Writing your clinical question. The PICOT format is a formula for developing answerable, researchable questions. Writing a good one can make the rest of the process of finding and evaluating evidence much easier!

Types of questions Intervention: What tx has the best outcome? Etiology: What are the greatest risk factors or causes? Prognosis: What is the course/compli-cation of a condition? Diagnosis: What test is most accurate/ precise? Meaning: What is the meaning of an experience for an individual? Your picot will be one of these types. As you write your picot, determine which yours fits into. Keep in mind, most of you will have a question that fits into the first 4 types. That is because many times (for clinical questions especially), you are looking at quantitative studies rather than qualitative. Do you remember from your undergrad and grad research courses what the difference is between the two? If not, that would be important for you to review! It is somewhat easy to tell just by the words . . . “quant” means to quantify like with numbers. Now thing about what “qual” would mean. Be sure to review these two. The Melynk et al text also discusses this. For a “meaning” questions one is not quantifying with numbers.

PICOT format Patient population (i.e., age, gender, disorder) Intervention or issue of interest (i.e., exposure, risk behavior, prognostic factor) Comparison intervention or group (ie., could be placebo or usual care group) Outcome (i.e., risk of disease, accuracy of dx, rate or occurrence Time frame (i.e., how long observed, time to achieve outcome) Pay close attention to the “I” . It is also the independent variable. In the Picot framework “I” can be intervention (like a treatment, a drug, a new educational strategy, etc.). In this case your “I” or the intervention could compare new asthma drug X with the standard of care drug Y on number of asthma episodes in adults with asthma. In the Picot framework the “I” can also be the “issue of interest”. For example, if you are asking, “Do infants exposed to BPA in the first year have a greater chance of “failure to thrive” than those not exposed?-----than the “I” is identified as the exposure of BPA. It is not really an intervention but that is why in the picot sense, “I” is intervention OR issue of interest. Sometimes that is confusing but it is important for you to know.

“Good” or “Not so good”? Identify the “PICOT” for each question. Is this question a well-written PICOT question? Why or why not? How would you make it better? It would help your learning if you write down your answer before you read my notes below (the ones outside the actual slide)!

“Good” or “Not so good”? Is there a difference in the duration of recovery in patients receiving a total hip replacement for those who contracted a post-operative infection compared to those who do not, 6 weeks following surgery? “P” = post op patient receiving total hip; “I” = post op infection, “C”= no post-op infection, “O”=duration/length recovery, “T”= 6 wks post op------Did you identify all of these correctly? Here is how I’d reword, In patient undergoing a total hip replacement, , is there a difference in duration of recovery (e.g.—define here what you consider recovery) 6 wks post op in those who acquired a post op infection vs those who did not?

“Good” or “Not so good”? Are NSAIDs effective in treating menstrual cramps? I’d say this is not so good! Who is the pt population. Of course you say women, obviously! But you need to be more specific. For example, since my research tends to focus on adolescence I would choose “P” = post-menarcheal adolescents age 11-18. Then the “I” = NSAIDS. That’s easy to identify but there is no “C”. You need to know more effective than what? If you are not comparing it to something you can’t determine if it is more effective. The “C” could be something like a new drug that came out or maybe it is NSAIDS + something. You decide based on your clinical knowledge and research from the lit. Now what about the “O”? All that is here is “treating” menstrual cramps. You need to be more specific (e.g. reducing frequency, intensity, duration, etc.). You decide but it needs to be defined so you can decide if literature you find addresses the question. For example, if I use the description I provided here, then if I find an article that focuses on the “O” where it is the effect on school absence . . . Than that specific article is not addressing my picot. You may or may not have a “T”----it depends how you have worded the whole question and also your clinical expertise whould help you define what the T may be.

“Good” or “Not so good”? What is the “quality of life” in patients diagnosed with cancer? This is a not so good question. The “P” is so broad you would likely find a million articles. You likely need an age group, maybe gender and/or a type of cancer to elaborate on the “P”. Sometimes you can’t decide this until you have done a little searching in the lit. Let’s say you do find a million articles . . . Then of course you need to narrow it down. Further elaboration is needed for QOL and also I would wonder “when” e.g., at time of dx, post chemo course, at end of life etc. Depending how you rewrite this it could be a “meaning” question and then you would be looking for qualitative studies or it could be the other types of questions where more quantitative studies would be used as evidence.

“Good” or “Not so good”? Are adolescent girls who are sexually active and begin using DEPO more likely to have higher weight gain, compared to OCP users one year later? Actually, this one is pretty good. You could elaborate on the “P” by including what age of adolescent girls you mean. Otherwise all parts of the PICOT are there.

