The Well-Built Clinical Question:

The PICO Principle

MUHAMMAD ALI
FM USU
Is vitamin C more effective than echinacea
in preventing the common cold in adult?

Is that a good question?

Is that a well focused question?
Can it identify the key problem of the
patient?
Answerable?
Characteristics of Good
Question
First, the question should be directly
relevant to the problem at hand.
Next the question should be phrased
to facilitate searching for a precise
answer. To achieve these aims, the
question must be focused and well
articulated.
(Richardson et al, 1995)
 THE FIVE STEP EBM MODEL

first, converting information needs into answerable

questions

second, finding the best evidence with which to answer

the questions

third, critically appraising the evidence for its validity

and usefulness

fourth, applying the results of the appraisal into clinical

practice

fifth, evaluating performance

 EBM Process
Drawing
Drawingconclusion
conclusion
Patient Diagnosis
Diagnosis
Therapy
That
Thatimpact
DOES
impacton
onpractice
practice Encounter Therapy
Prognosis
DOES Prognosis
POEM Etiology
POEM Etiology

Appraising the Formulating the

Evidence Clinical Question

Patient
Patient
Hierarchy Intervention
Hierarchyof
ofevidence
evidence Intervention
Pre Comparison
Preappraised
appraisedresources
resources Searching the Comparison
Outcome
Outcome
Evidence
(Lang,
(Lang,2000)
2000)
 Formulating Answerable Clinical Questions

One of the difficult steps in practising EBM may be the translation of a

clinical problem into an answerable question

When we come across a patient with a particular problem, various

questions may arise for which we would like answers

These questions are frequently unstructured and complex, and may not
be clear in our minds

The practice of EBM should begin with a well formulated clinical

question

We should develop the skill to convert our information needs into

answerable questions

Good clinical questions should be clear, directly focused on the problem

at hand, and answerable by searching the medical literature
 P I C O: Formulate an Answerable Question

Questions often spring to mind in a form that makes

finding answers in the medical literature a challenge

Asking the right question is a difficult skill to learn

Fundamental to the evidence-based decision-making

process

Dissecting the question into its component parts and

restructuring it so that it is easy to find the answers is
an essential first step in Evidence Based Medicine (EBM)
 PICO is a method of putting together a search strategy that
allows you to take a more evidence based approach to your
literature searching when you are searching bibliographic
databases like Medline (OVID), PubMed and Embase

PICO, was originally defined by physicians at McMaster

University in the early 1990's

PICO stands for:

Patient/Population: Who or What?

Intervention: How?
Comparison: What is the main alternative? (If appropriate)
Outcome: What are you trying to accomplish, measure,
improve, effect?
Remember the PICO Principle

Remember
P Population / problem

I Intervention

C Comparator / control

O Outcome

ASSESS the Patient

1. Start with the patient: a
clinical problem/question arises
from the care of the patient
ASK the Question
2. Construct a well-built question
derived from the case

EBM always begins and ends with

the patient
Two additional elements of the well-built clinical question are:
type of question and the type of study

The most common types of questions related to clinical

tasks are:

Diagnosis
how to select and interpret diagnostic tests
Therapy
how to select treatments to offer patients that do more good
than harm and that are worth the efforts and costs of using
them
Prognosis
how to estimate the patient's likely clinical course over time
and anticipate likely complications of disease
In each case the P I C O method can be used
Harm/Etiology
to to
how formulate the question
identify causes for disease (including iatrogenic forms)
 The type of question is important and can help
lead you to the best study design:

Type of Question Suggested best type of study

Diagnosis prospective, blind comparison to a gold standard

Therapy RCT > cohort > case control > case series
Prognosis Cohort study > case control > case series
Harm/Etiology RCT > cohort > case control > case series
Prevention RCT > cohort study > case control > case series
Clinical Exam Prospective, blind comparison to gold
standard
Cost Benefit Economic analysis
Types of
Studies:
 Anatomy of a Good Clinical Question: PICO

PICO is a mnemonic that helps one remember the key components

of a well focused question
The question needs to identify the key problem of the patient

P = Patient or problem
How would you describe a group of patients similar to yours? What
are the most important characteristics of the patient? This may
include the primary problem, disease, or co-existing conditions.
Sometimes the sex, age or race of a patient might be relevant to
the diagnosis or treatment of a disease.

