Ebm Ph2c

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Ebm Ph2c

  1. 1. Y HOÏC CHÖÙNG CÔÙ NG BS HOAØNG LEÂ PHUÙC NG BEÄNH VIEÄN NHI ÑOÀNG 1 NH NG
  2. 2. Rule 31 – Review the World Literature Fortnightly* *quot;Kill as Few Patients as Possiblequot; - Oscar London 5,000? 2500000 per day Medical Articles per Year 2000000 1500000 1,400 1000000 55 per per day 500000 day 0 Trials MEDLINE BioMedical 27Kg of Guidelines
  3. 3. Indexing bias…MEDLINE Ongoing Ongoing All RCTs Unpublished Unpublished Completed Completed Abstracts, Abstracts, theses, etc theses, etc Non-MEDLINE Non-MEDLINE Published Published journals journals (c. 12 000) (c. 12 000) 1966 1966 Journals Journals RCTs not RCTs not MEDLINE identified by identified by MEDLINE journals journals MEDLINE MEDLINE (c. 3 700) (c. 3 700) 1966 1966 RCTs RCTs identified by identified by MEDLINE MEDLINE
  4. 4. KHAÙI NIEÄM Y HOÏC CHÖÙNG CÔÙ NG Moät phöông phaùp ñieàu trò ñöôïc chöùng minh coù ng hieäu quaû - Thöïc haønh chuaån: 8 - 13 naêm nh (Phillips,1998) 70% caùc phöông phaùp ñieàu trò: chöa ñuû chöùng côù ng chöùng minh toát hôn khoâng ñieàu trò ng (Chalmers,1993) Treân 12 trieäu CTNC / Medline: nghieân cöùu ñuùng + khoâng ñuùng phöông phaùp ng ng
  5. 5. …reduced osmolarity ORS with WHO standard ORS in children with acute diarrhoea unscheduled IV 41 studies fluid infusions, stool volume, (-)6 / RCTs(-) vomiting, (-)9 / intervention >< reduced osmolarity ORS hyponatraemia (-)6 / control group did not use (WHO) std. ORS 20 remaining RCTs (-)2 / not in children; (-)2 / no relevant outcomes reported; 2 excluded (Mexico 1988, Mexico 1990b, Mexico 1990a). 13 remaining RCTs (Panama 1982, USA 1982). 14 studies met the inclusion criteria.
  6. 6. Feed thickener for newborn infants with gastro-oesophageal reflux MEDLINE from 1966 to March 2004, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004). CINAHL from 1982 to December 2001, Conference and symposia proceedings published in Pediatric Research 1990 to 1994. Conference proceedings for the ESPGAN and NASPGAN from 1994 to December 2001 There is no evidence from RCTs to support or refute the efficacy of feedthickeners in newborn infants with GOR
  7. 7. KHAÙI NIEÄM Y HOÏC CHÖÙNG CÔÙ NG Thu heïp khoaûng caùch: ng ch nghieân cöùu - thöïc haønh ? nh Caäp nhaät caùc thaønh quaû cuûa caùc nghieân cöùu coù nh giaù trò vaøo thöïc teá ? Y HOÏC CHÖÙNG CÔÙ NG
  8. 8. KHAÙI NIEÄM Y HOÏC CHÖÙNG CÔÙ NG YHCC laø vieäc söû duïng caån thaän, roû raøng, ñuùng ñaén ng ng ng caùc chöùng côù toát nhaát hieän coù ñeå ñöa ra quyeát ñònh ng chaêm soùc beänh nhaân cuï theå. nh
  9. 9. KHAÙI NIEÄM Y HOÏC CHÖÙNG CÔÙ NG Thöïc haønh döïa treân YHCC laø tích hôïp nh söï thaønh thaïo laâm saøng nh ng vôùi chöùng côù laâm saøng beân ngoaøi toát nhaát saün coù ng ng töø caùc nghieân cöùu heä thoáng ng vaø cô ñòa, söï mong ñôïi cuûa beänh nhaân nh
  10. 10. KHAÙI NIEÄM Y HOÏC CHÖÙNG CÔÙ NG Söï thaønh thaïo laâm saøng nh ng – Kyõ naêng & söùc phaùn ñoaùn laâm saøng – Kinh nghieäm thöïc haønh laâm saøng
