循证医学的定义、发展、基础及实践

循证医学是结合医生的个人专业技能和临床经验,考虑患者的愿望,对患者作出医疗决策而发展起来的新兴临床学科。高质量的证据是指尽可能保证结果真实性的、以患者为中心的临床研究数据。证据及其质量是循证医学的关键。研究人员应该尽量提供高质量的证据,临床医生应尽可能使用现有的最佳证据。循证医学在进行诊断和治疗决策时,考虑患者的愿望,从而体现以患者为中心的医疗服务宗旨。高素质的临床医生、最佳的研究证据、临床流行病学的基本方法和知识及患者的参与是循证医学的基础。循证医学实践包括提出问题,检索证据,评价证据,结合临床经验与最好证据对患者进行处理和效果评价5个步骤。     

根除幽门螺杆菌治疗功能性消化不良的临床证据

目的为临床实践提供有关功能性消化不良(FD)根除幽门螺杆菌(HP)治疗的循证医学证据。方法根据HP感染与FD的关系和HP根除治疗在治疗FD中的作用两个临床问题,检索VIP(1989～2005)、CBMdisc(1978～2005)、MEDLINE (1978～2006)以及Cochrane图书馆(2005年第4期)的系统评价,Meta分析,随机对照试验和临床指南,评价HP感染与FD的关系和HP根除治疗在治疗FD中的作用,为临床实践提供最佳的循证医学证据。结果共纳入2篇系统评价、1篇Meta分析和11篇随机对照试验。现有证据显示:FD患者HP感染率高于无症状者,但HP感染在FD发生中的作用还有待流行病学研究及病理生理研究的证据证实。HP根除治疗HP阳性FD,可以减缓部分消化不良患者的症状,但对改善患者生活质量无明显意义。HP根除治疗的成本-效益价值主要取决于患者希望明确诊断的愿望,还没有很好地证据显示需要对HP阳性FD都行HP根除治疗。结论基于目前的临床证据,我们认为对FD是否行HP根除治疗应根据患者的情况,做到个体化,对一些常规治疗差的患者可考虑采用HP根除治疗。     

长期气管切开患者气管套管更换护理策略的证据总结

目的评价与总结长期气管切开患者气管套管更换护理策略的最佳证据,为临床实践提供参考。方法提出循证问题,并系统检索BMJ循证医学库、JBI循证卫生保健中心数据库、英国国家卫生与临床优化研究所指南网、Cochrane library、Pubmed、中国生物医学文献数据库、万方、中国知网等数据库中关于气管套管更换的临床决策、指南、证据总结、系统评价、专家共识等文献,并对纳入文献进行质量评价。结果共纳入8篇文献,包括2篇指南、1篇临床决策、1篇专家共识、4篇系统评价,总结得出长期气管切开患者气管套管更换护理策略最佳证据20条,包括换管时机的识别与观察、常规换管频率、换管评估、换管人员及场所、换管前准备、换管过程配合及换管后维护等7个方面。结论本研究可为长期气管切开患者气管套管的更换提供参考,应用前还需考虑特定的医院科室临床背景,结合患方意愿,审慎明智地选用证据,从而降低呼吸道并发症的发生率,提高护理质量。     

腹膜透析患者运动管理方案的最佳证据总结

目的 总结了腹膜透析患者运动管理方案的最佳证据,为腹膜透析患者运动管理临床实践提供参考。方法 检索国内外中英文相关指南和专家共识库、循证资源数据库、原始研究数据库、护理学专业数据库中关于腹膜透析患者运动管理方案的文献,包括临床决策、临床实践指南、最佳临床实践、证据汇总、专家共识、系统评价以及随机对照试验。然后,基于文献质量评价系统和证据分级系统进行文献质量分析、证据汇总和制定推荐意见。结果 最终共纳入20篇文献,包括1篇临床指南、1篇专家共识、6篇系统评价以及12篇随机对照试验,并从6个方面总结了11条最佳证据。结论 医护人员应在安全性原则下根据腹膜透析患者的意愿、临床实践情况制定个体化运动处方,提高患者远期存活率。     

