This document discusses evidence-based practice and how to formulate clinical questions using the PICO framework. It emphasizes asking answerable clinical questions, acquiring the best evidence to answer those questions, critically appraising the evidence, and applying it to patient care. Examples are provided to demonstrate how to develop well-structured clinical questions using PICO components and identify the optimal study design to answer each type of question. Resources for self-education in evidence-based medicine are also highlighted.

1. Literature
Searching: Asking
Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MemAcadMEd MSc MBBS
Chairman, Knowledge Translation Committee
Department of Medicine, KAMC,KSA

2. 2
Why Evidence-based Practice?
 Improves the quality of patient care
 Standardizes the delivery of healthcare
 Reduces the expense of healthcare
 Incorporates patient values into healthcare
decisions
Bridging the Gaps
 Knowledge Practice
 Resources Expenditure

3. What is Evidence-based Medicine
 “ Evidence-based medicine is the
 integration of:
 best available research evidence with
 clinical expertise and
 patient values”
 Sackett, et al 2001

4. EBP!
The
Patient
Clinical
Expertise
Best
Evidence
4
Evidence:
Clinically
relevant
research,
the
literature
Expertise:
Practitioner’s
knowledge
& experience
Expectations: Patient’s
characteristics, preferences
& values
Three Pronged Approach
4

5. Integrates Evidence With
 Clinical expertise
 Experience
 Judgment
 Patient values and preferences
 Quality of life
 Costs
 Other important factors

6. EVIDENCE-BASED MEDICINE

7. What is Evidence-based Practice
EBP is about asking questions and
searching for answers in the body of
medical research, and having found a likely
source of information appraising the paper
for its scientific validity and then applying
the result to your problem.

8. Evidence-based Practice
Ask clinical
Questions
Acquire the
best evidence
Appraise
the evidence
Apply
evidence to
your patient
5A’s !!
Assess
effectiveness,
efficiency of EBM
process

9. Evidence-based Practice
Ask clinical
Questions: PICO
Acquire the
best evidence:
Literature Searching
Appraise
the evidence:
Critical Appraisal
Apply
evidence to
your patient:
Knowledge Translation
(Implementation)
5A’s !!
Assess
effectiveness,
efficiency of EBM
process

10. Self-Education & Training in EBM
 EBM Resources:
 http://guides.mclibrary.duke.edu/content.php?pid=
274373&sid=2262393
 http://www.med.yale.edu/library/education/guides/
feature/finditfast
 CEBM Website:
 http://www.youtube.com/user/cebmed,
 http://www.cebm.net/index.aspx?o=1965
 YouTube:
 http://www.youtube.com/watch?v=odfo9CQGi0c

11. Clinical Query: EBM Approach
Ask clinical
questions
Acquire the
best evidence
Appraise
the evidence
Apply
evidence to
Your patient
5A’s !!
Assess
effectiveness,
efficiency of
EBM process

12. EVIDENCE-BASED MEDICINE

13. Ask clinical question
Background /Foreground questions
• Background Question
• Asks for general knowledge about a disorder. Textbooks
are good for answering background questions
• Foreground Question
Asks for specific knowledge about managing patients
with a disorder; consists of three or four components
(PICO): Diagnosis, Therapy, Prognosis etc
Journal articles are good for answering foreground
questions.

14. Ask clinical question

15. Templates for EBP Questions
 For a therapy: In _______(P), what is the effect of _______(I) on
______(O) compared with _______(C)?
 For etiology: Are ____ (P) who have _______ (I) at ___
(Increased/decreased) risk for/of_______ (O) compared with ______
(P) with/without ______ (C)?
 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: Does __________ (I) influence ________ (O) in patients
who have _______ (P)?
Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York:
Lippincott Williams & Wilkins.

16. Ask Clinical Questions: PICO
Patient/
Population Outcome
Intervention/
Exposure
Comparison
Components of Clinical Questions
In patients with
acute MI
In post-
menopausal
women
In women with
suspected
coronary disease
does early treat-
ment with a statin
what is the
accuracy of
exercise ECHO
does hormone
replacement
therapy
compared to
placebo
compared to
exercise
ECG
compared to no
HRT
decrease cardio-
vascular mortality?
for diagnosing
significant
CAD?
increase the
risk of
breast cancer?

