Clinical Question Formulation in Evidence-Based Medicine at The Florida State University College of Medicine

Learn the essential steps in formulating clinical questions in evidence-based medicine at The Florida State University College of Medicine. Understand the distinction between background and foreground questions, PICO format, and the multi-step EBM process. Enhance your ability to find evidence-based answers to clinical queries and improve patient care outcomes.

• Clinical Medicine
• Evidence-Based Medicine
• Florida State University
• Medical Education
• Clinical Question Formulation

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1. THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Asking Clinical Questions and Finding an Evidence-Based Answer Daniel Van Durme, MD, MPH Chair, Dept. of Family Med and Rural Health Nancy Clark, MEd Director of Medical Informatics Education 2015-2016 1

2. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Objectives Distinguish a background question from a foreground clinical question Formulate an evidence-based, PICO formatted, foreground question Find evidence-based answers to your clinical questions 2015-2016 2

3. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE EBM A Multi-Step Process 1. Start with the patient -- a clinical problem or question arises out of the care of the patient The patient 2. Construct a well built clinical question derived from the case 3. Select the appropriate resource(s) and conduct a search The question The resource 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) The evaluation 5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice The patient 6. Evaluate your performance with patient & process Self-evaluation 2015-2016 3

4. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE The Question 2. Construct a well built clinical question derived from a case 2015-2016 4

5. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Background and Foreground Questions What do I know about this condition? How common is it? Is it usually aggressive and rapidly fatal? How can it be treated surgery, chemotherapy, radiation? What about family history what about his son s risk? Etc. These are called background questions not suitable for PICO format Best source of information for background information? Recent reputable textbook, med app, Google search

6. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Foreground Questions - apply to that specific patient (or population) What are my choices to best care for THIS patient? What is the best way to diagnose and treat this patient? What are the patient s preferences and special considerations? Use PICO format for Foreground questions

7. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Constructing A Clinical Question P I C O intervention comparison outcome patient Alternative Intervention? Outcomes Who? What? What is the patient oriented outcome better prognosis? Higher rate of cure? Etc.? How would I describe a group of patients similar to this particular patient? Which treatment, test or other intervention? Compared to what other treatment, test, or perhaps compared to doing nothing 2015-2016 7

8. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Examples P I C O No treatment except acetaminophen for pain/fever Kids with acute otitis media -2-4 y/o No pain after two days? Antibiotics Diagnostic accuracy (Predictive value or likelihood ratio) Adult with microhematuria IVP CT scan Rates of CVA within 90 days Adult patients <70 TIA No TIA Routine No screening evaluate only if problems Pain, disability, need for intervention Healthy adolescents scoliosis screen 2015-2016 8

9. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Types of Questions Best Answered by EBM Resource Therapy Question In patients with migraine headaches without auras, are antiepileptics more effective than beta blockers for prophylaxis of headaches? Prognosis Question In diabetic patients with foot ulcers, is the diagnosis of osteomyelitis with MRI as predictive of healing as an audible pulse on Doppler examination? Diagnosis Question In geriatric patients with suspected carotid stenosis, is duplex ultrasound as good as magnetic resonance angiography in detecting significant carotid stenosis? Harm Question For pregnant patients, does the consumption of large amounts of coffee, (compared to non-coffee drinkers) increase the rate of spontaneous abortion? 2015-2016 9

10. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Question Worksheet P - Who? I - What? C- Alternatively? Outcome? Type of Question Therapy Prognosis Diagnosis Harm/Etiology Screening Construct a clinical question from your own clinical experience. 2015-2016 10

11. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Acquire the Evidence 3. Select the appropriate resource(s) and conduct a search 2015-2016 11

12. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Major EBM Databases (Foraging Tools) Cochrane ACP Journal Club InfoPOEMS Evidence Based _____ USPSTF National Guidelines Clearinghouse 2015-2016 12

13. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE NLM: Drilling down for the Best Evidence Based Information Start at the top and work your way down till you find what you need Cochrane Library Clinical Inquiries Specialty-specific POEMs ACP Journal Club Usefulness Textbooks, Guidelines Journals/ Medline PubMed Impractical and time consuming

14. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Major Comprehensive EBM Tools LOE Cochrane ACP Journal Club Guide- lines US- PSTF Tools Web and Mobile Essential Evidence +* Dynamed Plus Up-To-Date PEPID Summaries and Clinical Inquiries * Mobile Formatted Websites 2015-2016 14

15. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Fastest Method to Answer Start with comprehensive resources: Dynamed Plus Up-To-Date Essential Evidence Plus Search using terms in PICO question If no answer Trip, Pubmed or Google Scholar Search the journals for the latest research articles on that question. 2015-2016 15

16. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE APPENDIX Descriptions of Major EBM Databases 2015-2016 16

17. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Cochrane Library The current resource with the highest methodological rigor For each clinical question, all of the English literature meticulously searched for randomized trials Large systematic reviews with valid methods + collaborative effort by Review Groups Conclusions are based on all the evidence from valid randomized trials (treatment and harm questions) Structured abstracts easy to digest Link to abstract 2015-2016 17

18. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE ACP Journal Club About 130 internal medicine journals systematically surveyed Highest-validity articles abstracted. Link to article. Structured abstracts to guide critical appraisal Clinical commentary Now published in the Annals of Internal Medicine Alerts available (RSS feed) 2015-2016 18

19. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE InfoPOEMS Patient Oriented Evidence that Matters Journal of Family Practice and other specialty journals Systematic surveillance of 100 journals Reviews of recent research articles linked to Pubmed Effect patient concerns morbidity, mortality, quality of life Included in Essential Evidence Plus Daily e-mail updates available Let us know if you would like to receive these Link to a Daily InfoPOEM 2015-2016 19

20. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Guidelines.gov Stored at National Guidelines Clearinghouse Agency for Healthcare Research and Quality Over 2365 Guidelines may be Explicit evidence-based Evidence-based Research-based (highly referenced) expert consensus Multiple guidelines on one condition Link to guideline see Recommendations 2015-2016 20

21. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE US Preventive Services Task Force First convened by the U.S. Public Health Service in 1984 Since 1998 Agency for Healthcare Research and Quality Leading independent panel of private-sector experts in prevention and primary care Conducts rigorous, impartial assessments of the scientific evidence for effectiveness of broad range of clinical preventive services, including screening, counseling, and preventive medications Its recommendations considered "gold standard" for clinical preventive services Link to Online Tool AHRQ Home 2015-2016 21

22. THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Trip Database Allows you to put in your PICO terms and search Pubmed, ClinicalTrials, Guidelines, as well as lower level online resource like eMedicine. Linked to Trip 2015-2016 22