  11. 11. KHAÙI NIEÄM Y HOÏC CHÖÙNG CÔÙ NG Chöùng côù laâm saøng beân ngoaøi – Nghieân cöùu laâm saøng thích hôïp – Nghieân cöùu laáy beänh nhaân laøm trung taâm veà caùc lónh vöïc: tính ñuùng vaø chính xaùc cuûa xeùt nghieäm (daáu hieäu laâm saøng), ñoä maïnh cuûa caùc yeáu toá tieân löôïng, hieäu quaû vaø an toaøn cuûa phöông phaùp ñieàu trò, phuïc hoài vaø döï phoøng. – Thay theá caùc phöông phaùp chaån ñoaùn, ñieàu trò cuõ baèng phöông phaùp khaùc maïnh, chính xaùc, hieäu quaû vaø an toaøn hôn
  12. 12. THÖÏC HAØNH YHCC NH Ñaët caâu hoûi veà thoâng tin caàn truy caäp Truy caäp thoâng tin coù giaù trò chöùng côù Ñaùnh giaù ñoä maïnh chöùng côù cuûa thoâng tin coù ñöôïc Aùp duïng vaøo thöïc teá laâm saøng Löôïng giaù hieäu quaû vieäc aùp duïng
  13. 13. Unsound Research 1 Aware Accepted Applicable Able Acted on AgreedAdhered to Sound Research 3 4 Systems (bottomline± ref) Synopses (user summary of research) 2 Systematic Reviews and CATs (search; appraisal; synthesis) © Elsevier Ltd 2005. Straus et al.: Evidence-based medicine
  14. 14. WAYS TO INCORPORATE EVIDENCE INTO PRACTICES Doing Using Replicating
  15. 15. TRUY CAÄP THOÂNG TIN Y HOÏC CHÖÙNG CÔÙ NG
  16. 16. GIÔÙI HAÏN THOÂNG TIN Usefulness = Relevance * Validity / Effort
  17. 17. CAÙC BÖÔÙC TRUY CAÄP THOÂNG TIN Y HOÏC CHÖÙNG CÔÙ CÔ BAÛN 1. Laøm roõ caâu hoûi laâm saøng vaø tìm caùc töø khoùa theo phöông phaùp PICO 2. Phaân loaïi vaán ñeà thaønh Ñieàu trò, Chaån ñoaùn, Tieân löôïng, Nguy cô,... 3. Choïn nguoàn döõ lieäu ñeå tìm kieám thoâng tin 4. Thöïc hieän tìm kieám caùc töø khoùa ñaõ coù ñöôïc töø böôùc 1 5. Giôùi haïn keát quaû coù ñöôïc töø böôùc 4 baèng caùch keát hôïp vôùi böôùc 2.
  18. 18. Phöông phaùp PICO Patient or population Moâ taû beänh nhaân (tuoåi, giôùi, chuûng (Beänh nhaân / Daân soá) toäc, tieàn söû,...) Intervention/ exposure Vieäc xaûy ra hay ñaõ ñöôïc laøm : ñieàu (Can thieäp / Tieáp xuùc) trò, xeùt nghieäm chaån ñoaùn, phôi nhieãm (VD: huùt thuoác laù thuï ñoäng) Comparison So saùnh vôùi gì ? Khoâng so saùnh, (So saùnh) placebo, loaïi can thieäp khaùc Outcomes Hieäu quaû cuûa can thieäp laø gì? Phaûi (Keát quaû, thöôøng laø ñaëc hieäu ( töû vong, tyû leä nhaäp vieän...) laâm saøng) Böôùc 1
  19. 19. In patients undergoing hip replacement, to what extent is the risk of post-operative infection reduced by antimicrobial prophylaxis? patients undergoing hip Population replacement Intervention FACETS antimicrobial prophylaxis Comparison placebo Outcome post-operative infection Böôùc 1
  20. 20. Hip replacement, Hip joint, hip prothesis, patients Total-hip replacement, total-joint replace.. undergoing hip Hip surgery, hip operation, acetabulum replacement hip arthroplasty,… OF SYNONYMS AND DRAW UP A LIST FACETS ABBREVIATIONS AND SPELLING Anti-infective agents, infection control, antimicrobial VARIANTS WHICH MAY BE USED BY antibiotics, antibiotic prophylaxis, prophylaxis antimicrobial, anti-microbial, ultraclean, hypersterile AUTHORS Bacterial infections, postopertavie post-operative complications, surgical wound infections, infection prothesis-related infections, sepsis Böôùc 1
