實證醫學資源應用解析 實證醫學資源應用解析

實證醫學資源應用解析 實證醫學資源應用解析

報告人：林芳輝

實證醫學乃是從龐大的醫學資料庫中搜尋相關文獻，

並以流行病學及統計學方法過濾出值得信賴的文獻，

並以流行病學及統計學方法過濾出值得信賴的文獻 再經過嚴格評讀及綜合分析後，將所獲取之最佳研 究證據 (evidence) 、臨床經驗 (experience) 及患者期望 (expectation) 相互整合，配合診療情境後制定出一套 最佳的臨床醫療決策，並可用來協助醫護人員進行 終身學習

終身學習。

N t l kill b t l ttit d h

Not only a skill but also an attitude change

for everyone in hospitals

臨床決策模型 臨床決策模型

J Am Med Inform Assoc. 1997 Jul-Aug;4(4):266-78. Elson RB, Faughnan JG, Connelly DP

J Am Med Inform Assoc. 1997 Jul Aug;4(4):266 78. Elson RB, Faughnan JG, Connelly DP

實證醫學三大要素 實證醫學三大要素

Evidence

EBM

Experience Expectation

實施實證醫學五大步驟 實施實證醫學五大步驟

y

asking an answerable question

y

tracking down the best evidence

y

critical appraisal

y

integrating the appraisal with clinical expertise  and patients preference

y

auditing performance in step 1‐4g p p 4

臨床問題從哪裡來？

臨床問題從哪裡來？ ？ ？

y

y

y

y

y

y

y

y

y

臨床問題的種類 臨床問題的種類

y

例如 服用 阿斯匹林 是否可以預防中風 例如：服用“阿斯匹林＂是否可以預防中風？

y

研究檢查方法或臨床表徵對疾病診斷的有效性 研究檢查方法或臨床表徵對疾病診斷的有效性

例如：McBurney’s sign 診斷急性盲腸炎的敏感度及特異度為何？

y

例如：停經婦女使用荷爾蒙治療是否會增加乳癌的機會？

P i ：預後

y

建立疾病預後的預測模式

例如：利用Ranson’s criteria 預測急性胰臟炎死亡率為何？

例如: In healthy women who have recently had a miscarriage(流 產), what is the usual grieving(悲傷) process and are any factors  associated with longer than normal grieving?

associated with longer than normal grieving?

Leve

l Therapy/Prevention,

Aetiology/Harm Prognosis Diagnosis Differential

diagnosis/symptom

l t d

Economic and decision analyses

Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001)

prevalence study 1a SR (with homogeneity*) of

RCTs SR (with homogeneity*) of

inception cohort studies;

CDR†validated in different populations

SR (with homogeneity*) of Level 1 diagnostic studies;

CDR†with 1b studies from different clinical centres

SR (with homogeneity*) of

prospective cohort studies SR (with homogeneity*) of Level 1 economic studies

1b Individual RCT (with narrow

Confidence Interval‡) Individual inception cohort study with > 80% follow

Validating** cohort study with good†††reference

Prospective cohort study

with good follow up**** Analysis based on clinically sensible costs or

Confidence Interval‡) study with > 80% follow- up; CDR†validated in a single population

with good†††reference standards; or CDR†tested within one clinical centre

with good follow-up**** sensible costs or alternatives; systematic review(s) of the evidence;

and including multi-way sensitivity analyses 1c All or none§ All or none case-series Absolute SpPins and

SnNouts†† All or none case-series Absolute better-value or worse-value analyses ††††

SnNouts†† worse value analyses ††††

2a SR (with homogeneity*) of

cohort studies SR (with homogeneity*) of either retrospective cohort studies or untreated control groups in RCTs

SR (with homogeneity*) of

Level >2 diagnostic studies SR (with homogeneity*) of

2b and better studies SR (with homogeneity*) of Level >2 economic studies

2b Individual cohort study

(including low quality RCT; Retrospective cohort study

or follow-up of untreated Exploratory** cohort study

with good†††reference Retrospective cohort study,

or poor follow-up Analysis based on clinically sensible costs or

( g q y

e.g., <80% follow-up) p

control patients in an RCT;

