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Thread: [Evidence-Based Medicine] Five Types of Foreground Clinical Questions

  1. #1

    Exclamation [Evidence-Based Medicine] Five Types of Foreground Clinical Questions

    1.Therapy: determining the effect of interventions on patient-important outcomes (symptoms, function, morbidity, mortality, and costs)

    2.Harm: ascertaining the effects of potentially harmful agents (including therapies from the first type of question) on patient-important outcomes.

    3.Differential diagnosis: in patients with a particular clinical presentation, establishing the frequency of the underlying disorders.

    4.Diagnosis: establishing the power of a test to differentiate between those with and without a target condition or disease.

    5.Prognosis: estimating a patient's future course.

    [Evidence-Based Medicine] Five Types of Foreground Clinical Questions-screen-shot-2015-09-19-at-10-17-33-am-png
    [Evidence-Based Medicine] Five Types of Foreground Clinical Questions-screen-shot-2015-09-19-at-10-17-56-am-png
    [Evidence-Based Medicine] Five Types of Foreground Clinical Questions-screen-shot-2015-09-19-at-10-18-26-am-png
    Last edited by admin; Sat 19th September '15 at 2:30pm.
    Clinical Pharmacy Specialist - Hematology

  2. #2

    Default Example 1: Diabetes and Target Blood Pressure

    Example 1: Diabetes and Target Blood Pressure

    A 55-year-old white woman present with type 2 diabetes mellitus and hypertension. Her glycemic control is excellent with metformin, and she has no history of complications. To manage her hypertension, she takes a small daily dose of a thiazide diuretic. During a 6-month period, her blood pressure is near 155/88 mm Hg.

    Initial Question: When treating hypertension, at what target blood pressure should we aim?
    Clinical Pharmacy Specialist - Hematology

  3. #3

    Default Digging Deeper

    One limitation of this formulation of the question is that it fails to specify the population in adequate detail. The benefits of tight control of blood pressure may differ among patients with diabetes,and among patients with and without diabetic complications.

    The detail in which we specify the patient population is a double-edged sword. On the one hand, being very specific (middle-egged women with uncomplicated type 2 diabetes) will ensure that the answer we get is applicable to out patient. We may, however, fail to find any studies that restrict themselves to this population. The solution is to start with a specific patient population but be ready to remove specifications to find a relevant article. In this case, we may be ready to remove the "female," "middle-aged," "uncomplicated," and "type 2," in that order. If we suspect that the optimal target blood pressure may be similar among patients with and without diabetes, and if it proves absolutely necessary, we might remove "diabetes" from the question.

    The order in which we remove the patient specifications depends on how likely it is that those characteristics will influence response to treatment. We suggest removing "female" first because we think it likely that optimal target blood pressure will be similar in men and women. Similarly, younger, middle-aged, and elderly individuals are likely to have the same optimal targets (although here we are not quite so sure). As our doubts about the same optimal targets across populations becomes progressively greater (uncomplicated vs complicated diabetes, type 1 vs type 2, or patients with diabetes vs those without), we become increasingly reluctant to remove the particular patient characteristic from the question.

    We may wish to specify that we are interested in the addition of a specific antihypertensive agent. Alternatively, the intervention of interest may be any antihypertensive treatment. Furthermore, a key part of the intervention will be the target for blood pressure control. For instance, we might be interested in knowing whether it makes any difference if our target diastolic blood pressure is less than 80 mm Hg vs less than 90 mm Hg. Another limitation of the initial question formulation is that it fails to specific the criteria (the outcomes of interest) by which we will judge the appropriate target for our hypertensive treatment.
    Last edited by CheneyHsiung; Sat 19th September '15 at 10:53am.
    Clinical Pharmacy Specialist - Hematology

  4. #4

    Default Improved (Searchable) Question for Example 1/Therapy

    Patients: Patients with hypertension and type 2 diabetes without diabetic complications.

    Intervention: Any antihypertensive agent that aims at a target diastolic blood pressure of 90 mm Hg.

    Comparator: Target diastolic blood pressure of 80 mm Hg.

    Outcomes: Stroke, myocardial infarction, cardiovascular death, and total mortality.
    Clinical Pharmacy Specialist - Hematology

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