Developing Answerable

Clinical Questions
DINI WIDIARNI
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 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
Drawing
Drawingconclusion
conclusion
That
Thatimpact
impacton
onpractice
practice
DOES
DOES
POEM
POEM

Patient
Encounter

Formulating the
Clinical Question

Appraising the
Evidence

Hierarchy
Hierarchyofofevidence
evidence
Pre
Preappraised
appraisedresources
resources

Diagnosis
Diagnosis
Therapy
Therapy
Prognosis
Prognosis
Etiology
Etiology

Searching the
Evidence

Patient
Patient
Intervention
Intervention
Comparison
Comparison
Outcome
Outcome

(Lang,
(Lang,2000)
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/ consu
B
Experience with condition

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

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

description of the test or treatment that you are

considering

Be specific!

what you plan to do for that patient

Comparison

the alternative. Not all questions need a comparison,

Outcome

something that not only matters to you, but matters to

the patient. Be specific!

Be specific!

the

main alternative you are considering

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?
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

In a child with
frequent febrile
seizures

Intervention

Comparison Outcome

anticonvulsant
therapy

no treatment

seizure
reduction?

Diagnosis
Patient /
Problem /
Population

Intervention
how does the
clinical exam

7-year-old boy
with sore throat

Comparison Outcome

compare to
throat culture

In diagnosing
Group A
streptococus
infection?

Prognosis

Patient /
Problem /
Population
In children with
Down
syndrome,

Intervention
Is IQ an
important
prognostic
factor

Comparison Outcome
Chrom, gene

in predicting
Alzheimers later
in life?

Etiology / Harm
Patient /
Problem /
Population
controlling for
confounding
factors, do
otherwise
healthy children

Intervention

Comparison Outcome

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 which

question to answer?
Most important to patients wellbeing

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 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

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