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1、實證醫學簡介與實務實證醫學簡介與實務-如何改善教學技巧如何改善教學技巧-臺北醫學大學九十二學年度教師發展中心研討會臺北醫學大學九十二學年度教師發展中心研討會Clinical Epidemiology-臨床流行病學臨床流行病學 以流行病學及統計學的方法，從龐大的醫學資料中過濾出值得信賴的部份，嚴格評讀、綜合分析、將所能獲得的最佳文獻、證據(Evidence)，與醫護人員的經驗(Experience)，及病人期望(Expectation)的結合，以應用於臨床工作中。Triple“E”of EBMEvidenceExperienceExpectationDecision Analysisupdate
2、 knowledge知識更新browsing綜覽problem solving問題導向primary journal一級雜誌secondary journal二級雜誌eg.JAMA,NEJMeg.Evidence Based Medicine,EBM reviews,讀者文摘initial questionsearchable questionSearch evidenceDave SackettEvidence Cart-CEBM-Centre for Evidence Based Medicine工具篇教學資源Oxford Centre for EBMhttp:/實施實證醫學五大步驟實施實
3、證醫學五大步驟 1.整理出一個可以回答的問題 (Asking an answerable question)2.尋找文獻證據 (Tracking down the best evidence)3.嚴格評讀文獻(Critical appraisal)4.應用於病人身上(Integrating the appraisal with clinical expertise&patients preference)。5.對過程進行稽核 (Auditing performance in step 1-4)EBM密碼QSAAQ:PECOT S:PubMedA:CATA:NNTEBM解碼QSAAQuestio
4、n:PECOTParticipantExposureComparisonOutcomesTime Search:PubMedAppraisal:CAT critical appraisal of topicsApply:NNT Number need to treatment洪清霖教授推薦醫學的讀者文摘Prefiltered DATABASESCochrane Library(HINT有)Cochrane Database of Systematic Reviews(CDSR)Cochrane Controlled Trials Register(CCTR)Database of Review
5、s of Effectiveness(DARE)NHS Economic Evaluation Database Health Technology Assessment DatabaseCochrane Library http:/EMBASE操作操作pre-filtered EBM resourceTo answer focused clinical questions,the most efficient approach is to begin with a pre-filtered evidence-based medicine resource such as Best Evide
6、nce,the Cochrane Library,or Clinical Evidence National Guideline Clearinghouse Boolean Operators(AND,OR,NOT,*,(a or b)and c)http:/Screening for breast cancer:recommendations and rationale,2002filter http:/操作Search evidenceUnfiltered DATABASESMEDLINECINAHLPsycINFOERIC(Education Resources Information
7、Center)Searching Key Words:搜尋策略搜尋策略 top downRCTCase-ControlCase ReportsOpinionsCan hyperbaric oxygenation accelerates the healing rate of nonischemic chronic diabetic foot ulcers?PECOTP:nonischemic chronic diabetic foot ulcersE:Hyperbaric oxygenation acceleratesC:wound care O:the healing rateT:one m
8、onth Text+GraphVPN(Virtual Private Network)MEDLINEIf a search of UpToDate,Best Evidence,and the Cochrane Library does not provide a satisfactory answer to a focused clinical question,it may be time to turn to MEDLINE.the first medical literature databasesomething for everyoneStepsProblem 1:You are t
9、rying to find a known paper 眾裡尋她眾裡尋她Problem 2:You want to answer a specific question 直指核心直指核心Problem 3:You want to get general information quickly about a well defined topic綜覽主題綜覽主題Problem 4:Your search gives irrelevant articles去蕪存菁去蕪存菁Problem 5:The search gives no articles,or too few 絕處逢生絕處逢生Proble
10、m 6:You dont know where to start searching無從下手無從下手Problem 7:Limiting a set loses important articles but does not exclude those of low methodological quality點石成金點石成金Problem 8:Medline hasnt helped另謀蹊徑另謀蹊徑StepsUp to 63%of all availableRCTs may be missed by a search strategy limited to MEDLINE Antman EM
11、,Lau J,Kupelnick B,Mosteller F,Chalmers TC.A comparison of results of metaanalyses of randomized control trials and recommendations of clinical experts:Treatment formyocardial infarction.JAMA.1992;268:240-247.Beyand MedlineOther Searching Strategyhandsearchingreference listsdirect contact with pharm
12、aceutical companies/researchersPubMed甲、甲、Help/FAQ http:/乙、乙、PubMed filter丙、丙、Cubby操作Search evidenceTextbooks and the InternetFinding Answers to More General Questions:Textbooks and the Internete-bookMEDLINEplus:A golden gateway to health information resources 操作原文哪裡找原文哪裡找HINT e journal eg.衛生署中辦處圖書館衛