  21. 21. Hip replacement, Hip joint, hip prothesis, patients Total-hip replacement, total-joint replace.. undergoing hip Hip surgery, hip operation, acetabulum replacement hip arthroplasty,… DRAW UP A LIST OF SYNONYMS AND ABBREVIATIONS AND SPELLING Anti-infective agents, infection control, antimicrobial antibiotics, antibiotic prophylaxis, VARIANTS WHICH MAY BE USED BY prophylaxis antimicrobial, anti-microbial, ultraclean, FACETS hypersterile AUTHORS Bacterial infections, postopertavie post-operative complications, surgical wound infections, infection prothesis-related infections, sepsis Böôùc 1
  22. 22. Hip replacement, Hip joint, hip prothesis, patients Total-hip replacement, total-joint replace.. undergoing hip Hip surgery, hip operation, acetabulum replacement hip arthroplasty,… Anti-infective agents, infection control, antimicrobial antibiotics, antibiotic prophylaxis, prophylaxis antimicrobial, OF SYNONYMS AND ABBREVIATIONS DRAW UP A LIST anti-microbial, ultraclean, hypersterile VARIANTS WHICH MAY BE USED BY AND SPELLING Bacterial infections, postopertavie post-operative AUTHORS FACETS complications, surgical wound infections, infection prothesis-related infections, sepsis Böôùc 1
  23. 23. Hip replacement, Hip joint, hip prothesis, patients Total-hip replacement, total-joint replace.. undergoing hip Hip surgery, hip operation, acetabulum replacement hip arthroplasty,… Anti-infective agents, infection control, antimicrobial antibiotics, antibiotic prophylaxis, prophylaxis antimicrobial, anti-microbial, ultraclean, hypersterile BacterialUP A LIST OF SYNONYMS AND ABBREVIATIONS DRAW infections, postopertavie post-operative complications, surgical wound infections, infection prothesis-related infections, USED BY AUTHORS AND SPELLING VARIANTS WHICH MAY BE sepsis Böôùc 1
  24. 24. Hip replacement, Hip joint, hip prothesis, patients Total-hip replacement, total-joint replace.. undergoing hip Hip surgery, hip operation, acetabulum replacement hip arthroplasty,… Anti-infective agents, infection control, antimicrobial antibiotics, antibiotic prophylaxis, prophylaxis antimicrobial, anti-microbial, ultraclean, hypersterile Bacterial infections, postopertavie post-operative complications, surgical wound infections, infection prothesis-related infections, sepsis Böôùc 1
  25. 25. CAÙC BÖÔÙC TRUY CAÄP THOÂNG TIN Y HOÏC CHÖÙNG CÔÙ CÔ BAÛN 1. Laøm roõ caâu hoûi laâm saøng vaø tìm caùc töø khoùa theo phöông phaùp PICO 2. Phaân loaïi vaán ñeà thaønh Ñieàu trò, Chaån nh ñoaùn, Tieân löôïng, Nguy cô,... ng 3. Choïn nguoàn döõ lieäu ñeå tìm kieám thoâng tin 4. Thöïc hieän tìm kieám caùc töø khoùa ñaõ coù ñöôïc töø böôùc 1 5. Giôùi haïn keát quaû coù ñöôïc töø böôùc 4 baèng caùch keát hôïp vôùi böôùc 2.
