Professional Documents
Culture Documents
P= Patient Problem:
How would you describe a group of patients
similar to yours? What are the most important
characteristics of the patient? This may include the
primary problem, disease, or co-existing
conditions. Sometimes the gender, age or race of a
patient might be relevant to the diagnosis or
treatment of a disease.
I= Intervention, prognostic factor or exposure:
Which main intervention, prognostic factor, or
exposure are you considering? What do you want
to do for the patient? Prescribe a drug? Order a
test? Order surgery? Or what factor may influence
the prognosis of the patient - age, co-existing
problems, or previous exposure?
C= Comparison:
What is the main alternative to compare with the
intervention? Are you trying to decide between
two drugs, a drug and no medication or placebo,
or two diagnostic tests? Your clinical question
may not always have a specific comparison.
O= Outcome:
What can you hope to accomplish, measure,
improve or affect? What are you trying to do for
the patient? Relieve or eliminate the symptoms?
Reduce the number of adverse events? Improve
function or test scores?
P.I.C.O TABLE
OUR CASE
Patient
obese, diabetes type 2, male
Problem
Intervention stomach stapling (gastric bypass surgery;
bariatric surgery)
Comparison standard medical care
Outcome remission of diabetes; weight loss;
mortality
CLINICAL QUESTION
For our patient, the clinical question might be: In
patients with type 2 diabetes and obesity, is
bariatric surgery more effective than standard
medical therapy at increasing the probability of
remission of diabetes?
Two additional elements of the well-built clinical
question are the type of question and the type of
study. This information can be helpful in focusing
the question and determining the most
appropriate type of evidence or study.
The type of question is important and can help
lead you to the best study design:
Enter the term for the patient problem and the intervention:
obesity AND diabetes type 2 AND bariatric surgery. PubMed
attempts to map your terms to appropriate Medical Subject
Headings (MeSH). MeSH is the standard terminology used by
the indexer and helps find articles on specific topics,
regardless of the exact wording used by the authors.
Step 2. Look at Search Details to verify MeSH
terms
Look in the Search Details box (lower right
column; click on "See more" to expand) to see
the terms that PubMed actually used in its
search. You want to be sure PubMed found the
appropriate MeSH terms. PubMed will
automatically also search for your terms as
words in the title and abstract. Obesity is a
MeSH term, diabetes type 2 is translated to the
MeSH term of diabetes mellitus, type 2, and
bariatric surgery is a MeSH term. If your
search did not find the appropriate MeSH
Step 3. Limit to appropriate study design
This is a therapy question. We know from the previous discussion
that the best evidence for a therapy question is a randomized
controlled clinical trial (RCT). Use the Filters column from the main
results page to limit to Randomized Controlled Trial as an article
type. You may need to click on "more" to see additional filters if
RCT is not listed.
You can also use the Clinical Queries function to limit the results to
study methodologies relevant to therapy questions. Copy your last
search strategy obesity AND diabetes type 2 AND bariatric surgery.
Click on Advanced under the search box; then click on More
Resources near the top of the page; then select Clinical Queries.
Paste the search strategy in the Clinical Query search box and hit
Search. The first column of results is Clinical Study Categories.
Select the type of question (Therapy) and the type of search
(Narrow). You may get more search results using the Clinical
Queries function.
Step 4. Review the results
Both methods limit your results to RCTs. The fourth citation is the
Mingrone article that we found in ACP Journal Club.
Step 1: Use PICO to formulate the search strategy; start with the Patient
problem(s) and Intervention
Step 2. Look at Search Details to verify MeSH
terms
Step 3. Limit to appropriate study design
Evaluating the Validity of a Therapy Study
The study should begin and end with the same number
of patients in each group. Patients lost to the study
must be accounted for or risk making the conclusions
invalid. Patients may drop out because of the adverse
effects of the therapy being tested. If not accounted for,
this can lead to conclusions that may be overly
confident in the efficacy of the therapy. Good studies
will have better than 80% follow-up for their patients.
When there is a large loss to follow-up, the lost patients
should be assigned to the "worst-case" outcomes and
the results recalculated. If these results still support the
original conclusion of the study then the loss may be
acceptable.
6. Were patients analyzed in the groups to which
they were first allocated?