research questions using pico

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Defining the Question: Foreground & Background Questions

In order to most appropriately choose an information resource and craft a search strategy, it is necessary to consider what  kind  of question you are asking: a specific, narrow "foreground" question, or a broader background question that will help give context to your research?

Foreground Questions

A "foreground" question in health research is one that is relatively specific, and is usually best addressed by locating primary research evidence. 

Using a structured question framework can help you clearly define the concepts or variables that make up the specific research question. 

 Across most frameworks, you’ll often be considering:

• a who (who was studied - a population or sample)
• a what (what was done or examined - an intervention, an exposure, a policy, a program, a phenomenon)
• a how ([how] did the [what] affect the [who] - an outcome, an effect). 

PICO is the most common framework for developing a clinical research question, but multiple question frameworks exist.

PICO (Problem/Population, Intervention, Comparison, Outcome)

Appropriate for : clinical questions, often addressing the effect of an intervention/therapy/treatment

Example : For adolescents with type II diabetes (P) does the use of telehealth consultations (I) compared to in-person consultations  (C) improve blood sugar control  (O)?

Framing Different Types of Clinical Questions with PICO

Different types of clinical questions are suited to different syntaxes and phrasings, but all will clearly define the PICO elements.  The definitions and frames below may be helpful for organizing your question:

Intervention/Therapy

Questions addressing how a clinical issue, illness, or disability is treated.

"In__________________(P), how does__________________(I) compared to_________________(C) affect______________(O)?"

Questions that address the causes or origin of disease, the factors which produce or predispose toward a certain disease or disorder.

"Are_________________(P), who have_________________(I) compared with those without_________________(C) at_________________risk for/of_________________(O) over_________________(T)?" 

Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation.

In_________________(P) are/is_________________(I) compared with_________________(C) more accurate in diagnosing_________________(O)?

Prognosis/Prediction:

Questions addressing the prediction of the course of a disease.

In_________________(P), how does_________________(I) compared to_________________ (C) influence_________________(O)?

Questions addressing how one experiences a phenomenon or why we need to approach practice differently.

"How do_________________(P) with_________________(I) perceive_________________(O)?" 

Adapted from: Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Beyond PICO: Other Types of Question Frameworks

PICO is a useful framework for clinical research questions, but may not be appropriate for all kinds of reviews.  Also consider:

PEO (Population, Exposure, Outcome)

Appropriate for : describing association between particular exposures/risk factors and outcomes

Example : How do  preparation programs (E) influence the development of teaching competence  (O) among novice nurse educators  (P)?

SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research Type)

Appropriate for : questions of experience or perspectives (questions that may be addressed by qualitative or mixed methods research)

Example : What are the experiences and perspectives (E) of  undergraduate nursing students  (S)  in clinical placements within prison healthcare settings (PI)?

SPICE (Setting, Perspective, Intervention/phenomenon of Interest, Comparison, Evaluation)

Appropriate for : evaluating the outcomes of a service, project, or intervention

Example : What are the impacts and best practices for workplace (S) transition support programs (I) for the retention (E) of newly-hired, new graduate nurses (P)?

PCC (Problem/population, Concept, Context)

Appropriate for : broader (scoping) questions

Example : How do nursing schools  (Context) teach, measure, and maintain nursing students ' (P)  technological literacy  (Concept))throughout their educational programs?

Background Questions

To craft a strong and reasonable foreground research question, it is important to have a firm understanding of the concepts of interest.  As such, it is often necessary to ask background questions, which ask for more general, foundational knowledge about a disorder, disease, patient population, policy issue, etc. 

For example, consider the PICO question outlined above:

"For adolescents with type II diabetes does the use of telehealth consultations compared to in-person consultations  improve blood sugar control ?

To best make sense of the literature that might address this PICO question, you would also need a deep understanding of background questions like:

• What are the unique barriers or challenges related to blood sugar management in adolescents with TII diabetes?
• What are the measures of effective blood sugar control?
• What kinds of interventions would fall under the umbrella of 'telehealth'?
• What are the qualitative differences in patient experience in telehealth versus in-person interactions with healthcare providers?
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Do you want to know whether a Cochrane Review is relevant to you?  

Look for the PICO.  

PICO stands for four different potential components of a health question used in Cochrane Review research: 

• What are the characteristics of the patient or population (demographics, risk factors, pre-existing conditions, etc)? 
• What is the condition or disease of interest?
• What is the intervention under consideration for this patient or population? 
• What is the alternative to the intervention (e.g. placebo, different drug, surgery)? 
• What are the included outcomes (e.g. quality of life, change in clinical status, morbidity, adverse effects, complications)? 

These components give you the specific who, what, when, where and how, of an evidence-based health-care research question.  

The PICO model is widely used and taught in evidence-based health care as a strategy for defining Review criteria, formulating questions and search strategies, and for characterizing included studies or meta-analyses.  

There are three different sorts of PICOs within Cochrane Reviews: 

• Review PICOs - Used to decide which studies to include in a Review. You can find this documented in the Methods section of the Review 
• Comparison PICOs – One Review may have multiple comparisons, which group different parts of the Review PICO in different ways, to answer more specific questions.  
• Included Study PICOs – Each included study has its own PICO which may include additional PICO components, such as other outcomes, that the Review is not interested in. 

See more on using PICO in the Cochrane Handbook for Systematic Reviews of Interventions . 

Find out more about the Cochrane PICO linked data project .

How can I use PICO on the Cochrane Library? 

Pico summaries on cochrane reviews and cochrane clinical answers.

For Cochrane intervention reviews , we display included PICO terms below the Abstract.  

This gives an at-a-glance summary of Population, Intervention, Comparison, Outcome for the review as annotated by Cochrane Community experts.  

With one click on a PICO term, users can see search results for reviews with the same included PICO term. There is also prominent Help material giving clear guidance on using PICOs, linking to the relevant section of the Cochrane Handbook.  

On the Review Information pages, MeSH and PICOs are now grouped together for easy discoverability. 

For Cochrane Clinical Answers , we display PICO terms for the Cochrane review from which the Answer is derived below the Answer.  

Read more at Cochrane.org | Find Exactly the Evidence You Need: At-a-Glance PICO Summaries

PICO summaries on search results 

For Intervention Reviews, included PICOs are also displayed on search results.  

Get started with PICO Search on Wiley Customer Success Hub  

Browse by PICO 

You can browse Cochrane content using themed groups of included PICOs from the Cochrane Library and Biblioteca Cochrane homepages.  

Users can discover Cochrane content using themed groups of included PICOs curated and maintained by Cochrane experts. With one click, users can see all available search results for categories with included PICOs. 

In addition, there is clear contextual help for those new to PICOs, with clear guidance on using PICOs and links to the relevant section of the Cochrane Handbook. 

Search by PICO  

PICO search allows you to use those same terms to find Reviews most relevant to your PICO questions. 

For example, the term "Diabetes Mellitus" is cited in Cochrane Reviews in some cases as a Population term, and in other cases as an Outcome term. PICO search allows you to search on the PICO context that you are interested in. 

Read more on PICO search on Cochrane Library    

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Research with Powerful PICO Questions: A Guide and Resources

DNP Capstone Project Help

Crafting a clear and focused research question is the cornerstone of any successful research project. In healthcare, the PICO framework offers a structured approach to formulating research questions that guide evidence-based practice. This article equips you with the knowledge and resources to develop impactful PICO question s, empowering your research journey.

What is a PICO Question?

PICO stands for P opulation, I ntervention, C omparison, and O utcome. It’s a framework for building research questions that target specific clinical issues. By pinpointing the patient population, the proposed intervention, a comparison group (if applicable), and the desired outcomes, a PICO question provides a roadmap for your research.

Why Use PICO Questions?

PICO questions offer several advantages for healthcare research:

• Clarity and Focus: PICO ensures your research focuses on a well-defined area, directing your data collection and analysis.
• Improved Search Strategies: A clear PICO question allows you to identify relevant research articles more efficiently.
• Enhanced Communication: PICO fosters clear communication with collaborators and reviewers, ensuring everyone is on the same page.

