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Cochrane Workshop Picos

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Cochrane Review author training workshop, January 22-23, 2009 at the University of Calgary Health Sciences Centre

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Cochrane Workshop Picos

  1. 1. Defining a Researchable Question: the PICOS Approach Cochrane Reviewers’ Training Workshop January 22-23, 2009 Session Presenter: Marcus Vaska Slides adapted from “Defining a Researchable Question..” by Miranda Cumpston, with additions and deletions by Dr. Roger Thomas; “Review Protocol and Designing Your Research Question,” by the Cochrane Collaboration
  2. 2. Session Goals  Learn about strategies/tips used to help design a research question  Learn about the PICOS approach, and be able to apply this method when defining your own researchable question
  3. 3. Strategies/Tips for Designing a Research Question  Main Objective: summarize the question in order to help the reader understand the evidence and/or make a practical decision about a health care decision  Remember: Remain neutral, not biased (do not impose own values and/or  preferences when defining your research question) Although you may be an expert in your particular subject area,  don’t assume your readership is. Therefore, the Cochrane review needs to be easy to understand and follow by a person who may have only marginal knowledge about the topic.
  4. 4. A Brief Note on Cochrane Review Titles  All Cochrane titles and reviews of diagnostic tests utilize one of the following standard formats: <intervention> for <health problem>  i.e. <antibiotics> for <tuberculosis>  <intervention A> vs. <intervention B. for <health  problem> i.e. <modern medicine> vs. <traditional, homeopathic  remedies> for <malaria> <intervention> for <health problem> in  <participant group/location> i.e. <education programs> for <AIDS> in  <pastoralist/nomadic societies>
  5. 5. Sample Topic for Demonstration Purposes In lieu of traditional homeopathic remedies, can the administration of modern medicine help alleviate the malaria epidemic among children in Africa?
  6. 6. The PICOS Approach: What is it and Why is it Important?  PICOS = a framework designed to make the process of defining and designing a research question easier  Why is it Important? To create a clear question  To identify the information needed to answer that question  To translate the question into searchable terms  To develop and refine the search approach  “It looks easy. It can be tricky. It is absolutely invaluable.” [Evidence-Based Answers to Clinical Questions for Busy Clinicians. (2006). The Centre for Clinical Effectiveness, Monash Institute of Health Services Research, Melbourne, Australia, p. 2]
  7. 7. The PICOS Approach  P Population, Patient   I Intervention   C Comparison   O Outcome   S Study Design 
  8. 8. P = Population/Patient When defining this question component,  consider the following patient characteristics: Disease/condition, including the duration,  localization, and type of symptoms  Age  Gender  Setting  Standard Diagnostic Criteria
  9. 9. Sample: Modern Medicine for Treating Malaria Who are the Children in Africa P (Population, patients? Who is (excluding Patient) affected? Any adults) suffering exclusions? from malaria Describe the specific patient population characteristics and/or context of the disease
  10. 10. P (Population/Patient) Considerations to Remember Restrictions on populations/settings  should be based on a sound rationale – important for Cochrane reviews to be globally relevant
  11. 11. I = Intervention When deciding on the intervention(s) that  will be present in a systematic review, the following should be explicitly described: Type of intervention   Intensity of intervention  Frequency of intervention  Duration of intervention
  12. 12. Sample: Modern Medicine for Treating Malaria I (Intervention) What is being Modern medicine done? What (antibiotics) interventions should be evaluated? Define the intervention!
  13. 13. I (Intervention) Considerations to Remember Interventions can consist of: treatment,  diagnostic/screening test, exposure, or prognostic factor  Should all variations be included?  How will co-interventions, or trials that only include part of an intervention be handled?
  14. 14. C = Comparison Main alternative being considered   Intervention should be explicitly defined Placebo   Standard therapy  No treatment  Another treatment  Usual care (“the gold standard”)
  15. 15. Sample: Modern Medicine for Treating Malaria What is the Traditional C alternative to the medicine (Comparison) intervention? How (homeopathic effective are remedies) different interventions?
  16. 16. C (Comparison) Considerations to Remember Control groups  Inactive Control   Active Control
