Formulating clinical questions

BACKGROUND QUESTION

CLINICAL SCENARIO
CREATE RELEVANT QUESTION
USING FOREGROUND QUESTION
THERAPY
DIAGNOSIS
PROGNOSIS
HARM
ETIOLOGY
PREVENTION
 Different aspects of clinical questions

Etiology – how to identify causes for disease

Differential diagnosis – how to rank possible
causes by likelihood, seriousness & treatability
Diagnostic tests – how to select and interpret
diagnostic tests (either to rule in or rule out), need
to consider accuracy, precision, acceptability,
expense, safety etc
Prognosis – how to estimate patient’s likely
clinical course and complications over time

Therapy – how to select treatments that do

more good than harm and are worth efforts
& costs

Prevention/screening – how to identify &

modify risk factors for disease/diagnose
disease early
 A 2-month-old infant with large VSD
 Birth weight 3.1 kg
 BW 3.8 kg, HR=132, RR 68
 Retractions (+)
 Systolic murmur, gallop rhythm
 Hepatomegaly
 Dx: Large VSD, CHF, FTT
 Definite Rx: early surgery
 Alternative Rx: Drugs first?
 BACKGROUND QUESTION

 1. GENERAL KNOWLEDGE OF
DISORDER
 2.ROOT QUESTION:
WHO,WHAT,WHERE,WHEN,HOW,
WHY
 3.DISORDER OR ASPECT DISORDER
 (Background question)

 What is VSD?
 How to Dx?
 What are symptoms & signs of
CHF in infants with L-R shunt?
 What is the treatment?
 FOREGROUND QUESTION

 1. PATIENT AND/OR PROBLEM

 2. INTERVENTION
 3. COMPARISON INTERVENTION ( IF
RELEVANT)
 4. OUTCOME
 (Foreground question)

 In infants with large VSD and CHF,

would administration of digoxin or other
inotropic agent delay the need for
surgery?
 Other example

 In neonates born to mothers with

history of herpes simplex infection,
does the administration of IVIG
(intravenous immunoglobulin) reduce
the possibility of neonatal herpes?
 Four elements
of
good clinical question
PICO
 The Patient or Problem
 The Intervention
 Comparative intervention (if relevant)
 The Outcome
 Question for Diagnosis
A 11 year-old girl was evaluated for thyroid solitary
nodule. She has been complaining of pain on
palpation; other physical findings were negative.
Thyroid function showed normal results. The
physician was thinking about screening with
ultrasound.
P: In young women with solitary thyroid nodule
and normal thyroid function,
I: what is the likelihood of ultrasound
C: -
O: in excluding malignancy?
 Harm
A 15-month-old infant was brought for MMR
vaccination. The mother inform that her daughter is
very allergic to egg. Knowing that all MMR vaccine
contain small amount of egg protein ovalbumin,

Question formulation

P: In patients allergic to egg,

I: does administration of MMR vaccine
O: cause significant allergic reaction?
Four elements of a well constructed clinical question
PICO

P I C O

How would I Which main What is the What can I

describe a intervention alternative hope
group of am I to compare from this
patients considering? with the intervention?
like mine? intervention?
B e b r i e f a n d s p e c i f i c
 Example 1:

 Female, 28 years, known to have SLE,

shortness of breath on exertion, swollen
ankles at end of day
 Previous pericardial effusion, uncomplicated
MI, taking ibuprofen for painful knees
 No chest pain, fever, cough or sputum
 BP 145/85 mmHg, HR regular 88 bpm
 Elevated neck veins, fluid in lungs & third
heart sound but no murmurs
 Etiology

P I C O

In young ..does giving …compared …lead to

female with ibuprofen with no increased
SLE & history ibuprofen likelihood of
of cardiac heart failure?
involvement
 Differential diagnosis

P I C O

In SLE ….with pre- ….and taking ….which one

patients existing and taking Is more likely
with new Cardiac NSAID explanation?
onset Involvement
heart failure
 Prognosis

P I C O

In young …does ….compared …lead to

female dev’ment of with no heart increased
SLE heart failure failure mortality?
 Therapy

