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Determining the type of question will help you to select the best resource to consult for your
answer.
Background questions ask for general knowledge about an illness, disease, condition, process
or thing. These types of questions typically ask who, what, where, when, how & why about
things like a disorder, test, or treatment, etc.
For example
Foreground questions ask for specific knowledge to inform clinical decisions. These questions
typically concern a specific patient or particular population. Foreground questions tend to be
more specific and complex compared to background questions. Quite often, foreground
questions investigate comparisons, such as two drugs, two treatments, two diagnostic tests, etc.
Foreground questions may be further categorized into one of 4 major types: treatment/therapy,
diagnosis, prognosis, or etiology/harm.
For example
Is Crixivan effective when compared with placebo in slowing the rate of functional
impairment in a 45 year old male patient with Lou Gehrig's Disease?
In pediatric patients with Allergic Rhinitis, are Intranasal steroids more effective than
antihistamines in the management of Allergic Rhinitis symptoms?
A well-built clinical foreground question should have 4 components. The PICO model is a
helpful tool that assists you in organizing and focusing your foreground question into a
searchable query. Dividing into the PICO elements helps identify search terms/concepts to use in
your search of the literature.
P = Patient, Problem, Population (How would you describe a group of patients similar to you?
What are the most important characteristics of the patient?)
I = Intervention, Prognostic Factor, Exposure (What main intervention are you considering?
What do you want to do with this patient? What is the main alternative being considered?)
C = Comparison (Can be None or placebo.) (What is the main alternative to compare with the
intervention? Are you trying to decide between two drugs, a drug and no medication or placebo,
or two diagnostic tests?)
O= Outcome (What are you trying to accomplish, measure, improve or affect? Outcomes may
be disease-oriented or patient-oriented.)
Foreground questions can be further divided into questions that relate to therapy, diagnosis,
prognosis, etiology/harm
Therapy: Questions of treatment in order to achieve some outcome. May include drugs,
surgical intervention, change in diet, counseling, etc.
Knowing the type of foreground question can help you select the best study design to answer
your question. You always want to look for the study design that will yield the highest level of
evidence. Consult the pyramid (click the image to enlarge it) and the definitions below.
To see more info on the relationship between study design and question type, check out Chapter
Four "What is the Question? from the Users' Guide to the Medical Literature.
Definitions of Study Types
(From BMJs Clinical Evidence Glossary)
Meta-analysis: A statistical technique that summarizes the results of several studies in a single
weighted estimate, in which more weight is given to results of studies with more events and
sometimes to studies of higher quality.
Systematic Review: a review in which specified and appropriate methods have been used to
identify, appraise, and summarize studies addressing a defined question. (It can, but need not,
involve meta-analysis). In Clinical Evidence, the term systematic review refers to a systematic
review of RCTs unless specified otherwise.
Randomized Controlled Trial: a trial in which participants are randomly assigned to two or
more groups: at least one (the experimental group) receiving an intervention that is being tested
and another (the comparison or control group) receiving an alternative treatment or placebo. This
design allows assessment of the relative effects of interventions.
Controlled Clinical Trial: a trial in which participants are assigned to two or more different
treatment groups. In Clinical Evidence, we use the term to refer to controlled trials in which
treatment is assigned by a method other than random allocation. When the method of allocation
is by random selection, the study is referred to as a randomized controlled trial (RCT). Non-
randomized controlled trials are more likely to suffer from bias than RCTs.
Cohort Study: a non-experimental study design that follows a group of people (a cohort), and
then looks at how events differ among people within the group. A study that examines a cohort,
which differs in respect to exposure to some suspected risk factor (e.g. smoking), is useful for
trying to ascertain whether exposure is likely to cause specified events (e.g. lung cancer).
Prospective cohort studies (which track participants forward in time) are more reliable than
retrospective cohort studies.
Case control study: a study design that examines a group of people who have experienced an
event (usually an adverse event) and a group of people who have not experienced the same
event, and looks at how exposure to suspect (usually noxious) agents differed between the two
groups. This type of study design is most useful for trying to ascertain the cause of rare events,
such as rare cancers.
Case Series: analysis of series of people with the disease (there is no comparison group in case
series).
Foreground questions are best answered by consulting medical databases such as MEDLINE
(via PubMed or Ovid), Embase, Cochrane Database of Systematic Reviews and ACP Journal
Club.
DML's Clinical Quick Reference page is a great place to locate EBM resources. Each resource
has been labeled background and/or foreground, for you!