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序言序言

衛生署台北醫院衛生署台北醫院 丁賢偉醫師丁賢偉醫師

元智大學資訊管理學系元智大學資訊管理學系 講師講師

9898年年99月月2424日日

Reference：實證醫學----臨床實踐與教學指引

何謂實證醫學何謂實證醫學

將以下各方面進行統整將以下各方面進行統整

最佳研究證據最佳研究證據

臨床專家意見臨床專家意見

病人獨特價值觀病人獨特價值觀

臨床狀況臨床狀況

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最佳研究證據最佳研究證據

有效且與臨床相關的研究有效且與臨床相關的研究

通常來自於基礎醫學通常來自於基礎醫學

以病人為中心以病人為中心

‧‧確認診斷試驗的準確性確認診斷試驗的準確性

‧‧預後指標的效力預後指標的效力

‧‧治療、復健以及預防方案的有效性與安全性治療、復健以及預防方案的有效性與安全性

來自臨床的新證據，不僅可以取代先前的來自臨床的新證據，不僅可以取代先前的診斷與治療的方法，並以更有效、更精診斷與治療的方法，並以更有效、更精確、更安全的方法取代之確、更安全的方法取代之

臨床專家意見臨床專家意見

運用個人臨床技能與過去經驗的能力運用個人臨床技能與過去經驗的能力

快速檢驗每一個病人快速檢驗每一個病人

‧‧獨一無二的健康狀態獨一無二的健康狀態

‧‧診斷診斷

‧‧各別風險各別風險

‧‧可能介入的益處可能介入的益處

‧‧病人個人狀況與期望病人個人狀況與期望

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病人獨特的價值觀與臨床狀況病人獨特的價值觀與臨床狀況

病人獨特的價值觀病人獨特的價值觀

•• 個人偏好個人偏好•• 關注關注•• 期望期望

臨床狀況臨床狀況

‧‧病人個別的臨床狀態與情境病人個別的臨床狀態與情境

為何要發展實證醫學為何要發展實證醫學

每天都需要確認與診斷每天都需要確認與診斷、、預後預後、、治療與預防相關的治療與預防相關的資訊資訊

傳統資訊來源的不適當傳統資訊來源的不適當•• 過時過時•• 錯誤頻傳錯誤頻傳•• 無效無效•• 數量過於龐大數量過於龐大•• 效度差異太大而不易在臨床應用效度差異太大而不易在臨床應用診斷技巧診斷技巧//臨床判斷與新知識臨床判斷與新知識//臨床表現之間的落臨床表現之間的落差差，前者會因經驗累積而增加，後者卻會逐漸退步，前者會因經驗累積而增加，後者卻會逐漸退步

不會為每一位病人多花時間來發現與理解證據不會為每一位病人多花時間來發現與理解證據

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實證醫學的五大發展實證醫學的五大發展

發展有效追蹤與評讀證據的策略發展有效追蹤與評讀證據的策略((針對證據針對證據的有效性與相關性的有效性與相關性))製造關於醫療照護效果的系統性回顧製造關於醫療照護效果的系統性回顧