13、生署中辦處圖書館http:/sp1.E mail圖書館圖書館 操作Try Google http:/甲、+pdf 乙、+docRecommend“Reference Manager”internet search操作The extent to which beliefs are based on evidence is very much less than believers suppose.Bertrand Russell,Skeptical Essays,1928我們所相信的事物中，證據的成分，超乎我們想像的少。教學流程篇EBMEBM結合結合PBeLPBeL教學教學How to get
14、start.Read bookLearn to do a searchDisseminate evidence based clinical practice guidelines for common conditionsEBM journal clubAttend EBM workshopSponsor an annual workshop at your institutionPractice,practice practice!Teach EBMEvidence-Based Medicine1.整理出一個可以回答的問題整理出一個可以回答的問題 (Asking An Answerable
15、 Question)提出問題提出問題,才有可能解決問題才有可能解決問題 1st stepCase Thinking process Study goalsHomework:PECOT THE 5 PARTS TO A WELL FORMULATED CLINICAL QUESTIONEach question has 5 parts that should be considered:1 1 P Patients/consumers/participants:atients/consumers/participants:2 2 E Exposure:xposure:3 3 C Comparis
16、on:omparison:What is/are the main alternative/s to compare with the exposure?Ref:New Zealand Guidelines Group(NZGG).Handbook for the preparation of explicit evidence-based clinical practice guidelines,2001 p16.4 4 OOutcome:utcome:What is really important to the patient/consumer?What does this exposu
17、re affect?Which outcomes should be considered?-intermediate or short term measures(eg lowering in cholesterol levels),mortality,morbidity and treatment complications,rates of relapse,late morbidity and readmission,return to work and physical and social functioning and other measures such as quality
18、of life,general health status.Cost to the consumer is another outcome that should be considered.5 5 T Time:ime:Over what time frame is it reasonable to expect an effect?Ref:New Zealand Guidelines Group(NZGG).Handbook for the preparation of explicit evidence-based clinical practice guidelines,2001 p1
19、6.THE 5 PARTS TO A WELL FORMULATED CLINICAL QUESTION教育處方Ref:New Zealand Guidelines Group(NZGG).Handbook for the preparation of explicit evidence-based clinical practice guidelines,2001 p46.2.尋找文獻證據尋找文獻證據(Tracking down the best evidence)In the long run,were all dead.John Maynard Keynes,1883- 2nd step
20、Review the case on the websiteReview previous established flow chartsDiscuss with the clinicianAfter the discussionHomework:Cubby3.嚴格評讀文獻嚴格評讀文獻(Critical Appraisal)Are We Doing the Right Things Right?3rd stepModify the flow charts,discuss with the tutorPresent study goals or new concept of diseases u
21、nder EBM3 to 4 days laterHomework:My Lesson-CATmaker-共同評讀軟體應用介面共同評讀軟體應用介面-CAT search-共同評讀軟體應用介面共同評讀軟體應用介面-CAT exampleCATmaker Centre for Evidence Based Medicinebottom line財務報告上頂線(top line)是營收、底線(bottom line)是利潤A companys bottom line is its net income,or the“bottom”figure on a companys income stateme
22、nt.The top line of a company is its gross sales,or revenue figure.The Evidence Pyramid圖片來源:方信元 醫師演講簡報Classification of evidence-US Agency for Health Care Policy and Research Classification(AHCPR,1992)Evidence levelDescriptionIa:evidence from meta-analysis of randomised controlled trialsIb:evidence f
23、rom at least one randomised controlled trialIIa:evidence from at least one controlled study without randomisationIIb:evidence from at least one other type of quasi-experimental studyIII:evidence from non-experimental descriptive studies,such as comparative studies,correlation studies and case-contro
24、l studiesIV:evidence from expert committee reports or opinions and/or clinical experience of respected authoritiesGrading of recommendations Eccles M et al.(1998)North of England Evidence Based Guideline Development Project:guideline for angiotensin converting enzyme inhibitors in primary care manag