Crafting a Powerful PICO Question

Let’s explore how to build a strong PICO question:

• Population (P): Identify the specific patient group you’re interested in. This could be based on age, diagnosis, or other relevant characteristics.
• Example: Nurses working night shifts in intensive care units (ICUs).
• Intervention (I): Define the specific intervention you’re proposing to improve patient care or healthcare processes.
• Example: Implementing mandatory fatigue risk management strategies for night shift nurses.
• Comparison ©: If applicable, define the comparison group. This could be the current standard practice or another intervention you’re comparing yours to. Not all PICO questions require a comparison group.
• Example: The current approach to managing nurse fatigue during night shifts.
• Outcome (O): Specify the measurable outcomes you aim to achieve through your intervention. These outcomes should be directly linked to your chosen population and intervention.
• Example: A reduction in medication administration errors by nurses working night shifts.

Example PICO Question

Among nurses working night shifts in intensive care units (P), will implementing mandatory fatigue risk management strategies (I), compared to the current approach C, lead to a reduction in medication administration errors (O)?

PICO Resources to Help You

This guide equips you with valuable resources to further enhance your PICO question development:

• The Well-Built Clinical Question (UNC): https://guides.lib.unc.edu/pico/resources
• Asking Focused Questions (Centre for Evidence Based Medicine): https://www.cebm.ox.ac.uk/resources/ebm-tools/finding-the-evidence-tutorial
• Formulating Answerable Questions (Practice tool): Link to be replaced (add a link to a practice tool where users can build PICO questions)
• Forming Focused Questions with a Specialty (UNC Health Sciences Library): https://guides.lib.unc.edu/pico/resources

Remember: A well-constructed PICO question serves as the foundation for your research project. It guides your data collection, analysis, and ultimately, the impact of your research on improving healthcare practices.

Let PICO empower your research journey!

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Developing Your Question

Developing your research question is one of the most important steps in the review process. At this stage in the process, you and your team have identified a knowledge gap in your field and are aiming to answer a specific question, such as

• If X is prescribed, then Y will happen to patients?

OR assess an intervention

• How does X affect Y?

OR synthesize the existing evidence 

• What is the nature of X? ​

​​Whatever your aim, formulating a clear, well-defined research question of appropriate scope is key to a successful review. The research question will be the foundation of your review and from it your research team will identify 2-5 possible search concepts. These search concepts will later be used to build your search strategy. 

PICOT Questions

Formulating a research question takes time and your team may go through different versions until settling on the right research question.  A research question framework can help structure your systematic review question.  

PICO/T is an acronym which stands for

• P        Population/Problem
• I         Intervention/Exposure
• C        Comparison
• O       Outcome
• T       Time

Each PICO includes at least a P, I, and an O, and some include a C or a T. Below are some sample PICO/T questions to help you use the framework to your advantage. 

For an intervention/therapy

In _______(P), what is the effect of _______(I) on ______(O) compared with 

_______(C) within ________ (T)?

For etiology

Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

Diagnosis or diagnostic test

Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)?

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) over ______ (T)?

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)?

Melnyk B., & Fineout-Overholt E. (2010). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

Ghezzi-Kopel, Kate. (2019, September 16). Developing your research question. (research guide). Retrieved from  https://guides.library.cornell.edu/systematic_reviews/research_question

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Evidence-Based Practice

• Introduction to EBP
• PICO(T) for Clinical Questions

Creating a Clinical Question: PICO / PICOTS

Picot example.

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PICO  is an acronym that can help you create a well-built clinical question by identifying the key aspects of a complex patient presentation. 

• Patient or Population or Problem  The disease or condition you are investigating, and the particular demographic you are wanting to learn about (if applicable)
• I ntervention or Indicator  Primary treatment option
• Comparison or Control  Comparison treatment (if applicable)
• Outcome What you you expect to see?
• Timeline**:  Time it takes to demonstrate a clinical outcome or how long patients are observed.
• Study Type:  What kind of study would best answer this question (i.e., RCT, Case Series, etc.). Rather than using keywords in your search strategy, you can often use filters to limit to specific study types / designs. ** Note that the timeframe does not always show up in the abstract. If you aren't getting enough results, you may need to remove this from your search, and just eliminate results that don't fit your preferred timeframe in the Prisma screening section.

Patient or Problem = hypertension

KEYWORDS: hypertension, high blood pressure, hypertensive

Intervention = telemonitoring blood pressure

KEYWORDS: telemonitor, telemedicine, MeSH term is “Blood Pressure Monitoring, Ambulatory”

Comparison = n/a

Outcome = improve blood pressure

MeSH term is “Blood Pressure” (but if you are using terms for “telemonitoring blood pressure ,” this is unnecessary).

Timeframe = within one year

one year, twelve months (searching for timeframes can be tricky -- this won't find studies that were  less  than 12 months! If your results are too limited, you can try removing this from your search).

Potential search strategy:

or if you search everything in a single line:

Want to see an example in action? Check out the video below.

PICOT example begins at the 3:00 mark.

"Table 1" is from:

Gallagher Ford, L., & Melnyk, B. M. (2019). The Underappreciated and Misunderstood PICOT Question: A Critical Step in the EBP Process. Worldviews on Evidence-Based Nursing, 16(6), 422–423. https://doi.org/10.1111/wvn.12408

• PICO Tutorial from University of Washington
• Johns Hopkins EBP Question Development Tool Worksheet to help EBP teams develop an question that will answer a clinical, administrative, or knowledge problem.
• PICOT Worksheet This worksheet will help you build a PICOT question and identify keywords for your searchable question.
• Pubmed Clinical Queries This tool uses predefined filters to help you quickly refine PubMed searches on clinical or disease-specific topics.
• The Underappreciated and Misunderstood PICOT Question: A Critical Step in the EBP Process
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• Last Updated: Aug 27, 2024 10:55 AM
• URL: https://researchguides.gonzaga.edu/EBP

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Clinical Questions: PICO and PEO Research

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Table of Contents

When you’re beginning the clinical research process, one of your first decisions will be around framing your clinical question. That, in turn, will depend on if your research is quantitative, or based on numerical data, or qualitative research based on non-numerical data. A PICO clinical question is tied to quantitative data, whereas a PEO question relates to qualitative data.

Let’s take a look at both of these clinical question formats.

What is a PICO Question?

As mentioned above, a PICO research question is used when quantitative data is involved. PICO stands for:

• P – Population, Patient and/or Problem: How do you describe the patients, people or the problem that you’re looking at?
• I – Intervention: What are you considering for an intervention, exposure or factor?
• C – Comparison: Do you have something to compare to the intervention, exposure or factor that you’re considering?
• O – Outcome: What are you hoping to measure, improve, affect or accomplish?

So, essentially, your PICO question will answer the above aspects. This type of clinical question is most often used when the research is investigating evidence-based medicine or other interventions. However, the PICO question format can also be used for non-clinical settings, such as psychological interventions for school-age children, and how they relate to academic achievement.

How to Write a PICO Question

It can sometimes be a challenge to write PICO Questions, as they can be very complex. Since we are looking at evidence-based conclusions, great thought has to be put into formulating a PICO research question. Once the question has been written and clarified, it can help the researcher determine what type of study model will work best to answer the question. So, in a very real way, asking the question properly helps you select what type of study you’ll be conducting.

Fortunately, once you are comfortable with the elements of a PICO question, it almost becomes a plug and play model. For example, if you are looking at questions around prognosis, you might structure your PICO question like this:

Would ________________ (I) affect or influence _________________________ (O) with patients or people who have ___________________________________________________ (P) compared to __________________________(C)?

Another example of a PICO research question might include an inquiry into prevention:

With ___________________ (P) does the practice or use of ________________________ (I) reduce or prevent risk of __________________________(O), compared with __________________________(C)?

What is a PEO Question?

A PEO research question focuses on non-numerical data, or qualitative research. Here, relationships and associations are explored. For example, a PEO question can try to explore whether there is a correlation between taking baby aspirin and a lowered risk of heart attacks.

PEO stands for:

• Population: Who are you studying? Infants? Males who are between the ages of 55 and 60? Adolescent females?
• Exposure: What is your population exposed to? Baby aspirin? Soy supplements? Peanuts?
• Outcome: What is the result of the exposure on your population? Lowered risk for heart attacks? Food allergies? Increased menstrual cramps?

How to Write a PEO Question

Writing a PEO question isn’t generally as complex as writing a PICO question, since you’re only looking at what population, what they’re exposed to, and what your expected outcome is. For example, if you’re looking at food allergies in infants, your PEO question might look like this:

In infants between the age of 6 to 9 months (P), is there an association between exposure to micro-doses of common food allergens (E) and reduced childhood food allergies? (O)

Similar questions can be explored this way:

In or with ___________________ (P), will ________________________(E) result in _________________________ (O)?

