Kurang pelan 2' Kurang aktif

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Kurang pelan2. Kurang aktif
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Developing Answerable Clinical Questions

• Bambang Tridjaja
• Dept of Child Health
• Faculty of Medicine University of Indonesia

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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
  

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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.

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EBM Process
(Lang, 2000)
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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.

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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?

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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.

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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.

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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.

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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
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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.

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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

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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)

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Asking Questions

• Questions are usually of 2 types background or
  foreground

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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?

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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
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Learn to Ask a Focused Clinical Question -
Foreground
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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?

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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?

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The componentsC

• The comparison or alternative (not applicable to
  all questions) e.g.
• Anti-biotic therapy?
• Nothing?
• Fluids alone?
• What alternatives actions might I try?

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The componentsO

• 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)?

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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

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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

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Comparing DOEs and POEs2
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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)

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PICO Applicability
Alan Schwartz
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PICO Applicability
Alan Schwartz
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PICO Applicability
Alan Schwartz
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PICO Applicability
Alan Schwartz
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CLINICAL EXPERTISE
Patient
Intervention
Comparison
Outcome
Roots
Disorder
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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?

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Good ACQ?

• Does the treatment with antibiotics result in
  more rapid improvement of otitis media than no
  treatment?

• Is Amoxicillin an effective treatment for
  children with otitis media?

• Does Amoxicillin work better for otitis media
  than placebo in children who are in daycare?

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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?

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Treatment
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Diagnosis
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Prognosis
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Etiology / Harm
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My 1 yr old just had a febrile seizure - what
will happen to her?
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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?

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This patient has elevated blood pressure - should
I start ACE inhibitors?
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This patient has elevated blood pressure - should
I start ACE inhibitors?

• Patient In middle aged men with diastolic
  BPgt90ile for age
• Intervention would diuretics or ACE inhibitors
  be best to
• Outcome prevent heart disease stroke end-organ
  damage?

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My dad is 70 years old - should his doctor order
a PSA?
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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?

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PRACTICE
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Case 1- Therapy

• Jimmy Coryza is a 14 year old with seasonal
  allergies. You wonder should I prescribe a nasal
  corticosteroid or a non-sedating anti-histamine?

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Case 1- Therapy

• Jimmy Coryza is a 14 year old with seasonal
  allergies. You wonder should I prescribe a nasal
  corticosteroid or a non-sedating anti-histamine?

Q In patients with seasonal allergies, is an
inhaled corticosteroid or a non-sedating
antihistamine better at relieving coryza?
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Case 2 -Diagnosis

• Hack Fredrickson has been coughing for 6 weeks.
  He is a heavy smoker, and you are considering
  skipping the chest x-ray and going straight to a
  CT scan.

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Case 2 -Diagnosis

• Hack Fredrickson has been coughing for 6 weeks.
  He is a heavy smoker, and you are considering
  skipping the chest x-ray and going straight to a
  CT scan.

Q In patients with cough, does chest x-ray or
chest CT have a better positive and negative
predictive value?
Q In patients with cough, does initial chest
x-ray or initial chest CT result in better
patient outcomes?
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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).
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Develop ACQs for this case (treatment,
diagnosis, prognosis, cause)

• CC 18 mo male with ear pain
• HPI
• fussy, not eating or sleeping well for the past
  2 days
• One prior OM 6mo ago
• Attends daycare
• Meds none
• PE
• T 38.9C
• Left ear red, bulging,decreased mobility
• Few small anterior lymph nodes
• Rest of the exam is normal

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Treatment
Q Among young children with otitis media, does
treatment with Amoxicillin compared with placebo
result in more rapid improvement?
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Diagnosis
Q Among young children with otitis media, how
does the clinical exam compare to tympano
centesis in diagnosing otitis media?
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Prognosis
Q Among young children with otitis media, is
smoking an important prognostic factor in
predicting frequency of disease?
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Etiology / Harm
Q Controlling for confounding factors, do
otherwise healthy children who attend daycare,
compared to children who do not have increased
incidence of otitis media in the first two years
of life?
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How do you choose whichquestion to answer?

• Most important to patients well-being
• Most feasible to answer in time available
• Most interesting to you
• Most likely to encounter repeatedly in practice

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THANK YOU

• ANY QUESTIONS?

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Tips
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Steps to improve your ability to ask and answer
questions 

• Become an effective computer user
• make information easily available on a computer.
• carry a handheld computer during patient care
  activities
• Know excellent sources of evidence-based
  information
• Cochrane Library from the Cochrane Collaboration
• Best Evidence reference from the American College
  of Physicians and the British Medical Journal
  Publishing Group.

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Steps to improve your ability to ask and answer
questions 

• Create a culture of inquiry
• Regularly reflecting on decisions and practices
  will stimulate clinical questions. Answering
  these clinical questions using valid, relevant
  information will keep a database up-to-date.

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Steps to improve your ability to ask and answer
questions 
Inquire, Dont Advocate

• Advocacy
• I think ,
• I believe ,
• The facts are ,
• Experience says .,
• My colleagues always .
• Advocacy ? uphold status quo

• Inquiry
• What do you think?
• I wonder whether there is a better way?
• Should I keep doing this?
• Why have I always ?
• Inquiry ? new knowledge and new insights.

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Additional Questions

• Should b-blocker (metoprolol) be used to continue
  treatment for a male with hypertension and
  coronary artery disease even though he has Type 2
  diabetes mellitus?
• Do patients surviving an AMI and experiencing
  transient or ongoing congestive heart failure
  (CHF) have reduced mortality and morbidity when
  treated with an ACE inhibitor (ex. Ramipril)?

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• In a child with asthma, do increased doses of
  inhaled corticosteroids lead to a decrease in
  growth?
• A Growth was significantly slower in the group
  receiving higher dose inhaled steroids (3.6 cm,
  CI95 3.0 to 4.2) with double dose beclometasone v
  5.1 cm (CI95 4.5 to 5.7) with salmeterol v 4.5 cm
  (CI95 3.8 to 5.2) with placebo (Barton, 2002)

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• For example, the sample question in section 1 can
  be represented in a simple PICO format as
  follows
• P asthma
• I inhaled corticosteroids
• C
• O growth

• A more-complete PICO representation of the same
  question is this
• P child with asthma
• I increased doses of inhaled corticosteroids
• C
• O decrease in growth