Meta-analysis

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헌엽 표
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1 체계적문헌고찰논문작성을위한핵심 고려대학교의과대학근거중심의학연구소 김현정

2 순서 체계적고찰의최근연구동향과문제점 체계적고찰은무엇인가? 체계적고찰은항상좋은근거인가? 체계적고찰의수행방법

3 체계적고찰의최근출간

4 The Mass Production The Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-analyses, J.P.A. Ioannidis, The Milbank Quarterly, Vol. 94, No. 3, 2016 (pp )

5 Policy Points Currently, there is massive production of unnecessary, misleading, and conflicted systematic reviews and meta-analyses. Instead of promoting evidence-based medicine and health care, these instruments often serve mostly as easily produced publishable units or marketing tools. Suboptimal systematic reviews and meta-analyses can be harmful given the major prestige and influence these types of studies have acquired. The publication of systematic reviews and meta-analyses should be realigned to remove biases and vested interests and to integrate them better with the primary production of evidence.

6 정형외과논문의체계적고찰출간 (2015 년 ) 8.2% 6 개 (33.3%)/18 개연구 정형외과전체논문 22,630 체계적고찰논문 788(3.5%)

7 영역별인용지수상위논문의체계적고찰논문의출간비율

8 왜? Journal editors recognize that publishing systematic reviews can help increase their impact factors since such articles tend to be cited more than other types of studies. Industry employees can use the results of meta-analyses as a marketing device for their products. Researchers face pressures to publish (or perish) in order to advance their careers. Mass Production of Systematic Reviews and Meta-analyses: An Exercise in Megasilliness? MATTHEW J. PAGE, The Milbank Quarterly, Vol. 94, No. 3, 2016 (pp )

9 또다른문제? Medline 70 만건이상의출간 /1 년 1917 건 /1 일..80 건 /1 시간..1.3 건 /1 분..

10 Research questions? 우리가알고있는것은무엇인가? 우리가궁금한것은무엇인가? 우리가답을줄수있는것은무엇인가? 우리가답을줄수없는것은무엇인가? The USPSTF states: "Decision makers do not have the luxury of waiting for certain evidence. Even though evidence is insufficient, the clinician must still provide advice, patients must make choices, and policy makers must establish policies" 그렇다면우리가해야하는것은무엇인가?

11 믿을수있는가?

12 믿을수있는가? 혹시더있는것은아닌가?

13 어떻게할것인가? 만약급한치료를필요로하는환자가있다, 문헌을찾았다 찾은문헌은 17 개의연구 : 10 개연구는유의한결과가있었고, 7 개연구는그렇지않았다면 더찾는다 효과를믿는다 효과를믿지않는다 무엇을결정할수 있는가?

14 Systematic Review or meta-analysis? A Systematic Review 는명백하게구조화된질문을가진종설로, 체계적이고엄격한방법에따라관련된연구를모두찾고선택하여연구에포함된자료를수집분석한것으로정의됨. 통계적인방법 (meta-analysis) 은포함된연구의결과를요약하기위해사용되거나사용하지않을수있음

16 체계적고찰은무엇인가?

17 질문 1 상자안에무엇이있을까? 질문 2 동일한상자안에다른표본이나오는이유는? 표본 1 모집? 표본 4 표본 2 표본 3

18 표본 1 체계적고찰의본질 : 모아서합친다 표본 4? Systematic Review!!! 모집단 표본 2 표본 3

19 가정은. 표본 1 표본 4 모집단 표본 2 표본 3

20 체계적고찰의본질적인한계 : 이질성 & 합칠수있는가? 진실은!!! 표본 1 표본 4 모집단 표본 2 표본 3

21 Systematic Review 1 질문에대한구조화 2 사전에정의된명백한기준 3 엄격하고재생산가능한방법론적용 4 체계적인문헌검색 5 선택된문헌에대한비평적평가 6 근거의요약과결과해석

22 체계적고찰의효용성 찾고자하는진실에대한효율적인정보제공 관련모든문헌에대한검색으로인한시간절약 비평적평가 결과에대한요약및해석 의사결정에대한신뢰성제공 비뚫림의위험이적은정보의제공 사전에계획된선택기준 명백하고재생산가능한방법론적용 체계적인검색및비뚫림의위험이적은문헌의선택

23 모든체계적고찰은항상좋은근거인가?