Using PICO and PEO Research Questions for Literature Reviews of Searching

Just as you might utilize PICO and PEO question formatting for designing your research, you can also tap into their formats when you’re looking for previous studies on your topic of interest. For example, if you are looking for information on dietary interventions and type 2 diabetes reversal, you can use keywords related to the formulation of a research question:

P: Individuals with type 2 diabetes E: Mediterranean Diet O: Reversal of type 2 diabetes

To find research related to the above question, you would pull out keywords, like:

“type 2 diabetes,” “reversal” and “Mediterranean Diet”

Clinical Question Formats

There are a wide variety of clinical question formats, in addition to PICO and PEO. These can include PICO(T), which adds a “time-frame” ingredient, and (P)PICO if your population is more complex, like white males, age 50-55.

The bottom line is that an effective clinical research question needs to be relevant to the patient or problem, and worded in a way that it’s easy for those looking for your research to find it. If you’re designing a research project, starting with an effective and well-written clinical research question is a critical first step.

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Evidence-Based Practice in Health

• Introduction
• PICO Framework and the Question Statement

Using the PICO Framework

Writing your question statement.

• Types of Clinical Question
• Hierarchy of Evidence
• Selecting a Resource
• Searching PubMed
• Module 3: Appraise
• Module 4: Apply
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PICO Framework

Without a well-focused question, it can be very difficult and time consuming to identify appropriate resources and search for relevant evidence. Practitioners of Evidence-Based Practice (EBP) often use a specialized framework, called PICO , to form the question and facilitate the literature search. 1 PICO stands for:  

• P atient Problem, (or Population)
• I ntervention,
• C omparison or Control, and

When forming your question using PICO , keep the following points in mind:

• Your P atient is a member of a population as well as a person with (or at risk of) a health problem. So, in addition to age and gender, you may also need to consider ethnicity, socioeconomic status or other demographic variables.
• A C omparison is not always present in a PICO analysis.
• O utcomes should be measurable as the best evidence comes from rigorous studies with statistically significant findings.
• An O utcome ideally measures clinical wellbeing or quality of life, and not alternates such as laboratory test results.

PICO Elements Change According to Question Type (Domain)

When forming your question using the PICO framework it is useful to think about what type of question it is you are asking, (therapy, prevention, diagnosis, prognosis, etiology). The table below illustrates ways in which P roblems, I nterventions, C omparisons and O utcomes vary according to the t ype (domain) of your question. 2

Once you have clearly identified the main elements of your question using the PICO framework, it is easy to write your question statement.  The following table provides some examples.

1. Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making , 7, 16. doi: http://dx.doi.org/10.1186/1472-6947-7-1

2. Fineout-Overholt, E., & Johnston, L. (2005). Teaching EBP: asking searchable, answerable clinical questions. Worldviews On Evidence-Based Nursing , 2, 157-160.

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Background vs. Foreground

Pico examples, asking different types of questions, pico resources & worksheet.

• Evidence Appraisal
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Evidence based practice requires that clinicians make use of the best research they can find to help them in decision-making. To find that research efficiently, the clinician must ask a well-designed clinical question with all the elements that will lead to finding relevant research literature.

The first step in doing this is to determine the type of question: background or foreground. The type of question helps to determine the resource to access to answer the question.

Background questions ask for general knowledge about a condition or thing.

• Broaden the scope - "The Forest"
• Provides basics for a a greater grasp of concepts
• Typically found in textbooks, guidelines, point-of-care monographs, encyclopedias, or topic reviews
• A question root (who, what, when, etc.) with a verb
• A disorder, test, treatment, or other aspect of healthcare

The background question is usually asked because of the need for basic information. It is not normally asked because of a need to make a clinical decision about a specific patient.

Foreground questions ask for specific knowledge to inform clinical decisions or actions.

• Focused in scope - "The Trees"
• Requires a grasp of basic concepts to fully comprehend
• Typically found in journals and conference proceedings
• Have 3 or 4 essential components (see PICO below)

PICO is a mnemonic used to describe the four elements of a good clinical foreground question:

P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine?

I = Intervention - What main intervention, prognostic factor or exposure am I considering?

C = Comparison - Is there an alternative to compare with the intervention?

O = Outcome - What do I hope to accomplish, measure, improve or affect?

 Fill in the blanks with information from your clinical scenario: THERAPY In_______________, what is the effect of ________________on _______________ compared with _________________?

PREVENTION For ___________ does the use of _________________ reduce the future risk of ____________ compared with ______________? DIAGNOSIS OR DIAGNOSTIC TEST Are (Is) ________________ more accurate in diagnosing _______________ compared with ____________? PROGNOSIS Does ____________ influence ______________ in patients who have _____________? ETIOLOGY Are ______________ who have _______________ at ______________ risk for/of ____________ compared with _____________ with/without______________? MEANING How do _______________ diagnosed with _______________ perceive __________________? Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice . Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

• PubMed PICO Tool
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PICO- What's in a queston?

The PICOT question format is a consistent "formula" for developing answerable, researchable questions.

Note: Not every question will have an intervention (as in a meaning question) or time (when it is implied in another part of the question) component.

PICO(T) Templates

Template for Asking PICOT Questions

For an intervention/therapy:

In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?

For etiology:

Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

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) over ______ (T)?

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)?

Melnyk B., & Fineout-Overholt E. (2010). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

Develop your Research Question

The PICO(T) Question

A clinical question that is composed using the PICO or PICOT format will help you to focus your search and help you to develop your research skills which are essential in finding the best available evidence.

The most common PICO(T) elements are:

P - Population

• How you would describe a group of people with a similar problem or complaint.

I - Intervention

• How you plan to treat, medicate, diagnose and/or observe the patient's care.

C - Comparison (if applicable)

• The main intervention alternative you are considering (i.e. placebo, alternative therapy, different drug, surgery).

O - Outcome

• The result from proposed treatment that is measurable, including improvement of symptoms,no symptoms, or complications.

(T) - Time (if applicable)

• The time frame of treatment and/or measurable outcome.

In order be successful in using Evidence Based Practice (EBP) you will need to learn how to develop well-composed clinical questions.  By formatting your research question in a PICO(T) format you can gather evidence relevant to your patient's problem.   Well-composed PICO(T) questions generally contain up to four components each represented in the acronym  " PICO(T)"  P=Patient or Population and Problem; I=Intervention or Indicator; C=Comparison or Control (not part of all questions); O=Outcome; T=Time or Type.

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Evidence Based Practice

• 1. Ask: PICO(T) Question
• 2. Align: Levels of Evidence
• 3a. Acquire: Resource Types
• 3b. Acquire: Searching
• 4. Appraise
• Primary vs. Secondary Sources
• Qualitative and Quantitative Sources
• Managing References

Ask: Write a focused clinical question

Use the PICOT format to break down your question into smaller parts and identify keywords:

• The Well-Built, Patient-Oriented Clinical Question Use this worksheet to break down the parts of your PICO question.

PICO Question Template Examples

It can be helpful to classify your question based on the clinical domain(s) it falls under.  

See below for definitions, PICO templates, and example questions from the primary clinical domains: intervention , diagnosis , etiology , prevention , prognosis/prediction , quality of life/meaning , and therapy .

Intervention

Questions addressing the treatment of an illness or disability.

In _________ (P), how does _________ (I) compared to _________(C) affect _______(O) within _______ (T)? In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?

Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation.

Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)? In ________ (P) are/is ________(I) compared with ________(C) more accurate in diagnosing ________(O)?  

Questions addressing the causes or origin of disease, the factors that produce or predispose toward a certain disease or disorder.

Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

Are ______(P) who have ______(I) compared with those without _______(C) at ________ risk for/of _______ (O) over ________(T)?

Questions on how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening.

For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?

Prognosis/Prediction

Questions addressing the prediction of the course of a disease.

Does __________ (I) influence ________ (O) in patients who have _______ (P) over ______ (T)? In _______ (P), how does ________ (I) compared to ________ (C) influence _________ (O) over _________ (T)?

Quality of Life/Meaning

Questions addressing how one experiences a phenomenon.

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)?

Questions around how to select treatments to offer our patients that do more good than harm and that are worth the efforts and costs of using them.

In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?

Source1 Source2 Source3  

Click "Next" below to start your research.

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EBP Learning Module

Ask the Question

Formulating a question using pico.

