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Th ự c Hành Y H ọ c Ch ứ ng C ứ trong Y T ế Công C ộ ng Gs Ts Bs Lê Hoàng Ninh.

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Presentation on theme: "Th ự c Hành Y H ọ c Ch ứ ng C ứ trong Y T ế Công C ộ ng Gs Ts Bs Lê Hoàng Ninh."— Presentation transcript:

1 Th ự c Hành Y H ọ c Ch ứ ng C ứ trong Y T ế Công C ộ ng Gs Ts Bs Lê Hoàng Ninh

2 Th ự c hành y t ế công c ộ ng d ự a trên ch ứ ng c ứ Ki ế n th ứ c/ nghiên c ứ u Th ự c tr ạ ng b ệ nh nhân/ các tham kh ả o Kinh nghiêm lâm sàng/ s ự cân nh ắ c

3 Câu H ỏ i PICO Tìm ki ế m trên y văn Đánh Giá ch ứ ng c ứ

4 “M ộ t trong nh ữ ng khám phá quan tr ọ ng nh ấ t, đ áng kính ng ạ c nh ấ t là bi ế t cái mà Ta có th ể làm và bi ế t s ợ cái mà Ta không th ể làm.” Henry Ford

5 M ụ c tiêu 1)Hi ể u ý nghĩa v ề đ ánh giá các ch ứ ng c ứ 2) Mô t ả m ứ c đ ộ ch ứ ng c ứ đư ợ c dùng trong đ ánh giá các ch ứ ng c ứ 3) Th ă m dò các ph ươ ng pháp khác nh ư ( th ố ng kê…) có th ể dùng trong đ ánh giá ch ứ ng c ứ. 4) ứ ng d ụ ng qui trình n ầ y trong y t ế công c ộ ng. Cây h ỏ i PICO Tìm y văn Đánh giá ch ứ ng c ứ

6 Th ự c Hành Y H ọ c Ch ứ ng C ứ Dùng nh ữ ng hi ể u bi ế t có ch ấ t l ư ợ ng cao nh ấ t trong ch ă m sóc s ứ c kh ỏ e cho cá nhân và c ả c ộ ng đ ồ ng

7 Đánh Giá Ch ứ ng C ứ Là chìa khóa quan trong trong th ự c hành ch ứ ng c ứ Là k ỹ n ă ng c ầ n, c ố t lõi trong th ự c hành y h ọ c

8 Đánh Giá Ch ứ ng C ứ Ph ả i đ ả m b ả o r ằ ng ch ứ ng c ứ tìm th ấ y trên dân s ố nghiên c ứ u có th ể đư ợ c th ự c hi ệ n trên dân s ố mà các b ạ n mu ố n áp d ụ ng

9 N ộ i Dung Đánh Giá Ch ứ ng C ứ 1) Đ ị nh l ư ợ ng s ứ c / đ ộ m ạ nh c ủ a ch ứ ng c ứ khoa h ọ c 2) Đánh giá ch ấ t l ư ợ ng và kh ả n ă ng áp d ụ ng khi ra quy ế t đ ị nh ch ă m sóc s ứ c kh ỏ e

10 1)Đ ộ M ạ nh c ủ a B ằ ng Ch ứ ng X ế p h ạ ng đ ộ m ạ nh c ủ a ch ứ ng c ứ c ầ n xem xét k ế t h ợ p : Ch ấ t l ư ợ ng (Quality) ▫Sai l ệ ch h ệ th ố ng đư ợ c gi ả m thi ể u không?, Nh ư Th ế nào? S ố L ư ợ ng (Quantity) ▫Đ ộ l ớ n c ủ a ả nh h ư ở ng, tác đ ộ ng, S ố nghiên c ứ u, c ỡ m ẫ u và l ự c c ủ a m ẫ u. Tính h ằ ng đ ị nh / Ổ đ ị nh Nh ữ ng nghiên c ứ u khác, t ươ ng t ự cho k ế t qu ả gi ố ng nhau

11 1) Đ ộ m ạ nh c ủ a ch ứ ng c ứ Evidence exists on a continuum of rigor Amount of research attention or maturity of science varies, therefore evidence varies Type of research design reflects the strength of the evidence – known as levels of evidence Stevens & Ledbetter, 2000

