1. Developing Answerable Clinical Questions Clinical Epidemiology and Evidence-based Medicine Unit FKUI – RSCM

2. 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

3. Evidence-Based Medicine 1 “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.”

4. EBM Process Patient Encounter Formulating the Clinical Question Searching the Evidence Appraising the Evidence Diagnosis Therapy Prognosis Etiology Diagnosis Therapy Prognosis Etiology Patient Intervention Comparison Outcome Patient Intervention Comparison Outcome Hierarchy of evidence Pre appraised resources Hierarchy of evidence Pre appraised resources Drawing conclusion That impact on practice DOES POEM Drawing conclusion That impact on practice DOES POEM (Lang, 2000)

5. 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.

6. 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?

7. Knowledge Gaps In an underfive with recurrent wheezing, does education reduces the incidence of asthma attack?

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

13. 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

14. 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)

15. Asking Questions Questions are usually of 2 types: background or foreground FOREGROUND BACKGROUND NOVICEEXPERT

16. 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?

17. Foreground Questions Specific to managing patients with a disorder Have 4 parts: –Patient or problem - P –Intervention - I –Comparison of intervention - C –Outcomes - O

18. 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?

19. 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…?

20. 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?

21. 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…)?

22. The 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”

23. 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

24. Comparing DOEs and POEs 2

25. 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)

26. 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?”

27. 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?

28. 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?

29. Treatment Patient / Problem / Population InterventionComparisonOutcome In a child with frequent febrile seizures would anticonvulsant therapy compared to no treatment result in seizure reduction?

30. Diagnosis Patient / Problem / Population InterventionComparisonOutcome In an otherwise healthy 7-year- old boy with sore throat how does the clinical exam compare to throat culture in diagnosing GAS infection?

31. Prognosis Patient / Problem / Population InterventionComparisonOutcome In children with Down syndrome, is IQ an important prognostic factor -in predicting Alzheimer’s later in life?

32. Etiology / Harm Patient / Problem / Population InterventionComparisonOutcome 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?

33. 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?

34. 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?

35. 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?

36. 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

37. THANK YOU ANY QUESTIONS?

38. 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?”

39. 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

40. PICO & Applicability InterventionCould 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

41. 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

42. PICO & Applicability OutcomeAre 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

43. CLINICAL EXPERTISE PAST CLINICAL EXPERIENCE NEW CLINICAL (EBM PARADIGM) EXPERIENCE Formal Education Clinical Skills BACKGROUNDFOREGROUND Medical School CME Medical School Practice RootsDisorder PatientInterventionComparisonOutcome

44. 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)].