24 체계적고찰에대한평가가필요한이유? The medical review article revisited: has the science improved? McAlister., Annals of Intern Med 1999 주요의학잡지를선택하여각각의저널에등재된 158 개고찰에대한평가를수행 * 15 개의체계적고찰에대한평가지표를선정하여평가 이중중요한 10 개지표에대한결과값비교

25 연구대상의학잡지및선택된연구수 New England Journal of Medicine 60 Annals of Internal Medicine 33 British Medical Journal 24 American Journal of Medicine 18 JAMA 13 Journal of Internal Medicine 10

26 체계적고찰에대한평가기준 1. The review addressed a focused clinical question 2. The method of locating evidence was described 3. Explicit criteria were used to select studies 4. The methodologic validity or quality of the included studies was assessed 5. Assessments of studies were reproducible (that is, they were done by more than one reviewer 6. Directives for future research initiatives were In reviews that included treatment recommendations 7. Sources of heterogeneity (clinical or study design) in existing data were addressed 8. Quantitative synthesis of existing data was done 9. The major clinically relevant outcomes (benefits and harms) were considered 10.The generalizability of existing data was addressed

27 10 개기준에대한논문포함 80%

28 무엇을평가해야하는가?

29 모든리뷰는항상좋은가? FAST appraisal Question What is the PICO? Finding *** 대부분의연구를찾았는가? Appraisal** 좋은연구를선택하였는가? Synthesis 의미는무엇인가? Transferability of results

30 Finding : 모두찾았는가?

31 좋은검색을위한엄격한접근 체계적문헌고찰에서문헌검색조건 포괄적인 (comprehensive) 재생산가능한 (reproducible) 제한된검색은바이어스를가져올수있음 대표적이지않은연구들포함 부정확한결과 일반화의감소

32 FIND: 가능한모든연구를찾았는가? 좋은검색은무엇인가? 검색어 : 자연어와통제어 (text and MeSH) 최소 2개이상의검색원 : MEDLINE, EMBASE, CINAHL, CCTR,... 추가검색 관련문헌의참고문헌 추가적인검색어에대한고려 검색된문헌을중심으로한추가적인검색 (snowballing) Medline Embase Cochrane Trials Registry

33 DATABASE 에따른 RCT CCTR identified 78.5% of the 781 trials; MEDLINE then yielded an extra twenty-six trials (3.3%); Embase then identified an extra six trials (0.8%), four were non-english; Science/Social Sciences Citation Index then yielded an extra seven trials (0.9%)

34 어디서? 어떤용어로찾았는가? Do pedometers increase activity and improve health? Find: 검색전략은무엇인가? Databases? Terms? Other methods?

35 검색어로제시 ( 재현성 ) 1. "Brain Ischemias"[tiab] OR "Cerebral Ischemia"[tiab] OR "Cerebral Ischemias"[tiab] OR "Brain Ischemia"[tiab] OR "Brain Infarctions"[tiab] OR "Brain Infarction"[tiab] OR "Posterior Circulation Infarction"[tiab] OR "Anterior Cerebral Circulation"[tiab] OR "Strokes"[tiab] OR "Stroke"[tiab] OR "CVA"[tiab] OR "Cerebrovascular Accident"[tiab] OR "CVAs"[tiab] OR "Cerebrovascular Accidents"[tiab] "Intracranial Hemorrhage"[tiab] OR "Intracranial Hemorrhages"[tiab] OR "Brain Hemorrhage"[tiab] OR "Brain Hemorrhages"[tiab] OR "Cerebral Hemorrhages"[tiab] OR "Cerebral Hemorrhage"[tiab] OR "Intracerebral Hemorrhages"[tiab] OR "Intracerebral Hemorrhage"[tiab] OR "Intracranial Thrombosis"[tiab] OR "Brain Infarctions"[tiab] OR "Brain Infarction"[tiab] OR "Cerebral Hypertensive Hemorrhage"[tiab] OR "Cerebral Hypertensive Hemorrhages"[tiab] OR "Intracranial Hypertensive Hemorrhage"[tiab] OR "Intracranial Hypertensive Hemorrhages"[tiab] OR "SAH"[tiab] OR "Subarachnoid Hemorrhage"[tiab] OR "SAHs"[tiab] OR "Subarachnoid Hemorrhage"[tiab] Brain Ischaemias"[tiab] OR "Cerebral Ischaemia"[tiab] OR "Cerebral Ischaemias"[tiab] OR "Brain Ischaemia"[tiab] "Intracranial Hemorrhages"[Mesh:noexp] OR "Cerebral Hemorrhage"[Mesh:noexp]) OR "Brain Infarction"[Mesh] OR "Basal Ganglia Hemorrhage"[Mesh] OR "Intracranial Hemorrhage, Hypertensive"[Mesh] OR "Subarachnoid Hemorrhage"[Mesh:noexp] "Brain Ischemia"[Mesh] OR "Stroke"[Mesh] OR

