1. Answerable Clinical Questions
Developing
Answerable Clinical Questions
Bambang Tridjaja
Dept of Child Health
Faculty of Medicine University of Indonesia

2. Goals At the end of this module, you will:
Be able to create a well-formed clinical question
Appreciate the importance of well-formed clinical questions in keeping up-to-date

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

4. 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.
Dalam suatu penelitian ternyata dari dokter umum yang bekerja di klinik selama setengah hari rata-rata didapatkan 1 pertanyaan untuk setiap 4 pasien. Rata-rata sepanjang hari pertanyaan klinis yang muncul dapat mencapai 15 pertanyaan denag rata-rata 25 pasien.
Semakin minimnya pengalaman berpraktek, semakin banayk pertanyaan yang muncul dari dokter umu hingga 2 pertanyaan untuk setiap 3 pasien.
Dari sebagai besar pertanyaan –pertanyaan yang muncul 33% berhubungan denagn terapi 25% denagn diagnosis dan 15% dengan farmakoterapi. Sayang sekali 2/3 dari pertanyaan=pertanyaan yang muncul tersebut dibiarkan tidak terjawab. Bagaimana pengaruh pertanyaan-pertanyaan klinis tersebut terhadap praktek sehari=hari? Hasilnya cukup mengagetkan karena hampir 50% dari pertanyaan-pertanyaan yang dibiarkan tidak terjawab mempunyai dampak langsung terhadap pelayanan kesehatan yang seharusnya dilakukan.

5. WHY BOTHER FORMULATING QUESTIONS CLEARLY?
Answerable Clinical Questions:
Help focus our scarce learning time on evidence that is directly relevant to our patients’ clinical needs.
Help us focus our scarce learning time on evidence that directly addresses our particular knowledge needs, or those of our learners.
(Strauss et al, 2005)

6. WHY BOTHER FORMULATING ANSWERABLE CLINICAL QUESTIONS?
Suggest high-yield search strategies
Suggest the forms that useful answers might take
When sending or receiving a patient in referral, they can help us to communicate more clearly with our colleagues.
(Strauss et al, 2005)

7. WHY BOTHER FORMULATING QUESTIONS CLEARLY?
Answerable Clinical Questions:
When teaching, ACQ help our learners to better understand the content of what we teach, while also modeling some adaptive processes for lifelong learning.
(Strauss et al, 2005)

8. WHY BOTHER FORMULATING QUESTIONS CLEARLY?
Answerable Clinical Questions:
When our questions get answered, our knowledge grows, our curiosity is reinforced, our cognitive resonance is restored, and we can become better, faster, and happier clinicians.
(Strauss et al, 2005)

9. ANSWERABLE CLINICAL QUESTIONS
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
Why do we not answer more of these questions? Limitations include a lack of convenient access to reference materials at the point of care, the time needed to search for information, and the challenge of formulating an answerable question.[4] 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.[7]
For example, consider the physician who wants to know how to prescribe famciclovir for herpes zoster. Although he or she can be confident of finding a dosage recommendation in the PDR, this reference will not answer questions about the medication’s effectiveness. Information about the number of patients this physician would have to treat to prevent a case of postherpetic neuralgia might be found in a randomized trial, but access to that information is unlikely at the point of care, and the question remains unanswered. Thus, the information a patient and physician might want so they can decide whether the medication is worth paying for and taking is not available.
A useful way to think about clinical questions is by the type of information needed.[8] For example, a relatively large randomized controlled trial has shown that patching corneal abrasions only increases discomfort and healing time.[9] A family physician who is unaware of this outcome and who continues to patch corneal abrasions has an unrecognized information need, because his or her patients would benefit from a change in practice. When that same family physician asks this clinical question: “I wonder whether there is any evidence that patching corneal abrasions improves outcomes that my patients and I care about?” he or she has recognized an information need and asked a clinical question. When the physician asks a colleague, he or she has begun to pursue this information need. Searching the Journal of Family Practice POEMs (patient-oriented evidence that matters) Web site ( using the term “corneal abrasion” will locate an article that answers that clinical question; the information need is now satisfied. Finally, the information must be implemented in the physician’s practice to affect patient outcomes.
ANSWERABLE CLINICAL QUESTIONS

10. How do you choose which question to answer?
Important to a patient's well-being (in terms of outcomes that they care about)
Feasible to address in the time available (you think you might be able to find an answer)
Likely to recur in your practice (common to family practice)
Involve an intervention that is feasible and not your current practice
Interesting to you
Medico-legal issue

11. Type of Question
Evidence based practice requires that clinicians make use of the best research they can find to help them in decision-making. To find that research efficiently, the clinician must ask a well-designed clinical question with all the elements that will lead to finding relevant research literature.
The first step in doing this is to determine the type of question: background or foreground. The type of question helps to determine the resource to access to answer the question.

12. Type of Questions "Background" "Foreground"
questions ask for general knowledge about a condition or thing.
Answering the background question.
excellent review article or respected evidenced-based textbook. When in need of an overview on clinical presentation of a disease, standard therapies, diagnostic tools, etc., consult a textbook.
questions ask for specific knowledge to inform clinical decisions or actions.
Answering the foreground question.
Primary source : journal
Secondary source : Cochrane

13. Background Questions
Ask for general knowledge about a disease or disease process
Have two essential components:
A question root (who, what, when, etc.) with a verb
A disorder, test, treatment, or other aspect of healthcare
Example: What causes migraines? or How often should women over the age of 40 have a mammogram?
The background question is usually asked because of the need for basic information. It is not normally asked because of a need to make a clinical decision about a specific patient.

