Evidence Based Medicine :

Developing a Well Build Question

Diani Puspa Wijaya

 Learning objectives
• Mengaplikasikan EBM pada langkah
developing a well built question terkait
masalah pada kehamilan dan reproduksi
Dr. Sackett defines EBM as:
“…The conscientious, explicit, and judicious
use of current best evidence in making
decisions about the care of individual
patients.”

Sackett, et al. BMJ 1996;312:71-72

 Practice of EBM - steps
1. Asking answerable clinical question
2. Find current best evidence
3. Critically appraising
4. Apply the evidence
5. Evaluate
 Well built clinical question

The FIRST step

The HARDEST step
The MOST IMPORTANT step

“To get the right answer, you must first ask the
right question”
 Background question
• Ask for general knowledge about a
condition / thing
• Have 2 essential components :
– A question root (who, what, where, how, why)
and a verb
– A disorder, test, treatment or other aspect of
health care
• Example :
What causes abortus in pregnancy ?
 Foreground question
• Ask for specific knowledge to inform
clinical decision / action
• Have four essential components
– Patient and / or problem
– Intervention / exposure
– Comparison (if relevant)
– Clinical outcomes
• Example :
In hiperemesis gravidarum, is ginger extract
effective to reduce nausea ?
The PICO problem components
• The patient situation, population, problem
P of interest
– What is the disease ?
– What are the important characteristics
of my patient? – age, gender, etnic
• Starting with your patient, ask "How
would I describe a group of patients
similar to mine?“
• Be precise but brief
The PICO problem components
• Intervention
– What is the intervention I am looking for?
I C – Defined very broadly – an exposure, a dx
test, a profnostic factor, a tx, a patient
perception, etc
– Is it realistic (availability, cost, convenience,
etc)?
– Is this different from how I currently
practice?
• Comparison
– What is the alternative to the intervention /
exposure?
– Other prior, new or existing therapy
The PICO problem components
– Clinical outcome of interest

O – DOEs or POEMS (GE is good antiemetic vs GE is

effective to reduce nausea)
– Ask "What can I hope to accomplish?" or "What
could this exposure really affect?“
– Select patient-oriented outcomes instead of “the
numbers”
– Outcomes to focus on:

• Time course: Untreated HG resolves by 16 week pregnancy

for 4 of 5 pregnant women
• Pain: Ginger extract do not reduce nausea at 1 day, but may
reduce it at 2 and 7 days follow up (quality of life)
• Complications: Ginger extract do NOT decrease incidence of
dehidration (morbidity)
• Side effects: Ginger extract cause rash, diarrhea and nausea
with an equal likelihood as treatment success (quality of life)
 DOEs vs POEM
Disease Oriented Patient Orieted Evidence
Evidence that Matters
• Pathophysiology • Morbidity
– Lab values – Symptoms
– Biochemical markers – Daily function
• Pharmacology • Mortality
– Plaque size • Quality of Life
– Blood pressure – (as perceived by the
• Etiology patient)
 Foreground question

Background question
 Background question
Basic, concrete

1. QUESTION
• Who, What, Where, When, Why, How

2. VERB
• is, causes, does, treats, reduces, cures, prevents, affects

3. GENERAL KNOWLEDGE ABOUT DISORDER

clinical manifestations of disease, patient findings, differential
diagnosis, etiology, patient experience, comorbid condition,
screening and diagnostic tests, prognosis, therapy, risk factors,
etc.
 Foreground question
New posibility, indefinite answer

PT AND/OR PROBLEM Differential dx, Unusual presentation, uncertain

etiology, pt’s prior experience, comorbid conditions

INTERVENTION Exposure, test. Prognostic factor,

treatment, pt perception, etc.

COMPARISON

OUTCOMES
Types of Foreground questions
 Harm or Etiology: Are there harmful effects of a
particular intervention, or how these harmful effects can
be avoided.

 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 for a particular condition.

 Prognosis: What is the patient's likely course of

disease, or screen for or reduce risk of outcome.

 Prevention: How can the patient's risk factors be

adjusted to help reduce the risk of disease?

 Cost: Looks at cost effectiveness, cost/benefit analysis.

 Exercise
• Seorang perempuan berusia 28 tahun
dalam kehamilan 20 minggu, pasien
diketahui memiliki BMI sebelum kehamilan
dalam kategori obese. Hasil pemeriksaan
GDS saat ANC didapatkan 180 gr/ dl.
 Evaluate
Apply

Appraise

Search
best
research
evidence
Well
build
question
• Keyword : PICO TT
• Google scholar, Pubmed, biomedical
database
EBM Resources

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 Systematic Reviews
• Comprehensive search
• Use only high quality studies
• Summary of the results

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 Sources of Systematic Reviews

• Cochrane

• DARE – Database of Abstracts of Reviews of

Effects

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The Cochrane
Collaboration

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 Cochrane Library - Limitations
• Only addresses questions that can be in
randomized controlled trials
• Doesn’t address all subject matter
• Only available through subscription

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 Clinical Evidence

• A database of questions (summaries) covering the

effects of treatments and interventions.
• Online Update Frequency: Monthly
• PDA format: Yes
• Publisher: BMJ Publishing Group

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 Synopses
• Published in secondary journals
– Appraise for validity
– Use only high quality original studies and
review articles
– Provide a “bottom line”
– Succinct, accurate, and authoritative

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ACP Journal Club Resource Information
• Surveys over 150 peer-reviewed medical journals
to produce summaries of original studies and
systematic reviews
• For the internist or sub-specialist physician
• Online Update Frequency: Bi-monthly
• Publisher: American College of Physicians (ACP)

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 PubMed Central
• U.S. National Institutes of Health (NIH)
• Free digital archive of biomedical and life
sciences journal literature
• A platform for enriched linking, analysis, and use
of research reports and data
• Indexes over 4600 peer reviewed journals
• Contains over 13.5 million citations from 1951-

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NEJM

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 Evaluate
Apply

Appraise

Search
best
research
evidence
Well
build
question
 Critical Appraisal

Are the result valid ?

Is the valid evidence important ?

Can we apply this valid, important

evidence to our patient ?

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 Evaluate
Apply

Appraise

Search
best
research
evidence
Well
build
question
• AAFP. EBM Toolkit
• http://www.aafp.org/journals/afp/authors/ebm-
toolkit/resources.html
• University of Oxford. EBM toolkit
• http://www.cebm.net/index.aspx?o=1023
• Evidence Based Medicine How to Practice
and Teaching