36 논문의선택과정

37 Controlled vocabulary / text words 검색전략에대한설계 각검색원에서제시하는표준화된의학용어사용 Medline = MeSH, EMBASE = EMTREE Free-text terms 동일어, 유사어모두고려 (caffeine = coffee, head/brain) 어미가다른여러동일단어, 다른철자 ( 미국식, 영국식표현등 ) wildcards (e.g. caffein* = caffeine, caffeinated) 보다적절하고포괄적인검색을위해서는 controlled vocabulary or thesaurus ( exploded ) 와 free-text terms 의조합이필요함

38 제목과초록 : free text MeSH 영역 어디서찾아지는가?

39 MeSH 로찾을수없는것 influenza AND pandemic AND vaccine 3262 influenza AND pandemic AND vaccine AND medline[sb] 2911(89%) (influenza AND pandemic AND vaccine )Filters: Publication date from 2012/01/01 to 2012/08/ (influenza AND pandemic AND vaccine AND medline[sb] )Filters: Publication date from 2012/01/01 to 2012/08/29 211(47%)

40 MeSH 검색의제한점 Search strategy: Is it posibble that more RCT's would have been retrieved if authors had included a MeSH term 'pregnancy, ectopic' or 'ectopic pregnancy'as a free text term? Response to comment: Thank you for your comment. MEDLINE and EMBASE can be searched using standardized subject terms assigned by indexers not authors. Standardized subject terms are useful because they provide a way of retrieving articles that may use different words to describe the same concept and because they can provide information beyond that which is simply contained in the words of the title and abstract. When searching for studies for a systematic review, however, the extent to which subject terms are applied to references should be viewed with caution. Authors may not describe their methods or objectives well and indexers are not always experts in the subject areas or methodological aspects of the articles that they are indexing. Also text word searches are necessary to retrieve older records. In order to identify as many relevant records as possible searches should comprise a combination of subject terms selected from the controlled vocabulary or thesaurus with a wide range of free-text terms (Cochrane handbook6.4.5,

41 MeSH 검색의제한점 Our studies included flowing free text terms and MeSH(Medical Subject Headings) terms. Only two of nine studies were indexed as Pregnancy, Ectopic, 3 studies were indexed as Pregnancy or Pregnancy, Tubal, 5 studies were not in MEDLINE. ID free text terms MeSH MeSH Gungorduk K ectopic pregnancy Pregnancy, Tubal Pregnancy Alleyassin A ectopic pregnancy Pregnancy, Ectopic Pregnancy Amirian M ectopic pregnancy NOT Guvendag Guven ES ectopic pregnancy Pregnancy, Tubal Pregnancy Hamed ectopic pregnancy Pregnancy, Ectopic Pregnancy Klauser ectopic pregnancy NOT Saadati ectopic pregnancy NOT Song ectopic pregnancy NOT Zargar ectopic pregnancy NOT

42 검색전략에따른검색결과 How to identify randomized controlled trials in MEDLINE J Med Libr Assoc 94(2) April 2006