Often our need for information is not formulated as a question to begin with - but if you don't ask a question, it is probably fair to say you will not get an answer! Asking the right question is an important start to finding the information needed to inform clinical practice.

Structuring the question is the first step. Vague, broad, poorly framed questions will most likely result in lost time and an inability to locate useful evidence. In comparison, asking a specific and focused question enables the development of relevant keywords and an effective search strategy.

Most questions can be broken down into three or four components that describe the population, the intervention or treatment (and sometimes an alternative treatment), and the outcome you want to investigate. This is known as the PICO method, and it is widely used by health researchers, healthcare professionals, and related collaborations such as those in The Cochrane Library, to construct searchable questions that give relevant and precise results.

The table below shows how the PICO method is used.

The acronym is sometimes given as PICOT where T stands for time, type of study, or test; or PECOT where E stands for the exposure group, C for the control group and T for time, type of study, or test.

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NURS 4953 - Professional Nursing Synthesis: Searching with PICO

• Video Tutorials and Nursing Databases
• Searching with PICO
• Searching Professional Databases
• Searching Public Databases
• APA Citations

PICO Resources

In Evidence-based Nursing, PICO (sometimes styled PICOT) formatted questions assist nurses in developing effective and efficient search parameters that produce high quality, specific, and evidence-based results.

PICO(T) stands for:

• Patient Population or Problem
• Intervention
• Time-frame.

The following resources explain the PICO Process and guide in precise formulation of PICO questions.

• NIH: Using PICO to Frame Clinical Questions
• Evidence-Based Practice: PICO (Duke University)
• OSHU: Asking Your Question (PICO)

PICO Videos

A PICO question is used to perform effective and efficient searches of nursing literature to make evidence-based clinical decisions. The following videos provide guidelines on developing a PICO question and using the PICO question to search the CINAHL and MEDLINE databases.

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Nursing research guide.

• Introduction
• Scholarly vs Non-Scholarly
• Primary, Secondary, & Tertiary Research
• Qualitative & Quantitative Data
• Evidence-Based Practice
• Types of Study Designs
• Types of Reviews
• Searching Tips
• Books, Images, & More
• Open Educational Resources (OER)
• Finding Guidelines
• PICO Questions
• News, Blogs, & More
• CIting, Writing, & Publishing

Example Sources:

• UNC-Chapel Hill Health Sciences Library PICO Examples

What is PICO?

• P: Population, patient, or problem
• I: Intervention or indicator
• C: Comparison or control

PICO  is a formula used to develop a researchable clinical question. 

The purpose of a PICO question is to help breakdown a research question into smaller parts, making the evaluation of evidence more straightforward.

P:  Population, patient, or problem

I:  Intervention or indicator

C:  Comparison or control

O:  Outcome

Note: Not every question will have a time frame or a comparison. Outcomes should be a measure of clinical well-being/quality of life.

P: Population, patient, or problem

Who is the patient or population? (Think demographics: age, sex, gender, race).

What problem or disease or situation are you facing?

I: Intervention or indicator

What do you plan to do for your patient? (medications, diagnostic tests, therapies, procedures)

What intervention is implemented to help make a difference to your patient/population?

C: Comparison or control

What other interventions should be considered? What can we compare our research too?

Is there a control group you would like to compare your intervention with?

O: Outcome

What is the desired or effective outcome of the intervention compared to the control?

Forming Focused Question with PICO: Case Study

Case: patient education.

• You are a nurse working in a busy inpatient medical surgical unit. The patients on your unit are admitted for a wide variety of conditions: renal, GI, dermatologic, etc.
• All patients admitted that are chronic smokers are given brief counseling by an RN and a self-help brochure about smoking cessation, but no follow up counseling after that.
• You hear your coworkers complaining that they feel like they are wasting their time because they think the patients will resume smoking after discharge.
• You decide you want to find out if this minimal contact intervention works in the long term.

P: Consider when choosing your Patient/Problem/Population

• What are the most important characteristics?
• Relevant demographic factors
• The setting

I: Consider for your Intervention

• What is the main intervention, treatment, diagnostic test, procedure, or exposure?
• Think of dosage, frequency, duration, and mode of delivery

C: Consider for your Comparison

• Inactive control intervention: Placebo, standard care, no treatment
• Active control intervention: A different drug, dose, or kind of therapy

O: Consider for your Outcome

• Be specific and make it measurable
• It can be something objective or subjective

PICO: Putting It Together

Your full PICO question is:

"Among hospitalized chronic smokers, does a brief educational nursing intervention lead to long term smoking cessation [when compared with no intervention]?"

PICO Question Examples

• Infection Control
• Labor & Delivery

Patients on coronary artery bypass graft (CABG) waiting lists often experience anxiety and depression and your nurse manager wants to know if it would be a good idea to reach out to these patients with presurgical home visits and follow-up calls from a specialist cardiac nurse.

P: patients on CABG waiting lists I: program consisting of presurgical home visit and follow-up calls form a specialist cardiac nurse C: no intervention O: decreased patient anxiety and depression  

For patients on CABG waiting lists, does an intervention program consisting of presurgical home visits and follow-up calls from a specialist cardiac nurse lead to decreased patient anxiety and depression [when compared with no intervention]?

You work in the Big City Hospital ICU. Your mechanically ventilated patients sometimes contract nosocomial pneumonia, which leads to costly complications. You want to know if raising the head of the bed lowers the chance of the patient contracting pneumonia compared to letting the patient lie flat on their back.

P: mechanically ventilated ICU patients I: semi-fowlers position C: supine position O: lower incidence of nosocomial pneumonia In mechanically ventilated ICU patients, does positioning the patient in semi-fowlers result in a lower incidence of nosocomial pneumonia when compared to the supine position?

In the past few years, your hospital has installed antibacterial foam dispensers on all the nursing units. You’ve had nurses asking you if the foam is just as effective as washing their hands with water and soap.

P: hospital nurses I: using antibacterial foam C: hand washing with soap and water O: decreased bacteria count In hospital nurses, does antibacterial foam decrease bacteria count on hands as much as hand washing with soap and water?

You’re a new nurse on a labor and delivery unit. You’ve noticed that most women give birth in the lithotomy position at the encouragement of their doctors. However, you’re sure you heard in nursing school that other positions are less likely to lead to deliveries with forceps or a vacuum...or did you? You want to find some literature to back up your claim.

P: laboring women delivering in a hospital I: positions other than the lithotomy position C: lithotomy position O: decreased incidence of assisted deliveries In laboring women delivering in the hospital, do positions other than lithotomy position lead to a decreased incidence of assisted deliveries?

You’re the nurse manager of a NICU unit. One concern of parents of infants receiving tube feedings is being able to successfully breastfeed their child upon discharge. One of your staff nurses asks if it would be helpful to give the infants cup feedings instead of tube feedings during their NICU stay.

P: Infants in the NICU I: cup feeding throughout the hospital stay C: tube feedings throughout the hospital stay O: greater reported success with breastfeeding post-discharge In infants in the NICU, will cup feeding throughout the hospital stay lead to greater success with breastfeeding post-discharge when compared to tube feedings?

You work with patients with advanced cancer and have been taught to suggest pain diaries for your patients as a form of pain management. You’ve been wondering for a while now if these diaries actually improve pain control or make pain worse by making patients more aware of their pain.

P: patients with advanced cancer I: keeping a pain journal C: no intervention O: lower reported pain scores In patients with advanced cancer, does keeping a pain journal result in lower reported pain scores when compared to no intervention?

You work in a pediatrician’s office and give patients their routine vaccinations. The younger children are often fearful of needles, and some of the RNs use toys to distract the patients. You want to know if this technique actually has an effect on the children's pain response.

P: young children I: distraction techniques during immunization C: no intervention O: lower pain scores rated by the Faces pain scale In young children, do distraction techniques during immunization administration using toys result in lower pain scores when compared to no intervention?

You work on an inpatient psychiatric unit. One of your patients with chronic schizophrenia, Joe, normally mumbles to himself, but will occasionally speak to others when residents play games together. Noticing this, you say to a coworker that maybe social skills group training sessions would bring out Joe’s conversational skills. Your coworker shakes her head and says "I don’t think so. Joe is in and out of this hospital, he’s a lost cause."

P: Inpatient chronic schizophrenia patients I: social skills group training sessions C: standard care O: increased conversational skills as evidenced by greater number of interactions with peers In inpatient chronic schizophrenia patients, do social skills group training sessions increase conversational skills when compared to standard care?