14. Foreground questions
Ask for specific knowledge about managing patients with a disease
Have 3 or 4 essential components
Patient and/or problem
Intervention
Comparative intervention (optional, include if relevant)
Clinical outcome
In young children with acute otitis media, is short-term antibiotic therapy as effective as long term antibiotic therapy?

15. PICO
PICO is a mnemonic used to describe the four elements of a good clinical foreground question.
P--Patient I--Intervention C--Comparison O--Outcome

16. P=Population/Patient/Problem
How would you describe a group of patients similar to yours?
What are the most important characteristics of the patient?
This may include the primary problem, disease, or co-existing conditions.
Sometimes the sex, age or race of a patient might be relevant to the diagnosis or treatment of a disease.

17. I=Intervention; E=Exposure
Which main intervention, prognostic factor, or exposure are you considering?
What do you want to do for the patient? Prescribe a drug?
Order a test? Order surgery?
What factor may influence the prognosis of the patient? Age? Co-existing problems?
What was the patient exposed to? Asbestos? Cigarette smoke?

18. Comparison
What is the main alternative to compare with the intervention?
Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests?
Your clinical question does not always need a specific comparison.

19. Outcome What can you hope to accomplish, measure, improve or affect?
What are you trying to do for the patient? Relieve or eliminate the symptoms?
Reduce the number of adverse events? Improve function or test scores?

20. Question CAtegories

21. Question Categories
Diagnosis How to select a diagnostic test or how to interpret the results of a particular test.
Therapy Which treatment is the most effective, or what is an effective treatment given a particular condition.
Harm or Etiology Are there harmful effects of a particular treatment, or how can these harmful effects be avoided.
Prognosis What is the patient's likely course of disease, or how to screen for or reduce risk.

22. Diagnosis Therapy Harm
Exercise
In patients with suspected depression what is the accuracy of a two-question case-finding instrument for depression compared with six previously validated instruments?
In patients with acute bronchitis, do antibiotics reduce sputum production, cough or days off work?
Diagnosis
Therapy
In women taking oral contraceptives, is there an association between their use and cardiovascular disease?
Harm

23. EXERCISE
In patients with suspected depression what is the accuracy of a two-question case-finding instrument for depression compared with six previously validated instruments?
P =
I =
C =
O =

24. EXERCISE
In women taking oral contraceptives, is there an association between their use and cardiovascular disease?
P =
I =
C =
O =

25. EXERCISE
In patients with acute bronchitis, do antibiotics reduce sputum production, cough or days off work?
P =
I =
C =
O =

26. PICO & Applicability
Adapted from: Sackett et al.’s Evidence-Based Medicine: How to Practice and Teach EBM

27. PICO & Applicability
Information Pyramid

28. GUIDE TO PICO APPLICABILITY
PATIENT/PROBLEM
INTERVENTION
COMPARISON
OUTCOME
Wanita Usia Reproduksi yang tidak hamil
Urinalisis Sedimen Leukosit
Kultur Urin
Diagnosis ISK
PICO: Pada wanita usia reproduksi tidak hamil dengan kecurigaan mengalami ISK, apakah pemeriksaan urinalisis sedimen leukosit lebih dapat diterapkan dibandingkan kultur urin untuk diagnosis?
Type of Question:
Diagnostic
Type of study/methodology: Controlled trial/SR/Meta-analysis of CT

29. Case #1
Your next patient is a 72-year-old woman with osteoarthritis of the knees and moderate hypertension, accompanied by her daughter, a lab tech from the hospital. The daughter wants you to give her mother a prescription for one of the new COX-2 inhibitors. She has heard that they cause less GI bleeding.

30. Case #1 PICO: Type of Question: Type of study/methodology:
PATIENT/PROBLEM
INTERVENTION
COMPARISON
OUTCOME
72 year old woman with osteoarthritis of the knee and moderate hypertension
COX-2 Inhibitor
other NSAIDS
less GI bleeding
PICO:
In a 72 year old woman with osteoarthritis of the knee, can COX-2 Inhibitor use decrease the risk of GI bleeding compared with other NSAIDs?
Type of Question:
Therapy/Treatment
Type of study/methodology:
Systematic Review/Meta Analysis of Double-Blind Randomized Controlled Trials

31. Case #2
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.

32. Case #2 PICO: Type of Question: Type of study/methodology:
PATIENT/PROBLEM
INTERVENTION
COMPARISON
OUTCOME
70 year old man
Stroke
Seizure
PICO:
In a 70 year old man does a history of stroke increase his risk for seizure?
Type of Question:
Prognosis
Type of study/methodology:
Cohort studies

33. Case #3
You admit a 75 year old woman with community-acquired pneumonia. She responds nicely to appropriate antibiotics but her hemoglobin remains at 10 g/dl 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 10,5 g/dl about 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.

34. Case #2 PICO: Type of Question: Type of study/methodology:
PATIENT/PROBLEM
INTERVENTION
COMPARISON
OUTCOME
Elderly woman with anaemia
Ferritin
Iron deficiency anaemia
PICO:
In an elderly woman with hypochromic, microcytic anaemia, can a low ferritin diagnose iron deficiency anaemia?
Type of Question:
Diagnosis
Type of study/methodology:
Controlled Studies; Systematic Review/Meta Analysis of Controlled Studies

35. You have pass the 1st step
CONGRATULATION!
You have pass the 1st step ?
questions