實 證 醫 學 EBM 過去、現在與未來

1. 實 證 醫 學EBM過去、現在與未來 林口長庚醫院實證醫學中心 余光輝醫師

2. Medical Education in the New Century • 醫學人文教育 • Bioinformatics • Patient-centered care • Problem-based learning • Evidence-based medicine

3. 實證醫學(EBM, Evidence-based Medicine) 以流行病學和統計學的方法，從龐大的醫學資料庫中嚴格評讀、綜合分析並找出值得信賴的部分，並將所能獲得的最佳文獻證據，應用於臨床工作中，使病人得到最佳的照顧。

4. 實證醫學沿革 • 1972年英國臨床流行病學者Archie Cochrane提出實證醫學的概念。 ~ 所有醫療行為都應有嚴謹研究且證實為有效的根據，才能將醫療資源做最有效的運用，並強調 Randomized controlled trials 的重要性。 • 1992英國國家衛生部成立實證醫學中心，並以Archie Cochrane之名命名，進而促使1993年Cochrane Collaboration的設立。(Iain Chalmers, David Sackett) Lancet 曾把Cochrane Collaboration比作臨床醫學的人類基因組計劃

5. Dr. Sydney Burwell, Dean of Harvard Medical School • Half of what you are taught as medical students will in ten years have been shown to be wrong. And the trouble is, none of your teachers knows which half.

6. E B M ※ Use of current best evidence in making decisions about the care of individual patients ※ Not only a skill but also an attitude change ※ Conscientious, explicit, and judicious use of current best evidence in making decisions about individual patients. ~ Archie Cochrane 1972

7. 實證醫學的實施 • 醫師在處置病人所面臨的問題時有許多不確定性，這種不確定性常以機率來表示。機率的估計，可以來自個人的經驗，但是免不了有某種程度的偏差，因此我們必須借重客觀可信的臨床研究結果，來作為照顧病人的主要依據。 • 實證醫學是兼具科學方法，及人文特質的診療模式，且以病人為中心，以問題為導向的精神，正確的應用可以提昇整體的醫療品質。 • 隨著資訊科技的發展，醫師與病人可以很容易的從公正、可靠的資訊中獲得以實證為基礎的相關訊息。為了要跟得上醫學最新的腳步及病人被告知的權利，提供高品質的醫療照護，實證醫學應為醫學教育的核心原則。

8. 進階學習目前國外推動實證醫學著名的單位 • 加拿大McMaster University的HIRU（Health Information Research Unit）是Cochrane Collaboration的重鎮 • http://hiru.mcmaster.ca/ • 英國OxfordUniversity的 Centre for Evidence-Based Medicine • http://cemb.jr2.ox.ac.uk • 美國American College of Physician（ACP），在全球資訊網出版 ACP Journal Club Online • http://www.acpjc.org

9. 實證醫學的五大進行步驟 Five Steps to Practice EBM • Step 1. Converting the need for information (about prevention, diagnosis, prognosis, therapy, causation, etc.) into an answerable question. • Step 2. Searching the best evidence with which to answer that question. • Step 3. Critically appraising the evidence for its validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice). • Step 4. Integratingthe evidence with our clinical expertise and patients’ unique biology, values and circumstances. • Step 5. Evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time.

10. The Evidence Pyramid Meta - analysis Randomized Controlled Double Blind Studies Randomized Controlled Studies Cohort studies Case Control Studies Case series/Reports Ideas, Editorials, Opinions Animal research In vitro (test tube) research

11. 實證醫學的五個進行步驟 • 由個案的臨床資料尋找能解答、且具體的臨床問題。﹝asking an answerable question﹞ • 尋找相關的醫學證據﹝包括各種文獻及醫學資料庫，發表及未發表的研究成果﹞。﹝searching the best evidence﹞ • 評估各種醫學報告的可信度及臨床相關性，並作成結論。﹝critical appraisal the evidence﹞ • 將結論應用於實際患者的治療。﹝臨床應用﹞ • 評估治療的效果。﹝evaluation ﹞

12. Asking Answerable Clinical Questions Well-built clinical question • “Background” question • Ask general knowledge about a disorder • Have two essential components: • A question root (who, what, why, when…) with a verb • A disorder, or an aspect of a disorder • “Foreground” question • Ask for specific knowledge about managing patients with a disorder • Have four (or three) essential components: • 1. Patient and/or problem • 2. Intervention (treatment) • 3. Comparison intervention • 4. Clinical outcomes

13. There are four elements of a well-formulated question Patient ~ Who is the patient or what is the problem being addressed? Intervention ~ What is the intervention? Comparison ~ What are the alternatives? Outcome ~ What are the outcomes?

