Expanded PICO V1
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This document discusses evidence-based practice and how to formulate clinical questions using the PICO framework. It emphasizes asking answerable clinical questions, acquiring the best evidence to answer those questions, critically appraising the evidence, and applying it to patient care. Examples are provided to demonstrate how to develop well-structured clinical questions using PICO components and identify the optimal study design to answer each type of question. Resources for self-education in evidence-based medicine are also highlighted.
Expanded PICO V1
- 1. Literature Searching: Asking Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MemAcadMEd MSc MBBS Chairman, Knowledge Translation Committee Department of Medicine, KAMC,KSA
- 2. 2 Why Evidence-based Practice? Improves the quality of patient care Standardizes the delivery of healthcare Reduces the expense of healthcare Incorporates patient values into healthcare decisions Bridging the Gaps Knowledge Practice Resources Expenditure
- 3. What is Evidence-based Medicine “ Evidence-based medicine is the integration of: best available research evidence with clinical expertise and patient values” Sackett, et al 2001
- 4. EBP! The Patient Clinical Expertise Best Evidence 4 Evidence: Clinically relevant research, the literature Expertise: Practitioner’s knowledge & experience Expectations: Patient’s characteristics, preferences & values Three Pronged Approach 4
- 5. Integrates Evidence With Clinical expertise Experience Judgment Patient values and preferences Quality of life Costs Other important factors
- 7. What is Evidence-based Practice EBP is about asking questions and searching for answers in the body of medical research, and having found a likely source of information appraising the paper for its scientific validity and then applying the result to your problem.
- 8. Evidence-based Practice Ask clinical Questions Acquire the best evidence Appraise the evidence Apply evidence to your patient 5A’s !! Assess effectiveness, efficiency of EBM process
- 9. Evidence-based Practice Ask clinical Questions: PICO Acquire the best evidence: Literature Searching Appraise the evidence: Critical Appraisal Apply evidence to your patient: Knowledge Translation (Implementation) 5A’s !! Assess effectiveness, efficiency of EBM process
- 10. Self-Education & Training in EBM EBM Resources: http://guides.mclibrary.duke.edu/content.php?pid= 274373&sid=2262393 http://www.med.yale.edu/library/education/guides/ feature/finditfast CEBM Website: http://www.youtube.com/user/cebmed, http://www.cebm.net/index.aspx?o=1965 YouTube: http://www.youtube.com/watch?v=odfo9CQGi0c
- 11. Clinical Query: EBM Approach Ask clinical questions Acquire the best evidence Appraise the evidence Apply evidence to Your patient 5A’s !! Assess effectiveness, efficiency of EBM process
- 13. Ask clinical question Background /Foreground questions • Background Question • Asks for general knowledge about a disorder. Textbooks are good for answering background questions • Foreground Question Asks for specific knowledge about managing patients with a disorder; consists of three or four components (PICO): Diagnosis, Therapy, Prognosis etc Journal articles are good for answering foreground questions.
- 15. Templates for EBP Questions For a therapy: In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C)? For etiology: Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C)? Diagnosis or diagnostic test: Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)? Prevention: For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)? Prognosis: Does __________ (I) influence ________ (O) in patients who have _______ (P)? Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.
- 16. Ask Clinical Questions: PICO Patient/ Population Outcome Intervention/ Exposure Comparison Components of Clinical Questions In patients with acute MI In post- menopausal women In women with suspected coronary disease does early treat- ment with a statin what is the accuracy of exercise ECHO does hormone replacement therapy compared to placebo compared to exercise ECG compared to no HRT decrease cardio- vascular mortality? for diagnosing significant CAD? increase the risk of breast cancer?
