實施實證醫學五大步驟
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實施實證醫學五大步驟. step 1. 整理出一個可以回答的問題 step 2. 尋找文獻證據 step 3. 嚴格評讀文獻 ( Critical appraisal ) step 4. 應用於病人身上 step 5. 對過程進行稽核. What is CAT?. Systematic evaluation of study/studies To critically appraise -- not only “ read ” , but also “ assess ”

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實施實證醫學五大步驟

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5602004

實施實證醫學五大步驟

step 1.整理出一個可以回答的問題

step 2. 尋找文獻證據

step 3. 嚴格評讀文獻 (Critical appraisal )

step 4. 應用於病人身上

step 5. 對過程進行稽核


What is cat

What is CAT?

  • Systematic evaluation of study/studies

  • To critically appraise -- not only “read”, but also “assess”

  • Simplify appraisal with VIP (or PICO/RAMbo)


Critical appraisal skills what is vip

CRITICAL APPRAISAL SKILLSWhat is VIP?

Validity (Reliability) 效度/信度

Can we believe it ?

(研究方法的探討)

Importance (Impact) 重要性

We believe it ! But does it matter?

(研究結果的分析)

Practice (Applicability) 臨床適用性

If we believe it - does it apply to our patients?

(如何在臨床運用)


Validity reliability what is ram bo

Validity (Reliability)What is RAMbo?

“Do we believe it? ”

  • Randomized:Was it randomised?Were the groups similar?

  • Accounted for all patients

  • Measurement: blinded or objective


Evidence based medicine how to practice and teach ebm

“該治療性研究結果是可信的嗎?” EVIDENCE-BASED MEDICINE How to Practice and Teach EBM

  • 病人的治療分派是否為隨機?隨機方式是否恰當?實驗開始前,實驗組及對照組是否相似、可比較?(R)

  • 病人追蹤是否夠久、夠完整?所有病人是否依其原先分派組別作分析?(A)

  • 病人及醫師是否對治療不知情(blind)?實驗組及對照組是否被同等對待?(M)


Importance impact

Importance (Impact)

“ We believe it !But-does it matter? ”

  • What were the results?-How large was the treatment effect? -How precise was the estimate of the treatment effect?


In therapy study

In therapy study

  • Number needed to treat (NNT)

  • Relative risk (RR)

  • Relative risk reduction (RRR)

  • Absolute risk reduction (ARR)


5602004

將12,562位有不穩定型心絞痛的患者分兩組進行隨機對照試驗,分別接受aspirin或合併使用clopidogrel ,九個月後研究結果:單獨使用aspirin(對照組)其心肌梗塞、中風或心臟血管疾病死亡率為11.47%;合併使用aspirin及clopidogrel (實驗組)其心肌梗塞、中風或心臟血管疾病死亡率為9.28%。對照組發生非致死性出血副作用為2.7% ;實驗組為3.6% 。

CER=11.47%; EER=9.28%

RR=9.28%/11.47%=0.81

RRR=(11.47%-9.28%)/11.47%=19%

ARR=11.47%-9.28%=2.19%

NNT=1/2.19%=46

ARI(絕對危險性增加率)=3.6%-2.7%=0.9%

NNH=1/0.9%=111


Practice applicability

Practice (applicability)

If we believe it, does it apply to our patient?

  • Can it be applied to my patient? 病患差異

  • Can it be done here? 風土(可運用的資源)

  • How do patient values affect the decision? 民情(病患的偏好)


How to decide on the applicability of clinical trials results to your patient 1

How to Decide on the Applicability of Clinical Trials Results to Your Patient(1)

  • Biologic Issues If the treatment can work?有效~同樣的治療應用在不同的病患族群是否有不同的反應? ~我們的病人與研究中的病人是否非常不同,以致於無法應用這個研究結果?


How to decide on the applicability of clinical trials results to your patient 2

How to Decide on the Applicability of Clinical Trials Results to Your Patient(2)

  • Social and Economic Issues If the treatment will work?可行~這個治療適用於我們的診療環境嗎?

    ~病患配合度?醫療提供者(醫事人員、醫療單位、保險制度)的配合度與能力?


How to decide on the applicability of clinical trials results to your patient 3

How to Decide on the Applicability of Clinical Trials Results to Your Patient(3)

  • Epidemiologic Issues How efficient the treatment will be?~我們的病人是否有其他共病狀況可能改變治療的結果?影響有多大? ~病人可能從治療中得到什麼好處或壞處?經由治療而減少的不良後果是否比不治療有明顯的差別?


How to find and determine current best evidence

如何進行文獻搜尋及評讀how to find and determine current best evidence

  • 直接搜尋已經評讀的文獻

    - ACP journal club, Cochrane Library

  • 自行評讀文獻 - Simplify appraisal with VIP or PICO/RAMbo

  • 必要時使用評讀工具 - 如CATMaker, CASP


5602004

我們的臨床狀況

  • An 80 year-old Chinese women with 20 years of type 2 DM with triopathy, dyslipidemia, and under medications.

  • Recent myocardial infarction 6 months ago.

  • Poor glycemic control, HbA1c: 10, fasting sugar usually above 200.


Am j med 2004 feb 15 116 4 230 5

假設以下為您找到的文獻之一Am J Med. 2004 Feb 15;116(4):230-5


1 paul glasziou university of oxford

逐步逐項嚴格評讀該文獻(1)Paul Glasziou, University of Oxford

確認該研究所提出的問題及所回答的問題(PICO)-PURPOSE


2 paul glasziou university of oxford

逐步逐項嚴格評讀該文獻(2)Paul Glasziou, University of Oxford

確認該研究的內部效度 (V-R1-randomization) -METHOD


3 paul glasziou university of oxford

逐步逐項嚴格評讀該文獻(3)Paul Glasziou, University of Oxford

確認該研究的內部效度 (V-R2-similarity)- RESULTthe result should have a table of “baseline characteristics” (always table 1)


4 paul glasziou university of oxford

逐步逐項嚴格評讀該文獻(4)Paul Glasziou, University of Oxford

確認該研究的內部效度 (V-A-accounted)-RESULT


5 paul glasziou university of oxford

逐步逐項嚴格評讀該文獻(5)Paul Glasziou, University of Oxford

確認該研究的內部效度 (V-M-measurement/blind)-METHOD&RESULT


6 paul glasziou university of oxford

逐步逐項嚴格評讀該文獻(6)Paul Glasziou, University of Oxford

若該研究通過效度審核,審視並解讀其結果。該介入的效果有多大? 相關性如何?(I)—RESULT


7 paul glasziou university of oxford

逐步逐項嚴格評讀該文獻(7)Paul Glasziou, University of Oxford

確認該研究結果是否可以運用在我們上述的病人身上?應如何應用? (P)

DO IT YOURSELF!!


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