循证医学在康复临床中的应用

在康复医学领域如何开展循证医学?循证医学证据的分级,实践循证医学的步骤,以及怎样才能够通过临床医师参与和利用Cochrane协作网、阅读和应用循证医学文献来寻找到目前最好的证据,以解决患者的实际问题;循证医学应用于心肺疾患、神经系统疾患、骨关节疾患等已取得较好的经济效益和社会效益;而目前的部分系统评价所收集的原始文献尚不充分,大部分缺乏大型、多中心随机对照试验的支持,有的系统评价无法得出对临床有帮助的结论。文章综述了康复科主要相关疾病的循证医学研究概况,为临床康复医师如何实践循证医学和进行康复医学科研提供参考。     

循证医学的定义、发展、基础及实践

循证医学是结合医生的个人专业技能和临床经验，考虑患的愿望，对患作出医疗决策而发展起来的新兴临床学科。高质量的证据是指尽可能保证结果真实性的、以患为中心的临床研究数据。证据及其质量是循证医学的关键。研究人员应该尽量提供高质量的证据，临床医生尽可能使用现有的最佳证据。循证医学在进行诊断和治疗决策时，考虑患的愿望，从而体现以患为中心的医疗服务宗旨。高素质的临床医生、最佳的研究证据、临床流行病学的基本方法和知识及患的参与是循证医学的基础。循证医学实践包括提出问题，检索证据，评价证据，结合临床经验与最好证据对患进行处理和效果评价5个步骤。     

循证医学教学对研究生相关知识、技能、态度和行为的影响研究

目的探讨循证医学课程对医学研究生知识、技能、态度和行为的影响以及循证临床实践中的障碍,为进一步有效地开展循证医学教学和循证临床实践提供参考。方法采用封闭式问题和开放式问题相结合的自填问卷对四川大学2004年秋选修《循证医学》的111名医学研究生进行调查,比较选修前后学生在循证医学知识、技能、态度、行为,以及循证临床实践中障碍方面的差异。结果医学研究生在选修“循证医学”课程前后,其循证医学知识、技能、态度、行为,以及在循证临床实践的障碍方面有一定差异。在知识和技能方面:选修后学生对循证医学相关专业术语的理解有显著提高(75%项目差异有统计学意义),特别是对绝对危险度、系统评价、Meta分析和发表偏倚(P<0.01);认为自己在熟练使用检索工具这一技能上有所提高(P<0.05)。在态度方面:选修前,有55%左右的条目分值均较高(>4分);选修后“现在多数用于病人诊治的干预措施缺乏强有力的证据支持”和“循证医学实践需要考虑病人的意愿”这两项分值提高明显(P<0.01)。“在医疗实践中采用循证医学是合理的要求”和“循证医学不受临床实践场所的限制”这两个条目选修前后的分值都偏低(<3分),在“日常工作中需要增加医学证据的使用”和“对应用循证医学进行临床实践和改进临床技能有兴趣”两项上,分值接近。在行为方面:选修后医学生对文献的使用仍不十分重视。如选修前后都有60%左右的医学生基本上不阅读相关的专业文献。虽然检索MEDLINE和其他电子数据库次数较多(>6次/月,选修前60.3%,选修后65.7%),但在临床实践中应用却不多(>6次/月,课前仅占29%,课后仅占35.1%)。学生对临床实践指南的应用情况,选修前后差异无统计学意义。在障碍方面:选修前后学生均认为最大的障碍是严格评价文献的能力有限,但排名第2与第3的障碍有差别。选修前缺乏查询循证医学的相关技能排在缺乏信息资源前,而选修后相反。结论目前的循证医学课程对提高医学研究生循证医学知识的效果显著,对其对待循证医学的态度和行为也有一定的提高。在临床实践中,医学研究生应用循证医学的三大障碍是严格评价文献能力有限,缺乏查询循证医学相关的技能和缺乏信息资源。     

循证医学在康复临床中的应用

在康复医学领域如何开展循证医学？循证医学证据的分级，实践循证医学的步骤，以及怎样才能够通过临床医师参与和利用Cochrane协作网、阅读和应用循证医学文献来寻找到目前最好的证据，以解决患者的实际问题；循证医学应用于心肺疾患、神经系统疾患、骨关节疾患等已取得较好的经济效益和社会效益；而目前的部分系统评价所收集的原始文献尚不充分，大部分缺乏大型、多中心随机对照试验的支持，有的系统评价无法得出对临床有帮助的结论。文章综述了康复科主要相关疾病的循证医学研究概况，为临床康复医师如何实践循证医学和进行康复医学科研提供参考。     

