循证医学临床实践步骤第七节Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.循证医学实践的五步曲1、确定拟弄清的问题l人群/病人l干预措施l比较l结局指标l检索策略l电子检索 l手工检索3、严格评价证据l真实性l重要性l适应性4、得出结论l肯定的最佳证据：推荐临床应用 l无效或有害：建议停止或废弃临床应用 l尚无证据：建议进一步研究5、后效评价、与时俱进lEvidence is never enough l不断更新 l终身教育2、全面查找证据Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.收集证据证据评价提出问题临床决策循证医学实践的步骤后效 评价 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.临床问 题 病因 诊断 治疗 预后 这些问题临床医生 关心,患者也关心关键的一步关键的一步提出临床问题Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.n 疑难 癌证的抗病毒疗效是否确切？ n 重要 阿司匹林是否能降低急性脑梗死患者的短期死亡率？ n 发展 抗菌药在消化道溃疡疾病中的应用前景如何？ n 提高 冠心病二级预防措施中可否常规应用他汀药？提出临床问题Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.u针对所提出的临床问题开始设计收集相关证据u收集证据的途径 文献检索科学研究http:/www.websters-online-dictionary.org/收集证据Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 期刊、电子光盘检索； 参考文献目录； 与同事、专家、药厂联系获得未发表的文献 ，如学术报告、会议论文、毕业论文等； 个人通信； 电子数据库。收集证据文献检索Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 真实性：研究结果是否真实可信? 重要性：研究结果的是什么?有多大? 适用性：研究结果能否应用于我的病人？证据评价Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.研究方法选择 一般来讲病因研究以队列研究或巢式病例对照研究提供的证据最佳,临床治疗试验以随机对照试验最佳。证据金字塔证据评价真实性Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.研究对象选择 临床研究所选用的对象主要是病人,评价时要考虑诊断标准是否可靠、所选的病例是否具有代表性、分组是否坚持随机化、研究所用的样本是否足够大等。证据评价真实性Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.因素确定 研究中所选用的观测指标应当客观、定量、稳定、灵敏,否则研究的结果是不可靠的。盲法观察 这是衡量一项研究真实性的重要条件之一,只有按照盲法设计的临床研究所得到的结论才具有真实性。非盲法设计的临床研究证据是不可采用的。我猜我猜我猜猜猜宏观(社会因素 )微观(分子水平 )证据评价真实性Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.统计分析方法统计分析方法 未进行统计检验的证据不能排除机遇未进行统计检验的证据不能排除机遇可能可能, ,也就不能采用。如果进行了统计学检验也就不能采用。如果进行了统计学检验, ,其方法其方法选择是否恰当选择是否恰当, ,应用是否合理也应当进行分析。应用是否合理也应当进行分析。偏倚的认识与控制偏倚的认识与控制 如果文献未讨论可能发生的偏倚如果文献未讨论可能发生的偏倚, ,或未采取控制措施或未采取控制措施, ,或采取的措施不足以控制偏倚或采取的措施不足以控制偏倚, ,其其证据是不真实的。证据是不真实的。证据评价真实性Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.根据证据的质量和可靠程度分为5个等级 A级：全部随机对照试验的协调评价 B级：单个大样本的随机对照试验 C级：非随机的对照研究 D级：无对照的系列病例观察 E级：专家意见证据评价重要性Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.结果能否用于自己的病人检查样本的代表性：研究人群与我的病人越接近，应用结果的把握就越大是否考虑到临床上所有的重要结果治疗的利与弊 治疗作用； 不良事件； 费用证据评价适用性Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.临床决策是针对一个患者所制定的一系列诊治方案。将获取的最佳证据结合医院的具体情况、以往的经验、社会的接受能力、病人的自身情况等提出的新方案。通过决策分析技术与传统方案比较,确定其优越性后开始应用于临床实践。 最佳证据个人经验医院情况病人意愿社会意识临床决策Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0.Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd.当临床决策确定以后，开始具体实施决策的内容,这就是临床实践的过程