mis实证医学个案讨论会简报范例

实证医学与个案讨论实证医学与个案讨论简报大纲l简述实证医学五大步骤l如何问问题及形成PICO的内容l资料搜寻的策略、使用数据库及 搜寻结果l对资料的评读l如何落实实证医学于个案讨论过去过去 现在现在 未来未来当一个医生该具备的的能力三日不读书，面目可憎三日不读书，面目可憎医病照护教学研究 2000年Sackett将实证医学定义为“整合最佳研究证据、临床经验以及病患价值以达成病患最佳治疗的过程”实证医学的实行是一种终身的、自发的、以问题为导向的学习过程实证医学的重要性临床经验临床经验病患价值病患价值最佳研究证据最佳研究证据实证医疗实证医疗Sackett et al 2000实证医学的五个步骤1.Asking an answerable question (提出可回答的临床问题提出可回答的临床问题)2.Tracking down the best evidence (搜寻最佳实证文献资料搜寻最佳实证文献资料)3.Critical appraisal (严谨的文献评读严谨的文献评读)4.Integrating the appraisal with clinical expertise and patients preference (将临床专业与病人价值观相结合将临床专业与病人价值观相结合)5.Evaluation the effectiveness and efficiency in executing steps 1-4 (评估改善评估改善)A stroke patient who has long term gouty arthritis Does gout cause a higher risk of stoke?痛风会增加中风的风险吗？找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAskingEBM的步骤Sir Austin Bradford Hill(1897-1991),English epidemiologist and statisticianHe described the clinical trial as being a CAREFULLY,and ETHICALLY,described experiment with the aim of answering some PRECISELY FRAMED QUESTIONGreater precision is required in the objectives.We need to haveA defined populationDefined endpointsRelatively few question to be answered.问题要怎么问？1.形成问题(Clinical Question)Does gout cause a higher risk of stoke?痛风会增加中风的风险吗？临床的问题模型(PICO)P:Patient,Population 指此病人或族群的年龄层指此病人或族群的年龄层、体质体质、疾病史疾病史、过去史等过去史等 I:Intervention 指治疗指治疗、诊断诊断、预后预后、成本效益分析等成本效益分析等，为研究的主题为研究的主题 C:Comparison 指做与不做或不同处置间的比较指做与不做或不同处置间的比较 O:Outcome 指预后或与目前问题有关的比较基准指预后或与目前问题有关的比较基准找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAskingEBM的步骤PICO 1 Does gout cause a higher risk of stoke?PICO type:TherapyPatient:老年人老年人Intervention:痛风痛风Comparison:无痛风无痛风Outcome:中风的风险中风的风险问题要怎么问？2.Tracking down the best evidence 直接使用实证医学资料库直接使用实证医学资料库(secondary databases)如如ACP journal club,Cochrane Library,UpToDate,MD Consult,Practice Guideline 找初步筛选的资料库找初步筛选的资料库(primary databases)PubMed,OVID,Proquest 未经筛选的资料库未经筛选的资料库如如Google可搜寻实证医学的数据库可搜寻实证医学的数据库如何寻找与EBM相关的馆藏资源？主题切入主题切入本院一般综合性数据库本院一般综合性数据库 1.PudMed：可查出：可查出abstract 2.Ovid：可查出：可查出abstract、Fulltext 3.Proquest：可查出：可查出abstract、Fulltext 4.Clinicalkey：可查出：可查出abstract、Fulltext 找实证医学数据时可加上找实证医学数据时可加上 Systemic Review(系统性评论系统性评论)、Meta-analysis(整合分析整合分析)、Randomized Controlled Trial(随机对照临床试验研究随机对照临床试验研究)、Controlled Trials 利用数据库功能键利用数据库功能键MeSH to identify every term for example找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAskingSearching Strategy Finding out The Correct Keywords原始关键词原始关键词Primary Term 或或MeSH Term 同义字同义字1同义字同义字2P(oror)andI(Goutor Hyperuricemia or)andC(oror)andO(strokeoror)找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAskingSearching Strategy Finding out The Correct KeywordsKeywords from PICO item:(“gout”OR“hyperuricemia”)AND“stroke”MeSH to identify every term for example找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAsking善用搜寻 Systematic review关键词:(“gout”OR“hyperuricemia”)AND(“stroke”OR“cardiovascular disease”)找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAskingThe Evidence PyramidV.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 图示结果Forest plot*Hierarchy of evidence:arranges study designs by their susceptibility to bias.