应用循证医学,推动妇产科临床工作更科学地发展

循证医学是一门在医学实践中寻找、评价和使用最佳临床证据的新兴学科,循证医学的理念与方法为临床医生和科研人员从事临床研究和医疗实践提供了新的思路与方法.循证医学不仅适用于内、外、妇、儿、护理、保健、诊断、预防等临床医学下属学科,同时也可应用于卫生经济、卫生决策、医疗质量促进、医疗保险及医学教育等医疗卫生领域.     

证据的来源与检索

循证医学是指认真、明确和明智地应用现有的最好证据,同时结合医生的个人专业技能和临床经验,考虑病人的愿望,对患者做出医疗决策.因此证据及其质量是循证医学的关键.本文旨在系统介绍证据的来源和如何检索证据,为卫生健康工作者的循证医学实践提供服务和帮助.     

通过改进挽留政策提高农村和边远地区卫生人力的可及性:WHO2010全球政策建议解读

农村和边远地区卫生人力资源不足是世界各国普遍关注的卫生问题之一,严重影响卫生公平的实现.对此,WHO提出全球政策建议——通过改进挽留政策提高农村和边远地区卫生人力的可及性.本文重点从循证医学方法学和指南制定角度,对该政策指南制定的关键步骤进行解读,主要包括背景及问题的提出、证据的检索与遴选、证据质量分级与推荐方案形成,从而进一步探讨卫生决策过程中如何正确认识、获得、评价与应用当前可得的研究证据,以及如何基于证据,利用GRADE系统做出科学可行的推荐,强调证据及GRADE系统在循证卫生决策中的重要作用.     

Cochrane图书馆--循证医学的重要资料库

循证医学是指遵循科学依据的医学,提倡在临床实践中将个人经验、病人的需求与当前最佳科学依据结合起来进行医疗决策,倡导根据研究依据和个人经验处理病人.循证医学最可靠的证据来自按照特定方法收集所有质量可靠的随机对照试验(randomized controlled trial,RCT)后所作的系统评价(systematic review,SR).目前SR的结果正成为许多发达国家卫生决策的参考依据,影响着这些国家的医疗实践、卫生决策、医疗保险和医学教育,促进临床研究与实践进入一个全新的时代,即从经验医学到循证医学.     

循证卫生决策研究方法介绍

循证决策是卫生决策者最常用的、客观的、也是最重要的一种卫生政策研究方法。其目的是改变传统的主观臆断卫生决策,促进卫生政策和系统研究知识的应用与传播,以改进国家和地区卫生系统的绩效。影响循证卫生决策效果的三个要素是：研究证据,可利用的卫生资源以及政策的价值取向。本文介绍了一些实用的循证决策方法,特别是系统评价、优先重点的选择和CAM矩阵分析方法。     

循证医学学科知识可视化研究之三:循证医学知识传播可视化研究

目的通过研究循证医学期刊与相关期刊的引证关系,揭示期刊之间的信息交流关系和结构,找出循证医学证据传播的相关领域,为循证医学的学科定位与证据传播提供科学依据。方法收集《中国循证医学杂志》、《循证医学》、《中国循证儿科杂志》和《Cochrane Database of Systematic Review》(CDSR)的引用和被引期刊信息,可视化期刊间的引证关系。统计《中国循证医学杂志》、《循证医学》、《中国循证儿科杂志》、CDSR的高频关键词,建立共现矩阵,绘制主题图谱。结果 CDSR的证据生产和引用都很高,引文环境成熟。中文循证医学期刊的发文量和引用量逐年上升,引文环境、交流广度和强度不一,从高到低依次为《中国循证医学杂志》、《循证医学》和《中国循证儿科杂志》。CDSR主要交流疾病的控制和治疗证据,中文循证医学期刊刊载内容主要集中在循证医学教育和研究、临床试验设计方法和质量评价、循证决策和循证临床、肿瘤、儿科等领域。结论循证医学的相关知识和证据在各医学期刊得到广泛传播和交流,并形成相应的领域期刊群;但各个循证医学期刊的引文环境不同,交流广度和强度不一。国外循证医学在临床、儿科、药物、精神卫生、妇产科等领域发展成熟;国内循证医学主要在临床、中医药、儿科、肿瘤、护理、卫生经济与管理、医学教育等领域传播和研究,但各领域的发展程度不一,多个领域才刚起步。循证医学的研究主题已开始由药物治疗向手术等其他治疗手段扩展;由临床治疗向临床诊断、临床康复、临床预防等方向扩展;由循证临床向循证管理和决策和实践方面扩展。不同国家和地区对本土化证据的生产和使用正快速增长,循证医学的理念、方法、证据生产和转化正从发达国家向发展中国家尤其是非英语语系国家扩展。     

