Pico+Kuliah+Modul+Ebm+2010 Edit

7/27/2019 Pico+Kuliah+Modul+Ebm+2010 Edit

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Bambang Tridjaja

delivered by Nia Kurniati

Developing

Answer

able Clinical Questions


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Goals

At the end of this lecture, you will:

Be able to create a well-formed clinical

question

Appreciate the importance of well-formed

clinical questions in keeping up-to-date


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EBM

PatientEncounter

FormulatingClinical

Question

Searchingthe

Evidence

Appraisingthe

Evidence

Diagnosis

Therapy

Prognosis

Etiology

Patient

Intervention

Comparison

Outcome

Hierarchy of evidence

Pre appraised resources

Drawing conclusion

That impact on practice

Ask

Acquire

Appraise

Apply

(Lang, 2000)


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What Questions Do Clinicians Ask at the

Point of Care?

RESEARCH Physicians reported

1 question / 4 patients( day)

15 questions / 25patients per day

Primary care doctors 2 questions / 3 patient

Questions relation

33 % ~ treatment 25 % ~ diagnosis 15 % ~ pharmaco -

therapeutics.

2/3 clinical questionsunanswered.

Are the unansweredquestions important? 50% of the answers direct impact onpatient care.


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WHY BOTHER FORMULATING QUESTIONS

CLEARLY?

Answerable Clinical Questions:

1. Help focus our scarce learning time on

evidence that is directly relevant to our

patients clinical needs.

2. Help us focus our scarce learning time on

evidence that directly addresses our

particular knowledge needs, or those of our

learners.

(Strauss et al, 2005)


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WHY BOTHER FORMULATING ANSWERABLE

CLINICAL QUESTIONS?


3. Suggest high-yield search strategies

4. Suggest the forms that useful answers mighttake

5. When sending or receiving a patient in

referral, they can help us to communicatemore clearly with our colleagues.



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CLEARLY?


6. When teaching, ACQ help our learners to

better understand the content of what we

teach, while also modeling some adaptive

processes for lifelong learning.



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CLEARLY?


7. When our questions get answered, our

knowledge grows, our curiosity is reinforced,

our cognitive resonance is restored, and we

can become better, faster, and happier

clinicians.



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Answerable

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 physicianswill 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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How do you choose which

question to answer?

Important to a patient's well-being (in terms of

outcomes that they care about)

Feasible to address in the time available (you think

you might be able to find an answer) Likely to recur in your practice (common to practice)

Involve an intervention that is feasible and not your

current practice Interesting to you

Medico-legal issue


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Type of Question

Evidence based practice requires cliniciansmake use of the best research they can find tohelp them in decision-making. To find thatresearch efficiently, they must ask a well-designed clinical question with all theelements that will lead to finding relevantresearch literature.

The first step in doing this is to determine thetype of question: background or foreground.It helps to determine the resource (reference)to answer the question.


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Type of Questions

"Background"

Questions on general

knowledge about a

condition or thing. Answering the

background question.

excellent review article

or respected evidenced-based textbook.

"Foreground"

Questions on specific

knowledge to inform

clinical decisions oractions.

Answering the

foreground question.

Primary source : journal

Secondary source :

Cochrane


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Background Questions

Ask for general knowledge about a disease ordisease process

Two essential components:

A question root (who, what, when, etc.) with averb

A disorder, test, treatment, or other aspect ofhealthcare

Example: What causes migraines?or How oftenshould women over the age of 40 have amammogram?


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Foreground questions

Ask for specific knowledge about managingpatients with a disease

Have 3 or 4 essential components Patient and/or problem

Indicator / Intervention

Comparative intervention (optional, include ifrelevant)

Clinical outcome

In young children with acute otitis media, isshort-term antibiotic therapy as effective as longterm antibiotic therapy?


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Type of question depend onthe clinical experience

GENERAL KNOWLEDGE

SPECIFIC KNOWLEDGE

Question

type

Clinical experience


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PICO

PICO is a mnemonic used to describe the four

elements of a good clinical foreground

question.

P--Patient

IIndicator/Intervention

C--Comparison

O--Outcome


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P=Population/Patient/Problem

How would you describe a group of patientssimilar to yours?

What are the most important characteristics

of the patient? May include the primary problem, disease, or

co-existing conditions.

Sometimes the sex, age or race of a patientmight be relevant to the diagnosis ortreatment of a disease.


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I=Indicator/Intervention; E=Exposure Which main intervention/prognostic factor/or

exposure are you considering?

