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Step 3. Critical appraisal

Step 3. Critical appraisal. 家庭醫學科 王慈蜂醫師. 台北醫學大學　市立萬芳醫院. What is CAT?. Systematic evaluation of study/studies To critically appraise -- not only “read”, but also “assess” Simplify appraisal with VIP or PICO / RAM bo.

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Step 3. Critical appraisal

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  1. Step 3. Critical appraisal 家庭醫學科 王慈蜂醫師 台北醫學大學　市立萬芳醫院

  2. What is CAT? • Systematic evaluation of study/studies • To critically appraise -- not only “read”, but also “assess” • Simplify appraisal with VIP or PICO/RAMbo

  3. CRITICAL APPRAISAL SKILLSWhat is VIP? Validity (Reliability) 效度/信度 Can we believe it ? (研究方法的探討) Importance (Impact) 重要性 We believe it ! But does it matter? (研究結果的分析) Practice (Applicability) 臨床適用性 If we believe it - does it apply to our patients? (如何在臨床運用)

  4. CRITICAL APPRAISAL SKILLS What is the RAMbo? • Randomized • Accounted for all patients • Measurement: blinded or objective

  5. Valid (Reliable) “ Do we believe it? ” • Was it randomised? • Were the groups similar? • Was it blinded?

  6. “該治療性研究結果是可信的嗎?” EVIDENCE-BASED MEDICINE How to Practice and Teach EBM • 病人的治療分派是否為隨機? 隨機方式是否恰當? • 實驗開始前，實驗組及對照組是否相似、可比較? • 病人追蹤是否夠久、夠完整? • 所有病人是否依其原先分派組別作分析? • 病人及醫師是否對治療不知情(blind)? • 實驗組及對照組是否被同等對待?

  7. 該治療性研究結果是可信的嗎?” EVIDENCE-BASED MEDICINE How to Practice and Teach EBM • 病人的治療分派是否為隨機? 隨機方式是否恰當? • 實驗開始前，實驗組及對照組是否相似、可比較? • 病人追蹤是否夠久、夠完整? • 所有病人是否依其原先分派組別作分析? • 病人及醫師是否對治療不知情(blind)? • 實驗組及對照組是否被同等對待?

  8. 該研究結果是可信的嗎?” EVIDENCE-BASED MEDICINE How to Practice and Teach EBM • 病人的治療分派是否為隨機? 隨機方式是否恰當? • 實驗開始前，實驗組及對照組是否相似、可比較? • 病人追蹤是否夠久、夠完整? • 所有病人是否依其原先分派組別作分析? • 病人及醫師是否對治療不知情(blind)? • 實驗組及對照組是否被同等對待?

  9. Importance (impact) “ We believe it !But-does it matter? ” • What were the results?-How large was the treatment effect? -How precise was the estimate of the treatment effect?

  10. Therapy:“Will treatment with interferon decrease the risk of progression in MS patients?” • Number needed to treat (NNT) • Number needed to harm (NNH) • Relative risk (RR) • Relative risk reduction (RRR) • Absolute risk reduction (ARR) • Event rates (ER)

  11. Practice (applicability) If we believe it, does it apply to our patient? • Can it be applied to my patient? 病患差異 • Can it be done here? 風土(可運用的資源) • How do patient values affect the decision? 民情(病患的偏好)

  12. How to Decide on the Applicability of Clinical Trials Results to Your Patient(I) • Biologic Issues If the treatment can work?有效~同樣的治療應用在不同的病患族群是否有不同的反應? ~我們的病人與研究中的病人是否非常不同，以致於無法應用這個研究結果？

  13. How to Decide on the Applicability of Clinical Trials Results to Your Patient(II) • Social and Economic Issues If the treatment will work?可行~這個治療適用於我們的診療環境嗎？ ~病患配合度? ~醫療提供者(醫事人員、醫療單位)的配合度與能力?

  14. How to Decide on the Applicability of Clinical Trials Results to Your Patient(III) • Epidemiologic Issues How efficient the treatment will be?~我們的病人是否有其他共病狀況可能改變治療的結果?影響有多大? ~病人可能從治療中得到什麼好處或壞處？ ~經由治療而減少的不良後果是否比不治療有明顯的差別?

  15. 如何進行文獻搜尋及評讀(1)how to find and determine current best evidence ※直接搜尋已經評讀的文獻 ■ACP journal club, Cochrane Library ※自行評讀文獻

  16. 如何進行文獻搜尋及評讀(2)how to find and determine current best evidence ※直接搜尋已經評讀的文獻 ※自行評讀文獻■必要時使用評讀工具, 如 CATMaker, CASP

  17. Where to get CATMaker/CASP? \ • http://www.cebm.net • http://www.phru.nhs.uk/casp/casp.htm

  18. Our clinical scenario • An 80 year-old Chinese women with 20 years of type 2 DM with triopathy, dyslipidemia, and under medications. • Recent myocardial infarction 6 months ago. • Poor glycemic control, HbA1c: 10, fasting sugar usually above 200.

  19. Am J Med. 2004 Feb 15;116(4):230-5 台北醫學大學　市立萬芳醫院

  20. Our CAT results with CATmaker) NNH=4 In insulin group

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