P I C O

In SLE …would …versus …alleviate

patient on removal of NSAID heart
ibuprofen NSAID removal plus failure?
with and diuretic plus
heart addition ACE inhibitor
failure of diuretic…
 Prevention

P I C O

In SLE ….…would …compared …prevent

patients long-term with no recurrence
with ACE ACE & improve
heart failure inhibitor inhibitor quality
Inhibitor of life
 Example

Female, 73 years, shortness of breath on

exertion, swollen ankles at end of day
previous uncomplicated MI, no beta-
blockers, taking ibuprofen for painful knees
no chest pain, fever, cough or sputum
BP 145/85mmHg, HR regular 88 bpm
elevated neck veins, fluid in lungs & third
heart sound but no murmurs
 Etiology

P I C O

In elderly ..does giving …compared …lead to

female with ibuprofen with no increased
CHD … ibuprofen likelihood of
heart failure?
 Prognosis

P I C O

In elderly …does ….compared …lead to

female development with no heart increased
patients of heart failure failure… mortality?
with CHD
 Therapy

P I C O

In CHD on …would …versus …alleviate

ibuprofen removal of NSAID heart
with NSAID removal of failure?
heart and diuretic plus
failure addition ACE inhibitor
of diuretic…
 Prevention

P I C O

In patients ….…would …compared …prevent

with long-term with no recurrence
heart failure ACE ACE & Improve
Inhibitor… inhibitor… quality
of life
 Diagnostic test

Male, 38 years, complaining of stomach pains

(again)
previously responsive to antacids
you suspect H. pylori and suggest referring for
endoscopy
after describing what is involved, patient is not
keen and asks if there is another test
you agree to find out about sensitivity and
specificity of non-invasive tests
 Diagnosis

P I C O

in patients …is non- …compared …as sensitive

(men?) with invasive with and specific at
recurrent …
diagnostic test endoscopy identifying H.
stomach …
(breath test)) pylori status…
complaints
responsive to
antacids…
 Prevention

male, 28 years, with symptoms

suggestive of influenza
illness has caused misery, resulted in
time off work (self-employed)
aware that elderly are vaccinated, wants
to know if it can benefit him next year
you decide to look for evidence on
efficacy of vaccine among young, healthy
adults
 Prevention

P I C O

In healthy …is influenza …compared …effective in

adults… immunization with no reducing
immunization incidence
of flu
 Therapy

 Infant, 13 months, experienced 2

attacks of febrile convulsions
 Variable recommendations on the use of
maintenance anticonvulsants
 Not sure whether to give or not in order to
prevent further attacks
 Therapy

P I C O

In infants .. is anti- compared better

with convulsant with control
repeat drugs… no drugs further
febrile con seizure
vulsion ..
 Prognosis

Female, 46 years, had ulcerative colitis for 11

years, in remission at present
extensive involvement of colon, severe
symptoms at times
not keen on surgery, but has read about
possible increased risk of cancer
you agree to find out what the risk might be
 Prognosis

P I C O

In middle- with history …cf no what is

aged of ulcerative colitis the risk of
women… colitis… developing
Ca
 Prevention
male, 28 years, with symptoms
suggestive of influenza
illness has caused misery, resulted in
time off work (self-employed)
aware that elderly are vaccinated, wants
to know if it can benefit him next year
you decide to look for evidence on
efficacy of vaccine among young, healthy
adults
 Prevention

P I C O

In healthy …is influenza …compared …effective in

adults… immunization with no reducing
immunization incidence
of flu
 CLINICAL SCENARIO
You are a general practitioner working in a primary health
care team who frequently sees older patients reporting
memory loss and concerned about the onset of
dementia. You routinely use the Mini-Mental State
Examination (MMSE) screening tool with these patients
to evaluate their cognitive function as you know this tool
to be sensitive, valid and reliable. Recently you have
heard of a tool called the Mini-Cog which is considered
quicker to administer and better for patients who or
older, less educated, or from culturally and linguistically
diverse (CALD) communities. You wish to find out if the
Mini-Cog test is as accurate as the MMSE in detecting
Alzheimer's disease or dementia.
 P.I.C.O

