Developing Answerable Developing Answerable Clinical Questions Clinical Questions

Developing Answerable Developing Answerable Clinical Questions Clinical Questions

Clinical Epidemiology and Evidence-based Medicine Unit

FKUI – RSCM

Goals and toolsGoals 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 Medicine1

Evidence-Based Medicine1

• “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”.

• The practice of evidence-based medicine requires integration of individual clinical expertise and patient preferences with the best available external clinical evidence from systematic research.”

EBM ProcessEBM 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)

Clinical ScenarioClinical Scenario• A 2-year-old patient presents with a 12-month

history of recurrent wheezing, cough, dyspnea, and mucopurulent nasal discharge.

• There are no smokers in the household, and all pets have been removed. Antibiotics and antihistamines have been tried without sustained benefit.

• Physical examination demonstrates normal growth and normal vital signs. Thick yellow nasal discharge is noted, and bilateral expiratory wheezes are heard on chest auscultation.

Knowledge Gaps Knowledge Gaps

During this patient encounter, several issues are raised:

• What is the differential diagnosis for this problem?

• Which diagnostic studies would best discover the underlying disorder?

• What is the natural history of children having a chronic cough?

• When is antibiotic therapy indicated?

Knowledge Gaps Knowledge Gaps

• In an underfive with recurrent wheezing, does education reduces the incidence of asthma attack?

Introduction Introduction

• Physicians learn best when learning – is in the context of patient care – answers our questions – directly applicable to our work– does not take too much time.

• Successful physicians lifelong learners developed critical reflection skills.

Curbside ConsultationsCurbside Consultations

• Clinical questions more likely to be answered directly and less likely to require a formal consultation when the question defined clearly both a proposed intervention and a relevant outcome.

• However, only about 40% of questions asked of consultants contained these two components.

What Questions Do Clinicians Ask at the Point of Care?

What Questions Do Clinicians Ask at the Point of Care?

RESEARCH • Physicians reported

– 1 question / 4 patients (½ day)

– 15 questions / 25 patients per day

• Primary care doctors– 2 questions / 3 patient

• Questions relation– 33 % ~ treatment– 25 % ~ diagnosis– 15 % ~ pharmaco -

therapeutics.

• 2/3 clinical questions unanswered.

• Are the unanswered questions important? 50% of the answers direct impact on patient care.

What Questions Do Clinicians Ask at the Point of Care?

What Questions Do Clinicians Ask at the Point of Care?

• Why do we not answer more of these questions? – lack of convenient access to reference materials – time needed to search for information

• Two characteristics that predict whether physicians will seek and find an answer to a clinical question are – the urgency of the problem and – their confidence that they will find an answer

ANSWERABLE CLINICAL QUESTIONSANSWERABLE CLINICAL QUESTIONS

Why do we need to formulate ACQ?

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.

Why do we need to formulate ACQ?

Why do we need to formulate ACQ?

• Stimulate us and excite us, because it will awaken our “curiosity and delight in learning”

• Foster better communication with other practitioners who are familiar with the format for clearly worded questions

• Because vague question can only lead to a vague answer & specific question to specific answer

Characteristics of Good Question

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)

Asking QuestionsAsking Questions

• Questions are usually of 2 types: background or foreground

FOREGROUND

BACKGROUND

NOVICE EXPERT

Background QuestionsBackground Questions

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

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

• Ex: what population is most at risk for hepatitis?

Foreground QuestionsForeground Questions

• Specific to managing patients with a disorder

• Have 4 parts:– Patient or problem - P– Intervention - I– Comparison of intervention - C– Outcomes - O

The components: PThe components: P

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

• e.g chronic recurrent cystitis

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

– particular groups of people• e.g. sexually active young women?• the elderly?• children?

• How would you describe your clients / setting?

The components: IThe components: I

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

specific detail / consideration to the description…

• What exactly am I considering…?

