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從實證到臨床應用 From Evidence-Based Medicine to Knowledge Translation

從實證到臨床應用 From Evidence-Based Medicine to Knowledge Translation. - 第 14 屆醫療品質獎 標竿學習課程. 陳杰峰 Chiehfeng (Cliff) Chen MD MPH PhD 萬芳醫院 實證醫學中心 主任 日 期: 102 年 5 月 1 日 ( 星期三 )15:00~15:40 地 點:台北市立萬芳醫院六樓國際會議廳 主辦單位:財團法人醫院評鑑暨醫療品質策進會. 大綱. I: EBM – 實證醫學 (Evidence-based Medicine) EBM 5 Steps

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從實證到臨床應用 From Evidence-Based Medicine to Knowledge Translation

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  1. 從實證到臨床應用From Evidence-Based Medicine to KnowledgeTranslation - 第14屆醫療品質獎 標竿學習課程 陳杰峰 Chiehfeng (Cliff) Chen MD MPH PhD 萬芳醫院 實證醫學中心 主任 日 期:102年5月1日(星期三)15:00~15:40 地 點:台北市立萬芳醫院六樓國際會議廳 主辦單位:財團法人醫院評鑑暨醫療品質策進會

  2. 大綱 • I:EBM – 實證醫學(Evidence-based Medicine) • EBM 5Steps • II: KT - 知識轉譯 (Knowledge Translation, KT) • II-1.K- 建構知識 Creating Knowledge • II-2.T- 應用知識 Applying Knowledge

  3. I:EBM – 實證醫學(Evidence-based Medicine) EBM 20 年 • JAMA 1992 • Cochrane Collaborations • 改善品質的目標達成了嗎? • ISEHC 2012 • 國際實證健康照護學會

  4. 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 7A 5S

  5. Knowledge Translation in Health Care: Moving from Evidence to Practice Sharon Straus Knowledge Translation in Health Care: Moving from Evidence to Practice. Sharon Straus (Editor), Jacqueline Tetroe (Editor), Ian D. Graham (Editor) ISBN: 978-1-4051-8106-8 May 2009, Wiley-Blackwell

  6. II: KT - 知識轉譯 (knowledge translation, KT) 什麼是知識轉譯?What is Knowledge Translation: • 知識轉譯是一個包含對知識的合成,傳播,交換,以及符合倫理的應用動態流程;用以增進人民健康,提供有效的健康照護以及產能,進一步強化整個健康體系. • "Knowledge translation (KT) is defined as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the health care system." Canadian Institutes of Health Research Sharon E. Straus, Jacqueline Tetroe and Ian D. Graham. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2009, ISBN: 978-1-405-18106-8

  7. 建構實證應用管道 II: KT - 知識轉譯 (knowledge translation, KT) [1] Balas EA, Boren S. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray A, editors. Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer VerlagsgesellschaftmbH, 2000:65-70. 根據Balas and Boren 2000年的文獻指出,需要花費17年的時間,才只有14%的原始研究(original research)最後被實際應用於病人身上[1],由此反映出有眾多的研究在實務應用時,存在著實際的障礙。

  8. 如何實踐知識轉譯?How Knowledge Translation is Done: • K(knowledge):創造知識 Creating Knowledge • T(translation):應用知識 Applying Knowledge K T Sharon E. Straus, Jacqueline Tetroe and Ian D. Graham. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2009, ISBN: 978-1-405-18106-8

  9. 兩種EBM比賽之比較

  10. EBM比賽之改變 • 評分比重改變 • 例如: 知與行的比重改變 • 評分條文改變 • 改變的邏輯 • 評審共識 共識會議, 電子郵件, 網路平台 • 知識轉譯 • 操作型定義(Operational definition) • KT 的3generations 以及 7 phases

  11. 評分比重改變 K 50% => 40% T 50% => 60%

  12. Part II-1:K- 創造知識 Creating Knowledge

  13. 知識漏斗The "Knowledge Funnel" • 1st G. Knowledge Inquiry 知識查詢 • 2nd G. Knowledge Synthesis 知識合成 • 3rd G. Knowledge Tools/Products 知識工具 • Clinical Practice Guidelines 臨床指引 • Patients Decision Aids 決策輔助工具 Sharon E. Straus, Jacqueline Tetroe and Ian D. Graham. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2009, ISBN: 978-1-405-18106-8

