Bambang Tridjaja

deliveredbyIndahS.Widyahening
 Goals
Attheendofthislecture,youwill:
Beabletocreateawellformedclinical
question
Appreciatetheimportanceofwellformed
clinicalquestionsinkeepinguptodate
 Patient Diagnosis
Drawing conclusion Encounter Therapy
That impact on practice Prognosis
Etiology

Apply

EBM
Appraising Formulating
Appraise the Clinical Ask
Evidence Question

Acquire
Patient
Intervention
Hierarchy of evidence Searching Comparison
Pre appraised resources the Outcome
Evidence
(Lang, 2000)
 WhatQuestionsDoCliniciansAskatthe
Point ofCare?
RESEARCH
Physiciansreported 2/3clinicalquestions
1question/4patients unanswered.
(day)
15questions/25 Aretheunanswered
patientsperday questionsimportant?
Primarycaredoctors 50%oftheanswers
2questions/3patient directimpacton
Questionsrelation patientcare.
33%~treatment
25%~diagnosis
15%~pharmaco
therapeutics.
 WHYBOTHERFORMULATINGQUESTIONS
CLEARLY?
AnswerableClinicalQuestions:
1. Helpfocusourscarcelearningtimeon
evidencethatisdirectlyrelevanttoour
patientsclinicalneeds.
2. Helpusfocusourscarcelearningtimeon
evidencethatdirectlyaddressesour
particularknowledgeneeds,orthoseofour
learners.

(Straussetal,2005)
 WHYBOTHERFORMULATINGANSWERABLE
CLINICALQUESTIONS?
AnswerableClinicalQuestions:
3. Suggesthighyieldsearchstrategies
4. Suggesttheformsthatusefulanswersmight
take
5. Whensendingorreceivingapatientin
referral,theycanhelpustocommunicate
moreclearlywithourcolleagues.

(Straussetal,2005)
 WHYBOTHERFORMULATINGQUESTIONS
CLEARLY?
AnswerableClinicalQuestions:
6. Whenteaching,ACQhelpourlearnersto
betterunderstandthecontentofwhatwe
teach,whilealsomodelingsomeadaptive
processesforlifelonglearning.

(Straussetal,2005)
 WHYBOTHERFORMULATINGQUESTIONS
CLEARLY?
AnswerableClinicalQuestions:
7. Whenourquestionsgetanswered,our
knowledgegrows,ourcuriosityisreinforced,
ourcognitiveresonanceisrestored,andwe
canbecomebetter,faster,andhappier
clinicians.

(Straussetal,2005)
 Answerable
Whydowenotanswermoreofthesequestions?
lackofconvenientaccesstoreferencematerials
timeneededtosearchforinformation
Twocharacteristicsthatpredictwhetherphysicians
willseekandfindananswertoaclinicalquestionare
theurgencyoftheproblemand
theirconfidencethattheywillfindananswer