43 엄격한검색전략수립 체계적고찰은체계적인검색이요구됨 MEDLINE 만으로는충분하지않음 포괄적인 (comprehensive) 재생산가능한 (reproducible) 제한된그러나 검색은효율성과검색은민감도간의대표성있는균형이결과를필요가져오지못할가능성이있음 불완전한결과 선택비뚫림 일반화의감소

44 출판된모든문헌을찾았다면 충분한가? Publication bias

45 출판편향 (Publication Bias) Unbiased 된결론에도달하기위해서는 해당연구주제에관한대부분의 primary study 들이포함되어야함 통계적으로유의한결과를보인연구들 보다빨리출판되는경향이있음 위양성결과가더많이포함될수있음 Published bias 의개념 출판된연구만을포함하는것은연구결과를부정확하거나효과를과추정하게되는결론을야기할수있음

46 Trials and references Conceived Stages of a trial and its findings Performed Submitted Published Cited

47 Trials and references Conceived Performed Risk of bias during conduct of the trial( 문헌평가과정 ) Submitted Published Cited

48 Trials and references Conceived Performed Submitted Published Cited Because the results are exciting... (publication bias) quickly? (time-lag bias) published many times? (duplicate/multiple publication bias) published in English journals? (language bias) with only some outcomes? (outcome reporting bias) to MEDLINE-indexed journals? (database bias)

49 Time to publication 결론적으로.. 오랜시간 Time to publication for results of clinical trials, Hopewell S, The Cochrane Library 2008, Issue 2

50 Protocol vs publish article _primary outcome 의변화 Empirical Evidence for Selective Reporting of Outcomes in Randomized Trials, JAMA, May 26, 2004

51 Incompletely Outcome Report 연구결과에따른불완전한결과보고의차이 POSITIVE NEGATIVE

52 Grey vs published trials 효과의차이 Grey literature in meta-analyses of randomized trials of health care interventions Hopewell S, The Cochrane Library 2008, Issue 2

53 Industry sponsorship and research outcome. Lundh A, et.al., Cochrane Database Syst Rev Dec

54 Industry sponsorship and research outcome. Lundh A, et.al., Cochrane Database Syst Rev Dec

55 publication bias 의확인방법들 The funnel plot 가장일반적인방법 smaller study 들의결과들 o larger random error 때문에평균효과주위에더넓게퍼지게될것 만일 publication bias 가존재하지않는다면각 study 들의 sample size 와 treatment effect 의 plot 은전체적으로깔때기모양을형성해야할것이다. 만일 positive statistically sig. result 나 larger effect size 를보인 study 들의 publication 가능성이높다면 funnel plot 의모양은 skewed 되어질것

56 출판편향이의심될수록출판편향을판단할수없다???

57 Publication Bias: 해답 모든연구는시작시기에등록 o The National Clinical Trials Registry: Cancer Trials o National Institutes of Health Inventory of Clinical Trials and Studies o International Registry of Perinatal Trials 등록된연구만을저널에등재 회색문헌을포함

58 계획된결과를보고하는것은완전한가? 불완전한보고 리뷰결과 Six studies reported intention-to-treat analyses (Alberts 1996;Gadducci 2000;GOG172;Markman 2001; Yen2001; Yen 2009). Most trials reported expected outcomes except for Yen 2009 where the stated objective was to construct a nomogram for survival, but additional data was provided by the investigators for the purposes of this review. Zylberberg 1986 did not report adverse effects 부정적결과인 PAIN 은연구의질적수준이높은 3 개의연구에서만보고되었음 불완전한보고가없다고평가할수있는가?

59 unpublished information: 사용해야되나? unpublished 된 study 들을모두확인해서사용한다면 publication bias 는어느정도해결될수있을것. 그러나 Cook, et al. (1993) 메타분석에서의 unpublished data 에관한성향조사 150 편중 46 편만이 unpublished result 를사용 journal editor 에대한설문조사 o unpublished data 는 probably or certainly 포함되어야된다 : 46.9% o unpublished data 가 포함된 메타분석논문은 publish 시키지않을것이다 : 30%!!!

