Evidence Based Medicine part 1 ..

Clinical Questions, PICO and Study Design

Illingworth Library
Supporting your Knowledge for Healthcare
PREPARING YOUR SEARCH

• Clinical Questions – PICO

• Study Design and the Evidence Pyramid

• Search Terms and Limits

CLINICAL QUESTIONS - PICO

Focus Purpose Clarify Timeframe

TYPES OF QUESTIONS

What is
What are the clinical
How does deep Sepsis?
manifestations of
vein thrombosis Ebola?
occur in the body?

Background Questions

What causes What are the How is shortness of

eczema complications of root breath linked to
canal treatment? smoking
TYPES OF QUESTIONS
In children with suspected
appendicitis can an MRI scan
Is surgery better than confirm or exclude a diagnosis
conservative treatment for
preventing re-dislocation in
adults with primary patella Does music therapy
dislocation? improve quality of life and
depression symptoms in
Foreground Questions dementia sufferers?

Is the body mass index

In middle aged men who
a reliable measure of
are overweight what are
obesity in children
their perceptions of
dieting?
 P I CO
The Well-Built Clinical Question

Patient / Population/ Problem (among ….)

Intervention / Exposure (does ….)
Comparison (versus….)
Outcome (affect….)
 P I CO
P = Patient/Population of Interest

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
 P I CO
I = Intervention or Exposure

What therapeutic, diagnostic, preventive or other health care

interventions are you interested in knowing more about?

What health care management strategies are you interested

in comparing? It also means exposure or risk factor.
 P I CO
C = Comparison of Interest

Is there a comparison to be evaluated against the

intervention? Only used if more than one intervention
or if no intervention is a factor.
 P I CO
O = Outcome of Interest

What is the desired outcome to be evaluated?

How will the patient or population be affected, or not affected,

by the intervention?
Question types: Treatment/therapy
Is paracetamol or ibuprofen better at reducing fever in
Drug young children?
Are sheepskin mattresses effective at preventing
Clinical therapy pressure ulcers?
Is total hip replacement better than open reduction and
Surgery internal fixation at fixing displaced femoral neck fractures?

Lifestyle Can exercise help prevent obesity in children?

Can music therapy help reduce agitation in dementia

Social sufferers?
How effective are nurse-led clinics for patients with
Service coronary heart disease?

A treatment/therapy designed to improve a patient/population, state or condition

USING PICO REFINE TREATMENT/THERAPY QUESTIONS

A clinician wants you to undertake a literature search for him. He

is interested in finding out whether ibuprofen is better than
paracetamol at reducing fever in young children

P
I
C
O
USING PICO REFINE TREATMENT/THERAPY QUESTIONS

A clinician wants you to undertake a literature search for him. He

is interested in finding out whether ibuprofen is better than
paracetamol at reducing fever in young children

P Young children with fever

I Ibuprofen
C Paracetamol
O Reducing Fever
Question types: Diagnosis
Can an MRI scan accurately diagnose acute appendicitus in
Imaging pregnancy?

What is the added value of heart fatty acid protein

Biomarkers assay (HFABP) in the rapid diagnosis of acute
myocardial infarction?

Measures of How sensitive is the initial ECG in predicting an acute

body functions myocardial infarction?

What is the diagnostic utility of the physical examination

Physical in detecting pulmonary hypertension?
examination
How useful is genetic testing in a prenatal diagnosis of
Genetic testing muscular dystrophy?

A selection of diagnostic tests/procedures to confirm/exclude a diagnosis/ classification of a condition

USING PICO REFINE DIAGNOSIS QUESTIONS #1

Is an MRI scan more sensitive/specific than bone scintigraphy at

diagnosing scaphoid fractures in the elderly?

P
I
C
O
USING PICO REFINE DIAGNOSIS QUESTIONS #1

Is an MRI scan more sensitive/specific than bone scintigraphy at

diagnosing scaphoid fractures in the elderly?

Elderly
P Scaphoid fracture
I MRI scan
C Bone scintigraphy
O Sensitivity/specificity
USING PICO REFINE DIAGNOSIS QUESTIONS #2

Can ultrasound accurately detect obstructive biliary

disease in adults with acute abdominal pain?

