Dewi Sutriani Mahalini

Divisi Neurologi Anak, Bagian /SMF IKA ,FK Unud

Email: dewi_sutriani@yahoo.com
 Understand the reasons for focused questions
(PICO)
 Learn how to formulate clinical questions
 Use the PICO to formulate your search strategy
 Introduction to Boolean logic to combine your
search strategy
 Learn how to use systematic approach to
locating the evidence

www.cebm.net
 EBM process starts with a clinical scenario that
needs the best answer

 One of the difficult steps in practicing EBM may

be the translation of a clinical problem into an
answerable question.
  CLINICAL PROBLEM ?

 CLINICAL QUESTION ?

 ANSWERABLE QUESTION ?

 RESEARCH QUESTION ?
E S
B T
M E
P
S
 Convert the clinical problem into an
answerable question

 The key to successful searching is to

convert your clinical problem into a clear
answerable question, which should
ideally be framed in the PICO/PIO format.
 Originate from
everyday clinical problem
 Clinicians have 0.7 to 18.5 questions for every 10 patients
they care for.
 However, answers to 2/3 of the questions are either not
pursued or pursued but not found.
 Subsequent analyses show that almost all unanswered
questions could be answered through improved query
formulation and better search.
 Dissect what you want
to know into its
component parts

PICO is the commonly used acronym

for forming clinical questions when
practicing EBM
A child, 8 years, hospitalized in PICU because
severe GBS and need ventilator support .
The doctor want to know, are there any other
therapy option is better or the best? Any treatment
already used such as prednisone, plasma
exchange and other.
Does IVIG therapy deliver outcome better than
other therapy?

Every day clinical problem

Clinical Problem PICO Answerable question
The doctor want to P=child with severe GBS 1. In child with severe
know, are there any GBS, does IVIG
other therapy option is I /C = therapy deliver survival
better for child 1. Plasma rate better than plasma
hospitalized with GBS exchange exchange therapy?
& need ventilator 2. Prednisone 2. In child with severe
supports? 3. IVIG GBS, does IVIG
O= therapy deliver
1. Survive/Death sequalae less than
Does IVIG therapy 2. Sequalae plasma exchange
deliver outcome better 3. LOS in PICU therapy?
than other therapy? 4. Outcome scoring 3. In child with severe
5. Recovery GBS, does IVIG
6. Etc. therapy deliver
sequalae less than
Prednisone ?
"PICO" is the acronym for this 4 part question
which consists of the first letters of
1. Population/ patients
2. Intervention/ Indicator/ Exposure
3. Comparison / Control
4. Outcome.
P Population The patient or problem in question
Clinical Who are the relevant people in relation to
problem clinical problem?
I Intervention The intervention/test/exposure of interest.
Indicator Management strategy, exposure or test to
Index test find out about relation to clinical problem
C Comparator Comparison interventions
Control Alternative/control strategy, exposure or
test for comparison
O Outcome The outcome of interest
What are you most concerned about
happening or stopping happening
 should be clear
 directly
 focused on the problem
 answerable by searching the medical
literature.
Assume that you are working in a general hospital as
a pediatrician.
A three year old boy presented with acute
diarrhea,
You want to know if combination of probiotics and
prebiotics are effective in decreasing the duration
of diarrhea compared to probiotics only.
 Patient Children with acute diarrhea
P Population

Intervention Probiotic+Prebiotic therapy

I
Comparison Probiotic only
C
Outcome Decrease duration of diarrhea
O
question In children with acute diarrhea, whether giving
? combination probiotics+prebiotics more
effective compared with probiotic for decreasing
duration of diarrhea
 Who are you intersted in?
 How would you describe the patients or
population of interest?
Patients or population
Which is referred to the specific group the
patient or population belong to ?
 Diabetes mellitus type 1
 Infant with acute diarrhea
 Adult with chronic kidney disease
 Epilepsy in adult/children/ neonates
 Low birth weight infant
 Children with dermatitis atopic
 Pregnant woman
 Patient epilepsy with phenobarbital
 Cause
 Risk Factor
 Prognostic Factor
 Treatment/intervention
Intervention
Which is the kind of treatment or procedure we
want to know its efficacy ?.
RISK FACTOR PROGNOSTIC FACTOR

 Family with epilepsy  Control of blood

 Social economy pressure
 Low protein intake  HbA1C
 Obese  Hb concentration
 Less exercise  Regular exercise
 Age  MRI result
 High blood pressure  CRP
 HDL/LDL ratio
INTERVENTION TREATMENT

 Plasma exchange  Amphicillin

 V-P shunt  Carbamazepin
 Certain Procedure  Paracetamol
 Elastic bandage  Ibuprofen
 Elastic stocking  High protein intake
 Catheterization  Hiperosmoler fluid
 What is the alternative to the
intervention?
 May not always be necessary

Comparison
Which is the standard treatment for
comparing the effect of Intervention ?
 What do I hope to accomplish?
 What could this exposure really affect?

