1. (totoro96a@gmail.com)EBM Evidence Pyramid2

2. (Systematic Review) (SystematicReview)? , 1 , , . (SystematicReview) 1 . bias . 1 . 3/(review) 4 3. 51) , , . PICO / Riskofbias , 6 4. (PICO ) Patient(P): Intervention(I) Exposure Therapeuticintervention Diagnosticprocedure Prognosticfactor Comparison(C): Outcome(O): StudyDesign(S) Time (T):1 Setting(S)7Example article P: I: C: O: S:HF,CVDandHTNpatient,Generalpopulationetc.. Chronickidneydisease(CKD) NoChronickidneydisease(NoCKD) Allcauseandcardiovascularmortality Randomizedcontrolledtrial, Prospectivecohortstudy Retrospectivecohortstudy 8 5. 2) SR SR 1 SR CPG Cochranelibrary CochraneDatabaseofSystematicReviews(CDSR) NLM PubMed ClinicalQueries SystematicReviews ,Population,Intervention,Outcomes MEDLINE ,MeSH(MedicalSubjectHeadings) (AND,OR,NOT) .9 COSI 10 6. MEDLINE 11EMBASE 12 7. PublicationBias . . PublicationBias . 133) (Reference Manager,Endnote,Procite ) . . . . 2 .14 8. (PRISMA flow chart)15 Example16 9. 4) : (Cochranehandbook, 2011)17 ( : ) ( : )18 10. Example195) . bias . . RCT :CochranegroupsRiskofbias :RiskofBiasAssessmenttoolfor NonrandomizedStudy(RoBANS) 20 11. 1) Cochrane groups Risk of bias (Allocationconcealment) , 212) RoBANS 22 12. Riskofbiasgraphs()23 Example24 13. 6) (Meta Analysis) (SystematicReview,SR) 2 intervention Population,Intervention,Outcome . .25 26 14. 1. 27 Vitamin E StudyPlacebo RREvent (E1)Total (N1)Event (E2)Total (N2)GISSI19998356609556640.87HOPE2000209476118047801.17ATBC200050914238548142810.93PPP20012222311822641.24WHS200524119937246199390.98WACS2007137408315140880.91PHSII2008237731522773261.05Binary outcome RiskRatioorRelativeRisk(RR)=(E1/N1)/(E2/N2) OddsRatio(OR)=(E1(N2E2))/(E2(N1E1)) RiskDifference(RD)=(E1/N1) (E2/N2)28 15. Vitamin E StudyPlacebo MDTotalMean (M1)SDTotalMean (M2)SDGISSI1999194.840.65195.200.360.36HOPE2000304.500.61304.630.370.13ATBC2000184.260.52284.570.620.31PPP2001942.401.39962.711.280.31WHS20053414.560.593344.610.650.05WACS2007711.420.78691.600.700.18PHSII2008205.060.31215.470.420.41SPACE2000455.420.71445.300.740.12Continuous outcome MeanDifference(MD)=M1M2 StandardizedMeanDifference 292. 30 16. (Summaryestimate) , . . ,, , . . (Pooledeffectestimate)= ( :i , :i )31 : (1) (Fixedeffectmodel) , 32 17. : (2) (Randomeffectmodel) , , 33Metaanalysisresult forbinaryoutcome Forest plot ( )PooledRR34 18. Metaanalysisresultforcontinuousoutcome Forest plot ( )PooledMeanDifference353. (Heterogeneity) (Heterogeneity) , . Bychance:, . Bias: bias .36 19. Forestplot( )BinaryoutcomeContinuousoutcome 37 LAbb plot LAbb plot . = A . , .38 20. Galbraithplot 2 outlier outlierBinaryoutcomeContinuousoutcome39 (Qstatistics) , , . 5% 10% 40 21. (Qstatistics) H0: .vs H1: . Pvalue>=0.10 Pvalue=0.1 FixedEffectmodel Binaryoutcome Strokeoutcome vitaminE .43 Continuousoutcomeoutput moderateheterogeneity=0.1 FixedEffectmodelOutlier Continuousoutcome vitaminE .473) subgroupanalysis ParkerMJ,GillespieWJ,GillespieLD.Effectivenessofhipprotectorsforpreventinghipfracturesin 48 elderlypeople:systematicreview.BMJ.2006Mar11;332(7541):5714. 25. 4. Publication bias Publicationbias: bias positiveresult bias. Publicationbias .49Funnel plot Funnelplot: OR , funnelplot publicationbias . 10 . Symmetricalplotinthe absenceofbias Asymmetricalplotinthe presenceofpublicationbias Asymmetricalplotinthe presenceofbiasduetolow methodologicalqualityof 50 smallerstudies 26. Publication bias largeststudy cumulativemetaanalysis Rosenthalsfiledrawer method(failsafeN) unpublishedpapers selectionmodel TrimandFillmethod sensitivity (Copas,1999)51Trim and Fill method TrimandFillmethod Imputation publicationbias . Funnelplot publicationbias publicationbias corrected .52 27. Examplefortrimandfillmethod TrimandFillmethod TrimandFillmethod 53 TrimandFillmethod TrimandFillmethod Continuous outcome vitaminE .54