Clinical Question Formulation in Evidence-Based Medicine at The Florida State University College of Medicine
undefined
1
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
2
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
3
EBM – A Multi-Step Process
2015-2016
The Question
2. Construct a well built clinical question
derived from a case
2015-2016
4
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
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
Constructing A Clinical Question
2015-2016
8
Examples
2015-2016
9
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
10
Question Worksheet
P - Who?
I - What?
C- Alternatively?
Outcome?
Type of Question
Therapy
Prognosis
Diagnosis
Harm/Etiology
Screening
C
C
o
o
n
n
s
s
t
t
r
r
u
u
c
c
t
t
a
a
c
c
l
l
i
i
n
n
i
i
c
c
a
a
l
l
q
q
u
u
e
e
s
s
t
t
i
i
o
o
n
n
f
f
r
r
o
o
m
m
y
y
o
o
u
u
r
r
o
o
w
w
n
n
c
c
l
l
i
i
n
n
i
i
c
c
a
a
l
l
e
e
x
x
p
p
e
e
r
r
i
i
e
e
n
n
c
c
e
e
.
.
2015-2016
Acquire the Evidence
3. Select the appropriate resource(s) and
conduct a search
2015-2016
11
11
12
Major EBM Databases (Foraging Tools)
Cochrane
ACP Journal Club
InfoPOEMS
Evidence Based _____
USPSTF
National Guidelines
Clearinghouse
2015-2016
NLM: Drilling down for the Best Evidence
Based Information
S
t
a
r
t
a
t
t
h
e
t
o
p
a
n
d
w
o
r
k
y
o
u
r
w
a
y
d
o
w
n
t
i
l
l
y
o
u
f
i
n
d
w
h
a
t
y
o
u
n
e
e
d
Impractical and time consuming
Major Comprehensive EBM Tools
14
Web and Mobile
*
Mobile Formatted Websites
2015-2016
Summaries and Clinical Inquiries
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
APPENDIX
Descriptions of Major EBM Databases
2015-2016
16
16
17
Cochrane Library
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
18
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
19
InfoPOEMS
P
atient
O
riented
E
vidence that
M
atters
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
20
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
21
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
2015-2016
Trip Database
Allows you to put in your PICO terms and search
Pubmed, ClinicalTrials, Guidelines, as well as lower
level online resource like eMedicine.
2015-2016
22
Linked to Trip
Contact me with questions.
NBClark
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.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
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
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
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
THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE The Question 2. Construct a well built clinical question derived from a case 2015-2016 4
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
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
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
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
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
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
THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE Acquire the Evidence 3. Select the appropriate resource(s) and conduct a search 2015-2016 11
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
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
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
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
THE FLORIDA STATE UNIVERSITY COLLEGEOF MEDICINE APPENDIX Descriptions of Major EBM Databases 2015-2016 16
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
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
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
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
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
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
