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 hNot only a skill but also an attitude changefor 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 DPJ 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

整理出一個可以回答的問題asking an answerable question尋找文獻證據tracking down the best evidence嚴格評讀文獻critical appraisal應用於病人身上integrating the appraisal with clinical expertise and patients preference對過程進行稽核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？？？

臨床發現 ( clinical findings )( g )病因 ( etiology )疾病的臨床表徵( clinical menifestations of (diseases )鑑別診斷與診斷檢查 ( DDx & diagnostic test )治療 ( therapy)預後 ( prognosis )預防措施 ( prevention )（生病）的經驗與意義 ( experience & meaning )自我學習發展的過程 ( self-improvement )

臨床問題的種類臨床問題的種類Therapy/Prevention：治療/預防的問題研究治療或預防方法的有效性

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？

Diagnosis：診斷問題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？Harm/Etiology：危害/病因問題gy研究暴露的危害或疾病的原因

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Prognosis：預後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?

Level

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 study1a 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.,

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 2002by David A Grimes, Kenneth F Schulz,2002by David A Grimes, Kenneth F Schulz,2002

Did investigatorAssign exposures?g p

Observational studyExperimental study

Yes No

Comparison group?Random allocation?

Yes Yes NoNo

RandomizedControlled trial

Non-Randomized

Controlled trial

Analyticalstudy

Descriptivestudy

Direction？

Exposure OutcomeExposure Outcome

Exposure and Outcomeat same time

Cohortstudy

Case-controlstudy

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 researchevidence 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 diOriginal journal articles Studies

by R Brain Haynes, 2006by R Brain Haynes, 2006

二次研究證據 (已經整理的文獻)1. System系統 S i f  B k d  i 搜2. Summaries – for Background questions

(1) Evidence‐based CPG (free)(2) Best Practice‐Clinical Evidence(3) UpToDate

搜尋流(3) p

(4) ACP Pier & ACP Medicine(5) FirstConsult(6) DynaMed(7) Medscape eMedicine (free)

流程

(

自(7) Medscape‐eMedicine (free)3. Synopses精要（ Article reviews） ‐ for Background questions 

(1) ACP Journal Club(2) Evidence‐based Medicine

自二次研

(2) Evidence based Medicine(3) Evidence‐based Nursing

4. Syntheses統整（ Systematic reviews） ‐ for Foreground question(1) The Cochrane Library ‐ CDSR & Other Reviews (中文版摘要 free)

研究證(2) PubMed‐Clinical Queries之 systematic review (free)

(3) Medline之systematic review原始研究證據 (未經整理的文獻)

證據找起5. Studies（Original journals articles）‐ for Foreground question

(1) The Cochrane Library‐ Clinical trials(2) PubMed ‐Clinical Queries之Clinical study search (free)(3) Medline (善用more limit之功能)

起)

(3) Medline (善用more limit之功能)

Background QuestionsBackground Questionsg Qg Q

Information can be found in textbooks and review articleand review article.

General questions about conditions , illnesses, syndromes and patterns of disease , pathophysiology.

Foreground QuestionsForeground Questionsg Qg 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 ForegroundBackground vs Foreground

What causes osteoporosis?

g gg g

pBackgroundWhich therapy have more benefit for Which therapy have more benefit for Osteoporosis either EVISTA or FOSAMAX. ForegroundForegroundWhat are the symptoms of asthma? BackgroundBackgroundCan I effectively treat asthma with Inhaled t id steroids

Foreground

ACP JOURNAL CLUBACP 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。

MEDLINEMEDLINE

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：OsteoprosisDiphosphonatesCross-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

–NLM在分析生物醫學方面之期刊文獻、圖書、視NLM在分析生物醫學方面之期刊文獻 圖書 視聽資料、電子資源等資源的主題時，為了將同一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 於是建立一套醫學標題詞（MeSH），以達到控制詞彙的目的。索引專家們更在眾多標題詞中建立主題關係連結– 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 SolutionEBM 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

檢索關鍵字

檢索MeSH

條件限制Clinical Queries

條件限制Clinical Queries

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：直接輸入MeSH term檢索二：直接輸入MeSH term

ATOPIC DERMATITIS / dt主標題 副標題

檢索三：交集MeSH 主標題及 Floating Sub-Heading檢索三：交集MeSH 主標題及 Floating Sub-Heading

ATOPIC DERMATITIS/ and drug therapy.fs主標題 Floating Sub-Heading

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-analysisMeta-analysisyy

Randomized Controlled TrialRandomized Controlled Trial

Review ArticleReview Article

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