K - 2 Asking Answerable Question

ROZAIMAH ZAIN-HAMID
ISTI ILMIATI FUJIATI
Community Research Program

Faculty of Medicine
Universitas Sumatera Utara
Evidence-Based Medicine
The conscientious, explicit,
and judicious use of
current best evidence
in making decisions
about the care
of individual patients.
Zain-Hamid, R; CRP, Faculty of Medicine,
Practices of
EBM
Best available clinical evidence
from systematic research
Clinical expertise
Patient preferences
EBM Process
Clinical
question
Searching evidence
Critical appraisal
Using evidence
Evaluation
Drawing
Conclusion
that Impact
on practice
* DOES
* POEM
EBM Process
Patient
encounter
Appraising
the evidence
* Hierarchy
of evidence
* Pre appraise
resource
(Lang, 2000)
Diagnosis
Therapy
Prognosis
Etiology
Formulating
the Clinical
Questions
Searching
evidence
Patient
Intervention
Comparison
Outcomes
The reason formulate ACQ

Essential to improving practice
(if we never pose questions about what we
are doing we can never change what we are
doing on a rational basis.
Save time for electronic search

to answer questions
Essential for lifelong learning process

(will continually improve our ability to serve
patients)
The reason formulate ACQ

Stimulate curiosity and delight in learning
Foster better communication with
other practitioners who are familiar with
the format for clearly worded questions
Vague question lead to a vague answer
Specific question specific answer
Clinical questions answered directly
Questions defined clearly
Proposed
intervention
Relevant
outcome
Two characteristics that predict

whether physicians will seek and find
an answer to a clinical questions
The urgency of
the problem
Their confidence that

they will find an answer
ANSWERABLE CLINICAL QUESTIONS

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)
How do you choose which

question 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
Type of Question
Background
questions
Foreground
questions
Background questions
Ask for general knowledge about a
disorder (anatomy, physiology,
pathophysiology, diagnosis, treatment,
prognosis, or basic management)
Components:
what, when, where, why, whom, how
Example: What is the pathogenesis of asthma?
Background questions
General or background knowledge
2 parts:
have
1st question: who, what, where, when, why, how

2nd : disorder, condition, therapy, etc.
Example:
What population is most at risk for hepatitis?
Foreground questions
Ask for specific about the disease,
Components:
Patient, intervention, comparison, outcome
Example:
What is the best drug combination for
asthma management?
Are you sleepy ?
Foreground:
Four-part clinical question
The Patients and/or Health Problem (P)
Intervention (I)
Comparison of intervention (C)
Outcome (O)
Intervention x
for clinical outcome y
in patient/problem z
Foreground:
Four-part clinical question
The Patients
: pregnant women with

preterm labor
Intervention
: calcium channel blocker
Comparison
: other tocolytics
Clinical outcome : prolongation of pregnancy
Is calcium channel blocker

more effective in prolongation of
pregnancy than other tocolytics?
Learn to Ask a Focused Clinical Question

- Foreground
Patient
Problem /
Population
Description of the group to which your patient

belongs, (age, gender, race, ethnicity, and
stage of disease). The description should be
specific enough to be helpful, but not overly
specific.
Intervention
description of the test or treatment that you

are considering
Be specific!
what you plan to do for that

patient
Comparison
the alternative. Not all questions need a

comparison,
the main alternative you are considering
Outcome
something that not only matters to you, but

matters to the patient. Be specific!
what is the main concern?
Be specific!
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?

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?

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

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...)?
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
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)
PICO & Applicability

Patient
Problem /
Population
Is my patient similar enough to

the patients in the study that the
evidence can be applied? Would
my patient have met the study's
inclusion criteria? A valid study
may not be applicable to your
patient if your patient
differs in important ways from
the study patients. .
Alan Schwartz

Intervention
Could the intervention in the

study be carried out in my
setting, and in a way that is
similar enough to the way it was
conducted in the study? A valid
study may not be applicable to
your patient if the study
intervention is impractical, too
costly, requires skills,
equipment, or medications that
are not locally available, etc
Alan Schwartz

Comparison
Is the comparison in the study

similar to the standard of care
(or for a diagnostic test study,
the gold standard) in my
setting? A valid study may not
be applicable to your patient if
you are already using a better
standard of care (or for a
diagnostic test study, you have a
better gold standard) than that to
which the study intervention is
compared.
Alan Schwartz

Outcome
Are the outcomes measured in

the study similar enough to
those that are relevant and
important in my setting or to my
patient? A valid study may not
be applicable to your patient if it
reports outcomes that can not
be measured practically in your
setting, or that are unimportant
to your patient
Alan Schwartz
Simple vs complete PICO format

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
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?
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?

Conclusions
* ACQ Essential for lifelong learning
process
* ACQ Background & Foreground
question
* Foreground question PICO
Comparing
DOEs and POEs2
Evidence-Based Medicine
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.


K - 2 Asking Answerable Question

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ROZAIMAH ZAIN-HAMID

ISTI ILMIATI FUJIATI

Community Research Program

The reason formulate ACQ

Save time for electronic search

Essential for lifelong learning process

The reason formulate ACQ

Clinical questions answered directly

Questions defined clearly

Two characteristics that predict

Their confidence that

ANSWERABLE CLINICAL QUESTIONS

Characteristics of Good Question

How do you choose which

1st question: who, what, where, when, why, how

Are you sleepy ?

: pregnant women with

Is calcium channel blocker

Learn to Ask a Focused Clinical Question

Description of the group to which your patient

description of the test or treatment that you

what you plan to do for that

the alternative. Not all questions need a

something that not only matters to you, but

People in a particular care setting?

Particular groups of people

How would you describe your clients / setting?

What exactly am I considering?

What alternatives actions might I try?

What am I hoping to accomplish

POEs and DOEs

POE = Patient oriented evidence

PICO & Applicability

Is my patient similar enough to

PICO & Applicability

Could the intervention in the

PICO & Applicability

Is the comparison in the study

PICO & Applicability

Are the outcomes measured in

Simple vs complete PICO format

This patient has elevated blood

My dad is 70 years old - should his

Zain-Hamid, R; CRP, Faculty of Medicine,

Zain-Hamid, R; CRP, Faculty of Medicine,

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