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Questions and outcomes

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Asking background and foreground questions, deciding on patient-oriented vs. disease-oriented outcomes

Asking background and foreground questions, deciding on patient-oriented vs. disease-oriented outcomes

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  • 1. Questions and Outcomes Self-Study Module John Epling, MD, MSEd Preventive Medicine Program SUNY-Upstate Medical University
  • 2. Acknowledgements
    • This presentation reviews material from:
      • the Evidence-Based Medicine Working Group
        • http://www.cebm.net/
        • http://ktclearinghouse.ca/cebm/
      • the Information Mastery Working Group
        • http://www.medicine.virginia.edu/clinical/departments/familymed/information_mastery
  • 3. Questions and Outcomes
    • Two topics to start our course with:
      • Clinical Questions
        • How we know what we don’t know…
      • Outcomes
        • What are we striving for?
    • Click through these slides – there are definitions and examples for all the concepts. You’ll practice what you learned in class.
  • 4. Clinical Questions
    • Teach thy tongue to say 'I do not know,' and thou shalt progress.
      • Maimonides
  • 5. Why talk about Questions?
    • Because most of medical school is composed of asking YOU questions…
    • We don’t emphasize enough teaching you the reasons and ways to ask questions…
    • Questions help us be specific about how much and what we don’t know…
    • They can also help us efficiently fill our knowledge deficits…
  • 6. Two types of Questions
    • Background
    • Foreground
  • 7. Background Questions
    • Useful when you don’t have ANY knowledge about a topic
    • Non-focused, general knowledge questions
    • Think Stem + Clinical Topic
      • Stem = What is, Why do, How does…
      • Clinical Topic – the disease/condition of interest
  • 8. Background Questions
    • Examples:
      • What is atrial fibrillation?
      • What are the causes of dyspnea?
      • What are the treatment options for deep vein thrombosis?
    • NOT a Background Question:
      • Should I use unfractionated heparin or low-molecular weight heparin for a patient with deep vein thrombosis? (too specific, comparing therapies)
  • 9. Foreground Questions
    • Useful when you know about a topic, but you’re asking about a specific clinical comparison or test or detail about that topic.
    • Think: PICO
      • P – patient/population
      • I – intervention/exposure/diagnostic test
      • C – comparison/no exposure/gold standard
      • O – outcome of interest/diagnosis
  • 10. Foreground Questions
    • There are four main types of foreground questions:
      • Therapy questions – comparing two or more interventions for a condition
      • Etiology/Harm – looking for an association between an exposure and an outcome
      • Diagnosis – comparing a new diagnostic test to the reference standard test
      • Prognosis – given a condition, does a certain factor portend a worse prognosis?
  • 11. Therapy Questions
    • Example (Using the PICO format)
      • In patients with deep vein thrombosis (DVT), does unfractionated heparin vs. low-molecular weight heparin lead to decreased recurrence of DVT?
        • P – patients with DVT
        • I – unfractionated heparin
        • C – low molecular weight heparin
        • O – recurrence of DVT
  • 12. Therapy Questions
    • Example:
      • In a population at risk for H1N1 influenza, does a new H1N1 vaccine (versus no vaccine) decrease disease rates?
      • In adults, does colorectal cancer screening (versus no screening) decrease mortality?
    • NOT a Foreground Therapy Question:
      • How is influenza treated in adults? (too broad, looking for treatment options, not comparing two or more for their effect on outcomes)
  • 13. Diagnostic Test Questions
    • These compare the accuracy of a new diagnostic test with that of the “reference standard” (the true confirmatory test) for the condition. The outcome is the diagnosis .
    • Example (using PICO):
      • In patients in whom acute appendicitis is suspected, does CT scan, as compared with exploratory laparotomy, diagnose appendicitis?
        • P – pts with abdominal pain and poss appendicitis
        • I – CT scan
        • C – exploratory laparotomy (surgery, the reference standard)
        • O – diagnosis of appendicitis
  • 14. Diagnostic Test Questions
    • Example:
      • In patients with a history of recent chest pains, does stress echocardiography versus cardiac catheterization diagnose coronary artery disease?
    • NOT a diagnostic test question:
      • In patients presenting to the ED with dyspnea, does the use of a beta-natriuretic peptide test result in decreased morbidity and hospital stay?
      • (tricky, the question is about a diagnostic test, but it is about how the use of the test alters clinical outcomes…not how well it diagnoses the disease)
  • 15. Etiology/Harm Questions
    • Useful to determine if one or more risk factors/exposures makes a clinical outcome more likely.
    • Example with PICO:
      • In adults, does cell phone use (versus no cell phone use) increase the risk of brain cancer?
        • P – adults
        • I – cell phone use (exposure…you may want to define a certain amount of exposure as qualifying
        • C – no cell phone use (or below the certain amount)
        • O – brain cancer rates
  • 16. Etiology/Harm Questions
    • Example: In previously healthy children, does vaccination with MMR vaccine increase the risk of autism?
    • Example: In adults with high risk of coronary heart disease, does exposure to vitamin E reduce the risk of coronary events?
    • NOT an etiology question: What are the causes of autism? (too broad…although several etiology questions might provide the evidence to answer this some day)
  • 17. Prognosis Questions
    • Useful to determine which factors change the prognosis of a given disease.
    • Example (using PICO): In patients with diabetes, does the development of neuropathy portend a greater mortality risk?
      • P - patients with type 2 diabetes,
      • I – development of neuropathy
      • C – not developing neuropathy
      • O –greater risk of mortality
  • 18. Prognosis Question
    • Examples: In patients with coronary heart disease, does an episode of CHF lead to reduced overall quality of life?
    • NOT a prognosis question:
      • In diabetics, does smoking lead to a greater risk of neuropathy?
      • (while the difference between harm and prognosis questions is sometimes slight, this is really asking about a risk factor rather than a clinical development)
  • 19. Questions about Questions?
    • There you have it.
    • Background Questions – used when you need a general review of a given topic.
      • They’re best answered with review articles from trustworthy sources (we’ll talk about this later)
    • Foreground Questions – used when you have a focused, clinical question
      • Look to original research (or structured synopses of original research) for these answers (we’ll talk about these later too!)
  • 20. Quick Break!
    • Get up and stretch, get that second (or seventh) cup of Starbucks™, and then press on!
  • 21. Outcomes
    • All studies have outcomes…That’s what the study authors want to see change in as a result of the intervention or the exposure.
    • Outcomes can be any definable clinical condition – a lab test result, a diagnosis, reaction or opinion, life or death, etc.
  • 22. Outcomes
    • For our purposes, we can divide outcomes into those that are PATIENT-ORIENTED and those that are DISEASE-ORIENTED.
    • Patient-Oriented – these are outcomes that patients can identify with: life/death, sickness events (heart attacks, strokes), hospitalizations, disability, symptom rates, etc.
    • Disease-Oriented – everything else – especially numbers – HgbA1c or lipid levels, blood pressure numbers.
  • 23. Outcomes
    • Frequently, in research, we look for “proxy measures” of disease – if we can prove that a high blood pressure is associated with mortality, then we can assume that lowering that blood pressure will reduce mortality.
    • That just ain’t necessarily so – the body is complex, our interventions have side effects and there may be unintended consequences.
  • 24. Outcomes
    • Examples of proxy outcomes that failed:
      • CAST – we assumed that treating ventricular dysrhythmia after a heart attack was a good thing…but the treatment was worse than the disease .
      • Womens’ Health Intiative – we improved cholesterol, bone density and possibly Alzheimer’s with estrogen in post-menopausal women, but not until the better trial was performed did we realize we were causing disease .
  • 25. Outcomes
    • So, we, as busy clinicians, should try to find all the Patient-Oriented Evidence we can. By doing so, we can avoid hasty or premature conclusions about how the body and our treatments work.
    • When faced with Disease-Oriented Evidence, we must use caution in interpreting its results, and look for more Patient-Oriented results (elsewhere in the literature, or in the future from better studies)
  • 26. Outcomes
    • When we’re evaluating the medical literature, outcomes aren’t the only important criteria, but focusing on Patient-Oriented outcomes can help us avoid overtreating based on preliminary findings.