14. Searching The Best Evidence尋找最佳實證資料 • 一是研究論文資料庫(primary journals or databases) ~ 如 Medline, NEJM, Lancet… • 或是直接使用實證醫學資料庫 (secondary journals or databases) ~ ACP journal club, Cochrane. • 盡量搜尋與病人問題相同且證據等級(level of evidence) 較高之文獻，再謹慎的評讀與評估其在此人問題的適用性。

15. 實證醫學資料庫查詢的優點 • 文獻資料可經由網路快速查詢，最新的醫學進展可以立即見於網路，比傳統教科書更update。 • 以實證醫學特有的文獻格式，表達資料取得方法及重要結果，醫師不須花很多時間便能了解其要旨，與長篇大論的傳統文獻不同。 • 利用這些資源，醫師可以節省閱讀大量文獻的時間。 • 實證醫學＝臨床流行病學＋醫學資訊學＋團隊合作

16. 實證醫學主要的四個資料庫 • ACP Journal Club:含括「ACP Journal Club」（American College of Physicians， 美國內科醫師學會出版）與「Evidence-Based Medicine」（ACP 與 British Medical Journal Group合作出版）兩種出版品，每月至少過濾50種以上之核心期刊，搜尋最佳之原始與評論性文章，結構化整理摘要出其中重要實證所得。 • DARE: Database of Abstracts of Reviews of Effectiveness 收錄評論性文章的全文型資料庫，由 National Health Services' Centre for Reviews and Dissemination（NHS CRD）組織出版， 此一組織針對部份經過評估、挑選有學術價值的醫學期刊中選出系統性評論的文章，並將之集合而成 DARE。 • CDSR：Cochrane Database of Systematic Reviews 為「Cochrane 合作研究機構」（ Cochrane Collaboration）所出版， 其為一個人與機構共同組成之國際性網路組織，有系統的研究上百種期刊文獻，專門從事有系統的評論儲備、維護和傳遞影響醫療保健相關之業務主題性評論。 • CCTR：Cochrane Central Register of Controlled Trials 超過 300,000筆有關健康保健的控制實驗樣品參考型書目資料，內容包括 RCT〈Randomized Controlled Trials〉及 CCT 〈 Clinical Controlled Trials 〉。由 Cochrane groups 及其單位組織將 Medline 及 EMBASE 檢索出來的隨機樣品文獻登記集中而成。

17. 本院EBM資料庫比較

18. 實證醫學的參考書籍

20. 常用實證醫學網路連結 CGMH長庚醫院圖書館資料庫PubMed: http://www.ncbi.nlm.nih.gov/PubMed/ 1. ACP Journal Club: http://www.acpjc.org/ (1-4, 7項需由圖書館進入) 2. Cochrane ~ DARE (Database of Abstracts of Reviews of Effects) 3.CDSR (Cochrane Database of Systematic Reviews) ~ Collaborative Review Groups http://www.cochrane.org/cochrane/revabstr/crgindex.htm 4.CCTR (Cochrane Central Register of Controlled Trials): 5.Cochrane collaberation介紹 6.NGC (National Guideline Clearinghouse): http://guideline.org 7.Micromedex (CCIS) 為毒物、藥學及急診醫學專業之全文資料庫，每季更新 8.Centre for Evidence-Based Medicine: http://www.cebm.net/ = http://cemb.jr2.ox.ac.uk 9.加拿大McMaster University的HIRU（Health Information Research Unit）是Cochrane Collaboration的重鎮: http://hiru.mcmaster.ca/ 10. 美國的 American College of Physician（ACP）: http://www.acponline.org 11.Bandolier: http://www.ebandolier.com = http://www.jr2.ox.ac.uk/bandolier/ 12.AHRQ website: http//www.ahrq.gov 13.InfoPOEMs: http://www.infopoems.com 14.Other resources: http://www.google.com.tw/www.yahoo.com/ http://www.mdconsult.com/ 15.彰化基督教醫院證據醫學中心 16.萬芳醫院實證醫學中心 17.醫藥衛生研究資訊網 (HINT): http://www.hint.org.tw以上建議由部門版面直接連結較快

