Searching, Evaluating & Using Evidence

for Informed Decisions

Dr. Ruzegea, M.A (PhD)

MUHAS Library
 SESSION 5:
PICO Concepts, Types of Clinical Questions,
Study Designs & Levels of Evidence

4th March 2021

Agenda
1. EBP model
2. 5 Steps of EBP Process Model
3. Types of Clinical Questions
4. Skills for developing Clinical Questions
5. Using PICO Format to formulate/build answerable
research questions
6. Types of Study Designs
EBP Models
What do you need for EBP?

Reliable, objective, high-quality information

Tools for critical evaluation of evidence (Models)

The 5 Steps of EBP Process
1. ASK: Formulate a well built
answerable clinical question
Ask
2. ACCESS/Acquire: Search &
find evidence. Track down the best
Evidence

3. APPRAISE: Critically appraise the Assess Access

evidence for its validity and
usefulness & synthesize the
evidence

4. APPLY: Integrate the results,

your expertise, patient
values/local conditions into Apply Appraise
clinical practice
5. ASSESS: Evaluate performance
of your clinical decisions (i.e.
effectiveness of the process)
 Step 1: ASK
Two components need to be understood in step 1:

1. Types of clinical questions (a well build,

answerable clinical question) &

2. PICO format
 Types of clinical Questions
(1) Background Questions
•Ask for general knowledge about a
condition, test or treatment.  They ask
about: who, what, where, when, how & why
about things
•These questions are asked when want to
learn a new topic. e.g. “Disorder”
•What is the disorder?
•What causes it?
•How does it manifest?
•Treatment options?
•Background Information Resources include:
•books
•guidelines (best practice)
•narrative reviews which gives general
overview of a topic. E.g. “treatment of
heart disease”
(2) Foreground Questions
•Ask specific clinical questions
about population/patient
•INTERVENTION/PREVENTION
•ETIOLOGY, RISK
•DIAGNOSIS
•PROGNOSIS
FQ questions e.g. “In patients with
osteoarthritis of the hip, is water
therapy more effective than land-based
exercise in restoring range-of-motion?”
•Foreground Information
Resources include:
•journal articles
•synopses of articles
•systematic reviews
Skills for Developing Clinical Questions

1. Some background knowledge of the

condition

2. Understanding
patient/population/problem and the
outcomes and beliefs/values that
matter to this
patient/population/problem:
e.g. Death? Disability? Quality of life? Cost?
Improvement of symptoms?
 Searching Evidence by Using PICO Format

Step 1: ASK
Use PICO to write a focused and answerable research question
P = Patient, population or problem
I = Intervention
C = Comparison intervention (optional)
O = Outcome
Patient or Population of interest –
 Think about their characteristics in terms of disease, problems or
coexisting conditions

 Gender, age, ethnicity, sexuality or location may be additional

descriptions relevant to your research questions
Intervention
 Comparison/Control intervention
Treatment with Treatment
 Comparing intervention with another alternative
Treatment with Placeable Treatment with No Treatment
 Outcome
 What are the results of your intervention?

What are you hypothesizing that your intervention has caused?

Time
 Is there a time frame?

 How long will it take for intervention to achieve an outcome, or how

long will participants be observed?
Are you following women during pregnancy?
Are you observing sports injuries over the season?
Following study participants for a certain recovery time?
etc…
PICO/PICOT FORMAT
 Why should I use PICO?
• Define problem - clarify it in your own mind

• Identify concepts/terms for searching

• Ask patient centered questions:

• treatment of Pneumococcal Pneumonia SHOULD be different for:
– Terminal Cancer Patient
– Young, mother of 2 children
Example
1. Initial research question = What effect will the campus smoking
ban have on students who smoke?
2. Think about the question with PICO framework in mind!
P = Students who smoke, college campus
I = Smoking ban
C= No Smoking ban
O = Students smoke less

3. New PICO Question = Do college campus smoking bans decrease

the amount that students smoke?
4. Identify the key words to search for resources. Ask your self what
are the main concepts of the question?

