محمد مرادی جو دانشجوی دکتری سیاستگذاری سلامت دانشگاه علوم پزشکی تهران آبان 1396

WHY do we need Clinical Questions? Well-developed clinical questions help to focus on evidence that is relevant to the consumers and clinicians, making the searching more efficient.

Type of clinical question Background questions are those which have been answered in the past and are now part of the “fiber of medicine.” Answers to these questions are usually found in medical textbooks. The learner must beware, since the answers to these questions may be inaccurate and not based upon any credible evidence. Typical background questions relate to the nature of a disease or the usual cause, diagnosis, or treatment of illnesses. Foreground questions are those usually found at the cutting edge of medicine. They are questions about the most recent therapies, diagnostic tests, or current theories of illness causation. These are the questions that are the heart of the practice of EBM. A four-part clinical question called a PICO question is designed to easily search for this evidence.

background vs. foreground Background information is sought when a learner has general clinical questions regarding a topic such as what is the disorder; what causes it; how does it present; what are some treatment options. These questions can be answered by using "background" resources such as textbooks (both in print and electronic) and narrative reviews in journals which give a general overview of the topic. Foreground information answers specific questions a clinician has regarding a specific patient. Foreground resources can be divided into primary sources such as original research articles published in journals; and secondary sources such as systematic reviews of the topic, and synopses and reviews of individual studies.

The relationship between foreground and background questions and the clinician’s experience Background Questions Foreground Questions Clinical Experience StudentExperienced Clinician

Background vs. Foreground Background Questions – General knowledge – Who, what, how? Foreground Questions – PICO Model

Asking the Question: PICO Every foreground clinical question should include description of population, intervention, comparison, and outcome measures. Patient Problem or Population (P) Intervention (I) Comparison (C) Outcome (O)

Addresses specific knowledge to inform clinical decisions or actions. Foreground question P I C O

Addresses specific knowledge to inform clinical decisions or actions. Foreground question Patient/ Population Intervention/ Exposure Comparison Outcome

Addresses specific knowledge to inform clinical decisions or actions. Patient/ Population How would I describe a patient or group of patients similar to mine? Intervention/ Exposure Which main intervention (exposure, finding, test, risk factor) am I considering? ComparisonWhat is the main alternative to the intervention? Outcome What can I hope to accomplish? What could this exposure really affect? Foreground question

PICOExample P (Problem or Patient or Population) hospital acquired infection I (Intervention/indicator)hand washing C (Comparison) no hand washing; masks ; other solution O (Outcome)reduced infection

14 Fundamentals of Searching P I C O Population Intervention Comparison Outcome Question Formulation Using PICO

Develop a search strategy Using OR then AND to broaden then focus the search PIO Sore throat* or tonsillitis or pharyngitis Antibiotic* or antibacterial* or penicillin Symptom relief or Symptom alleviation and

Boolean Search

Combine terms with OR pharyngitis Sore throat Pharyngitis OR sore throat – either term can be present

Combine terms with AND Antibiotics AND sore throat – both terms must be present sore throat antibiotics

Type of Clinical Question and Study Design Two additional important elements of the well-built clinical question to consider are the type of foreground question and the type of study (methodology). This information can be helpful in focusing the question and determining the most appropriate type of evidence. Foreground questions can be further divided into questions that relate to therapy, diagnosis, prognosis, etiology/harm Therapy: Questions of treatment in order to achieve some outcome. May include 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.

Questions Diagnosis Etiology? Risk Factors? Prognosis Therapy

Question type – Study design Question domainBest feasible study design DiagnosisCross-sectional study Etiology /HarmCohort or RCT PrognosisCohort TreatmentSystematic review or RCT

Structured questions for systematic reviews and relations between question components in a comparative study

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