宫颈癌患者根治术后尿潴留预防及管理的最佳证据总结

目的 检索、评价和汇总宫颈癌患者根治术后尿潴留的预防和管理的最佳证据,为临床护理工作提供参考。方法 计算机检索BMJ Best Practice、UpToDate、Cochrane图书馆、Joana Briggs Institute循证卫生保健国际合作中心数据库、OVID循证数据库、中国指南网、美国指南网、ClincalKey for Nursing、加拿大安大略注册护士协会、PubMed、荷兰医学文摘数据库、护理文献累积索引数据库关于宫颈癌患者根治术后尿潴留预防及管理的所有证据,包括临床实践指南、最佳临床实践信息册、证据汇总及系统评价。检索时限从建库至2018年5月。结果 共纳入16篇文献,包括临床实践指南5篇、系统评价5篇、证据总结4篇、临床决策2篇,最终获取14条最佳证据。结论 临床科室在应用证据时,应结合文化背景、具体的临床环境、患者意愿及偏好等有针对性地选择证据,及时关注相关证据的更新。     

肿瘤日间化疗患者静脉血栓栓塞症预防和管理的证据总结

目的 :通过检索、评价及总结肿瘤日间化疗患者静脉血栓栓塞症预防和管理的相关证据,为临床实践提供依据。方法 :提出肿瘤日间化疗患者静脉血栓栓塞症的循证问题并检索文献,采用澳大利亚JBI循证卫生保健中心的文献评价标准和证据分级系统,对各类研究进行文献质量评价、证据总结及证据级别评定。结果 :本研究共纳入14篇文献,总结出19条证据,涵盖了肿瘤日间化疗患者静脉血栓栓塞症的风险筛查、评估与诊断、机械预防、药物预防、管理策略和健康教育6个方面。结论 :通过循证的方法为临床医护人员提供可靠的肿瘤日间化疗患者静脉血栓栓塞症预防和管理的实践依据,但还需进行证据转化应用于临床才能使患者真正受益。     

Application of the principles of evidence-based medicine to patient care

Evidence-based medicine (EBM) is the conscientious and judicious use of the best evidence available collected from clinical trials, guidelines, and consensus statements. This article provides simple ways to practice EBM using five steps (assess the patient, ask a clearly focused clinical question, acquire the best evidence available from the medical literature, appraise the evidence, and apply the evidence to patient care) and how to execute each step properly, multiple examples of how to apply EBM to patient care, and examples of how to apply the PICO mnemonic (patient, intervention, comparison, and outcome) to the process of EBM.     

Evidence-based management: a literature review

This paper presents a review of evidence-based management (EBM), exploring whether management activities within healthcare have been, or can be, subject to the same scientific framework as clinical practice. The evidence-based approach was initially examined, noting the hierarchy of evidence ranging from randomized control trials to clinical anecdote. The literature varied in its degree of criticism of this approach; the most common concern referring to the assumed superiority of positivism. However, evidence-based practice was generally accepted as the best way forward. Stewart (1998) offered the only detailed exposition of EBM, outlining a necessary 'attitude of mind' both for EBM and for the creation of a research culture. However, the term 'clinical effectiveness' emerged as a possible replacement buzz-word for EBM (McClarey 1998). The term appears to encompass the sentiments of the evidence-based approach, but with a concomitant concern for economic factors. In this paper the author has examined the divide between those who viewed EBM as an activity for managers to make their own practice accountable and those who believed it to be a facilitative practice to help clinicians with evidence-based practice. Most papers acknowledged the limited research base for management activities within the health service and offered some explanation such as government policy constraints and lack of time. Nevertheless, the overall emphasis is that ideally there should be a management culture firmly based in evidence.     

Integrating evidence into clinical practice: an alternative to evidence-based approaches

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient.     

临床医学生对循证医学课程认知和态度分析

目的 对首都医科大学临床医学生学习循证医学课程的效果进行调查和评估,进而提出教学建议.方法 采用事先设计的调查问卷对该校2006级临床5年制和7年制医学生开设循证医学课程前、后在文献检索利用、循证医学常用术语掌握、学科认知态度方面进行调查,并辅以访谈法收集学生的意见进行统计分析.结果 开设循证医学课程后,医学生的文献平均阅读时间和文献检索次数较开设前明显增加(P＜0.05);循证医学实践涉及的术语理解程度在课程后也明显提高(P＜0.05);学生文献严格评价能力在5年制学生中也有明显提高(P＜0.05).在访谈中,学生建议增加文献检索和筛选文献课时,并对医学统计学内容进行复习.结论 循证医学课程的学习对学生认知和行为均有较大改变,结合案例教学法进行循证医学课程讲授具有较好的教学效果,循证医学理念和技能的学习对于临床医学生应用医学研究证据、自我学习和临床中付诸实践均有较大意义.     