(Level IV)From:Oxford Center for EBM研究设计研究设计 与与 证据强度证据强度Level Therapy/Prevention,Aetiology/HarmPrognosisDiagnosisDifferential diagnosis/symptom prevalence studyEconomic and decision analyses1aSR(with homogeneity*)of RCTs SR(with homogeneity*)of inception cohort studies;CDR validated in different populationsSR(with homogeneity*)of Level 1 diagnostic studies;CDR with 1b studies from different clinical centresSR(with homogeneity*)of prospective cohort studies SR(with homogeneity*)of Level 1 economic studies1bIndividual RCT(with narrow Confidence Interval)Individual inception cohort study with 80%follow-up;CDR validated in a single populationValidating*cohort study with good reference standards;or CDR tested within one clinical centreProspective cohort study with good follow-up*Analysis based on clinically sensible costs or alternatives;systematic review(s)of the evidence;and including multi-way sensitivity analyses1cAll or noneAll or none case-seriesAbsolute SpPins and SnNoutsAll or none case-seriesAbsolute better-value or worse-value analyses 2aSR(with homogeneity*)of cohort studiesSR(with homogeneity*)of either retrospective cohort studies or untreated control groups in RCTsSR(with homogeneity*)of Level 2 diagnostic studiesSR(with homogeneity*)of 2b and better studiesSR(with homogeneity*)of Level 2 economic studies2bIndividual cohort study(including low quality RCT;e.g.,80%follow-up;CDR validated in a single populationValidating*cohort study with good reference standards;or CDR tested within one clinical centreProspective cohort study with good follow-up*Analysis based on clinically sensible costs or alternatives;systematic review(s)of the evidence;and including multi-way sensitivity analyses1cAll or noneAll or none case-seriesAbsolute SpPins and SnNoutsAll or none case-seriesAbsolute better-value or worse-value analyses 2aSR(with homogeneity*)of cohort studiesSR(with homogeneity*)of either retrospective cohort studies or untreated control groups in RCTsSR(with homogeneity*)of Level 2 diagnostic studiesSR(with homogeneity*)of 2b and better studiesSR(with homogeneity*)of Level 2 economic studies2bIndividual cohort study(including low quality RCT;e.g.,80%follow-up)Retrospective cohort study or follow-up of untreated control patients in an RCT;Derivation of CDR or validated on split-sample onlyExploratory*cohort study with good reference standards;CDR after derivation,or validated only on split-sample or databasesRetrospective cohort study,or poor follow-upAnalysis based on clinically sensible costs or alternatives;limited review(s)of the evidence,or single studies;and including multi-way sensitivity analyses2cOutcomes Research;Ecological studiesOutcomes Research Ecological studiesAudit or outcomes research3aSR(with homogeneity*)of case-control studiesSR(with homogeneity*)of 3b and better studiesSR(with homogeneity*)of 3b and better studiesSR(with homogeneity*)of 3b and better studies3bIndividual Case-Control StudyNon-consecutive study;or without consistently applied reference standardsNon-consecutive