Derivation of CDR†or validated on split- sample§§§ only

g

standards; CDR†after derivation, or validated only on split-sample§§§ or databases

alternatives; limited review(s) of the evidence, or single studies; and including multi-way sensitivity analyses 2c "Outcomes" Research;

E l i l t di "Outcomes" Research Ecological studies Audit or outcomes research

Ecological studies

3a SR (with homogeneity*) of

case-control studies SR (with homogeneity*) of

3b and better studies SR (with homogeneity*) of

3b and better studies SR (with homogeneity*) of 3b and better studies 3b Individual Case-Control

Study Non-consecutive study; or

without consistently applied reference standards

Non-consecutive cohort study, or very limited population

Analysis based on limited alternatives or costs, poor quality estimates of data, but including sensitivity but including sensitivity analyses incorporating clinically sensible variations.

4 Case-series (and poor quality cohort and case- control studies§§)

Case-series (and poor quality prognostic cohort studies***)

Case-control study, poor or non-independent reference standard

Case-series or superseded

reference standards Analysis with no sensitivity analysis

control studies§§) studies ) standard

5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

Expert opinion without explicit critical appraisal, or based on economic theory or "first principles"

New

http://www.cebm.net/index.aspx?o=5653 10 June 2010

研究設計分類

( A taxonomy of clinical research) by David A Grimes Kenneth F Schulz 2002

研究設計分類

( A taxonomy of clinical research) by David A Grimes Kenneth F Schulz 2002 by David A Grimes, Kenneth F Schulz,2002 by David A Grimes, Kenneth F Schulz,2002

Did investigator Assign exposures? g p

Observational study Experimental study

Yes No

Comparison group?

Random allocation?

Yes No Yes No

Randomized Controlled trial

Non- Randomized Controlled trial

Analytical study

Descriptive study

Direction？

Exposure Î Outcome

Exposure Í Outcome

Exposure and Outcome at same time

Cohort study

Case-control study

Cross- sectional

study

at same time

Steps to the solution as proposed

G i id f h

Steps to the solution as proposed

•Generating evidence from research

•Synthesising the evidence

•Creating evidence based clinical policies

•Applying the policies

Brian Haynes, Andrew Haines. Education and debate: Getting research findings into practice: Barriers and bridges to evidence based clinical practice. BMJ

1998;317:273-276. ;

The “5S” levels of organization of The “5S” levels of organization of evidence from health care research evidence from health care research

Computerized decision support

E id b d t tb k

Computer

Evidence based textbooks

Evidence based journal abstracts

Summaries

Evidence based journal abstracts

S t ti i

Synopses

Systematic reviews

O i i l j l ti l

Syntheses

St di Original journal articles Studies

by R Brain Haynes, 2006

by R Brain Haynes, 2006

二次研究證據 (已經整理的文獻)

y

 S i f  B k d  i 搜

y

–

y (1) Evidence‐based CPG (free)

y (2) Best Practice‐Clinical Evidence

y (3) UpToDate

搜尋流

(3) p

y (4) ACP Pier & ACP Medicine

y (5) FirstConsult

y (6) DynaMed

y (7) Medscape eMedicine (free)

流程

( 自

y (7) Medscape‐eMedicine (free)

y

‐

y (1) ACP Journal Club

y (2) Evidence‐based Medicine

自二次研

(2) Evidence based Medicine

y (3) Evidence‐based Nursing

y

‐

y (1) The Cochrane Library ‐ CDSR & Other Reviews (中文版摘要 free)

研究證

y (2) PubMed‐Clinical Queries之 systematic review (free)

y (3) Medline之systematic review

原始研究證據 (未經整理的文獻)

證據找起

y

‐

y (1) The Cochrane Library‐ Clinical trials

y (2) PubMed ‐Clinical Queries之Clinical study search (free)

y (3) Medline (善用 more limit之功能)

起)

y (3) Medline (善用 more limit之功能)

Background Questions Background Questions g g Q Q

™Information can be found in textbooks and review article

and review article.