“Good” or “Not so good”? In the obese adolescent, is diet and exercise more effective in reducing weight compared to exercise alone? Not so good but not terrible! I think the “P” needs to be embellished with age and also perhaps thinking about gender differences. For the “I” I think the diet and exercise likely needs to be more defined. You would likely need to see what is out there in the lit before you settle on which diet and which exercise. It would also be good to have a “T” e.g., 6 mo, 1 yr etc.

“Good” or “Not so good”? Does treatment with chemo drug X for 6 months change the health outcome in patients with cancer? Work through these and see what you come up with now that I’ve shown you some examples. You could always work with your classmates on this via our discussion board.

“Good” or “Not so good”? Is there a greater chance of exhibiting more symptoms of dementia in people with lower compared to higher serum concentrations of serum Vitamin D?

“Good” or “Not so good”? Are there gender differences in mortality rates in adults who binge drink compared to those who do not binge drink?

Case example---what is the PICOT? JG is pregnant for the 2nd time. She had her first baby when she was 33 and had amnio to find out if the baby had Down's Syndrome. The test was negative but it was not a good experience as she did not get the result until she was 18 weeks pregnant. She is now 35, 1 month pregnant and asks if she can have a test that would give her an earlier result. The local hospital offers serum biochemistry plus nuchal translucency ultrasound as a 1st trimester test for Down's Syndrome. You wonder if this is as reliable as conventional amniocentesis. PICOT?--- For pregnant women, is nuchal translucency ultrasound plus serum biochemistry testing in the first trimester as accurate (ie with equal or better sensitivity and specificity) as conventional amniocentesis for diagnosing Down's Syndrome?’ I’ve shown you an example of a PICOT that stems from a case study.

Case example---what is the PICOT? Your next patient is a 72-year-old woman with osteoarthritis of the knees and moderate hypertension, accompanied by her daughter. The daughter wants you to give her mother a prescription for one of the new COX-2 inhibitors. She has heard that they cause less GI bleeding. Her mother is concerned that the new drugs will mean more out of pocket costs each month. PICOT? In elderly women with osteoarthritis of the knee, can COX-2 Inhibitor use decrease the risk of GI Bleeding compared with other NSAIDs?

Case example---what is the PICOT? Your 60-year old female patient has been experiencing a continued deterioration of her periodontal tissues. Her attempts to quit smoking have been unsuccessful; otherwise she is in good health and taking no medications. Because you are her primary care NP, she has questioned you about her current dilemma. The periodontist has suggested a 3-week course of doxycycline therapy to control her latest exacerbation of periodontal disease, but she is concerned about reports asking for prudent use of antibiotics. How do you advise this patient? PICOT? In middle-aged women with periodontal disease, how effective is the therapeutic use of doxcyline decrease gum bleeding and recession compared to no treatment?

Case example---what is the PICOT? On morning rounds in the peds Hem/Onc unit a new NP turns to you for consultation. She wants to discuss options for managing moderate nausea and vomiting that result from chemo. She shares an experience of a relative taking ginger when prochlorperazine did not provide effective relief and asks for your input. PICOT? In pediatric patients receiving chemo who are experiencing moderate nausea and vomiting is the use of ginger as effective as prochlorperazine in reducing nausea & vomiting?

Case example---what is the PICOT? Clinicians have used a conservative approach to the diagnostic evaluation of head injured infants, arguing that infants are at risk of intracranial injury (ICI) and that symptoms/signs of brain injury many not be reliably present in those with ICI. Previous studies have report a significant fraction of ICIs in infants occur in patients with a normal neuro status and no signs/symptoms of brain injury. You want to see how well clinical features predict ICI in infants (Adapted from Greenes & Schutzman; Pediatrics 1999; 104(4):861-7). PICOT? Among infants with a minor head injury does the use of CT scan versus other clinical findings affect identification and diagnosis of intracranial hemorrhage?

Case example---what is the PICOT? The traditional view of withholding feeds in VLBW infants has recently been challenged. Provision of trophic feeds has been found to result in faster maturation of the gut, making it much more receptive for subsequent enteral feeds. You’ve been asked to find evidence on whether feeds should be administered fast or slow to this vulnerable population. PICOT? Among very low birth weight infants, are slow vs fast enteral feeds better tolerated (e.g., decreased episodes of regurgitation, change in VS, etc.)?

Case example---what is the PICOT? Working on the Developmental Assessment Team for school-aged children of mothers who used cocaine during pregnancy, you are interested in learning the developmental outcomes for these children as they begin school compared to children not exposed to cocaine during pregnancy. PICOT? Controlling for other confounding factors, do otherwise healthy children exposed in utero to cocaine, compared those not exposed, have increased incidence of learning disabilities at age 6?