Dental Hygiene

• P: Population
• I: Intervention
• C: Comparison
• O: Outcome

PICO stands for population, intervention, comparison, and outcome. If you have a clinical question you can divide it up into searchable concepts using the PICO framework. Question: Is chewing gum more or less effective for reducing pain in children with ear infections when compared with decongestants? In this case, your population is children with ear infections, intervention is chewing, gum your comparison is decongestants and your outcome is reducing pain. Here's the PICO framework in a chart format:

You can take two or more of your PICO elements and use them as search terms. You can combine these elements using Boolean Operators (AND or OR).

The Boolean operator AND is used to combine different concepts and always gets less results because it narrows your search.

[Venn diagram illustrates the results using the AND Boolean Operator: showing Otitis media on one side and Chewing gum on the other with a highlighted part in the centre.]

In the example above, you've got otitis media AND chewing gum. By combining them both and you only get the sliver in the middle that contains both those terms.

With the Boolean Operator OR you combine similar concepts. OR always gets more results because it's pooling results together.

[Ven diagram illustrates the results using the OR Boolean Operator: showing Otitis media on one side and Ear infection. The whole Venn diagram is highlighted.]

In this example, you get everything about ear infection and everything about otitis media as well as the part in the middle that contains both those terms.

[Venn diagram with three circles, each containing a concept: chewing gum, ear infection, decongestants. The overlap with eachother and the centermost overlapped area contains all 3 concepts.]

You would normally start off a search with two concepts, so in this case chewing gum and ear infection, but if need be and you're getting way too many results you can combine in a third concept, such as decongestants.

In most databases they have a limited search function to restrict your search to children and different age groups.

A few more search tips:

• Truncation, which is done by putting an asterisk (*) after a word gets, all the variations of endings of that word. In this case diet with a truncation (diet*) gets diet, diets, dieted, and dieting.
• A wildcard replaces a word so by putting a question mark (?) in the word analyze (analy?e) you get analyzed (with a 'Zed') or analysed (with an 's').
• Phrase searching, which is often done automatically in databases, but in other databases is done by putting quotes ( “ “) around words, finds that exact quote. For example, “prosthetic joint Infection” as an exact phrase.

Choose a database and execute your search. You are now ready to do your search in an indexing and abstracting database such as Medline, PubMed, EMBASE, SCOPUS, or CINAHL.

Video source: JWSLibrary. (2011, September 9). Using PICO to structure your literature search [Video]. YouTube. https://www.youtube.com/watch?v=iOSWnQpVMjc

Welcome to the PICO tutorial for the mastering medical information course. This tutorial describes a method for constructing a literature search that will enable you to find information on the clinical situations that you encounter. This will in turn help you to provide the best care.

This method is called PICO (nope it's not just for nachos anymore) it's also a tool, well not that kind of tool. PICO is a clinical tool that helps you to transform an information need into an answerable clinical question, so that you can search the literature efficiently.

Each of the four letters in Pico represent a common component of a clinical question the ‘P’ stands for patient population or problem, the ‘I’ refers to the intervention or exposure ‘C’ stands for the comparative intervention or exposure and finally ‘O’ stands for outcome. There is also an optional fifth letter in the Pico method: ‘T’, which refers to the type of clinical question being considered.

Before we get into the details of using Pico let's review some information about questions.

If your question concerns general information (who, what, where, why, how) then it is a background question. You can usually find answers to these questions in textbooks and other reference materials.

If your question deals with specific information on managing a patient, then it is a foreground question. Your answer can usually be found in the research literature.

Next let's consider the most common clinical question types this is the silent ‘T’ in PICO. When searching the literature it's important to know what kind of clinical question you are trying to answer. Typically, your question will fall into one of these four categories:

1. A therapy question: involves information on the effectiveness and/or the risk associated with a specific treatment. Is this intervention more effective than another?
2. A diagnosis question: is concerned with the accuracy of a diagnostic tool or test.
3. Etiology and harm questions: asked about the causes or risk factors associated with a disease or condition.
4. Prognosis questions: involve information about the probable outcome progression or survivability of a disease or condition and the likelihood that it will occur.

