1、Department of Epidemiology Public Health College of Harbin Medical University1临床流行病学与循证医学临床流行病学与循证医学哈尔滨医科大学流行病学教研室哈尔滨医科大学流行病学教研室 Department of epidemiology，Harbin Medical UniversityDepartment of Epidemiology Public Health College of Harbin Medical University2CONTENTS 目录目录OutlineFeatures MethodsConte
2、ntsTaskEvidence based Medicine概述概述临床流行病学的特征临床流行病学的特征研究方法研究方法研究内容研究内容临床流行病学任务临床流行病学任务循证医学循证医学Department of Epidemiology Public Health College of Harbin Medical University3医学医学 Medicinep Basic medicine p Clinical medicine p Preventive medicine Epidemiology has always been a necessary part of medicine
3、practice.流行病学一直医学实践必不可少的部分流行病学一直医学实践必不可少的部分p基础医学基础医学p临床医学临床医学p预防医学预防医学Department of Epidemiology Public Health College of Harbin Medical University4医学之母医学之母 The mother of medicine Because,the epidemiology is from macro point of view to observe the any question.e.g.from macro point of view to study t
4、he disease and health.因为流行病学是从因为流行病学是从宏观宏观观察问题，观察问题，亦即从宏观研究疾病和健康亦即从宏观研究疾病和健康Department of Epidemiology Public Health College of Harbin Medical University5 疾病预防控制的应用学科 现代病因研究的方法学科 临床诊疗手段的循证学科 卫生决策产生的思维学科Department of Epidemiology Public Health College of Harbin Medical University6第一个流行病学家第一个流行病学家主要的流
5、行病学著作：主要的流行病学著作：Epidemic Epidemic On Airs,Waters and Places中国：中国：“疫疫”“”“时疫时疫”“”“疫疠疫疠”-18世纪世纪 自从有自从有人类文明人类文明到到18世纪世纪.这期间这期间,该该学科（学科（分支）分支）尚未形成，但已形成雏形尚未形成，但已形成雏形.Department of Epidemiology Public Health College of Harbin Medical University7VitC缺乏缺乏 坏血病坏血病 二、学科形成期二、学科形成期Department of Epidemiology Publi
6、c Health College of Harbin Medical University8第一阶段(194620世纪60年代中期)第二阶段(20世纪60年代中期80年代早期)第三阶段(20世纪80年代中期至今)Department of Epidemiology Public Health College of Harbin Medical University9吸烟吸烟-肺癌肺癌王瑞芳王瑞芳.Doll和和Hill关于吸烟与肺癌关系的研究关于吸烟与肺癌关系的研究.见见:钱宇平钱宇平,主编主编.流流行病学研究实例行病学研究实例(第第1卷卷).北京北京:人民卫生出版社，人民卫生出版社，1984.
7、p74-86.Department of Epidemiology Public Health College of Harbin Medical University10Sackett DL.Bias in analytic research.J Chron Dis 1979;32:51-63.(35种偏倚种偏倚)Miettinen OS.Theoretical epidemiology.New York:J.Wiley.1985.(3大类偏倚：比较、选择、信息偏倚大类偏倚：比较、选择、信息偏倚)Cornfield J.Joint dependence of risk of coronary
8、 heart disease on serum cholesterol and systolic blood pressure:a discriminant function analysis.Fed Proc 1962;2:58-61.(多变量分析多变量分析)Department of Epidemiology Public Health College of Harbin Medical University11MacMahon B and Pugh TF.Epidemiology Principles and Methods.Boston:Little,Brown and Company
9、.1970.Lilienfeld AM and Lilienfeld DE.Foundations of Epidemiology(2nd ed.).New York:Oxford University Press.1980Last JM.A dictionary of epidemiology.Oxford University Press.1983.Rothman KJ.Modern Epidemiology.Boston:Little,Brown and Company.1986Department of Epidemiology Public Health College of Har
10、bin Medical University12Department of Epidemiology Public Health College of Harbin Medical University Randomization beautifully solved the problem of confounding.随机分组以最美丽最简单的方式解决了混杂的问题 Placebo and blinding reduce selection and information bias.安慰剂和盲法协助控制选择偏倚和信息偏倚 The scientifically most rigorous met
