台北醫學大學.市立萬芳醫院
This presentation is the property of its rightful owner.
Sponsored Links
1 / 72

EBM 在臨床上的應用及發展現況 PowerPoint PPT Presentation


  • 109 Views
  • Uploaded on
  • Presentation posted in: General

台北醫學大學.市立萬芳醫院. EBM 在臨床上的應用及發展現況. 陳杰峰 台北醫學大學市立萬芳醫院 實證醫學中心 整形外科 地點 : 門諾醫院 時間 : 2008/5/23 8:10-9:00 [email protected] http://www.wanfang.gov.tw/ebm. EBM— 醫學的知識轉譯. 一種將 ” 科學研究證據 ” 用以改善 ” 專業執行成果 ” 的活動或固定流程

Download Presentation

EBM 在臨床上的應用及發展現況

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Ebm

台北醫學大學.市立萬芳醫院

EBM在臨床上的應用及發展現況

陳杰峰

台北醫學大學市立萬芳醫院 實證醫學中心 整形外科

地點:門諾醫院

時間: 2008/5/23 8:10-9:00

[email protected]

http://www.wanfang.gov.tw/ebm


Ebm

EBM—醫學的知識轉譯

一種將”科學研究證據”用以改善”專業執行成果”的活動或固定流程

Knowledge Translation (or KT)(知識轉譯) describes either a structured process or the activity that results in scientifically researched evidence being used to improve the outcomes of professional practice.

http://en.wikipedia.org/wiki/Knowledge_translation


Ebm

注意到>接受>可行>有能力做>開始做>認同>養成習慣

Unsound Research

Aware Accepted Applicable Able Acted on Agreed Adhered to

Sound Research

Systems

Summaries

Synopses

Syntheses

Studies

Modify from “Straus et al.: Evidence-based medicine, Elsevier Ltd., 2005”, Brian Haynes, R Evid Based Med 2006;11:162-164

實證醫學之知識轉譯地圖

--from bench to bed (“B2B” : “5S” , “7A”)

7A

5S


Ebm

洗手有那麼難嗎?

Richard Grol; Jeremy Grimshaw. From best evidence to best practice: Effective implementation

of change in patients' care. The Lancet; Oct 11, 2003; 362,9391. pg. 1225


Ebm

推動洗手運動的效果

Richard Grol; Jeremy Grimshaw. From best evidence to best practice: Effective implementation

of change in patients' care. The Lancet; Oct 11, 2003; 362,9391. pg. 1225


Ebm

(Burt & Hing, 2005)

據美國CDC(Centers for Disease Control)2005年的統計資料顯示,其診所門診含CDSS之電子醫令的普及率不到10%


Conclusion

Conclusion


Ebm

EBM

Steps

.Answerable Question

.Search +

.Appraise

Apply

Time :6 minutes

Systematic Review

Steps

. Answerable Question

.Search ++++

.Appraise × 2

.Synthesize

Apply

Time :6 months

我們需要哪種搜尋策略?When systematic reviews are not available, clinicians need efficient strategies for identifying relevant research

摘錄自Paul Glasziou ‘s lecture, 2006


Doer or user

“Doer” or “User”製造者或使用者

  • Doer

    • Clinical trial (重工業)

    • Systematic review (輕工業)

    • Guideline development

  • ?% of us are “Users” only.

U

D


Ebm 3

EBM 3大步驟

Knowledge gap

Knowing-doing gap


1 asking an answerable question

台北醫學大學.市立萬芳醫院

實證醫學(1)提出問題 (Asking An Answerable Question)


Universal doubt rene descartes 1596 1650

Universal Doubt : ---笛卡兒 Rene Descartes 1596-1650

  • I think therefore I am. (我思故我在)

  • Self-evident

    • I

    • Think : doubt


Ebm

實證醫學—問題日誌

  • 編譯: 萬芳醫院 EBM Center

  • 2007


Ebm

問題日誌案例

  • CVP放置7天一定要換嗎?


Clinical bottom line

Clinical bottom line

  • Pulmonary and peripheral artery catheters need not be routinely replaced more often than every 5–7 days

  • Other short-term CVCs and arterial catheters need not be routinely replaced

  • Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002 Nov;81(6):466-79.


Reference

reference

  • Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002 Nov;81(6):466-79.

  • Single citation matcher (PubMed)


Appraisal

appraisal

  • Level Ib


Action

action

Action的空白頁留給大家填…


Ebm

台北醫學大學.市立萬芳醫院

實證醫學(2)搜尋及評讀文獻


Ebm

Dave Sackett

Evidence Cart

-CEBM - Centre for Evidence Based Medicine


Ebm

  • Mobile CDSS

  • 行動資訊車


Questions answerable by an ebm resource

Questions answerable by an EBM resource

Koonce TY, Giuse NB, Todd P. Evidence-based databases versus primary medical literature: an in-house investigation on their optimal use.

