循证医学和循证口腔医学2012-12-13.ppt

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 如何选择急需解决的问题？ 在临床实践中，每天都会要面临许多问 题，一下解决所有问题是不可能的 在病人的诊治过程中，哪一个问题最重 要？ 在现在有限的时间内，最有可能回答哪一个 问题？ 最感兴趣的问题是什么？ 哪一个问题在临床实践中经常遇到？ Anatomy of a good clinical question: PICO P = Patient or problem I = Intervention, prognostic factor, or exposure C = Comparison O = Outcomes Patient / Problem heart failure, ejection fraction 40%, elderly Intervention Irbesartan 厄贝沙坦片，苏适，伊贝沙坦 Comparison, if any none, placebo, standard care Outcome primary: reduce need for hospitalization; secondary: reduce mortality ??? 3.2 查寻最好的证据 教科书、专著、专业杂志 电子出版物 Cochrane library MEDLINE(1966-) EMBASE Sciensearch(Science Citation Index) 中国生物医学文献数据库 CBMdisc (1981-) 累积期刊索引 查寻的策略 要系统、全面地查寻与某一临床问题相关的必威体育精装版信息，检索前确定检索的渠道和资料库，具体检索方法、检索年限和语种等。 采用多种渠道查寻，避免遗漏重要信息； 图书管理员共同检索 提高检索的敏感性和特异性； 正确应用检索词 先用多个检索词或意义相近的检索词进行检索，然后逐渐缩窄范围。检索词应包括：研究的疾病、采用的干预措施以及研究的设计方案等，检索词应明确、具体。 ? 3.3 评价临床证据 临床证据的评价包括两方面的内容：◆证据的真实性(validity) ◆临床重要性(importance) ●应对病因、诊断、治疗、预后等方面证据评价 Are the results valid? Random sequence generation (selection bias): Selection bias (biased allocation to interventions) due to inadequate generation of a randomised sequence; Allocation concealment (selection bias): Selection bias (biased allocation to interventions) due to inadequate concealment of the allocation; Blinding of participants and personnel (performance bias): Performance bias due to knowledge of the allocated interventions by participants and personnel during the study; Blinding of outcome assessment (detection bias): Detection bias due to knowledge of the allocated interventions by outcome assessors; Incomplete outcome data (attrition bias): Attrition bias due to incomplete outcome data; Selective reporting (reporting bias): Reporting bias due to selective outcome reporting; Other bias: Bias due to problems not covered by the above 6 items, such as baseline imbalance, confounding bias, contamination and co-intervention, etc. GRADE Working Group grades of e