17. Study designs
Descriptive
Observational Intervention
Analytic
cross-
sectional case-
controlcohort
prospective
natural
experiment
quasi-
experiment
RCT
retrospective
•Case report
• Case series
• Survey

18. Decide on the best type of study design for your
question: For each type of question there is a
hierarchy of evidence
Therapy/Prevention
What should I do about this
problem?
RCT>cohort > case control > case series
Diagnosis
Does this person have the
problem?
Cross-sectional study with blind
comparison to a gold standard
Etiology/Harm
What causes the problem?
RCT > cohort > case control > case series
Prognosis/Prediction
Who will get the problem?
RCT >cohort study > case control > case
series
Frequency and Rate
How common is the problem?
cohort study > cross-sectional study
NOTE: A well designed systematic review of RCTS (randomized controlled
trials) is best as it is least biased therefore more valid.

19. Finding the Evidence

20. “Finding Evidence”: Sources
 Primary: PubMed, EmBase, Cinahl, Pyschlit
 Secondary:
 Systematic Reviews: Cochrane Library, PubMed
 Guidelines websites: Guidelines Clearinghouse, Guidelines
International Network
 CATS: BestBets, ACP ournal Club
 Point of Care: Clinical Evidence, EvidencePlus, UpToDate etc
 Tertiary resources (meta search engines, databases of
databases):
 TRIP+ (Translating Research Into Practice), PrimeEvidence

21. Ask clinical question:

22. Expanded PICO=PICOT3
P Population/Patient/
Problem
How would I describe a group of patient's similar
to mine
I Intervention/
Indicator
Which main intervention, exposure, prognostic
factor am I considering?
C Comparator/
Control
What is the main alternative to compare with the
intervention?
O Outcome What can I hope to accomplish, measure,
improve, affect?
T Type of Study Question
you are asking
How would I categorize this question? e.g.
Diagnostic, Therapeutic etc.
T Type of Study Design
you would want to find
What would be the best study design in order to
answer this question? e.g. Randomized Controlled
Study, Cohort study etc.
T Time you got How much time you got to answer your question?
Point-of Care Resources versus the others!

23. Example:
A 28-year-old male presents with recurrent
furunculosis (skin boils) for past 8 months; these
episodes have been treated with drainage and
several courses of antibiotics but keep recurring.
He asks if recurrences can be prevented. To
convert this to an answerable question, use the P I
C O method as follow:

24. Question:
‘In patients with recurrent furunculosis, do prophylactic
antibiotics, compared to no treatment, reduce the recurrence
rate?’
P Population/Patient/
Problem = patients with
recurrent
furunculosis
I Intervention/
Indicator = prophylactic
antibiotics
C Comparator/
Control = no treatment
O Outcome
= reduction in
recurrence rate of
furunculosis

25. Expanded PICO=PICOT3
P Population/Patient/
Problem
How would I describe a group of patient's similar
to mine: patients with recurrent
furunculosis
I Intervention/
Indicator
Which main intervention, exposure, prognostic
factor am I considering? prophylactic
antibiotics
C Comparator/
Control What is the main alternative to compare with the
intervention? no treatment
O Outcome What can I hope to accomplish, measure,
improve, affect? reduction in recurrence rate
of furunculosis
T Type of Question you
are asking
How would I categorize this question?
Prevention
T Type of Study you
would want to find
What would be the best study design in order to
answer this question? Randomized
Controlled Study
T Time you got How much time you got to answer your question?
Point-of Care Resources POCR versus the others!
e.g.no time! Check it in POCR e.g.
UpToDate, Dynamed, Cochrane etc.

26. Example:
Mr. X wants to discuss the possibility of 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
low but want to give him a more precise answer.

27. Question:
‘In men, does having a vasectomy (compared to not having
one) increase the risk of getting testicular cancer in the future?’
P Population/
patient
= adult males
I Intervention/
indicator
= vasectomy
C Comparator/
control
= no vasectomy
O Outcome = testicular cancer

28. Expanded PICO=PICOT3
P Population/Patient/
Problem
How would I describe a group of patient's similar
to mine: adult males
I Intervention/
Indicator
Which main intervention, exposure, prognostic
factor am I considering? vasectomy
C Comparator/
Control What is the main alternative to compare with the
intervention? no vasectomy
O Outcome What can I hope to accomplish, measure,
improve, affect? testicular cancer
T Type of Question you
are asking How would I categorize this question? Harm
T Type of Study you
would want to find
What would be the best study design in order to
answer this question? Randomized
Controlled Study or Cohort study
T Time you got How much time you got to answer your question?
Point-of Care Resources POCR versus the others!
e.g.no time! Check it in POCR e.g.
UpToDate, Dynamed, Cochrane etc.