Evidence And Clinical Questions
Evidence And Clinical Questions
Neck pain is the second rated diseases among the complications that affect the spinal cord. It has been reported in a helps relax the entire body muscles and the mind too.“The simulation and manipulation treatment has helped in reducing death rates of women under this age and helped solve community problems.T-This mode of therapy has proofed to provide excellent results within a short period of four weeks. Our PICOT statement looks like: “Community women of above 45 years. Evidence And Clinical Questions.
I simulation and manipulation treatment (SMT)C“ Neck only simulation and manipulation treatment – Death rates.T- within four weeks.
Conclusion
The clinic attendants are very eager and interested to know the research progress that is in a relationship and about patient care. PICOT is an important model which helps in carrying out clinical research. The model helps those utilizing it which include researchers and the clinicians and help them in communication and coming together to help solve related problems.[bookmark: _GoBack]Some considerations should be made in the treatment of neck pains under the PICOT program (Kaka, Ogwumike, Ogunlade, & Adeniyi., 2015). The treatment requires patients that are willing to adhere to the clinic orders and directions. The design above requires a variety of patients with similar neck problems to find out the efficiency of the PICOT program. The interventions are specific and should be administered by only clinicians to avoid doing a common work. Under this program, the patient is mostly depended upon in giving the outcomes of the treatment rather than taking the same patient through machine tests and evaluations. This idea is not hundred percent since patience sometimes gets tired of explaining to the clinician how they feel and getting the correct response for what they feel.
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The measurement of outcomes only occurs on a regular basis of every four months to identify the changes made by the neck pain patients. The research, as discussed in this article, is always important to look into the efficiency of PICOT model and relate it to other findings probably by a different researcher. The literature search above has identified the existing neck pain research and conclusions that were completed through Simulation, manipulation, and treatment (SMT) method. The PICOT method allows for enough and systematic study since it gives information on the target population apparently on the P which stands for the community. It also gives room for the researcher to outline the interventions or methods to be employed in providing the treatment. This section allows the doctor to study the effectiveness of the process administered and make possible changes if need be. Evidence And Clinical Questions. The outcomes are also keenly looked at if they are unusual, then proper medication is administered. The timing of research is also critical to ensure that the time used is not significant to give biased results or too little to giving unrealistic results. The method proofed to be effective in that it reduced the death rates tremendously.
References
Echevarria,? I.? M., & Walker,? S. (2014). To make your case, start with a PICOT question.? Nursing,44(2), 18-19. doi:10.1097/01.nurse.0000442594.00242.f9Echevarria,? I.? M., & Walker,? S. (2015). Start with a PICOT question to make your case. Nursing Critical Care,? 10(3), 14-16. doi:10.1097/01.ccn.0000464307.39978.1aElias, B. L., Polancich, S., Jones, C., & Convoy, S. (2015). Evolving the PICOT Method for the Digital Age: The PICOT-D.? Journal of Nursing Education, 54(10), 594-599. Kaka,? B., Ogwumike,? O.? O., Ogunlade,? S.? O., &Adeniyi,? A.? F. (2015).Effects of neck stabilization and dynamic exercises on pain, disability and fear avoidance beliefs in patients with non-specific neck pain a randomized clinical trial. Archives of Physiotherapy and Global Researches, 19(3), 17-29. doi:10.15442/apgr.19.2.14PICOT, S.? J. (1995). Rewards, Costs, and Coping of African American Caregivers.j Nursing Research,? 44(3), 147-152. doi:10.1097/00006199-199505000-00004PICOT,? S.? J. (1995). Rewards, Costs, and Coping of African American Caregivers.? Nursing Research, 44(3), 147-152. doi:10.1097/00006199-199505000-00004`
Abstract
Evidence based medicine (EBM) involves the integration of the best scientific evidence available with physician experience and patient preferences. One of the first steps in EBM involves developing a question based on issues encountered with patients or a disease and finding evidence to answer the question. This paper is a guide to plastic surgeons in how to begin the practice of EBM by developing clinical questions and finding evidence to answer these questions.Evidence And Clinical Questions.
Clinical Scenario
You are a surgeon and your patient is a 25-year-old man with a severe type III open tibial fracture as a result of a motorcycle accident. The options for treatment are reconstruction or amputation. Understandably this is an emotional issue for the patient and he wants the leg to be saved using reconstructive surgery. Your preference is for flap reconstruction of the limb. Patient and physician preferences must be taken into account when making the decision whether to reconstruct the leg or amputate, but you question whether the decision is based on the best available scientific evidence.