P = Students who smoke, college campus

I = Smoking ban

C= No Smoking ban

O = Students smoke less

5. Think about possible additional key words in each PICO category.
They can be synonyms or different ways to describe the identified
key words

6. This will help you to focus on the topic and in searching the best
most relevant results (evidence).
List Synonyms along the key words

• Students, College University

• Smoke, smoking, tobacco, cigarette
• Smoking ban, smoking regulations, smoke free
• “no smoking ban”
• Smoke less, decrease, reduce
Combining the key words with Boolean Operators AND OR &
NOT
to further define your search
Population Intervention Comparison Outcome
Student 1OR Smoke ban 8 OR Smoking “No smoking ban” 12 Smoke less 13 OR quit 14
Student 2 ban 9 OR Regulations of OR decrease 15 OR reduce
smoking 10 OR “smoke 16
free law” 11

Smoking tobacco 3
OR Smoking 4
Cigarette 5
College 6 OR
University 7

Combining Search Terms by Boolean Operators:

((1 OR 2) AND (3 OR 4 OR 5) AND (6 OR 7)) AND ((8 OR 9 OR 10 OR 11)) AND 12 AND ((13 OR 14 OR 15 OR 16))
Types of EBP Questions & Study Designs

After you have crafted your question using the PICO format,
another step is the process to identify the type of question
you are asking, and identify the optimal type of research
design to answer your question. 
 Types of Questions
There are four primary question types:

1.Therapy: Does the treatment work? How effective is the

intervention?

2.Diagnosis / Diagnostic Test: What is the ability of the test to

predict the likelihood of a disease?

3.Prognosis: What is the future course of the patient?

4.Harm/Etiology: What is the cause of the problem? What is the

harmful effect of an intervention or exposure?
 Types of Studies /Designs
(From BMJ’s Clinical Evidence Glossary)

• 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 summarize studies addressing a defined question. (It
can, but need not, involve meta-analysis). In Clinical
Evidence, SR refers to a systematic review of RCTs
• Randomized Controlled Trial (RCT): 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 (CCT): a trial in which

participants are assigned to two or more different
treatment groups. (Treatment is assigned by a method
other than random allocation. 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 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).

• 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).
Type of Clinical Question and the
Appropriate Study Design
 Example 1: Therapy/Intervention
Questions

• A 54 year old male patient was diagnosed with intermediate grade

prostate cancer and wants to know whether to get a radical
prostatectomy or radiation treatment. He is concerned about the risk
of impotence.

• Identify the 4 PICO components

Example 1 cont…
Formulate the Clinical Question:
• PICO Format
P: Population/patient/problem - 54 year old male /
prostate cancer
I: Intervention/therapy - radical prostatectomy
C: Comparison intervention/Comparator - radiation
treatment
O: Outcome - reduce risk of impotence

• Focused Clinical Question

In 54 year old male patients with intermediate grade
prostate cancer, is radical prostatectomy more effective
compared to radiation treatment in reducing the risk of
impotence?
Example 2: Etiology/Risk Questions
1. What causes a disease or health condition?
The reverse of intervention questions, they deal with harmful
outcomes of an activity or exposure (public health issues)

2. Develop PICO and a clinical question for the case below.

Sally is a smoker and just found out that she is 3 months
pregnant. She quit smoking immediately. But she is worried
if her developing baby was harmed and if the baby is at risk
for having developmental problems. She is asking you if
smoking during the first trimester can harm her baby?
 Example
2…
Clinical Question for Etiology or Risk Question:

• PICO Format
P-babies of mothers who smoke
I-smoking in first trimester
C-nothing
O-increase risk of developmental problems

• Focused Clinical Etiology Question

Are babies of mothers who smoke during their first trimester
at an increased risk of developmental disabilities?
Example 3: Diagnosis Questions

• Questions seek to differentiate between those with and

without a condition or disease.
Questions seek to understand how accurate a diagnostic
test is in various groups and in comparison to other tests
or usually to a “gold standard test” (best available
benchmark) e.g. PCR test for covid 19.