正确认识循证护理推动护理实践发展

循证护理即通过寻求最佳临床证据为临床护理实践中的决策提供可靠的科学依据.然而在开展循证护理过程中,也出现了一些概念认识上的误区,本文对循证护理的概念、方法的认识及应用方面存在的一些误区进行分析,认为循证护理既是一种工作方法,又是一种观念,但并非一种模式或工作形式,同时在实施循证护理的过程中存在一些方法论上的误区,应加以纠正,才能切实推进循证护理在我国护理实践中的应用.     

循证医学的发展与临床医学

循证医学正越来越深刻地影响着临床医学实践。在临床医疗实践中，充分应用循证医学的原则与方法，可为临床、科研、卫生决策、医学教育等提供最佳证据，并应用最佳证据指导临床决策。通过循证医学的概念、物理结构（Cochrane协作网）、主要期刊；进一步论述了循证医学与临床医学的相互关系及其应用于临床的重要指导意义，强调了单凭推理或病理生理学理论来指导临床行为有时是不可靠的。并通过具体实例说明了循证医学在临床实践中所起的重要作用。     

卫生研究中证据的定义与循证规范

近20年随着循证医学的发展及其方法学的不断完善，证据概念和循证原则不仅在医学各领域广泛应用，且逐渐渗透于非医学领域。我们调查了不同组织对卫生研究中证据的定义，结合实际工作提出对证据的新定义：“证据是系统评价后的信息”；同时论述循证规范的形成，为其服务于其他学科和行业提供借鉴和参考。     

循证医学的发展与临床医学

循证医学正越来越深刻地影响着临床医学实践。在临床医疗实践中,充分应用循证医学的原则与方法,可为临床、科研、卫生决策、医学教育等提供最佳证据,并应用最佳证据指导临床决策。通过循证医学的概念、物理结构(Cochrane协作网)、主要期刊;进一步论述了循证医学与临床医学的相互关系及其应用于临床的重要指导意义,强调了单凭推理或病理生理学理论来指导临床行为有时是不可靠的。并通过具体实例说明了循证医学在临床实践中所起的重要作用。     

系统评价是发展中国家卫生系统循证研究的有效工具吗?

越来越多的卫生体制研究人员运用系统评价的方法来综合研究证据,促进全球和国家的卫生政策发展。然而,在卫生体制研究中开展卫生政策文献的系统评价面临方法学上的挑战。本文探讨了系统评价作为一种研究工具,在发展中国家卫生体制循证研究中的应用前景及局限性。文中首先简要介绍了系统评价方法及其在卫生研究领域过去数十年的发展,然后讨论了卫生体制研究作为系统科学的定义,并将其特点与医学研究相比较,最后讨论和分析了系统评价能否成为发展中国家卫生体制循证研究的有效工具。我们认为,系统评价可能会是卫生体制循证研究中解决特定政策问题的一种非常有用的工具,然而,在某些卫生体制及卫生政策问题的研究上,系统评价方法并不适用。     

Producing systematic reviews of interventions in speech–language pathology: A framework for sustainability

Systematic reviews in the health and social sciences are increasingly recognized as a valuable scientific tool to support decision making by clinicians, managers, administrators, and policy makers. Numerous organizations have arisen to fulfill growing demand for high-integrity systematic reviews with practical applications, each with a unique model for their review production process. This paper presents the results of a purposive sample of current production models in use by organizations engaged in the production of systematic reviews to support evidence-based practice. This paper also evaluates elements of review production such as major review steps, evidence standards, resource use, and cost. The results provide a potential framework for organizing resources to conduct systematic reviews. Applying this framework, producers can identify key areas of systematic-review production with the best fit between individual production models and their organization's mission and policy environment.     