ANSWERABLE CLINICAL QUESTIONS

 Howdoyouchoosewhich
questiontoanswer?
Importanttoapatient'swellbeing(intermsof
outcomesthattheycareabout)
Feasibletoaddressinthetimeavailable(youthink
youmightbeabletofindananswer)
Likelytorecurinyourpractice(commontopractice)
Involveaninterventionthatisfeasibleandnotyour
currentpractice
Interestingtoyou
Medicolegalissue
 TypeofQuestion
Evidencebasedpracticerequiresthatclinicians
makeuseofthebestresearchtheycanfindto
helpthemindecisionmaking.Tofindthat
researchefficiently,theclinicianmustaskawell
designedclinicalquestionwithalltheelements
thatwillleadtofindingrelevantresearch
literature.
Thefirststepindoingthisistodeterminethe
typeofquestion:background orforeground.The
typeofquestionhelpstodeterminetheresource
toaccesstoanswerthequestion.
 TypeofQuestions
"Background" "Foreground"
questionsaskforgeneral questionsaskforspecific
knowledgeabouta knowledgetoinformclinical
conditionorthing. decisionsoractions.
Answeringthebackground Answeringtheforeground
question.
question.
excellentreviewarticleor
respectedevidencedbased Primarysource:journal
textbook.Wheninneedofan Secondarysource:Cochrane
overviewonclinical
presentationofadisease,
standardtherapies,diagnostic
tools,etc.,consultatextbook.
 BackgroundQuestions
Askforgeneralknowledgeaboutadiseaseordisease
process
Havetwoessentialcomponents:
Aquestionroot(who,what,when,etc.)withaverb
Adisorder,test,treatment,orotheraspectofhealthcare
Example:Whatcausesmigraines? orHowoftenshould
womenovertheageof40haveamammogram?
Thebackgroundquestionisusuallyaskedbecauseof
theneedforbasicinformation.Itisnotnormallyasked
becauseofaneedtomakeaclinicaldecisionabouta
specificpatient.
 Foregroundquestions
Askforspecificknowledgeaboutmanaging
patientswithadisease
Have3or4essentialcomponents
Patientand/orproblem
Indicator/Intervention
Comparativeintervention(optional,includeif
relevant)
Clinicaloutcome
Inyoungchildrenwithacuteotitis media,is
shorttermantibiotictherapyaseffectiveaslong
termantibiotictherapy?
Type of question depend
on the clinical experience

SPECIFIC KNOWLEDGE
Question
type
GENERAL KNOWLEDGE

Clinical experience
 PICO
PICOisamnemonicusedtodescribethefour
elementsofagoodclinicalforeground
question.
PPatient
IIndicator/Intervention
CComparison
OOutcome
 P=Population/Patient/Problem
Howwouldyoudescribeagroupofpatients
similartoyours?
Whatarethemostimportantcharacteristics
ofthepatient?
Thismayincludetheprimaryproblem,
disease,orcoexistingconditions.
Sometimesthesex,ageorraceofapatient
mightberelevanttothediagnosisor
treatmentofadisease.
 I=Indicator/Intervention;E=Exposure
Whichmainintervention,prognosticfactor,or
exposureareyouconsidering?
Whatdoyouwanttodoforthepatient?
Prescribeadrug?
Orderatest?Ordersurgery?
Whatfactormayinfluencetheprognosisofthe
patient?Age?Coexistingproblems?
Whatwasthepatientexposedto?Asbestos?
Cigarettesmoke?
 Comparison
Whatisthemainalternativetocomparewith
theintervention?
Areyoutryingtodecidebetweentwodrugs,a
drugandnomedicationorplacebo,ortwo
diagnostictests?
Yourclinicalquestiondoesnotalwaysneeda
specificcomparison.
 Outcome
Whatcanyouhopetoaccomplish,measure,
improveoraffect?
Whatareyoutryingtodoforthepatient?
Relieveoreliminatethesymptoms?
Reducethenumberofadverseevents?
Improvefunctionortestscores?
QUESTIONCATEGORIES
 QuestionCategories
Diagnosis Howtoselectadiagnostictestorhow
tointerprettheresultsofaparticulartest.
TherapyWhichtreatmentisthemosteffective,
orwhatisaneffectivetreatmentgivena
particularcondition.
HarmorEtiologyArethereharmfuleffectsofa
particulartreatmentorexposureorriskfactor
Prognosis Whatisthepatient'slikelycourseof
diseasegiventhecharacteristic
 Exercise
Inpatientswithsuspecteddepressionwhatisthe
Inpatientswithacutebronchitis,doantibiotics
accuracyofatwoquestioncasefinding
reducesputumproduction,coughordaysoff
instrumentfordepressioncomparedwithsix
work?
previouslyvalidatedinstruments?