  26. 26. ÑOÄ MAÏNH CUÛA CHÖÙNG CÔÙ NH NG Loaïi I : töø CT ñaùnh giaù heä thoáng nh ng Loaïi II : töø ít nhaát 1 CT NC coù ñoái chöùng ngaãu nhieân ng Loaïi III : töø caùc NC thöïc nghieäm, khoâng ñoái chöùng ng Loaïi IV : töø caùc NC khoâng thöïc nghieäm Loaïi V : töø quan ñieåm caù nhaân, ca LS
  27. 27. ÑOÄ MAÏNH CAÙC THIEÁT KEÁ NGHIEÂN CÖÙU CHO CAÙC LOAÏI CAÂU HOÛI LAÂM SAØNG Clinical Prospective, blind comparison Examination to gold standard Diagnostic Prospective, blind comparison Testing to gold standard Prognosis Cohort study > Case Control > Case Series Therapy Therapy Randomized control trial (RCT) Randomized control trial Etiology / Harm Cohort study > Case Control > Case Series Prevention RCT > Cohort study > Case Control >Case Series Böôùc 2
  28. 28. ÑOÄ MAÏNH CAÙC THIEÁT KEÁ NGHIEÂN CÖÙU CHO CAÙC LOAÏI CAÂU HOÛI LAÂM SAØNG Caùc toång quan heä thoáng coù theå traû lôøi cho moïi loaïi caâu hoûi laâm saøng vôùi ñoä tin caäy cao nhaát neáu thöïc hieän ñuùng phöông phaùp Böôùc 2
  29. 29. CAÙC BÖÔÙC TRUY CAÄP THOÂNG TIN Y HOÏC CHÖÙNG CÔÙ CÔ BAÛN 1. Laøm roõ caâu hoûi laâm saøng vaø tìm caùc töø khoùa theo phöông phaùp PICO 2. Phaân loaïi vaán ñeà thaønh Ñieàu trò, Chaån ñoaùn, Tieân löôïng, Nguy cô,... 3. Choïn nguoàn döõ lieäu ñeå tìm kieám thoâng tin 4. Thöïc hieän tìm kieám caùc töø khoùa ñaõ coù ñöôïc töø böôùc 1 5. Giôùi haïn keát quaû coù ñöôïc töø böôùc 4 baèng caùch keát hôïp vôùi böôùc 2.
  30. 30. PHAÂN LOAÏI DÖÕ LIEÄU NGUYEÂN PHAÙT ÑAÕ ÑÖÔÏC ÑAÙNH GIAÙ NH – GIAÙ TRÒ TÖØNG NGHIEÂN CÖÙU NG – TOÅNG QUAN HEÄ THOÁNG NG NG – GUIDELINES – KINH ÑIEÅN
  31. 31. DÖÕ LIEÄU NGUYEÂN PHAÙT MEDLINE (MEDlars onLINE) EMBASE CINAHL (Cumulative Index to Nursing and Allied Health Literature) LILACS (Latin American and Caribbean Health Sciences) PsycInfo
  32. 32. DÖÕ LIEÄU NGUYEÂN PHAÙT MEDLINE NATIONAL LIBRARY OF MEDICINE: 1879 1960, MEDLARS (Medical Literature Analysis and Retrieval ( System) TOÅ CHÖÙC DÖÔÙI DAÏNG INDEX (Medical Subject Headings) NG 12 TRIEÄU RECORDS 4600 TÔØ BAÙO CAÄP NHAÄT MOÃI TUAÀN 86 % TÖØ TIEÁNG ANH / ABSTRACTS NG 76% COÙ ABSTRACT
  33. 33. DÖÕ LIEÄU NGUYEÂN PHAÙT MEDLINE TRUY XUAÁT DÖÕ LIEÄU TUØY THUOÄC TOÅ CHÖÙC SÔÛ HÖÕU DÖÕ LIEÄU – MIEÃN PHÍ & TRAÛ TIEÀN
  34. 34. DÖÕ LIEÄU NGUYEÂN PHAÙT JOURNAL Abridged Index Medicus (AIM) Journal Titles University of Texas Health Science Center at San Antonio Evaluating Web-sites – The URL: .ORG; .GOV & .DOH; .EDU & .AC – Health Information Quality Assessment Tool, – Health On the Net Foundation:
  35. 35. DÖÕ LIEÄU THÖÙ PHAÙT CAT (Critical Appraised Topics) – Moät hình thöùc bình baùo – Ñaùnh giaù giaù trò cuûa 1 baøi baùo theo tieâu nh chuaån ñaõ ñöa ra. – Nhoùm chuyeân vieân cuûa moät trung taâm – FORM
  36. 36. DÖÕ LIEÄU THÖÙ PHAÙT Critical Appraised Topics
  37. 37. DATA REVIEW SAMPLE DÖÕ LIEÄU THÖÙ PHAÙT
  38. 38. DÖÕ LIEÄU THÖÙ PHAÙT Toång quan heä thoáng ng ng – Toång quan TAÁT CAÛ taøi lieäu COÙ LIEÂN QUAN ng theo moät khuoân maãu ñònh saün – Ñaùnh giaù giaù trò cuûa moät vaán ñeà nh – Nhoùm chuyeân vieân
  39. 39. …reduced osmolarity ORS with WHO standard ORS in children with acute diarrhoea unscheduled IV 41 studies fluid infusions, stool volume, (-)6 / RCTs(-) vomiting, (-)9 / intervention >< reduced osmolarity ORS hyponatraemia (-)6 / control group did not use (WHO) std. ORS 20 remaining RCTs (-)2 / not in children; (-)2 / no relevant outcomes reported; 2 excluded (Mexico 1988, Mexico 1990b, Mexico 1990a). 13 remaining RCTs (Panama 1982, USA 1982). 14 studies met the inclusion criteria.