The real value of PICO is that it's methodical. This enables you to think through the present problem before you sit down to the keyboard. When you need information begin by using Pico to break it down. Doing this helps you to separate the most important concepts from the less relevant details.

P: Start by identifying the most important characteristics of the patient including the disease or condition and ending relevant information.

I: Next, describe the intervention you are considering for your patient. Is it a drug, a surgical procedure, a diagnostic test, etc.?

C: Then, describe the main alternative being considered for comparison. Is it a different drug or procedure, no treatment, a placebo, etc?

O: Next identify the outcome you are concerned about. Is it symptom control, reduced mortality, accurate and timely diagnosis?

Finally, consider what type of clinical question you have. This becomes important when you must determine which resources to use for your literature search.

Let's try one for practice. Consider the following scenario...

Scenario: A 45 year old woman with clinical depression reads in Redbook that St. John’s Wort can be taken for depression. As her physician what research can you find on the effectiveness of St. John's wort in treating depression and adults?

Using PICO let's identify the important concepts:

First who is the patient (P)?

P: The patient is a 45 year old woman with clinical depression.

Now what intervention (I) are you considering to treat her?

I: St. John's Wort.

What is the comparison (C) treatment?

C: It is a placebo.

What is the desired outcome (O)?

O: It is the efficacy in treatment of depression.

Finally, what kind of clinical question (T) is this?

T: It is a therapy question.

Thus, our clinical question could be stated as follows: Is Saint John's wort more effective than placebo in the treatment of clinical depression in adult women?

The next step is to use the PICO to pick out the important concepts to use when conducting the literature search.

Remember the nachos from earlier? Treat your search terms like hot peppers, a little goes a long way!  So start with the essentials and add more as needed.

When it comes to search terms to pick the intervention is usually the most helpful, followed by the comparison and the patient. The outcome is usually least helpful when choosing search terms.

Therefore, the concepts that we will use for our literature search are St. John's Wort and clinical depression.

Let's see what this search looks like in PubMed:

Begin your search at the miner library homepage by clicking on the link to PubMed. Once you are in PubMed, click on the clinical queries link. A clinical query is an efficient way to find evidence-based clinical medicine articles.

Begin your search by typing your search terms into the search box and then click the search button. Use the specialized filter under the clinical studies category to narrow your search to the kind of clinical question that you are trying to answer. The default filter is therapy, but the other question types are available by clicking the dropdown arrow.

The results show the first 5 citations from a set of 244. You can click on a specific title to read the abstract or you can click on the see all link to see the complete results list.

The second citation looks like it is relevant to our topic. You can click on the title of the article and read the abstract to evaluate the quality of the study. Notice also that there are 51 systematic reviews in the next column of results. This is another type of PubMed filter that narrows the search results to systematic reviews, meta-analyses, reviews of clinical trials, evidence-based medicine consensus, development conferences, and guidelines. Considering these results is important because systematic reviews represent the highest level of evidence for clinical questions. There are a few points to keep in mind when using PICO:

1. First, if your question does not fit into the PICO framework it is probably a broader background question. Refer to textbooks and reference materials for answers to these kinds of questions.
2. For diagnosis questions: the diagnostic tool or test is the intervention, the comparison is the best tool or test, also known as the gold standard, and the outcome is the ability to predict the presence of disease.
3. For prognosis questions: the intervention is a prognostic factor (such as the size of a tumor or a complicating illness) and the comparison is the lack of such a factor, the outcome is the quantity of life that can be expected.
4. For etiology questions: the intervention is some form of exposure and the comparison is the lack of such exposure, finally the outcome is the progression to a disease state.

When you have an information need, begin with the Pico formula. You will find your questions are more focused and your search results are more relevant. Thank you for watching and best of luck on the PICO assignment!

Video source: Miner Library. (2014, January 20). PICO tutorial [Video]. YouTube. https://www.youtube.com/watch?v=KgvwQVz6Aic