• Develop PICO and a clinical question for the case

below
As part of your clinic assessment of elderly patients, there
is a hearing check. You think that a simple whispered voice
test is very accurate compared to other methods. You want
to do a literature search. What is your question?
Example 3…

Focused Clinical Diagnosis Question

In elderly people, does the whispered voice compared to
other tests give an accurate diagnosis of hearing problems?

PICO Format
P-elderly people
I-whispered voice test
C-no test (or other tests)
O-accurate diagnosis of hearing problems
EBP Step 2:
Access

1. Track Down the Best Evidence…

Start “hunting” from the best resources.
match your question to the best information
resource for your question.
2. Beware of information overload…
 EBP Step 2… Access
Best information resources for tracking down the
best evidence come from:
 Journal articles

 Study synopsis

 Systematic reviews
Levels of Evidence
A useful way
to view the
quality of
information
you will find
when doing
research
 Hierarchy of Evidence
(Research Studies)

synthesis

experimental

observational

primary literature – comes directly from a study

secondary literature – combines findings from primary literature
Why evidence is  hierarchical?
• The higher you go into the hierarchy the more confident
you become about the results and applicability to your
Paitent/population

• Information from sources e.g. PubMed, CINAHL or

COCRANE Library are considered to be unfiltered

• Such evidences are made up of individual studies that have

not been evaluated according to evidence based measures

• The filtered information is at the top, there is less of it and

has higher quality
Evidence Categories
 Hierarchy of Evidence - Medical Literature
access at the level that will give you the best evidence

Track Down
Filtered & Critically Appraised

Expert Opinion and Not Filtered

Background info.

Most clinically relevant (at the top) Least clinically relevant (at the bottom)
(Run EBP algorithms in the back ground)
 (CAT
)

• CAT is where the literature/information on a particular disease,

condition, treatment etc is evaluated according to evidence
based criteria
Some of these can
provide evidence but no
independent group has
appraised them according
to the evidence based
protocols
 The majority of health
science research falls
under this category
 Depends on the textbook
Many newer ones are
following EBP guidelines,
 For the most part text books
generally are outdated by the
time they gate publish and
there is a lot of information
that is not based on evidence
1. Dahlgren Memorial Library. Evidence-based medicine resource guide
EBP Step 3: Appraise

Appraise (check for studies validity & impact): Appraise

primary and secondary research

Validity: Is the evidence valid?

1. Internal validity – Ask: How well the study was conducted?
(Methods/methodology of the study). Is it biased? Does PICO of the
study match my PICO question?

2. External validity - Ask: How applicable are the findings to the

real world? Generalizability of the results from a sample
population to a larger population. How large was the study sample?

Impact: - Ask: Are the findings relevant? Does the evidence make a
EBP Step 4: Apply

Integrate the results with your clinical

expertise and your patient values:
• Patient
• Is my patient similar enough that the results of the study apply?
• Will the potential benefits outweigh the potential harms of treatment ?
• What does my patient think? What are his cultural beliefs?
• Setting
• Is the intervention feasible in my settings?
• What alternatives are available?
 EBP Step 5: Assess

Assess or Evaluate the effectiveness of the process:

1. How your patient/population/problem is doing? &
2. Your ability to apply EBP process. Ask: How am I doing?
1. Am I asking appropriate questions?
2. Am I writing down my information needs?
3. How is my searching going? Am I becoming more efficient?
4. What is my success rate in the EBP steps?
5. Am I periodically syncing (checking) my skills and knowledge with new
developments?
6. Teach others EBP skills
7. Keep a record of your questions
THANK YOU !

Questions?
Comments!
REFERENCES
1. Dahlgren Memorial Library. Evidence-based medicine resource
guide: Clinical questions, PICO, & study designs. 
http://guides.dml.georgetown.edu/ebm/ebmclinicalquestions.
Updated 2016. Accessed June 24, 2016.
2. GATE Appraisal Form:
https://www.fmhs.auckland.ac.nz/en/soph/about/our-depar
tments/epidemiology-and-biostatistics/research/epiq/2015-
evidence-based-practice-and-cats.html
3. University of Oxford’s Center of EBM:
http://www.cebm.net/index.aspx?o=1157
4. Evaluating the Evidence section in the EBM tutorial at:
http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm

nd