™General questions about conditions ,

illnesses, syndromes and patterns of disease , pathophysiology

.

Foreground Questions Foreground Questions g g Q Q

™Information found in primary literature, evidence-based extraction service,

evidence based extraction service, guidelines, or systematic reviews.

™Questions about issue of care, i.e.

diagnostic tests or therapies needed for diagnostic tests or therapies, needed for clinical decision-making.

Background vs Foreground Background vs Foreground

™What causes osteoporosis?

g g

g g

p

Background

™Which therapy have more benefit for

™Which therapy have more benefit for

Osteoporosis either EVISTA or FOSAMAX.

Foreground Foreground

™What are the symptoms of asthma?

Background Background

™Can I effectively treat asthma with Inhaled t id

steroids

Foreground

ACP JOURNAL CLUB ACP JOURNAL CLUB

由美國醫師學會(The American College

of Physicians)出版的 ACP Journal Club，

of Physicians)出版的 ACP Journal Club，

係每二個月由超過100種核心期刋中評讀出重要新 的研究發表，並加以整理及摘述，以提供臨床工作 的研究發表，並加以整理及摘述，以提供臨床工作 者作最有效率的資訊搜尋。

MEDLINE MEDLINE

™收錄年代：1946~Current

™收錄主題範圍

基礎醫學 臨床醫學 生物科學 基礎醫學 臨床醫學 生物科學

解剖學 醫務管理學 化學與藥物 心理學 社會醫學 生物農業與營養 心理學 社會醫學 生物農業與營養 醫材設備 醫事技術 醫事資訊

™收錄內容：文獻之書目資料、摘要

MeSH 醫學標題 MeSH 醫學標題

Title FRAX or fiction: determining optimal screening strategies for treatment of osteoporosis in residents in long-term care facilities. p g

主標題：Osteoprosis

Diphosphonates

Cross-Sectional Studies 副標題：

Diagnosis Osteoprosis

Diagnosis Drug therapy Epidemiology

文獻的重點為討論 t i 的流行病學

文獻的重點為討論osteoprosis的流行病學

研究，但文中有討論到治療及藥物治療

而且是以Diphosphonates為主要治療用藥

什麼是MeSH？

什麼是MeSH？

運動、遊戲、娛樂圈、音樂...什麼都有

–

概念用固定的詞彙表達，於是建立一套醫學標題 概念用固定的詞彙表達

索引專家們更在眾多標題詞中建立主題關係連結

–

可利用樹狀結構圖呈現出詞彙間語義或從屬上的 關係

關係。

臨床問題 臨床問題 臨床問題 臨床問題

Which therapy have more benefit for Atopic Dermatitis

either Tacrolimus or Corticosteroids.

原始關鍵字Primary

Term 或MeSH Term

同義字1 同義字2

P

( Atopic Dermatitis

with children or or ) and

I

( Tacrolimus or or ) and

C

( Corticosteroids or or ) and

O

( lit f lif ⁾

O

( quality of life ^{or or )}

EBM Solution

EBM Solution

ACP MEDICINE

TREATMENT

TREATMENT

ACP PIER

藥品的用法

相關ADR

應提供給患者的用藥資訊

ACP Journal Club

MEDLINE 文獻檢索主要步驟 MEDLINE 文獻檢索主要步驟

檢索

檢索

條件限制

條件限制

Publication Type

全文、內容

輸出

書目資料管理 全文 內容

檢 索

檢索一 檢索一

輸入檢索詞

選擇主標題 選擇主標題

選擇副標題

檢索二：

檢索二：

ATOPIC DERMATITIS / dt

主標題 副標題

檢索三：

檢索三：

ATOPIC DERMATITIS/ and drug therapy.fs

條件限制

選擇欲篩選的結果 選擇欲篩選的結果

選擇欲設定的條件 選擇欲設定的條件

針對年齡及文獻類型做篩選 針對年齡及文獻類型做篩選

Meta-analysis 1篇

RCTs 10篇

Meta-analysis

Meta-analysis y y

Randomized Controlled Trial

Randomized Controlled Trial

Review Article

Review Article

Thank You!

Thank You!