MmtkicebiTi medicinis zogadi

principebi meanobasa da
ginekologiaSi
 Pprezentaciis damTavrebisas studentma unda
icodes:
• Oorsulobisa da mSobiarobis marTvis ZiriTadi
principebi

• Mmtkicebuleebze dafuZnebuli meanoba,

meTodebi da midgomebi

• Ggaidlainebi da protokolebi
 Pprezentaciis damTavrebisas studentma unda
SesZlos:
• ganvsazRvros mcneba-”mtkicebiTi medicina”
• axsnas mtkicebiTi medicinis mniSvneloba
• daaxasiaTos mtkicebiTi medicinis
komponentebi
 OusafrTxo orsuloba-safuZvlebi

• orsulobisa da mSobiarobis marTva erTian midgomas

moiTxovs
• orsuloba da mSobiaroba mniSvnelovani personaluri,ojaxuri da
socialuri movlenaa
• mSobiarobisa da orsulobis bunebriv procesSi CarevisaTvis
unda arsebobdes mniSvnelovani Cveneba
• orsulis, dedisa da axalSobilisaTvis samedicino Careva unda
iyos misawvdomi,saWiro da usafrTxo
 usafrTxo orsuloba-principebi

safuZvlebis gaTvaliswinebiT,orsuloba da mSobiaroba

qalisaTvis unda iyos:
• uzrunvelyofili GarCevanis gakeTeba qalis gadawyvetilebis
safuZvelze
• ojaxze orientirebuli,pativi vceT qalis
privatulobas,konfidencialobas,Rirsebas
• Seesabamebodes qalis kulturul da religiur tradiciebs
• emyarebodes mecnierul mtkicebulebebs da iyos ekonomiurad
momgebiani
• emyarebodes efeqturi teqnologiebis gamoyenebas, unda iyos
regionalizirebuli da mravalprofiliani
 rogor vRebulobT gadawyvetilebas?

• ra saxis mtkicebulebebs emyareba eqimebis

mier miRebuli gadawyvetilebebi?
• rogor xdeba am mtkicebulebebis moZieba?
• rogori kvlevebis Sedegad miiReba maRali
xarisxis mtkicebulebebi?
 marTebulia Tu ara Cveni qmedeba?
• samedicino praqtikaSi gamoyenebuli
tqnologiebis umravlesobas ar gaaCnia
efeqturobis sakmarisi mtkicebuleba
• efuZneba individualur klinikur gamocdilebas
• Aar pasuxobs pacientis moTxovnebs
 marTebulia Tu ara Cveni qmedeba

• samedicini CarevaTa mxolod 15% emyareba

sarwmuno samecniero mtkicebulebebs
 rodis gaCnda mtkicebiTi medicina ?
• 1940 weli-pirveli randomizirebuli kvleva
• 1960 weli-talidomidis procesi
• 1971 wels pirvelad arCi koxranma wamoayena mosazreba
mecnieruli mtkicebulebebis simciris Sesaxeb
• 1974 wels aRmoCenil iqna Seusabamoba Teoriasa da
praqtikas Soris
• 1980-90 wlebSi sistemuri mimoxilvis Sedegebis Setana
klinikur saxelmZRvaneloebSi aucilebeli gaxda
 ra aris mtkicebiTi medicina?

• individualuri pacientisaTvis samedicino

daxmarebis gadawyvetilebis miRebis procesSi
axali, saukeTeso mtkicebulebebis gaazrebuli,
zusti, gonieri gamoyeneba
 ra aris mtkicebiTi medicina?
• axali mtkicebuleba uvargiss xdis adre miRebul
diagnostikur testebsa da mkurnalobis
meTodebs da cvlis maT axlebiT- ufro mZlavri,
zusti, efeqturi da usafrTxo testebiTa da
meTodebiT
 ra aris mtkicebiTi medicina?
• mtkicebulebiTi medicinis praqtika gulisxmobs
individualuri klinikuri gamocdilebis
gaerTianebas sistemuri kvlevebis Sedegad
miRebul saukeTeso, misawvdom,
dasabuTebul mtkicebulebebTan
 ra aris mtkicebiTi medicina?

