A question is considered well-built if it addresses the most pertinent parts of your information need and will lead to a focused answer for your clinical question.
PICO is an acronym for the four parts of a well-articulated clinical question:
P = Population or Problem - recipients or potential beneficiaries of a service or intervention, or the situation being examined
I = Intervention or exposure - the service or planned action to be delivered to the population
C = Comparison - an alternative service or action that may or may not achieve similar outcomes
O = Outcome - the ways in which the service or action can be measured to establish whether it has had a desired effect
Think about the keywords for each of the PICO parts of the clinical question.
Sample Question: Is prophylactic physical therapy for patients undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?
The PICO parts with keywords for this question would look like this:
|Parts of the Question||Clinical Scenario||Keywords|
|Patient Population||patients undergoing upper abdominal surgery||upper abdominal surgery|
|Intervention||prophylactic physical therapy||prophylactic physical therapy|
|Comparison (if any)||no prophylactic physical therapy||none|
|Outcome||prevent post-operative pulmonary complications||prevent pulmonary complications|
|Type of Study||RCT||Randomized Controlled Trial|
Hierarchy of evidence for clinical questions (Booth & Brice, 2004)
Always start an EBPT search looking for the highest level of evidence. If a meta-analysis is not available on the topic, look next for systematic reviews without statistical synthesis, next for randomized control trials, next for controlled comparison or case control studies, etc.
Credibility: looks at truth and quality and asks, "Can you believe the results?"
Some questions you might ask are: Were patients randomized? Were patients analyzed in the groups to which they were (originally) randomized? Were patients in the treatment and control groups similar with respect to known prognostic factors?
Transferability: looks at external validity of the data and asks, "Can the results be transferred to other situations?"
Some questions you might ask are: Were patients in the treatment and control groups similar with respect to known prognostic factors? Was there a blind comparison with an independent gold standard? Were objective and unbiased outcome criteria used? Are the results of this study valid?
Dependability: looks at consistency of results and asks, "Would the results be similar if the study was repeated with the same subjects in a similar context?"
Some questions you might ask are: Aside from the experimental intervention, were the groups treated equally? Was follow-up complete? Was the sample of patients representative? Were the patients sufficiently homogeneous with respect to prognostic factors?
Confirmability: looks at neutrality and asks, "Was there an attempt to enhance objectivity by reducing research bias?"
Some questions you might ask are: Were 5 important groups (patients, care givers, collectors of outcome data, adjudicators of outcome, data analysis) aware of group allocations? Was randomization concealed?
Guidelines for applying evidence in clinical practice can be found in the classic text:
Guyatt, G., Rennie, D., Meade, M., and Cook, D. (2008) Users' guides to the medical literature: a manual for evidence-based clinical practice (2nd ed.). New York, NY: McGraw-Hill Professional.
Chapters in this guide are organized by type of clinical question: therapy, harm, diagnosis, and prognosis.
Other good resources for both appraisal and applying evidence in clinical practice can be found on these two websites: