Lecture 2

Dewi Sutriani Mahalini

Department of Pediatrics, Faculty of Medicine, Udayana University
Email: dewi_sutriani@unud.ac.id
 CURRICULUM VITAE

Tempat/tgl lahir: Singaraja, 27 Juni 1970

Pendidikan:
2006 ~ PPDS I Ilmu Kesehatan Anak FK Unud/ RSUP Sanglah
2010 ~ Fellowship Bagian Neurologi Anak FKUI/RSCM Jakarta
2018 ~ Program Doktor/S3 Ilmu Kedokteran, Universitas Udayana
Instansi : Divisi Neurologi Anak
Departemen Ilmu Kesehatan Anak FK UNUD/RSUP Sanglah
Email : dewi_sutriani@unud.ac.id
1. Understand the reasons for focused
questions (PICO)
2. Learn how to formulate clinical questions
3. Use the PICO to formulate your search
strategy
4. Introduction to Boolean logic to combine
your search strategy
5. Learn how to use systematic approach to
locating the evidence

www.cebm.net
E S
B T
M E
P
S
BACKGROUND QUESTIONS;
❑ Ask for general knowledge about a condition, test,
or treatment.
❑ Have 2 essential components:
1. A question root (who, what, where, when, how, why)
2. A disorder, test, treatment, or other aspect of healthcare
❑ Examples:
▪ How does heart failure cause pleural effusions?
▪ What cause dengue fever?
FOREGROUND QUESTIONS;
❑ Ask for specific knowledge to inform clinical
decisions or actions
❑ Have 4 essential components:
1. P
2. I
3. C
4. O
➢ EBM process starts with a clinical scenario
that needs the best answer

➢ One of the difficult steps in practicing EBM

may be the translation of a clinical problem
into an answerable question.
 Convert the clinical problem into an
answerable question

 The key to successful searching is to

convert your clinical problem into a clear
answerable question, which should
ideally be framed in the PICO/PIO format.
 Originate from
everyday clinical problem
 Clinicians have 0.7 to 18.5 questions for every 10
patients they care for.
 However, answers to 2/3 of the questions are either
not pursued or pursued but not found.
 Subsequent analyses show that almost all
unanswered questions could be answered through
improved query formulation and better search.
 Dissect what you
want to know into its
component parts

PICO is the commonly used acronym

for forming clinical questions when
practising EBM
 CLINICAL PROBLEM PICO

A child, 8 years, P= Child with severe GBS

hospitalized in PICU
because severe GBS, I = IVIG
need ventilator support C= (1) Plasma exchange
(2) Prednison
The doctor want to know,
are there any other therapy O= (1) survive/death
option is better ? (2) sequele
Does IVIG therapy deliver (3) LOS in PICU
outcome better than other (4) outcome scoring
therapy? (5) Recovery
(6) etc
"PICO" is the acronym for this 4 part question
which consists of the first letters of
1. Population/ patients
2. Intervention/ Indicator/ Exposure
3. Comparison / Control
4. Outcome.
P Population The patient or problem in question
Clinical Who are the relevant people in relation to
problem clinical problem?
I Intervention The intervention/test/exposure of
Indicator interest.
Index test Management strategy, exposure or test to
find out about relation to clinical problem
C Comparator Comparison interventions
Control Alternative/control strategy, exposure or
test for comparison
O Outcome The outcome of interest
What are you most concerned about
happening or stopping happening
 should be clear
 directly
 focused on the problem
 answerable by searching the
medical literature.
Assume that you are working in a Emergency
Unit in general hospital as a General
Practitioner.
A eight years old boy presented with acute
diarrhea.
You want to know if combination of probiotics
and prebiotics are effective in decreasing the
duration of diarrhea compared to probiotics
only.
 Patient Children with acute diarrhea
P Population

Intervention Probiotic+Prebiotic therapy

I
Comparison Probiotic only
C
Outcome Decrease duration of diarrhea
O
question In children with acute diarrhea, whether
? giving combination probiotics+prebiotics
more effective compared with probiotic for
decreasing duration of diarrhea
❑ Who are you intersted in?
❑ How would you describe the patients
or population of interest?
Patients or population
Which is referred to the specific group the
patient or population belong to ?
 Diabetes mellitus type 1
 Infant with acute diarrhea
 Adult with chronic kidney disease
 Epilepsy in adult/children/ neonates
 Low birth weight infant
 Children with dermatitis atopic
 Pregnant woman
 Patient epilepsy with phenobarbital
 Cause
 Risk Factor
 Prognostic Factor
 Treatment/intervention
Intervention
Which is the kind of treatment or
procedure we want to know its efficacy ?.
RISK FACTOR PROGNOSTIC FACTOR

 Family with epilepsy  Control of blood

 Social economy pressure
 Low protein intake  HbA1C
 Obese  Hb concentration
 Less execise  Regular exercise
 Age  MRI result
 High blood pressure  CRP
 HDL/LDL ratio
INTERVENTION TREATMENT

 Plasma exchange  Amphicillin

 V-P shunt  Carbamazepin
 Certain Procedure  Paracetamol
 Elastic bandage  Ibuprofen
 Elastic stocking  High protein intake
 Catheterization  Hiperosmoler fluid
 What is the alternative to the
intervention?
 May not always be necessary

Comparison
Which is the standard treatment
for comparing the effect of
Intervention ?
 What do I hope to accomplish?
 What could this exposure really affect?

Outcome
Which is the intended outcome we
expected to have by our intervention ?
 Length of stay
 Duration of diarrhea
 Duration of fever
 Accuracy
 Life expected
 Survival rate
 Creates a clear focused question !
 Defines the important outcomes !
 Structures your search !
 Saves you time!
Formulate an answerable question
Write here the clinical issue that you wrote down
earlier

Identify what sort of question it is

 Intervention

 Etiology

 Diagnosis

 Prognosis/prediction

 Frequency/rate

 Phenomenon
Now built up a research question using PICO

P population =

I intervention =

C comparator =

O outcome =
RESEARCH QUESTION
CLINICAL PROBLEM/ PICO ANSWERABLE/
SCENARIOS RESEARCH QUESTION
The doctor want to P=child with severe GBS 1. In child with severe
know, are there any GBS, does IVIG
other therapy option is I /C = therapy deliver survival
better for child 1. Plasma rate better than plasma
hospitalized with GBS exchange exchange therapy?
& need ventilator 2. Prednisone 2. In child with severe
supports? 3. IVIG GBS, does IVIG
O= therapy deliver
1. Survive/Death sequalae less than
Does IVIG therapy 2. Sequalae plasma exchange
deliver outcome better 3. LOS in PICU therapy?
than other therapy? 4. Outcome scoring 3. In child with severe
5. Recovery GBS, does IVIG
6. Etc. therapy deliver
sequalae less than
Prednisone ?