The components:CThe components:C

• The comparison or alternative (not applicable to all questions) e.g.– Anti-biotic therapy?– Nothing?– Fluids alone?

• What alternatives actions might I try?

The components:OThe components:O

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

• What am I hoping to accomplish (what outcomes might reasonably be affected…)?

The 4 part clinical questionThe 4 part clinical question

1. “Population”

2. “Intervention”

3. “Comparison”

4. “Outcome”

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

Relevance: POEs and DOEs

Relevance: POEs and DOEs

• DOE = Disease oriented evidence– “Ologies” (path-, etiol-, pathophys-)– ie Med school

• POE = Patient oriented evidence– Morbidity, mortality or quality of life– Something a patient would care about without

explanation– Highest quality evidence

Comparing DOEs and POEs2

Comparing DOEs and POEs2

Examples Disease-Oriented Evidence

Patient-Oriented Evidence that

Matters Comment

Antiarrhythmic Therapy, HRT

Drug X PVCs on ECG

Drug X increases mortality

POEM study contradicts DOE study

Anti-HTN therapy

Antihypertensive therapy BP

Antihypertensive therapy mortality

POEM agrees with DOE

Prostate Screening

PSA screening detects prostate cancer early

? whether PSA screening mortality

DOE exists, but the POEM is unknown

POEMsPOEMs

• Patient Oriented Evidence that Matters

• Matters because if it is true,it requires you to change your practice

• (Also a review of an article written and published in a specified format = secondary literature)

Learn to Ask a Focused Clinical Question

Learn to Ask a Focused Clinical Question

• “What test should I order for this 28-year-old woman with chest pain?”.

• “What is the best test to rule out myocardial infarction in this person with chest pain and a low likelihood of disease?”

Good ACQ?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?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?

TreatmentTreatment

Patient / Problem / Population

Intervention Comparison Outcome

In a child with frequent febrile seizures

would anticonvulsant therapy

compared to no treatment

result in seizure reduction?

DiagnosisDiagnosis

Patient / Problem / Population

Intervention Comparison Outcome

In an otherwise healthy 7-year-old boy with sore throat

how does the clinical exam

compare to throat culture

in diagnosing GAS infection?

PrognosisPrognosis

Patient / Problem / Population

Intervention Comparison Outcome

In children with Down syndrome,

is IQ an important prognostic factor

- in predicting Alzheimer’s later in life?

Etiology / Harm Etiology / Harm

Patient / Problem / Population

Intervention Comparison Outcome

controlling for confounding factors, do otherwise healthy children

exposed in utero to cocaine,

compared to children not exposed

have increased incidence of learning disabilities at age six years?

My 1 yr old just had a febrile seizure - what will happen to

her?

• Patient: In children 6mo-6yrs who have had

• Exposure: a first febrile seizure, what is

• Outcome: the likelihood of recurrent febrile seizures; epilepsy; neurologic damage?

This patient has elevated blood pressure - should I

start ACE inhibitors?

• Patient: In middle aged men with diastolic BP>90%ile for age

• Intervention: would diuretics or ACE inhibitors be best to

• Outcome: prevent heart disease; stroke; end-organ damage?

My dad is 70 years old - should his doctor order a PSA?

• Patient: In asymptomatic older men

• Intervention: does PSA testing

• Outcome: lower the morbidity or mortality of prostate cancer?

How do you choose which

question to answer?

How do you choose which

question 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

THANK YOUTHANK YOU

ANY QUESTIONS?ANY QUESTIONS?

Learn to Ask a Focused Clinical Question - Foreground

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?”

PICO & Applicability 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 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 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 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

CLINICAL EXPERTISECLINICAL EXPERTISE

PAST CLINICAL EXPERIENCE

NEW CLINICAL (EBM PARADIGM) EXPERIENCE

Formal Education

Clinical Skills

BACKGROUND FOREGROUND

Medical School

CME

Medical School

Practice

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EBP in ActionEBP 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)].