出版時正期刊以及出版如出版時正期刊以及出版如Clinical EvidenceClinical Evidence之類的實證摘要之類的實證摘要

創造在幾秒內取得知識的資訊系統創造在幾秒內取得知識的資訊系統

找出並應用有效的策略終身學習找出並應用有效的策略終身學習，讓臨床，讓臨床表現不斷進步表現不斷進步

實證醫學施行五大步驟實證醫學施行五大步驟

針對資訊需求，轉換成可回答的問題針對資訊需求，轉換成可回答的問題‧‧包括預防、診斷、預後、治療與注意事項包括預防、診斷、預後、治療與注意事項

搜尋最佳證據，並據以回答該問題搜尋最佳證據，並據以回答該問題

嚴格評讀該證據嚴格評讀該證據‧‧正確性正確性

‧‧影響力影響力

‧‧適用性適用性

將評讀結果與臨床專業、病人獨特的生物將評讀結果與臨床專業、病人獨特的生物特性、價值觀與情境相結合特性、價值觀與情境相結合

評估執行的成效並尋求改善方案評估執行的成效並尋求改善方案

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臨床醫師通常使用的三大模式臨床醫師通常使用的三大模式

操作模式：至少會執行前四項步驟操作模式：至少會執行前四項步驟

使用模式：僅限於預先評讀過的實證資使用模式：僅限於預先評讀過的實證資訊，通常會略過第三步驟訊，通常會略過第三步驟

複製模式：以意見領袖的意見為最高指導複製模式：以意見領袖的意見為最高指導原則，至少會放棄第二與第三步驟原則，至少會放棄第二與第三步驟

因此我們平時應時常練習第二與第三步驟因此我們平時應時常練習第二與第三步驟((進行資料搜尋與評讀進行資料搜尋與評讀))亦可略過第三步驟，找尋已被嚴格評讀過亦可略過第三步驟，找尋已被嚴格評讀過的資源的資源

我們在實證醫學所扮演的角色我們在實證醫學所扮演的角色

精通實證醫學五大步驟的臨床醫師精通實證醫學五大步驟的臨床醫師

專注成為有效率的證據使用者專注成為有效率的證據使用者

成為知識管理者成為知識管理者

知識複製者知識複製者

‧‧服從權威服從權威??

‧‧經過評讀模式的資訊經過評讀模式的資訊??

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臨床醫師可以確實實行實證醫學嗎臨床醫師可以確實實行實證醫學嗎??

對學習實證醫學技能很感興趣對學習實證醫學技能很感興趣

對實證醫學術語理解程度的自我認知比實對實證醫學術語理解程度的自我認知比實際的能力為高際的能力為高

對實證醫學術語時常誤解對實證醫學術語時常誤解

臨床醫師若是有輔助系統，可以輕易的實臨床醫師若是有輔助系統，可以輕易的實行實證醫學技能以照顧病人行實證醫學技能以照顧病人

實證醫學技能可以改變資淺醫師其診斷與實證醫學技能可以改變資淺醫師其診斷與治療能力治療能力25%~48%25%~48%

實證醫學的誤解實證醫學的誤解

忽略病人的價值觀與喜好忽略病人的價值觀與喜好

食譜醫療：按譜操作的醫療食譜醫療：按譜操作的醫療

‧‧看看實證醫學的定義看看實證醫學的定義

成為管理者降低成本的工具成為管理者降低成本的工具

‧‧促進病人生活品質通常會增加成本促進病人生活品質通常會增加成本

實證醫學只是學術象牙塔的研究實證醫學只是學術象牙塔的研究

‧‧許多醫師自稱利用了許多醫師自稱利用了““使用模式使用模式＂＂進行診療進行診療

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實證醫學的限制實證醫學的限制

需要新技術來蒐集與評估證據需要新技術來蒐集與評估證據

在有限的臨床時間發展並應用這些技術在有限的臨床時間發展並應用這些技術

可能藉用的技術可能藉用的技術‧‧Information Retrieval TechnologyInformation Retrieval Technology‧‧Text Mining TechnologyText Mining Technology‧‧Decision Support SystemDecision Support System‧‧Statistical Methodology for Systemic Statistical Methodology for Systemic

Review and Meta Analysis Review and Meta Analysis ‧‧New Technology for Literature Appraisal New Technology for Literature Appraisal

Search StrategySearch Strategy

衛生署台北醫院衛生署台北醫院 丁賢偉醫師丁賢偉醫師

元智大學資訊管理學系元智大學資訊管理學系 講師講師

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OutlineOutline

Strategic approach to locating Strategic approach to locating studiesstudiesDesigning a search strategyDesigning a search strategyTips to search Tips to search PubMedPubMedDocumenting a searchDocumenting a search

Contexts Contexts

Clinical careClinical care

Clinical educationsClinical educations

Clinical research Clinical research

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Use Multiple Sources and Start Use Multiple Sources and Start with Highest Yield with Highest Yield

•• Electronic databasesElectronic databasesCochrane Review Group registerCochrane Review Group registerCochrane Central Register of Controlled Trials Cochrane Central Register of Controlled Trials (CENTRAL)(CENTRAL)UpToDateUpToDateMDConsultMDConsultMicromedexMicromedexPubMedPubMed/Medline/MedlineEMBASEEMBASEOther databases Other databases –– depends on your topicsdepends on your topics

