4.病因性研究证据的评价与应用-华西循证医学中心全套EBM资料

1ebasedEtiologyHarm2•掌握评价病因性研究真•掌握评价病因性研究重•学会应用病因性研究证3病因性研究基本知识•病因性研究基本概念•与病因相关的临床问题•病因性研究的主要方法4病因性研究基本概念(1)•病因是指引起人体发生疾病的原因。病因学是•病因：致病因素(直接、间接、危险因素)•研究内容：用流行病学方法研究并验证危险因系的强弱。例“吸烟与肺癌关系”，性实，性实性病因性研究基本概念(2)••不良反应的研究实质上也是病因学研究“因”：造成不良反应的各种因素，如各种治疗措施 ••用他人的研究结果来回答提出的问题55 •Do •Dostatinscausecancer?••该疾病是什么原因造成的？•该药物或治疗措施会导致什么不•DoesexposuretoaluminumcauseAlzheimer•DoesexposuretoaluminumcauseAlzheimer’sdementia?66病因性研究的主要方病因性研究的主要方法77:病因性研究常用统计学指标88研究疾病的发病率较低时，OR近似于RR，故在回•RR或OR有多大才有意义，无一定的标准>3.0:强联系99概率去估计总体参数所在的范 •查阅教科书clinicalAcquiretheclinicalAcquiretheasedMedicineAskAskAAppraisetheevidenceAAYtitYtit高胆固醇症•右眼白内障术后2天，出现易激、高胆固醇症•右眼白内障术后2天，出现易激、•无，贫血及代谢异常的临床证抗精神病药物氟哌啶醇,haloperidol,奋乃静生中会诊perphenazine,,olanzapine••84岁的男性，近记忆力明显下降.高ion老年患者中，用传统性抗精神病药物(如氟哌啶醇,haloperidol,奋乃静perphenazine,)是否,olanzapine,)是否对老年人更安全？第步提出问题第步提出问题•Why?节约时间，什么类型的临床问题，便于检索•患者类型(P)elderlypatients•对照措施(C)olanzapine•临床结局(Odeath--病因/不良反应研究常用数据库 ••选择数据库：ACPjournalclub(ovid22•ACPjournalClubsummary:ConventionalantipsychoticdrugsincreasedriskfordeathmorethandidatypicalantipsychoticdrugsinelderlypatientsACPJournalClub.2007;147:23.•SchneeweissS,SetoguchiS,BrookhartA,DormuthC,WangPS.Riskofdeathassociatedwiththeuseofconventionalversusatypicalantipsychoticdrugsamongelderlypatients.CMAJ.2007;176:627-32第三步评价证据 第三步评价证据 ••证据的真实性2324252526rlypatientsassociationofconventionaloratypicalantipsychoticdrugs(APDs)withdeath?signCohortstudytstientsyofageonventionalnmeanageyatypical(n=24359,meanage80y).usioncriteriacanceranduseofAPDsintheyearbeforetheindexdate.2两组结局暴露因素的blindedto2两组结局暴露因素的blindedtoexposure?)gpmeasuredinthesamewaysinbothgroups?(Wastheassessmentofoutcomeseitherobjectiveorblidd?)..、测量方法是否一致？dihibh?(W•dihibh?(W••Weretheoutcomesandexposuresmeasuredin2727型肝炎肝癌药物与肺纤维化关系的研型肝炎肝癌药物与肺纤维化关系的研究2828293.随访时间及失访率•举例：HP与胃癌：5年(无差异)，100•Dotheresultsoftheharmstudysatisfysomeofthediagnostictestsforcausation?1充分的生物学依据(CCB与癌症，坏血充分的生物学依据(CCB与癌症，坏血2importantwaysotherthanimportantwaysotherthanexposuretothetreatmentorotherKeyKeyPoints11.Werethereclearlydefinedgroupsofpatients,similarinall2.Weretreatments/exposuresandclinicaloutcomesmeasuredinthesamewaysinbothgroups?patientssufficientlylong(fortheoutcometooccur)andcomplete?3.patientssufficientlylong(fortheoutcometooccur)andcomplete?34nce•RR•RRORNNH5nceureandoutcome•Whatisthemagnitudeoftheassociationbetweenhureandoutcome••Howstrongistheassociationbetweenexposureome6nce•Whatistheprecisionoftheestimateoftheassociationbetweentheexposureandoutcome?•Howpreciseistheestimateofrisk?•95%CIAdjustedHRtorsAdjustedHRtorstia7 AssociationwithdeathAnyconventionalAPD32AnyconventionalAPD32(1.23to1.42) alAPDtoLow-doseconventionalAPD1.23(1.14to1.33)mentiaursinghome8lyinglyinglyingstudythatitsresultscannotapply?•Isourpatientsostudythatitsresultscannotapply?••9•Patients:•Patients:•Exclusioncriteria:canceranduseofAPDsintheyearbeforetheindexdate.trifluoperazine,thioridazine,pimozide,promazne,perphenazine,fluphenazine,mesoridazine,andthiothixene.yyoage,-women•Used1medicalservice,andfilled1prescriptioninthetwo6-month•AtypicalAPDs:risperidone,quetiapine,olanzapine,andclozapine•ConventionalAPDs:loxapine,haloperidol,chlorpromazine,iflihiidiiidiihi440harmfromtheharmfromtheagent?NNTandNNHlying••Whatisourpatient’sriskofbenefitand44142•一项心律失常抑制试验(CAST):别为7.7%和3.0%，NNH＝21(平均每21个患•NSIAD与消化道出血：NNH＝2000(每200043物patient’spatient’spreferences,concernsandconcerns,andexpectationsfromthis44lyingWhatareour45lying•Whatalternative高胆固醇症•右眼白内障术后2天，出现易激、高胆固醇症•右眼白内障术后2天，出现易激、•无，贫血及代谢异常的临床证抗精神病药物氟哌啶醇,haloperidol,奋乃静