• mtkicebiTi medicina-es aris saukeTeso mecnieruli mtkicebulebebis

integracia klinikur gamocdilebasa da pacientis moTxovnebTan.

mecnieruli monacemebiKklinikui gamocdileba

Ppacientis moTxovnebi
 mtkicebulebebze dafuZnebuli medicina definicia

• “klinikuri gadawyvetilebis safuZvlad

sistematuri Zebnis, Sefasebis procesisa da
Tanamedrove kvlevis Sedegebis gamoyeneba”

MeSH - National Library of Medicine

 daskvna
• Mmtkicebulebebze dafuZnebuli medicina, Tu is sworad aris
gagebuli da gamoyenebuli uzrunvelyofs Tavisufali
gadawyvetilebis miRebas
• Tu xelmZRvanelebi da eqimebi sworad gamoiyeneben mm-is
principebs da muSaoben rogorc erTi gundi, maSin mm
mniSvnelovan gavlenas axdens samedicino daxmarebis
xarisxze
rogor davamtkicoT Carevis efeqturoba da usafrTxoeba

• maRali xarisxis klinikuri kvlevis Catareba

1)randomizirebuli kontrolirebadi kvleva
2)randomizirebuli kontrolirebadi kvlevis
sistemuri analizi
 randomizirebuli kontolirebadi kvleva

axali mkurnaloba

1jgufi gamosavali

mosaxleoba

2jgufi gamosavali

mkurnaloba
State University of New York, USA, 2002
 randomizacia
• procedura, romelic uzrunvelyofs avadmyofTa
SemTxveviT gadanawilebas eqsperimentul da
sakontrolo jgufebSi

SeTxveviTi gadanawilebiT miiRweva:

• jgufebs Soris sxvaobebis ar arseboba
• sistematur SecdomaTa albaTobis Semcireba
 randomizirebuli kontolirebadi kvleva

• eqsperimentuli jgufi - jgufi, romelSic tardeba

sakvlevi Careva (mkurnaloba)
• sakontrolo jgufi – sacdeli jgufi, romelsac
mkurnaloba saerTod ar utardeba an utardeba
Cveulebrivi an placebo mkurnaloba
 Bbrma meTodi
• brma meTodi-informaciis ar qona imis
Sesaxeb, Tu romel jgufs, eqsperimentuls Tu
sakontrolos ekuTvnis kvlevaSi monawile
konkretuli piri
• gamoiyeneba klinikuri kvlevebis dros
sistematuri Secdomis Tavidan acilebis
mizniT
 Bbrma meTodi
B brma kvlevis variantebi
• ubralo-informacia ar aqvs mxolod pacients
• ormagi- informacia ar aqvs pacients da
mkvlevars
• sammagi-informacia ar aqva pacients,
mkvlevars da masalis statistikur
damuSavebaSi monawile pirebs
 Mmeta-analizi da sistemuri mimoxilva

samecniero kvlevebi

1 2 3 4

Mmeta-analizi

kombinirebuli rezultatebi

State University of New York, USA, 2002

 sistemuri kvleva
• Temis yovelmxrivi ganxilva, romelSic
Sejamebuli da Sefasebulia am Temaze aqamde
Sesrulebuli yvelaze maRali xarisxis kvlevebi
(ZiriTadad rkk ), romelic iqna moZiebuli
 Mmeta-analizi
• erTi da igive Carevis ramdenime klinikuri kvlevis
gaerTianebuli Sedegebis raodenobrivi analizi
• mimoxilva, romelSic yvela kvlevis Sedegi gaerTianebuli da
gaanalizebulia, rogorc erTi mTeli

