L4.

CLINICAL QUESTION

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NIDA GHITA A

M IMRAN KHAN I

M ILHAM DHIYA R

GUSTI CHANDRA P

AWLIYA

DIANTIKA NARINASTITI

JOSUA K H

[ft. KKI 2015] SYAFIRA NURLAILA D

RIFQI RIZKANI E

IRFAN ARIEQAL HATTA A

QC: AFIAH SALSABILA

DR. EKA DIAN SAFITRI

SP.T.H.T.K.L
EBM
 CLINICAL QUESTION
DAFTAR ISI

DAFTAR ISI ......................................................................................................................................................................... 1

Clinician, Clinical Practice and Evidence-based Practice................................................................................................... 2
Introduction: What Questions Do Clinicians Ask at the Point of Care? ........................................................................ 2
Evidence-based Practice ................................................................................................................................................... 3
Evidence-based Medicine ............................................................................................................................................. 3
Clinical Question ........................................................................................................................................................... 4
 Clinician, Clinical Practice and Evidence-based Practice

Introduction: What Questions Do Clinicians Ask at the Point of Care?

Based on observational research, it is found that primary physicians generate at
least 10 – 15 questions when practicing every day (Covell, 1985; Ely, 1999; Ebell,
2003). Other researchers found that:
- Specifically, physicians ask 1 question per 4 patients in half a day. And 15
questions per 25 patients in each day
- Primary care doctors: 2 questions per 3 patients
The questions that arise are about:
- 33% related to treatment
- 25% related to diagnosis
- 15% related to pharmaco-therapeutics
Unfortunately 2/3 of these clinical questions are unanswered or not pursued at
the point of care (Ely, 1999; Ely, 2000), which is alarming because half of the
answers to these questions have direct effects on patient care or treatment.
Why does this happen? It is likely because of these three interrelated things:
- Information overload
The body of research for a certain topic might contain conflicting information,
for example: one paper states that drug A is effective, but another states
otherwise.
- The ability (of medical doctors) to formulate questions
- Lack of literature searching skills
-
Medical-related literature is developing very rapidly. The Medline database itself
has around 24 million citations. This is why asking the right questions is really
important to find the most relevant papers. Barriers to finding relevant
information include:
- Difficult access to reference materials
- Limited time

There are two factors that predict whether a physician will find and answer to a
clinical question:
- Urgency of the problem
- Confidence that they will find the answer
 Evidence-based Practice

Three principles of Evidence-Based Medicine/Evidence-Based Practice include:

- Patient values (values held by patients)
- Clinical expertise (Physicians’ clinical skills and abilities)
- Best available evidence (availability of literature sources)
These three aspects will influence decision making regarding patient care

Evidence-based Medicine
- Cycle of Evidence-based Medicine
 ▪ Patient encounter
o Patients may ask one to several questions about medicine that they
heard outside the facility; using amateur phrase. Doctors and students
may be the ones asking question;
either way, there are four types of question: etiology & risk factors,
diagnosis, therapy (intervention), and prognosis
▪ Formulating clinical question (THE MEAT OF THIS LECTURE)
We need to know the right keywords to search the article that meet our
need (PICO)
▪ Searching the evidence
➢ Scroll through the article list
➢ Filter those that dont meet our criteria
➢ Prioritize articles that has high hierarchy of evidence
▪ Appraising the evidence
“is this article valid? Can i trust whatever they write here?”
▪ Read the articles
▪ Draw a conclusion
▪ Answer the question

Importance of a well defined review question

• A well-defined review questions is an essential first step for your review

• It will guide many aspects of your methods
o Eligibility criteria
o Search strategy
o Data collection and analysis
• You should plan out some details at the beginning of the process
• You should have clear boundaries for the scope of your review. This will
avoid bias and reduce risk of making decisions