60 Appraial: 비평과선택 The question we ask ourselves is Is the study informative? rather than Is the study perfect?

61 APPRAISE & select studies 좋은질의연구는무엇인가?

62 biased? OK? 1. 모든긍정적인결과의연구 2. 대상환자가 100 명이상인연구 3. BMJ, Lancet, JAMA or NEJM 등의저널에등재된연구 4. 모든사전등록연구

63 연구대상선정 대상의할당 Selection bias Randomisation Concealment 대조군 중재 실험군 중재 Performance bias Standardisation of care protocol Blinding of care providers and patients 추적조사 추적조사 Attrition bias Drop-outs? Cross-over? Is everyone accounted for? 결과측정 결과측정 Measurement bias Blinding of outcome assessors and patients

64 문헌평가방법 연구설계에따라문헌평가방법을적용 무작위대조군연구 : Cochrane Risk of Bias o 무작위방법 o 배정은폐 o 맹검적용 o 불완전한보고 비무작위대조군연구 : The Newcastle-Ottawa Scale o 선택 o 비교 o 결과 진단방법 : QUADAS Scale 적절한도구를선택 ( 점수화시키는도구는사용을권고하지않음 )

65 보다근본적으로.. 과일과야채를먹으면 Hepatocellular Carcinoma 의위험을감소시킬것인가? 중재는? 대조군은? 연구기간은? 연구결과는?

66 Vegetables and fruit intake and cancer mortality in the Hiroshima/ Nagasaki Life Span Study British Journal of Cancer (2003) The Life Span Study (LSS) is a prospective study of subjects including atomic-bomb survivors and nonexposed controls. The Atomic Bomb Casualty Commission (ABCC), followed by the Radiation Effects Research Foundation (RERF), initiated the follow-up in 1950, and regularly monitors the causes of death among the participants through death certificates and other vital status surveys (Pierce et al, 1996). A mail survey was carried out among the LSS subjects who were alive as of 1 September 1978 (Radiation Effects Research Foundation, 1978), and of whom persons completed the questionnaire (response rate of 72.5%). Completion of the mail survey was effective as from 1 January 1980 for men, and 1 February 1981 for women, during which time 525 persons had died. After exclusion of 1284 cancer cases at baseline based on the information of incidence cases from the Hiroshima and Nagasaki tumour registries, the study population consisted of

67 중재및결과확인 중재에대한확인 : The mailed lifestyle questionnaire included questions on past medical history, smoking and drinking habits, marital status, reproductive history, occupation, education, and 22 dietary items, which assessed the average frequency of intake over the previous year. 용량에대한확인 : For the analyses, green-yellow vegetables and fruit consumption were classified into three frequency categories: once per week or less, 2 4 times per week, and daily or almost daily. 암으로인한사망확인 : Follow-up for mortality was linked with the Japanese nationwide family registration system (Koseki). The Koseki provides complete mortality ascertainment for the LSS cohort members residing in Japan. The cause of death was coded according to the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9, ICD-10). The end of the follow-up was defined as the date of death, or 31 March 1998, whichever came first.

68 무엇을평가해야할까? 만약 The Newcastle-Ottawa Scale 로평가한다면? 선택 : 코호트의재현성, 대조군의선택, 시작시기의질병없음의확인, 노출의확인 비교 : 양군의비교가능성 결과 : 탈락율, 탈락이유, 맹검적용에의한결과확인 이것으로충분한가?

69 Synthesis: 연구결과에대한합산혹은요약 어디까지합산할것인가?

70 Meta-analysis (Forest) plot

71 연구결과의합산 모든연구가메타분석이가능하지는않음 메타분석이가능하지않은연구의경우연구결과의범위, 정도등을요약하여제시 무작위대조군연구의경우 연구대상이무작위에의한배정을수행하였음으로두군의차이는중재의차이임 비무작위대조군연구의경우 각군간의위험요인이다름으로두군의차이가중재의차이만이아닌다른교란변수의효과가잠재되어있음. 따라서이러한교란변수의효과를보정한상태에서의결과를비교하여야함