I = Intervention, prognostic factor, or exposure

Which main intervention, prognostic factor, or exposure are you
considering? What do you want to do for the patient? Prescribe a
drug? Order a test? Order surgery? What factor may influence the
prognosis of the patient? Age? Co-existing problems? Has the
patient been exposed to something? Asbestos? Cigarette smoke?
C = Comparison
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? Your clinical question
does not always need a specific comparison

O = Outcomes
What can you hope to accomplish, measure,
improve or affect? What are you trying to do for
the patient? Relieve or eliminate the symptoms?
Reduce the number of adverse events? Improve
function or test scores?
 'P I C O' examples

1.Interventions
- Cover a wide range of activities from drug treatments and other clinical therapies,
to lifestyle changes and social activities
- Can include individual patient care or population health activities

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 follows :

Question:In patients with recurrent furunculosis, do prophylactic antibiotics,

compared to no treatment, reduce the recurrence rate?

P Population/patient = patients with recurrent furunculosis

I Intervention/indicator = prophylactic antibiotics
C Comparator/control = no treatment
O Outcome = reduction in recurrence rate of furunculosis
Is vitamin C more effective than echinacea in preventing the
common cold?
Put the following search terms into the correct boxes

Vit C
Adult with a cold
Prevention of the cold
echinacea

Patient /
Problem / Intervention Comparison Outcome
Population
 P is for Patient
Patient
Who is your patient?
Interventi
A clinical question must identify a patient or patient group. Additionally
onto the
a clinical question should include any information that is relevant
treatment or diagnosis or the patient . For example, you might include
the patient's: Compariso
Sex, age or race n
Disease History
Primary Complaint Outcome

Case:
You examine a 35 yr old man in your office and determine that he is suffering
from cold. He mentions that he read an article regarding the useful of Vit C for
preventing cold. Since echinecea also known has a same useful, he needs your
expert opinion which is the most effective to prevent cold
 I is for Intervention

Patient
What is the Intervention

Interventi
The intervention is what you plan to do for your patient or patient group.
For example, you might: on

Run tests
Compariso
Prescribe drug treatment n
Refer to a specialist
Schedule sugery Outcome

Case:
You examine a 35 yr old man in your office and determine that he is suffering from cold. He
mentions that he read an article regarding the useful of Vit C for preventing cold. Since
echinecea also known has a same useful, he needs your expert opinion which is the
most effective to prevent cold
 C is for Comparison

What is the Comparison Patient

In general most, but not all, clinical questions have a comparison.
A comparison is the alternative that you want to compare to Interventi
your intervention. on
For example: Compariso
Is aspirin as effective in preventing strokes as warfarin?
Is chicken soup as effective as bed rest in treating a cold? n

Outcome

Case:
You examine a 35 yr old man in your office and determine that he is suffering from cold. He mentions that he
read an article regarding the useful of Vit C for preventing cold. Since echinecea also known has a same
useful, he needs your expert opinion which is the most effective to prevent cold
 O is for Outcome

Patient
What is the Outcome?
Interventi
The outcome is the hoped for effect of the intervention
on
For example:
Compariso
If I prescribe ibuprofen for my patient it will prevent pain n
Outcome = Pain Prevention.