12 Các M ứ c Đ ộ c ủ a Ch ứ ng C ứ X ế p h ạ ng cao là các ch ứ ng c ứ t ừ nh ữ ng nghiên c ứ u can thi ệ p lâm sàng Đ ộ m ạ nh c ủ a ch ứ ng c ứ : tin c ậ y càng l ớ n khi xác su ấ t áp d ụ ng ch ứ ng c ứ vào th ự c hành s ẽ mang l ạ i hi ệ u qu ả Các m ứ c đ ộ ch ứ ng c ứ : đư ợ c d ự a vào lo ạ i thi ế t k ế nghiên c ứ u

13 Các M ứ c Đ ộ Ch ứ ng C ứ Experts have developed a number of taxonomies to rate strength of evidence Most are organized around research designs

14 Các M ứ c Đ ộ Ch ứ ng C ứ Theo National Guidelines Clearinghouse Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials Ib Evidence obtained from at least one randomized controlled trial IIa Evidence obtained from at least one well-designed controlled study without randomization IIb Evidence obtained from at least one other type of well-designed quasi- experimental study, without randomization III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

15 M ứ c Đ ộ Ch ứ ng C ứ “Rating System for the Hierarchy of Evidence” Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence based clinical practice guidelines based on systematic reviews of RCTs Level II: Evidence obtained from at least one well-designed RCT Level III: Evidence obtained from well-designed controlled trials without randomization (quasi-experimental) Level IV: Evidence from well-designed case-control and cohort studies (studies of prognosis) Level V: Evidence from systematic reviews of descriptive and qualitative studies Level VI: Evidence form a single descriptive or qualitative study Level VII: Evidence from the opinion of authorities and/or reports of expert committees (Melnyk & Fineout-Overholt, 2005)

16 M ứ c Đ ộ Ch ứ ng C ứ Hê th ố ng x ế p h ạ ng m ứ c đ ộ ch ứ ng c ứ Type of evidence I. Meta analysis or comprehensive systematic review of multiple experimental research studies (Cochrane, National Guidelines Clearinghouse (AHRQ), The Joanna Briggs Institute, Other groups) II. Well designed experimental study III. Well designed quasi-experimental study (Non-randomized controlled, Single group pre-post design, Cohort, Time series (one group of subjects over time), Matched case-controlled studies (two or more groups are matched on certain variables) IV. Well designed non-experimental study (Correlational or comparative descriptive studies, Case study design, Qualitative studies) V. Clinical examples and expert opinion (Text books, Non-research journal articles, Verbal report, Non-research based professional standards/guidelines/ group article) Strength of evidence A. Type I evidence or consistent findings from multiple studies from levels II, III, or IV. B. Multiple studies with evidence types II, III, or IV that are generally consistent. C. Multiple studies with evidence types II, III, or IV that are inconsistent. D. Limited research evidence or one type II study only. E. Type IV or V evidence only Adapted from Joanna Briggs Institute and AHCPR Eilers & Heerman, 2005

17 The U.S. Preventive Services Task Force (2008)

18 Level of CertaintyDescription High The available evidence usually includes consistent results from well-designed, well conducted studies in representative primary care populations. Thee studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: The number, size, or quality of individual studies Inconsistency of findings across individual studies Limited generalizability of findings to routine primary care practice Lack of coherence in the chain of evidence As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because: The limited number or size of studies Important flaws in study design or methods Inconsistency of findings across individual studies Gaps in the chain of evidence Findings not generalizable to routine primary care practices Lack of information on important health outcomes More information may allow estimation of effects on health outcomes

19 Đánh giá/ xem xét h ệ th ố ng (Systematic Reviews) ▫Provides state of the science conclusions about evidence supporting benefits and risks of a given healthcare practice (Stevens, 2001) ▫Most powerful and useful evidence available ▫T ổ ng h ợ p các k ế t qu ả có giá tr ị, đư ợ c s ử d ụ ng t ừ các nghiên c ứ u nguyên phát vào trong th ự c hành lâm sàng Systematic Reviews & Meta Analysis

20 Phân Tích Meta (Meta-Analysis) Cách ti ế p c ậ n th ố ng kê đ ể t ổ ng h ợ p các k ế t qu ả t ừ các nghiên c ứ u – tóm t ắ t k ế t q ủ a t ừ các nghiên c ứ u đư a vào review Produces a larger sample size and thus greater power to determine the true magnitude of an effect, yields a summary statistic Systematic Reviews & Meta Analysis

21 Th ử Nghiêm có nhóm ch ứ ng và phân ph ố i ng ẫ u nhiên (Randomized Controlled Trial ) ▫Experimental studies are the gold standard of research design (randomization of participants to treatment and control, rigorous methods used to minimize bias) ▫Provides most valid, dependable research conclusion about clinical effectiveness of an intervention and establishing cause and effect ▫Allows us to say with a high degree of certainty that the intervention we used was the cause of the outcome Systematic Reviews & Meta Analysis Randomized Controlled Trials

22 Gi ả Th ự c Nghi ệ m (Quasi-Experimental ) ▫Differs from RCT’s only in that participants are NOT randomized to treatment and control groups Systematic Reviews & Meta Analysis Randomized Controlled Trials Quasi- Experimental

23 Phi Th ự c Nghi ệ m Non-Experimental ▫Cohort – participants are studied over time, study population shares common characteristics ▫Case-Control – studies that address questions about harm or causation, investigates why some people develop a disease or behave the way they do vs others who do not ▫Descriptive – main objective is to describe some phenomena ▫Qualitative - "any kind of research that produces findings not arrived at by means of statistical procedures or other means of quantification" (Strauss and Corbin, 1990, p. 17).Strauss and Corbin, 1990, p. 17 Systematic Reviews & Meta Analysis Randomized Controlled Trials Quasi-Experimental Non-Experimental

24 . Ý Ki ế n chuyên gia và Thí d ụ v ề lâm sàng (Clinical Examples & Expert Opinion). ▫Expert Opinion – arriving at a value judgement which incorporates the main information available on the subject as well as previous experiences ▫Clinical examples – ▫The “5 rights” Systematic Reviews & Meta Analysis Randomized Controlled Trials Quasi- Experimental Non- Experimental Clinical Examples & Expert Opinion

25 2) Đánh giá ch ấ t l ư ợ ng và tính ứ ng d ụ ng ( Evaluating Quality & Applicability) What are the results? Are the results valid? Can the results be applied to the targeted population and/or public health practice and intervention?

26 What are the results? K ế t qu ả có t ươ ng t ự v ớ i k ế t qu ả t ừ các n.c ứ u khác không ( n ế u có systematic review hay meta-analysis)? K ế t qu ả đ ó là gì? K ế t qu ả có chính xác không? Có th ể có s ự liên h ệ bên trong t ừ b ộ d ữ li ệ u không?

27 K ế t qu ả có giá tr ị không? Does this article explicitly address our public health question? Was the search for our article detailed and exhaustive? Is it likely that important, relevant studies were missed? Does the study selected appear to be of high methodological quality? Do you feel the study selected is reproducible?

28 K ế t qu ả có ứ ng d ụ ng đư ợ c không? How can the results be interpreted and applied to public health practice and intervention? Are study subjects similar to clients to whom care is to be delivered? Were all important outcomes considered? Are the benefits worth the costs and potential risks?

29 Search evidence rich resources first

30 EBP Rich Resources Cochrane review DARE – Database of Abstracts of Reviews of Effectiveness cochrane/cochrane_cldare_articles_fs.ht ml

31 Agency for Healthcare Research and Quality (AHRQ) National Guidelines Clearinghouse Guide to Clinical Preventive Services (2008) d.htm d.htm Evidence reports ahrq

32 EBP Rich Resources for P/CHN Guide to Community Preventive Services x.htmlhttp://www.thecommunityguide.org/inde x.html

33 Centers for Disease Control & Prevention CDC for Public Health Professionals ealth_professionals.html

34 Association of State and Territorial Health Officials Evidence Based Practice e_based_ph_practice.htmlhttp://www.astho.org/?template=evidenc e_based_ph_practice.html

35 National Association of City and County Public Health Officials The Model Practices Database ▫Online searchable collection of practices across public health areas. ▫Allows you to benefit from colleagues' experiences, to learn what works, and to ensure that resources are used wisely on effective programs that have been implemented with good results. The database features practices in the following areas: ▫Community Health ▫Environmental Health ▫Public Health Infrastructure ▫Emergency Preparedness

36 EBP Rich Resources Health Services/Technology Assessment Text (HSTAT) Searchable collection of large, fulltext practice guidelines, technology assessments and health information

37 EBP Rich Resources Health Policy Guide ▫evidence-based policies to improve the public’s health ▫150 policy topics to support advocacy and decision making at the state and local levels

38 EBP Rich Resources hp?pid=14371&sid=96991http://guides.nursinglibrary.yale.edu/content.p hp?pid=14371&sid=96991 National Institute for Health & clin NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.

