The Well-Built Clinical Question:

The PICO Principle

MUHAMMAD ALI
FM USU

ICE EBM Workshop, Medan 9-10 March 2013

Consider the following clinical scenario...

“George, 40 years old, 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.”

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And this question...
“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?

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 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)

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 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

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

Appraising the Formulating the

Evidence Clinical Question

•Patient
•Patient
•Hierarchy •Intervention
•Hierarchyofofevidence
evidence •Intervention
•Pre •Comparison
•Preappraised resources
appraised resources Searching the •Comparison
•Outcome
•Outcome
Evidence
(Lang,
(Lang,2000)
2000) 6
 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)

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• 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

• 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?

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 Remember the PICO Principle

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!

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Two additional elements of the well-built clinical question:
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
Harm/Etiology
how to identify causes for disease (including iatrogenic forms)

In each case the P I C O method can be used to

formulate the question
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 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
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Types of Studies:

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 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?
Sex, age or race of a patient?
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 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?

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 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

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 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?

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 '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
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Is vitamin C more effective than echinacea in preventing the common cold in adult?

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

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

Case:
A mother came to your clinic bringing her son, Charly, a ten-year old boy. She would like to know of
your opinion about the best option for her son’s Atrial Septal Defect/ASD closure, whether the
transcatheter closure with Amplatzer device is better than that with open heart surgery.

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 I is for Intervention

What is the Intervention

Patient

The intervention is what you plan to do for your patient or patient group.
For example, you might: Intervention
• Run tests
• Prescribe drug treatment Comparison
• Refer to a specialist
• Schedule surgery/other intervention
Outcome

Case:
A mother came to your clinic bringing her son, Charly, a ten-year old boy. She would like
to know of your opinion about the best option for her son’s Atrial Septal Defect/ASD
closure, whether the transcatheter closure with Amplatzer device is better than that
with open heart surgery.

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 C is for Comparison
Patient
What is the Comparison

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

Case:
A mother came to your clinic bringing her son, Charly, a ten-year old boy. She would like to know of your
opinion about the best option for her son’s Atrial Septal Defect/ASD closure, whether the transcatheter
closure with Amplatzer device is better than that with open heart surgery.

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 O is for Outcome
Patient
What is the Outcome?
Intervention
The outcome is the hoped for effect of the intervention

For example: Comparison

If I prescribe ibuprofen for my patient it will prevent pain
Outcome = Pain Prevention. Outcome

Case:
A mother came to your clinic bringing her son, Charly, a ten-year old boy. She would like
to know of your opinion about the best option for her son’s Atrial Septal Defect/ASD
closure, whether the transcatheter closure with Amplatzer device is better than that
with open heart surgery.

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 PICO
You determined the following were important factors for our case.

• Patient: Child with ASD

• Intervention: Transcatheter closure
• Comparison: Surgical closure
• Outcome: Better result/efficacy

Case:
A mother came to your clinic bringing her son, Charly, a ten-year old boy. She would like
to know of your opinion about the best option for her son’s Atrial Septal Defect/ASD
closure, whether the transcatheter closure with Amplatzer device is better than that
with open heart surgery.

• Put your PICO elements together to form an researchable clinical question

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 Your Clinical Question

Case:
A mother came to your clinic bringing her son, Charly, a ten-year old boy. She would like
to know of your opinion about the best option for her son’s Atrial Septal Defect/ASD
closure, whether the transcatheter closure with Amplatzer device is better than that
with open heart surgery.

Here is a well-formulated clinical questions that a physician might research based on

the case above

Is transcatheter closure more effective than surgical closure in child with ASD?

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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

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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
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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 27
 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)

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 The Clinical Question
Your clinical question will impact the entire EBM research process.

Evidence Based
Clinical Question Search terms Literature search
Answer

• 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.
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 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) 30
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THANK YOU

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