p.i.c.o model

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Published on December 16, 2008

Author: kassab

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Using the PICO model to formulate a search question : Using the PICO model to formulate a search question Dr.abdelkafi alkassab KJO HOSPITAL Dean, Harvard Medical School to students: : Dean, Harvard Medical School to students: “We believe that 50% of what we are teaching to you now will prove to be false 5 years later; the problem is that we do not know which 50%” EBM : EBM Best Clinical Evidence Patient’s Needs/ Preferences Clinical Experience Don’t put the cart before the horse : Don’t put the cart before the horse The question must be defined before the answer to the question can be elucidated through a careful search Introduction : Introduction Many questions happen during patient care! 2/3 of the questions are not answered Almost all the unanswered questions could be answered through improved query formulation and better search ? Develop well-built, focused questions Slide 7: TYPES OF QUESTIONS (1) Background Questions : (1) Background Questions Asked for general knowledge about a disorder  Has two essentials components: a question root ( who, what, where, how, why) with a verb a disorder Slide 9: Textbooks answer background questions.   Not all topics are covered, easy to use, relatively inexpensive and can be opinion-based rather than evidence-based, written by experts in their fields. (2) Foreground Questions : (2) Foreground Questions Asked for specific knowledge about managing patients with a disorder It has 4 components (PICO analysis): P - Patient/Population I - Intervention C - Comparison O - Outcome Slide 11: Novice Expert Searcher   Searcher Background Information Foreground Information EBM Principles : EBM Principles 1.  Construct a well-built clinical question and classify it into one category (therapy, diagnosis, etiology or prognosis) 2.  Find the evidence in health care literature 3.  Critically appraise or formally evaluate for validity and usefulness 4.  Integrate the evidence with patient factors to carry out the decision 5.  Evaluate the whole process Slide 14: Ask Acquire Appraise Apply Act & Assess Patient dilemma Principles of evidence-based practice Evidence alone does not decide – combine with other knowledge and values Hierarchy of evidence Process of EBP Slide 15: Belief at the beginning of an endeavor is the one thing that will ensure success What is PICO? : What is PICO? A useful model to help structure an answerable question Used to formulate clinical questions Breaks down the question into four key elements Good questions are the backbone of practicing EBM. It takes practice to ask the well-formulated question. : Good questions are the backbone of practicing EBM. It takes practice to ask the well-formulated question. The PICO model : The PICO model Patient, Population, Problem Intervention Comparison Outcome Patient, Population, Problem : Patient, Population, Problem Patient or patient group (gender, race, age) Disease or condition Stage of the illness Care setting Intervention : Intervention Type of treatment (drug, procedure, therapy) Intervention level (dosage, frequency) Stage of intervention (preventative, early, advanced) Delivery (who delivers the intervention? where?) Comparison : Comparison Alternative interventions (standard treatment, placebo, another intervention) There may not always be a comparison Outcome : Outcome The outcome or effects you are interested in, for example Improvement of symptoms, healing Side effects Improved quality of life Cost effectiveness and benefits for the service provider What makes a clinical question well built? : What makes a clinical question well built? Question should be directly relevant to the problem at hand. Question should be phrased to facilitate searching for a precise answer. Asking a well-built question, like many clinical skills, needs practice. Categories of EBM Questions : Categories of EBM Questions After constructing the PICO analysis, determine the category of the question.   There are the four categories of EBM questions 1) Therapy : 1) Therapy Solves questions about which treatment to administer, and what might be the outcome of different treatment options.  