cohort study,or very limited populationAnalysis based on limited alternatives or costs,poor quality estimates of data,but including sensitivity analyses incorporating clinically sensible variations.4Case-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 standardsAnalysis with no sensitivity analysis5Expert opinion without explicit critical appraisal,or based on physiology,bench research or first principlesExpert opinion without explicit critical appraisal,or based on physiology,bench research or first principlesExpert opinion without explicit critical appraisal,or based on physiology,bench research or first principlesExpert opinion without explicit critical appraisal,or based on physiology,bench research or first principlesExpert opinion without explicit critical appraisal,or based on economic theory or first principlesOxford Centre for Evidence-based Medicine-Levels of Evidence(March 2009)http:/=1025找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAsking Title:-Hyperuricemia and risk of stroke:a systematic review and meta-analysis.(2009)Source:Arthritis Rheum.2009 Jul 15;61(7):885-92 Level:2aLarge epidemiologic studies have shown that hyperuricemia is associated with an increased incidence of coronary heart disease(CHD)and increased mortality in those with and without preexisting CHD.Fang J,Alderman MH.Serum uric acid and cardiovascular mortality the NHANES I epidemiologic follow-up study,1971-1992.National Health and Nutrition Examination Survey.JAMA 2000;283:2404.Freedman DS,Williamson DF,Gunter EW,Byers T.Relation of serum uric acid to mortality and ischemic heart disease.The NHANES I Epidemiologic Follow-up Study.Am J Epidemiol 1995;141:637.Brand FN,McGee DL,Kannel WB,et al.Hyperuricemia as a risk factor of coronary heart disease:The Framingham Study.Am J Epidemiol 1985;121:11.Niskanen LK,Laaksonen DE,Nyyssnen K,et al.Uric acid level as a risk factor for cardiovascular and all-cause mortality in middle-aged men:a prospective cohort study.Arch Intern Med 2004;164:1546.Choi HK,Curhan G.Independent impact of gout on mortality and risk for coronary heart disease.Circulation 2007;116:894.Proposed mechanisms for such an increase in risk include the development of hypertension and oxidative stress.Johnson RJ,Segal MS,Srinivas T,et al.Essential hypertension,progressive renal disease,and uric acid:a pathogenetic link?J Am Soc Nephrol 2005;16:1909.Baker JF,Krishnan E,Chen L,Schumacher HR.Serum uric acid and cardiovascular disease:recent developments,and where do they leave us?Am J Med 2005;118:816.It is unclear if hyperuricemia has a causal effect or,as has been more often suggested,is simply a marker for other risk factors,such as hypertension,dyslipidemia,and diabetes.Culleton BF,Larson MG,Kannel WB,Levy D.Serum uric acid and risk for cardiovascular disease and death:the Framingham Heart Study.Ann Intern Med 1999;131:7.Wannamethee SG,Shaper AG,Whincup PH.Serum urate and the risk of major coronary heart disease events.Heart 1997;78:147.Wheeler JG,Juzwishin KD,Eiriksdottir G,et al.Serum uric acid and coronary heart disease in 9,458 incident cases and 155,084 controls:prospective study and meta-analysis.PLoS Med 2005;2:e76.Feig DI,Kang DH,Johnson RJ.Uric acid and cardiovascular risk.N Engl J Med 2008;359:1811.