21. The Evidence Pyramid Meta - analysis Randomized Controlled Double Blind Studies Randomized Controlled Studies Cohort studies Case Control Studies Case series/Reports Ideas, Editorials, Opinions Animal research In vitro (test tube) research

23. 統計數字會說話評估時以具體的數字呈現結果 • 敏感度（sensitivity）、特異度（specificity）、概似比（likelihood ratio）、檢測前機率（pre-test probability）、檢測後機率（post-test probability） • ARR (Absolute risk reduction) = EER (Experimental Event Rate) - CER (Control Event Rate)、 Number needed to treat, NNT=1/ARR（增加一位病患得到某種處置好處所需的治療病人數）、相對危險度減少百分比（relative risk reduction，RRR） • 絕對危險度增加百分比（absolute risk increase，ARI）= EER (Experimental Event Rate) - CER (Control Event Rate)、Number needed to harm, NNH=1/ARI（增加一位受試者罹患某種醫源性傷害的治療病人數） • 相對危險 (Relative risk)、勝算 (Odds)、勝算比 (Odds ratio) 、信賴區間(confidence interval)

24. Diagnosis Sensitivity = a/a+c = 731/809 = 90% Specificity= d/b+d = 1500/1770 = 85% Positive predictive value = a/a+b = 731/1001 = 73% Negative predictive value = d/c+d = 1500/1578 = 95% LR+for a positive result = sens/(1- spec) = 90%/15% = 6 LR- for a negative result = (1-sens)/spec = 10%/85% = 0.12 Pre-test probability (prevalence)= a+c/a+b+c+d= 31% Pre-test odds = prevalence/(1-prevalence) = 31%/69% = 0.45 Post-test odds = Pre-test odds × Likelihood Ratio Post-test probability= Post-test odds/(Post-test odds + 1)

25. Calculation of OR/RR EER = a/a+b = 0.033 CER = c/c+d = 0.30 Relative risk= EER/CER = (a/a+b)/(c/c+d) = 0.11 Experimental event Odds = a/b = 0.034 Control event Odds = c/d = 0.43 Relative Odds = Odds ratio= (a/b)/(c/d) = ad/bc = 0.08 Odd: a ratio of non-events to events

26. Asking Answerable Clinical Question

27. Treatment Effects • Occurrence of diabetic retinopathy at 5 years among insulin-dependent diabetic in the DCCT trial • Usual insulin regimen (CER: control event rate): 38% • Intensive insulin regimen (EER: experimental event rate): 13% Risk Reduction (calculation) • Absolute risk reduction (ARR) = CER-EER = 38%-13% = 25% • Relative risk reduction (RRR) = CER-EER/CER = 25%/38% =66% • Number needed to treat (NNT) = 1/ARR = 1/25% = 4 patients • The number of patients that need to be treated to prevent one bad outcome or get one good outcome.

28. Harm • The proportion of patients with at least one episode of symptomatic hypoglycemia • Usual insulin regimen (CER: control event rate): 23% • Intensive insulin regimen (EER: experimental event rate): 57% Risk Increase(calculation) • Absolute risk increase (ARI) = EER - CER = 57% - 23% = 34% • Relative risk increase (RRI) = EER–CER/CER = 57% - 23%/23% = 148% • Number needed to harm (NNH)=1/ARI = 1/0.34= 3 patients (取整數) • The number of patients that need to be treated to cause one bad outcome (being harmed)

29. Treatment of Class III-IV Lupus Nephritis Meta-Analysis Treatment of diffuse proliferative lupus nephritis: A meta-analysis of randomized controlled trials Am J Kidney Dis. 2004 Feb;43(2):197-208. Cochrane Renal Group Cochrane Database of Systematic Reviews. 1, 2004.

