临床实践证据

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1、如何形成可回答的临床问题(Pico)背景问题(Backgroundquestions):意指与疾病相关的知识性问题，问题的结构通常包括有带有动词的疑问句(vh。、what,where,when,how、why)与疾病。Who：病患特性、危险因子等What：自然病程、症状学等Where：影响的器官与系统、疾病分布的区域等When：疾病好发的年龄、时间、季节等How：病理生理学Why：病因举例：急性心肌梗塞Who：老年人、男性、家族史What：胸痛、心电图的变化等等Where：冠状动脉阻塞的位置、程度等

2、等When：气温低、心肌耗氧量高之活动等How：动脉硬化斑块破裂、血栓形成Why：动脉硬化危险因了、糖尿病、高血压、高血脂症、抽菸，肥胖，少运动前景问题(Foregroundquestions):指与治疗病患相关的特殊性问题，问题的架构通常包扌舌有4个项日：•与病患相关的问题(Thepatientand/orproblemofinterest)•主要的治疗措施，包扌舌诊断、治疗、预后、及病患的观点(Themainintervcntion(definedverybroadly,includinganex

3、posure,adiagnostictest,aprognosticfactor,atreatment,apatientperception,andsoforth))•比较相关的治疗措施(Comparisonintervention(s),ifrelevant)•相关的临床成效(Theclinicaloutcome(s)ofinterest)PICO问题P：patientand/orproblem(病患)I：intervention(处理)C：comparisonofintervention(对照)0

4、：clinicaloutcome(临床结果)形成臨床問題“PICOIComponentsofClinicalQuestionsPatient/PopulationIntervention/ExposureComparisonOutcomeInpatientswithacuteMlcomparedtoplacebodoesearlytreat-mentwithastatindecreasecardio-vascularmortalrty?comparedtoexerciseECGfordiagnosin

5、gsignificantCAD?InwomenwithsuspectedcoronarydiseasewhatistheaccuracyofexerciseECHOInpost-menopausalwomendoeshormonereplacementtherapycomparedtonoHRTincreasetheriskofbreastcancer?LevelsofEvidenceLevelsofEvidence(March2009)elTherapy/Prevention,Aetiology/l

6、larmDiagnosislaSystematicReview(SR)ofRCTsSRofLevel1diagnosticstudies;Clinical)ecisionRule(CDR)withlbstudiesfromdifferentclinicalccntreslbIndividualRandomizedcontrolledtrial(RCT)Validatingcohortstudywithgoodreferencestandards;orCDRtestedwithinoneclinical

7、centrelcAll-or-noneAbsoluteSpPinsandSnNouts2aSystematicreviewofcohortstudiesSRofLevel>2diagnosticstudies2bIndividualcohortstudyExploratorycohortstudywithgoodrefereneestandards;CDRafterderivation,orvalidatedonlyonsplit-sampleordatabases2c"Outcomes"Resear

8、ch;Ecologicalstudies3aSystematicreviewofcasc-controistudiesSRof3bandbetterstudies3bIndividualCase-ControlStudyMon-consecutivestudy;orwithoutconsistcntlyappliedreferencestandatds4Case-seriesCaso-controlstudy,poorornon-indopondentr