Developing Answerable Clinical Developing Answerable Clinical Questions Questions

DINI WIDIARNI Clinical Epidemiology and

Evidence-based Medicine UnitFKUI – RSCM

Goals and tools

At the end of this module, you will:• Appreciate the importance of clinical

questions in keeping up-to-date • Be able to create a well-formed

clinical question

Evidence-based medicine evidence-based practice

• the process of systematically finding, appraising and using the best available research findings, integrated with clinical expertise, as the basis for clinical decisions about individual patients.”

• Black's Medical Dictionary, 41st Edition (2006)

EBM Process

Patient Encounter

Patient Encounter

Formulating theClinical QuestionFormulating the

Clinical Question

Searching theEvidence

Searching theEvidence

Appraising theEvidence

Appraising theEvidence

Diagnosis TherapyPrognosisEtiology

Diagnosis TherapyPrognosisEtiology

•Patient•Intervention•Comparison•Outcome

•Patient•Intervention•Comparison•Outcome

•Hierarchy of evidence•Pre appraised resources

•Hierarchy of evidence•Pre appraised resources

Drawing conclusionThat impact on practice•DOES•POEM

Drawing conclusionThat impact on practice•DOES•POEM

(Lang, 2000)(Lang, 2000)

Why do we need to formulate ACQ?

• it will awaken our “curiosity and delight in learning”

• Better communication with other practitioners who are familiar with the format for clearly questions

• Specific question to specific answer

Characteristics of Good Question

• “First, the question should be directly relevant to the problem at hand. Next the question should be phrased to facilitate searching for a precise answer. To achieve these aims, the question must be focused and well articulated.”

(Richardson et al, 1995)

• One of the benefits of careful and thoughtful question-forming is that the search for evidence is easier.

• The well-formed question makes it relatively straightforward to elicit and combine the appropriate terms needed to represent your need for information in the query language of whichever searching service is available to you.

• Once you have formed the question using the PICO structure, you can think about what type of question it is you are asking, and therefore what type of research would provide the best answer.

Formulating a Well Built Clinical Question

Centre for Evidence Based Medicine (CEBM), "one of the fundamental skills required for practising EBM is the asking of well-built clinical questions. To benefit patients and clinicians questions need to be both directly relevant to patients' problems and relevant precise answers."

.Why do we need to formulate ACQ?

• Essential to improving practice, because if we never pose questions about what we are doing we can never change what we are doing on a rational basis.

• Save us time during an electronic search for the answer.

• Essential to the process of lifelong learning that will continually improve our ability to serve clients.

Asking Questions

• Questions are usually of 2 types: background or foreground

FOREGROUND

BACKGROUND

A. student C.EXPERT/ consultant

B Experience with condition

CLINICAL EXPERTISE

PAST CLINICAL EXPERIENCE

NEW CLINICAL (EBM PARADIGM) EXPERIENCE

Formal Education

Clinical Skills

BACKGROUND FOREGROUND

Medical School

CME

Medical School

Practice

Ro

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Patien

t Interven

tion C

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pariso

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Background Questions

• General or background knowledge about the disease, condition (anatomy, physiology, pathophysiology, diagnosis, treatment, prognosis, or basic management)

• Have 2 parts:– First: Question root– who, what, where, when, why, how– Second: disorder, condition, therapy, etc. aspect of itnteres

• Ex: How does URTI cause otitis media or laringitis ( LPR) • what population is most at risk for hepatitis?• How does heart failure cause pleural effusion

Foreground question

• A well-built clinical foreground question should have 4 components.

• The PICO model is a helpful tool that assists you in organizing and focusing your foreground question into a searchable query.

• Dividing into the PICO elements helps identify search terms/concepts to use in your search of the literature.

Foreground Questions

• Specific to managing patients with a disorder• Have 4 parts:

– Patient, population or problem (P)– Intervention, exposure, test ( I)– Comparison of intervention,exposure,test ©– Outcomes of clinical importance including time

when relevant ( O )

• In adult sinusitis would nasal irigation and medication would reduce immediately the nasal symptom compare to medication without nasal irigation

• In Dengue Hemorrhagic Fever patients does guava juice increase the platelet count when compared to no treatment”

•

The components: P

• Think about who / what you wish to apply this evidence to… e.g.– People with a particular disorder?

• e.g chronic sinusitis

• People in a particular care setting?• e.g. community

– particular groups of people• The adult?• children?

• How would you describe your clients / setting?

