Formulating Question

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Formulating Question
Soroush Mortaz Hejri, MD http//ssrc.tums.ac.ir/sy
stematicreview
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Formulating review questions
Searching selecting studies
Study quality assessment
Extracting data from studies
Data synthesis
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Rationale for well-formulated questions

• Determining the structure of a review
• Determining Strategies for locating and selecting
  studies or data,
• Critically appraising the relevance and validity,
• Helping readers in their initial assessments of
  relevance.

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Where clinical questions come from

• Therapy
• Diagnostic Test
• Clinical Findings
• Etiology
• Differential Diagnosis
• Prognosis
• Prevention

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Clinical scenario

• A 77-year-old man is admitted for dyspnea and
  fever. He fell ill 4 days ago with low-grade
  fever, chills, myalgias, rhinorrhoea and a
  non-productive cough. One day ago he developed
  dyspnea on exertion, purulent sputum, lateral
  chest wall pain with inspiration and a shaking
  chill. His general health is fairly good he has
  had essential hypertension for 12 years, well
  controlled on diuretic therapy. He has not
  smoked.

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• On examination, respiratory rate 28, heart rate
  108 and temperature 39.2C.
• He have subtle cyanosis. His chest expands
  symmetrically, he has no wheezing. There is
  bronchophony and egophony in the left lower
  posterior lung field.

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• Initial blood tests show leukocytosis and
  hyponatremia.

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• The team suspects acute community-acquired
  pneumonia with hypoxemia, and plans chest
  radiographs, sputum studies, supplemental oxygen
  and antimicrobial therapy.

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• what questions you have about this case?

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• What microbial organisms can cause
  community-acquired pneumonia?
• How does pneumonia cause egophony?
• What is the prevalence of community-acquired
  pneumonia?

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• These questions ask for general orbackground
  knowledge about pneumonia.
• not normally asked because of a need to make a
  clinical decision about a specific patient.

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type of question

• Background
• asked because of the need for basic information
• two essential components
• A question root (who, what, where, when, how)
• A disorder, or an aspect of a disorder

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• In this patient is a chest radiograph necessary
  for the diagnosis?
• In this patient is the probability of Legionella
  infection sufficiently high to consider covering
  this organism with the initial antibiotic choice?
• In this patient , do clinical features predict
  outcome well enough that as a low risk patient
  can be treated safely at home?

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• Specific knowledge about diagnosis, prognosis,
  and treatment of patients with pneumonia, might
  be called foreground knowledge.
• Foreground Questions ask for specific knowledge
  about managing patients with a disorder.

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type of question

• Foreground
• The patient and/or problem
• The main intervention (including an exposure, a
  diagnostic test, a prognostic factor, a
  treatment, a patient perception,)
• Comparison intervention
• The clinical outcome .

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Formulating a clinical question

• This skill can be improved by
• breaking the question down into its component
  parts
• classifying the question into a domain
• therapy, diagnosis, prognosis, harm

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Question components PICO

• What types of Participants?
• What types of Interventions?
• What types of Comparison?
• What types of Outcomes?

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What types of participants?

• Disease or condition of interest
• Potential co-morbidity
• Setting
• Demographic factors

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What types of intervention?

• Treatment
• Diagnostic test
• Causative agent
• Prognostic factor
• Exposure to disease
• Risk behavior

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What types of outcomes?

• For treatment include all outcomes important to
  people making decisions to define success of
  therapy
• For prognosis, outcome is the chosen endpoint of
  the disease

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Patient oriented outcomes

• Mortality/Survival
• Risk of disease
• Disease free period
• Quality of life
• Work absenteeism
• Disability/ Duration and severity of illness
• Pain
• Accuracy of diagnose

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Common Types of question

• Diagnosis
• Therapy
• Prognosis
• Causation / Etiology

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What types of study designs?

• RCTs are considered the best when addressing
  questions regarding therapeutic efficacy,
• Cohort and case-control studies for questions
  relating to etiology or risk factors

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Example

• A 27 year old student describes depression,
  tiredness and lack of enjoyment.
• You diagnose dysthymia. You wonder about
  prescribing antidepressants. However, you are
  unsure whether there is evidence supporting their
  use in dysthymia.

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formulate the question

• In adults with dysthymia (problem),
• do antidepressants (intervention)
• more than placebo (comparison)
• improve mood (outcome)?

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Example

• A 75 year old man with a stroke is admitted to
  general medicine. He has left-sided weakness. He
  is otherwise well and you decide to transfer him
  to a stroke unit.
• His family is concerned because they live close
  to the hospital where he is currently as an
  inpatient and want to know why he needs to be
  transferred to a stroke unit of a different
  hospital and why he can't stay on the general
  medicine ward.

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formulate the question

• In a patient with a stroke, (problem)
• does admission to a stroke unit (intervention)
• decrease the risk of death and dependency?
  (outcome)

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Example

• A acute cough is a common reason for patients to
  consult their GP. The causes of acute cough
  varies a lot. the treatment often includes
  antibiotics.
• The effectiveness of Abx is questionable and
  there has been a great deal of concern about
  bacterial resistance from over-prescribing.

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Patient Acute Cough in primary care setting
Intervention Antibiotics
Comparison No antibiotics
Outcomes Duration and severity of illness
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A 1 yr old just had a febrile seizure - what will
happen to her?

• Patient In children 6mo-6yrs who have had

Intervention (Exposure) a first febrile seizure,
what is
Outcome the likelihood of recurrent febrile
seizures epilepsy neurologic damage?
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Broad or Narrow Questions?

• Broad
• Do drug X reduce mortality and morbidity in
  people with severe malaria?
• Narrow
• Do drug X suppositories reduce mortality in
  children with cerebral malaria?

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What is the Best Treatment for Zoster?

• What is the most cost-effective treatment for
  zoster if we consider pain reduction, quality of
  life and prevention of post-herpetic neuralgia?

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What is the Best Treatment for Zoster?

• Is famciclovir effective at preventing
  postherpetic neuralgia (defined as pain 3 months
  after rash healing) in otherwise healthy patients
  aged 60-70 who present within 48 hours of zoster
  rash, compared with placebo?

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Balance precision with brevity

• Equal precision in addressing each component is
  not necessary.

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THANK YOU
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