P
I
C
O
USING PICO REFINE DIAGNOSIS QUESTIONS #2

Can ultrasound accurately detect obstructive biliary

disease in adults with acute abdominal pain?

P Adults with acute abdominal pain

Obstructive biliary disease
I Ultrasound
C NOT APPLICABLE
Accurate diagnosis (as measured by sensitivity
O
and specificity of test)
Question types: Aetiology/risk factors/harm

Risk –
Public Health Does smoking increase the risk of lung cancer?

Risk – Does smoking cannabis increase the risk of

Mental Health schizophrenia?

Risk – Is exposure to radiation in the atmosphere a

Environment risk factor for childhood leukemia?

Possible causes of disease, harmful outcomes of an activity or exposure

USING PICO REFINE AETIOLOGY/RISKFACTOR/
HARM QUESTIONS

Are post-menopausal women on hormone replacement

therapy at risk of developing breast cancer?

P
I
C
O
USING PICO REFINE AETIOLOGY/RISKFACTOR/
HARM QUESTIONS

Are post-menopausal women on hormone replacement

therapy at risk of developing breast cancer?

P Post-menopausal women
I Hormone replacement therapy
C NOT APPLICABLE
O Breast cancer
Question types: Prognosis

Recurrence/Relapse What is the likelihood of relapse in schizophrenia patients

who smoke cannabis?
Recovery/survival/ What is the likelihood of an otherwise healthy 18 year
death old with schizophrenia making a complete recovery?

Complications of Is it likely that an elderly man with moderate-severe

disease rheumatoid arthritis will become bedridden?
What is the survival time of a middle-aged woman with
Timescales localised breast cancer?

Is age at diagnosis a prognostic factor for children with

Prognostic risk factors acute lymphocytic leukemia?

What is the likely course/potential complications of a disease/illness/condition?

USING PICO REFINE PROGNOSIS QUESTIONS

What is the likelihood of a premature baby (born at 35

weeks) developing hearing problems?

P
I
C
O
USING PICO REFINE PROGNOSIS QUESTIONS

What is the likelihood of a premature baby (born at 35

weeks) developing hearing problems?

P Premature baby
I NOT APPLICABLE
C NOT APPLICABLE
O Development of hearing problems
Question types: Meaning

Patient What are patient’s experiences with attending the

experience emergency department?

Patient Women’s perceptions and satisfaction of emotional

support following childbirth
satisfaction
Attitudes of
Nurses attitude towards patients who self-harm
healthcare
staff
What are the main worries of parents whose children
Concerns are to undergo surgery?

Questions about people’s experiences, beliefs, opinions, attitudes, concerns etc.

USING PICO REFINE MEANING QUESTIONS

What are women’s expectations or experiences

of childbirth?

P
I
C
O
USING PICO REFINE MEANING QUESTIONS

What are women’s expectations or experiences

of childbirth?

P Women who have given birth

I NOT APPLICABLE
C NOT APPLICABLE
O Experiences or expectations
PICO summary by question type
EXERCISE1: IDENTIFY THE PICO

Does cognitive behavioural therapy improve self-esteem in adults with eating

disorders?

How effective is vitamin 3D in preventing relapses in patients with multiple sclerosis?

Is a CT scan or ventilation perfusion scintigraphy better at detecting pulmonary

embolism in pregnant women?

How does laparoscopic colectomy compare with open surgery in terms of cost-
effectiveness, recurrence and survival rates in patients with colon cancer?

In children with pyrexia with suspected urinary tract infection, what is the sensitivity
and specificity of dipstick urinalysis?
Does cognitive behavioural therapy improve self-esteem in
adults with eating disorders?

P I CO
P Adults with eating disorders

I Cognitive behavioural therapy

C None applicable

O Improve self-esteem
How effective is vitamin 3D in preventing relapses in
patients with multiple sclerosis?

P I CO
P Multiple sclerosis

I Vitamin 3D

C No comparison

O Preventing relapses
Is a CT scan or ventilation perfusion scintigraphy better at
detecting pulmonary embolism in pregnant women?

P I CO
P Pregnant women

I CT scan

C Perfusion scintigraphy

O Detecting pulmonary embolism

How does laparoscopic colectomy compare with open
surgery in terms of cost-effectiveness, recurrence and
survival rates in patients with colon cancer?