Other ReferencesOther References

Reference list of trial and reviewsReference list of trial and reviewsHandsearchingHandsearching journal and journal and conference proceedingsconference proceedings•• Index Index MedicusMedicusPersonal communicationsPersonal communications

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Design a Search StrategyDesign a Search Strategy

Formulate a focused question (PICO)Formulate a focused question (PICO)Identify SEARCH terms from the Identify SEARCH terms from the elements of the focused questionselements of the focused questionsCombine the SEARCH terms Combine the SEARCH terms Search the databasesSearch the databases

Focused QuestionsFocused Questions

Translate the clinical problem into a Translate the clinical problem into a focused questionfocused question

Does back brace improve outcomes in Does back brace improve outcomes in patients undergoing lumbar disc surgery?patients undergoing lumbar disc surgery?

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Extract the PICO terms from the Extract the PICO terms from the Focused QuestionFocused Question

RCT, systemic reviewsRCT, systemic reviewsDesign Design

Pain, QOL, mobility, LOSPain, QOL, mobility, LOSOutcome Outcome

No back braceNo back braceControl Control

Back brace Back brace Interventions Interventions

Lumbar disc surgery patientsLumbar disc surgery patientsPatients or ProblemsPatients or Problems

PICOD NotePICOD Note

Not all PICOD terms are equally useful for Not all PICOD terms are equally useful for searchingsearching•• Typically start with P & ITypically start with P & I•• C is useful if s specific comparator in namesC is useful if s specific comparator in names

e.g.: placebo or active treatmente.g.: placebo or active treatment•• D is useful for limiting search to goldD is useful for limiting search to gold--standard standard

designdesign

DO NOT have to use all PICOD elements, DO NOT have to use all PICOD elements, sometimes just 2 will sufficesometimes just 2 will sufficeSearching is an iterative process (try and Searching is an iterative process (try and error)error)DO NOT expect to get it right at the FIRST DO NOT expect to get it right at the FIRST

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Searching ProcessesSearching Processes

Using FreeUsing Free--text termstext termsUsing Using MeSHMeSH termstermsUSE search box with ORUSE search box with ORPreview the resultsPreview the resultsCombine P and I using ANDCombine P and I using ANDClick Click ““DetailsDetails”” to read syntaxto read syntaxDocumenting your SearchDocumenting your Search

The Searching Strategy OutlineThe Searching Strategy Outline

Which of the PICOD elements will I Which of the PICOD elements will I initially useinitially useShall I do both Shall I do both MeSHMeSH and/or freeand/or free--text searchestext searchesShall I limit the searchShall I limit the search

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Search NoteSearch Note

DO NOT limit search on DO NOT limit search on •• LanguageLanguage•• Sources (which journal, database, etc.)Sources (which journal, database, etc.)•• Publication status (full article, conference Publication status (full article, conference

abstract, unpublished, etc.)abstract, unpublished, etc.)•• Publications datePublications date

FOCUS the search FOCUS the search •• Clinical trialClinical trial•• MetaMeta--analysisanalysis•• Randomized control trial (RCT)Randomized control trial (RCT)•• Review Review

Summary of ProcessSummary of Process

Decide on the searchable PICO termsDecide on the searchable PICO termsFind the closest matching Find the closest matching MeSHMeSHterms and freeterms and free--text termstext termsCombine the terms within PICO Combine the terms within PICO elements with OR and searchelements with OR and searchCombine the searches across 2 or Combine the searches across 2 or more PICO elements with ANDmore PICO elements with ANDUse limit and additional PICO Use limit and additional PICO elements to further narrow the elements to further narrow the search if necessary search if necessary

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Too Many ReferencesToo Many References

Is your topic too broad?Is your topic too broad?Is your question focused enough?Is your question focused enough?Have you used enough PICO Have you used enough PICO elements?elements?Have you mistakenly used OR Have you mistakenly used OR instead of AND to combine across instead of AND to combine across PICO elements?PICO elements?Try using limitsTry using limitsTry using NOT to exclude specific Try using NOT to exclude specific articlesarticles

