Developing Answerable Clinical Questions

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 Medicine1 • “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. Patient Encounter Diagnosis Therapy Prognosis Etiology • Drawing conclusion • That impact on practice • DOES • POEM Formulating the Clinical Question Appraising the Evidence • Patient • Intervention • Comparison • Outcome • Hierarchy of evidence • Pre appraised resources Searching the Evidence EBM Process (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. 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. What Questions Do Clinicians Ask at the Point of 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. FOREGROUND BACKGROUND NOVICE EXPERT Asking Questions • Questions are usually of 2 types: background or foreground

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 PICO

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 • “Population” • “Intervention” • “Comparison” • “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 POEs2

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

30. Diagnosis

31. Prognosis

32. Etiology / Harm

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 whichquestion 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

39. PICO & Applicability Alan Schwartz

40. PICO & Applicability Alan Schwartz

41. PICO & Applicability Alan Schwartz

42. PICO & Applicability Alan Schwartz

43. CLINICAL EXPERTISE Patient Intervention Comparison Outcome Roots Disorder

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)].