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Evidence-BasedMedicine循证医学Evidence-basedPractice(EBP)Models•TraditionalpracticeModel(×)•Model1:Usethehighestqualityinforma

tiontoguideclinicaldecisions•Model2:Search,evaluate,andmakeavailablespecialtyspecificbestavailableevidence•Model3:C

reateoriginalresearchorsystematicreviewsEBMPractice-FivestepsPatientHistoryandPE……•QuestionAskingAnswerableClinicalQuestions.•Sea

rchSearchingforthebestcurrentevidence.•AppraiseCritically-appraisingtheevidence.•Application:Integrating

theevidencewithourexpertiseandourpatient’suniquebiologyandvalues•AuditEvaluatingourperformanceStep1AskingAns

werableClinicalQuestions•EBMstartswithaclearclinicalquestion•Well-builtclinicalquestionsguidethewholeEBMprocess•Typeofquestion?–

Causation/etiology–Intervention–Diagnosis–Prognosis•TypeofStudy?–Whatwouldbethebeststudydesigninordertoanswerthequestion?

–studydesignsshouldlimitbiasStep1AskingAnswerableClinicalQuestions•Questioncomponents:PICO–WhattypesofParticipants?–WhattypesofInterventions?–What

typesofComparison?–WhattypesofOutcomes?Step1AskingAnswerableClinicalQuestions•Whattypesofparticipants?–Diseas

eorconditionofinterest–Potentialco-morbidity–Setting–Demographicfactors–TaskofclinicalproblemStep1AskingAnswerableClini

calQuestions•Whattypesofintervention?–Typesoftreatment–Typeofdiagnostictest–Typeofcausativeagent–Typeofp

rognosticfactorStep1AskingAnswerableClinicalQuestions•Whattypesofoutcomes?–Forcausation,outcomeisdis

ease–Fordiagnostictest,outcomeindiseaseofinterest–Fortreatmentincludealloutcomesimportanttopeoplemakingdecisionstodefinesucc

essoftherapy–Forprognosis,outcomeisthechosenendpointofthediseaseStep1AskingAnswerableClinicalQuestions•Broadornarrowquestio

ns–Broad•Dogefinitibimprovesurvivalinlungadenocarcinoma?–Narrow•Dogefinitibimprovesurvivalinfemallungadenocarcinomarefractorytofirst-linechemo?S

tep1AskingAnswerableClinicalQuestions•Causation–People-Exposure-Comparison-Outcomes•Doesheavysmokerhavehigherincidenceoflungcance

r?–Prognosis:People-Exposure-Comparison-Outcomes•IslungadenocarcinomawithhighlevelofCEAaremorelikelyto

haverecurrentdisease?Step2Searchingforthebestcurrentevidence•Textbook–Annuallyrevised–Usehighlevelevidences–Withreference•Guidelines•Coc

hraneLibrary•MedlineNationalGuidelineClearinghouse(http://www.guideline.gov/)Step2Toomuch?•即使是小的问题也有相关

指南Step2Step2CochraneLibrary•Advantage–highestqualityevidencewe’lleverhaveontheeffectivenessofhealthcare•Disadvantage–noty

etmanysystemicreviews–necessarilyomitsthenewesttreatmentStep2EBPModels•TraditionalpracticeModel(×)•Model1:Usethehighestqualityinformati

ontoguideclinicaldecisions•Model2:Search,evaluate,andmakeavailablespecialtyspecificLevel1information•Model

3:CreateoriginalresearchorsystematicreviewsStep2PubMed/MEDLINE•http://www.ncbi.nlm.nih.gov/PubmedStep2Medline-PubMedAdvantage–ex

haustiveness,flexibilityofsearching–journalcoverage,currency(on-lineversions)–widespreadavailabilityandsupportDisadvantage–havetodoyourownqualityfilt

ering–puttingtogethergoodsearchesisdifficult–gapsincoverage(medical,geographicalandlinguistic)Step2Step2Step2Step2Step2Step2Step2Searching

forthebestcurrentevidence•Forprimaryliterature–Notjustabstract!–TrytogetFull-textStep3Critically-appraisingtheevidence•Valid?–Designandmethodol

ogy:logical?–Sample–ExperimentorMeasure:carriedoutinasoundwayandConvincible？Follow-uprate?–Analysis–Conclus

ion–Ethical?•Importance?–Clinicalsignificance？–Cost-effective？•Applicable?–Willtheresultshelplocally?Step3Criti

cally-appraisingtheevidence•Quickscreeningbytitle,abstractandrelatemessage–Authors•Well-known？Pastrecord？C