J Med Libr Assoc. 2004 Oct;92(4):407-11.


Finding data practice strategy

  • Usefulness 效益 = relevance 關聯 x validity 效力

  • work 工作

尋找資料: 操作策略Finding data: Practice strategy

Slawson, 1994


How ebm helps cme

How EBM Helps CME?

  • 「灌輸」(push) :「以防萬一(備用)」學習法(“just in case” learning)

    • SkolarMD

    • MDConsult

    • Cochrane databases

  • 「汲取」(pull): 「恰如其時(即時)」學習法(“just in time” learning)

    • Auto alert or MyNCBI

    • Google 快訊


Ebm

POC (Point of Care) Searching


Ebm

台北醫學大學.市立萬芳醫院

實證醫學(3)應用及評估


Ebm

對過程進行稽核


Ebm

評估成果及標準化


Clinical practice guideline

臨床診療指引(clinical practice guideline)

  • 「這是一種系統化製作的陳述,用來幫助臨床工作者或是病患,在面臨特定的臨床狀況時,能做出合適的健康照護決策」

    • Systemically defined statements to assist practitioner and patient decisions about appropriate health care of specific circumstances.

      -------Institutes of Medicine, 1990


Ebm

Evolution of Evidence-Based Medicine

Opinion –based Medicine

Physician Centered EBM

Patient Centered EBM

  • Relies on memory

  • Emphasizes experience

  • Popularized since 1992

  • Emphasize published clinical science

  • Practitioner experience is important

  • Acknowledge patient values

  • Emphasize clinical evidence

  • Focus on patient understanding

  • Integrate physician experience with patient values


Ebm

台北醫學大學.市立萬芳醫院

國內外實證醫學之新發展


Ebm

http://www.nhi.gov.tw/webdata/AttachFiles/Attach_613_1_CPG.pdf


Clinical epidemiology

Dave Sackett

Clinical Epidemiology - 臨床流行病學


Evidence based medicine how to practice and teach ebm with cd rom 3 e

實證醫學:臨床實踐與教學指引(Evidence-Based Medicine: How to Practice and Teach EBM with CD-ROM 3/e)

  • 出版者 : 合記

  • 出版年代 : 2007


Ebm

實證醫學—醫療照護決策

  • 總編譯: 郭耿南教授

  • 出版者 : 合記

  • 出版年代 : 2007


Ebm

編著者:財團法人彰化基    督教醫院

出版社:藝軒圖書出版社     (2006)


Http ebpg nhri org tw

「實證臨床指引平台」http://ebpg.nhri.org.tw--國家衛生研究院


Ebm roundtable on evidence based medicine institute of medicine

美國近期EBM發展~Roundtable on Evidence-Based Medicine, Institute of Medicine


Ebm

全人醫療

美國醫學機構(IOM)於 2003年7月提出每位醫療專業人員均應具備的5大核心能力:

1.以病人為中心的醫療2.跨領域的醫療團隊工作

3.基於實證醫學的專業執行

4.醫療品質促進

5.資訊技術運用

--Health Professions Education: A Bridge to Quality, Institute of Medicine 2003


Ebm

Goal

  • by the year 2020, ninety percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence.

LeighAnne Olsen, Dara Aisner, and J. Michael McGinnis, editors, Roundtable on Evidence-Based Medicine. The Learning Healthcare System: Workshop Summary (IOM Roundtable on Evidence-Based Medicine) (2007), p353


What next

What next?

  • IOM過去發表的總結報告幾乎沒有例外地每一次均帶動一波全球健康照護體系改革的熱潮

  • A Learning Healthcare System結論報告的發表必將成為下一波臨床照護品質、保險給付、醫學教育、醫療研究改革的關鍵核心


Ebm

國際性實證醫學發展機構之結盟與串連

(meta-analysis of seven trials)