A diabetic patient from a nursing home has recently been admitted with a stage III pressure ulcers on his heels. The unit nurses have called you in for a wound consult. You have to choose between standard moist wound therapy and using a wound vac.

P: elderly diabetic with stage III foot ulcers I: negative pressure wound therapy C: standard moist wound therapy O: improved wound healing as measured by pressure ulcer grading system guidelines In elderly diabetic patients with stage III foot ulcers, does negative pressure wound therapy lead to improved wound healing when compared to standard moist wound therapy?

The main concern for most of your patients coming out of anesthesia in your PACU is pain. You want to explore nursing interventions you can use on top of medication administration to decrease pain. One coworker mentions trying to make the PACU feel less clinical by playing soft music to relax patients.

P: PACU patients I: soft music as an adjunct to standard care C: standard care alone O: lower reported pain scores In PACU patients, will playing soft music in the PACU as an adjunct to standard care result in lower reported pain scores when compared to standard care alone?

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Evidence Based Nursing Practice

• PICO(T) and Clinical Questions
• Literature Review
• Study Design and Methodology
• Documenting EBP
• Additional Sources & Assistance
• MUHC Evidence Based Practice Model

PICO Templates

For an intervention/therapy:

In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?

For etiology:

Are ____ (P) who have _______ (I) at ___ (increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

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) over ______ (T)?

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)?

Based on Melnyk B., & Fineout-Overholt E. (2010). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins .

Using PICO to Formulate Clinical Questions

PICO  (alternately known as PICOT ) is a mnemonic used to describe the four elements of a good clinical question. It stands for:

P --Patient/Problem I --Intervention C --Comparison O --Outcome

Many people find that it helps them clarify their question, which in turn makes it easier to find an answer. 

Use PICO to generate terms - these you'll use in your literature search for the current best evidence.   Once you have your PICO terms, you can then use them to re-write your question.  (Note, you can do this in reverse order if that works for you.)

Often we start with a vague question such as, "How effective is CPR, really?"  But, what do we mean by CPR?  And how do we define effective?  PICO is a technique to help us - or force us - to answer these questions.   Note that you may not end up with a description for each element of PICO. 

P -  our question above doesn't address a specific problem other than the assumption of a person who is not breathing. So, ask yourself questions such as, am I interested in a specific age cohort? (Adults, children, aged); a specific population (hospitalized, community dwelling); health cohort (healthy, diabetic, etc.)   

I - our question above doesn't have a stated intervention, but we might have one in mind such as 'hands-only'

C - Is there another method of CPR that we want to compare the hands-only to?  Many research studies do not go head to head with a comparison.  In this example we might want to compare to the standard, hands plus breathing

O - Again, we need to ask, what do we mean by 'effective'?  Mortality is one option with the benefit that it's easily measured. 

Our PICO statement would look like:

From our PICO, we can write up a clearer and more specific question, such as:

 In community dwelling adults, how effective is hands-only CPR versus hands plus breathing CPR at preventing mortality?

More information on formulating PICO questions

Now that we've clarified what we want to know, it will be much easier to find an answer.

Breaking Down Your PICO into a Search Strategy

We can use our PICO statement to list terms to search on.  Under each letter, we'll list all the possible terms we might use in our search. 

P - Community Dwelling:  It is much easier to search on 'hospitalized' than non-hospitalized subjects.  So I would leave these terms for last. It might turn out that I don't need to use them as my other terms from the I, C, or O of PICO might be enough.

community dwelling  OR out-of-hospital

P - adults: I would use the limits in MEDLINE or CINAHL for All Adults.  Could also consider the following depending upon the population you need:

adult OR adults OR aged OR elderly OR young adult

CPR  -  cardiopulmonary resuscitation

I - Hands-only

 hands-only OR compression-only OR chest compression OR compression OR Heart Massage

C - Hands plus breathing Breathing is a tougher term to match.

breathing OR mouth to mouth OR conventional OR traditional

O - Mortality:  If your outcomes terms are general, they may not as useful in the literature search.  They will still be useful in your evaluation of the studies.

mortality OR death OR Survival

Putting it together - a search statement from the above might look like this:

cardiopulmonary resuscitation AND (hands-only OR compression-only OR chest compression OR compression OR Heart Massage) AND (breathing OR mouth to mouth OR conventional OR traditional)

Note that the above strategy is only using terms from the I and the C of PICO.  Depending upon the results, you may need to narrow your search by adding in terms from the P or the O.  

An easy way to keep track of your search strategy is to use a table. This keeps the different parts of your PICO question and their various keywords and subject terms together. This document shows you how to use the tables and provides a few options to organize your table. Use whichever works best for you!  Search Strategy Tables to Break your PICO into Concepts .

PICO and Qualitative Questions

A qualitative PICO question focuses on in-depth perspectives and experiences.  It does not try to solve a problem by analyzing numbers, but rather to enrich understanding through words.  Therefore, the emphasis in qualitative PICO questions is on fully representing the information gathered, rather than primarily emphasizing ways the information can be broken down and expressed through measurable units (though measurability can also play an important role). 

A strength of a qualitative PICO question is that it can investigate what patient satisfaction looks like, for example, instead of only reporting that 25% of patients who took a survey reported that they are satisfied. 

When working with qualitative questions, an alternative to using PICO in searching for sources is the SPIDER search tool.  SPIDER is an acronym that breaks down like this:

P=Phenomena of Interest

E=Evaluation

R=Research Type

Cooke, A., Smith, D., & Booth, A. (2012). Beyond PICO: The SPIDER tool for qualitative evidence synthesis . Qualitative Health Research, 22 (10), 1435-1443. doi:10.1177/1049732312452938

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• Introduction
• Your PICO Question
• Levels of Evidence
• Database Searching
• Appraising the Results
• Citation Styles
• Organizing Your Research

Background Knowledge

Provides comprehensive syntheses of evidence along with point of care recommendations including current drug information, medical calculators, and patient education handouts.

One way of focusing your question is by using the PICO format (you may also see PICO(T) or PICOTT). PICO includes several factors that, when searched together, comprise a well-built clinical question. It includes:

• Patient, Population, and/or Problem - Who or what is your question about?
• Intervention, Prognostic Factor, or Exposure - How do you want to treat your patient?
• Comparison - What is the standard of care in this situation? What other treatments have been used in past trials?
• Outcome  - What is the intended result?

You can clarify your intended results at the outset with additional, optional factors:

• Time  - Duration of study, duration between intervention and outcome
• Type of Question - Therapy, Etiology, Diagnosis, Prognosis, Prevention
• Type of Study - Meta-Analysis, Systematic Review, Randomized Controlled Trial, Cohort Study, Case Control Study 

Take the following sample question:

In adult patients with Cardiovascular Disease (CVD), does the consumption of plant-based saturated fats when compared to a monounsaturated fat result in a more improved CVD risk metabolic profile?

This example covers all elements of PICO, and provides us four distinct elements to convert into search terms:

• Patient  - adult patients with Cardiovascular Disease
• Intervention  - consumption of plant-based saturated fats
• Comparison  -  monounsaturated fat
• Outcome  - improved CVD risk profile

In the next section, "Levels of Evidence," you'll learn more about identifying the best possible evidence and the different types of clinical questions.

• Asking an Answerable Question from Cochrane Public Health
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Forming answerable search questions using frameworks

• Research question frameworks
• Example PICO

Build your own PICO

Use the following resources to help you structure your own PICO, which you can use to find information on your topic or clinical question.

You can also have a try at searching using the PICO framework using the database widget below.

• PICO structured search Use this worksheet to help formulate and plan your search question.
• Practice PICO with this example Use this worksheet to practice using the PICO model

This widget allows you to quickly search using the PICO structure for clinical questions. To find out more about PICO visit our guide.

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The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review

Associated data.

This review aimed to determine if the use of the patient, intervention, comparison, outcome (PICO) model as a search strategy tool affects the quality of a literature search.

A comprehensive literature search was conducted in PubMed, Embase, CINAHL, PsycINFO, Cochrane Library, Web of Science, Library and Information Science Abstracts (LISA), Scopus, and the National Library of Medicine (NLM) catalog up until January 9, 2017. Reference lists were scrutinized, and citation searches were performed on the included studies. The primary outcome was the quality of literature searches and the secondary outcome was time spent on the literature search when the PICO model was used as a search strategy tool, compared to the use of another conceptualizing tool or unguided searching.

