临床应用 張明揚醫師 .pptVIP

Evidence-Based Medicine臨床應用 張明揚醫師 長庚醫院內科部 2002-7-2 Medical Education in the New Century Patient-centered care Problem-based learning Evidence-Based Medicine Bioinformatics 醫學人文教育 Evidence-based Medicine Use of current best evidence in making decisions about the care of individual patients. Not only a skill but also an attitude change. Moving From Opinion-based Medicine to Evidenced-based Medicine Decision Making in Health Care Toss coins Guess “Do no harm.” Remember what you learned during your professional training Ask colleagues Text books Browse journals Searching bibliographic databases History Archie Cochrane : 1972 Effectiveness and Efficiency Dave Sackett: 1980‘s at McMaster University: Canada 1992:UK: Cochrane Collaboration by NHS(national health service) for review group. 1997:USA:12 EBPC(evidence based practice center) by AHCPR. Five Steps to Practice EBM Step 1 - converting the need for information into an answerable question Step 2 - searching the best evidence with which to answer that question Step 3 – appraising the evidence for its validity, impact, and applicability Step 4 – integrating the evidence with our clinical expertise and patient Step 5 – evaluating our effectiveness and efficiency Asking Answerable Clinical Question A 55 y/o man, Mr. Ronado, came with severe CHF, does spironolactone combined with usual care(ACEI + beta blocker) reduce the mortality? Benefits of Secondary Journal/database Topic: clinical problem-based Time: rapid and update Form: brief summary Application: ready to use The Evidence Pyramid 數字會說話:以具體的數字呈現結果之可應用性 敏感度（sensitivity）、特異度（specificity）、概數比率（likelihood ratio）、檢測前機率（pre-test probability）、檢測後機率（post-test probability）、信賴區間(confidence interval) 相對危險度減少百分比（relative risk reduction，RRR）、絕對危險度減少百分比（absolute risk reduction，ARR）、避免一位病患罹患某種疾病所需治療人數（number needed to treat，NNT）、避免一位病患罹患某種疾病造成的醫源性傷害人數（number needed to harm，NNH） Diagnosis Calculation of OR/RR Treatment Effects Occurrence of diabetic retinopathy at 5 years