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EBM 在臨床上的應用及發展現況

台北醫學大學．市立萬芳醫院. EBM 在臨床上的應用及發展現況. 陳杰峰 台北醫學大學市立萬芳醫院 實證醫學中心 整形外科 地點 : 門諾醫院 時間 : 2008/5/23 8:10-9:00 clifchen@tmu.edu.tw http://www.wanfang.gov.tw/ebm. EBM— 醫學的知識轉譯. 一種將 ” 科學研究證據 ” 用以改善 ” 專業執行成果 ” 的活動或固定流程

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EBM 在臨床上的應用及發展現況

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  1. 台北醫學大學．市立萬芳醫院 EBM在臨床上的應用及發展現況 陳杰峰 台北醫學大學市立萬芳醫院 實證醫學中心 整形外科 地點:門諾醫院 時間: 2008/5/23 8:10-9:00 clifchen@tmu.edu.tw http://www.wanfang.gov.tw/ebm

  2. EBM—醫學的知識轉譯 一種將”科學研究證據”用以改善”專業執行成果”的活動或固定流程 Knowledge Translation (or KT)(知識轉譯) describes either a structured process or the activity that results in scientifically researched evidence being used to improve the outcomes of professional practice. http://en.wikipedia.org/wiki/Knowledge_translation

  3. 注意到>接受>可行>有能力做>開始做>認同>養成習慣注意到>接受>可行>有能力做>開始做>認同>養成習慣 Unsound Research Aware Accepted Applicable Able Acted on Agreed Adhered to Sound Research Systems Summaries Synopses Syntheses Studies Modify from “Straus et al.: Evidence-based medicine, Elsevier Ltd., 2005”, Brian Haynes, R Evid Based Med 2006;11:162-164 實證醫學之知識轉譯地圖 --from bench to bed (“B2B” : “5S” , “7A”) 7A 5S

  4. 洗手有那麼難嗎? Richard Grol; Jeremy Grimshaw. From best evidence to best practice: Effective implementation of change in patients' care. The Lancet; Oct 11, 2003; 362,9391. pg. 1225

  5. 推動洗手運動的效果 Richard Grol; Jeremy Grimshaw. From best evidence to best practice: Effective implementation of change in patients' care. The Lancet; Oct 11, 2003; 362,9391. pg. 1225

  6. (Burt & Hing, 2005) 據美國CDC(Centers for Disease Control)2005年的統計資料顯示，其診所門診含CDSS之電子醫令的普及率不到10%

  7. Conclusion

  8. EBM Steps ．Answerable Question ．Search + ．Appraise Apply Time ：6 minutes Systematic Review Steps ． Answerable Question ．Search ++++ ．Appraise × 2 ．Synthesize Apply Time ：6 months 我們需要哪種搜尋策略?When systematic reviews are not available, clinicians need efficient strategies for identifying relevant research 摘錄自Paul Glasziou ‘s lecture, 2006

  9. “Doer” or “User”製造者或使用者 • Doer • Clinical trial (重工業) • Systematic review (輕工業) • Guideline development • ?% of us are “Users” only. U D

  10. EBM 3大步驟 Knowledge gap Knowing-doing gap

  11. 台北醫學大學．市立萬芳醫院 實證醫學(1)提出問題 (Asking An Answerable Question)

  12. Universal Doubt : ---笛卡兒 Rene Descartes 1596-1650 • I think therefore I am. (我思故我在) • Self-evident • I • Think : doubt

  13. 實證醫學—問題日誌 • 編譯: 萬芳醫院 EBM Center • 2007

  14. 問題日誌案例 • CVP放置7天一定要換嗎?

  15. Clinical bottom line • Pulmonary and peripheral artery catheters need not be routinely replaced more often than every 5–7 days • Other short-term CVCs and arterial catheters need not be routinely replaced • Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002 Nov;81(6):466-79.

  16. reference • Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002 Nov;81(6):466-79. • Single citation matcher (PubMed)

  17. appraisal • Level Ib

  18. action Action的空白頁留給大家填…

  19. 台北醫學大學．市立萬芳醫院 實證醫學(2)搜尋及評讀文獻

  20. Dave Sackett Evidence Cart -CEBM - Centre for Evidence Based Medicine

  21. Mobile CDSS • 行動資訊車

  22. Questions answerable by an EBM resource Koonce TY, Giuse NB, Todd P. Evidence-based databases versus primary medical literature: an in-house investigation on their optimal use. J Med Libr Assoc. 2004 Oct;92(4):407-11.

  23. Usefulness 效益 = relevance 關聯 x validity 效力 • work 工作 尋找資料: 操作策略Finding data: Practice strategy Slawson, 1994

  24. How EBM Helps CME? • 「灌輸」(push) :「以防萬一(備用)」學習法(“just in case” learning) • SkolarMD • MDConsult • Cochrane databases • 「汲取」(pull): 「恰如其時(即時)」學習法(“just in time” learning) • Auto alert or MyNCBI • Google 快訊

  25. POC (Point of Care) Searching

  26. 台北醫學大學．市立萬芳醫院 實證醫學(3)應用及評估

  27. 對過程進行稽核

  28. 評估成果及標準化

  29. 臨床診療指引（clinical practice guideline） • 「這是一種系統化製作的陳述，用來幫助臨床工作者或是病患，在面臨特定的臨床狀況時，能做出合適的健康照護決策」 • Systemically defined statements to assist practitioner and patient decisions about appropriate health care of specific circumstances. -------Institutes of Medicine, 1990

  30. Evolution of Evidence-Based Medicine Opinion –based Medicine Physician Centered EBM Patient Centered EBM • Relies on memory • Emphasizes experience • Popularized since 1992 • Emphasize published clinical science • Practitioner experience is important • Acknowledge patient values • Emphasize clinical evidence • Focus on patient understanding • Integrate physician experience with patient values

  31. 台北醫學大學．市立萬芳醫院 國內外實證醫學之新發展

  32. http://www.nhi.gov.tw/webdata/AttachFiles/Attach_613_1_CPG.pdfhttp://www.nhi.gov.tw/webdata/AttachFiles/Attach_613_1_CPG.pdf

  33. Dave Sackett Clinical Epidemiology - 臨床流行病學

  34. 實證醫學:臨床實踐與教學指引(Evidence-Based Medicine: How to Practice and Teach EBM with CD-ROM 3/e) • 出版者 : 合記 • 出版年代 : 2007

  35. 實證醫學—醫療照護決策 • 總編譯: 郭耿南教授 • 出版者 : 合記 • 出版年代 : 2007

  36. 編著者：財團法人彰化基　　　　督教醫院 出版社：藝軒圖書出版社 　　　　(2006)

  37. 「實證臨床指引平台」http://ebpg.nhri.org.tw--國家衛生研究院「實證臨床指引平台」http://ebpg.nhri.org.tw--國家衛生研究院

  38. 美國近期EBM發展～Roundtable on Evidence-Based Medicine, Institute of Medicine

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