51 cochrane review groups crgs

51 Cochrane Review Groups (CRGs)

26. Incontinence Group

27. Infectious Diseases Group

28. Inflammatory Bowel Disease and Functional Bowel Disorders Group

29 Injuries Group

30. Lung Cancer Group

31. Menstrual Disorders and Subfertility Group

32. Metabolic and Endocrine Disorders Group

33. Methodology Review Group

34. Movement Disorders Group

35. Multiple Sclerosis Group

36. Musculoskeletal Group

37. Neonatal Group

38. Neuromuscular Disease Group

39. Oral Health Group

40. Pain, Palliative and Supportive Care Group

41. Peripheral Vascular Diseases Group

42. Pregnancy and Childbirth Group

43. Prostatic Diseases and Urologic Cancers Group

44. Renal Group

45. Schizophrenia Group

46. Sexually Transmitted Diseases Group

47. Skin Group

48. Stroke Group

49. Tobacco Addiction Group

50. Upper Gastrointestinal and Pancreatic Diseases Group

51. Wounds Group

1.Acute Respiratory Infections Group

2.Airways Group

3.Anaesthesia Group

4.Back Group

5.Bone, Joint and Muscle Trauma Group

6.Breast Cancer Group

7.Childhood Cancer Group

8.Colorectal Cancer Group

9.Consumers and Communication Group

10.Cystic Fibrosis and Genetic Disorders Group

11.Dementia and Cognitive Improvement Group

12.Depression, Anxiety and Neurosis Group

13.Developmental, Psychosocial and Learning Problems Group

14.Drugs and Alcohol Group

15.Ear, Nose and Throat Disorders Group

16.Effective Practice and Organisation of Care Group

17.Epilepsy Group

18.Eyes and Vision Group

19.Fertility Regulation Group

20.Gynaecological Cancer Group

21.HIV/AIDS Group

22.Haematological Malignancies Group

23.Heart Group

24.Hepato-Biliary Group

25.Hypertension Group


Guidelines international network g i n

Guidelines International Network (G-I-N)

  • 2002年成立,主力推廣實證臨床指引之發展與應用

  • 現有32個國家、76個指引發展相關組織加入GIN

  • 國衛院衛政中心於95年底以台灣代表申請加入,繼香港、日本、馬來西亞後,為亞洲地區第四個加入之國家


Bench marks from our neighbourhood example of cpg development

Keeping up with the Joneses!

Bench Marks from our neighbourhood-example of CPG development


Ebm

日本發展經驗_以CPG為例

  • 由日本醫療機能評價機構(JCQHC)主導,並於2002年4月建置Minds醫療資訊交換平台


35 cpgs on minds

35 CPGs on Minds


Ebm

英國之EBM發展

  • Natioanl health insurance

  • NICE, SIGN

  • Oxford University – EBM curriculum

  • Cochrane collaboration

  • 大英國協


Ebpg in who

EBPG in WHO

In 2005 the WHO asked its Advisory Committee on Health Research (ACHR) for advice on ways in which WHO can improve the use of research evidence in the development of recommendations, including guidelines and policies.

The ACHR established the Subcommittee on the Use of Research Evidence (SURE) to collect background documentation and consult widely among WHO staff, international experts and end users of WHO recommendations to inform its advice to WHO.

Ref: Andrew Oxman et al, Health Research Policy and System, 2006, 4:12


Guidelines international network g i n1

Guidelines International Network (G-I-N)

  • 成立於2002年,著重於推廣實證臨床指引之發展與應用。

  • 現有32個國家、76個指引發展相關組織加入GIN。

  • 我國國家衛生研究院衛生政策研發中心於95年底以台灣代表申請加入,繼香港、日本、馬來西亞後,為亞洲地區第四個加入之國家。


Ebm

國內EBM發展的策略思考

  • 加強人才培育

  • 建立區域性合作機制

  • 建置軟硬體發展平台

  • 編列中長程性經費來源

  • 設定核心發展領域

  • 加深EBM推廣應用的深度及廣度

  • 設定發展目標、進行成效評估


Taiwan evidence basded medicine association tebma 2007 8 15

“台灣實證醫學學會”(Taiwan Evidence-Basded Medicine Association, TEBMA) 2007年8月15日正式成立

-歡迎入會-

http://www.tebma.org.tw

*推廣實證醫學之應用、教育及研究*

(立案證號:台內社字第0960137058號)


Ebm

「台灣實證醫學學會2008學術年會」將於9月20日假成功大學附設醫院第四講堂舉辦,同時舉辦今年度會員大會,會中將邀請國內外學者蒞臨,並針對實證醫學的研究、教學、與應用等多項主題徵求口頭及海報摘要投稿,大會期間並舉辦優良海報觀摩賽,敬請踴躍參與,摘要徵求自即日起開始,至 7月11日截止。

徵稿主題

1.從實證到應用(Evidence to Practice,E2P)

2.實證醫學與健康資訊科技(EBM & health information technology)

3.實證醫學教學及繼續教育(Teaching and continuing education in EBM)

4.臨床指引及法律議題(EBM/CPG & legal consideration)

5.各類醫事人員相關實證照護(EBM in allied health professions)

6.實證研究(Research,including appraisal, meta-analysis, systematic reviews…)

相關訊息請至台灣實證醫學學會查詢:http://www.tebma.org.tw


Thank you

謝謝聆聽Thank You !!!

[email protected]@ms1.hinet.net

歡迎加入台灣實證醫學學會!


  • Login