Before you begin your search for information, you may have to do some reading to better understand the disease state or drug. In EBM, these are called Background Questions: you need general/factual information on a topic which applied to all patients; i.e., What is the etiology of SARS? What is the pediatric dose of Atrovent? Such questions can usually be answered using resources such as textbooks, drug references, review articles, etc. As you gain skills and experience, you will do less background reading, but even experienced practitioners have Background Questions from time to time.
Foreground questions: These seek evidence to form a basis for decisions about a specific patient, an intervention or therapy. Such questions can usually be answered using resources such as original research articles or secondary sources such as systematic reviews. Using the PICOformat can help you design an answerable clinical foreground question.
PICO is a method that can help take you from a patient care situation/scenario to developing a foreground question, to help you focus on what exactly your information need is. Once you have these elements, you can move to converting them to search terms for your literature search.
P refers to the patient or population or problem
Describe either the patient's chief complaint or generalize the patient's condition to a larger population.
I refers to the intervention or indicator
What do you plan to do for that patient? This may include the use of a specific diagnostic
test, treatment, adjunctive therapy, medication or the recommendation to the patient to use a product or procedure.
C refers to the comparison or benchmark against which the intervention is measured
This is the main alternative you are considering. It should be specific and limited to one
alternative choice in order to facilitate an effective computerized search. The Comparison is
the only optional component in the PICO question. You may look at the Intervention without
exploring alternatives or, in some cases, there may not be an alternative.
O the outcome or the anticipated result of the intervention
This specifies the result(s) of what you plan to accomplish, improve or affect and should be measurable. When the intervention is a diagnosis the outcome may be about the reliability or validity of the test. With prognosis or treatment as the intervention, the outcome might be some specific morbidity. Outcomes may be worded in terms of relieving or eliminating specific symptoms, improving quality of life or maintaining or enhancing function, lowering costs, etc.
Here is an example of a scenario/patient situation expressed in PICO and the elements that might be identified:
Systemic steroids, such as prednisone, slow bone growth. Children with chronic asthma are often prescribed inhaled steroids or corticosteroids. Do these drugs have any impact on growth before adolescence?
P: preadolescents with asthma
I: inhaled corticosteroids
C: treatment without corticosteroids
O: growth at predicted rate
In preadolescents with asthma will inhaled corticosteroids suppress normal growth (as compared to treatment without corticosteroids)?
You try it:
Your patient is a 73 year old female in good health with normal cholesterol levels and no chronic diseases. However she has started to notice that she is forgetting things more often and having problems with some every-day tasks like balancing her checkbook; she’s fearful that she might be “getting Alzheimer’s Disease.” She mentions that her neighbor told her that Lipitor is supposed to help with the symptoms or maybe even prevent Alzheimer’s disease. She wants your advice. Would this help?
This template can help you put it all together
how does ________________________________________
compared with ____________________________________
*This verb will vary depending on your outcome; it might be a term such as lower,decrease, reduce, increase, relieve, eliminate, prevent, etc.
Not everyone will "see" the same question(s) in the same patient scenario. Some possible clinical questions from this situation: