Transcript mtkicebiTi medicina

mtkicebulebebze damyarebuli medicina
(Evidence based Medicine)
jandacvis profesionalebis swavlebis procesSi
saswavlo programis umTavresi aspeqtebi
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mtkicebulebebze damyarebuli medicinisa (Evidence Based Medicine) da
mtkicebulebebze damyarebuli jandacvis (Evidence Based Care) koncefcia;
mtkicebulebebze damyarebuli medicinis koncefciis praqtikaSi danergvis meTodebi;
mtkicebulebebze damyarebuli medicinisa da mtkicebulebebze damyarebuli samedicino
momsaxurebis yoveldRiur klinikur praqtikaSi danergvis gzebi;
mtkicebulebebisa da informaciis kritikuli Sefasebis meTodebi;
mtkicebulebebis danergvis processa da, amasTan kavSirSi, organizaciebisa da gundebis
dinamika;
gaidlainebis SemuSavebis process da multidisciplinarul garemoSi maTi ganxorcielebis
principebi;
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mtkicebulebebze damyarebuli medicina, rogorc koncefcia
Mmizani:
efeqturi da Sedegiani samedicino daxmarebis miwodeba,
jandacvis organizaciebis saqmianobaSi arsebuli xarvezebis
minimumamde Sesamcireblad
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EBM axali klinikuri specialobaa,
romelic saSualebas gvaZlevs
gamoviyenoT klinikuri da jandacvis
mecnieruli kvlevis Sedegebi
pacientis sawolTan, ambulatoriebsa da
saavadmyofoebSi da mTlianad mosaxleobaSi.
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mtkicebulebebze damyarebuli medicina
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mtkicebulebebze damyarebuli medicinis mizania samecniero kvlevasa da
klinikur praqtikas Soris napralis Semcireba;
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igi ganisazRvreba, rogorc Tanamedrove samecniero kvlevis Sedegebis
sistematuri Ziebis, Sefasebis da gamoyenebis procesi, rac klinikuri
gadawyvetilebis miRebis safuZveli unda gaxdes.
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pacientze zrunva
diagnostireba
prognozireba
mkurnaloba
sxva klinikuri
da
paraklinikuri
sakiTxebi . . .
? safuZvlianoba
saWiroebs dasabuTebas
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mecnieruli dasabuTebis procesi
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1. informaciis saWiroebis gardaqmna kiTxvebad, romlebsac SeiZleba gaeces pasuxi;
2. am pasuxebisaTvis saukeTeso mecnieruli dadasturebis Zieba;
3. mecnieruli kvlevis safuZvlianobisa (anu ramdenad axlosaa is simarTlesTan) da
misi praqtikuli gamoyenebis SesaZleblobis kritikuli Sefaseba;
4. aRniSnuli kritikuli Sefasebis Sedegebis gamoyeneba klinikur praqtikaSi;
5. samuSaos Sesrulebis Sefaseba.
.
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mtkicebaze dafuZnebuli medicinis mniSvneloba
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mecnierulad dasabuTebulia jandacvis profesionalebis mier Catarebuli samedicino
gamokvlevebisa da mkurnalobis mxolod 1/3-is saWiroeba;
mecnierulad dausabuTebelia samedicino gamokvlevebisa da mkurnalobis 1/3-is klinikuri
saWiroeba da efeqtianoba, magram miuxedavad amisa, isini mainc tardeba.
samedicino gamokvlevebisa da mkurnalobis danarCen 1/3-s, miuxedavad imisa, rom
maTi saWiroeba mecnierulad dasabuTebulia, klinikur praqtikaSi ar iyeneben.
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ra warmoadgens mtkicebas?
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mtkice dasabuTeba minimum erTi sistematiuri mimoxilvidan, romelic ramodenime kargad organizebul
randomizebul sakontrolo kvlevas moicavs;
mtkice dasabuTeba minimum erTi Sesabamisad struqturirebuli da Sesaferisi moculobis randomizebuli
sakontrolo kvlevidan;
samecniero dasabuTeba ararandomizebuli kargad organizebuli da struqturirebuli kvlevidan, kohortuli,
seriuli an SemTxveva kontrolis kvlevidan;
samecniero dasabuTeba kargad organizebuli araeqsperimentuli kvlevidan, romelic tardeba erTze meti
samecniero centris an jgufis mier;
mecnierulad dasabuTebuli mkvlevar-avtoritetTa azrebi, aRwerilobiTi naSromebi an eqspertTa
komitetebis angariSebi.
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mtkicebaze dafuZnebuli medicinidan mtkicebaze dafuZnebuli jandacvisaken
kritikuli faqtorebi
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ram SeiZleba Seuwyos xeli cvlilebas
problemis identifikacia
mtkicebulebebis Zieba
kritikuli Sefaseba
ekonomikuri Sefaseba
organizaciuli auditi
mtkicebulebaTa difuzia
ganxorcieleba (implementacia)
saqmianobis marTva
xarisxis uwyveti gaumjobeseba-cvlilebis ganmapirobebeli
Sinagani faqtori
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ra ganapirobebs “`cvlilebas`”
ZiriTadi elementebi:
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politikuri
sakanonmdeblo
ekonomikuri
socialuri
teqnologiuri
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mtkicebulebaTa Zieba
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The Cochrane Library on line (http://www.cochrane.org/)
b. NHS Economic Evaluation Database, University of York
(http://www1.york.ac.uk/inst/crd/welcome.htm)
c. MEDLINE database of journal articles published by the U.S.
National Library of Medicine, (http://www.nlm.nih.gov)
d. Bandolier - Newsletter of evidence-based health care from
Oxford (www.jr2.ox.ac.uk/bandolier)
e. The Centre for Evidence Based Medicine is a site containing
information, statistics, teaching materials and discussion of
Evidence-Based Medicine. (http://www.cebm.utoronto.ca/)
f. Centre for Health Evidence:
(http://www.cche.net/usersguides/main.asp)
g. Centre for Clinical Effectiveness
(http://www.med.monash.edu.au/healthservices/cce/) that will
actually search for you if given a clinical question.
h. Netting the evidence
(http://www.shef.ac.uk/~scharr/ir/netting/)
i. University of California resource centre
(http://medicine.ucsf.edu/resources/guidelines/users.html)
EBM journals such as the Evidence-Based Medicine published by
the BMJ Publishing Group (http://ebm.bmjjournals.com/ )
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zogierTi terminis ganmarteba
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absolituri riski_drois gansazRvrul monakveTSi, individualurad
specifikuri movlenis aRmocenebis albaToba
SedarebiTi riski_ramdenjer metia (SedarebiTi riski>1-ze) an
naklebia (SedarebiTi riski<1-ze) erT jgufSi, meoresTan SedarebiT,
raime movlenis aRmocenebis albaToba
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Kkritikuli Sefaseba
rogor gavceT pasuxi Semdeg SekiTxvebs:
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ramdenad sarwmunoa kvlevis Sedegebi?
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rogoria Sedegebi?
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damexmareba Tu ara es Sedegebi pacientis samedicino
momsaxurebis procesSi?
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kvlevis tipebi
aRwerilobiTi
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ekologiuri kvleva-moicavs mTels populacias
ganivi (erTmomentiani, prevalentobis kvleva)-fokusi individualebze
analizuri
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observaciuli
intervenciuli
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aRwerilobiTi kvlevebi
ekologiuri kvleva
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dakvirvebis erTeuli: populacia
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Seiswavlis avadobisa da saavadebianobis sxvadasxvaobas geografiuli
areebisa da drois trendis mixedviT
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gamousadegaria mizez-Sedegobrvi urTierTkavSiris dasadgenad
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aRwerilobiTi kvlevebi
ganivi (Cross-sectional) kvleva
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dakvirvebis erTeuli: individi
aRwers daavadebis gavrcelebas pirovnebasTan (asaki, sqesi, rasa, ojaxuri mdgomareoba,
samuSao, cxovrebis stili), adgilTan da drosTan mimarTebaSi;
tardeba swrafad da iolia
Sedegebi exmareba jandacvis mimwodeblebs resursebis efeqtian moxmarebasa da prevenciis
efeqturi gegmis SemuSavebaSi
saSualebas iZleva Sefasdes individis mdgomareoba daavadebis arseboba ararsebobis da, aseve,
im TvalsazrisiT ganicdis Tu ara individi kvlevis momentisaTvis raime zemoqmedebas.
magram, ganivi kvleva ar iZleva saSualebas ganisazRvros uswrebda Tu ara win zemoqmedeba
daavadebas.
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analizuri kvlevebi
observaciuli:SemTxveva-kontrolis kvleva
moicavs pacientebs (klinikur SemTxvevebs), romelTac aReniSnebaT Sesaswavli daavadeba an gamosavali, da
sakontrolo pacientebs, romelTac es daavadeba an gamosavali ar aReniSnebaT.
risk-faqtoris zemoqmedeba
daavadeba
Ddiax
Ddiax
ara
dro
kvleva
ara
amonarCevi
Sesaswavli
daavadebiT
(SemTxveva)
populacia, romelic ganicdis
risk-faqtoris
zemoqmedebas
amonarCevi
Sesaswavli
daavadebis gareSe
(kontroli)
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analizuri kvlevebi
observaciuli:SemTxveva-kontrolis kvleva
Zlieri mxareebi:
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ar aris Zviri da SesaZlebelia Sesruldes swrafad;
Sesaferisia im daavadebebis SefasebisaTvis, romelTac xangrZlivi latenturi periodi aqvT;
optimaluria iSviaTi daavadebebis evaluaciisaTvis;
iZleva saSualebas Seswavlil iqnas mravalferovani etiologiuri faqtorebi calkeuli daavadebisaTvis.
kvlevis sisusteebi:
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araefeqturia iSviaTi zemoqmedebis SeswavlisaTvis;
ar iZleva avadobis dadgenis saSualebas pirebSi, romlebic eqvemdebarebian an ar eqvemdebarebian
zemoqmedebas;
SesaZloa rTuli iyos zemoqmedebasa da daavadebas Soris droebiTi urTierTkavSiris dadgena;
gaxsenebis Secdomasa (Recall bias) da SerCevis SecdomasTan (speqtris Secdoma) (Selection
bias) dakavSirebuli problemebi.
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gaxsenebis Secdoma-sistemuri Secdoma, romelic gvxvdeba SemTxveva-kontrolis kvlevebSi.
zemoqmedebis an movlenebis gaxsenebis unari gansxvavdeba SemTxvevebis da sakontrolo jgufebSi.
SemTxvevebis jgufis pacientebs SeiZleba kiTxvebi ufro metjer da CaZiebiT dausvan, vidre
sakontrolo jgufis pacientebs. savaraudoa, rom daavadebulma ukeT gaixsenos, hqonda Tu ara
Sexeba ama Tu im zemoqmedebasTan, vidre janmrTelma.
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SerCevis Secdoma-sistemuri Secdoma dakavSirebuli SerCevasTan. gamowveulia imiT, rom
populaciis SerCeuli nimuSi ar aris reprezentatiuli (warmomadgenlobiTi) riskis qveS myofi mTliani
populaciis mimarT. kvlevaSi ar aris CarTuli pacientebis Sesabamisi speqtri. Sedarebad jgufebs Soris
arsebobs sistemuri gansxvavebebi (mag. daavadebis Sorswasuli formis mqone pacientebs adareben
janmrTel pirebs).
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analizuri kvlevebi
observaciuli:kohortuli kvleva
daavadeba ar aris
risk-faqtoris zemoqmedeba
risk-faqtoris zemoqmedeba icvleba
populacia
amonarCevi
dakvirvebis periodi
daavadeba
+
-
+
risk faqtoris zemoqmedebas adgili ara aqvs
-
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Kkohortuli kvlevebi
Zlieri mxareebi:
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Rirebulia iSviaTi zemoqmedebebis Sesaswavlad;
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SesaZlebelia calkeuli zemoqmedebis mravalgvari gamosavlebis Seswavla;
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maTi saSualebiT SesaZloa dadgindes droebiTi urTierTkavSiri zemoqmedebasa da daavadebas Soris;
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maTi saSualebiT SesaZlebelia Secdomis minimalizacia zemoqmedebis efeqtis dadgenisas;
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SesaZlebelia avadobis gamoTvla.
susti mxareebi:
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arasakmarisad efeqturia iSviaTi daavadebebis SefasebisaTvis;
prospeqtuli:Zviria da did dros moiTxovs;
danakargebma mimdinareobis periodSi SesaZloa zegavlena iqonios Sedegebze.
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analizuri kvlevebi
intervenciuli kvlevebi
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arakontrolirebuli klinikuri cda, rodesac intervencia xorcieldeba pacientebis jgufSi
sakontrolo jgufTan erTad da randomizaciis gareSe;
kontrolirebuli, magram ararandomizebuli klinikuri kvleva, rodesac arsebobs
sakontrolo jgufi, magram kvlevis subieqtebis ganawileba intervenciisa da sakontrolo
jgufebSi randomizebulad ar xdeba;
randomizebuli kontrolirebuli kvleva, rodesac subieqtebs randomizaciis principiT
anawileben
intervenciisa
da
sakontrolo
jgufebSi.
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randomizebuli kontrolirebuli kvleva
dadebiTi mxareebi:
yvelaze Zlier kvlevebs miekuTvneba !
!!
`damamaxinjebeli faqtorebis~ iseTi ganawileba, rac minimumamde amcirebs Secdomis albaTobas;
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SesaZlebelia "brma" meTodis gamoyeneba;
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randomizacia aiolebs statistikur analizs.
nakli:
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Zviria: moiTxovs did drosa da Tanxebs;
SesaZloa adgili hqondes "moxaliseTa Secdomas" (Volunteer bias)
drodadro Tavs iCens eTikuri problemebi.
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Kklinikuri kvlevis sarwmunoeba: Sinagani da garegani
ganmsazRvrebi faqtorebi:
ramdenad kargad aris SemuSavebuli kvlevis gegma;
sworad Catarda Tu ara SerCeva da monacemebis analizi;
ramdenad gamoxatulia sistematuri da SemTxveviTi Secdomebi.
?
sarwmunoeba=sargebloba
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garegani sarwmunoeba anu ganvrcobadoba (external validity, or
generalizability)-
eqimisaTvis es niSnavs pasuxs SekiTxvaze-`Tu mocemuli
kvlevis Sedegebi marTebulia, maSin SemiZlia Tu ara
maTi gamoyeneba Cemi pacientisaTvis?~
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ris safuZvelze SeiZleba miviRoT sarwmuno faqtebi?
mecnierul mtkicebulebaTa (evidence) sarwmunoebis done
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Ia done-randomizebuli sakontrolo kvlevebis meta-analizis safuZvelze miRebuli mecnieruli
mtkicebebi;
Ib done-sul mcire, erTi randomizebuli kvlevis Sedegad miRebuli mtkicebebi;
IIa done- mtkicebebi miRebuli: sul mcire, erTi kargad organizebuli ararandomizebuli kontrolirebuli
kvlevis safuZvelze
II b done-sul mcire, erTi sxva tipis kargad organizebuli eqsperimentuli kvlevis safuZvelze;
III done- mtkicebebi, miRebuli kargad organizebuli, araeqsperimentuli aRwerilobiTi kvlevebis,
rogoricaa mag. SedarebiTi kvlevebi, korelaciuri kvlevebi da klinikuri SemTxvevebis Seswavla,
safuZvelze;
IV done- eqspertis an eqspertTa jgufebis mosazreba da/an klinikuri gamocdileba.
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mecnierul faqtebze dayrdnobiT Camoyalibebuli rekomendaciis safuZvlianoba
(a) rekomendaciis safuZvlianoba sarwmuno mecnieruli faqtebiT dasturdeba
(b) rekomendaciis safuZvlianoba sakmaod sarwmuno mecnieruli faqtebiT
dasturdeba
(g) mecnieruli faqtebi naklebad sarwmunoa imisaTvis, rom rekomendacias daedos
safuZvlad. rekomendaciis Camoyalibeba sxva faqtorebisa da mosazrebebis
safuZvelze xdeba
(d) mecnieruli faqtebi sakmaod naTlad adasturebs rekomendaciis usafuZvlobas
(e) mecnieruli faqtebi savsebiT ewinaaRmdegeba rekomendacias
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Kkvlevis Sedegebis interpretacia
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absoluturi riskis Semcireba (ARR)
(ARR)=(CER)-(EER)
sakontrolo jgufSi movlenis sixSire eqsperimentul jgufSi movlenis sixSire
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SedarebiTi riskis Semcireba (RRR)
(RRR)=(CER-EER)/CER*100
pacientebis raodenoba, romelic mkurnalobas saWiroebs
(NNT)
NNT=1/ARR
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Sedegis gansazRvruloba
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sarwmunoebis intervali: sarwmunoebis intervali (si) raodenobrivad gansazRvravs Sedegebis
gazomvis sarwmunoebas. igi aRwers, Tu ramdenad misaRebia nimuSze (amonarCevze)
miRebuli Sedegi zogadi populaciisaTvis
P-maCvenebeli aRwers albaTobas, Tu ramdenad SesaZlebelia, rom kvlevis Sedegebi
SemTxveviTobiT iyos ganpirobebuli. p-maCvenebeli 0-dan 1-mde meryeobs. 0 miuTiTebs, rom
Sedegebi ar SeiZleba SemTxveviTobiT iyos ganpirobebuli, xolo 1,0 miuTiTebs, rom Zalian
maRalia SemTxveviTobis albaToba.
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kritikuli Sefasebis savarjiSo #1
miokardiumis infarqtisSemdgom periodSi angiotenzingardamqmneli fermentis
inhibitorebis gamoyenebis Taobaze Catarebuli AIRE kvleva Sefasda,
rogorc yvelaze mniSvnelovani, romelic mravali wlis manZilze Catarebula.
kvlevaSi monawile 2006 pacienti, romlebsac gulis ukmarisobis klinikuri
suraTi aReniSnebodaT randomizaciis principis safuZvelze gaanawiles
ramiprilisa da placebos jgufebSi (ix. cxrili 1).
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cxrili 1
ramiprili placebo
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pacientebis raodenoba 1014
992
sikvdili
170
222
sikvdilis riski 0,168 (170/1014) 0,224 (222/992)
gansazRvreT
SedarebiTi riskis Semcireba
absoluturi riskis Semcireba
mkurnalobisTvis saWiro raodenoba
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kritikuli Sefasebis savarjiSo #1
RR=0,168/0,224=0,75
RRR=1-0,75=0,25
ARR=0,224-0,168
NNT=1/ARR=18
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Eekonomikuri Sefaseba
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Cost minimisation-xarjis minimalizaciis analizi_identuri
gamosavlebis mqone, magram gasxvavebuli resursebiT ganxorcielebuli ori
programisaTvis gaweuli xarjebis Sedareba
resursebi gamoixateba monetaruli formiT
 iTvleba, rom sargebeli/gamosavlebi identuria da maTi Sedareba ar xdeba
 dadebiTi mxareebi:
martivi da iafia
gasagebad ioli
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gamosavlebis gaigiveba ararealuria
Nnakli
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Cost effectiveness-xarjT-efeqturobis analizi
xarjebi gamoxatulia monetaruli formiT
gamosavlebi izomeba fizikaluri erTeulebiT: SenarCunebuli sicocxlis wlebi,
uunarobis periodis Semokleba, arteriuli wnevis donis daqveiTeba da a.S.
nakli:
 zogjer erTi fizikaluri gamosavali ar asaxavs mkurnalobis
Sedegebs yvela ganzomilebaSi
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Cost benefit-Rirebuleba-sargeblis analizi
jandacviTi proeqtis ganxorcielebis alternativebis Sefasebis
ekonomikuri meTodi, romelic mdgomareobs saqmianobis
Rirebulebisa da mosalodneli sargeblis SedarebaSi fulad
erTeulSi gazomviT
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Rirebuleba-utilizaciis analizi
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ekonomikuri Sefasebis analizi, romelic erTmaneTTan akavSirebs jandacvis proeqtis
fulad Rirebulebas da Sedegebis qmediTobas, cxovrebis xarisxsa da sxva
indikatorebze maTi dadebiTi zegavlenis TvalsazrisiT
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xarjebi izomeba monetaruli formiT
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gamosavlebi-QALY-iT
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mtkicebebze damyarebuli medicinidan mtkicebebze damyarebuli jandacvisaken
EBM to EBC
The three
R
Rs& three Es
Doing the right things marTebuli saqmeebis
keTeba
In the right way
sworad keTeba
For the right price
keTeba swor fasad
E
Efficacy
Effectiveness
Efficiency
efeqtianoba
miznobrivi efeqtianoba
efeqturoba
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mtkicebaze dafuZnebuli medicinidan mtkicebaze dafuZnebuli jandacvisaken
Seki T xva
meT o d i s
Zi eba
o qr o s
st and ar t i
pr o bl emi s
i d ent i f i kaci a
evi d ensi s
Zi eba
kr i t i kul i
Sef aseba
eko no mi ur i
Sef aseba
evi d ensi s
saf uZvel i
evi d ensze
d af uZnebul i
Car evi s xar j T ef eqt ur o ba
cvl i l ebi s
gaSveba
Sesr ul ebi s
mar T va
benCmar ki ngi
Sesr ul eba
si st emebi s mi d go ma
l i d er o ba
cvl i l ebebi s mar T va
evi d ensi s
d i f uzi a
gacno bi er eba
mi Reba
gageba
o r gani zaci ul i
aud i t i
sad var T axl a?
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samedicino momsaxurebis xarisxis
uzrunvelyofa zogad praqtikaSi
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auditi da praqtikis menejmenti- samedicino momsaxurebis xarisxis uzrunvelyofis
safuZveli
"samedicino momsaxurebis xarisxi~
es aris saqmianobis is done, romelzec individebisa da mosaxleobisaTvis gaweuli
samedicino momsaxureoba SesabamisobaSia Tanamedrove profesiul codnasTan da
maRali albaTobiT ganapirobebs janmrTelobis mdgomareobis sasurvel
maxasiaTeblebs"
(US Institute of Medicine)
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audi t i s” spi r al i ”
st andar t ebi s m
i Rweva
ci kl i s gam
eo r eba
Sedar eba
cvl i l eba
Sef aseba
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ra sargebloba moaqvs auditis danergvas zogadi praqtikisaTvis
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amcirebs frustracias
moaqvs saWiro cvlilebebi
aumjobesebs efeqtianobas
aumjobesebs efeqturobas
demonstrirebas ukeTebs karg momsaxurebas
pasuxobs pacientis saWiroebebsa da molodins
iwvevs saganmanaTlebli procesis stimulirebas
amkvidrebs ufro maRal standartebs
xels uwyobs finansuri resursebis mozidvas
amcirebs samedicino (organizaciuli da klinikuri) Secdomebis risks
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samedicino auditi

