步驟一:Asking 問問題

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實證醫學基礎核心課程工作坊
- QUESTION FORMING
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執行EBM的五個步驟: 5A

步驟一:Asking 問問題
 形成一個可回答的臨床問題
 Converting the clinical uncertainties into an answerable
question.

步驟二:Accessing 找資料
 搜尋最佳證據
 Search the database and tracking down the best available
evidence.

步驟三:Appraising 分析判斷
 嚴格評讀證據
 Critical appraising that evidence for its validity and importance.
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執行EBM的五個步驟: 5A

步驟四:Applying 臨床應用
 應用證據於病患身上
 Integrating the critical appraising with our clinical expertise and
our patient’s unique biology, values and circumstances.

步驟五:Auditing 評估成果
 評估執行效果及效用
 Evaluating our effectiveness and efficiency in executing step 14 and seeking ways to improve them both for next time.
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學習目標
LEARNING OBJECTIVES

能了解臨床提問的重要性

能分辨前景問題與背景問題之不同

能掌握臨床問題之類別

能提出一個前景的臨床問題

能分析問題的結構
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提問之重要性
 決定蒐證的方向
 確立問題的內容
 培養提問的習慣
 衡量問題的輕重
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臨床問題從哪裡來?
1. 臨床發現(clinical findings)
 2. 病因(etiology)
 3. 疾病的臨床表徵(clinical menifestations of diseases)
 4. 鑑別診斷與診斷檢查(DDx & diagnostic test)
 5. 治療(therapy)
 6. 預後(prognosis)
 7. 預防措施(prevention)

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問一個可以回答的臨床問題
ASK AN ANSWERABLE QUESTION

Background & Foreground

Questions (PICO)

Types of Questions

Priority to answer
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背景問題
BACKGROUND QUESTIONS


詢問有關疾病的一般性知識
的問題
問題的結構通常包括有
 Who:病患特性、危險因
子等
 What:自然病程、症狀
學等
 Where:影響的器官與系
統、疾病分佈的區域等
 When:疾病好發的年齡、
時間、季節等
 How:病理生理學
 Why:病因

舉例:急性心肌梗塞
 Who:老年人、男性、家
族史
 What:胸痛、心電圖的
變化等
 Where:冠狀動脈阻塞的
位置、程度等
 When:氣溫低、心肌耗
氧量高之活動等
 How:動脈硬化斑塊破裂、
血栓形成
 Why:動脈硬化危險因子、
糖尿病、高血壓、高血脂
症、抽菸、肥胖、少運動
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前景問題
FOREGROUND QUESTIONS

詢問有關處理病人所需特別知識的問題

問題的架構通常包括有 4 個項目
 與病患相關的問題 (The patient and/or problem of
interest)
 主要的治療措施 (The main intervention),包括診斷、
治療、預後、及病患的觀點
 比較相關的治療措施 (Comparison intervention(s), if
relevant)
 相關的臨床成效 (The clinical outcome(s) of interest)

EBM主要是針對foreground questions
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BACKGROUND 與FOREGROUND 問題的關係
Novice asked more background questions
 Expert asked more foreground questions

一位臨床醫療的初學者會有較多的background questions,
而有經驗的老手則多提出foreground questions。
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策略
STRATEGY

利用PICO來建構一個特定的臨床問題
 A "well-built" question should include four parts, referred to as
PICO
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常見問題類型
COMMON TYPES OF QUESTIONS

Therapy -- how to select treatments to offer patients that do more good
than harm and that are worth the efforts and costs of using them.

Diagnostic test -- how to select and interpret diagnostic tests, in order to
confirm or exclude a diagnosis, based on considering their specificity,
sensitivity, likelihood ratios, expense, safety, etc.

Prognosis -- how to estimate the patient's likely clinical course over time
and anticipate likely complications of disease.

Harm/Etiology -- how to identify causes for disease (including iatrogenic
forms)

Prevention -- how to reduce the chance of disease by identifying and
modifying risk factors and how to diagnose early by screening

Cost-Analysis -- how to compare the cost and consequences of different
treatments and tests
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確定問題的類別,才能找尋到最佳研究
設計之證據
Type of Study
Therapy
Suggested best type of Study
RCT (Randomized Controlled Trial)
Diagnosis Test
prospective, blind comparison to a
gold standard
cohort study > case control > case
series
Prognosis
Etiology/Harm
Prevention
RCT> cohort > case control > case
series
RCT > cohort study > case control
Cost-analysis
economic analysis
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經過上述有系統有組織地解析臨床問題
後,進一步搜尋資料庫時才不會漫無目
的,也比較能夠找到相關且有效的資料
(證據)來回答臨床問題。
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問題的形成與回答優先順序

「PICO問題的形成」需對該疾病的相關知識有一定
程度的瞭解。

時間有限,必需將問題列出優先順序,一般考量的觀
點:
 與病人健康福祉有關的問題
 臨床上重複出現的問題
 時間許可內,最方便回答的問題
 與學習者自我需求有關的問題
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SCENARIO-1

Your patient is a 72-year-old woman with osteoarthritis
of the knees and moderate hypertension, accompanied by
her daughter.

The daughter wants you to give her mother a prescription
for one of the new COX-2 inhibitors. She has heard that
they cause less GI bleeding. Her mother is concerned
that the new drugs will mean more out of pocket costs
each month.
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SCENARIO-1
Patient / Problem
Intervention
Comparison
Outcome
Specific question:
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SCENARIO-2

45歲男性因上腹不適、解黑便及吐血,到某醫院急診
求診,經禁食及靜脈輸液後安排上消化道內視鏡檢查
。

術中發現胃潰瘍合併活動性出血,施以經內視鏡止血
治療,並達到止血效果。術後使用氫離子幫浦阻斷劑
(proton pump inhibitor)持續治療,是否可以減少併
發症?
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SCENARIO-2
Patient / Problem
Intervention
Comparison
Outcome
Specific question:
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SCENARIO-3
 70-year-old
woman undergoes a health
examination, which shows bacteriuria. She does
not have dysuria, urinary frequency or other
discomfort.
 老年女性發生無症狀菌尿症
(asymptomatic
bacteriuria)時是否需要使用抗生素治療?
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SCENARIO-3
Patient / Problem
Intervention
Comparison
Outcome
Specific question:
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ASKING FOCUSED QUESTIONS
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關鍵訊息
TAKE HOME MESSAGE

養成提問的習慣,是改善醫療品質的第一步。

實證醫學主要處理的是前景問題。

問題的結構可以分解為: P「病患」、I「介入」、C
「對照」與 O「結果」。

問題的類型可以分成:「治療」、「診斷」、「病
因」、「經濟」、「預防」及「預後」。

提問的過程是彈性靈活的,範圍或方向有不妥時,可
以回來修正原先的問題。
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