 1. Population: Older adults with early

signs/symptoms of Cognitive
impairment
2. Intervention: Mini-Cog screening test
(index test)
3. Comparison: Mini-Mental State
Examination (the reference standard)
4. Outcome: Accurate diagnosis of
dementia
or Alzheimer's disease
 Clinical question
In older adults with early signs of
cognitive impairment, is the Mini-
Cog test as accurate as the Mini-
Mental State Examination in
diagnosing dementia or Alzheimer's
disease?
Mini-cog OR minicog) AND (Mini-mental state
exam* OR MMSE OR SMMSE) AND (Alzheimer*
OR dementia)
 Clinical scenario
Roger, a 26 year old student, has been diagnosed
with major depression. He has tried three different
antidepressant medications in the past with no
improvement. Reluctant to try a further prescribed
medication he asks about non-pharmacologic
alternatives. You have heard that repetitive
transcranial magnetic stimulation has been trialed
for treatment resistant depression but you are not
sure if its effectiveness has been proven. You tell
Roger that you will look into this for him.
 P.I.C.O
1. Patient: Patients with major,
treatment- resistant depression
(treatment failure after two or more
courses of antidepressants)
2. Intervention: Repetitive transcranial
magnetic stimulation (rTMS)
3. Comparison: No rTMS
4. Outcomes: Reduction in depressive
symptoms, improved quality of life,
remission of illness.
 Clinical
question
In patients with major, treatment-resistant
depression, is repetitive transcranial
stimulation effective in treating the
depression?

(treatment resistant depress* OR treatment resistant

major depress* OR treatment resistant MDD OR
Treatment refractory depress* OR pharmaco-
resistant depress* OR pharmacoresistant depress*
OR medication resistant depress*) AND (repetitive
transcranial magnetic stimulat* OR rTMS OR DTMS)
 Scopus search strategy
Will work also in Web of Science
"treatment resistant depress*" or "treatment resistant
major depress*" or "treatment resistant MDD" or
"Treatment refractory depress*" or "pharmaco
resistant depress*" or "pharmacoresistant depress*"
or "medication resistant depress*"
AND
"repetitive transcranial magnetic stimulation*" or
rTMS or DTMS
AND
"systematic review" or "meta analysis" or
metaanalysis or random*
 Clinical question
In patients with suspected
schizophrenia, is magnetic
resonance imaging (MRI)
compared with computed
tomography (CT scan) more
accurate in diagnosing
schizophrenia?
 Examples of Examples of Search
PICO Potential
Search Strategies Strategies (Ovid
Components Search Terms
(PubMed) Medline)
patients with
exp Schizophrenia/
suspected
P schizophrenia Schizophrenia ORSchizophreni*.ti,k
schizophreni
w.
a

exp Magnetic
magnetic
magnetic Magnetic Resonance Resonance Imaging/
resonance
I resonance Imaging OR MRI OR"Magnetic
imaging
imaging (MRI) OR NMR Resonance".ti,kw.OR
(MRI)
(MRI OR NMR).ti.

exp Tomography, X-
"Tomography, X-Ray
computed computed Ray
Computed"[Mesh]
C tomography tomography Computed/OR("comp
OR “computed
(CT scan) (CT scan) ut* tomography" OR
tomography” OR CT
CT).ti,kw.

exp
Accurate
O diagnosis Diagnosis Diagnosis/ORdiagno
diagnosis
s*.ti,kw.
 clinical scenario
The patient is a 65 year old male with a long history of
type 2 diabetes and obesity. Otherwise his medical
history is unremarkable. He does not smoke. He had
knee surgery 10 years ago but otherwise has had no
other major medical problems. Over the years he has
tried numerous diets and exercise programs to reduce
his weight but has not been very successful. His
granddaughter just started high school and he wants to
see her graduate and go on to college. He understands
that his diabetes puts him at a high risk for heart
disease and is frustrated that he cannot lose the
necessary weight. His neighbor told him about a
colleague at work who had his stomach stapled and as a
result not only lost over 100 lbs. but also "cured" his
diabetes. He wants to know if this procedure really
works.
Patient Problem obese, diabetes type 2, male