Whats your plan for the patient? Prescribe a

drug? Order a test? Order surgery?

What factor may influence the prognosis of thepatient? Age? Co-existing problems?

What was the patient exposed to? Asbestos?Cigarette smoke?


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C=Comparison What is the main alternative to compare with

the intervention?

Are you trying to decide between two drugs, a

drug and no medication or placebo, or two

diagnostic tests?

Your clinical question does not always need a

specific comparison.


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O=Outcome What can you hope to accomplish, measure,

improve or affect?

What are you trying to do for the patient?

Relieve or eliminate the symptoms?

Reduce the number of adverse events?

Improve function or test scores?


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QUESTION CATEGORIES


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Question Categories

Diagnosis How to select a diagnostic test or how

to interpret the results of a particular test.

Therapy Which treatment is the most effective,

or what is an effective treatment given aparticular condition.

Harm or Etiology Are there harmful effects of a

particular treatment or exposure or risk factor Prognosis What is the patient's likely course of

disease given the characteristic


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Exercise

In patients with suspected depression what is theaccuracy of a two-question case-finding

instrument for depression compared with six

previously validated instruments?

In women taking oral contraceptives, is there an

association between their use and cardiovascular

disease?

In patients with acute bronchitis, do antibiotics

reduce sputum production, cough or days off

work?


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EXERCISE

In patients with suspected depression what is theaccuracy of a two-question case-finding

instrument for depression compared with six

previously validated instruments?

P =

I =C =

O =


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EXERCISE

P =

I =C =

O =

In women taking oral contraceptives, is there an

association between their use and cardiovascular

disease?


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EXERCISE

P =

I =C =

O =

In patients with acute bronchitis, do antibiotics

reduce sputum production, cough or days off

work?


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PICO & Applicability

Information Pyramid


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GUIDE TO PICO APPLICABILITY

PATIENT/PROBLEM INDICATOR COMPARISON OUTCOME

PICO:

Type of Question:

Type of study/methodology:


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Case #1

Your next patient is a 72-year-old woman with

osteoarthritis of the knees and moderate

hypertension, accompanied by her daughter, a

lab tech from the hospital. The daughterwants you to give her mother a prescription

for one of the new COX-2 inhibitors. She has

heard that they cause less GI bleeding.


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FILL IN THE COLUMN

PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME

PICO:

Type of Question:



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Case #1


72 year old woman

with osteoarthritis

of the knee and

moderate

hypertension

COX-2 Inhibitor other NSAIDS less GI bleeding

PICO:

In a 72 year old woman with osteoarthritis of the knee, can COX-2 Inhibitor use

decrease the risk of GI bleeding compared with other NSAIDs?

Type of Question:

Therapy/Treatment


Systematic Review/Meta Analysis of Double-Blind Randomized Controlled Trials


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Case #2

You see a 70 year old man in your outpatient

clinic 3 months after he was discharged from

your service with an ischemic stroke. He is in

sinus rhythm, has mild residual left-sidedweakness but is otherwise well. His only

medication is ASA and he has no allergies. He

recently saw an article on the BMJ websitedescribing the risk of seizure after a stroke and

is concerned that this will happen to him.


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FILL IN THE COLUMN


PICO:

Type of Question:



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Case #2


70 year old man Stroke Seizure

PICO:

In a 70 year old man does a history of stroke increase his risk for seizure?

Type of Question:

Prognosis


Cohort studies


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Case #3

You admit a 75 year old woman with community-acquired pneumonia. She responds nicely toappropriate antibiotics but her hemoglobin remains at10 g/dl with an MCV of 80. Her peripheral blood smearshows hypochromia, she is otherwise well and is on noincriminating medications. You contact her familyphysician and find out that her Hgb was 10,5 g/dlabout 6 months ago. She has never been investigatedfor anaemia. A ferritin has been ordered and comes

back at 10 mmol/l. You admit to yourself that you'reunsure how to interpret a ferritin result and aren't surehow precise and accurate it is.


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FILL IN THE COLUMN


PICO:

Type of Question:



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Case #2


Elderly woman with

anaemia

Ferritin Iron deficiency

anaemia

PICO:

In an elderly woman with hypochromic, microcytic anaemia, can a low ferritindiagnose iron deficiency anaemia?

Type of Question:

Diagnosis


Controlled Studies; Systematic Review/Meta Analysis of Controlled Studies


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Pico+Kuliah+Modul+Ebm+2010 Edit