  14. 1st G. 知識查詢 Knowledge Inquiry (e.g. RCT)

  15. 實證醫學應用類:臨床運用組

  16. 2nd G. 知識合成 Knowledge Synthesis (e.g. Systematic review)

  17. 嚴格的文獻評讀 3.4 正確的評定證據及整合知識 • 評分重點: • 1. 正確評定證據等級( LOE ),評估LOE來源,選用正確研究類型等。 • 2. 評定的證據能整合成可運用的知識。

  18. 3rd G.知識工具 Knowledge Tools/Products (e.g. Clinical Practice Guidelines 臨床指引, Patients Decision Aids 決策輔助工具)

  19. PartII-2:T- 應用知識 Applying Knowledge 行動循環的7期 (The 7 Phases of the Action Cycle)

  20. 行動循環的7期The 7 Phases of the Action Cycle Sharon E. Straus, Jacqueline Tetroe and Ian D. Graham. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2009, ISBN: 978-1-405-18106-8 • 1.找出知識與行動的差異 • Identifying the Knowledge-To-Action Gaps • 2.轉化知識到當地環境 • Adapting Knowledge to Local Context • 3.評估應用知識時的阻力或助力 • Assessing Barriers/Facilitators to Knowledge Use • 4.選擇,修正,實施介入方式 • Selecting, Tailoring, Implementing Interventions

  21. The 7 Phases of the Action Cycle (continue) Sharon E. Straus, Jacqueline Tetroe and Ian D. Graham. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2009, ISBN: 978-1-405-18106-8 • 5.監督知識應用 • Monitoring Knowledge Use • 6.評估結果 • Evaluating Outcomes • 7.持續應用知識 • Sustaining Knowledge Use • Theories and Models: Quality Improvement theory

  22. Phase 1. 找出知識與行動的差異 Identifying the Knowledge-To-Action Gaps

  23. 從實證到應用 4.1 找出知識與行動的差異(是否能應用在本案例及類似的病人上) • 評分重點: • 文獻是否可以直接應用在本病例上?是否考慮生物學(例如:人種、年齡、性別、疾病差異與嚴重度…)、經濟(例如:保險與費用相關議題、醫療資源…)、社會文化(宗教信仰、倫理風俗、價值觀…)等差異?

  24. Phase 2.  轉化知識到當地環境 Adapting Knowledge to Local Context

  25. 從實證到應用 4.2 轉化知識到當地環境(Adapting Knowledge to Local Context) • 評分重點: • 1.相關權益關係人(stakeholders)的參與,機構、病房、照護人員的實務考量。 • 2.確認實踐知識所需的技能及資源。 • 3.能提出知識轉化到單位/醫院的內容。

  26. Phase 3.  評估應用知識時的阻力或助力 Assessing Barriers/Facilitators to Knowledge Use

  27. 從實證到應用 4.3 擬定推行計畫(評估應用知識時的阻力或助力、成本效益) • 評分重點: • 1. 運用有效的量性/質性方法(如德菲/焦點團體/文獻查證)找出推行的助力/阻力。 • 2. 推行計畫於時間、人力及資源等的配置適當。

  28. 證據管道(evidence pipeline) • Glasziou教授稱這個應用模式為證據管道(evidence pipeline),由左邊的實證資料庫進入到右側的應用端,主要有7個應用階段,分別為 • 注意到(aware)、 • 接受(accepted)、 • 可行(applicable)、 • 有能力做(able)、 • 開始做(acted on)、 • 認同(agreed)及 • 養成習慣(adhered to)[4]。 [4] Glasziou P, Haynes B. The paths from research to improved health outcomes. ACP Journal Club 2005;142(2):A8-10.