Ggamoiyeneba:
• mravali klinikuri kvlevis Sedegebis ganzogadoebuli
warmodgenisaTvis
• kvlevaTa Sedegebis mtkicebiTi Rirebulebis gazrdisaTvis
• kvlevis statistikuri simZlavris gazrdisaTvis
miokardis infarqtis trombolituri mkurnalobis efeqturobis Sefaseba

State University of New York, USA, 2002

 SansTa Tanafardoba (odds ratio)

• erT jgufSi movlenis ganviTarebis Sansis

fardoba meore jgufSi mis SansTan
• movlenis ganviTarebis Sansis fardoba
SansTan, rom igi ar ganviTardeba
 sarwmunoebis intervali
• statistikuri maCvenebelia, romelic saSualebas
gvaZlevs SevafasoT Tu ra farglebSi Zevs
mocemuli parametris WeSmariti mniSvneloba
populaciaSi
• WeSarit mniSvnelobaTa meryeobis diapazoni
• gamoxatavs monacemTa damtkicebulobis
xarisxs
 mtkicebiTi medicinis xuTi etapi
• dasviT mkafio klinikuri SekiTxva ,romelzec gsurT pasuxis
miReba
• kiTxvaze pasuxis gasacemad moiZieT uaxlesi saukeTeso
mtkicebuleba
• kritikulad SeafaseT moZiebuli Mmtkicebulebis gamoyenebis
dasabuTeba
• moxdineT mtkicebulebis integrireba pacientis interesebTan,
konkretul garemoebebTan da klinikur gamocdilebasTan
• SeafaseT,SesaZlebeli iqneba Tu ara aRniSuli teqnologiis
danergva
 Aarsebuli praqtikebis Sefaseba

• ras vakeTeb?
• ratom vakeTeb?
• mivaRwev amiT mizans?
• arsebobs Tu ara sxva,ufro ukeTesi an ufro
misaRebi gza am miznis misaRwevad?
 rogor moviZioT tkicebulebebi

• srulyofili informaciis mopovebis mizniT

dReSi saWiroa 17 statiis wakiTxva, weliwadSi
-6200statiis
 Aantmanis modificirebuli cxrili

1 – Рутинное применение 3 – Экспериментальное применение

2 – Применение в особых случаях 4 – Не упоминается
Antman EM, et al., 1992
 rogor moviZioT mtkicebulebebi

• samedicino Jurnalebi da internet-resursebi

• mtkicebulebiTi medicinis monacemebis safuZvelze sxva
specialistebis mier Sedgenili daskvnebi (mag.Kkoxranis
biblioTeka,enkinis wigni,mjo-is baza da sxv)
• mtkicebiTi medicinis safuZvelze momzadebuli mza
protokolebi
• unda flobdeT literaturis moZiebis efeqtur saSualebebs
• unda erkveodeT sxvadasxva dizainis kvlevebSi
Pyramid of evidence
Систематический Оценка
обзор, мета анализ качества
РКИ

РКИ Quality
rating

Evidence Graded
Когортные, Quality recommend-
tables
случай контроль rating ations
Considered
judgement
Не –
экспериментальные
исследования

Мнение экспертов
 MmtkicebulebaTa WeSmariteba

rekomendaciis WeSmaritebis
WeSmariteba done
RonisZieba

1a rkk sistemuri mimoxilva

A rkk
1b
2a Kkohortuli kvlevis sistemuri
mimoxlva
2b Kkohortuli gamokvleva
B 3a “SemTxveva –kontrolis” sistemuri
mimoxilva
3b Ggamokvleva-”SemTxveva-kontroli”

4 SemTxvevaTa seria
C
Guyatt GH et al., 1995
5 eqspertTa azri
 sinapturi cxrilebi
• cxrili1 – movlis sasargeblo formebi,
mtkicebulebis xarisxi A
• cxrili 2 – meTodebi,romelic savaraudod efeqturia, mtkicebulebis
xarisxi B da C
• cxrili3 – meTodebi,romelsac gaaCniaT rogorc dadebiTi,aseve
uaryofiTi zemoqmedeba, mtkicebulebis done A-C
• cxrili 4 – meTodebi,romelTa efeqtuoba ucnobia
• cxrili 5 –meTodebi,romelTa efeqturoba naklebad
savaraudoa,evidensis done B daC
• cxrili 6-meTodebi,romelnic savaraudod aris araefeqturi an
mavne,mtkicebulebis done A
 ra aris klinikuri gaidlaini?

