研究設計 | 療效評估

一、研究設計

1.Randomised Controlled Trial (RCT)
a group of patients is randomised into an experimental group and a control group.These groups are followed up for the variable /outcomes of interest.隨機對照試驗是目前臨床流行病學中公認證據力最強之原始介入性研究設計 ( primary interventional study)。透過各種隨機取樣、隨機分派之方法將病人分成實驗及對照組,目的是為減少人體臨床試驗過程中有形及無形之偏差(bias)(已知及潛在的偏差)。在此設計中,雙盲對照(double blinded, placebo-controlled)是最基本的要求。好的RCT報告應該清楚說明從病人選擇到結果分析之整個過程中,每個環節病人與研究執行者如何做到(維持盲法)oncealment。

2.Cohort Study:
involves identification of two groups(cohorts)of patients, one which did receive the exposure of interest,and one which did not,and following these cohorts forward for the outcome of interest.世代研究提供比RCT證據力較次一級之研究證據。它可以提供因果關係探討,但不可以拿來與RCT一起混合計算療效。這是屬於臨床流行病學中之觀察性研究。

3.Case Control study
A study design that examines a group of people who have experienced an event(usually an adverse event)and a group of people who have not experienced the same event,and looks at how exposure to suspect (usually noxious) agents differed between the two groups. This type of study design is most useful for trying to ascertain the cause of rare events, such as rare cancers.個案對照研究僅能提供勝算比(odds ratio, OR),而不能提供相對危險率(relative risk, RR)。它的臨床證據力較Cohort study低,但是較Case series study高。

4.Systematic Review:
is a literature review focused on a single question which tries to identify, appraise, select and synthesis all high quality research evidence relevant to that question.系統性回顧是研究者針對某一個臨床問題,藉由搜尋引擎儘可能找尋各種資料庫,包括Medline, EMBASE, Cochrane Library, SUMSearch 等,擷取其中高品質之RCT文章進行資料之整合,由於收集之資料較完整,避免少數幾篇文章之以偏蓋全,證據力高,為實證文獻搜尋首要目標之一。在Medline or PubMed 之 Clinical Queries中皆有特別為此設計之獨立選項。

5.Meta-analysis:
is a systematic review or overview which uses quantitative methods to summarise the results.統合分析是系統性回顧的一部份。研究者經過上述之搜尋過程所獲得之高品質文章,將其結果以統計學之方法結合。某些個案數少之 RCT 所獲致之結論常令人質疑,此研究方法是為了減少此一瑕疵,結合多數RCTs 以增加個案數來強化統計力,提昇證據力之可信度。這類文獻也是實證文獻搜尋首要目標之一。

二、療效評估

1.P值
或稱為 significance level,用來衡量研究結果推翻虛無假設之強度有多強。 P 值越小 , 推翻虛無假設之強度越強 。 在 某 一 P 值 之 下 , 隨意將研究結果劃分為有(significant)或沒有統計意義(non-significant),不是統計推論的原意。P值0.05並不意味著研究結果能推翻虛無假設之強度夠強,不過一般認為,如果P<0.001,則強度夠強。研究結果應將P值詳實呈現,而不是以”<”或”>”表示。

2.Relative risk(RR)
it is the ratio of absolute risk for each group.相對危險比是試驗組事件發生率(A%) 與對照組中事件發生率(B%)之比值(A/B)。而各組之事件發生率(event rate)為研究追蹤過程中各組發生某一事件( event )之人數占該組總人數之百分比。通常被使用於RCT之中。

3.Odds ratio(OR):
It is the odds of an event happening in the experimental group expressed as a proportion of the odds of an event happening in the control group. The closer the OR is to one,the smaller the difference in effect between the experimental intervention and the control intervention. If the OR is greater (or less) than one, then the effects of the treatment are more (or less) than those of the control treatment.勝算比是試驗組的Odds除以對照組的Odds。各組的Odds為研究過程中各組發生某一事件 ( event ) 之人數除以沒有發生某一事件之人數。通常被使用於Case-Control study之中。當發生此一事件之可能性極低時,則relative risk 幾近於odds ratio.

4.Absolute risk reduction(ARR):
The absolute difference in risk between the experimental and control groups in a trial. It is used when the risk in the control group exceeds the risk in the experimental group, and is calculated by subtracting the absolute risk(AR) in the experimental group from the AR in the control group.絕對風險下降率是對照組發生某一事件(outcome)減去試驗組經過治療以後也發生同一事件之比率。如果這是一項有效的治療,那麼此一差額為正值,發生不良事件之風險下降。反之,如果這是一項無效的治療,那麼此一差額為負值,絕對風險上升(absolute risk increase)。

5.Relative risk reduction(RRR)
is the percent reduction in events in the treated group event rate(EER)compared to the control group event rate (CER)
RRR =〔(EER-CER)/CER〕x 100%

相對風險比率差:當 outcome event 發生的可能性很低時,此一指標容易高估治療療效。因此,一般在RCT中較傾向以NNT or ARR來表示療效。例如:對照組10000 人中最後罹病的人數為 2 人( 0.02% ),而治療組中最後罹病之人數為1人(0.01%),則 RRR = ( 2-1 / 2) x100%=50%。此意味著某一項藥物可以降低罹病率50%,但實際上它只降低了0.02%-0.01%= 0.01%而已。

6.Number needed to treat(NNT)
is the number of patients who need to be treated to prevent one bad outcome.It is the inverse of the ARR.
NNT = 1/ARR

此一數值越低,表示療效越大。但是到底此值多少,才能顯示此治療之療效可以接受,則必須估算threshold number needed to treat。不同疾病有不同之threshold number needed to treat。

7.Confidence Interval(CI):
the CI quantifies the uncertainty in measurement;usually reported as 95% CI, which is the range of values within which we can be 95% sure that the true value for the whole population lies.信賴區間是評估文獻外部效度很重要的指標。此值常需與 p value 一起考量。信賴區間越寬表示這項研究結果對母群體之推論信心不強,即便 p value小於0.05,那麼是否接受研究結果,則應持保留之態度。

8.Intention-To-Treat Analysis(ITT):
analysis of data for all participants based on the group to which they were randomised and not based on the actual treatment they received.立意治療分析是RCT最後針對結果在進行分析時所採用的減少偏差的統計原則。例如:試驗組最初 10000 人,5 年後,100 人失去追蹤,20 人罹病,則經過治療最後此病之發生率(event rate)為20/10000=0.2%,而不是20/9900=0.22%。因為這100人並不是在隨機狀態下失去追蹤的, 9900 人已不能代表最初的隨機分配狀態,所以不可以此當分母。

其他詞彙之介紹請參考相關網站
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