In another scenario, you are a surgeon who is interested in researching outcomes in rheumatoid arthritis patients who elect to have arthroplasty to replace deformed joints in their hands. You have performed arthroplasty on numerous patients and find your patients to be very satisfied with how their hands look after surgery and report good outcomes. However, you question if their hands actually function better after surgery. You speculate that patients are reporting better outcomes because their fingers are less deformed and the improved aesthetic appearance prompts the patients to report being satisfied. You are interested in researching this topic to apply evidence to your clinical experience, but are not sure how to start.
In both cases, you have identified a gap in your knowledge, and need to identify research evidence to fill that gap. You could answer your clinical questions by reading an expert opinion article, or consulting a colleague. However, the current environment of evidence based medicine (EBM) stresses the need to develop a good question and finding high quality research to answer clinical questions. Evidence And Clinical Questions. Sackett, one of the founding fathers of EBM, states that “studies show that busy clinicians who devote their scarce reading time to selective, efficient, patient driven searching, appraisal, and incorporation of the best available evidence can practice evidence based medicine”.1 As part of the emphasis to introduce the concepts and practices of EBM to readers of Plastic and Reconstructive Surgery, we present this paper as a guide to developing a clinical question and how to find the best available evidence to answer the question.
Types of clinical questions
Before developing a specific question, it is important to think about the type of question you have. Clinical questions can be narrowed down to four types: therapy, prognosis, diagnosis and economic/decision analysis. For example, if you are comparing two treatments such as amputation and reconstructive surgery, this is a therapy question. If you are interested in understanding the outcomes for older patients after breast reconstruction, this is a prognosis question. A diagnosis question might inquire about the accuracy of a new diagnostic test such as the use of ultrasound to detect silicone breast implant ruptures. If you are asking if a treatment results in lower costs and improved quality of life, this is an economic/decision analysis question.
The type of question also determines the type of study that you should look for when searching for evidence. For example, in the scenario for arthroplasty, you may want to determine if arthroplasty on the joints in the hand results in better outcomes than no surgery on the affected joints. A randomized controlled trial (RCT) is the preferred study type for answering treatment questions. However due to feasibility and ethical concerns, many surgical procedures cannot be randomly allocated or blinded. In this case, prospective cohort studies would be a better choice. When questioning the prognosis for a disease, a prospective cohort study would be more appropriate. Patients are enrolled at the time of diagnosis or treatment and followed over time to determine if any factors are associated with prognostic outcomes. Diagnostic studies that evaluate new diagnostic tests are more likely to be cross-sectional or prospective cohort studies. Economic and decision analysis questions arise when the best available evidence concerning treatments is inconclusive and an RCT is not ethically practical or feasible. Evidence And Clinical Questions.
Developing a question using PICO
The next step is developing a question. You want an answer to your question but you also want to avoid spending precious free time aimlessly searching through journals. Investing a few moments to craft a question can help to narrow the search for answers. (Figure 1) The question must be clinically relevant, well thought out and answerable. For example, a treatment (e.g. anticoagulant treatment for deep venous thrombosis) or surgery (e.g. replanting an amputated thumb) that is widely accepted with outstanding results would not be a good subject for a clinical question. On the other hand, researching whether the use of costly tissue sealant can decrease the incidence of postoperative seroma is an important study question. Or whether a particular face lift technique is associated with better outcomes and less complication rate is a timely study question.
PICO is a tool to help develop focused clinical questions.2-4 PICO is an acronym for Patient/Problem, Intervention, Comparison Intervention and Outcomes. The question will be more focused if you can be specific for each element. The first element in the question is a description of the patient population or problem of interest. The second and third elements contain the intervention and comparison intervention of interest respectively. An intervention is often a treatment but could also be a prognostic factor or a diagnostic test. In some cases, there will not be a comparison intervention. Lastly the question should consider the outcomes from the intervention. For example, will the intervention lead to fewer complications and less morbidity?
Using our scenarios as examples, we identify the pieces that will be used to formulate a question. In the case of tibial fractures, you consider the most severe types because these types of fractures are more likely to be considered for amputation. Based on Gustilo’s classification system,5 you decide to restrict your patient population to type IIIB and IIIC due to the lack of soft tissue coverage of the fracture that requires flap reconstruction. Evidence And Clinical Questions. The intervention of interest in your question is limb salvage using reconstructive surgery. This surgical procedure will then be compared to amputation. You consider what outcomes you would like to compare between these two treatments. After reviewing several of your cases, you decide to concentrate on improved limb function and quality of life after surgery. Putting the four elements together we construct a focused question: Do patients with severe type IIIB and IIIC open tibial fractures have better limb function and quality of life than patients who have amputations?
