Delineating a Clinical Problem: Asking the Right Question and Asking the Question Right

Delineating a Clinical Problem: Asking the Right Question and Asking the Question Right

Peter Wyer MD Associate Clinical Professor of Medicine

Columbia University College of Physicians & SurgeonsChair, Section on Evidence Based Health Care, New York Academy of Medicine

The Concept of Clinical Action

Silva, J Eval Clin Pract. 2011;17:585

“Knowledge does notextend from thosewho consider theyknow to those whoconsider they do notknow. Knowledge isbuilt in therelationship betweenhuman beings andperfects it self in theCritical Problematization ofthese relations.”Paulo Freire

The Concept and Role of PACT

• 4 subdomains of clinical action always tacitly present within a problem together with other determinants of care

• PACT is a tool of representation that allows deconstruction of a problem into actionable components

• This facilitates meaningful identification and assimilation of research evidence into the solution

The SIMPLE Model

ValuesValues

PreferencesPreferences

PrioritiesPrioritiesProblem delineation

“The process of problematization implies a critical return to action. It starts from action and returns to it”

Paulo Freire, 1972

Problem delineation

“The process of problematization implies a critical return to action. It starts from action and returns to it”

Paulo Freire, 1972

P

Problem

AAction

CChoices

TTargets

Utility

Performance

Probability

Silva, Charon, Wyer. JECP 2010.

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P

Problem

AAction

CChoices

TTargets

Utility Share consideration of the utility

Alternatives

Estimate of impact on patient outcomes

PerformanceShare

consideration of the

performance

Alternatives Estimate of effect of predictors

Probability Share

consideration of the

probability

---

Estimate of likelihood of possible outcomes

Silva, Charon, Wyer. JECP 2010.

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The Anatomy of the QuestionThe Anatomy of the Question

opulation

ntervention

omparison

utcome

Why PICO—the 2-PICO Assessment for Directness

Example: a Patient with Atrial FibrillationUma mulher de 68 anos é trazida ao pronto-socorro por causa do início

súbito de palpitações e é encontrada em FA (fibrilação atrial) com freqüência ventricular de 140-160. Seus sinais vitais encontram-se dentro da normalidade e ela não apresenta congestão pulmonar, insuficiência respiratória, angústia ou outros. Sua família afirma que isso já aconteceu antes e "os medicamentos utilizados não funcionaram e eles tiveram de chocá-la." Ela tem história de hipertensão leve, mas não de doença cardíaca estrutural ou de outras comorbidades importantes. Sua família espera que ela possa ser tratada e liberada do Departamento de Emergência. As instalações hospitalares deste hospital habitualmente admitem esses pacientes. Os médicos plantonistas discutem sobre qual droga deve ser utilizada para tratamento e se devem priorizar controle de FC (frequência cardíaca) ou controle do ritmo.

P

Problem

AAction

CChoices

TTargets

UtilityUtility of pharmacological agents

Alternative drug choices

Estimate of impact on return to sinus rhythm, complications of AF

PerformancePerformance of CHADAS2 score

---Estimate of accuracy

Probability

Short term probability of embolic events after emergency cardioversion

Estimate of likelihood

Silva, Charon, Wyer. JECP 2010.

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PP

II

CC

OO

TherapyTherapyUtilityUtility

PP

II

CC

OO

TherapyTherapyUtilityUtility

PPElderly patients with acute onset, stable, AF but no structural heart disease presenting to emergency departments within 48 hours of onset

II Rapid acting pharmacological agents safely titrated to effect

CC Alternative regimens safely titrated to effect

OOLikelihood of rate control or conversion, hospital admission rate, likelihood of complications of uncontrolled AF, adverse reactions to drugs

TherapyTherapyUtilityUtility

HarmHarmProbabilityProbability

PPElderly patients with acute onset, stable, AF but no structural heart disease presenting to emergency departments within 48 hours of onset

II Rapid acting pharmacological agents safely titrated to effect

CC Alternative regimens safely titrated to effect

OOLikelihood of rate control or conversion, hospital admission rate, likelihood of complications of uncontrolled AF, adverse reactions to drugs

TherapyTherapyUtilityUtility

HarmHarmProbabilityProbability

PPElderly patients with acute onset, stable, AF but no structural heart disease presenting to emergency departments within 48 hours of onset

Elderly patients with acute onset, stable, AF but no structural heart disease presenting to emergency departments within 48 hours of onset

II Rapid acting pharmacological agents safely titrated to effect

Cardioversion in ED with release and early follow up

CC Alternative regimens safely titrated to effect ----

OOLikelihood of rate control or conversion, hospital admission rate, likelihood of complications of uncontrolled AF, adverse reactions to drugs

Short term complications of cardioversion, embolic events, admission to hospital, other complications of AF.

Prognostic Prognostic PerformancePerformance

PPElderly patients with acute onset, stable, AF but no structural heart disease presenting to emergency departments within 48 hours of onset

IISpecific predictors of complications of AF or an organized prediction rule

CCNA

OOImpact of predictors or the prediction rule on likelihood of stroke, other embolic events, decompensated heart failure, MI

PP

II

CC

OO

PP

II

CC

OO

PP

II

CC

OO

SUMMARY• Scientifically informed, effective care, requires

“critical problematization” across all parties and dimensions

• The need for information is derived from the problem at all levels

• PICO allows connecting questions to research information and assessment of directness

• If the problem is wrong, the question is wrong; if the question is wrong, evidence based methods and resources are misguided