39 Application Exercise PICO QUESTION: For the 4 year old pre-K age group, are there fewer injection site complications with giving the immunizations in the thigh as compared to giving the immunizations in the arm?

40 Cochrane Review Tinnion O, Hanlon M. Acellular vaccines for preventing whooping cough in children. Cochrane Database of Systematic Reviews 1999, Issue 2. Art. No.: CD DOI: / CD pub2 “…Differences in trial design precluded pooling of the efficacy data and results should be interpreted with caution. Most systemic and local adverse events were significantly less common with acellular than with whole cell pertussis vaccines….” ed page to print off

41 National Guidelines Clearinghouse 1) General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). 2) Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine &string=vaccine+AND+administration+AND+site+AND+route

42 National Guidelines Clearinghouse Injection Route and Injection Site With the exception of Bacillus Calmette-Guerin (BCG) vaccine, injectable vaccines are administered by the intramuscular and subcutaneous route. The method of administration of injectable vaccines is determined, in part, by the presence of adjuvants in some vaccines. The term adjuvant refers to a vaccine component distinct from the antigen that enhances the immune response to the antigen. The majority of vaccines containing an adjuvant (e.g., DTaP, DT, Td, Tdap, PCV, Hib, HepA, HepB, and HPV) should be injected into a muscle because administration subcutaneously or intradermally can cause local irritation, induration, skin discoloration, inflammation, and granuloma formation.

43 National Guidelines Clearinghouse Routes of administration are recommended by the manufacturer for each immunobiologic. Deviation from the recommended route of administration might reduce vaccine efficacy or increase local adverse reactions.

44 CDC: Advisory Committee on Immunization Practices Route Administering a vaccine by the recommended route is imperative. Deviation from the recommended route of administration might reduce vaccine efficacy or increase the risk of local reactions. (p. D5)

45 CDC: Advisory Committee on Immunization Practices Site Although there are several IM injection sites on the body, the recommended IM sites for vaccine administration are the vastus lateralis muscle (anterolateral thigh) and the deltoid muscle (upper arm). The site depends on the age of the individual and the degree of muscle development. The usual sites for vaccine administration subcutaneously are the thigh (for infants 12 months of age). If necessary, the upper outer triceps area can be used to administer subcutaneous injections to infants.

46 CDC: Advisory Committee on Immunization Practices Injectable Vaccine Administration for Children Birth to 6 years IM ▫anterolateral thigh or deltoid – Use of deltoid muscle in children 18 monts and older (if adequate muscle mass) is an option for IM injections (p. D22) SC ▫anterolateral thigh or lateral upper arm (p. D22)

47 Schecter, Zempsky, Cohen, McGrath, McMurtry, & Bright (2007). Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics, 119(5), e Evidence is limited and somewhat controversial….. ▫The limited data available suggests that intramuscular administration of immunizations should occur in the anterolateral thigh or vastus lateralis for children 36 months of age. ▫Controversy exists in site selection for 18 to 36 month old children.

48 Schecter, Zempsky, Cohen, McGrath, McMurtry, & Bright (2007). Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics, 119(5), e The shift from thigh to arm should occur when the upper arm has adequate muscle mass to allow injection. This shift is driven by research with 18month old infants that suggests that injection in the thigh is more painful and causes more incapacitation (decreased movement of the extremity, limping) than injection in the arm. However, redness and swelling was found to occur more frequently when given in the arm.

49 Application Exercise PICO QUESTION: For the 4 year old pre-K age group, are there fewer injection site complications with giving the immunizations in the thigh as compared to giving the immunizations in the arm?

50 SourceLevel of Evidence Cochrane Review? National Guidelines Clearinghouse ? CDC: Advisory Committee on Immunization Practices ? Evidence Based Review?

51 Cochrane Review National Guidelines Clearinghouse CDC: ACIP Evidence Based Review Did the Evidence Answer our PICO Question?

52


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