A total of 2,163 records were identified, and after removal of duplicates and initial screening, 22 full-text articles were assessed. Of these, 19 studies were excluded and 3 studies were included, data were extracted, risk of bias was assessed, and a qualitative analysis was conducted. The included studies compared PICO to the PIC truncation or links to related articles in PubMed, PICOS, and sample, phenomenon of interest, design, evaluation, research type (SPIDER). One study compared PICO to unguided searching. Due to differences in intervention, no quantitative analysis was performed.

Conclusions

Only few studies exist that assess the effect of the PICO model vis-a-vis other available models or even vis-a-vis the use of no model. Before implications for current practice can be drawn, well-designed studies are needed to evaluate the role of the tool used to devise a search strategy.

INTRODUCTION

The development of systematic reviews is considered a means of enabling clinicians to use evidence-based medicine (EBM) [ 1 ], and the number of systematic reviews is growing quickly [ 2 ]. As literature searching forms the underlying basis of systematic reviews, the quality of the literature search is crucially important to the overall quality of the systematic review [ 3 ]. Although new techniques can automate the process of systematic reviews, such as using text mining to develop search strategies [ 4 ], the task of devising the search strategy still requires intellectual contributions from reviewers. In particular, as the search strategy builds upon the review question, formulating the review question is critical to developing the search strategy.

In their 1992 publication in the Journal of the American Medical Association, the Evidence-Based Medicine Working Group emphasized the precise definition of the patient problem, the required information needed to resolve the problem, and the ability to conduct an efficient search as the skills required for practicing EBM [ 5 ]. In addition to these skills, the use of conceptualizing models to structure a clinical question was introduced in 1995, when Richardson et al. proposed the use of a four-part model to facilitate searching for a precise answer [ 6 ]. They stated that a clinical question must be focused and well articulated for all four parts of its “anatomy”: the patient or problem (P); the intervention or exposure (I); the comparison intervention or exposure (C), if relevant; and the clinical outcome of interest (O).

Despite the existence of other models—such as sample, phenomenon of interest, design, evaluation, research type (SPIDER) [ 7 ] and setting, perspective, intervention, comparison, evaluation (SPICE) [ 8 ]—the PICO model is by far the most widely used model for formulating clinical questions. The purpose of using PICO is considered to be three-fold [ 9 ]. First, it forces the questioner to focus on what the patient or client believes to be the single most important issue and outcome. Second, it facilitates the next step in the process—the computerized search—by prompting the questioner to select language or key terms to be used in the search. Third, it directs the questioner to clearly identify the problem, intervention, and outcomes related to specific care provided to a patient.

The PICO model is also frequently used as a tool for structuring clinical research questions in connection with evidence syntheses (e.g., systematic reviews). The Cochrane Handbook for Systematic Reviews of Interventions specifies using PICO as a model for developing a review question, thus ensuring that the relevant components of the question are well defined [ 10 ]. The PICO framework is primarily centered on therapy questions, and although it can be adapted to formulate research questions related to prognosis or diagnosis, it is less suitable for other types of clinical information needs [ 11 ].

In addition to acting as a conceptualizing tool for asking clinical and research questions, the PICO model can be used as a tool for developing search strategies. According to Considine et al., “the PICO Framework should also be used to develop the search terms that are informed by the PICO question, Medical Subject Headings (MeSH) and any other terms deemed to be relevant” [ 12 ]. For a default search, the Cochrane Handbook suggests employing only search terms for patients, the intervention, and the study type [ 13 ], thus reducing the PICO model to P, I, and S/T (i.e., study type or types of study). Alternatively, instead of study type or types of study, the truncated PIC approach emphasizes the comparison intervention or exposure.

Although conceptualizing models are widely used by information specialists, little is known about the impact of using them as tools for developing search strategies. Therefore, the aim of this systematic review was to determine whether the use of the PICO model as a search strategy tool improves the quality of literature searches.

This systematic review was conducted and reported according to quality standards described in the AMSTAR measurement tool [ 14 ] and the PRISMA 2009 checklist [ 15 ]. Two reviewers independently carried out study selection, evaluation, and data extraction. We resolved discrepancies in our reviews by consensus. Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) was used to screen, select, and extract data from included studies. The review protocol was registered in the PROSPERO database (CRD42017055217).

Search strategy

We searched PubMed ( Table 1 ), Embase, CINAHL, PsycINFO, the Cochrane Library, Web of Science, Library and Information Science Abstracts (LISA), Scopus, and the National Library of Medicine catalog on January 9, 2017. After testing and validating our PubMed search strategy using the capture-recapture technique as well as evaluating retrieval of known items [ 16 ], we translated the search strategy for use in other databases, adjusting the controlled vocabulary as applicable ( supplementary Appendix A ). We also examined reference lists and performed citation searching (Web of Science, v.5.23.2, up to February 1, 2017) of included studies to identify other potentially relevant studies.

PubMed search strategy

Inclusion and exclusion criteria

We considered all primary studies, regardless of design, as eligible for inclusion if they examined PICO as a tool for developing a search strategy (distinct from other methods for developing a search strategy) for identifying potentially relevant studies in any topic area. We excluded review articles but examined their reference lists to identify other potentially relevant studies. We applied no other restrictions, such as those related to languages or publication years, in this review.

Outcome measures

Our primary outcome measure was the quality of literature searches using two measures: precision and sensitivity [ 17 ]. The Cochrane Handbook defines sensitivity as the number of relevant reports found divided by the total number of relevant reports in existence and precision as the number of relevant reports found divided by the total number of reports identified [ 10 ]. Our secondary outcome measure was time spent on the literature search.

Data extraction

We noted and summarized information pertaining to author, year of publication, study design, searchers, search strategy tools, and calculation of sensitivity and precision. Studies that did not evaluate and quantify the quality of the literature searches in terms of both precision and sensitivity were excluded from analysis. Empirical studies show that recall and precision are inversely related. High recall can easily be obtained but will, however, be at the expense of precision. Because a trade-off between recall and precision is unavoidable, one should only evaluate searches with both of these measures [ 18 ].

Risk of bias assessment

No validated criteria exist for assessing the risk of bias in studies evaluating the effect of PICO as a tool for developing the search strategy in terms of the quality of the searches. Therefore, we used a self-developed set of three criteria: (i) searcher skills, (ii) match between model and question, and (iii) performed searches ( Table 2 ). Each criterion consisted of a set of individual considerations and was assessed using the categories “low risk of bias,” “high risk of bias,” and “unclear risk of bias.” If one of the considerations in a criterion was judged as “high risk of bias” or “unclear risk of bias,” the overall judgment for that criterion was “high risk of bias” or “unclear risk of bias,” respectively. We developed the three criteria by consensus; however, this tool was not validated.

Risk-of-bias criteria

(i) Searcher skills

The searchers (i.e., study participants or authors) were the individuals performing the literature searches. If the searchers differed in their searching skills, this might have affected the overall results of the study. Thus, if some searchers had more training in literature searching than others, this could introduce a risk of bias. Similarly, if some of the searchers were familiar with the search strategy tools prior to the study, this also increases the risk of bias. Furthermore, if searchers used all included models in the study (e.g., were instructed to use particular conceptualizing models or unguided searching), the order in which the search strategy tools were applied might have affected search behavior, thus, introducing a risk of bias. Finally, although blinding of the searchers is not possible, blinding of the reviewers evaluating the search results is possible and serves to reduce the risk of bias resulting from knowing the identity of the searchers or search strategy tools that were applied.

(ii) Match between model and question

Our risk-of-bias assessment for this criterion was based on the consideration that particular conceptualizing models might be developed to fit different topics or quantitative versus qualitative research and might apply to some topics or research areas better than others, which could influence the study results. Recent recommendations show that different review types require different question formats (i.e., different conceptualizing models and, thus, different search strategy tools) [ 19 ]. The fit between model and topic cannot be manipulated (e.g., if a research question does not include an intervention, all elements of the PICO model will not be applicable and, thus, will not fit that particular research question). We considered applying a conceptualizing model that was not fit for that particular research area a high risk of bias.

