7/22/2019

Defining Clinical
Questions
ARDITYA DAMAR KUSUMA

1
 7/22/2019

• For aircraft passengers, does

using parachute compared to
empty backpack preventing death
and trauma related to
gravitational challenge?

Session outline

•Defining clinical questions

 Why
 What
 How
•Exercises

2
 7/22/2019

Defining clinical questions: Why?

• Essential first step in EBM

 Conduct efficient searching
 Determine search strategy
 Decide relevant paper

Defining clinical questions: What?

•Background Questions
•Foreground Questions

3
 7/22/2019

Background Questions

• Informational question that improve the

understanding of a topic (diseases or
conditions)
• Physiology or pathophysiology of diseases
• Basic questions (5W+1H)
• Example:
 What is angina pectoris?
 Why patients with angina pectoris get
decreasing in the quality of life?

Foreground Questions
• Specific questions related to patients’
management
• Being asked by experts
• Treatment/therapy, diagnosis, prognosis, or
etiology/harm
• Use PICO (TS*) / PECO (TS*)  to focus
clinical questions
• Example:
 In patients with angina pectoris, is the
usage of nitroglycerin oral able to
increase quality of life?

4
7/22/2019

5
 7/22/2019

Evidence-Based Hierarchy

Type of questions Type of study designs

Therapy Information about Systematic review/Meta-
Types of clinical
patients’ questions
therapy analysis of RCTs
(e.g. effectiveness, Double-Blind RCT
adverse event, etc)

6
 7/22/2019

Type of questions Type of study designs

Types of clinical questions

Diagnosis Information about Systematic review/Meta-

diagnostic test (e.g. analysis of diagnostic studies
sensitivity, Cross-sectional study with
specificity, etc) random or consecutive sample

Type of questions Type of study designs

Types of clinical questions

Prognosis Information about Systematic review/Meta-

the course of illness analysis of prognostic studies
(e.g. morbidity, Cohort/survival study
complication, etc)

7
 7/22/2019

Type of questions Type of study designs

Types of clinical questions

Etiologic/Har Information about Systematic review/Meta-

m the cause of diseases analysis of RCTs/observational
or factor contributing studies
to diseases RCTs, cohort study, case-control
study

Defining clinical questions: How?

P I (E) C O
Population Intervention or Comparison Outcomes
Exposure

Common cold Antibiotic Placebo Cure Rate

Clinical Question’s Component

8
 7/22/2019

Population/ Problem/ Patient

Who are the relevant
patients?
• Clear definition to identify people of interest
 Health condition
 e.g. healthy people, specific stage of cancer, etc
 Population and setting. Consider whether
issues of equity and relevance to specific
populations are important to the questions
 e.g. sex, age, ethnicity, geographic, economic status,
etc

Intervention/Indicator/ Exposure
What is the management strategy,
diagnostic test, or exposure that you are
interested in?
• Clear definition of the intervention or exposure of interest
(e.g. dose, frequency, duration)

Therapy Diagnostic test Exposure

9
 7/22/2019

Comparison or Control
What is the control or alternative management
strategy, test or exposure that you will
be comparing the one you are
interested in with?
• Define specific active comparisons in as much
detail as the intervention
• Be clear what you mean by ‘no intervention’
 e.g. no intervention, placebo, usual care,
etc.
• Can remain open to any comparisons found,
but be explicit

Outcome

What are the patient-relevant

consequences of the exposure in
which we are interested?
• Desired and/or unwanted effect
e.g. cure rate, mortality rate, quality
of life, accuracy of diagnostic test,
adverse event

10
 7/22/2019

Example
• Parachute for preventing death
and trauma in aircraft passengers
P : Aircraft Passengers
I : Parachute
C : Without Parachute
O : Death and trauma

11
7/22/2019

12
7/22/2019

13
 7/22/2019

Exercises

Clinical questions: therapy

A 28-year-old male presents with recurrent furunculosis for

past 8 months; these episodes have been treated with
drainage and several courses of antibiotics but keep
recurring. He asks if recurrences can be prevented.