11、hod of establishing causal relationship and forms the gold standard for evaluation of clinical effectiveness.随机对照临床试验是在人群中建立因果关系最可靠的方式,因而成了评估医学干预效果的金标准Department of Epidemiology Public Health College of Harbin Medical University Over 200,000 randomized controlled trials have been published.累积了超过几十万个
12、关于医学干预效果的随机对照试验 The need for review methods:introduction of meta-analysis.系统地总结这些证据迫在眉睫:流行病学的另一颗新星meta-meta-分析崭露头角Department of Epidemiology Public Health College of Harbin Medical UniversitySystematic,objective and quantitative method to summarize or integrate results from different studies of the
13、same topic.一种系统地、客观地、定量地总结或整合来自不同研究的(关于同一问题的)研究结果的综述方法,又称系统综述Department of Epidemiology Public Health College of Harbin Medical University Of 226 maneuvers in obstetrics&childbirth(在产科使用的226种方法中,通过临床试验或系统综述证明)were beneficial(有效:疗效大于副作用)were harmful or of doubtful value(有害或疗效可疑)had no RCT evidence av
14、ailable(缺乏随机试验证据)Iain Chalmers et al.Effective Care in Pregnancy and Childbirth.Oxford:Oxford University Press,1989Department of Epidemiology Public Health College of Harbin Medical UniversityExperience is not reliable.Medical interventions,old or new,should all be scientifically evaluated.经验是不可靠的.医
15、学干预,不管新旧,都应接受严格的科学评估Ineffective therapies must be stopped and new ineffective innovations must not be allowed to start.应停止使用无效的干预措施,阻止新的无效措施引入医学实践Medical practice should all be based on effective interventions.所有医学干预都应基于严格的研究证据之上Department of Epidemiology Public Health College of Harbin Medical Univ
16、ersity18 1992:BIRTH OF EVIDENCE-BASED MEDICINE1992年：年：循证医学诞生循证医学诞生“A new paradigm for medical practice is emerging in 1992”出现医学实践进模式出现医学实践进模式-A New Approach to Teaching the Practice of Medicine医学教育新方法医学教育新方法Evidence-Based Medicine Working GroupMcMaster University Health Science CentreJAMA 1992;268:2
17、420-2425.Department of Epidemiology Public Health College of Harbin Medical University The buzzword in medicine in the 21th century:Where is the evidence?二十一世纪医学界最流行的一句话:证据在哪里?Department of Epidemiology Public Health College of Harbin Medical University20DAVID SACKETTActivist in clinical epidemiolog
18、y 临床流行病学活动家临床流行病学活动家The pioneer in EBM 循证医学先驱循证医学先驱The first book on EBM 第一本循证医学书第一本循证医学书 McMaster University Health Science Centre Chairman of Oxford Centre for EBM Department of Epidemiology Public Health College of Harbin Medical University21 WORLD COCHRANE COLLABORATION国际国际COCHRANECOCHRANE合作合作In
19、 1992,the very first Cochrane centre was established in Oxford.Mission:Collecting,summarizing and disseminating evidence from organized research.19921992年第一个年第一个COCHRANECOCHRANE中心在牛中心在牛津建立津建立使命：收集、总结使命：收集、总结和传播研究证据和传播研究证据Department of Epidemiology Public Health College of Harbin Medical University22
20、Today there is a total of 15 national or regional Cochrane centers and over 40 review groups world wide.Chinese national Cochrane/EBM Centre is in Sichuan Universityp目前，全球有目前，全球有1515个国个国家和地区家和地区COCHRANE COCHRANE 中中心和心和4040多个评价组多个评价组p中国国家循证医学中中国国家循证医学中心在四川大学心在四川大学WORLD COCHRANE COLLABORATION国际国际COCHR
21、ANECOCHRANE合作合作Department of Epidemiology Public Health College of Harbin Medical UniversityStarted from studying communicable diseases起源于传染病研究的方法Studying chronic disease用于慢性非传染病研究:疾病分布学Modern epidemiology:Studying causes of disease现代流行病学:病因研究Clinical epidemiology临床流行病学(病因、诊断、治疗、预后等)Post-modern epid