Inwomentakingoralcontraceptives,istherean
associationbetweentheiruseandcardiovascular
disease?
 EXERCISE
Inpatientswithsuspecteddepressionwhatisthe
accuracyofatwoquestioncasefinding
instrumentfordepressioncomparedwithsix
previouslyvalidatedinstruments?

P=
I=
C=
O=
 EXERCISE
Inwomentakingoralcontraceptives,istherean
associationbetweentheiruseandcardiovascular
disease?

P=
I=
C=
O=
 EXERCISE
Inpatientswithacutebronchitis,doantibiotics
reducesputumproduction,coughordaysoff
work?

P=
I=
C=
O=
 PICO&Applicability

Adaptedfrom:Sackettetal.sEvidenceBasedMedicine:HowtoPracticeandTeachEBM
PICO&Applicability

InformationPyramid
 GUIDETOPICOAPPLICABILITY
PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

PICO:

TypeofQuestion:

Typeofstudy/methodology:
 Case#1
Yournextpatientisa72yearoldwomanwith
osteoarthritisofthekneesandmoderate
hypertension,accompaniedbyherdaughter,a
labtechfromthehospital.Thedaughter
wantsyoutogivehermotheraprescription
foroneofthenewCOX2inhibitors.Shehas
heardthattheycauselessGIbleeding.
 FILLINTHECOLUMN
PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME

PICO:

TypeofQuestion:

Typeofstudy/methodology:
 Case#1
PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME
72yearoldwoman COX2Inhibitor otherNSAIDS lessGIbleeding
withosteoarthritis
ofthekneeand
moderate
hypertension
PICO:
Ina72yearoldwomanwithosteoarthritisoftheknee,canCOX2Inhibitoruse
decreasetheriskofGIbleedingcomparedwithotherNSAIDs?
TypeofQuestion:
Therapy/Treatment
Typeofstudy/methodology:
SystematicReview/MetaAnalysisofDoubleBlindRandomizedControlledTrials
 Case#2
Youseea70yearoldmaninyouroutpatient
clinic3monthsafterhewasdischargedfrom
yourservicewithanischemicstroke.Heisin
sinusrhythm,hasmildresidualleftsided
weaknessbutisotherwisewell.Hisonly
medicationisASAandhehasnoallergies.He
recentlysawanarticleontheBMJwebsite
describingtheriskofseizureafterastrokeand
isconcernedthatthiswillhappentohim.
 FILLINTHECOLUMN
PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME

PICO:

TypeofQuestion:

Typeofstudy/methodology:
 Case#2
PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME
70yearoldman Stroke Seizure
PICO:
Ina70yearoldmandoesahistoryofstrokeincreasehisriskforseizure?
TypeofQuestion:
Prognosis
Typeofstudy/methodology:
Cohortstudies
 Case#3
Youadmita75yearoldwomanwithcommunity
acquiredpneumonia.Sherespondsnicelyto
appropriateantibioticsbutherhemoglobinremainsat
10g/dlwithanMCVof80.Herperipheralbloodsmear
showshypochromia,sheisotherwisewellandisonno
incriminatingmedications.Youcontactherfamily
physicianandfindoutthatherHgb was10,5g/dl
about6monthsago.Shehasneverbeeninvestigated
foranaemia.Aferritin hasbeenorderedandcomes
backat10mmol/l.Youadmittoyourselfthatyou're
unsurehowtointerpretaferritin resultandaren'tsure
howpreciseandaccurateitis.
 FILLINTHECOLUMN
PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME

PICO:

TypeofQuestion:

Typeofstudy/methodology:
 Case#2
PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME
Elderlywomanwith Ferritin Irondeficiency
anaemia anaemia
PICO:
Inanelderlywomanwithhypochromic,microcytic anaemia,canalowferritin
diagnoseirondeficiencyanaemia?
TypeofQuestion:
Diagnosis
Typeofstudy/methodology:
ControlledStudies;SystematicReview/MetaAnalysisofControlledStudies