14
 7/22/2019

Clinical questions: therapy

A 28-year-old male presents with recurrent furunculosis for

past 8 months; these episodes have been treated with
drainage and several courses of antibiotics but keep
recurring. He asks if recurrences can be prevented.

Clinical questions: therapy

A 28-year-old male presents with recurrent furunculosis for

past 8 months; these episodes have been treated with
drainage and several courses of antibiotics but keep
recurring. He asks if recurrences can be prevented.

15
 7/22/2019

Clinical questions: therapy

A 28-year-old male presents with recurrent furunculosis for

past 8 months; these episodes have been treated with
drainage and several courses of antibiotics but keep
recurring. He asks if recurrences can be prevented.

Clinical questions: therapy

• Population/patient = patients with recurrent furunculosis

• Intervention/indicator = prophylactic antibiotics
• Comparator/control = no treatment
• Outcome = reduction in recurrence rate of furunculosis

Question: ‘In patients with recurrent

furunculosis, do prophylactic
antibiotics, compared to no
treatment, reduce the recurrence
rate?’

16
 7/22/2019

Clinical Questions: Diagnosis

Julie is pregnant for the second time. She had her first baby
when she was 33 and had amniocentesis to find out if the
baby had Down syndrome. The test was negative, but it was
not a good experience as she did not get the result until she
was 18 weeks pregnant. She is now 35, one month pregnant
and asks if she can have a test that would give her an earlier
result. The local hospital offers serum biochemistry plus
nuchal translucency ultrasound screening as a first trimester
test for Down syndrome. You wonder if this combination of
tests is as reliable as conventional amniocentesis.

Clinical Questions: Diagnosis

Julie is pregnant for the second time. She had her first baby
when she was 33 and had amniocentesis to find out if the
baby had Down syndrome. The test was negative, but it was
not a good experience as she did not get the result until she
was 18 weeks pregnant. She is now 35, one month pregnant
and asks if she can have a test that would give her an earlier
result. The local hospital offers serum biochemistry plus
nuchal translucency ultrasound screening as a first trimester
test for Down syndrome. You wonder if this combination of
tests is as reliable as conventional amniocentesis.

17
 7/22/2019

Clinical Questions: Diagnosis

Julie is pregnant for the second time. She had her first baby
when she was 33 and had amniocentesis to find out if the
baby had Down syndrome. The test was negative, but it was
not a good experience as she did not get the result until she
was 18 weeks pregnant. She is now 35, one month pregnant
and asks if she can have a test that would give her an earlier
result. The local hospital offers serum biochemistry plus
nuchal translucency ultrasound screening as a first trimester
test for Down syndrome. You wonder if this combination of
tests is as reliable as conventional amniocentesis.

Clinical Questions: Diagnosis

Julie is pregnant for the second time. She had her first baby
when she was 33 and had amniocentesis to find out if the
baby had Down syndrome. The test was negative, but it was
not a good experience as she did not get the result until she
was 18 weeks pregnant. She is now 35, one month pregnant
and asks if she can have a test that would give her an earlier
result. The local hospital offers serum biochemistry plus
nuchal translucency ultrasound screening as a first trimester
test for Down syndrome. You wonder if this combination of
tests is as reliable as conventional amniocentesis.

18
 7/22/2019

Clinical Questions: Diagnosis

Julie is pregnant for the second time. She had her first baby
when she was 33 and had amniocentesis to find out if the
baby had Down syndrome. The test was negative, but it was
not a good experience as she did not get the result until she
was 18 weeks pregnant. She is now 35, one month pregnant
and asks if she can have a test that would give her an earlier
result. The local hospital offers serum biochemistry plus
nuchal translucency ultrasound screening as a first trimester
test for Down syndrome. You wonder if this combination of
tests is as reliable as conventional amniocentesis.