  17. 17. O = Outcome  When determining the desired/expected outcomes of a systematic review, it is key to consider the following: Explicit outcome measures and tools  Standardized, validated, established outcome  measures appropriate for the disease condition Focus on outcomes that are important to patients  Side effects (if known) should be included  Timing of outcome measures should be described 
  18. 18. Sample: Modern Medicine for Treating Malaria What are the Malaria O (Outcome) relevant prevention, death outcomes? What reduction do you want to accomplish, measure, improve? Define specific outcomes
  19. 19. O (Outcome) Considerations to Remember Include all important outcomes (primary  and secondary)  Include adverse effects  Consider Economic Data  Do Not Include an outcome that is trivial or meaningless to decision makers!
  20. 20. S = Study Design The type of study design utilized is  dependent on the type of question defined. The presence of bias with different designs should be considered before deciding which one is most suited to the question being pondered
  21. 21. Types of Study Designs  (Interrupted) Time Series A research design that collects observations at multiple time  points before and after an intervention (interruption). The design attempts to detect whether the intervention has had an effect significantly greater than the underlying trend.  Case-Control Study A study that compares people with a specific disease or  outcome of interest (cases) to people from the same population without that disease or outcome (controls), and which seeks to find associations between the outcome and prior exposure to particular risk factors. This design is particularly useful where the outcome is rare and past exposure can be reliably measured. Case-Control studies are usually retrospective, but not always Source: Glossary of Terms in the Cochrane Collaboration Version 4.2.5 May 2005
  22. 22. Types of Study Designs (continued)  Cohort Study An observational study in which a defined group of people  (the cohort) is followed over time. The outcomes of people in subsets of this cohort are compared, to examine people who were exposed or not exposed (or exposed at different levels) to a particular intervention or other factor of interest  Randomized Controlled Trial (RCT) An experiment in which two or more interventions, possibly  including a control intervention or no intervention, are compared by being randomly allocated to participants. In most trials one intervention is assigned to each individual but sometimes assignment is to defined groups of individuals (for example, in a household) or interventions are assigned within individuals (for example, in different orders or to different parts of the body) Source: Glossary of Terms in the Cochrane Collaboration Version 4.2.5 May 2005
  23. 23. Sample: Modern Medicine for Treating Malaria What is the best Therapy = S (Study study design to prospective RCT; Design) answer the Prevention = RCTCohort question ? StudyCase Control
  24. 24. S (Study Design) Considerations to Remember Most reviews use RCT’s as a threshold  (RCTs are considered the least biased form of evidence) Cochrane and Campbell collaborations  may also take evidence from interrupted time series
  25. 25. Class Exercise Topic: Interventions to increase influenza vaccination rates of the elderly in the community and in institutions
  26. 26. Exercise: Interventions to Increase Influenza Vaccination Rates Who are the P (Population, Age=adults, elderly, seniors, NOT patients? Who is Patient) children, NOT affected? Any adults <60) exclusions? Gender= male & Describe the female specific patient Setting=institution population (hospital, care centre) characteristics vs. community (home, public place) and/or context of Disease/Condition = the disease influenza
  27. 27. Exercise: Interventions to Increase Influenza Vaccination Rates I (Intervention) What is being Patient done? What interventions; interventions Administrative should be interventions; evaluated? Health care Define the workers (HCW) intervention interventions; Societal interventions
  28. 28. Exercise: Interventions to Increase Influenza Vaccination Rates No alternative What is the C intervention, other alternative to the (Comparison) than to observe the intervention? How effectiveness of effective are different interventions different interventions? Comparison of influenza rates, illness, mortality
  29. 29. Exercise: Interventions to Increase Influenza Vaccination Rates What are the Effects of O (Outcome) relevant interventions on outcomes? What both immediate do you want to and long-term accomplish, changes in measure, influenza improve? Define vaccination rates, specific outcomes and on outcomes of interest
  30. 30. Exercise: Interventions to Increase Influenza Vaccination Rates What is the best RCTs S (Study study design to Design) answer the question ?

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