“sistematurad ganviTarebadi
mtkicebulebebi,formulirebi praqtikosebisa da
pacientebisaTvis specifiur klinikur situaciaSi
Sesabamisi gadawyvetilebis miRebaSi
dasxmareblad”

Field & Lohr. Clinical practice guidelines: directions for a new program. 1990
 ratom klinikuri gaidlainebi?

• jan-dacvaSi gamosayenebeli
• informaciis momcveli
• infrmaciis da gadawyvetilebis miRebis erTianoba
• MmarTvis riskis Semcireba
• efeqturoba
 http://www.ncbi.nlm.nih.gov/pubmed/

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http://www.who.int/rhl/en/
 ra ar aris mtkicebiTi medicina?

• Mmtkicebulebebze dafuZnebuli medicina ar

aris cook-book medicina

• Mmtkicebulebebze dafuZnebuli medicina ar

aris cost-cutting medicina
 Pproblemebi danergvaSi
• 1601 wels kapitanma lankasterma daamtkica, rom limonis
wveni suravandis profilaqtikuri saSualebaa
I46 wlis Semdeg
• 1747 wels didi britaneTis sazRvao floti imeorebs lankasteris
Sedegebs
48wlis Semdeg
• 1795 wels britaneTis floti gadawyvets limonis wvenis
micemas mezRvaurebisaTvis
70 wlis Semdeg
• 1865 wels floti
 Bbarierebi mtkicebiTi
medicinisaTvis

Dr. Ivan Lejnev, 2005

 M mgznebarebaze dafuZnebuli medicina

• Mmoridebul kolegebze
Vehemence based medicine

gasamarjveblad da avadmyofisa da
misi axlblebisdasarwmuneblad
mtkicebulebebis Secvla
moculobiT Zalzed efeqturi
saSualebaa
 mWermetyvelebaze dafuZnebuli medicina
Eloquence based medicine

• moduri tansacmeli da
mWermetyveleba
mtkicebulebebis mZlavr
iSemcvlelia
 bedisweraze dafuZnebuli medicina

• roca eqimma ar icis rogor imoqmedos

SemdgomSi,saukeTeso gamosavali iqneba
Providence based medicine

uflisaTvis gadawyvetilebis mindoba.

 Mmeryeobaze dafuZnebuli medicina

• zogierTi eqimi xedavs problemas da eZiebs

pasuxs,zogierTi xedavs mxolod problemas,
urwmuno eqimi romelic gamouvalobis grZnobiTaa
Diffidence based medicine

Sepyrobli arafers ar akeTebs. garkveulwilad es

saqcieli sjobs reputaciis SenarCunebis mizniT
ganxorcielebul qmedebas.
 Nnervozulobaze dafuZnebuli medicina

• sasamarTlo garCevebis SiSis arseboba zedmeti

analizebisa da arasaWiro mkurnalobis Zlier
Nervousness based medicine

stimuls warmoadgens.
 uryev rwmenaze dafuZnebuli medicina

• Ees mxolod qirurgebisaTvis

Confidence based medicine
 problemebi klinikuri swavlebis kursSi mtkicebiTi
medicinis danergvaSi

• mtkicebiTi medicinis koncefcia ar aris

srulyofilad aTvisebuli
• SezRudulia internetiT sargebloba
• enobrivi barierebi qmnis problemebs
• kvalificiur pedagogTa nakleboba