For most therapy questions one may want to look for the best evidence namely a randomized controlled study, and if the study can be a double blind, so much the better. Slide 27: “In patients with an acute MI, are antiarrhythmic drugs more effective than standard therapy in preventing sudden cardiac death?” P I C O Acute myocardial infarction Antiarrhythmic drugs Standard therapy Sudden cardiac death Therapy 2) Diagnosis : 2) Diagnosis Solves questions about degree to which a test is reliable and clinically useful, to decide whether the patient would benefit from it Most articles compare result of a certain diagnostic test with that of a standard test regarded as being a "gold standard". Slide 29: “In patients with suspected pulmonary fibrosis, how does high-resolution CT compare with lung biopsy for establishing the diagnosis?” P I C O Pulmonary fibrosis High-resolution CT Lung biopsy Sensitivity/specificity/PVs/LRs Diagnosis 3) Etiology : 3) Etiology Solves problems about the relationship between a disease and a possible cause Slide 31: “Do obstetrical complications during pregnancy increase the likelihood of schizophrenia in the child?” P I C O Pregnant females Obstetrical complications No obstetrical complications Childhood schizophrenia Etiology 4) Prognosis : 4) Prognosis Answers questions about a patient's future health, life span and quality of life in the event one chooses a particular treatment option Slide 33: “In patients with acute leukemia, is a normal white cell count at the time of diagnosis an independent predictor of disease-free survival?” P I C O Acute leukemia Normal white cell count Abnormal white cell count Disease-free survival Prognosis Remember… : Remember… Including more search terms will narrow your search Use for very specific questions and larger databases to make number of results more manageable For a broader search, less specific details are needed Use for broader questions and smaller databases which bring back fewer results case1 : case1 A nine-year-old girl presents in the ER with diffuse abdominal pain and loss of appetite. You suspect appendicitis, and need to decide which imaging modality is best for making the diagnosis—CT or ultrasound. Slide 37: P I C O child with suspected appendicitis CT ultrasound reliable diagnosis of appendicitis A good clinical quistion would be : is ultrasound or CT better for diagnosig appendicitis in a child? Slide 38: You are seeing a child with acute diarrhea and a lower respiratory infection. You know that zinc supplementation will improve the diarrhea, but will it help the respiratory infection as well? Or is there something else that you can add that might work with the zinc? P I C O Child with diarrhea and respiratory infection Zinc supplementation Zinc supplementation plus something else Improvement in diarrhea and respiratory infection case2 case3 : case3 A 52-year-old man, with a history of knee pain due to osteoarthritis of the joint, visits your office and mentions that a co-worker has suggested that electrical nerve stimulation—also known as TENS (transcutaneous nerve stimulation)—can relieve his symptoms. You need to find some solid evidence that TENS has been used to relieve knee pain. Slide 40: In adults with knee osteoarthritis . Is electrical nerve stimulation(tens) an effective therapy for providing pain relief? P I C O osteoarthritis of the kmee transcutaneous nerve stimulation there is no comparative intervention or complication mentioned pain relief case4 : case4 A patient of yours, a 56 year old woman, has recently developed what she refers to as a racing or fluttering heart, which she has noticed following exercise or other exertion. You suspect that she has an atrial fibrillation. Your patient has recently read in the popular press about the debate between whether to treat these patients with anti-arrhythmic drugs or nodal ablation to control their cardiac rhythms. She is concerned about invasive procedures. You would like to find evidence to guide your management of this patient. Slide 42: In a patient with atrial fibrillation ,is rhythm control best achieved though medical management with antiarrthythmic drugs or nodal ablation ? P I C O atrial fibrillation antiarrthythmic drugs nodal ablation rhythm control SUMMARY : SUMMARY The well-built clinical question is widely believed to be the key to finding the best evidence efficiently and also the key to evidence-based decisions . A well-built clinical question is one that is focused and well articulated in all four components of its anatomy They are: patient/problem, intervention, comparison, outcome, commonly referred to with the mnemonic PICO: References : References Booth, A. (2004) “Formulating answerable questions” in Booth, A. and Brice, A. Evidence-based practice for information professionals: a handbook. Facet Publishing. pp. 61-70 Nordenstrom, J. (2007) Evidence-based medicine in Sherlock Holmes’ footsteps. Blackwell Publishing. Zakowski, L., Seibert, C. and VanEyck, S. (2004) “Evidence-based medicine: answering questions of diagnosis.” Clinical Medicine & Research, 2(1) pp. 63-69. Slide 45: A

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