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Evidence-Based Practice

A guide to evidence-based practice for health care delivery. Clinical students, faculty, and staff interested in evidence-based practice will find these resources particularly useful. Use this page as a jumping-off point to locate journal articles, books

Forming the Well-Built Clinical Question

Background questions ask for general knowledge about an illness, disease, condition, process or thing. For example:

  • What is the clinical definition of overweight vs. obese?
  • What causes dental cavities?
  • Is stretching always necessary to recover ROM?

Consult textbooks or point-of-care tools, such as UpToDate to answer background questions. 

Foreground questions ask for specific knowledge to inform clinical decisions, typically concerning a specific patient or population. These questions tend to be more specific and complex compared to background questions. Foreground questions may be further categorized into one of 4 major types: treatment/therapy, diagnosis, prognosis, or etiology/harm. For example,

  • Is the combination of anti-depressive agents such as Bupropion with nicotine replacement more successful in achieving smoking cessation than nicotine replacement alone? 
  • In adolescent girls, is macrodantin more effective than bactrim in treating UTI?
  • Does occupational therapy improve cognitive function among adults with early onset Alzheimer's disease?

Consult medical databases such as PubMed, Cochrane Database of Systematic Reviews, and ACP Journal Club to address foreground questions.

Why should you use PICO to define the clinical question?

  • PICO helps you create a focused question and generate keywords to create efficient searches. 
Patient, Population or Problem How would I describe a group of patients similar to mine?
Intervention Which main intervention, exposure, or prognostic factor am I considering?
Comparison (if appropriate) What is the main alternative to compare with the intervention?
Outcome  What can I hope to accomplish, measure, improve, affect?
Type of Question  How would I categorize this question (therapy, diagnosis, prognosis, etiology/harm)?
Type of Study  What would be the best study design in order to answer this question? (see Types of Studies tab) 

 

Recognizing the type of clinical question of interest is an important part of the Evidence-Based Practice (EBP) process. Establishing the question type allows you to:

  • Identify the research methodology that provides the best evidence to answer the question.  
  • Select the best EBP Tools to search for the evidence. The Cochrane Database of Systematic Reviews, for example, only addresses treatment and prevention questions.  Other databases address questions of treatment and prevention, diagnosis, prognosis, etiology, quality improvement, and health economics, among others.
  • Select evidence filters in PubMed / CINAHL and other databases that will help narrow your search to papers using appropriate research methods.

Identifying your question type will also assist you in critically appraising the evidence based on the appropriateness and rigor of the research methods described in a paper.

 
Question Type Types of Evidence
Therapy/Treatment: Questions about effectiveness of interventions on improving patient outcomes. Meta-Analysis; Systematic Review; Randomized controlled trial
Prevention: Questions about effectiveness of an intervention or exposure in preventing morbidity and mortality. Meta-Analysis; Systematic Review; Randomized controlled trial; Prospective study
Diagnosis: Questions about the ability of a test or procedure to differentiate between those with and without a condition or disease Randomized controlled trial; Cohort study
Prognosis: Questions about the probable cause of a patient's disease or the likelihood that he or she will develop an illness Cohort Study, Case Control Series
Etiology: Questions about the harmful effect of an intervention or exposure on a patient Cohort study
 
Syntheses
Systematic Review: summary of studies conducted using specified criteria to identify, appraise, and summarize studies about a particular research question.
Meta-Analysis: summary of therapy trials using statistical methods to create a single weighted estimate of the intervention effect; studies with higher sample size are given more weight
Experimental Design
Randomized Control Trial (RCT): An experimental method where randomization should ensure that comparison groups are equal.
Non-Experimental Design
Cohort Study: follow one or more groups of individuals who have not yet suffered the adverse event and monitor the number of outcomes that occur over time. These need to be done when it is either not ethical or not practical to randomly assign patients to be "exposed" to something. Observational Design can be prospective or retrospective.
Case-Control Study: Collection of "cases" who have suffered the outcome and "controls" who have not. Investigators count the number of patients with a prognostic factor in the cases and the controls. These need to be done when the outcome of interest is rare or takes a long time to develop.
Case Series and Reports: Reports of patient scenarios that do not provide evidence of a causal relationship.

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Case 1: A 55-year African American male with hypertension lives in a rural area about 2-hours from his medical doctor. The doctor is considering prescribing a telemonitoring device to track the patient's blood pressure and to assess his compliance with the medication regimen.

P: 55-year old African American male with hypertension

I: telemonitoring

C: usual care

O: compliance with medication regimen

Study question: Among middle-aged adult African American males on medication for hypertension, is telemonitoring an effective approach for ensuring compliance with a medication regimen?

Case 2: A 12-year old girl presents for her annual dental check up. She has three new cavities and you are trying to decide whether to prescribe a home-based fluoride regimen or recommend fluoride treatments at the dentist to prevent future caries.

P: 12-year old girl

I: home-based fluoride treatment

C: fluoride treatments at provider

O: prevention of dental caries

Study Question: Among adolescent girls, how does a home-based fluoride regimen compare with fluoride treatments at the dentist to prevent cavities?

Case 3: A 70-year old female has made multiple attempts to quit smoking in the past using nicotine replacement therapy. She presents at your practice with renewed motivation. You remember reading that anti-depressants can help people quit tobacco and would like evidence about this potential treatment in older women.

P: 70-year old female smoker

I: Anti-depressant, e.g. Buproprion, in combination with nicotine replacement therapy

C: nicotine replacement therapy alone

O: tobacco cessation