samedicino auditi-es aris meTodi (instrumenti), romelsac iyeneben janmrTelobis profesionalebi
imisaTvis, rom sistematurad Seafason, ganaviTaron da gaaumjobeson pacientisaTvis miwodebuli
samedicino momsaxureba, raTa gaumjobesdes maTi janmrTeloba da sicocxlis xarisxi.

"samedicino auditi-es aris samedicino momsaxurebis xarisxis sistematuri kritikuli analizi".
ZiriTadi SekiTxvebi
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aris Tu ara is, rasac Cven vakeTebT, swori?
ras vakeTebT arasworad?
SegviZlia Tu ara ukeT vakeToT?
ras niSnavs xarisxi pacientisaTvis?
45
Aauditis samuSao CarCo

struqtura-fizikaluri atributika, rogoricaa Senoba, aRWurviloba, pjg-is wevrebis raodenoba da kvalifikacia,
dokumentacia-Canawerebi. mokled, komfortuli garemo, swori aRWurviloba, Sesaferisi adamianebi,
Canawerebisa da organizaciuli sistemebis dizaini-Camoyalibeba da a.S.

procesi-aRwers personalis profesionalur praqtikas, rac warmoadgens moqmedebebisa da gadawyvetilebebis
erTobliobas, asaxavs damokidebulebas, codnasa da unar-Cvevebs, mimarTulia pacientis sasargeblod. droTa
ganmavlobaSi praqtikis moqmedebebSi yalibdeba mag., gasinjvis, rCeva-darigebis, wamlis daniSvnis, referalis,
gamokvlevebis gamoyenebis, gadawyvetilebis miRebis nimuSebi. auditi ikvlevs swored am nimuSebs jandacvis
mniSvnelovan aspeqtebze.

gamosavali-es aris janmrTelobis gansazRvruli indikatorebi. isini aRweren efeqturobas, afaseben sargebels
pacientisaTvis-socialuri funqcionirebis, fsiqologiuri funqcionirebis, fizikuri funqcionirebis, pacientis kmayofilebis
TvalsazrisiT.
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auditis dagegmareba- 10 saxelmZRvanelo wesi (gaidlaini)
1. ganisazRvros problemis buneba
2. naTeli, werilobiTi amocanebis dasma-unda iyos araambiciuri, Sesrulebadi, realuri
(smart)
3. Sesaferisi meTodis SerCeva-roca amocana naTelia da sworadaa dasmuli, meTodic
advilad SeirCeva
4. gadawyvetilebebis SerCeva-gamoiyeneba informaciis retrospeqtuli an prospeqtulad
monacemTa Segrovebis safuZvelze
5.
analizi-gamoiyeneba cxrilebisa da grafikebis Sedgenis, monacemTa dajgufebis, da
sxv. meTodebi
47
auditis dagegmareba- 10 saxelmZRvanelo wesi (gaidlaini)
6. unda ganisazRvros vin unda iyos CarTuli-Sedegebze pasuxismgeblobis gaziarebis
mizniT
7. unda daviwyoT mcirediT, yuradReba unda gamaxvildes ZiriTad aspeqtebze
8. drois Skala unda iyos xanmokle-nabij-nabij mivaRwioT mizans
9. cvlilebebis marTva-mivuTiToT, ra saxis
10. cvlilebebis moxdena SeiZleba realurad
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saWiroebebis Sefaseba da cvlilebebis marTva
unda gvaxsovdes, rom:
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aucilebelia efeqturi cvlilebebis moxdena auditiT gansazRvruli Sedegebis aRmosafxvrelad
regularuli auditireba, monitoringi praqtikis menejmentis gegmis integraluri nawilia
amocanebis dasma, dagegmareba, saimedo informaciis saWiroeba da gunduri muSaoba,
saerToa praqtikis menejmentisa da auditisaTvis
amrigad, erTdroulad, auditis gareSe da swori menejmentis gareSe, sadac auditi
funqcionirebs da misi Sedegebi inergeba, audits Rirebuleba ar gaaCnia.
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Ffaqtebis difuzia
modelebi

rojersi

lomasi

logani&grehemi
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rojersis modeli
inovaciis difuziis siCqaresa da doneze
zegavlenas axdens:
 inovaciis Tvisebebi (maxasiaTeblebi)
 potenciuri mimRebebis (adaptorebis) Tvisebebi
 komunikaciis procesi
 institucionaluri da socialuri kon-teqsti
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inovaciis maxasiaTeblebi

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SedarebiTi upiratesoba_ekonomikuri, araekonomikuri
SeTavsebadoba_SesabamisobaSia arsebul CvevebTan, normebTan,
RirebulebebTan, qselTan
kompleqsuroba-aRqmadoba, sistemuri ganzomileba, urTierTdamokidebulebebi.
kompleqsurobis gansazRvra niSnavs: xarisxobrivad SevafasoT Tu ramdenad
gasagebi da advilad aRsaqmelia dasanergi siaxle
SesaZlebelia Tu ara misi gamocda _demonstrirebadi Sedegebi, "swavla
moqmedebaSi"
SesaZlebelia Tu ara masze dakvirveba_ramdenad TvalsaCinoa sargebeli
52
•
potenciuri adaptorebis maxasiaTeblebi
azrTa liderebi
tradicionalistebi
zantebi
53
lomasis modelebi