reditable？–Institute•Competencetodothisstudy？Well-known？–Specialty•Hasorhadpublishedincorejournals?Yourpractice？Valuable？•GoforFull-textDiscrimi

nation？Rational？EBM？Step3Critically-appraisingtheevidenceTypeofQuestionSuggestedbesttypeofStudyTherapyRCT>cohort>casecontrol>caseseriesDiagnos

isProspective,blindcomparisontoagoldstandardEtiology/HarmRCT>cohort>casecontrol>caseseriesPrognosisCohortstudy>casecont

rol>caseseriesPreventionRCT>cohortstudy>casecontrol>caseseriesClinicalExamProspective,blindcomparisontogoldstandardCostEconomicanalysisRightmetho

dsiscrucialTheEvidencePyramidHierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobiasPrimaryResearchExperimentalobservationalSecondaryRese

arch•Forquantitativestudies•ForqualitativestudiesNoconsensusabouttherelativerigourofdifferentmethodsSystematicreviewStep3Critically

-appraisingtheevidenceImprovedsurvivalandsamplesizedControlSurvival（%）5%10%15%101,290394134151,894544208202,444676328252,926788374PhaseIIIRCTheadto

headComparesurvivalAdequatesamplesizeStep3Critically-appraisingtheevidence•Measure–Objective：Labtest，Radiology–Subjective：pain，symptoms•Endpoint

–alternative：relieveofsymptom,shrinkoftumor–GoldStandard：prolongsurvivalStep3Critically-appraisingtheevidence•Conclusion–Basedonth

edata?–New?•Updated?•Comparewithotherstudy•And,Whatnext?Step3Critically-appraisingtheevidence•Attention!–Don’ttrustitjustbecauseitisfro

mabigboss,meta-analysis,RCT,orguideline.–Evidenceshouldbeinconsistencewithknownmedicalscience(physiology,pathology,pharmacology,etc）Usageofscie

ntificlanguageisnotnecessarilymeanscientificbasedScientificmethodscreditNotalltheevidencesarethesameimport

anceHollingworth&Jarvik,Radiology2007;244:31-38Flowchartofcost-effectivenessateachlevelofTAhierarchyTechnicalPerfor

manceDiagnosticPerformanceDiagnosticImpactTherapeuticImpactImpactonHealthStep4Application•Integratingtheevidencewithou

rexpertiseandourpatient’suniquebiologyandvalues–Yourquestion–Yourpatient–Yourexpertise–Yourhospital–Howto……Step5Evaluatingourp

erformance•Follow-up•Evaluate–Thepatientsbenefit……?•Next……•……Oragainanother5steps•CollectdataandwriteanarticleEBPModels•Traditionalpra

cticeModel(×)•Model1:Usethehighestqualityinformationtoguideclinicaldecisions•Model2:Search,evaluate,andmakeavailablespecialtyspecificbestavailableev

idence•Model3:CreateoriginalresearchorsystematicreviewsSelectiveEBP•Maynotneedtocarryoutall5steps•1.AskingAnswerableClinic

alQuestions.•X2.Searchingforthebestcurrentevidence.•X3.Critically-appraisingtheevidence.•4.Applicatio

n:Integratingtheevidencewithourexpertiseandourpatient’suniquebiologyandvalues•5.EvaluatingourperformanceSelec

tiveEBP•3differentmodesofEBP–Searching&appraising•providesE-Bcare,butisexpensiveintimeandresources–Searchingonly•much,quicker,an

difcarriedoutamongE-Bresources,canprovideE-Bcare–Replicatingthepracticeofexperts•quickest,butmaynotdistinguishevidence-basedfromego-bas

edrecommendationsSelectiveEBP•EvenfullyEBM-trainedcliniciansworkinall3modes–Searching&appraising•fortheproblemsIencounterdaily.–Searchingonl

y•forproblemsIencounteronceamonth.–Replicating•forproblemsIencounteronceadecade(andcrossingmyfingers!).Case1•Male,ZSUProfessor，62yea

rsold•Smallcelllungcancer,limiteddisease,chemofor6cycleswithcompleteresponse–Medicaloncologist：prophylacticcranialirradiation（PC