  29. 實證應用進展的流程,是Glasziou參考Pathman在1996年所提出模型改造而成。Pathman從證據到行動包含4個階段:實證應用進展的流程,是Glasziou參考Pathman在1996年所提出模型改造而成。Pathman從證據到行動包含4個階段: • 臨床工作人員首先需要有注意到新的研究建議(awareness),而且 • 認同該建議(agreement),接著 • 採用(adoption),到最後 • 養成習慣(adherence)[5]。 [5] Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The Awareness-to-Adherence Model of the Steps to Clinical Guideline Compliance: The Case of Pediatric Vaccine Recommendations. Medical Care 1996;34(9):873-89.

  30. 這個發現和Rogers所提出創新的擴散裡的5個階段(stage)是不謀而合,這5個stage是這個發現和Rogers所提出創新的擴散裡的5個階段(stage)是不謀而合,這5個stage是 • 知道(knowing)、 • 接受(accepting)、 • 決定(deciding)、 • 實施(implementing)與 • 持續操作(continuing)[6]。 [6] Rogers EM. Diffusion of innovations. 5th ed. New York: Free Press, 2003.

  31. The 7 “A”s- the pipeline fromawareness to patient outcome

  32. 第一個「A」:注意到(awareness) 臨床工作人員在繁忙的工作裡,很難注意到所有與臨床工作相關的證據,所以如何讓證據可以進入到繁忙的工作流程中,讓醫師可以「不得不」注意到,就變成很重要的一個步驟。

  33. Causes of deviations from guidelines Fürthauer J, Flamm M, Sönnichsen A. Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study. BMC Fam Pract. 2013 Apr 4;14(1):47.

  34. 2005年考科藍文獻回顧資料庫(Cochrane Database of Systematic Reviews,CDSR)即指出對於要做電腦斷層的病人在打顯影劑時,首先需要考量病人的腎功能是否正常[9]。 [9] Zacharias M GI, Herbison GP, Sivalingam P, Walker RJ. Interventions for protecting renal function in the perioperative period. Cochrane Database Syst Rev 2005;20(3):CD003590.

  35. Contrast media reminding system • Safe • Timely

  36. 第二個「A」:接受(acceptance) 當臨床工作者知道一個新的介入或處置的好處時,他卻不一定能接受這個新的作法。

  37. “傷口是不是都不能碰水? 台北醫學大學 市立萬芳醫院 實證醫學中心

  38. CDSR There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it. However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents. Water for wound cleansing Ritin Fernandez1 Published Online: 15 FEB 2012 台北醫學大學 市立萬芳醫院 實證醫學中心

  39. 第三個「A」: 可行(applicable) 通常證據雖然被接受了, 但是臨床工作人員或是臨床指引有時候不一定能夠用在正確的病人族群裡

  40. “這個燒傷病人前幾天用Uburn換藥, 現在為什麼不用了?” 台北醫學大學 市立萬芳醫院 實證醫學中心

  41. U burn 會延緩燙傷癒合 The use of silver sulphadiazine (SSD) as a comparator on burn wounds for the full duration of treatment needs to be reconsidered, as a number of studies showed delays in time to wound healing and increased number of dressing applications in patients treated with SSD dressings. Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD002106. 台北醫學大學 市立萬芳醫院 實證醫學中心

  42. 第四個「A」:有能力做(available &able) 在很多複雜的操作裡,這不只是給止痛藥這麼單純而己,例如要完成一個減重計畫或是操作顯微手術,這些都是需要長時間的教育訓練,尤其現在醫療愈來愈複雜,這部分也就愈來愈重要。

  43. 前列腺手術 (data suggest that there is little learning before 250 procedures) Andrew J Vickers, Caroline J Savage...The surgical learning curve for laparoscopic compared to open radical prostatectomy: a retrospective cohort study Lancet Oncol. 2009 May ; 10(5): 475–480.

  44. 經蝶骨手術(Transsphenoidal surgery) Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997 Feb;40(2):225-36; discussion 236-7.

  45. 第五個「A」:開始做(acted on) 儘管我們已經知道並且接受一件事情,有時仍會忽略或忘記去做,因此,如何讓醫護人員或病人開始做,這需要各種「提醒」的功能

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