pasiuri difuzia
aqtiuri disseminacia
danergva koordinaciis daxmarebiT
54
loganisa da grehemis monacemebi
kvlevis monacemebis praqtikaSi danergvaze
zegavlenas axdens:
a.
praqtikis garemo

struqturuli faqtorebi

pacientebi
b.
potenciuri adaptorebi

midgoma, codna, motivacia

dainteresebuli mxareebi-dainteresebis sxvadasxva done/tipi
g. inovacia

procesi da inovacia

codna, rwmena, gadawyvetileba, danergva, damtkiceba
d. faqtebis mecnieruli garemodan praqtikaSi danergvis strategiebi
55
Kkritikuli Sefaseba
abstraqti
moicavs Tu ara kvlevis ZiriTad aspeqtebs da ramdenad axasiaTebs
mis:



- amocanebs
- dizains
- mniSvnelovan Sedegebs daskvnebs
56
Kkritikuli Sefaseba



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Sesavali
naTladaa Tu ara Camoyalibebuli kvlevis miznebi da amocanebi?
ras Seexeba kvleva?
ramdenad zustia amocanebi?
aris Tu ara kvleva eTikurad misaRebi? (mag. ramdenad gamarTlebuli
SeiZleba iyos potenciurad sasargeblo mkurnalobis Sewyveta sakontrolo
jgufSi)
57
Kkritikuli Sefaseba
kvlevis dizaini
ramdenad gamarTlebulia kvlevis amgvari dizaini?
 SemTxvevis aRwera
 SemTxvevaTa seria
 ganivi kvleva
 kohortuli kvleva
 SemTxveva-kontrolis kvleva
 kontrolirebuli kvlevebi
58
Kkritikuli Sefaseba
kvlevis dizaini: kvlevis nimuSi (amonarCevi)
ramdenad warmomadgenlobiTia (reprezentatiulia) kvlevis nimuSi?



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

nimuSis wyaroebi
amonarCevi Sesaswavli populaciisagan unda iyos warmodgenili
nimuSis Seqmnis meTodi
nimuSis Seqmna randomizaciis principis safuZvelze amcirebs SerCevis Secdomas
SesaZloa misaRebi iyos ararandomizebuli SerCevac
nimuSis zoma-nimuSis zoma sakmarisia statistikurad mniSvnelovani Sedegebis misaRebad
59
Kkritikuli Sefaseba

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monacemebisa da gamosavlebis xarisxi
sarwmunoeba
pirdapiri sazomebi arapirdapirTan SedarebiT
reproduqciuloba
inter&intra damkvirveblis variabeloba
faqtebi principuli monacemebis ganmeorebadobis Taobaze
"brma" principi
ormxrivad brma calmxrivad brmasTan SedarebiT
xarisxis kontrolis sazomebi
60
Kkritikuli Sefaseba
sisrule

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ramdenad asrulebda kvlevis subieqti miTiTebebs
analizi ganzraxuli mkurnalobis mixedviT
kvlevis danakargi
sikvdili eqsperimentulsa da sakontrolo jgufebSi
ar arsebuli an gamotovebuli an dakarguli monacemebi
seleqciuroba angariSgebisas
mxolod dadebiTi Sedegebis dafiqsireba da uaryofiTi gamosavlebis ugulebelyofa
61
Kkritikuli Sefaseba
damazianebeli zemoqmedeba


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
gauTvaliswinebeli mkurnaloba
"dabinZureba"
cvlilebebi droSi
damamaxinjebli faqtorebi
gadaxris koreqciisTvis statistikuri
monacemebis Secvla
62
Kkritikuli Sefaseba
daskvnebi
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
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
ramdenad obieqturadaa axsnili Sedegebi?
warmodgenilia Tu ara racionaluri diskusia Sedegebis Taobaze?
kavSiri Tu SemTxveviToba?
naxsenebia Tu ara klinikuri mniSvneloba?
63
gaidlainebis maxasiaTeblebi

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sarwmuno
xarjT-efeqturi
reproduqciuli
saimedo
warmomadgenlobiTi
klinikurad ganxorcielebadi
klinikurad moqnili
naTeli (gasagebi)
dokumentirebuli
winaswar dagegmili vadebi mimoxilvisTvis
utilizaciis mimoxilva
64