25、ement of adults with symptomatic heart failure.British Medical Journal 316:1369.A directly based on category I evidence,or assigned this grading by the developers,for explicit and documented reasonsB directly based on category II evidence,or assigned this grading by the developers,for explicit and d
26、ocumented reasonsC directly based on category III evidence,or assigned this grading by the developers,for explicit and documented reasonsD directly based on category IV evidence,or assigned this grading by the developers,for explicit and documented reasons萬芳醫院實證醫學推展歷程91.04.24 於臺北醫學大學MY TMUMY TMU 開立實
27、證 醫學看版，建立知識學習的介面。/延伸學習Centre for EBM 牛津實證醫學中心http:/Critical Appraisal Skills Programme(CASP)英國國家健康保險之嚴格評讀技巧計劃http:/www.phru.nhs.uk/casp/casp.htm4.應用於病人身上應用於病人身上(Integrating the Appraisal with Clinical Expertise&Patients Preference)Information must be translated into action.EBM-Decision Support ATP-I
28、II guidelineDecision Support SystemSupport other knowledge domain userComputer Human InterfaceEfficiencyFriendly GUIQuality control5.對過程進行稽核對過程進行稽核(Auditing performance in step 1-4)Hierarchy of Outcome MeasuresBackground:Evidence-based medicine(EBM)is a part of many medical school and residency curr
29、icula worldwide,but there is little research into the most effective methods to teach these skills.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;8:4.Purpose:To evaluate whether a cour
30、se on EBM utilizing adult learning principals leads to both immediate and short-term attitudinal,confidence,and behavioral change.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;8:4.Met
31、hods:73 Internal Medicine and Internal Medicine/Pediatric residents attended a half-day seminar on EBM.Participants completed pre-and post-course 5-point Likert questionnaires,and set two personal goals for integrating EBM into their daily practice.We performed nonparametric two-sample Wilcoxon Rank
32、-Sum tests to compare responses.We also elicited the self-reported success of the residents in meeting their goals one-month post-course.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;
33、8:4.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;8:4.Results:Attitudes about EBM improved(3.5 pre-course vs.3.7 post-course),as well as self-reported EBM skills(3.0 vs.3.3).72%of res
34、idents reported having met at least one of their two goals for the integration of EBM into their practice.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;8:4.-Baum K.The impact of an ev
35、idence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;8:4.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 20
36、03;8:4.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;8:4.Conclusions:An EBM workshop based upon adult learning principles was successful in meeting multiple educational goals.The link
37、s between andragogy,learners internal drive for behavior change,and successful EBM education should be further explored.-Baum K.The impact of an evidence-based medicine workshop on residents attitudes towards and self-reported ability in evidence-based practice.Med Educ Online 2003;8:4.執行成果（九）執行成果（九
38、）課程問卷調查結果課程問卷調查結果實證醫學實證醫學態度態度前後測差異前後測差異 執行成果（十）執行成果（十）課程問卷調查結果課程問卷調查結果實證醫學實證醫學技巧技巧前後測差異前後測差異 延伸學習Oxford Centre for EBMhttp:/Canada Centre for health evidencehttp:/操作Reference How to read a paper:the Medline database New Zealand Guidelines Group(NZGG).Handbook for the preparation of explicit evidence-based clinical practice guidelines,2001.The Users Guides to Evidence-based Medicine,JAMA.(2000;283(14):1875-1879).操作陳杰峰醫師陳杰峰醫師實證醫學中心 http:/敬請指教敬請指教!