讀軟體應用介面--CATexampleCATmakerCentreforEvidenceBasedMedicinebottomline財務報告上頂線(topline)是營收、底線(bottomline)是利潤Acompany'sbottomlineisitsnetincome,orthe“bottom”figureonacompany'sincomestatement.Thetoplineofacompanyisitsgrosssales,orrevenuefigure.TheEvidencePyramid圖片來源:方信元醫師演講簡報Classificationofevidence

--USAgencyforHealthCarePolicyandResearchClassification(AHCPR,1992)

EvidencelevelDescriptionIa:evidencefrommeta-analysisofrandomisedcontrolledtrialsIb:evidencefromatleastonerandomisedcontrolledtrialIIa:evidencefromatleastonecontrolledstudywithoutrandomisationIIb:evidencefromatleastoneothertypeofquasi-experimentalstudyIII:evidencefromnon-experimentaldescriptivestudies,suchascomparativestudies,correlationstudiesandcase-controlstudiesIV:evidencefromexpertcommitteereportsoropinionsand/orclinicalexperienceofrespectedauthoritiesGradingofrecommendations

EcclesMetal.(1998)NorthofEnglandEvidenceBasedGuidelineDevelopmentProject:guidelineforangiotensinconvertingenzymeinhibitorsinprimarycaremanagementofadultswithsymptomaticheartfailure.BritishMedicalJournal316:1369.

AdirectlybasedoncategoryIevidence,orassignedthisgradingbythedevelopers,forexplicitanddocumentedreasonsBdirectlybasedoncategoryIIevidence,orassignedthisgradingbythedevelopers,forexplicitanddocumentedreasonsCdirectlybasedoncategoryIIIevidence,orassignedthisgradingbythedevelopers,forexplicitanddocumentedreasonsDdirectlybasedoncategoryIVevidence,orassignedthisgradingbythedevelopers,forexplicitanddocumentedreasons萬芳醫院實證醫學推展歷程91.04.24於臺北醫學大學MYTMU開立實證醫學看版，建立知識學習的介面。延伸學習CentreforEBM牛津實證醫學中心CriticalAppraisalSkillsProgramme(CASP)英國國家健康保險之嚴格評讀技巧計劃4.應用於病人身上

(IntegratingtheAppraisalwithClinical

Expertise&Patients’Preference)Informationmustbetranslatedintoaction.EBM-DecisionSupportATP-IIIguidelineDecisionSupportSystemSupportotherknowledgedomainuserComputerHumanInterfaceEfficiencyFriendlyGUIQualitycontrol5.對過程進行稽核

(Auditingperformanceinstep1-4)HierarchyofOutcomeMeasuresBackground:Evidence-basedmedicine(EBM)isapartofmanymedicalschoolandresidencycurriculaworldwide,butthereislittleresearchintothemosteffectivemethodstoteachtheseskills.---BaumK.Theimpactofanevidence-basedmedicineworkshoponresident’sattitudestowardsandself-reportedabilityinevidence-basedpractice.MedEducOnline2003;8:4.Purpose:ToevaluatewhetheracourseonEBMutilizingadultlearningprincipalsleadstobothimmediateandshort-termattitudinal,confidence,andbehavioralchange.---BaumK.Theimpactofanevidence-basedmedicineworkshoponresident’sattitudestowardsandself-reportedabilityinevidence-basedpractice.MedEducOnline2003;8:4.Methods:73InternalMedicineandInternalMedicine/Pediatricresidentsattendedahalf-dayseminaronEBM.Participantscompletedpre-andpost-course5-pointLikertquestionnaires,andsettwopersonalgoalsforintegratingEBMintotheirdailypractice.Weperformednonparametrictwo-sampleWilcoxonRank-Sumteststocompareresponses.Wealsoelicitedtheself-reportedsuccessoftheresidentsinmeetingtheirgoalsone-monthpost-course.---BaumK.Theimpactofanevidence-basedmedicineworkshoponresident’sattitudestowardsandself-reportedabilityinevidence-basedpractice.MedEducOnline2003;8:4.---BaumK.Theimpactofanevidence-basedmedicineworkshoponresident’sattitudestowardsandself-reportedabilityinevidence-basedpractice.MedEducOnline2003;8:4.Results:AttitudesaboutEBMimproved(3.5pre-coursevs.3.7post-course),aswellasself-reportedEBMskills(3.0vs.3.3).72%ofresidentsreportedhavingmetatleastoneoftheirtwogoalsfortheintegrationofEBMintotheirpractice.---BaumK.Theimpactofanevidence-basedmedicineworkshoponresident’sattitudestowardsandself-reportedabilityinevidence-basedpractice.MedEducOnline2003;8:4.---BaumK.Theimpactofanevidence-basedmedicineworkshoponresident’sattitudestowardsandself-reportedabilityinevidence-basedpractice.MedEducOnline2003;8:4.---BaumK.Theimpactofanevidence-basedmedicineworkshoponresident’s