Section B

Deciding the Type and Scope of Your Question

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Classifying Question Types

Question

Classification/type

What proportion of the population is newly diagnosed with

this problem each year?

Incidence

What proportion of the population is currently living with this

problem?

Prevalence

What should be done to treat this problem?

Therapy

Will detecting this problem early, before symptoms, make a

difference in my health?

Screening

How good is this test at detecting this problem?

Diagnostic accuracy

What is the likely outcome of this problem?

Prognosis

Will there be any negative effects (of an intervention)?

Harm

What causes this problem?

Etiology

How can this problem be prevented?

Prevention
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Examples of Types of Questions

Type question

Example

Incidence, prevalence

What is the incidence of low birth weight in minority populations

compared to the white population?

Therapy

Is exercise effective in improving quality of life in persons with COPD?

Screening

Is PSA to detect prostate cancer effective in reducing mortality?

Diagnostic accuracy

How effective is an MRI at detecting new breast cancers in follow-up of

women with breast cancer having lumpectomy?

Prognosis

What is the effect of pregnancy on exacerbating the symptoms of MS

Harm

What proportion of postmenopausal women receiving Ca++/vita D can

expect to have kidney stones?

Etiology

Is coffee consumption causally associated with developing pancreatic

cancer?

One Size Does NOT Fit All! Use Your Question Classification to Seek the
Appropriate Type of Evidence
Question

Look for evidence from:

Incidence, prevalence

Surveys, cohort studies

Therapy

Clinical trials

Screening

Clinical trials

Diagnostic accuracy

Clinical trials, cross sectional studies

Prognosis

Clinical trials, cohort studies

Harm

Clinical trials, cohort studies, case control studies

Etiology

Cohort studies, case control

Hierarchy of
Evidence for
Intervention
Studies
(Treatment,
Prevention,
Screening, Harm)

Systematic
review of
randomized trials
Single randomized trial
Systematic review of observational
studies addressing patient-important
outcomes
Single observational study addressing
patient-important outcomes
Physiologic studies
Unsystematic clinical observations

Source: adapted from Guyatt et al for the EvidenceBased Medicine Working Group. JAMA.
2000;284:1290-1296.

Formulating the Question in a Systematic Review

! The most important maxim for data analysis to heed, and one which many
statisticians have shunned is this: far better an approximate answer to the right
question, which is often vague, than an exact answer to the wrong question, which can
always be made precise.

Source: Tukey J. (1963). Ann Mathem Stat. 33:13-14.

Ways Similar
Studies May Differ

! Patient population
! Inclusion and exclusion criteria
! Exposure definition/intervention composition, dose, timing
! Comparison group/controls
! Management protocol (e.g., cointerventions) for trials
! Outcome definition (e.g., follow-up time, cause-specific
mortality)
! Quality of design and execution
! Analysis
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Broad or Narrow Question?

! Narrow questions:
! May not be applicable to multiple settings, populations, or exposures
! Can result in spurious or biased conclusions (like subgroup analysis)
Efficacy of aspirin in preventing strokes in women
Association between dysfunctional uterine bleeding and BMI, in African American
women
Reviewer familiar with literature can narrow question, to exclude articles with
conflicting results

! See Chapter 5 of Cochrane Handbook, Table 5.6.a, for comparison of pros and cons of
broad or narrow question
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Broad or Narrow Question?

! Broad questions:
! May not be valid (apples and oranges)
! Searches may be more time-consuming
! Synthesis and interpretation difficult
! Difficult to maintain
Can split broad question into subparts

! See Chapter 5 of Cochrane Handbook, Table 5.6.a, for comparison of pros and cons of
broad or narrow question
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