Outcome
Which is the intended outcome we
expected to have by our intervention ?
 Length of stay
 Duration of diarrhea
 Duration of fever
 Accuracy
 Life expected
 Survival rate
 Clinical
PROBLEM

Jean is a 55 year-old woman

who quite often trip with a long flights
She tends to get swollen legs on these flights and is
worried about her risk of developing deep vein thrombosis
(DVT), because she has read quite a bit about this in the
newspaper lately. She asks you if she should wear elastic
stockings on her next trip to reduce her risk of this.
P population = Passengers on long haul flight

I intervention = Wearing elastic compression

stockings

C comparator = No elastic stockings

O outcome = Development of DVT

In passengers on long-haul flights, does
wearing elastic compression stockings,
compared with not wearing elastic stockings,
prevent DVT?
George has come to your surgery to discuss the
possibility of getting a vasectomy.
He says he has heard something about vasectomy
causing an increase in testicular cancer later in
life.
You know that the risk of this is very low but want
to give him a more precise answer
Develop a ‘clinical research question’ using PICO

P population = adult male

I intervention = vasectomy

C comparator = No vasectomy

O outcome = testicular cancer

In men, does having a vasectomy (compared with
not having one), increase the risk of getting
testicular cancer in the future?
Mrs Smith has acute lower back pain. She has never
had such pain before and is convinced that it must be
caused by something really serious. You take a
history and examine her but find no indicators of a
more serious, but she is still not convinced.

Develop a clinical research question using PICO to

help reassure Mrs Smith.
P = adults with lower back pain

O = more serious condition

Question :

In adults with lower back pain, what is the

frequency that the pain may reflect a more serious
condition (such as tumour or infection)?
 Creates a clear focused question !
 Defines the important outcomes !
 Structures your search !
 Saves you time!
 Source Subjects
Population Subject

Intervension
Study Group
Comparator

Outcome Result
 Enter the word of interest and combine with
: “AND”, “OR”, “NOT”
 Eg.
1. Hypertention
2. Therapy
3. 1 AND 2
Hypertension AND therapy
When do we use OR ? When do we use AND ?

 Combining synonyms,  To combine different

spelling variants, concepts
acronyms,
related terms of each
concept
 Interested in retrieving
documents which discuss
one /more items of
interest
 children OR child OR infant OR
Patient pediatrics OR paediatrics

Intervention/ phenobarbital OR phenobarbitone OR

Exposure luminal

Comparison VPA OR valproic acid OR depakene

Outcome controled seizure

 children OR child OR infant OR pediatrics OR
Patient paediatrics
AND
Seizure OR convulsion
AND
phenobarbital OR phenobarbitone OR luminal
Intervention/
AND
Exposure
VPA OR valproic acid OR depakene
Comparison
AND

Outcome controled seizure

Search strategy using keyword
(1) Viral bronchiolitis
(2) Corticosteroids OR steroids OR glucocorticoids
OR prednisolone OR dexamethasone
(3) Clinical score OR hospital stay
(4) (1) AND (2) AND (3).
 Click

Quick start
guide

Clinical
Queries
Question
type
 Question Type of question
What should I do about this INTERVENTION/
condition/problem? THERAPY
What cause the problem ? AETIOLOGY
RISK FACTOR
Does this person have the condition/ DIAGNOSIS
problem?
Who will get the condition/problem PROGNOSIS
PREDICTION
How common is the problem? FREQUENCY
RATE
What are the type of problem? PHENOMENA
THOUGHTS
Question Best study design
Intervention RCT
Etiology/Risk factors RCT
Cohort Study
Case Control Study
Frequency & Rate Cohort Study
Cross Sectional Study
Diagnosis Cross Sectional Study

Prognosis & Prediction Cohort/Survival study

 Least
biased
Meta-analisis
Analytical
Systematic review

Randomized Control Trial

Cohort study

Case Control Study

descriptive
Cross sectioal studies /
most Case Series/case Report
biased
Boolian
Logic
Jumlah artikel
yang semakin
sedikit
Formulate an answerable question
Write here the clinical issue that you wrote down earlier
(CLINICAL PROBLEM)

Identify what sort of question it is

 Intervention

 Etiology

 Diagnosis

 Prognosis/prediction

 Frequency/rate

 Phenomenon
Now built up a research question using PICO

P population =

I intervention =

C comparator =

O outcome =

ANSWERABLE QUESTION
RESEARCH QUESTION
 EVERY DAY
CLINICAL PROBLEM PICO
A child, 8 years, P= Child with severe GBS
hospitalized in PICU
because severe GBS, I = IIG
need ventilator support C= (1) Plasma exchange
(2) Prednison
The doctor want to know,
are there any other therapy O= (1) survive/death
option is better ? (2) sequele
Does IVIG therapy deliver (3) LOS in PICU
outcome better than other (4) outcome scoring
therapy? (5) Recovery
(6) etc