Faculty of Health and Medical Sciences

Formulate a Clinical Question

PICO example

This example focuses on the multidisciplinary care of a patient and some of the many clinical questions that may arise:

A 60 year old indigenous woman with poorly controlled diabetes and a past history of rheumatic valvular disease is admitted to hospital for management of a non-healing ulcer on her heel. Her mobility is poor, and her medical team note that she has several teeth requiring extraction.

  1. The nurse asks: ‘in patients with diabetic foot ulcers, do dressings containing hyaluronic acid improve wound healing, decrease length of hospital admission, and improve quality of life?’
  2. The physiotherapist wants to know: ‘in patients with active lower limb diabetic ulceration, is early ambulation preferable to ambulation after healing in maintaining mobility, length of stay, discharge home, and ulcer healing?’
  3. The podiatrist asks: ‘in high-risk patients with diabetic foot ulcers, does the addition of patient education to usual care decrease the rate of amputation, infective complications and hospital admission?’
  4. The dentist asks: ‘in patients with valvular heart disease, does antibiotic prophylaxis at tooth extraction decrease occurrence of infective endocarditis, sepsis, and hospital admission?.
  5. The intern is concerned that she may be at risk of infective endocarditis and wants to know: ‘in patients with valvular heart disease, is the presence of a diabetic foot ulcer a risk factor for infective endocarditis?’

P

Population

Ask: How would I describe a group of patients similar to mine?

The patient problem or situation. When building your question, this is easier if you characterise your patient sufficiently to allow comparison with patients in the studies you find, perhaps in terms of age, sex, ethnic group, risk profile and other clinically important traits.

For example:

  • Patients with valvular heart disease
  • High risk patients with diabetic foot ulcers
  • Patients with diabetic foot ulcers
  • Patients with active lower limb diabetic ulceration

I

Intervention (or exposure/prognostic factor)

Ask: Which main intervention am I considering?

The intervention you wish to assess could be:

  • Therapy (drugs or procedure)
  • Prevention (eg, lifestyle counselling)
  • Diagnostic testing (eg. How much more likely is your patient to have had a myocardial infarction if the test is positive?)
  • Aetiology/Harm (eg. To what extent are smokers at risk of lung cancer?)

For example:

  • Patient education plus usual care
  • Antibiotic prophylaxis
  • Dressings containing hyaluronic acid
  • Early ambulation
  • Diabetic foot ulcer (prognostic factor for Q of prognosis)

C

Comparison Intervention (or exposure/prognostic factor)

Ask: What is the main alternative?

What is the main alternative or treatment to the intervention being considered, if any? Are you trying to decide between two drugs, a drug and no medication or placebo, surgical techniques or two diagnostic tests? Exposure vs no exposure? Your clinical question doesn't always have to have a specific comparison.

For example:

  • Usual care
  • No antibiotic prophylaxis
  • Dressings not containing hyaluronic acid
  • Ambulation after healing

O

Outcome

Ask: What could this intervention affect?

What you wish to achieve in terms of treatment goals, adverse effects to avoid, diagnoses to refine, etc. What are you trying to accomplish, measure, improve or affect. A precise endpoint must be defined. It could be survival or death, remission or cure, disability prevention, recovery of function and savings in time or money. Patients will also be concerned about endpoints such as side effects, quality of life, operative morbidity and time in hospital. Health care payers may be concerned about cost effectiveness of an intervention.

For example:

  • Amputation
  • Hospital admission length of stay
  • Ulcer healing
  • Mortality
  • Quality of life
  • Mobility
  • Discharge home
  • Risk of infective endocarditis (Q of prognosis)