Intervention stomach stapling

(gastric bypass surgery; bariatric surgery)

Comparison standard medical care

Outcome remission of diabetes; weight loss; mortality

 clinical question

clinical question In patients with

type 2 diabetes and obesity, is
bariatric surgery more effective than
standard medical therapy at
increasing the probability of
remission of diabetes?
 PICO Clinical Question Search Strategy

Patient / obese, diabetes type

diabetes type 2, obesity
Problem 2, male

stomach stapling
Interventio (gastric bypass
bariatric surgery
n surgery; bariatric
surgery)

Compariso
standard medical care
n (if any)

remission of diabetes;
Outcome
weight loss; mortality

Type of
therapy (see below)
Question
 clinical scenario
Seorang pasien laki laki umur 69 tahun dengan
tekanan darah 180/110 dia menceritakan pada
dokternya bahwa pada pemeriksaan kadar kalsium
darah sering rendah. ia mengetahui dari temannya
bahwa kadar kalium rendah merupakan gejala dari
penyakit aldesteron. Ia menanyakan kepada dokter
apakah ia menderita penyakit aldesteron
 Search Terms/keyword
MeSH 47 items à really no relevant
("Potassium/blood"[MAJR] articles except for a French study
OR "Potassium/diagnostic by Massien-Simon C. ** a
use"[MAJR]) AND ‘relevant articles’ search did not
"Hyperaldosteronism"[MeSH yield anything. 839 items à too
] many. ** limited to ‘RTC’ à 4
"Potassium"[MeSH] AND articles, of which were none
"Hyperaldosteronism"[MeSH relevant.
]
 clinical scenario
You admit a 65 year old man with a stroke. On
examination you find that he has mild weakness of the
right arm and right leg and bilateral carotid bruits. You
send the patient for carotid doppler ultrasonography
and subsequently receive the report that he has
moderate stenosis (50-69% by NASCET criteria) of the
ipsilateral carotid artery. You've noticed in the pile of
journals that is accumulating in your office that there
has been some recent literature addressing surgical
versus medical therapy for patients with symptomatic
carotid stenosis but you are unsure what the results of
these studies indicate.
 question can be generate

1. Can ASA decrease the risk of

stroke?
2. Does a carotid bruit predict
significant carotid stenosis?
3. How effective is a carotid
endarterectomy in someone with
moderate carotid stenosis?
 P.I.C.O question
Patient Comparison Out
Intervention
or Problem Intervention come
65 year old
man with a
stroke and ASA Placebo Stroke
moderate
carotid
stenosis
 question

In a 65 year old man with a stroke

and moderate carotid stenosis,
can ASA decrease the risk of
another stroke compared with no
treatment?
 P.I.C.O question

Comparison Out
Patient or Problem Intervention
Intervention come
65 year old man Carotid Medical Stroke
with stroke and endarterec therapy
moderate carotid tomy
stenosis
 question

In a 65 year old man with stroke and

moderate carotid stenosis, can carotid
endarterectomy decrease the risk of
stroke compared with medical
therapy?
 clinical scenario
You admit a 75 year old woman with community-
acquired pneumonia. She responds nicely to
appropriate antibiotics but her hemoglobin remains
at 100 g/l with an MCV of 80. Her peripheral blood
smear shows hypochromia, she is otherwise well and
is on no incriminating medications. You contact her
family physician and find out that her Hgb was 105
g/l 6 months ago. She has never been investigated for
anaemia. A ferritin has been ordered and comes
back at 10 mmol/l. You admit to yourself that you're
unsure how to interpret a ferritin result and aren't
sure how precise and accurate it is.
 P.I.C.O question

Patient or Problem:
Elderly woman with anaemia
Intervention:
Ferritin
Outcome:
Iron deficiency anaemia
 question

