Studies: What’s Wrong with PICO?
Transcript of Studies: What’s Wrong with PICO?
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Searching for Clinical Guidelines, Algorithms, and Mixed Methods
Studies: What’s Wrong with PICO?
Janice M. Jones, PhD, CNS, RN
University at Buffalo School of Nursing
Buffalo, NY
43rd BIENNIAL STTI CONVENTION
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Disclosures
• Janice M. Jones, University at Buffalo, School of Nursing
• Objectives
• Assess the pros and cons of using the PICO format in
conducting a search for evidence-based practices.
• Identify alternative search strategies in the retrieval of
evidence, clinical guidelines, and clinically relevant
evidence-based algorithms.
• The author declares no Conflict of Interest of any sort
related to this presentation.
• The author is receiving no sponsorship or commercial
support related to this presentation.43rd BIENNIAL STTI CONVENTION
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PICO(T) format4 dimensions
P = Population of interest
I = Intervention
C = Comparison
O = Outcome
T = Time (optional)
Specificity of keywords forms the basis for the
literature search.
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PICO Advantages and Challenges
Promoted as the best method to formulate a clinical
question for specific patient problems and populations.
- Known interventions
- Clear outcomes
What about 3 or 4 comparisons?
Reduce stress and BP: mediation, yoga, prayer, exercise
- Able to do this in most databases
Less useful for clinical guidelines, algorithms, mixed
methods studies or qualitative research
Adapt these clinical questions into PICO questions?
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Evidence-Based Clinical Guidelines
More prolific in the literature
Generally comprised of a variety of evidence-based
resources
• Meta-analyses
• RCTs
• Experimental and quasi experimental studies
Published by notable organizations such as American
Heart Association, Society for Gastroenterologists
Example: A.S.P.E.N. Enteral Nutrition Practice
Recommendations: acceptable residual volumes for ICU
patients receiving enteral feedings
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PICO lends itself to one or two aspects of the guidelines but not in total.
C = Comparison
Use guidelines or not
Difficult to search in CINAHL or PubMed
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Evidence-Based Bundles and Algorithms
Need to know that a bundle exists e.g. ventilator
associated pneumonia (VAP) – background
information
I = use of VAP bundle – gold standard
C = not use the VAP bundle
Search term “bundle” no results
Search term “algorithm” no results PubMed,
some results CINAHL
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Qualitative and Mixed Methods Research
PICO lends itself well to quantitative data
PIO may or may not lend itself to qualitative data
P = population
I = interpretation or issue of interest
O = outcome
SPIDER method: Sample – Phenomenon of Interest –
Design – Evaluation – Research Type
• Smith, D., & Booth, A. (2012). Beyond PICO: The
SPIDER tool for qualitative evidence synthesis.
Qualitative Health Research, 22(10), 1435-1443.
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Quality Improvement StudiesProcess improvement questions.
Quality assurance or quality improvement questions.Healthcare delivery science questions.
All are based on some level of evidence.
Quality of Care or Donabedian model
- Structure – Process – Outcomes
Plan – Do – Study/Check - Act
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Alternative to PICO(T)
PICOT(T)
• Population
• Intervention
• Comparison or comparisons
• Outcome
• Type of study design
• Time may or may not be included
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Type of Study Design
Evidence-based guidelines
Evidence-based algorithm
Quality improvement – evidence informed
Systematic reviews, RCTs etc.
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CINAHL and PubMed
Allow for some of these variations in their search
options
PubMed – clinical queries and special interest
CINAHL - EBP
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Treatment algorithm for the management of type II diabetes
http://gaby.fachrul.com/img/diabetesmedication/medicine-diabetes/treatment-algorithm-for-
the-management-of-type-2-diabetes-suggested-by558-x-359-109-kb-jpeg-x.jpg
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Web browser search: ADA guidelines type II diabetes
American Diabetes Association Clinical Practice Recommendations – 2015
Is google better in findingsome types of evidence?
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What is or should be the expectation of students?
Variations in levels of nursing students
Train students to be mini librarians?
Some literature related to EBP processes
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Leveling in proficiency of search strategies
Undergraduate
• Basic to advanced
• How advanced?
• AD/RN to BSN
• Traditional BSN
• Accelerated BSN
Graduate – MS and DNP
• Advanced search
Learning the
EBP process
More advanced
search methods
Novice nurse with AD, diploma vs BSN?
Expert nurse with AD, diploma or years from education?
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More advanced searchP = Population
I = Intervention
C = Comparisons (and, or, not) – Boolean operators
O = Outcomes
T = Time (optional)
________________________________________
T = Type of study design• Systematic reviews, RCTs
• Guidelines and algorithms
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What’s in the future?New or different search strategies are needed.
Most robust databases to support queries, user-friendly.
Librarian consultation.
• Should all searches be done by librarians or in
consultation with one?
• Can produce more complex search strategies.
• Can produce more precise searches.
• Can select best databases to answer the clinical
question.
• Hospital or academic setting – librarians available
• Clinic or primary care office?
EBP consultant
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Ultimate goal: guidelines and algorithms should be embedded into the clinical support system,
computerized provide order entry system, the electronic
health/medical record and nursing practice in all settings and at every
level.
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Select ReferencesCenter for Evidence-Based Medicine. Retrieved from
http://www.cebm.net
Center for Evidence-Based Practice (2014). Quality Management/Library, Medical University of South Carolina. Retrieved from http://musc.libguides.com/c.php?g=107906&p=699471
Cook, A., Smith, D., & Booth, A. (2012). Beyond PICO: The SPIDER tool for qualitative evidence synthesis. Qualitative Health Research, 22(10), 1435-1443.
Duke Center for Nursing Research and Translational Science. Retrieved from http://sites.nursing.duke.edu/research/2015/05/15/duke-ctsa-update/
Higgins, J.P.T., & Green, S. (Eds.). (2011, March). Cochrane Handbook for Systematic Reviews of Interventions. Retrieved January 17, 2014 from http://handbook.Cochrane.org/
Huang, X., Lin, J., & Demner-Fushman, D. (2006). Evaluation of PICO as a knowledge representation for clinical questions. AMIA Annual Symposium Proceedings, 359-363.