The components: I

• The intervention / topic of interest (e.g. cause, change in practice etc.) e.g.– surgery– Might want to specify how much / how often– For complex interventions may need to give

specific detail / consideration to the description…

The components: I

The components:C

• The comparison or alternative (not applicable to all questions) e.g.– Nacl with Anti-biotic therapy?– Only antibiotic therapy

The components:O

• The outcome… e.g.– Cure– Duration of disease– prevention– complication– Side effects– Pain (reduced)– Wellbeing

Type of Clinical Question and Study Design

Important elements of the well-built clinical question

• Two additional important elements of the well-built clinical question to consider are

• the type of foreground question • the type of study (methodology). • This information can be helpful in focusing the

question and determining the most appropriate type of evidence.

• Knowing the type of foreground question can help you select the best study design to answer the question.

• Always want to look for the study design that will yield the highest level of evidence.

• Consult the pyramid

Learn to Ask a Focused Clinical Question - Foreground

Patient Problem / Population

Description of the group to which your patient belongs, (age, gender, race, ethnicity, and stage of disease). The description should be specific enough to be helpful, but not overly specific.

Intervention

Be specific!

description of the test or treatment that you are considering

“what you plan to do for that patient “

Comparison the alternative. Not all questions need a comparison,

“the main alternative you are considering”

Outcome

Be specific!

something that not only matters to you, but matters to the patient. Be specific!

“what is the main concern?”

• Therapy

• Questions of treatment in order to achieve some outcome.

• drugs, surgical intervention, change in diet, counseling, etc..

• Diagnosis: Questions of identification of a disorder in a patient presenting with specific symptoms.

• Prognosis: Questions of progression of a disease or likelihood of a disease occurring.

• Etiology/Harm: Questions of negative impact from an intervention or other exposure

Good ACQ?

• Is Amoxicillin an effective treatment for children with otitis media?

• Does the treatment with antibiotics result in more rapid improvement of otitis media than no treatment?

• Does Amoxicillin work better for otitis media than placebo in children who are in daycare?

Good ACQ?

• Is there something more effective than albuterol in reducing length of hospital stay in children with asthma?

• In children with acute asthma, does the addition of atrovent to standard therapy with albuterol decrease the rate of hospitalization?

Treatment

Patient / Problem / Population

Intervention Comparison Outcome

In a child with frequent febrile seizures

anticonvulsant therapy

no treatment

seizure reduction?

Diagnosis

Patient / Problem / Population

Intervention Comparison Outcome

7-year-old boy with sore throat

how does the clinical exam compare to

throat culture

In diagnosing Group A streptococus infection?

Prognosis

Patient / Problem / Population

Intervention Comparison Outcome

In children with Down syndrome,

Is IQ an important prognostic factor

Chrom, gene

in predicting Alzheimer’s later in life?

Etiology / Harm

Patient / Problem / Population

Intervention Comparison Outcome

controlling for confounding factors, do otherwise healthy children

exposed in utero to cocaine, vit A

compared to children not exposed

have increased incidence of congenital ear deformity and hearing loss

How do you choose whichquestion to answer?

How do you choose whichquestion to answer?

• Most important to patient’s well-being

• Most feasible to answer in time available

• Most interesting to you

• Most likely to encounter repeatedly in practice

PICO & Applicability

Patient Problem / Population

Is my patient similar enough to the patients in the study that the evidence can be applied? Would my patient have met the study's inclusion criteria? A valid study may not be applicable to your patient if your patientdiffers in important ways from the study patients. .

Alan Schwartz

PICO & Applicability

Intervention Could the intervention in the study be carried out in my setting, and in a way that is similar enough to the way it was conducted in the study? A valid study may not be applicable to your patient if the study intervention is impractical, too costly, requires skills, equipment, or medications that are not locally available, etc

Alan Schwartz

PICO & Applicability

Comparison Is the comparison in the study similar to the standard of care (or for a diagnostic test study, the gold standard) in my setting? A valid study may not be applicable to your patient if you are already using a better standard of care (or for a diagnostic test study, you have a better gold standard) than that to which the study intervention is compared. Alan Schwartz

PICO & Applicability

Outcome Are the outcomes measured in the study similar enough to those that are relevant and important in my setting or to my patient? A valid study may not be applicable to your patient if it reports outcomes that can not be measured practically in your setting, or that are unimportant to your patient

Alan Schwartz

EBP in Action

“It is harder to ask the right questions than to find answers for the wrong questions.” [Chinese Fortune Cookie (The Orient Express, Dayton, OH, 2002)].

THANK YOU