Division of Neonatology

Evidence-Based Medicine Resources-Types of Questions

Questions may be thought of as being of two general categories:

• Background Questions

Background questions concern the disease process itself, including such elements as epidemiology, physiology, pathophysiology, presentations, pharmacology, and general outcomes. Information regarding background information may be found in numerous sources including reviews, textbooks, educational presentations, etc. Information about background questions may be slowly evolving (pharmacokenitics of gentamicin in adults) or rapidly changing (molecular techniques in gene identification).

Most of our backgrounds and training developed around studying background questions. Generally, however, in evidence-based medicine, an emphasis is placed on answering specific patient-related questions rather than background questions. Still, asking well-structured background questions is also important, though beyond the realm of these pages.

Our approach for focused background questions is based on targeting the question to a disease or process, identifying the category of question, and focusing the question on one aspect of the disease, process, or category. For example, the background question "What are the physiological activities of pulmonary surfactant?" will result in a broad answer to a non-specific question. A focused question might be built as follows.

Category: (Patho)physiology

Aspect: SP-A

Target (Disease State, Biological System, Biological Process, Nursery Policy): RDS

Focused Question: What is the role of Surfactant Associated Protein A in RDS?

This will result in a focused, specific answer that can be developed rapidly from sources available on line or in the nurseries. The MUSC template for this approach to background questions is available here:

Background Question Worksheet

• Foreground Questions

  Foreground questions are specific patient or problem generated questions frequently arising from patient encounters. They can be thought of as having relevance to the clinical situation at hand. Formulating such questions well will provide an efficient and practical approach to addressing clinical questions utilizing principles of evidence-based medicine. While we face therapeutic questions on a daily basis in clinical practice, many of us may not be skilled in developing answerable questions, let alone developing efficiently answered questions. Several approaches to asking answerable questions have been developed. One such approach is outlined below. Although this approach - PICO - has been adopted here, other approaches may be equally useful.

  P: Patient population or problem

  I: Intervention

  C: Comparison or control

  O: Outcome

  By addressing the above statements, a three- or four-part question may be developed ("comparison" may be omitted when it is appropriate to do so).

   

  P: The patient, population, and/or problem should be defined. Depending on the situation, the question may be focused by restricting characteristics of the the patients - such as age, sex, or other factors. Similarly, the disease or problem may be restricted to severe or moderate degrees, as appropriate. Remember, however, there is a trade-off. While restrictions may make more applicable to a given individual, they also may lessen the likelihood of locating acceptable evidence. Modifications may be made at any point, of course.

  I: The intervention refers to that which is being evaluated. This may be a test, a treatment, a risk factor, etc. An intervention might increase our ability to diagnose disease more accurately (tests and diagnostic measures), identify high-risk populations (screening programs, exposure analysis, examinations), or intervene more effectively (therapeutic measures, palliation, education).

  C: Comparison groups are often appropriate when comparing interventions, especially therapeutic interventions. The principles of scientific investigation become important in evaluating how well comparison groups are used.

  O: Knowing what outcome you wish to evaluate is critical to formulating questions. Generalities (Do patients do better...) should be avoided and specific outcomes identified. Some outcomes may be grouped (death or disability), while others will stand alone (life prolongation). The outcome will often be dependent on the clinical situation giving rise to the question.

   

  A good, brief, introduction to formulating answerable questions can be found on the Mount Sinai Hospital / University of Toronto's EBM web site.

   

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