Clinical Question
- Types of Clinical Questions
Based on the content:
1. Diagnosis Questions : Questions about the ability of a test or
procedure to differentiate between those with and without a condition or
disease, or the comparison one diagnostic tool with the others.
2. Therapy Questions : About the effectiveness of interventions in
improving outcomes in sick patients / patients suffering from some
condition.
3. Etiology Questions : About the harmful effect of an intervention or
exposure on a patient
4. Prognosis Questions : About the probable cause of a patient’s disease
or the likelihood that one will develop an illness or condition.
Based on the format:
1. Background Questions : General questions about a health topic. This type
of questions typically ask 5W+1H (who, what, where, when, how, and why)
about common things like a disorder, test, or treatment, or other aspect of
 healthcare. It covers terminology, general pathology, patient education
resources, general drug information, examination/assessment procedure.
For example:
What is clinical manifestation of menopause?
What causes migraines?
2. Foreground Questions : Focused questions about a health topic. These
questions ask for specific knowledge regarding a disease to inform clinical
decisions. They typically concern a specific patient or particular population
and are more specific and complex than background questions. Quite often,
foreground questions investigate comparison, such as two drugs or two
treatments.
For example:
Is Crixivan effective in slowing rate of functional impairment in a 45 year
old male patient with Lou Gehrig’s Disease?

- Determining Question Type

▪ Therapy : Asks about the effect of an alternative treatment compared to
standard treatment on improving health or producing adverse events
▪ Harm (etiology): Asks about the effects of potentially harmful agents,
morbidity and mortality of the disease
▪ Diagnosis: Asks about the ability of an intervention to differentiate
between those with and without the disease
▪ Prognosis: Asks about estimates regarding the future course of a disease
- Component of Clinical Question
P: patient/population
I: intervention/indicator
C: comparison
O: outcome
 - Clinical Scenario
▪ We can find clinical scenarios from real clinical cases and the news
▪ Real clinical cases:
✓ From clinical rounds or consultation
✓ Journal clubs
✓ Online video clips
▪ News stories
✓ Newspapers, news web-sites
✓ Blogs
✓ Journal web-sites – in the news
Example clinical scenario:

A 40-year-old patient came with, ringing in the left ear with fluctuation hearing
loss problem and vertigo since one year a ago. Examination from anamnesis and
physical finding the diagnosis is Meniere Syndrome. The doctors gave her Betahistin
with doses 24 mg and patient has to limited salt intake for two months. From the
follow up, patient’s problem is not improve and the doctor think about to increase the
dose of Betahistin based on the literature that He has read. Patient ask the doctor
whether consumption of high dose of Betahistin is effective and safe for her.

- From that scenario, here are the possible background questions :

1. What is Meniere Syndrome?
2. How is Meniere Syndrome diagnoses?
3. How is Betahistin therapy can reduce the symptoms?

- From that scenario, the possible foreground question is below (which is a

question related to therapy) :

Population/Patient Intervention Comparison Outcome

In adults with Does Betahistin Compare to high Would reduce the
 Meniere low doses doses symptoms and
Syndrome recurrence
In adults with Meniere Syndrome, does Betahistin low doses compare to high doses
would reduce the symptoms and recurrence?

- Examples of questions in different types for the above scenario (adult patient
with Meniere syndrome) :

Diagnosis :

Population/Patient Intervention Comparison Outcome

In adults with Does CT scan Compare to MRIWould increase
Meniere the accuracy to
Syndrome detect
endolymphatic
hidrops
In adults with Meniere Syndrome, does CT Scan compare to MRI would increase the
accuracy to detect endolymphatic hidrops?

Prognosis :

Population/Patient Intervention Comparison Outcome

In adults with Does various - Would increase
Meniere clinical factors recurrency
Syndrome like
cardiovascular
problem
In adults with Menier Syndrome, does various clinical factors like cardiovascular
problem would increase recurrency?

A. Eligibility Criteria
- Eligibility criteria is the essential components to determine whether a study is
▪ Included and discussed in a review
▪ Excluded
- To determine the eligibility criteria, the consideration is based on
▪ Some or all of the PICO component
▪ Definition of eligible study design

Two additional important elements of the well-built clinical question to consider

are the type of foreground question and the type of study (methodology). This
information can be helpful in focusing the question and determining the most
appropriate type of evidence. Knowing the type of foreground question (Therapy,
Diagnosis, Prognosis, Etiology/Harm) can help you select the best study design
to answer your question. You always want to look for the study design that will yield
the highest level of evidence.