Evidence-based medicine: a Kuhnian perspective of a transvestite non-theory

Evidence-based medicine (EBM) has been presented by its protagonists as a new paradigm for medical practice. In this article that claim is analysed through the theory of scientific development proposed by Thomas S. Kuhn in 1962. Traditional medical paradigms are discussed, as well as the assumptions of the supposedly ‘new’ paradigm of EBM. The value of the results of randomized clinical trials (RCTs) for the elaboration of clinical guidelines is analysed within the context of the assumptions of EBM and the paradigm concept of Thomas S. Kuhn. It is argued that the results of RCTs, whenever contradicted by fundamental medical theory, constitute inadmissible evidence for the development of clinical guidelines. The supremacy of results of clinical trials over traditional medical paradigms, advocated by the protagonists of EBM, is rejected. Fundamental contradictions of EBM are also exposed: the fact that there is no evidence to support the utility of EBM and its call for a new type of authoritarianism in medicine. Finally, it is suggested that ‘epidemiology-based medical practice’ is a better, rhetoric-free designation for what is currently termed evidence-based medicine*. It is concluded that EBM is not what it claims to be and that its assumptions are simply irrational.     

Principles governing heart failure therapy re-examined relative to standard evidence-based medicine-driven guidelines

Although all aspects of clinical work nowadays are modified by the pervading influence of evidence-based medicine (EBM) and multiplicative guidelines, not many clinicians realize that the underlying premise of EBM-driven guidelines is a particular strain of consequentialist ideology. Subservience to this ideology has transformed modern medical practice, but there is a real risk of distorting good medical practice, of belittling clinical judgement, of disempowering clinicians, and subjecting patients to skewed medical reality and treatment options. With so many heart failure (HF) guidelines issued by various august bodies, it is therefore timely to reappraise principles governing modern HF therapy with a fresh examination of the hierarchy of medical imperatives, the role of alternatives to consequentialism including deontological principles in HF therapy. In addition, other ideology worth re-examining, aside from EBM, are the principle of appropriate definition of HF underlying therapeutic goals and the principle of prioritizing objectives of HF therapy. Even within standard EBM, there are many questions to reconsider: about what types of evidence are admissible, different interpretations of available evidence, emphasizing patient-centered outcome measures instead of randomized controlled trials quantifiable therapeutic outcomes, how to prescribe drugs for prognostic versus symptomatic benefits, and how to deliver HF therapy based on pathophysiological features through mechanistic considerations and not just confined to randomized controlled trials or meta-analytical statistical imperatives. Through re-examination of these fundamental principles of HF therapy, it is hoped that clinicians will be empowered to manage HF patients more holistically and better deliver HF therapies in the best interest of each individual patient.     

Principles governing heart failure therapy re-examined relative to standard evidence-based medicine-driven guidelines

Although all aspects of clinical work nowadays are modified by the pervading influence of evidence-based medicine (EBM) and multiplicative guidelines, not many clinicians realize that the underlying premise of EBM-driven guidelines is a particular strain of consequentialist ideology. Subservience to this ideology has transformed modern medical practice, but there is a real risk of distorting good medical practice, of belittling clinical judgement, of disempowering clinicians, and subjecting patients to skewed medical reality and treatment options. With so many heart failure (HF) guidelines issued by various august bodies, it is therefore timely to reappraise principles governing modern HF therapy with a fresh examination of the hierarchy of medical imperatives, the role of alternatives to consequentialism including deontological principles in HF therapy. In addition, other ideology worth re-examining, aside from EBM, are the principle of appropriate definition of HF underlying therapeutic goals and the principle of prioritizing objectives of HF therapy. Even within standard EBM, there are many questions to reconsider: about what types of evidence are admissible, different interpretations of available evidence, emphasizing patient-centered outcome measures instead of randomized controlled trials quantifiable therapeutic outcomes, how to prescribe drugs for prognostic versus symptomatic benefits, and how to deliver HF therapy based on pathophysiological features through mechanistic considerations and not just confined to randomized controlled trials or meta-analytical statistical imperatives. Through re-examination of these fundamental principles of HF therapy, it is hoped that clinicians will be empowered to manage HF patients more holistically and better deliver HF therapies in the best interest of each individual patient.     

