How to Formulate Clinical QuestionProblem

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How to Formulate Clinical Question/Problem

• Pyatat Tatsanavivat M.D.
• EMB Workshop
• CEU-KKU 2548

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Clinical Decision Making
Patient circumstances
Preferences, values and rights
Evidence from research
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WHEN TO SEARCH FOR EVIDENCE

• When a patient problem is bothering you
• or
• when a patient presents with a comman problem you
  will encounter often

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EBM Skills

• Formulate a clinically relevant and searchable
  question
• Find the evidence
• Evaluate the evidence
• Validity
• Importance of results
• Apply to your patient
• USE COMMON SENSE

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Where Do Questions Come From?

• Patients
• Diagnosis
• Etiology
• Prognosis
• Treatment/prevention
• Practice variations-which is best?
• New treatment or diagnosis

Counsell C. Ann Intern Med. 1997127380-7
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Importance of a Question

• Depends on area of expertise
• Effects on patients
• severity-morbidity/mortality/QoL
• Duration
• Financial cost
• Effects on society
• Prevalence/severity
• Financial cost
• Feasibility of assessment
• Ability to change practice

Counsell C. Ann Intern Med. 1997127380-7
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Formulating the Question

• Basic components
• Type of person
• Type of exposure
• Type of control
• Outcome of interest
• Type of study design

Counsell C. Ann Intern Med. 1997127380-7
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Type of Person

• Disease or condition
• Definition
• Cause
• Stage
• Severity
• Personal characteristics
• Age
• Sex
• Symptoms
• Population or setting
• Community
• Hospital (outpatient or inpatient)

Counsell C. Ann Intern Med. 1997127380-7
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Type of Exposure
Definition Intensity or dose Timing
Duration Method of delivery group therapy
individual therapy oral therapy or
intravenous therapy)

• Risk factor
• Prognostic factor
• Intervention
• Diagnosis

Counsell C. Ann Intern Med. 1997127380-7
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Type of Control Absence of risk or prognostic
factor (risk and prognostic reviews) Gold
standard test (diagnostic reviews) Treatment
controls (treatment and prevention
reviews) Active treatment or no treatment
Placebo control or open control
Counsell C. Ann Intern Med. 1997127380-7
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Type of Outcome
Importance to patient Clinically relevant or
surrogate Death, quality of life, disability,
and symptoms or signs Beneficial and harmful
effects of interventions Use of health care
resources (economic evaluations) Definitions Timin
g of outcome assessment
Counsell C. Ann Intern Med. 1997127380-7
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Type of Study Design

• Experimental or observational
• Randomized or nonrandomized controlled trails
• Blinded or open trials
• Confounded or unconfounded studies (that is a
  comparison of treatment A versus no treatment is
  confounded by treatment B, whereas trial of A
  and B versus B alone is not confounded

Counsell C. Ann Intern Med. 1997127380-7
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THE FOCUSED CLINICAL QUESTION

• P Relevant patients
• I Interventions or risk factors
• C Comparisons
• O Outcomes of interest (benefits, harm, costs)
• Ex is eye patching improve the healing rate of
  traumatic corneal epithelial defects?

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Should a echinacea preparation used for common
cold?
Subjects with common cold

• Patient
• Intervention
• Outcome

Echinacea preparation
Total daily symptom scores TDSS
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Medical Students Questions

• What are the symptoms of common cold?
• How does echincea work?
• What is the etiology of common cold?
• What is the incidence of common cold?

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Background Questions

• Ask for general knowledge about a disorder
• Have two essential components
• A question root (who, what, where, when, how,
  why) with a verb
• A disorder, or an aspect of a disorder

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Practitioners Questions

• In this patient are any clinical findings
  sufficiently powerful to diagnose common cold?
• Should common cold be treated with drug or
  biological extract?
• What are the potential harmful effects of common
  cold?
• In these patient , what are the predictors
  indicating echinacea will be beneficial
• What is the compliance of echinacea treamtent?

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• Notice that these questions ask for specific
  knowledge about how to diagnose, prognose, and
  treat the patients with common cold, which might
  be called foreground knowledge.
• Ask for specific knowledge about managing
  patients with a disorder

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Foreground Questions

• Have four (or three) essential components
• The patient and/or problem of interest
• The main intervention (defined very broadly,
  including an exposure, a diagnostic test, a
  prognostic factor, a treatment, a patient
  perception, and so forth)
• Comparison intervention(s), if relevant
• The clinical outcome(s) of interest.

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Background and foreground questions
C
A - less C - experienced
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• Clinical practice demands large amounts of both
  background and foreground knowledge.

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Background vs Foreground Questions

• Background
• What is?
• Use Textbooks for these
• Foreground
• Specific Clinical Issues
• More Sophisticated Resources

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Sources of Relevant Studies

• Electronic databases
• Manual search journal, proceedings book
• Reference lists
• Existing study registries
• Current-awareness publications
• Pharmaceutical and appliance companies
• Personal contact with colleagues researchers

Counsell C. Ann Intern Med. 1997127380-7
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Key Points to Remember

• Choose important well-focused question
• Refine the four major components
• Set clear, workable inclusion criteria
• Take time to plan a sensible and thorough search
  strategy
• Use multiple overlapping sources of data
• Ensure that clinical and methodological expertise
  and support are available

Counsell C. Ann Intern Med. 1997127380-7