Developing attributes for discrete choice experiments in health: a systematic literature review and case study of alcohol misuse interventions

Discrete choice experiments (DCEs) become increasingly popular to value outcomes for health economic studies and gradually gain acceptance as an input into policy decisions. Developing attributes is a key aspect for the design of DCEs, as their results may misguide decision-makers if they are based on an inappropriate set of attributes. However, the area lacks guidance, and current health-related DCE studies vary considerably in their methods of attribute development, with the consequent danger of providing an unreliable input for policy decisions. The aim of this article is to inform the progress toward a more systematic approach to attribute development for DCE studies in health. A systematic review of the published health-related DCE literature was conducted to lay the foundations for a generic framework which was tested in a case study of alcohol misuse interventions. Four stages of a general attribute development process emerged: (i) raw data collection; (ii) data reduction; (iii) removing inappropriate attributes; and (iv) wording. The case study compared and contrasted a qualitative and mixed-methods approach for the development of attributes for DCEs in the area of alcohol misuse interventions. This article provides a reference point for the design of future DCE experiments in health.     

如何阅读系统评价

目的介绍系统评价的阅读方法。方法全面检索当前有关阅读与评价医学文献的论文、专著,总结归纳出指导阅读系统评价的一般原则和方法。结果以下十个要点有助于科学、快速、高效阅读系统评价：①是否有同类评价？②是否属最新更新？③是否整合了之前相关的系统评价？④是否制定和实施了完善的检索策略？⑤是否对原始研究进行了质量评价？⑥是否对原始研究结果进行了适当合并？⑦是否对其自身局限性或不足予以说明？⑧是否提出了下一阶段需要解决的问题？⑨是否充分报告了摘要和全文？⑩是否能够用于解决实际问题？本文还从对系统评价利用的角度,将读者分为四个人群：卫生政策制定者、卫生保健提供者、研究人员、患者及普通用户。结论应重视对系统评价的阅凄,以便更好的指导决策,推动循证实践。     

The development and descriptions of an evidence-based case management educational program

Educational preparation is the key to successful case management and better patient outcomes. Closer examination reveals that existing case management education programs often lack a theoretical underpinning. In order to address the issues, this paper describes the development process of using an expanded version of Donabedian's structure-process-outcome framework as a base and program itself. Four main stages were used in the development process. A systematic literature review and needs assessment provided relevant evidence for the program design. Then, a panel review was undertaken and pilot testing initiated with public health nurses. The expert panel review and the findings of the pilot test both supported the selection of the program content and the learning approaches adopted throughout the program. Sixteen hours of workshops provided detailed content on the case management process. Four main learning strategies were chosen based on transformative learning theory and the findings of the needs assessment. The paper provides an example of the development of a program based on existing theory and evidence.     

Atención a la cronicidad: desafío estratégico,macrogestión y políticas de salud

The prevalence of chronic diseases is increasing, with the patients who suffer from them having greater need for healthcare.This fact forces a redirection in the health system, currently focused on the acute diseases, to achieve an efficient care. For this reason, it is necessary to work at all levels, starting with political decisions. These decisions should be based on the technical and scientific evidence available.Health planning is essential to establish care strategies, defining the actions to ensure the coordination and continuity of care, and also the redefinition of professional roles, where primary care nurses assume more competencies, becoming key professionals in the care of the chronic patient. The new model should include the professionalization of the management of health services.Information and communication technologies will play an important role in the development of strategies, but considering them as the tools that they are, allowing for the patient to be the focus of attention, and ensuring the privacy and the confidentiality.     

"Heads up": concussions in high school sports

In the United States, sports-related head injuries occur frequently. The Centers for Disease Control estimates more than 300,000 sports-related concussions occur each year in the United States. There are a number of myths and misunderstandings among health care professionals regarding concussions. In this article, we clarify some reasons for these misunderstandings and provide some of the possible causes for the increased susceptibility of the adolescent athlete, along with evidence-based assessment tools for assisting physicians in making return-to-play decisions. Finally, suggestions for a concussion safety program in the high school setting are also provided.     

循证医学与中药上市后的再评价

目前,我国已逐渐开展对上市后药物的不良反应监测,并开始重视其对患者生存质量、患者死亡率等指标的影响.已获上市批准的中药中,有很多在不良反应的发现和管理上存在时滞现象,且在临床有效性和安全性方面存在一定问题.对中药上市后的再评价,需要有效、规范的评价体系.循证药物评价运用循证医学的理念,结合临床流行病学、系统评价、卫生技术评估等手段,评价新药和上市后药物的临床有效性、安全性、经济性和适用性,对我国中药的现代化与国际化进程具有重要作用.