1. Developing an Answerable Question
PICO
Jo Dorsch
This portion – going to focus on developing an answerable question
-and to do that – going to use something called “PICO” which for those of you unfamiliar with that term – I will explain what it is in a few minutes

2. Steps in the EBM process
Converting information need into a clinical question
Searching the literature for the best evidence
Critical appraisal of the literature
Applying the literature
Evaluation
Kristina mentioned earlier today the steps in the EBM process – but up until this point – we have been providing you with background information to help you as we introduce these steps
-a real important step – that begins this whole process is having a question and articulating that question in a way to retrieve the best clinical information
-so we are going to start the more hands on part of this whole process
-work on asking – what really is the questions and what is the best way to go about searching for it

3. Types of Clinical Questions
Therapy
Diagnosis
Etiology
Prognosis
Harm
Prevention
Quality Improvement
The first thing you need to think about before doing anything – is ask yourself –what type of question am I asking
Therapy
Diagnosis
Etiology
Prognosis
Harm
Prevention
Quality improvement
-when you answer this question – you really help yourself out in terms of one) figuring out how to best search for the article and two) once you find some article and you have picked the best one – the types of questions that you will ask about that article are going to depend on the type of question that you have (now – the types of questions that you ask is more for tomorrow)

4. Levels of Evidence http://www.exempla.org/courses/FindBestEBM/pyramid/
We spend a good part of the morning talking about the structure and organization of the literature
Research designs and the levels of evidence
Not only is it important to understand what the level of the study is in order to determine the quality of the research – but it is also important to realize that understanding the level of evidence (or the type of study design) that will likely be used to investigate something – is also information that you can use when searching for articles
-certain types of research/ levels of evidence lend themselves to certain types of questions
-so we have talked about how finding a randomized controlled trial or meta analysis is the best evidence if you can find it – but – for both ethical and methodological reasons – is just not realistic to expect that all types of questions are going to be answered by finding a randomized controlled clinical trial

5. Therapy Diagnosis Prognosis Etiology Prevention Quality Improvement
Type of Question
Type of Study/Methodology
MEDLINE Filters
Therapy
-Double-Blind Randomized Controlled Trial
-Systematic Review / Meta-analysis
Randomized Controlled Trial [PT], double [TW] and blind [TW]
Meta-analysis
Diagnosis
Controlled Trial
Sensitivity and Specificity [MH], Diagnosis [SH]
Prognosis
Cohort Studies, Case Control, Case Series
EXP Cohort Studies [MH], Prognosis [MH], Survival Analysis [MH]
Morbidity [MH] Mortality [MH]
Etiology
EXP Cohort Studies [MH], Risk [TW]
Prevention
Randomized Controlled Trial, Cohort Studies
Randomized Controlled Trial [pt], Cohort Studies [MH], Prevention and Control [SH]
Quality Improvement
Randomized Controlled Trials
Randomized Controlled Trial [PT] Practice Guideline [PT] Consensus Development Conference [PT]
Therapy – really should not accept less than a randomized controlled trial
Diagnosis – find out when we study it more tomorrow – when you test a diagnostic test – you don’t randomly assign people to get one type of test and another person gets the other – best way to test the accuracy of a test if for a person to get tested with the Gold standard or a highly accurate test – and the new test – to see how the 2 compare. - can’t compare the results unless everyone takes both tests – just a controlled trial - sensitivity and specifitiy are the statistical test being examined – might search for that – or might select in the subheadings for diagnosis
Prognosis and cause – unethical to assign people to some form of harm – but – if look at a group of people who are similar – some who have been exposed to something and some who have not - looking at if fluoridation of water is good or bad - some say good for bones and cavities – other say causes bone problems and other things later in life - look at similar groups of people who happen to have been exposed to different levels of fluoride in the water including no fluoride to see – are there similar illinesses or benefits that can be seen in each of those groups – but – its just not something that you would randomly assign – especially if you thought fluoride could harm people
Prevention – very similar to treatment – similar types of studies – you might look to see – does gingo blogo help memory, green tea help with preventing cancer – note that there is cohort studies here – cohort studies often give ideas of what prevents things – people who drink green tea don’t get cancer – cohort suggest cause and effect – RTC would do more do control for unknown variables and come to a more definitive answer
-point is – different types of questions – are best answered by different types of studies – and you can use that information when searching
From:
More MEDLINE Filters at

6. PICO P Patient, Population, or Problem I
Intervention, Prognostic Factor, or Exposure C
Comparison or Intervention (if appropriate)
Outcome you would like to measure or achieve
What type of question are you asking?
Diagnosis, Etiology, Therapy, Prognosis, Prevention, Harm
Type of study you want to find
What would be the best study design/methodology?

7. PICO Patient – 54 year old male with a cold Intervention – vitamin c
Comparison – no vitamin c
Outcome – prevent the common cold
Type of Question: Prevention / Treatment
Type of study design: RTC

8. Clinical Scenario 1
55-yr old female; history of hypertension; sudden onset of chest pain and shortness of breath
Swelling in R leg for 2 days since return from recent vacation
Current meds: estrogens and atenelol
V/Q read as high probability for pulmonary embolism
Patient started on Lovenox; treatment with coumadin initiated in hospital
Sent home in stable condition; coumadin for 6 months

9. PICO Exercises
Clinical Scenario 2: A 72 y/o male with osteoarthritis wants to take glucosamine and chondroitin sulfate instead of other meds. Is there any evidence of effectiveness?
Clinical Scenario 3: A women in her mid 40s with a family history of breast cancer is scheduling her yearly breast exam. Should an MRI or a mammogram be scheduled?

10. PICO Exercises
Clinical scenario 4: You have an infant with suspected congenital heart disease and order an MRI. The parents request an echocardiogram. Which test should be performed or both?
Clinical scenario 5: In children with asthma, 2mg/kg of prednisone is commonly used. In other countries the usual dose is 1mg/kg. Which is more effective in reducing length of exacerbations?

11. PubMed Clinical Queries Sandy De Groote
Searching PubMed
PubMed
Clinical Queries
Sandy De Groote

12. Steps in the EBM process
Converting information need into a clinical question
Searching the literature for the best evidence
Critical appraisal of the literature
Applying the literature
Evaluation

13. MEDLINE PubMed www.pubmed.gov
MEDLINE is premiere biomedical database. Produced by the National Library of Medicine, MEDLINE is an international bibliographic database of over biomedical journals. It covers the fields of medicine, nursing, dentistry, veterinary medicine, the health care system and the preclinical sciences.
PubMed
-search for primary literature (also indexes meta-analyses and systematic reviews)
- Clinical Queries
It dates from 1966 to the current
Who already uses PubMed?
Ovid MEDLINE
Another MEDLINE interface?

14. Exercise Search PubMed
Clinical Scenario 2
Clinical Scenario 3
Based on the results – select one or two that you think you might want to look at further.
Why did you choose it?