预防医学以循证医学为基础的健康体检200904

你计划给李先生安排什么体检项目？ 要给他做胸部X线片吗？为什么？
以证据为基础的医学方法
循证医学 （Evidence Base Medicine）
P = PATIENT 病人 I = INTERVENTION干预 C = COMPARISON对比 O = OUTCOME结局
Evidence Based Medicine循证医学
案例继续：你计划安排个体化的健康体检
以李先生为例：
李先生54岁，从事后勤管理工作。 有30年吸烟史，每天一包。
他知道戒烟的害处，确感到戒烟很难。
他现在没有不适的感觉，但担心长期吸
烟史是否会使他患肺癌。
他问医生是否应该进行CT或胸片检查？
他既往曾患胃食道反流疾病，父亲65岁
时死于肺癌。
课程大纲
1. 周期性健康体检的概念 2.以证据为基础的医学方法
3.疾病的筛查原则
4.筛查实验的缺陷 5.符合循证医学的成人健康体检项目
案例讨论
• 某单位有职工20人，年龄分布从20岁至55 岁。现要求为职工安排集体健康体检。你 计划如何安排体检项目？
周期性健康检查的概念
• 概念：针对就诊者的不同年龄、性别、职业等 存在的主要卫生问题或健康危险因素进行的周 期性的、终生健康检查。 对象：无症状的个体； 目标：一、二级预防； • 我国缺少符合循证医学的“临床预防服务指 南”。
U.S. Preventive Services Task Force Ratings: Strength of Recommendations and Quality of Evidence. Guide to Clinical Preventive Services, Third Edition: Periodic Updates, 2000-2003. Agency for Healthcare Research and Quality, Rockville, MD. /clinic/3rduspstf/ratings.htm
筛查的精确性 Accuracy of the screening test
风险和利益 Risks and Benefits
循证医学方法EBM approach
Strength of Recommendations
A.— The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms. B.— The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms. C.— The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation. D.— The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits. I.— The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
Ideal Screening Program: 理想的筛查项目
Sens43; Test Value
Ideal: 理想的
Disease
No Disease
Reality: 现实的
Disease
No Disease
Principles of Screening 筛查原则
Focused clinical question: 临床关注的问题
In a healthy, asymptomatic, male smoker, does screening for lung cancer lead to prolonged survival, compared to no testing? 与没有进行检查的人相比，健康无症状的 男性吸烟者筛查肺癌会延长寿命吗？
Patient = healthy, asymptomatic male smoker 病人=健康，无症状男性吸烟者 Intervention = lung cancer screening 干预=肺癌筛查 Comparison = no test 对比=不检查 Outcome = prolonged survival 结局=延长生存期