Clinical Questions: Diagnosis

• Population/patient = pregnant women

• Intervention/indicator = nuchal translucency ultrasound
screening plus serum biochemistry (first trimester)
• Comparator/control = conventional amniocentesis
• Outcome = accurate diagnosis (measured by sensitivity
and specificity) of Down syndrome (trisomy 21)

Question: ‘For pregnant women, is nuchal translucency

ultrasound screening plus serum biochemistry testing in
the first trimester as accurate (i.e. with equal or better
sensitivity and specificity) as conventional amniocentesis
for diagnosing Down syndrome?’

19
 7/22/2019

Clinical Questions: Etiology or Risk Factor

Jeff has come in to your surgery to discuss the possibility of
getting a vasectomy. He says he has heard something about
vasectomy causing an increase in testicular cancer later in
life. You know that the risk of this is low but want to give him
a more precise answer.

Clinical Questions: Etiology or Risk Factor

Jeff has come in to your surgery to discuss the possibility of
getting a vasectomy. He says he has heard something about
vasectomy causing an increase in testicular cancer later in
life. You know that the risk of this is low but want to give him
a more precise answer.

20
 7/22/2019

Clinical Questions: Etiology or Risk Factor

Jeff has come in to your surgery to discuss the possibility of
getting a vasectomy. He says he has heard something about
vasectomy causing an increase in testicular cancer later in
life. You know that the risk of this is low but want to give him
a more precise answer.

Clinical Questions: Etiology or Risk Factor

Jeff has come in to your surgery to discuss the possibility of
getting a vasectomy. He says he has heard something about
vasectomy causing an increase in testicular cancer later in
life. You know that the risk of this is low but want to give him
a more precise answer.

21
 7/22/2019

Clinical Questions: Etiology or Risk Factor

• Population/patient = adult males
• Intervention/indicator = vasectomy
• Comparator/control = no vasectomy
• Outcome = testicular cancer

Question: ‘In men, does having a vasectomy (compared to

not having one) increase the risk of getting testicular
cancer in the future?’

Clinical questions: prognosis

Childhood seizures are common and frightening for the

parents and the decision to initiate prophylactic treatment
after a first fi t is a difficult one. To help parents make their
decision, you need to explain the risk of further occurrences
following a single seizure of unknown cause.

22
 7/22/2019

Clinical questions: prognosis

Childhood seizures are common and frightening for the

parents and the decision to initiate prophylactic treatment
after a first fi t is a difficult one. To help parents make their
decision, you need to explain the risk of further occurrences
following a single seizure of unknown cause.

Clinical questions: prognosis

Childhood seizures are common and frightening for the

parents and the decision to initiate prophylactic treatment
after a first fi t is a difficult one. To help parents make their
decision, you need to explain the risk of further occurrences
following a single seizure of unknown cause.

23
 7/22/2019

Clinical questions: prognosis

Childhood seizures are common and frightening for the

parents and the decision to initiate prophylactic treatment
after a first fi t is a difficult one. To help parents make their
decision, you need to explain the risk of further occurrences
following a single seizure of unknown cause.

Clinical questions: prognosis

• Population/patient = children
• Intervention/indicator = one seizure of unknown cause
• Comparator/control = no seizures
• Outcome = further seizures

Question: ‘In children who have had one seizure of

unknown cause, compared with children who have had no
seizures, what is the increased risk of further seizures?’

24
 7/22/2019

Referensi

• O’Connor D, Green S, Higgins JPT (editors). Chapter 5: Defining

the review question and developing criteria for including
studies. Higgins JPT, Green S (editors). Cochrane Handbook for
Systematic Reviews of Interventions Version 5.1.0 [updated
March 2011]. The Cochrane Collaboration, 2011. Available from
http://community.cochrane.org/handbook
• McKibbon A, Wyer P, Jaeschke R, Hunt D. Finding the evidence.
Ch. 4. In: Guyatt G, Rennie D, Meade MO, Cook DJ, eds. Users’
Guides to the Medical Literature: A Manual for Evidence-Based
Clinical Practice. 2nd ed. New York: McGraw-Hill, 2008.
Available:
http://0-
www.jamaevidence.com.innopac.wits.ac.za/content/3348229.
[Accessed 25.07.2012]

25