Transcript Asking clinical questions

Developing Answerable
Clinical Questions
Clinical Epidemiology and
Evidence-based Medicine Unit
FKUI – 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 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 Process
Drawing conclusion
That impact on practice
•DOES
•POEM
Patient
Encounter
Formulating the
Clinical Question
Appraising the
Evidence
•Hierarchy of evidence
•Pre appraised resources
Diagnosis
Therapy
Prognosis
Etiology
Searching the
Evidence
•Patient
•Intervention
•Comparison
•Outcome
(Lang, 2000)
Clinical 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
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
• In an underfive with recurrent wheezing,
does education reduces the incidence of
asthma attack?
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 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?
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?
• 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 QUESTIONS
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?
• 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
• “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 Questions
• Questions are usually of 2 types:
background or foreground
FOREGROUND
BACKGROUND
NOVICE
EXPERT
Background 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 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: 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: 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: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: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 question
1.
2.
3.
4.
•
“Population”
“Intervention”
“Comparison”
“Outcome”
“In Dengue Hemorrhagic Fever
patients does guava juice increase the
platelet count when compared to no
treatment”
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
2
DOEs and POEs
Examples
DiseaseOriented
Evidence
Patient-Oriented
Evidence that
Matters
Comment
Drug X  PVCs on Drug X increases
mortality
ECG
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
DOE exists, but
? whether PSA
the POEM is
screening  mortality
unknown
Antiarrhythmic
Therapy, HRT
POEMs
• 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
• “What test should I order for this 28-yearold 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?
• Does the treatment with antibiotics result in more
rapid improvement of otitis media than no
treatment?
• Is Amoxicillin an effective treatment for children
with otitis media?
• 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
would
anticonvulsant
therapy
compared to no
treatment
result in seizure
reduction?
Diagnosis
Patient /
Problem /
Population
In an otherwise
healthy 7-yearold boy with
sore throat
Intervention
Comparison Outcome
how does the
clinical exam
compare to
throat culture
in diagnosing
GAS infection?
Prognosis
Patient /
Problem /
Population
In children with
Down
syndrome,
Intervention
is IQ an
important
prognostic
factor
Comparison Outcome
-
in predicting
Alzheimer’s
later in life?
Etiology / Harm
Patient /
Problem /
Population
controlling for
confounding
factors, do
otherwise
healthy children
Intervention
Comparison Outcome
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?
• 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 YOU
ANY QUESTIONS?
Learn to Ask a Focused Clinical
Question - Foreground
Patient
Problem /
Population
Intervention
Be specific!
Comparison
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.
description of the test or treatment that you are
considering
“what you plan to do for that patient “
the alternative. Not all questions need a comparison,
“the
Outcome
Be specific!
main alternative you are considering”
something that not only matters to you, but matters to
the patient. Be specific!
“what is the main concern?”
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 patient
differs 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
CLINICAL EXPERTISE
PAST CLINICAL
EXPERIENCE
Formal
Education
Clinical
Skills
Outcome
Comparison
Intervention
Practice
FOREGROUND
Patient
CME
Disorder
Medical
School
BACKGROUND
Roots
Medical
School
NEW CLINICAL (EBM
PARADIGM) EXPERIENCE
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)].