Outcome

Case:
You examine a 35 yr old man in your office and determine that he is suffering from cold. He mentions
that he read an article regarding the useful of Vit C for preventing cold. Since echinecea also known
has a same useful, he needs your expert opinion which is the most effective to prevent cold
 PICO

You determined the following were important factors for our case.
[Fill in the fields below if you didn't provide answers earlier]

Patient: Adult with cold

Intervention: Vit C
Comparison: Echinacea
Outcome: Prevention of the cold

Case:
You examine a 35 yr old man in your office and determine that he is suffering from
cold. He mentions that he read an article regarding the useful of Vit C for preventing
cold. Since echinecea also known has a same useful, he needs your expert opinion
which is the most effective to prevent cold

Put your PICO elements together to form an researchable clinical

question
 Your Clinical Question

Case:
You examine a 35 yr old man in your office and determine that he is
suffering from cold. He mentions that he read an article regarding the
useful of Vit C for preventing cold. Since echinecea also known has a
same useful, he needs your expert opinion which is the most effective
to prevent cold

Here is a well-formulated clinical questions that a physician

might research based on the case above.

Is vitamin C more effective than echinacea in preventing the

common cold in adult?
2. Aetiology and risk factors

- Relate to questions that probe possible causes of a disease or

illness
- Deal with the harmful outcomes of an activity or exposure

George 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.

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
3. Frequency or rate

- Questions of FREQUENCY (prevalence) are about how many people in

the population have a disease or health problem
- If the question also includes a time period, it becomes a question of
rate (incidence)

Mabel is a 6-week-old baby at her routine follow-up. She was born

prematurely at 35 weeks. You want to tell the parents about her
chances of developing hearing problems.

Question:In infants born prematurely, compared to those born at full

term, what is the subsequent lifetime prevalence of sensory deafness?'

P Population/patient = infants
I Intervention/indicator = premature
C Comparator/control = full-term
O Outcome = sensorial deafness
4. Diagnosis
Concern with how accurate a diagnostic test is in various patient groups, and in
comparison to other available tests. Measures of test accuracy include its
sensitivity and specificity.

Julie is pregnant for the second time. She had her first baby when she was 33 and
had amniocentesis to find out if the baby had Down's Syndrome. The test was
negative but it was not a good experience as she did not get the result until she
was 18 weeks pregnant. She is now 35, one month pregnant and asks if she can
have a test that would give her an earlier result. The local hospital offers serum
biochemistry plus nuchal translucency ultrasound as a first trimester test for
Down's Syndrome. You wonder if this is as reliable as conventional amniocentesis.

Question:For pregnant women, is nuchal translucency ultrasound plus serum

biochemistry testing in the first trimester as accurate (ie with equal or better
sensitivity and specificity) as conventional amniocentesis for diagnosing Down's
Syndrome?

P Population/patient = pregnant women

I Intervention/indicator = nuchal translucency ultrasound plus serum
biochemistry (1st trimester)
C Comparator/control = conventional amniocentesis
O Outcome = accurate diagnosis (measured by sensitivity and
specificity) of Down's Syndrome
 Question Templates for Asking PICO Questions:

For an intervention/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/Predictions
Does __________ (I) influence ________ (O) in patients who have _______ (P)
 The Clinical Question

Your clinical question will impact the entire EBM research process.

Clinical Litaratur Evidence

Search terms
Question search Based Anwer

Make sure you start with a well-developed and answerable question

A good clinical question will:

Save time when researching
Keep the focus directly on the patient's need
Suggest the appropriate form that a useful answer may take

Note: Your clinical situation may raise more than one question. Don't try to
squeeze multiple topics into one clinical research question.
 The PICO Principle
Population and This shows who the relevant people are in ralation to the clinical
clinical problem problem that you have in mind

Intervention (or This shows the management strategy, exposure or test that you want
indicator or indext find out about in relation to the clinical problem. This might be:
text) a procedure, such as a drug treatment, surgery or diet
(intervention)
Exposure to an environmental chemical or other hazard a physical
feature (such as being overweight) or a factor that might affect a
health outcome (indicator)
a diagnostic test, such as a blood test or brain scan (index test)

Comparator This shown an alternative or control strategy exposure or test for

comparison with the one you are interested

Outcome This shows

what are you most concerned about happening (or stopping
happening) AND/OR
what the patient 6 most concerned about

We call these four parts of a clinical question PICO pronounced pee-co) which
makes them easy to remember. A timeframe (T) is usually implicit in every
question, but it is some time useful to add this component explicitly (ie PICOT)