Another aspect of the fit between model and question is the relevance of the obtained search results. As sensitivity and precision measures are based on relevance, the search results need to be assessed for their relevance. Determination of the relevance of the obtained search results is performed ideally using a predefined set of publications (i.e., a gold standard), such as those retrieved in a systematic review, that can serve to assess the relevance of the search results. Alternatively, an expert group could assess the relevance of the retrieved results. A system’s view of relevance (i.e., the ranking of results or a study being present in the search results) is not sufficient [ 20 ]. We considered applying precision and recall without considering relevance based on a gold standard or an expert group a high risk of bias.

Finally, the number of search elements or search blocks needs to be considered, regardless of whether the search was unguided or structured by the use of a search strategy tool. All other things being equal, the number of retrieved articles will decrease as the number of blocks is increased. Consequently, the more elements, the fewer hits, which would affect the results of the study in terms of comparing applied search strategy tools. We considered search strategy tools (i.e., conceptualizing model or unguided search) that had a different number of search elements or search blocks a high risk of bias.

(iii) Quality of searches

Our risk-of-bias assessment for this criterion was based on our consideration that the quality of the literature searches might impact the results of the study. Searches could be consistently high quality or consistently low quality, which does not in itself imply high risk of bias. However, if the quality of the searches is not consistently high or low, bias can occur. The quality of searches in this case was determined using criteria outlined in the PRESS statement [ 3 ], stressing that the criteria and methods depended on the specific databases. If the literature search was not conducted uniformly or if subject headings were not correctly adapted for each database, we considered it to have a high risk of bias.

Due to differences in the comparisons among search strategy tools in the included studies, we did not perform quantitative analyses. We, therefore, did not follow the sections in the PRISMA 2009 checklist [ 15 ] that relate to meta-analysis.

The literature search identified a total of 1,269 unique records ( Figure 1 ). We assessed 22 full-text articles for eligibility and excluded 19 due to wrong study design (i.e., studies that did not examine PICO as a tool for developing a search strategy for identifying potentially relevant studies in any topic area), wrong outcomes, or wrong interventions ( supplementary Appendix B ). Therefore, three studies were included in the qualitative analysis [ 21 – 23 ] ( Table 3 ).

Study selection flow diagram

Use of the patient, intervention, comparison, outcome (PICO) model compared to another conceptualizing model as a literature search strategy tool

* Queries were combined with a †broad therapeutic intervention filter, ‡a narrow therapeutic intervention filter, or §no filter and further limited to **English language and human studies; ††English language, human studies, and Abridged Index Medicus titles; or ‡‡no limitations.

Agoritsas et al. evaluated searches outlined by the authors of the study based on the PICO framework and combined into queries; although not explicitly stated, the authors likely also performed the searches [ 21 ]. The study evaluated 15 search strategies that varied in their query structure (PIC or PICO), use of PubMed’s Clinical Queries therapeutic filters (broad or narrow), and search limits, as well use of PubMed links to related articles. A total of 450 searches were performed. Relevance was assessed on the first 40 records of the search output as well as the complete search output. The study reports that the PICO model resulted in increased median sensitivity and precision of the search results.

Hoogendam et al. evaluated the effectiveness of PICO versus unguided searching among 14 residents and 8 specialists who had an interest in vascular medicine [ 22 ]. Participants received a lecture by an expert searcher explaining the basics of PubMed to ensure a basic knowledge of PubMed functionality. Participants performed unguided searching for 5 minutes on 12 therapeutic questions regarding vascular medicine. After 2 weeks, an expert searcher explained the use of PICO, and participants performed PICO searching for 5 minutes on 12 different therapeutic questions. Although not statistically significant at the p <0.05 level, using the PICO model resulted in a higher average sensitivity and lower average precision than did unguided searching.

Methley et al. evaluated the SPIDER conceptualizing model [ 23 ]. The authors developed a detailed search strategy in collaboration with a specialist librarian and information specialist. Identical search terms were combined using the PICO, PICOS, or SPIDER search strategy tools and compared across PubMed, Embase, and CINAHL, resulting in a total of nine searches. The authors found that PICO retrieved the largest number of hits and recommended using PICO instead of SPIDER.

Qualitative analysis

The three included studies varied widely in their design, choice of comparators, number of databases searched, procedure for relevance assessment, and methods of calculating outcomes ( Table 3 ).

Study design

One study was designed as a randomized trial including health professionals (residents and specialists) [ 22 ]; the other two were observational studies in which the authors were involved in the literature searches along with a specialist librarian and information specialist [ 23 ] or without stating who exactly performed the searches [ 21 ].

Relevance assessment

Two of the three included studies used Cochrane systematic reviews to formulate the clinical questions. These reviews were used as a basis for the search strategies and as a gold standard for determining the sensitivity and precision of the search results [ 21 , 22 ]. One study compared PICO to PICOS and SPIDER with a focus on a specific research question; as a consequence, the search strategy was built from elements of the research question, and the relevance of search results was judged against inclusion criteria [ 23 ]. Consequently, the included studies calculated sensitivity and precision from a gold standard [ 21 , 22 ] or a list of included studies [ 23 ].

Choice of comparator

Two of the three included studies compared the PICO model to alternative conceptualizing models. However, the two studies compared PICO to different conceptualizing models; thus, the PICO model was not compared to the same alternative conceptualizing models across studies.

One study compared the PICO model to the truncated PIC model in PubMed and reported that the PICO model resulted in increased median sensitivity and precision of the searches [ 21 ]. However, the performance of the tested search strategies was highly variable depending on the clinical question, and none of the 15 strategies showed a consistently high sensitivity in retrieving relevant articles. The study also used PubMed links to related articles as a search strategy, which resulted in higher sensitivity and precision than both the PICO and PIC models. The calculations were based on the first 40 records of the PubMed output as well as the complete search output. When the full output was screened for relevant studies, about 85% of records were detected by the PIC queries and about 69% by the PICO queries [ 21 ].

One study compared the PICO model to PICOS and SPIDER in CINAHL, Embase, and MEDLINE [ 23 ]. Although hardly conclusive due to extremely limited data, the use of PICO as a search strategy tool resulted in higher sensitivity and lower precision than the use of PICOS and SPIDER. However, as different numbers of search blocks were used for each model (i.e., PICO: 3 search blocks, PICOS: 4 search blocks, SPIDER: 6 search blocks), these results are expected.

One study compared the PICO model to unguided searching [ 22 ]. The study reported that use of the PICO model resulted in higher average sensitivity and lower average precision than did unguided searches, although this difference was not statistically significant.

Outcomes reported

None of the included studies investigated the time spent on the literature search.

We used three risk-of-bias criteria to assess the risk of bias: (i) searcher skills, (ii) match between model and question, and (iii) quality of searches. Overall, there were several instances of unclear or high risk of bias with respect to all three criteria ( Table 4 ). The searcher skills criterion revealed either an unclear risk of bias [ 21 , 23 ] or a high risk of bias [ 22 ] in the studies. The match between model and question criterion revealed that two studies [ 21 , 23 ] had a high risk of bias and one study [ 22 ] had an unclear risk of bias. Finally, we found that the quality of searches criterion revealed that two studies [ 21 , 22 ] had an unclear risk of bias, and one study had a low risk of bias [ 23 ]. A complete overview of the risk of bias assessments can be found in supplementary Appendix C .

Risk-of-bias summary

This study is the first systematic review aiming to determine whether the use of the PICO model as search strategy tool affects the quality of the literature search, which had the potential to provide valuable evidence of the effect of using PICO to formulate search queries. This review is strengthened by the use of rigorous methods based on prespecified criteria in a protocol following both the AMSTAR measurement tool [ 14 ] and PRISMA 2009 checklist [ 15 ], a comprehensive literature search and duplicate screening process, data extraction, and risk-of-bias assessment. However, we identified only three studies that were eligible for inclusion in the review [ 21 – 23 ], and given the marked differences among studies, it was only possible to perform qualitative analysis.

Despite the rigorous methodology that we used, there are limitations for this review. No validated assessment tool exists for these types of studies, which led us to develop our own set of risk-of-bias criteria. As opposed to validated criteria such as Cochrane’s risk-of-bias tool for assessing randomized trials [ 24 ], our tool was not validated, which would have been preferable. Despite the limitations of our risk-of-bias tool, we regarded all three included studies [ 21 – 23 ] as having a high or unclear risk of bias. Consequently, it is extremely difficult to draw any conclusions from their findings.

As no similar reviews exist, we turn to the individual studies to enlighten our discussion on whether the use of the PICO model as search strategy tool affects the quality of the literature search. Two issues are prominent: the importance of the number of search blocks and the practice of avoiding outcome-related terms in the search strategy.

