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如何運用實證醫學資料庫 快速回答臨床問題 Quickly & Effectively

馬偕紀念醫院 全院學術演講 (2008.12.27). 如何運用實證醫學資料庫 快速回答臨床問題 Quickly & Effectively. 實證醫學中心課程 方靜如 / 實證醫學小組委員 ( 兼差 ) / 圖書館參考館員 ( 正職 ) for YOU ～資訊檢索諮詢˙利用課程講習 flora@ms1.mmh.org.tw / #3253. 臨床人員的處境 : Solution. 時間有限、情況緊急 : Quickly 醫療資訊太多 : Effectively 醫學進步太快 : Current 病人的期望 : Best

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如何運用實證醫學資料庫 快速回答臨床問題 Quickly & Effectively

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  1. 馬偕紀念醫院 全院學術演講 (2008.12.27) 如何運用實證醫學資料庫快速回答臨床問題Quickly& Effectively • 實證醫學中心課程 • 方靜如 / 實證醫學小組委員(兼差) • / 圖書館參考館員(正職) • for YOU～資訊檢索諮詢˙利用課程講習 • flora@ms1.mmh.org.tw /#3253

  2. 臨床人員的處境: Solution • 時間有限、情況緊急: Quickly • 醫療資訊太多: Effectively • 醫學進步太快: Current • 病人的期望: Best • 缺乏Time勝於缺乏Skill在搜尋與評讀上

  3. 理想的解決方案 • 以最好的實證資訊，快速答覆所有的問題 • 把尋找證據、嚴格評讀的重擔交給研究者與作者 • 臨床人員在使用實證資源時 • 快速（最好當下即可取得與應用） • 確實能夠提供答案

  4. 今日節目表 • 認識證據等級 • 搜尋實證障礙 • 實證資源類型 • PICO、關鍵字與MeSH Term • 資訊檢索概念 • Summaries Databases • PubMed Database • 動動腦時間

  5. 認識證據等級 證據力強 設計嚴謹 偏差少 並非所有臨床問題都可找到最高等級文獻，但應盡可能使用等級高的證據來源 證據力弱 設計薄弱 偏差多 表濃縮自: Oxford Centre for EBM Levels of Evidencehttp://www.cebm.net/index.aspx?o=1047

  6. 搜尋實證障礙 • 不知道怎麼定義關鍵字 • PICO, plus 同義字, MeSH Terms • 資源太多，不知道從何下手 • Filtered Resources FIRST, plus Unfiltered Resources • 不熟悉搜尋方式 • 只找到/看到片面現象(B)，而非貼近事實(A) (Information bias)

  7. 5S EBM Resources (非關證據強弱!) • 愈上層 • 資訊精萃 • 簡單的關鍵字 • 省時搜尋與評讀 • 快速支援決策 • 由下層積累 1.systems 連結個別病歷的臨床知識與支援決策系統 整合證據提供特定臨床問題之概述與建議 ACPPIER BMJ Clinical Evidence DynaMed FirstConsult UpToDate 2.summaries Filtered Resources 對單篇研究或回顧性文獻作摘要與評述 ACP Journal Club, Evidence-Based Medicine (PubMed, Ovid Medline) 3.synopses Meta Search TRIP SUMsearch 特定臨床問題的系統性評論文獻 Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effects (PubMed, Ovid Medline): Systematic Reviews 4.syntheses • 愈下層 • 文獻雜多 • 完整的關鍵字 • 費時搜尋與評讀 • 注重檢索技巧 • 資訊新穎 原始文獻 (PubMed, Ovid Medline, CINAHL, EMBASE Cochrane CENTRAL, Google Scholar CEPS中文電子期刊, 中文期刊篇目索引) Unfiltered Resources 5.studies Model from: Haynes, R. B. (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.

  8. Synopses: EBM Journals @ MMHLibrary • ACP Journal Club(P+E) • Evidence Based Medicine(P+E) • Bandolier(free E) • Evidence-Based Cardiovascular Medicine(E) • Evidence-Based Dentistry(P) • Evidence-Based Eye Care(E) • Evidence-Based Gastroenterology(E) • Evidence-Based Health Policy & Management(E) • Evidence-Based Healthcare(E) • Evidence-Based Mental Health(E) • Evidence-Based Obstetrics & Gynecology(E) • Evidence-Based Oncology(E)

  9. Where to start lookingfor… • 省力原則: 5S 由上往下 • Summaries (Critically-Appraised Topics) • Synopses (Critically-Appraised Individual Articles) • Syntheses (Systematic Reviews) • Studies (Original Papers) • 無從下手時: Meta Search、Google Search • 不熟悉哪個資源可以回答這個臨床問題、慣用的資源找不到答案 • 但請謹慎 • 很多來源缺乏critical appraisal • 訂購資源可能不在搜尋範圍內 • 只看到片面現象 • Background Information / Expert Opinion • E-Textbook • Drug Information • Micromedex PubMed Ovid Medline

  10. Filtered Resources (secondary) • 我能相信summaries或systematic reviews嗎? 如果… • 沒有利益衝突 • 清楚陳述問題 • 完整搜尋並取得相關研究 • 明確篩選準則，並列出參考書目 • 嚴格評讀原始研究 • 可再現(reproducible)相關決策 • 定期評論與更新，確保新證據沒有被遺漏 • Unsystematic narrative review • 混合個人意見和證據，而證據也常岀自reviewer個人的選擇 structured approach Heneghan C, Badenoch D (2006). Evidence-based Medicine Toolkit. Haynes, RB (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.

  11. Unfiltered Resources (primary) • 何時需要搜尋 Unfiltered Resources • 系統評論來自於 underpowered (small) trials • Filtered resources還未處理所關注的臨床問題 Haynes, RB (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8.

  12. 臨床情境 1 (王瑩玉藥師贊助播出) • 李先生是一位62 歲的已婚男士，育有一男一女，最近醫師告訴他有攝護腺肥大。 • 醫師處方 Finasteride (proscar*) 5mg/day 建議至少給3 – 6個月，才會改善尿流速、急尿及排尿困難。 • 他上網查得服藥可使攝護腺細胞不再增生，改善症狀，但也會有性功能障礙。 • 醫師為何又檢查PSA，難道有可能發生前列腺癌嗎? • 朋友介紹他吃保健食品proseren，請問藥師的意見。

  13. 關於朋友介紹的鋸棕櫚 saw palmetto

  14. PICO: 將臨床問題架構化為適當關鍵字 BPH OR benign prostatic hyperplasia saw palmetto OR serenoa serrulata OR serenoa repens Finasteride OR 5α-reductase inhibitor urinary symptoms OR urinary flow 

  15. PICO: 將臨床問題架構化為適當關鍵字 BPH OR benign prostatic hyperplasia saw palmetto OR serenoa serrulata OR serenoa repens Finasteride OR 5α-reductase inhibitor Sexual dysfunction OR impotence OR libido decreased 

  16. Summaries • ACPPIER • BMJ Clinical Evidence • DynaMed • FirstConsult • UpToDate

  17. UpToDate: Search BPH

  18. UpToDate: Result 症狀改善 - Saw palmetto

  19. UpToDate: Result 性功能障礙 - Finasteride

  20. UpToDate: Result 性功能障礙 - Saw palmetto

  21. UpToDate: Result Summary and recommendations- Saw palmetto

  22. UpToDate: ResultSaw palmetto brand names & quality criteria

  23. Summaries • ACPPIER • BMJ Clinical Evidence • DynaMed • FirstConsult • UpToDate

  24. DynaMed: Search BPH

  25. DynaMed: Result症狀改善 - Finasteride vs Saw palmetto

  26. DynaMed: ResultSaw palmetto

  27. DynaMed: ResultFinasteride

  28. Summaries • ACPPIER • BMJ Clinical Evidence • DynaMed • FirstConsult • UpToDate

  29. FirstConsult: ResultOrder of therapies BPH

  30. FirstConsult: Result症狀改善 - Finasteride vs Saw palmetto Finasteride Saw palmetto DynaMed :level 2

  31. FirstConsult: Result性功能障礙 - Finasteride vs Saw palmetto Finasteride Saw palmetto

  32. Summaries • ACPPIER • BMJ Clinical Evidence • DynaMed • FirstConsult • UpToDate

  33. Clinical Evidence: Search Benign prostatic hyperplasia

  34. Clinical Evidence: ResultClinical Questions

  35. Clinical Evidence: Result症狀改善 - Finasteride vs Saw palmetto

  36. Clinical Evidence: Result症狀改善 - Finasteride vs Saw palmetto

  37. Clinical Evidence: Result性功能障礙 - Finasteride vs Saw palmetto

  38. Clinical Evidence: ResultComment- Finasteride vs Saw palmetto

  39. Clinical Evidence: Grade All/most studies show benefit (or harm) RCTs/ SR of RCTs Problem with 2category Population AND outcome not generaliseable About GRADE:http://clinicalevidence.bmj.com/ceweb/about/about-grade.jsp

  40. Summaries • ACPPIER • BMJ Clinical Evidence • DynaMed • FirstConsult • UpToDate

  41. ACP PIER: Search BPH

  42. ACP PIER: ResultWhat’s New

  43. ACP PIER: Result Saw palmetto

  44. ACP PIER: ResultFinasteride

  45. 證據總結比較: Saw palmetto vs Finasteride 來源: 藥劑部王瑩玉技術主任 證據比較: level 2

  46. 資料庫特性比較 [1] UpToDate把同Medical Condition拆分為Diagnosis、Therapy等為一個Topic，故數量顯得相對多

  47. Summaries DB: 小結 • 為何用Summaries型資料庫 • 搜尋: 簡單、可搜尋全文內容 • 呈現: 評讀的精簡資訊 (並附summary)、推薦與證據 • 應用: 快速支援臨床決策 • 怎麼用Summaries型資料庫 • 將拿手主題來搜尋所有資料庫一輪 • 挑出一兩個滿意的資料庫拿來應急 • 使用What’New、Broswe來常保新鮮 • 對呈現的證據永遠保持合理懷疑 • 提出質疑給出版社 • 提供建議給圖書館

  48. 資訊檢索概念 • 布林邏輯 • 同義字 • 自由詞彙 vs 控制詞彙

  49. 地瓜 營養 地 瓜 營 養 資訊檢索概念: 布林邏輯 AND AND

  50. 資訊檢索概念: 布林邏輯 OR 地瓜 蕃藷 蕃 薯 地 瓜 OR

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