Formulate an answerable question


 Original Editor ­ Rachael Lowe

Top Contributors - Rachael Lowe, Andeela Hafeez, Admin, Kim Jackson, WikiSysop and Kapil Narale ­ 

Related Pages

1. Evidence Based Practice (EBP)
2. Step1: Formulate an answerable question
3. Step 2: Find the best available evidence
4. Step 3: Appraise the evidence
5. Step 4: Implement the evidence
6. Step 5: Evaluate the outcome

Description

Every time we see a patient, we need new information about some element of the diagnosis, prognosis or management. Because our time to try to find this information is often limited, we need to be very efficient in our searching. To achieve this efficiency, we need to become skilled at formulating clinical questions.

This first step in evidence-based practice is to formulate a specific question. The question you have concerning your practice should be formulated so it is possible to find a scientific answer to the question. Posing specific questions relevant to a patient’s problem provides a focus to thinking, and it helps in the formulation of search strategies and in the process of critical appraisal of evidence.

Types Of Question

Background Questions

Background questions ask for general knowledge about a disorder and contain two essentials components:

• A question root (who, what, where, how, why)
• A disorder or aspect of a disorder

Textbooks answer background questions.  Not all topics are covered, easy to use, relatively inexpensive and can be opinion-based rather than evidence-based, written by experts in their fields.

Foreground Question

Foreground questions are descriptive and ask for specific knowledge about managing patients with a disorder.  These types of questions have a number of essential components (PICO analysis):

1. P - Patient/problem
2. I – Intervention
3. C - Comparison or control
4. O - Outcome
   
   

PICO Questions

Before we begin the hunt for evidence that relates to our clinical questions,we need to spend some time making the questions specific. Structuring and refining the question makes it easier to find an answer. One way to do this is to break the problem into 4 parts:

1. Patient or Problem
2. Intervention (cause, diagnostic test, treatment etc)
3. Comparison intervention
4. Outcome

Patient or Problem	Intervention	Comparison Intervention	Outcome
Description of the patient or the target disorder of interest	Could include: Exposure Diagnostic test Prognostic factor Therapy Patient perception etc.	Relevant most often when looking at therapy questions	Clinical outcome of interest to you and your patient

Patient or Problem:

This involves identifying those characteristics of the patient or problem that are most likely to influence the effects of the intervention. If you specify the patient or problem in a very detailed way you will probably not get an answer, because the evidence is usually not capable of providing very specific answers.  So a compromise has to be reached between specifying enough detail to get a relevant answer, but not too
much detail to preclude getting any answer at all.

Intervention :

This includes the intervention that we are interested in and what we want to compare the effect of that intervention to.

• Type of treatment (drug, procedure, therapy)
• Intervention level (dosage, frequency)
• Stage of intervention (preventative, early, advanced)
• Delivery (who delivers the intervention? where?)

Comparison intervention:

This is relevant when looking at most 'Therapy' questions.  It compares the effect of an intervention to no intervention, or to another alternative intervention. There may not always be a comparison

Outcome:

The clinical outcome or effects you are interested in, for example: improvement of symptoms, reducation of pain, improved quality of life, cost effectiveness and benefits for the service provider.

There are two additional elements that round out the well-built clinical question. These help in focusing the question and determining the most appropriate type of clinical evidence:

1. Type of Question : this is a question about --
   • Harm or Exposure : 
   • Diagnosis : How to select and interpret diagnostic tests
   • Therapy : How to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using them
   • Prognosis : How to estimate the patient’s likely clinical course over time and anticipate likely complications of disease
   • Aetiology : How to identify causes for disease, including genetics
2. Type of Study : what type of study would provide the best answer --
   • Randomised Controlled Clinical Trials
   • Meta-Analysis
   • Cohort Studies
   • Case Series
   • Case Control
   • Cross Sectional

Example

You are presented with this scenario:

A 47 year old patient presented with unilateral low back pain after lifting some heavy boxes at work.  On examination you find that he has stiffness and pain on all movements and on unilateral joint palpation L2-L3.  You think that specific unilateral mobilisations would help to clear the joint symptoms in several sessions but have read in the literature recently that exercise therapy alone may be more cost effective.

Think about the questions that might arise from this scenario:

1. Can joint mobilisations reduce pain and stiffness in the lumbar spine.
2. Is exercise therapy alone likely to create the same results.

Patient or Problem	Intervention	Comparison Intervention	Outcome
Unilateral low back pain	Unilateral mobilisations	Exercise therapy	Reduced pain and stiffness on movement

We can now use this to formulate our clinical question:

In a 47 year old man with unilateral low back pain, is exercise therapy alone more effective than joint mobilisations at reducing pain and restoring range of movement?

Resources

Check out the PICOT Research Question page for another explanation on using the PICOT formula, with some additional tips.