- 17. Study designs Descriptive Observational Intervention Analytic cross- sectional case- controlcohort prospective natural experiment quasi- experiment RCT retrospective •Case report • Case series • Survey
- 18. Decide on the best type of study design for your question: For each type of question there is a hierarchy of evidence Therapy/Prevention What should I do about this problem? RCT>cohort > case control > case series Diagnosis Does this person have the problem? Cross-sectional study with blind comparison to a gold standard Etiology/Harm What causes the problem? RCT > cohort > case control > case series Prognosis/Prediction Who will get the problem? RCT >cohort study > case control > case series Frequency and Rate How common is the problem? cohort study > cross-sectional study NOTE: A well designed systematic review of RCTS (randomized controlled trials) is best as it is least biased therefore more valid.
- 20. “Finding Evidence”: Sources Primary: PubMed, EmBase, Cinahl, Pyschlit Secondary: Systematic Reviews: Cochrane Library, PubMed Guidelines websites: Guidelines Clearinghouse, Guidelines International Network CATS: BestBets, ACP ournal Club Point of Care: Clinical Evidence, EvidencePlus, UpToDate etc Tertiary resources (meta search engines, databases of databases): TRIP+ (Translating Research Into Practice), PrimeEvidence
- 22. Expanded PICO=PICOT3 P Population/Patient/ Problem How would I describe a group of patient's similar to mine I Intervention/ Indicator Which main intervention, exposure, prognostic factor am I considering? C Comparator/ Control What is the main alternative to compare with the intervention? O Outcome What can I hope to accomplish, measure, improve, affect? T Type of Study Question you are asking How would I categorize this question? e.g. Diagnostic, Therapeutic etc. T Type of Study Design you would want to find What would be the best study design in order to answer this question? e.g. Randomized Controlled Study, Cohort study etc. T Time you got How much time you got to answer your question? Point-of Care Resources versus the others!
- 23. Example: A 28-year-old male presents with recurrent furunculosis (skin boils) for past 8 months; these episodes have been treated with drainage and several courses of antibiotics but keep recurring. He asks if recurrences can be prevented. To convert this to an answerable question, use the P I C O method as follow:
- 24. Question: ‘In patients with recurrent furunculosis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate?’ P Population/Patient/ Problem = patients with recurrent furunculosis I Intervention/ Indicator = prophylactic antibiotics C Comparator/ Control = no treatment O Outcome = reduction in recurrence rate of furunculosis
- 25. Expanded PICO=PICOT3 P Population/Patient/ Problem How would I describe a group of patient's similar to mine: patients with recurrent furunculosis I Intervention/ Indicator Which main intervention, exposure, prognostic factor am I considering? prophylactic antibiotics C Comparator/ Control What is the main alternative to compare with the intervention? no treatment O Outcome What can I hope to accomplish, measure, improve, affect? reduction in recurrence rate of furunculosis T Type of Question you are asking How would I categorize this question? Prevention T Type of Study you would want to find What would be the best study design in order to answer this question? Randomized Controlled Study T Time you got How much time you got to answer your question? Point-of Care Resources POCR versus the others! e.g.no time! Check it in POCR e.g. UpToDate, Dynamed, Cochrane etc.
- 26. Example: Mr. X wants to discuss the possibility of a vasectomy. He says he has heard something about vasectomy causing an increase in testicular cancer later in life. You know that the risk of this is low but want to give him a more precise answer.
- 27. Question: ‘In men, does having a vasectomy (compared to not having one) increase the risk of getting testicular cancer in the future?’ P Population/ patient = adult males I Intervention/ indicator = vasectomy C Comparator/ control = no vasectomy O Outcome = testicular cancer
- 28. Expanded PICO=PICOT3 P Population/Patient/ Problem How would I describe a group of patient's similar to mine: adult males I Intervention/ Indicator Which main intervention, exposure, prognostic factor am I considering? vasectomy C Comparator/ Control What is the main alternative to compare with the intervention? no vasectomy O Outcome What can I hope to accomplish, measure, improve, affect? testicular cancer T Type of Question you are asking How would I categorize this question? Harm T Type of Study you would want to find What would be the best study design in order to answer this question? Randomized Controlled Study or Cohort study T Time you got How much time you got to answer your question? Point-of Care Resources POCR versus the others! e.g.no time! Check it in POCR e.g. UpToDate, Dynamed, Cochrane etc.