P I CO
P Colon Cancer

I Laparoscopic colectomy

C Open Surgery

O Cost-effectiveness, recurrence and survival rates

In children with pyrexia with suspected urinary tract
infection, what is the sensitivity and specificity of dipstick
urinalysis?

P I CO
P Children with pyrexia and suspected urinary tract
infection
I Dipstick urinalysis

C None applicable

O Sensitivity and specificity

Type of question and study design

Having decided what type of question you

are asking you need to consider

What is the best STUDY DESIGN to answer

your clinical question?
EVIDENCE PYRAMID
Type of Question Type of
Study/Methodology
Therapy Double-Blind
Randomized Controlled Trial
Diagnosis Controlled Trial
Prognosis Cohort Studies,
Case Control,
Case Series
Etiology Cohort Studies
Prevention Randomized Controlled Trial,
Cohort Studies
Quality Improvement Randomized Controlled
Trials
SEARCH TERMS

A search term may be a single word, phrase,

acronym or abbreviation that describes the concept,
e.g. “Father Christmas”

A synonym is another word that can be used to

describe the same thing, e.g. “Santa Claus”, “St
Nicholas”.
SEARCH TERMS
Heart CT scan Obesity Ibuprofen
attack surgery
Myocardial Computed Bariatric Nurofen
infarction tomography surgey

MI Cat-scan Gastric band Advil

Computed Weight loss

axial surgery Brufen
tomography

Gastroplasty Rimafen
SEARCH TERMS
UK/US Medical/ Acronyms/
terminology Drug brands
laymen’s terms abbreviations
• Tumour/ • Chickenpox • MRI / magnetic • Ibuprofen /
tumor /varicella resonance nurofen /
imaging brufen
• Whooping
• Paediatrics cough • MRSA / • Clopidogrel
/pediatrics /pertussis methicillin- /Plavix /
resistant Grepid
• Mumps / staphylococcus
• Thalassaemia aureus
/thalassemia epidemic • Simvastatin /
parotitis Simvador /
• COPD / chronic Zocor
• Oesophagitis • Vomiting / obstructive
/esophagitis emesis pulmonary
disease • Oesophagitis
/esophagitis
WORKED EXAMPLE: IDENTIFY SEARCH TERMS

In young children with a fever is ibuprofen better

than paracetamol at reducing the fever?

Search terms Synonyms

Child, infant, infants, paediatrics, paediatrics,
P Children, fever
febrile, pyrexia
I Ibuprofen Brufen, Nurofen, Calprofen

C Paracetamol Calpol
Temperature, reducing temperature, fever
O Reducing fever
reduction, lowering
EXERCISE 2: IDENTIFY SEARCH TERMS

Does cognitive behavioural therapy improve self-esteem in

adults with eating disorders?
Use of text-messaging in the self-management of long-term
conditions
Is a CT scan or ventilation perfusion scintigraphy better at
detecting pulmonary embolism in pregnant women?
EXERCISE 2: ANSWERS
Does cognitive behavioural therapy improve self-esteem in
adults with eating disorders?

Search terms Synonyms

Anorexia, appetite disorder, anorexia
P Adults eating disorders
nervosa, bulimia, binge-eating,
Cognitive behavioural CBT, talking therapy, psychotherapy,
I therapy psychological treatment
C N/A
Self-confidence, anxiety, depression,
Improvement in self-
O esteem
improved confidence, self-respect, self-
worth
EXERCISE 2: ANSWERS

Use of text-messaging in the self-management of

long-term conditions

Search terms Synonyms

Patients with long Chronic conditions, all specific ones eg
P term conditions asthma, diabetes COPD etc
I Text messaging SMS, messaging, texts, texting

C N/A

O Self-management Self-care, independence, self-reliance

EXERCISE 2: ANSWERS
Is a CT scan or ventilation perfusion scintigraphy better at
detecting pulmonary embolism in pregnant women?

Search terms Synonyms

Pregnant women with

P suspected pulmonary embolism
Gravida, PE, pulmonary embolism

Computerised tomography,
I CT scan
computed tomography, CAT scan
Ventilation perfusion
C scintigraphy
Perfusion scan, VQ scan

O Accurate detection Diagnosis, detection

Evidence Based Medicine part 2 ..
Doing a Literature Search

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Supporting your Knowledge for Healthcare
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