Too Few ReferencesToo Few ReferencesIs your topic too focused? Is your topic too focused? Try using Try using MeSHMeSH searches to capture all synonymssearches to capture all synonymsHave you used too many PICO elements?Have you used too many PICO elements?Have you mistakenly used AND instead of OR to Have you mistakenly used AND instead of OR to combine within PICO elements?combine within PICO elements?DO NOT use NOTDO NOT use NOTHave you left the limits function on by mistake?Have you left the limits function on by mistake?Try checking known references for relevant key Try checking known references for relevant key words words Are you searching the right database?Are you searching the right database?Is the terminology just too Is the terminology just too unstandardizedunstandardized & & inconsistently used in this field? inconsistently used in this field?

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Q and AQ and A

1

Search StrategySearch Strategy

衛生署台北醫院衛生署台北醫院 丁賢偉醫師丁賢偉醫師

元智大學資訊管理學系元智大學資訊管理學系 講師講師

OutlineOutline

• Strategic approach to locating studies• Designing a search strategy• Tips to search PubMed• Documenting a search

2

Contexts Contexts

• Clinical care

• Clinical educations

• Clinical research

Use Multiple Sources and Start Use Multiple Sources and Start with Highest Yield with Highest Yield

– Electronic databases• Cochrane Review Group register• Cochrane Central Register of Controlled Trials

(CENTRAL)• UpToDate• MDConsult• Micromedex• PubMed/Medline• EMBASE• Other databases – depends on your topics

3

Other ReferencesOther References

• Reference list of trial and reviews• Handsearching journal and conference

proceedings– Index Medicus

• Personal communications

Design a Search StrategyDesign a Search Strategy

• Formulate a focused question (PICO)• Identify SEARCH terms from the elements

of the focused questions• Combine the SEARCH terms • Search the databases

4

Focused QuestionsFocused Questions

• Translate the clinical problem into a focused question

Does back brace improve outcomes in patients undergoing lumbar disc surgery?

Extract the PICO terms from the Extract the PICO terms from the Focused QuestionFocused Question

RCT, systemic reviewsDesign

Pain, QOL, mobility, LOSOutcome

No back braceControl

Back brace Interventions

Lumbar disc surgery patientsPatients or Problems

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PICOD NotePICOD Note

• Not all PICOD terms are equally useful for searching– Typically start with P & I– C is useful if s specific comparator in names

e.g.: placebo or active treatment– D is useful for limiting search to gold-standard design

• DO NOT have to use all PICOD elements, sometimes just 2 will suffice

• Searching is an iterative process (try and error)• DO NOT expect to get it right at the FIRST TIME

Searching ProcessesSearching Processes

• Using Free-text terms• Using MeSH terms• USE search box with OR• Preview the results• Combine P and I using AND• Click “Details” to read syntax• Documenting your Search

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The Searching Strategy OutlineThe Searching Strategy Outline

• Which of the PICOD elements will I initially use

• Shall I do both MeSH and/or free-text searches

• Shall I limit the search

Search NoteSearch Note

• DO NOT limit search on – Language– Sources (which journal, database, etc.)– Publication status (full article, conference abstract,

unpublished, etc.)– Publications date

• FOCUS the search – Clinical trial– Meta-analysis– Randomized control trial (RCT)– Review

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Summary of ProcessSummary of Process

• Decide on the searchable PICO terms• Find the closest matching MeSH terms

and free-text terms• Combine the terms within PICO elements

with OR and search• Combine the searches across 2 or more

PICO elements with AND• Use limit and additional PICO elements to

further narrow the search if necessary

Too Many ReferencesToo Many References

• Is your topic too broad?• Is your question focused enough?• Have you used enough PICO elements?• Have you mistakenly used OR instead of

AND to combine across PICO elements?• Try using limits• Try using NOT to exclude specific articles

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Too Few ReferencesToo Few References• Is your topic too focused? • Try using MeSH searches to capture all synonyms• Have you used too many PICO elements?• Have you mistakenly used AND instead of OR to combine

within PICO elements?• DO NOT use NOT• Have you left the limits function on by mistake?• Try checking known references for relevant key words • Are you searching the right database?• Is the terminology just too unstandardized & inconsistently

used in this field?

Q and AQ and A