22、emiology后现代流行病学Department of Epidemiology Public Health College of Harbin Medical University24Definition of Epidemiology流行病学定义流行病学定义 Epidemiology:the study of the distribution and determinants and the occurrence of health-related states or events in specified and the application of this study to con
23、trol health problems.(Last)Department of Epidemiology Public Health College of Harbin Medical University25 流行病学是研究人群中疾病与流行病学是研究人群中疾病与健康状况的分布及其影响因素，并健康状况的分布及其影响因素，并研究防制疾病及促进健康的策略和研究防制疾病及促进健康的策略和措施的科学措施的科学Department of Epidemiology Public Health College of Harbin Medical University26Epidemiology p Pop
24、ulation MedicinePopulation Medicine群体医学群体医学p The Language of QuantificationThe Language of Quantification定量语言定量语言Department of Epidemiology Public Health College of Harbin Medical University27 流行病学是研究流行病学是研究中疾病与健康状况的分中疾病与健康状况的分布及其影响因素，并研究防制疾病及促进健康布及其影响因素，并研究防制疾病及促进健康的策略和措施的科学。的策略和措施的科学。研究对象研究对象Depar
25、tment of Epidemiology Public Health College of Harbin Medical University28 流行病学是研究人群中流行病学是研究人群中的分的分布及其影响因素，并研究防制疾病及促进健康布及其影响因素，并研究防制疾病及促进健康的策略和措施的科学。的策略和措施的科学。研究内容研究内容Department of Epidemiology Public Health College of Harbin Medical University29 疾疾 病病传染病、寄生虫病、地方病、非传染性疾病等传染病、寄生虫病、地方病、非传染性疾病等 伤伤 害害意外
26、、残疾、智障、身心损害等意外、残疾、智障、身心损害等 健康状态健康状态生理生化机能状态、疾病前状态、长寿等生理生化机能状态、疾病前状态、长寿等Department of Epidemiology Public Health College of Harbin Medical University30 流行病学是研究人群中疾病与健康状况的流行病学是研究人群中疾病与健康状况的及其及其，并，并的科学。的科学。研究任务研究任务Department of Epidemiology Public Health College of Harbin Medical University31找出原因找出原因提供
27、措施提供措施揭示现象揭示现象流行流行分布分布原因原因影响因素影响因素策略策略措施措施描述性流行描述性流行病学方法病学方法分析性流行分析性流行病学方法病学方法实验性流行实验性流行病学方法病学方法Department of Epidemiology Public Health College of Harbin Medical University32 三个层次：疾病、伤残、健康 三个阶段：揭示现象、找出原因、提供措施 三个范畴：描述、分析、实验 三种方法：观察法、实验法、数理法 三大要素：原理、方法、应用Department of Epidemiology Public Health Colle
28、ge of Harbin Medical University33 Principle of epidemiology 流行病学原理流行病学原理 pDistribution pEpidemic processpRelationship of human and environment pCausationpCausal inference pPrevention pTheoretical epidemiologyp分布分布p流行流行p人与自然关系人与自然关系p病因病因p病因推断病因推断p预防预防p理论流行病学理论流行病学 Department of Epidemiology Public He
29、alth College of Harbin Medical University34Study methods of Epidemiology 流行病学研究方法流行病学研究方法-Observation -Experimental-Theoretical Department of Epidemiology Public Health College of Harbin Medical University35Department of Epidemiology Public Health College of Harbin Medical University36Application of
30、 epidemiology流行病学应用1.Determine great public health Problems2.Response and deal with emergency event 3.Surveillance of disease related重大公共卫生问题重大公共卫生问题的确定的确定突发事件的应急与突发事件的应急与处理处理疾病相关监测疾病相关监测Department of Epidemiology Public Health College of Harbin Medical University37Application of epidemiology流行病学应用4
31、.Study the cause and risk factor of disease5.To study the natural history and prognosis of disease.6.Evaluate the prevent effect疾病病因和危险因疾病病因和危险因素研究素研究疾病的自然史研究疾病的自然史研究疾病防治的效果评疾病防治的效果评价价Department of Epidemiology Public Health College of Harbin Medical University38Features 特点特点Population medicineCompa
32、reProbability theory and statistics Social medicine Prevention Development 群体的特征群体的特征 对比的特征对比的特征 概率论和数理统计学的概率论和数理统计学的 特征特征 社会心理的特征社会心理的特征 预防为主的特征预防为主的特征 发展的特征发展的特征Department of Epidemiology Public Health College of Harbin Medical University39临床流行病学概念 临床流行病学是在临床医学领域内，应临床流行病学是在临床医学领域内，应用用流行病学原理与方法流行病学
33、原理与方法，解决临床医学所遇，解决临床医学所遇到到的临床诊断、治疗、判断预后、医院管到到的临床诊断、治疗、判断预后、医院管理及临床科研等方面问题，是以群体研究结理及临床科研等方面问题，是以群体研究结果为基础，判断个体病例的一门科学。果为基础，判断个体病例的一门科学。Department of Epidemiology Public Health College of Harbin Medical University40p前身：前身：临床医学：临床医学：为临床问题寻找答案，并且以当为临床问题寻找答案，并且以当前能够获得的前能够获得的最佳证据最佳证据指导临床决策指导临床决策 流行病学：流行病学：
34、将单个病人的诊断治疗问题融入将单个病人的诊断治疗问题融入相同疾病的相同疾病的患者群体患者群体下，应用类型表现的方法解下，应用类型表现的方法解决患者具体问题决患者具体问题Department of Epidemiology Public Health College of Harbin Medical University41发展史发展史p1970-80spSackett DLpFeinstein ARpFletcher RHp1982年pINCLENDepartment of Epidemiology Public Health College of Harbin Medical Univer
35、sity42Phase I projectpPennsylvaniapNorth CarolinapMcMasterpTorontopNewcastleDepartment of Epidemiology Public Health College of Harbin Medical University43ChinaClen华西医科大学（四川大学华西医学院）上海医科大学 （复旦大学上海医学院）R-CERTC:regional-clinical epidemiology resource training centerDepartment of Epidemiology Public Heal
36、th College of Harbin Medical University44DMEp1989年：成都p1991年：上海p1993年：广州pp2004年：北京Department of Epidemiology Public Health College of Harbin Medical University45临床流行病学特点临床流行病学特点p以临床医学为基础以临床医学为基础p流行病学理论为指导流行病学理论为指导p由临床医生进行由临床医生进行Department of Epidemiology Public Health College of Harbin Medical Univer
37、sity46研究方法研究方法 DMEpDesignDesignpMeasurementMeasurementpEvaluationEvaluationDepartment of Epidemiology Public Health College of Harbin Medical University47Designp科研目的p科研的假设/问题p科研设计方案p研究对象p如何分组p研究因素/结果因素p资料收集和数据处理方法p质控p时间表p经费Department of Epidemiology Public Health College of Harbin Medical University
38、48Measurementp研究因素p结果因素p混杂因素Department of Epidemiology Public Health College of Harbin Medical University49Evaluaiton(1)对各种设计有不同的评价方法RCT-CONSORTDiagnostic testing STARD（诊断试验诊断试验准确性研究报告规范准确性研究报告规范 ）Department of Epidemiology Public Health College of Harbin Medical University50Evaluaiton(2)p对发表的论文进行评价
39、pCritical appraisal:JAMADepartment of Epidemiology Public Health College of Harbin Medical University51常用临床科研设计方案常用临床科研设计方案pCase report/case seriesDepartment of Epidemiology Public Health College of Harbin Medical University52Cross-sectional study 目标人群 普查/抽样|研究对象|疾病/暴露Department of Epidemiology Publ
40、ic Health College of Harbin Medical University53Case-control Study 研究对象|病例组 对照组|暴露（Y N)暴露（Y N)Department of Epidemiology Public Health College of Harbin Medical University54Cohort study 研究对象|暴露 非暴露|发病 不发病 发病 不发病Department of Epidemiology Public Health College of Harbin Medical University55临床试验临床试验 研
41、究对象|试验组 对照组|效果评价Department of Epidemiology Public Health College of Harbin Medical University56临床流行病学-随机对照试验随机对照试验p随机分组以最美丽最简单的方式解决了混随机分组以最美丽最简单的方式解决了混杂的问题杂的问题p安慰剂和盲法协助控制选择偏倚和信息偏安慰剂和盲法协助控制选择偏倚和信息偏倚倚p是在人群中建立因果关系最可靠的方式是在人群中建立因果关系最可靠的方式,因而成了评估医学干预效果的金标准因而成了评估医学干预效果的金标准Department of Epidemiology Public Health College of Harbin Medical University57临床流行病学的任务临床流行病学的任务p探索病因探索病因p解决临床问题解决临床问题p提高临床科研提高临床科研
