Answering Clinical Questions at the Point of Care 王信傑 Ricky Wang Tel : Mobile :

Outline  About UpToDate  Evidence Grading  How to Search  New Function  Q&A 2

UpToDate  UpToDate is a Clinical decision support system that helps clinicians throughout the world provide the best patient care  We use the best available current evidence to answer clinical questions, quickly and easily at the point of care  This saves clinicians time, improves patient outcomes and lowers health care costs 3

Evidence is derived from a number of sources……………… including but not limited  Journals: 460+ peer reviewed journals  Databases:  MEDLINE, The Cochrane Database, Clinical Evidence and ACP Journal Club  Guidelines  Clinical trials  FDA, CDC, NIH  Proceedings  Clinical experiences and observations 4

Quick Facts about UpToDate  Topic reviews  Patient Information  Drug Information  systemic, topical, inhalation, nasal, ophthalmic 5 Written by Physicians for Physicians

Quick Facts about UpToDate  4,800+ world-renowned physician authors (international)  9,000+ clinical topic in 18 specialties  5,000+ unique drug entries in adult, pediatrics, international and natural drugs (Lexi-Comp)  23,000+ graphics  328,000+ references (Medline)  Updated every 4 months (March, July, November) 6

Specialties  Adult and Pediatric Emergency Medicine {November 2009}  Adult Primary Care & Internal Medicine  Allergy and Immunology {March 2010}  Cardiovascular Medicine  Endocrinology & Diabetes  Family Medicine  Gastroenterology & Hepatology  Geriatric Specialty {July 2011}  Hematology  Hospital Medicine {November 2010}  Infectious Diseases  Nephrology & Hypertension  Neurology {March 2009}  Obstetrics, Gynecology & Women’s Health  Oncology  Pediatrics  Pulmonary, Critical Care & Sleep Medicine  Rheumatology 7

Specialties in Development  Dermatology  Psychiatry  Surgery 8

Evidence Grading  In 2001, we began a collaboration with Gordon Guyatt, a world leader in EBM, and his colleagues in the international GRADE collaborative to implement a grading system for recommendations  UpToDate grades specific treatment and screening recommendations 9

何謂實證醫學 10  以流行病學和統計學的方法，從龐大的醫學資料中嚴 格評讀、綜合分析並找出值得信賴的部分，並將所能 獲得的最佳文獻證據，應用於臨床工作中，使病人獲 得最佳的照顧。

 傳統的臨床實務中，護理人員通常憑藉教課書及職場的學姐、專家的教導，以經驗解決臨床問題；隨 著畢業時間的增加，新知識累積愈少，導致知識落差。所以，傳統解決問題的方法已不符合目前詭變 的醫療環境。 實證護理（ Evidence-based Nursing ），依據國際護理榮譽學會的定義，涵概現有之最佳證據及 護理實務經驗，並重視個人、家庭及社區之價值與偏好的護理照護。 Ingersoll 對實證護理的定義：針 對一個病人或一群病人，能誠實、詳盡與明斷的運用「有理論為起源、研究為基礎的資訊」於臨床護 理決策，並考慮到個案的需求與喜好。換言之實證護理就是護理人員必需具備「定義臨床問題」、「 搜尋科學研究證據」、「評讀」、以及「將所得的證據應用病人臨床照護」之能力。 實證照護（ Evidence-based health care ）主要是引用最佳的證據，作為臨床照護決策依據。實證 醫學（ Evidence-based Medicine ）重視病患治療效果，偏重隨機試驗之量性研究，實證護理重視病患 的感受、態度，最佳研究證據來源，不單是量性研究文章，更包涵質性研究的文獻。透過實證護理， 希望護理人員能不斷更新知識，學習以實證的方式做出以病人為中心的臨床決策 。 何謂實證護理 11

Evidence Grading 12 RECOMMENDATION GRADES Grade 1 Strong Recommendation Benefits clearly outweigh the risks and burdens (or vice versa) for most, if not all, patients “We recommend…” Grade 2 Weaker Recommendation Benefits and risks closely balanced and/or uncertain “We suggest…” EVIDENCE GRADES Grade AHigh Quality Evidence Consistent evidence from randomized trials, or overwhelming evidence of some other form Grade BModerate Quality Evidence Evidence from randomized trials with important limitations, or very strong evidence of some other form Grade CLow Quality Evidence Evidence from observational studies, unsystematic clinical observations, or from randomized trials with serious flaws

How to Search  New Search  Search  display results  topic review  output  Others  Evidence grading  RECOMMENDATIONS  125 Calculators  Drug Interactions  ECG test  Movies  no need install software 13

How to use UpToDate based on a Clinical scenario  A 50 year old woman is obese (BMI=32) and has hypertension. She has not achieved weight loss despite counseling for diet and lifestyle changes. What is the best medication for pharmacologic management of her obesity.  Keyword:  Obesity drug 14

How to use UpToDate based on a Clinical scenario A 65 year old man comes to see you with moderately symptomatic heart failure. He has a remote history of a large anterior wall MI and an echocardiogram shows an ejection fraction of 30%. His LDL cholesterol is 150 mg/dL, currently untreated. Should he be started on a statin ? Keyword : – Statins in HF

How to use UpToDate based on a Clinical scenario Will grapefruit juice interact with Cisapride ?

How to use UpToDate based on a Clinical scenario How effective is long-term warfarin at preventing recurrent pulmonary embolism?

 New graphics search feature  Over 23,000+ graphics  Pictures, tables, figures, graphs, algorithms and movies New Function 18

Q&A 19