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Evidence Based Medicine: Ask

Formulating a Well Built Clinical Question (PICO)

According to the Centre for Evidence Based Medicine (CEBM), "one of the fundamental skills required for practising EBM is the asking of well-built clinical questions. To benefit patients and clinicians, such questions need to be both directly relevant to patients' problems and phrased in ways that direct your search to relevant and precise answers."

A well-built clinical foreground question usually has four components:

Hierarchy of Evidence

Study Types

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 summarise 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).

(From the British Medical Journal’s Clinical Evidence Glossary

Types of Questions

Primary Question Types

  • Therapy: how to select treatments that do more good than harm.
  • Diagnostic tests:select and interpret diagnostic tests, in order to confirm or exclude a diagnosis, based on their precision, accuracy, acceptability, expense, safety, etc.
  • Prognosis:  estimate a patient's likely clinical course over time due to factors other than interventions.
  • Harm / Etiology: identify causes for disease (including its iatrogenic forms).

Example Case

A 55 year old female has a diagnosis of osteoarthritis in her knees. She has been taking NSAIDs but wants to know if glucosamine sulfate would be an effective treatment.

P = 55 year old female with osteoarthritis in her knees
I = glucosamine sulfate
O = lessening of knee pain

PICO Question: In patients with knee osteoarthritis, is glucosamine sulfate an effective treatment when compared to NSAIDs?

Question Type: Therapy

More PICO examples

  • Do adults with acute bronchitis who are treated with antibiotics note earlier improvement in clinical symptoms, compared to those who are given inhaled albuterol?
  • In adults with minor depression, is St John’s wort or an SSRI more effective at relieving symptoms?
  • In smokers with cough, does chest x-ray or chest CT have a better positive or negative predictive value for lung cancer?

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