In the arthroplasty scenario, you have decided to concentrate your research efforts on rheumatoid arthritis patients who elect to replace joints in their hands. Based on your personal experience with rheumatoid hand deformities, you further decide to concentrate on arthroplasty at the metacarpophalangeal (MCP) joint. After considering the different type of implants that can be used for MCP arthroplasty, you select silicone metacarpophalangeal arthroplasty (SMPA) because it is has been used for over 40 years and is not experimental. You consider alternate surgeries but decide to compare SMPA patients with those who do not have surgery. The outcome that you decide upon is improvement in hand function as shown in patient reported questionnaires and biomechanical measurements. We put the pieces of the question together: “Do rheumatoid arthritis patients who undergo SMPA have better functional outcomes and quality of life than patients who do not have SMPA or any other type of arthroplasty”? Evidence And Clinical Questions.
Hierarchy of Evidence
Before searching for evidence, you will need to consider the hierarchy of evidence. (Figure 2) The hierarchy of evidence ranks study types from those with the highest evidence to lowest evidence. RCTs, systematic reviews and meta-analyses are at the top (highest evidence) and expert opinions and case reports at the bottom (lowest evidence). Systematic reviews and meta-analyses combine or pool data from multiple individual studies using systematic, predetermined methods. This pooling of data, if done correctly, allows the reader an unbiased summary of the available research. A systematic review of RCTs is considered higher in the hierarchy than a systematic review of observational studies. A narrative review or expert opinion is also a summary of studies but is done in a non-systematic manner and therefore more likely to be biased.
Electronic Databases (MEDLINE, EMBASE, CINAHL, Cochrane)
The next step in practicing EBM is finding the best available literature to answer your question. This is accomplished by searching through electronic databases such as MEDLINE, EMBASE, CINAHL and the Cochrane Library.
The Cochrane Collaboration was founded in 1993 and produces the Cochrane Library.6The library consists of several EBM databases. Most notable is the Cochrane Database of Systematic Reviews, which consists of systematic reviews and meta-analyses. The library is updated on a quarterly basis and considered a reliable source of EBM. All systematic reviews must meet rigorous standards before publication. Because not every condition has been investigated with a systematic review, it is often necessary to look at other databases.
MEDLINE is maintained by the National Library of Medicine, contains over 11 million citations from journals dating back to 1950 and is updated weekly.7 Articles are referenced using medical subject headings (MeSH). PubMed has over 19 million citations from life science journals and MEDLINE. PubMed has several search options that can help simplify your literature search. You can search specific journals or a single citation. Another search option is called Clinical Queries, which allows the user to narrow their search by subject and clinical study category (e.g. therapy, diagnosis, prognosis) or limit the search to systematic reviews. EMBASE contains biomedical and pharmacological articles from 1947 to the present.8 It contains more than 19 million records from more than 7000 journals. Although EMBASE and MEDLINE overlap in their coverage of the literature, EMBASE has a better coverage of European journals.9CINAHL (Cumulative Index to Nursing &Allied Health Literature) covers 2960 journals and other citations related to nursing and allied health from 1981 to present.10 CINAHL has over 2 million records. Evidence And Clinical Questions.
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The important thing when searching for evidence is to start at the top of the hierarchy and work your way down. You should begin by searching for systematic reviews or meta-analyses. The Cochrane Library is an excellent source for this type of evidence.6Another choice is the American College of Physicians (ACP) Journal Club which pre-appraises evidence for physicians.11 If there is no systematic review or meta-analysis, the next step involves searching MEDLINE or one of the other databases for RCTs. Many questions are not appropriately answered by RCTs and therefore few if any RCTs exist. This is often the case for surgical procedures.12, 13 It will then be necessary to move down the hierarchy and gather evidence from prospective cohort studies, case-control studies and lastly case reports. Case reports are best for generating hypotheses. The reader needs to be aware of the lower quality of these types of studies and take that into account when evaluating the evidence.
Search terms and limits/filters
Although there may be abundant research on your question, it is necessary for expediency to restrict your search such that you have a manageable number of papers to read. When asking a clinical question that needs a timely answer, a few high quality papers are adequate. However, in the research setting, it is important to find all the relevant papers. Developing accurate search terms will aid in finding the evidence you need to answer your question. The search terms need to be specific enough to narrow your search but not so narrow so that you miss important articles. In MEDLINE, each article is assigned Medical Subject Headings (MeSH). MeSH terms can then be used to search for pertinent research. MEDLINE gives the option to explode on terms (to include more narrowly defined terms) to gather the most research. In addition to MeSH terms, it is sometimes helpful to include text words to gather evidence. MeSH terms are usually combined with Boolean operators (AND, OR) to maximize the number of articles selected. It may take several attempts using different combinations of search terms to get the most comprehensive and relevant list of articles. Evidence And Clinical Questions.