In an elderly woman with

hypochromic, microcytic
anaemia, can a low ferritin
diagnose iron deficiency
anaemia?
 clinical scenario
You admit a 75 year old man with a stroke (left sided
weakness) who is having trouble ambulating, feeding,
bathing and dressing himself. He has hypertension but it is
well controlled with a diuretic. He is otherwise well and
now that he is medically stable you decide after discussion
with him to transfer him to a stroke unit. His family asks
to see you because they are concerned about this transfer.
They live very close to the acute care hospital and wonder
why he can't stay on the general medical ward where he
currently is. You arrange to meet with him and his family
to discuss their concerns. In the meantime, you decide to
review the evidence for the use of stroke units.
 P.I.C.O question

Patient or Problem:
75 year old man with a stroke and residual
weakness
Intervention:
Admission to a stroke unit
Comparison Intervention:
General care
Outcome:
Functional status\
 question

In an elderly man with a

stroke, does admission to a
stroke unit decrease the risk
of death and dependency?
 clinical scenario
You see a 70 year old man in your
outpatient clinic 3 months after he was
discharged from your service with an
ischemic stroke. He is in sinus rhythm, has
mild residual left-sided weakness but is
otherwise well. His only medication is ASA
and he has no allergies. He recently saw an
article on the BMJ website describing the
risk of seizure after a stroke and is
concerned that this will happen to him.
 P.I.C.O question

Patient or Problem:
70 year old man
Intervention:
Stroke
Comparison Intervention:
Outcome:
Seizure
 clinical scenario

You see a 50 year old man who asks for a

repeat prescription of sotalol which he has
been taking for extrasystoles for several
years. He has a remote history of an MI.
You haven't seen him previously and are
concerned about the proarrhythmic
properties of sotalol given what is known
about other antiarrhythmics.
 P.I.C.O question
Patient or Problem:
Man with extrasystoles
Intervention:
Sotalol
Comparison Intervention:
Placebo
Outcome
Death
 question

In a man with extrasystoles

and a remote history of MI,
does treatment with sotalol
increase his risk of death?
 Summary

Asking the right question is very important

saves time
search for evidence is directed
Necessary prior to applying subsequent
EBM steps
Practice it - central to your project!
 Concluding remark

 In patient with
X and X, would the
administration of
Y or Y, decrease the
likelihood of
developing
so and so?
 Concluding remarks

In appraising study results, focus

should be on confidence intervals
rather than on p values.
 PERMASALAHAN KLINIS PASIEN
Patient/Problem Intervention

FORMULASI PERTANYAN KLINIS YANG DAPAT DIJAWAB

Comparison Intervention PICO Outcome

PENELUSURAN ARTIKEL YANG RELEVAN

SOFTWARE
LIBRARY SEARCHING

PEMILIHAN ARTIKEL YANG RELEVAN LIST OF ARTIKEL

TELAAH KRITIS
KUMPULAN ARTIKEL RELEVAN
ARTIKEL/CRITICAL
APPRAISAL

APPLYING EVIDENCE/PENERAPAN BUKTI

 PENENTUAN ARTIKEL YANG COCOK UNTUK RUJUKAN TERAPI

1. Apakah artikel yang dibaca relevan------- baca Abstraknya

Telaah abstract:
1.1. Apakah hasil studi cocok dengan dengan kita butuhkan bila ya
lanjutkan bila tidak stop jangan dibaca.

1.2. Apakah permasalahan yang disajikan sering dijumpai pada praktek

anda sehari hari di RS dan intervensi yang dilakukan laik untuk
dilakukan bila ya lanjutkan bila tidak stop
1.3. Apakah informasi yang didapat dari artikel tersebut dapat
membawa perubahan pada cara perawatan pasien ditempat anda `
pada saat ini. Bila ya lanjutkan bila tidak stop

BiLA ARTIKEL SUDAH RELEVAN MAKA DAPAT DILANJUTKAN

KE TAHAP TELAAH KRITIS SELANJUTNYA
 Search Article with software/lacak artikel dengan perangkat lunak

Pilih tibial fracture (MeSH) and Shaft

Sudah dipilihkan sebanyak 24 artikel sekaligus oleh Software yang

Biasanya dengan pilihan terbaik pada urutan pertama

BhandariM.TornettaP. 3rd, Sprague S, Najibi S.Petrisor b.Griffith.L Predictor

of reoperation following operative management of fractures of the tibial
shaft

Critical appraisal
Applying evidence