不完全性颈髓损伤高位截瘫1例患者的循证治疗

背景：目前脊髓损伤治疗仍是世界难题之一,脊髓损伤后坏死神经元几乎不能再生,不同医院治疗方案均有不同,但均无有效的循证医学支持。目的：借助循证医学的方法为1例诊断为脊髓损伤的患者制定最为有效的治疗目标及治疗方案。方法：充分了解该患者病情一般情况后,从Cochran library、Pubmed、Embase上进行搜索。搜索主题词：spinal cord injuries;pharmacotherapy;long-term;rehabilitation;prognosis-assessment;cell transplantation therapy;Prevention-of-complications;meta-analysis;human;RCT;systematic review等。共检出27篇相关文献进入结果分析。结果与结论：通过检索结果分析,脊髓损伤恢复期患者,最主要的治疗目的为并发症的预防和康复治疗,以尽可能的促进脊髓的再生和功能的恢复。半年后随访,患者病情稳定,可自行排便,上肢肌力有所恢复,下肢痉挛减轻,可自行站立。采用循证治疗的方法,为脊髓损伤患者制定合理的治疗目标和治疗方案,有良好临床效果。     

An epistemological shift: from evidence‐based medicine to epistemological responsibility

In decision making concerning the diagnosis and treatment of patients, doctors have a responsibility to do this to the best of their abilities. Yet we argue that the current paradigm for best medical practice – evidence‐based medicine (EBM) – does not always support this responsibility. EBM was developed to promote a more scientific approach to the practice of medicine. This includes the use of randomized controlled trials in the testing of new treatments and prophylactics and rule‐based reasoning in clinical decision making. But critics of EBM claim that such a scientific approach does not always work in the clinic. In this article, we build on this critique and argue that rule‐based reasoning and the use of general guidelines as promoted by EBM does not accommodate the complex reasoning of doctors in clinical decision making. Instead, we propose that a new medical epistemology is needed that accounts for complex reasoning styles in medical practice and at the same time maintains the quality usually associated with ‘scientific’. The medical epistemology we propose conforms to the epistemological responsibility of doctors, which involves a specific professional attitude and epistemological skills. Instead of deferring part of the professional responsibility to strict clinical guidelines, as EBM allows for, our alternative epistemology holds doctors accountable for epistemic considerations in clinical decision making towards the diagnosis and treatment plan of individual patients. One of the key intellectual challenges of doctors is the ability to bring together heterogeneous pieces of information to construct a coherent ‘picture’ of a specific patient. In the proposed epistemology, we consider this ‘picture’ as an epistemological tool that may then be employed in the diagnosis and treatment of a specific patient.     

Improved health or improved decision making? The ethical goals of EBM

Evidence-based medicine (EBM) is frequently portrayed as a value-free approach to knowing what kinds of treatment 'really work.' Since practitioners should help patients to improve their health, and EBM tells us which interventions will work, then it follows that we must practice EBM, offering only those interventions supported by evidence. The primary goal of EBM, then, is an ethical one - to improve health. More recently, EBM's authors have also committed themselves to 'shared decision making' in which evidence plays a role in the clinical encounter, but where patients, motivated by their own values, should have final decision-making authority. Envisioned this way, strengthening the informed consent process, rather than improved health per se, is viewed as the goal of EBM. In this paper, I will explore this shift in EBM's ethics from the goal of improved health towards the goal of strengthened informed consent. Drawing upon data from a qualitative enquiry of scholars involved in the development of EBM, I will argue that EBM is now committed to both of these ethical goals. Where they conflict, the aim of the intervention will determine which goal practitioners should pursue. Having increased the ethical complexity of EBM, we are left with the question of whether EBM would still be judged a success if it did not lead to much in the way of improvements in health, but primarily strengthened informed consent. This paper will conclude by arguing that this more nuanced version of EBM's ethics accurately reflects the dynamics of real clinical practice but undermines the original, perceived need for EBM.