First, the number of search blocks in a literature search is important for the search output. That is, the more search blocks that are included, the more restricted the search output will be. One of the included studies did not compensate for the number of search blocks in each strategy, and thus, as expected, the search strategy tool with the lowest number of blocks retrieved a greater number of hits [ 23 ]. Existing guidelines recommend using only the truncated PIC version of the PICO model for performing literature searches for systematic reviews [ 13 ]. The rationale is that some or all outcome measures might not be mentioned in abstracts, and including a search block defining the outcomes leads to a lower sensitivity of the literature search.

One study that was included in this review investigated the median sensitivity and precision of the PICO model compared to the PIC model [ 21 ]. Surprisingly, the study reported that the PICO model performed better than the truncated PIC model with regard to sensitivity and precision. However, these results were based only on the first forty records of the search output, which might explain this surprising finding, because an inverse relationship usually exists between sensitivity and precision [ 18 ]. Also, depending on how the search results were sorted, different results could be obtained. When considering the full search output, the PIC model did show a higher sensitivity and lower precision, although both measures varied greatly across different searches [ 21 ]. This finding of higher sensitivity and lower precision when using the PIC model (three search blocks) compared with the PICO model (four search blocks) [ 21 ] is in accordance with another included study that found that the PICO model (using three search blocks: P, I, and O) resulted in higher sensitivity and lower precision than the PICOS model (four search blocks) or SPIDER model (five search blocks) [ 23 ]. Taken together, these results suggest that the number of search blocks impacts the quality of the search output as quantified by sensitivity and precision.

Second, the claim that searching for outcome-related terms when using the PICO model as a search strategy tool lowers the sensitivity of the search [ 13 ] is not substantiated. Based on the limited data from this review, however, we are not able to make any firm conclusions. The study addressing this issue [ 21 ] focused on identifying search components and tools that could help clinicians build more effective strategies to answer questions at the point of care and did not include sophisticated strategies used for performing systematic reviews; thus, its results are of limited generalizability. Future studies investigating the effect of searching for outcome-related terms are needed to support this recommendation [ 10 ].

The PICO model was developed to help structure a well-built clinical question and enable a literature search [ 6 ]. Since its introduction, it has played an important role as a conceptualizing model in EBM [ 10 ]. However, evidence of the effect of using the PICO model as a search strategy tool is still lacking, and the studies that were included in this review do not allow us to build upon this important body of evidence. To practice EBM with evidence-based methods, and thus ensure rigorous methodology, the results of this review indicate that more work is needed to assess the applicability of specific conceptualizing models. Furthermore, we propose that it is important for future research on this topic to address three potential risks of bias: (i) searcher skills, (ii) match between model and question, and (iii) quality of searches.

Overall, there have been few studies assessing the effect of using the PICO model versus other available models or unguided searching on the quality of literature search results. Specifically, despite a rigorous search and selection process, we found only three such studies. Due to heterogeneity among these studies, quantitative analysis was not possible, and no solid conclusions about the effect of using the PICO model on the quality of the literature search could be drawn. Before implications for current practice can be made, there is a need for well-designed studies to evaluate the role of the tool used to devise a search strategy.

SUPPLEMENTAL FILES

Acknowledgments.

We thank the anonymous referees for their useful suggestions and Rasmus Højbjerg Jacobsen for carefully revising the manuscript.

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Forming Focused Questions with PICO: Other Question Frameworks

Created by health science librarians.

• PICO's Limitations
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Other question development frameworks

PICO is a helpful framework for clinical research questions, but may not be the best for other types of research questions. Did you know there are at least 25 other question frameworks besides variations of PICO?  Frameworks like PEO, SPIDER, SPICE, ECLIPSE, and others  can help you formulate a focused research question. The table and example below were created by the  Medical University of South Carolina (MUSC) Libraries .

The PEO question framework is useful for qualitative research topics. PEO questions identify three concepts: population, exposure, and outcome.

Research question : What are the daily living experiences of mothers with postnatal depression?

The SPIDER question framework is useful for qualitative or mixed methods research topics focused on "samples" rather than populations.

SPIDER questions identify five concepts: sample, phenomenon of interest, design, evaluation,and research type.

Research question : What are the experiences of young parents in attendance at antenatal education classes?

The SPICE question framework is useful for qualitative research topics evaluating the outcomes of a service, project, or intervention. SPICE questions identify five concepts: setting, perspective, intervention/exposure/interest, comparison, and evaluation.

Research question : For teenagers in South Carolina, what is the effect of provision of Quit Kits to support smoking cessation on number of successful attempts to give up smoking compared to no support ("cold turkey")?

The ECLIPSE framework is useful for qualitative research topics investigating the outcomes of a policy or service. ECLIPSE questions identify six concepts: expectation, client group, location, impact, professionals, and service.

Research question : How can I increase access to wireless internet for hospital patients?

• Booth A, Noyes J, Flemming K, Moore G, Tunçalp Ö, Shakibazadeh E. Formulating questions to explore complex interventions within qualitative evidence synthesis. BMJ Glob Health. 2019;4(Suppl 1):e001107-e001107.
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Writing a PICOT Question

The PICOT question is a consistent “formula” for developing answerable, searchable questions that result in an effective literature search that yields the best, most relevant information. This resource will help you to write clinically specific, searchable PICO questions.

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Tools & Tutorials

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What is PICO?

PICO(T ) is a question formula that allows you to define your research question and determine the key components of your research.  It allows you to develop focused relevant questions.

PICO(T) stands for:

  P - Patient, Population or Problem           

  I - Intervention or Indicator                     

  C - Comparison or Outcome                  

  O - Outcome

(T) - Time, Type of Study, or Type of Question (This is optional, depending on your research question)

The Centre for Evidence Based Medicine (CEBM) states that " one of the fundamental skills required for practising EBM is the asking of well-built clinical questions. To benefit patients and clinicians, such questions need to be both directly relevant to patients' problems and phrased in ways that direct your search to relevant and precise answers "  PICO model assists you in organizing and developing your question to be able to search our databases effectively.

PICO Questions

• Characteristics
• When to use PICO

Characteristics of PICO Questions include:

• Structures and guides the search for literature evidence 
• Promotes a relevant, direct, and clear search
• Answers, What do I want to know about?
• Focus the question by identifying the components in the question
• Defines the concepts that will be used when performing a complex literature search
• Promotes access to professional evidence relevant to the question
• Determines if the identified evidence is able to efficaciously address the question
• Focuses on elements to support and update clinical practice
• ​Provide the information needed to make a decision whether or not the intervention in the PICO question should be implemented

(Duke University, 2014; Upstate Medical University, 2010)

The following are the four specific PICO(T) question components that will promote developing an answerable clinical questions and developing an efficient search strategy.

P atient or Problem

Describe the population or clinical problem? What are the most important characteristics of the patient or problem?

I ntervention, Prognostic Factor, or Exposure

What is the main intervention, prognostic factor, or exposure being considered? What do you want to do with this patient?

C omparison Intervention

What is the main alternative to compare with the intervention, if any?

What are you trying to accomplish, improve, or affect?

T ime /  T ype of Study

Time element or type of study.

(Centre for Evidence-Based Medicine, 2014; Duke University, 2014; Occupational Therapy Evidence-Based Practice in Western New York, n.d.; Upstate Medical University, 2010)

Clinical questions are often classified as either background or foreground. 

A.  Background questions - questions that ask for general knowledge about an illness, disease, condition, or process (who, what, when, where, how, and why about disorders, tests, or treatments).  Questions like:  What is considered overweight in a 45 year old male?  What are some symptoms of diabetes?  Background questions are often answerable by using "background resources" such as textbooks, manuals, and narrative reviews in scholarly articles.

B.  Foreground questions - questions that ask for specific knowledge that

1) affect clinical decisions and

2) include a broad range of issues, including psychological, biologic, and sociologic issues. 

 These questions will usually concern a specific patient/particular population and tend to be more complex.  Often, foreground questions require investigation and comparison between two treatments and/or outcomes.  These questions ask for specific knowledge to be able to make informed clinical decisions.  These are questions that require a search of current medical literature.

PICO allows you to formulate articulate foreground questions to be able to effectively research your topic.

Below are some websites and tutorials showing PICO examples:

• How to write a PICO/PIO question
• NCBI List of PICO questions

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