72 연구결과의합산 모든연구가메타분석이가능하지는않음 메타분석이가능하지않은연구의경우연구결과의범위, 정도등을요약하여제시 연구설계가무작위대조군다른연구의연구는경우서로다른비뚤림위험이있음으로합산할수없음 연구대상이무작위에의한배정을수행하였음으로두군의차이는중재의차이임 연구가비무작위대조군서로다르다면연구의 ( 동질경우하지않은경우 ) 합산 ( 메타분석 ) 하지말아야함 각군간의위험요인이다름으로두군의차이가중재의차이만이아닌다른교란변수의효과가잠재되어있음. 따라서이러한교란변수의효과를보정한상태에서의결과를비교하여야함

73 Meta-analysis (Forest) plot: 이질성에대한평가 연구결과의유사성에대한평가? 3 가지검사 1. 눈으로보기 - 결과 ( 효과의신뢰구간 ) 가유사하게분포하고있는가? 2. 차이가있다에대한가정에대한검정 (p-value) 3. 총변이중 Chance 에기인하지않은변이의분포 (I 2 )

74 Heterogeneity( 이질성 ) 은무엇인가? 이질성은연구들간에존재하는변이임

75 이질성 임상적다양성 방법론적다양성 비뚤림 이질성 우연 메타분석중요한과제 ; 1 통계이질성을수량화하고 2 어느정도까지임상적및방법론적의다양성에의해설명되는가? 3 어디까지메타분석할수있는가?

76 결론은 두군이같다??? 합칠수있는가?

77 THE VALIDITY OF THE MOOD DISORDER QUESTIONNAIRE FOR SCREENING BIPOLAR DISORDER: A META-ANALYSIS- THE VALIDITY OF THE MOOD DISORDER QUESTIONNAIRE FOR SCREENING BIPOLAR DISORDER: A META-ANALYSIS

78 Background the early detection of BD among patients diagnosed as MDD is very important. One of the most commonly used is the Mood Disorder Questionnaire (MDQ) developed by Hirschfeld et. al. In the original study by Hirschfeld, the authors suggested a standard cutoff value of 7

79 Questions According to previous studies, the MDQ seems to have relatively good sensitivity and specificity in detecting BD among psychiatric outpatients. However, it seems to have lower sensitivity in detecting BD in the general population. The MDQ has been translated into many other languages, and the validity of these versions has been investigated among patients with mood disorders there is a tendency for studies conducted in Eastern countries to demonstrate relatively lower optimal cutoff values than those conducted in Western countries.

80 cutoff of 7 Optimal cutoff

81 The summary sensitivity and specificity of the MDQ according to different inclusion/exclusion criteria of included studies SENSITIVITY/SPECIFICITY standard or modified cutoff of (95% CI = ) 0.85 (95% CI = ) optimal cutoff values 0.78 (95% CI = ) 0.76 (95% CI = ) Including subjects with both MDD and BD without using a broadened definition of the DSM-IV for BD Excluding subjects with known BD or using the broadened definition of the DSM-IV for BD 0.76 (95% CI = ) 0.81 (95% CI = ) 0.37 (95% CI = ) 0.88 (95% CI = ) Excluding subjects with known BD 0.37 (95% CI = ) 0.88 (95% CI = )

82 cross-cultural differences? First, when pooling studies excluding patients with known BD from the screened population, the summary sensitivity became significantly lower. Second, we found that when studies used a broadened definition of the DSM-IV for BD or when they used a final diagnosis elicited by re-interviewing 1 year later, the summary sensitivity became significantly lower. There have been reports that the optimal cutoff seemed to be lower in Eastern countries in comparison to their Western counterparts. However, after adjusting for various clinical correlates, these cross-cultural differences disappeared.

83 Subgroup Analysis: streptokinase versus placebo Second International Study of Infarct Survival (ISIS-2) (I) Reprinted from ISIS-2 Collaborative Group. Lancet 1988;2:349-60, with permission from Elsevier.

84 Subgroup Analysis: aspirin versus placebo Second International Study of Infarct Survival (ISIS-2) (II) Reprinted from ISIS-2 Collaborative Group. Lancet 1988;2:349-60, with permission from Elsevier.

