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Evidence Based Practice

ASK a clinical question

Melnyk & Fineout-Overholt (2015, p. 10), Step 1 = "Ask the burning clinical question".

 

The first step in the Evidence Based Practice (EBP) process, after cultivating a spirit of inquiry, is to ASK a clinical question that is structured and focused. You need to identify a problem or area of uncertainty where there is a need for more information, and then translate this into the clinical question.

 

Type of Question (study)

 

Explanation

Suggested type of Evidence
(see evidence pyramid in Understanding Evidence under 2. SEARCH)
Therapy - how to select treatments that do more good than harm to patients, and that are worth the effort and cost Randomized Controlled Trial (RCT)
Diagnostic Test - how to select and interpret diagnostic tests to confirm or exclude a diagnosis. Consider specificity, sensitivity, likelihood ratios, expense, safety, etc. Prospective, blind comparison to a gold standard
Prognosis - how to estimate the patient's likely clinical course over time and anticipate likely complications of disease Cohort study / Case control / Case series
Harm / Etiology - how to identify causes for disease (including iatrogenic forms) RCT / Cohort study / Case control / Case series
Prevention - how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose early by screening RCT / Cohort study / Case control
Cost-analysis - how to compare the cost and consequences of different treatments and tests Economic analysis

(Fineout-Overholt & Johnston, 2005)

 

There are a number of methods you can use to help formulate your clinical question; this guide will highlight TWO of these methods, namely PEO and PICO - see below.

Understanding PICO

THE PROBLEM:

An obese woman, aged 58, has been advised to have surgery on her knee for an anterior cruciate ligament injury. As both her parents died during surgery, she says she would prefer not to have surgery and rather try losing weight and exercising first.

Formulating your clinical question using PICO...

 

 

- the characteristics of the patient or the people (population), like symptoms, age, gender, etc.

 

 

e.g. female, obese, anterior cruciate ligament (ACL) injury

 

 

- the treatment, or procedure, or diagnostic test, or prognostic factors.

 

e.g. arthroscopic surgery, keyhole surgery

 

 

- a better or different kind of treatment or therapy; or in the case where a control group gets the placebo.

 

 

e.g. thigh strengthening exercises, weight loss

 

 

- the effect of the intervention, i.e. what you want to achieve via the study, what you hope to change or measure, or what could happen.

 

 

e.g. repair of ACL, blood clots, mortality

 

From here you can use a template to formulate your question:

  • For [population] how does [intervention] affect [outcome] when compared with the [comparison]?

 

Using PICO in this way, your CLINICAL QUESTION could be...

For female patients with anterior cruciate ligament injuries and obesity how does arthroscopic surgery affect the probability of walking without pain when compared with exercise and weight loss?

OR...

In female patients with anterior cruciate ligament injuries and obesity, is arthroscopic surgery more effective than exercise and weight loss in increasing the probability of walking without pain?

Understanding PEO

THE PROBLEM:

You have noticed that some patients with nerve damage caused by diabetes cope with amputation quite well, while other patients seem to struggle with the ordinary daily tasks.

Formulating your question using PEO...

- demographic information, i.e. the users, patients or community being affected. e.g. diabetic neuropathy
PEO E - a specific exposure (this term is used loosely) such as “witnessed resuscitation” or “domestic violence” (Bettany-Saltikov, 2012) e.g. amputated limb
- usually dealing with the patient's experiences, like improvements in pain, responsiveness to treatment, mobility, quality of life, daily living, etc.  e.g. lived experiences

 From here you can use a template to formulate your question:

  • Does [outcome] change when [population] is exposed to the [exposure]?

 

Using PEO in this way, your CLINICAL QUESTION could be...

Does the lived experience change when patients with diabetic neuropathy are exposed to limb amputation?

OR...

What are the lived experiences of patients with diabetic neuropathy who have had a limb amputated?