文献评读三部曲文献评读三部曲文献评读最主要的三个步骤，即是VIP V：Validity/Reliability;效度/信度我们能相信这篇文章吗?I：Importance/Impact;重要性我们相信它，但这个结论重要吗?P：Practice/Applicability;临床适用性如果我们相信它，这个结论可以应用在我们所照护的病患吗?找资料来回答问题找资料来回答问题Acquire严格评读文献严格评读文献Appraisal是否可应用到病人身上是否可应用到病人身上Apply将病人的问题写成将病人的问题写成PICOAskingAccording to“Sharon E.Straus et al,Evidence-based medicine:how to practice andteach EBM,Elsevier,2005:33-7.“ValidityImportanceApplicabilityResults fromsecondarydatabaseResults fromprimarydatabaseAppraised byexpertsNeeded tobeappraisedResults(NNT)ResultsConsiderpopulationand feasibilityConsiderpopulationand feasibility效度效度(Validity)：可以用：可以用RAM-bo方式审视效度方式审视效度研究族群是否有随机分配研究族群是否有随机分配(Randomized)？随机分配的方法是否适当随机分配的方法是否适当(Accounted)？结果的衡量结果的衡量(Measurement)，即是否依照即是否依照 盲法盲法(blind)及客观及客观(objective)二要素操作二要素操作治疗意图分析治疗意图分析(Intention-to-treat analysis,ITT)随机试验的一种分析方法随机试验的一种分析方法所有被分配在治疗组所有被分配在治疗组/对照组的病人无论是否完成该项对照组的病人无论是否完成该项 治疗治疗/安慰剂都应该被放进治疗组安慰剂都应该被放进治疗组/对照组对照组(原分派组别原分派组别)中做分析中做分析文献评读三部曲文献评读三部曲重要性重要性(Importance/Impact)：研究结果是什么研究结果是什么?研究结果如何被估计研究结果如何被估计?经过多久的时间经过多久的时间?文献结果的评估方式：文献结果的评估方式：胜算比胜算比(odds ratio)代表生物学上的影响。代表生物学上的影响。相对危险相对危险(relative risk)、绝对危险降低度绝对危险降低度(absolute risk reduction)、相对危险降低度相对危险降低度(relative risk reduction)、益一需治数益一需治数(NNT,number needed to treat):为预防一为预防一个不良结果或使一个病人达实验所求之有益结果所需个不良结果或使一个病人达实验所求之有益结果所需治疗的病人数治疗的病人数NNT=1/ARR文献评读三部曲文献评读三部曲可行性可行性(Practical,Applicability?)：临床实用性如何？：临床实用性如何？1.应考虑病患的生物因素应考虑病患的生物因素(biological issues):-同样的治疗应用在不同的病患族群是否有不同反应同样的治疗应用在不同的病患族群是否有不同反应?-我们的病人与研究中的病人是否非常不同，以致无法应用我们的病人与研究中的病人是否非常不同，以致无法应用 在研究结果？在研究结果？2.其他的社会经济因素其他的社会经济因素（social and economic issues）的考的考虑虑:-这个治疗适用于我们的诊疗环境吗？病患的配合度如何？这个治疗适用于我们的诊疗环境吗？病患的配合度如何？-医疗提供者的配合度及能力如何？医疗提供者的配合度及能力如何？3.3.流行病学因素流行病学因素(epidemiological issues）的考虑）的考虑:-我们的病人是否有其他共病状况，可能改变治疗的结果？我们的病人是否有其他共病状况，可能改变治疗的结果？影响有多大？影响有多大？-病人可能从治疗中得到什么好处或坏处？病人可能从治疗中得到什么好处或坏处？-经由治疗而减少的不良后果是否比不治疗有明显的差别？经由治疗而减少的不良后果是否比不治疗有明显的差别？文献评读三部曲文献评读三部曲帮助文献评读的工具依所搜寻文献类别依所搜寻文献类别，评读所问的问题评读所问的问题4.将临床专业与病人价值观相结合您的病人是否与研究中的病人差别很大，以至于无法适用该研究结果？族群/地域/文化差异您期望您的病人从研究结果中获得多大的好处？还有哪些替代方案？研究结果适用于您的病人吗？5.评估执行效果及改善过程您是否开始使用实证手法搜寻最佳证据？您搜寻及评读证据的速度有多快？您有能力将这些证据应用在适当的病人身上吗？您是否依循这些新证据来改变您的诊疗习惯？如何落实实证医学于个案讨论会如何落实实证医学于个案讨论会?如何落实实证医学于个案讨论会1.1.由讨论的个案找寻问题由讨论的个案找寻问题 (形成形成PICO)2.进行文献搜寻进行文献搜寻(PUB Med,Cochrane,Ovid)3.进行文献评读进行文献评读(Evidence level,Recommend grade)会议中报告文章重点与结论会议中报告文章重点与结论4.4.所搜寻的文献值得应用到本病人身上吗所搜寻的文献值得应用到本病人身上吗?实证医学个案讨论会顺序实证医学个案讨论会顺序1.Case report(个案报告个案报告)2.提出问题提出问题，建立建立 PICO格式格式3.文献搜寻文献搜寻(所使用关键词所使用关键词、数据库数据库)4.所搜寻到文献的题目所搜寻到文献的题目、出处出处、及及文献文献5.的证据等级的证据等级 6.5.报告文献的重点与结论报告文献的重点与结论7.6.是否可应用到我们的病人身上是否可应用到我们的病人身上 Clinical question:Does gout cause a higher risk of stoke?PICO type:TherapyPatient:Old patientIntervention:GoutComparison:Without goutOutcome:Risk of stroke Title:Hyperuricemia and risk of stroke:a systematic review and meta-analysis.(2009)Source:Arthritis Rheum.2009 Jul 15;61(7):885-92 Level:2a科别选定与讨论频率1.科别:内、外、妇、儿、皮肤科 药剂、护理、(检验、放射)2.频率:每月一次3.会议主题设定:实证医学个案讨论会实证医学个案讨论会4.请科部主任定期检视结果与统计