85 subgroup analysis vs multiple testing They did not register their protocol with PROSPERO so any methods they use could have been changed and in particular the subgroup analysis around BMI. 5 studies are in the review. Two have BMI where the mean is just above 30kg/m2 but for some reason one is in a subgroup analysis (Ismail) while the other one (Dolapciogluc) is in the group with the studies with BMI <30. This is not explained and I think has lead to results that they are over interpreting. I have used the AMSTAR tool - attached. Item 1 no 'a prior' design

86 사전등록 Where possible these investigations should be specified a priori, i.e. in the systematic review protocol.

87 적절한요약추정치는무엇인가? 메타분석은하지못하는게아니라하지않는것이다 주제에적합한추정치를결정함 연구의이질성을고려하여연구의이질성이높다면연구결과를합산하지않음 모든결과는통계분석할수있으나의미없을수있음 10 개미만의출판편향에대한통계검정 : 하지만통계검정을통계분석하지못한다고출판편향을평가하지말라는것은아님 의미있는결과를제시하는것이목적임

88 Transferability : 적용가능성

89 알고자하는것? 우리가아는것 대상상태를 가진환자군 우리가모르는것 연구에포함 연구에포함 되지않음 중재 A 중재 B 중재 A,B 결과 결과 결과 AUSTRALASIAN COCHRANE CENTRE

90 알고자하는것은반영하는가? 얼마나영향을미치는가? 대상상태를 가진환자군 얼마나같은가? 연구에포함? 연구에포함 되지않음 중재 A 중재 B 중재 A,B 결과 결과 결과 AUSTRALASIAN COCHRANE CENTRE

91 Transferable? 나의환자에게적용가능한가 연구들의대상과나의환자는유사한가? 만약아니라면, 이유는? 연구설계의차이 연구대상 ( 중재, 결과측정방법등등 ) 의차이 연구와실제대상의 Baseline risk 의차이 만약그렇다면, 추가고려해야할사항 연구대상군과다른대상에게적용가능성

92 systematic reviews 득과실 Advantages 많은대상자수와사건수로인한검정력 전체연구에대한체계적인결과수용 Disadvantages 실제효과가비뚤릴가능성

93 포함된문헌에따라 garbage in garbage out 체계적고찰에서포함된연구의추정된결과값은포함된연구가바이어스된연구라면개별연구자체보다더바이어스된결과를가져올수있음 출판혹은보고비뚫림을가진체계적고찰은적합하지않은추정값을가져올수있음 모두모았는가? 무엇을모았는가?

94 체계적고찰과메타분석 사과와오랜지의혼합 사과에대해알기를원할때적합하지않음 과일에대해알기를원할때보다적합함 연구는동일한주제를가지고있어야함 분석에사용된연구가너무다양하다면진실된효과를구별하기에적합하지앟을수있으며결과가무의미할수있음

95 체계적고찰결과에대한신뢰성에대한불확실성 체계적고찰은현재까지진행된 ( 보고된 ) 연구결과에대한비뚤리지않는포괄적인고찰이지, 모든 ( 보고되지않았거나, 이루어지지않은 ) 사건 ( 효과 ) 에대한고찰이아니다. 모든사건 ( 효과 ) 과체계적고찰의근거

96 체계적고찰결과에대한신뢰성에대한불확실성 체계적고찰은현재까지진행된 ( 보고된 ) 연구결과에대한비뚤리지않는포괄적인고찰이지, 모든 ( 보고되지않았거나, 이루어지지않은 ) 사건 ( 효과 ) 에대한고찰이아니다. 현재까지진행된연구가적거나없다. 연구에포함된대상자의수나효과를평가하기에적절하지않은사건수를가진다 대상연구들의대상과중재, 결과지표등의이질성이존재한다 포함된연구들의연구설계에따른연구수행이적절하지않아비뚤어질가능성이높다 긍정적인연구결과만이보고되었을가능성이존재한다

97 경청해주셔서감사합니다 고려대학교의과대학근거중심의학연구소 moole02@naver.com 김현정

Rheu-suppl hwp

Rheu-suppl hwp Objective: This paper reviews the existing Korean medical and public health, and nursing academy articles on disease-specific and domain-specific quality of life, and provides recommendations for the universally