I）notimporvesurvival,andwithAE！–Radio-oncologist：PCIimprovesurvival,andtolerable•Question:Why?Shouldt

hepatientbegivePCI?Improvesurvival?Howmuch?Sideeffect？When?How?TextbookPublish20061.ChanceofSCLCbrainmet：50%-80%for2years2.1995，aMETA-analysis：SCLCw

ithCR,PCIimprove3yearsurvival15%-21%，butnotanalysisthecomplication3.Reducebrainmetfrom30%→5%☆Conclusion：SCLCwi

thCR,PCIisrecommendafter2cyclesofchemoComplications?case1Guideline&SR•NCCN–LungcancerandProphylacticcranialirrad

iation1–2002TheCochraneLibrary,Issue2•Prophylacticcranialirradiationsignificantlyimprovessurvivalanddisease-freesurvivalforpa

tientswithsmallcelllungcancerincompleteremission.case1例1FromSecondarySource•PCIshouldstartearlyafterchemo•complications：–notRCT–2studyr

eportnodifferenceinmentalorneurologicaldisorder,butonlystudypartofthestudypatients，40%and60%（1995，1997）•N=300•N=314–InoneRCT（

N=46）,reportamentaldisorder（1997）case1PUBMED•"CranialIrradiation"[MESH]ANDlungneoplasms[mh]•("CranialIrradiation/adverseeffects"[MESH]OR"

CranialIrradiation/mortality"[MESH])ANDlungneoplasms[mh]☆25papers，3papersafter2006，onrelatepaper（level5）例1PUBMED•2009,JCOp

eer-review•Complications•Mentalandneurological•Increasebyconcurrentchemoirradiation•Increaseindoselevel≥40Gy，nomorethan30Gy，recommend20Gy

–SupportPCIinSCLClimiteddiseasewithchemoCR.例1Conclusion&Decision•PCIreducebrainmet,improvesurvival•WhenRT<30GY,rarecom

plications•Morebenefitthanharm•Recommendation：PCI，rightnowcase1EventsLikeThis……Sanlubabyformulamilkpowdercontaminatew

ithmelamine•Jul.16,2008–甘肃省卫生厅接电话报告，称今年该院收治的婴儿患肾结石病例明显增多，近几个月已达十几例，经了解均食用了三鹿牌配方奶粉。•Sept.11,2008–新华社报道：“高度怀疑”三鹿公司生

产的三鹿牌婴幼儿配方奶粉受到三聚氰胺污染。case2Sanlubabyformulamilkpowdercontaminatewithmelamine•Sept.17,2008国务院有关部门负责人和科学家–国家质检总局

局长李长江：……共检验了109家企业的491批次产品，有22家企业的69个批次的产品检出了三聚氰胺，检出不合格产品的企业约为20％……需要指出的是，这次被检出含有三聚氰胺产品的企业，不是所有批次的婴幼儿奶粉都有问题，比如，伊利、蒙牛、雅士利、施恩等企业被抽检的产品有几十个批次，但有问题的只有几个批

次。case2Sanlubabyformulamilkpowdercontaminatewithmelamine–卫生部陈竺部长：三聚氰胺……主要对膀胱和肾脏有影响，引发动物膀胱炎、膀胱结石、肾脏炎症等，但没有发现对人类有致癌作用。婴幼儿食用……出现不明原因的哭闹、呕吐、发热、尿液混浊、

血尿、少尿或无尿等症状，应立即就近到医疗机构筛查就诊。食用含有三聚氰胺的其他品牌婴幼儿奶粉，只有出现上述症状时，才需要立即到医院筛查就诊。–从2008年9月12日至17日8时，各地报告临床诊断患儿一共有6244例。其中，4917例患儿症状轻微，

生命体征稳定，正在进行院外随访治疗或已经治愈。现仍留院观察治疗患儿有1327人。所有临床诊断病历中，有158人发生过急性肾功能衰竭，占总病例数的2.5%。经有效治疗，目前158例重症患儿当中，已经有94人病情平稳或已经治愈出院。此外，回顾性

的调查发现有3例死亡病例，其中甘肃省有2名，浙江有1名，不包括在刚才提到的6244名诊断病例之中。case2TheEvidencePyramidHierarchyofevidence:arrangesstudydesignsbytheirsusceptibilitytobiasP

rimaryResearchExperimentalobservationalSecondaryResearch•Forquantitativestudies•ForqualitativestudiesNocon

sensusabouttherelativerigourofdifferentmethodsSystematicreviewSanlubabyformulamilkpowdercontaminatewithmelamine•Celloranimalisnoequaltohuman•But

thereareanycorelation?•Noevidencedoesnotmeannoharm!•Howshouldweact?Summary•EBMisaLifelonglearningmodel–lif

elong,self-directed,problem-basedlearning•Know-howinfinding,appraising,andapplyingevidenceFurtherReading

onEvidenceBasedMedicine