  40. 40. Meta-analysis
  41. 41. SYSTEMATIC REVIEW DÖÕ LIEÄU THÖÙ PHAÙT
  42. 42. The Cochrane Database of Systematic Reviews (3559) Database of Abstracts of Reviews of Effects (4795) The Cochrane Central Register of Controlled Trials (CENTRAL) (415918)
  43. 43. DÖÕ LIEÄU THÖÙ PHAÙT GUIDELINES
  44. 44. Treating giant cell arteritis: A consistent level 1 studies Grades of B consistent level 2 or 3 studies or extrapolations from level 1 studies C Give4 steroids (A) immediately (D) at level studies or extrapolations from level 2 or 3 studies Recommendation D dosesevidence or troublingly inconsistent or inconclusive studies of any level level 5 of at least 20 mg (C) daily (A).
  45. 45. SAÙCH GIAÙO KHOA CH CD ROM ONLINE – MD CONSULT – OVID – STATREF – Uptodate
  46. 46. TEXTBOOKS GUIDELINES / EBM COCHRANE LIBRARY DARE, HTA CAT
  47. 47. CAÙC BÖÔÙC TRUY CAÄP THOÂNG TIN Y HOÏC CHÖÙNG CÔÙ CÔ BAÛN 1. Laøm roõ caâu hoûi laâm saøng vaø tìm caùc töø khoùa theo phöông phaùp PICO 2. Phaân loaïi vaán ñeà thaønh Ñieàu trò, Chaån ñoaùn, Tieân löôïng, Nguy cô,... 3. Choïn nguoàn döõ lieäu ñeå tìm kieám thoâng tin 4. Thöïc hieän tìm kieám caùc töø khoùa ñaõ coù ñöôïc töø böôùc 1 5. Giôùi haïn keát quaû coù ñöôïc töø böôùc 4 baèng caùch keát hôïp vôùi böôùc 2.
  48. 48. GIÔÙI HAÏN THOÂNG TIN No. relevant items found Sensitivity = No. relevant items in existence No. relevant items found Precision = Total no. items found Böôùc 5
  49. 49. TIEÂU CHUAÅN VAØNG NG Anne McKibbon at McMaster University 10 TAÏP CHÍ NOÅI TIEÁNG 1983-1991 NG Handsearching
  50. 50. Table for Clinical Queries using Research Methodology Filters Optimized Sensitivity/ Category PubMed equivalent³ for Specificity² quot;randomized controlled trialquot; [PTYP] | quot;drug therapyquot; [SH] sensitivity 99%/74% Therapy | quot;therapeutic usequot; [SH:NOEXP] | quot;random*quot; [WORD] specificity 57%/97% (double [WORD] & blind* [WORD]) | placebo [WORD] quot;sensitivity and specificityquot; [MESH] | quot;sensitivityquot; [WORD] sensitivity 92%/73% | (quot;diagnosisquot; [SH] | quot;diagnostic usequot; [SH] | quot;specificityquot; Diagnosis [WORD] quot;sensitivity and specificityquot; [MESH] | ( quot;predictivequot; specificity 55%/98% [WORD] & quot;value*quot; [WORD] ) quot;cohort studiesquot; [MESH] | quot;riskquot; [MESH] | (quot;oddsquot; sensitivity 82%/70% [WORD] & quot;ratio*quot; [WORD]) | (quot;relativequot; [WORD] & quot;riskquot; Etiology [WORD]) | (quot;casequot; [WORD] & quot;control*quot; [WORD]) quot;case-control studiesquot; [MH:NOEXP] | quot;cohort studiesquot; specificity 40%/98% [MH:NOEXP] quot;incidencequot; [MESH] | quot;mortalityquot; [MESH] | quot;follow-up sensitivity 92%/73% studiesquot; [MESH] | quot;mortalityquot; [SH] | prognos* [WORD] | Prognosis predict* [WORD] | course [WORD] specificity 49%/97% prognosis [MH:NOEXP] | quot;survival analysisquot; [MH:NOEXP]
  51. 51. MEDLINEPRO.COM
  52. 52. Xin caùm ôn söï theo doõi cuûa Toaøn Theå Hoäi Tröôøng ng

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