31. This is a forest plot, with a vertical line at 1.0 representing equivalence in risk for an outcome with experimental and control treatment (null hypothesis). The RR for each outcome and its 95% CI are indicated by a solid square and a line. The size of the solid square represents the contribution (weight) of the trial to the analysis. Diamond-shaped symbols represent the summary estimator of overall effect pooling the weighted effect of individual RCTs. Values of RR less than 1 indicate a reduction in risk for the outcome with the experimental treatment. Conversely, values of RR more than 1 indicate an increase in risk. The 95% CIs are a measure of variability in the precision of the RR estimate and its statistical significance.Heterogeneity of treatment effects between studies was investigated by visual examination of graphic meta-analysis plots and from the Cochran Q (heterogeneity chi-square) and I2 statistic.

34. 實證醫學發展的重點 實證醫學發展的重點，主要有四大範疇： • 增進醫療決策技能 medical decision making technique • 改善醫療資訊擷取技能 accessing medical information • 嚴格評估醫療資訊及其臨床應用 assessing the validity of medical information • 促進專家間之合作，以作隨機對照試驗 (RCT randomized controlled trials) 的研究 應用最佳實證文獻，訂出臨床疾病診療的guideline，並促進clinical pathway形成。

35. Clinical Practice Guidelines • 醫療資源有限，對醫療資源的合理運用，必須利用現有的證據，及使用標準化的規範及流程。 • 大量的醫學知識文獻，使醫療提供者(health care-provider)無法消化這些知識。因此在實驗室或臨床研究獲得的知識，與一般醫師真正日常行醫行為之應用之間產生不一致的現象。 • 透過各種疾病的臨床診療指引(clinical practice guideline)，使醫療不一致性減低，以提高醫療品質。 醫院評鑑暨醫療品質策進會 中央健保局 實證醫學會國家衛生研究院

36. Resource Centers for Guidelines • NGC - National Guideline Clearinghousehttp://www.guideline.gov • AGREE - appraisal of guideline research & evaluationhttp://www.agreecollaboration.org/ • Guidelines International Networkhttp://www.g-I-n.net/ • SIGN - Scottish Intercollegiate Guidelines Networkhttp://www.sign.ac.uk/ 台灣實證醫學暨臨床診療指引平台之建置 國衛院郭耿南教授

37. Decision tree analysis

38. 實證醫學應用之障礙 • 沒有實證、找不到實證 • 實證之間有矛盾 • 實證很難去應用 • 缺乏時間與資源 • 缺乏保險給付 • 臨床診療指引制定費時

39. 實證醫學之展望 • 終身學習 ~ 醫學教育增加實證醫學訓練 • 發現臨床問題，進而帶動研究風氣 • 將有限的資源運用於具有實證的醫療 • 臨床指引制定 (學會、健保局、及醫院)制定各種疾病的臨床診療指引及設立本土醫學資料庫，也是躋身國際舞台所不可或缺，如何整合與發揮國內學界的力量，是本世紀重要的醫學課題

40. 林口長庚醫院實證醫學中心 • 每年舉行EBM統計教學﹝包括如何評讀論文，設計研究等﹞及EBM introduction各一次，﹝94.03舉行 EBM workshop ﹞。 • 實證醫學中心14位成員：朱世明，歐良修，江東和，陳漢明，謝邦鑫，陳敏煜，張鴻，高振益，高國晉，田亞中，陳俊吉，黃兆山，楊宗翰，余光輝。(每月開會)實證醫學指導顧問：醫教會副主委 方基存醫師，婦產科 張廷彰醫師，長庚大學公衛科生統中心 史麗珠博士，醫務管理學系暨工管系 許光宏博士 • 衛生署92年9月起實施“畢業後一般醫學訓練計劃”，實證醫學課程為基本課程之一，每位PGY1需完成8小時，﹝6-10小時﹞課程。目前PGY1在內科一般醫學訓練時每週二中午12:00~13:00於8A-8B間內科會議室做EBM病例討論並請PGY1與臨床教師討論及簽名，歡迎參加。

41. Interpretation of evidence is subjective: it dependents on how you view it.

43. Clinical Practice Guidelines • Systemically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. • Purpose~ to make explicit recommendations with a definite intent to influence what clinicians do.