Pico+Kuliah+Modul+Ebm+2010 Edit
Pico+Kuliah+Modul+Ebm+2010 Edit
Pico+Kuliah+Modul+Ebm+2010 Edit
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
Patient Encounter
Apply
Appraise
EBM
Acquire Searching the Evidence
Ask
(Lang, 2000)
2/3 clinical questions unanswered. Are the unanswered questions important? 50% of the answers direct impact on patient care.
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 physicians will seek and find an answer to a clinical question are
the urgency of the problem and their confidence that they will find an answer
Type of Question
Evidence based practice requires clinicians make use of the best research they can find to help them in decision-making. To find that research efficiently, they must ask a welldesigned clinical question with all the elements that will lead to finding relevant research literature. The first step in doing this is to determine the type of question: background or foreground. It helps to determine the resource (reference) to answer the question.
Type of Questions
"Background" "Foreground"
Questions on general knowledge about a condition or thing. Answering the background question.
excellent review article or respected evidencedbased textbook.
Questions on specific knowledge to inform clinical decisions or actions. Answering the foreground question.
Primary source : journal Secondary source : Cochrane
Background Questions
Ask for general knowledge about a disease or disease process Two essential components:
A question root (who, what, when, etc.) with a verb A disorder, test, treatment, or other aspect of healthcare Example: What causes migraines? or How often should women over the age of 40 have a mammogram?
Foreground questions
Ask for specific knowledge about managing patients with a disease Have 3 or 4 essential components
Patient and/or problem Indicator / Intervention Comparative intervention (optional, include if relevant) Clinical outcome
In young children with acute otitis media, is short-term antibiotic therapy as effective as long term antibiotic therapy?
Question type
GENERAL KNOWLEDGE
Clinical experience
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
P=Population/Patient/Problem
How would you describe a group of patients similar 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 patient might be relevant to the diagnosis or treatment of a disease.
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 the patient? Age? Co-existing problems? What was the patient exposed to? Asbestos? Cigarette smoke?
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.
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?
QUESTION CATEGORIES
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 a particular 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
Exercise
In patients with suspected depression what is the In patients acute bronchitis, do antibiotics accuracy ofwith a two-question case-finding reduce sputum production, cough or with days six off instrument for depression compared work? previously validated instruments? In women taking oral contraceptives, is there an association between their use and cardiovascular disease?
EXERCISE
In patients with suspected depression what is the accuracy of a two-question case-finding instrument for depression compared with six previously validated instruments?
P= I = C= O=
EXERCISE
In women taking oral contraceptives, is there an association between their use and cardiovascular disease?
P= I = C= O=
EXERCISE
In patients with acute bronchitis, do antibiotics reduce sputum production, cough or days off work?
P= I = C= O=
Adapted from: Sackett et al.s Evidence-Based Medicine: How to Practice and Teach EBM
Information Pyramid
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 daughter wants you to give her mother a prescription for one of the new COX-2 inhibitors. She has heard that they cause less GI bleeding.
Case #1
PATIENT/PROBLEM
72 year old woman with osteoarthritis of the knee and moderate hypertension
INTERVENTION
COX-2 Inhibitor
COMPARISON
other NSAIDS
OUTCOME
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
Type of study/methodology:
Systematic Review/Meta Analysis of Double-Blind Randomized Controlled Trials
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-sided weakness but is otherwise well. His only medication is ASA and he has no allergies. He recently saw an article on the BMJ website describing the risk of seizure after a stroke and is concerned that this will happen to him.
Case #2
PATIENT/PROBLEM
70 year old man
INTERVENTION
Stroke
COMPARISON
OUTCOME
Seizure
PICO:
In a 70 year old man does a history of stroke increase his risk for seizure?
Type of Question:
Prognosis
Type of study/methodology:
Cohort studies
Case #3
You admit a 75 year old woman with communityacquired pneumonia. She responds nicely to appropriate antibiotics but her hemoglobin remains at 10 g/dl with an MCV of 80. Her peripheral blood smear shows hypochromia, she is otherwise well and is on no incriminating medications. You contact her family physician and find out that her Hgb was 10,5 g/dl about 6 months ago. She has never been investigated for anaemia. A ferritin has been ordered and comes back at 10 mmol/l. You admit to yourself that you're unsure how to interpret a ferritin result and aren't sure how precise and accurate it is.
Case #2
PATIENT/PROBLEM INTERVENTION COMPARISON OUTCOME
Iron deficiency anaemia Elderly woman with Ferritin anaemia
PICO:
In an elderly woman with hypochromic, microcytic anaemia, can a low ferritin diagnose iron deficiency anaemia?
Type of Question:
Diagnosis
Type of study/methodology:
Controlled Studies; Systematic Review/Meta Analysis of Controlled Studies