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DEPARTMENTS: EDITORIAL

Evidence-Based Medicine: A FINER PICO Analysis

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Advances in Skin & Wound Care: July 2017 - Volume 30 - Issue 7 - p 294
doi: 10.1097/01.ASW.0000520707.06374.44
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Asking the right question is fundamental to any serious research endeavor. Developing a cogent research question specifies the trajectory for the planning, analysis, and reporting of a research study and its dissemination in grant proposals and scientific journals.1,2 The cognitive leap required to move a developing idea into a logical research question and then conclusively to a testable hypothesis is a useful and iterative process.1,2 A convenient prompt for defining the characteristics of good research questions that ultimately leads to a good research plan has been presented by Cummings et al.1,2 The prompt is based on the mnemonic “FINER”: feasible, interesting, novel, ethical, and relevant.1-3

Fortunately, the evolution of evidence-based medicine has provided systematic tools to simplify the formulation of interrogatives that serve as the foundation of a real clinical research question. One of the fundamentals in the evidence-based medicine toolkit is known by the acronym “PICO,”1–4 which represents diagnostic questions based on 4 areas of knowledge and action: patient or problem; intervention, cause, or prognosis; comparison or control; and outcome. This evidence-based method is designed to make a valid, successful decision based on the skills and knowledge of the clinician, and incorporating the values of the patient is also an important distinction.

The PICO acronym is a framework for asking cogent research questions or important clinical questions for an individual patient or a group of patients. Asking the right question is crucial, but it is especially important when patient care or research is involved. In addition, it is critical to know what types of questions to ask.

Types of Questions

There are 2 types of questions, “background” and “foreground.”2 Background questions usually have 2 components: (1) a question root made up of the basic interrogatives (who, what, when, where, how, why) with a verb and (2) an aspect of the condition or item of interest. Background questions tend to be more general and examine the whole condition, including signs and symptoms. They are pathophysiologic, and their answers are found in textbooks and online library resources. For example, in the wound care field, a background question may be: ”What is a deep tissue injury?”

Foreground questions typically consist of specific clinical decisions and primary/preassessed studies. They are also patient-centered and include the diagnosis, prognosis, and management of the disease. Foreground questions usually have 4 or 5 components and are adaptable to the PICO format:

  • the patient situation, population, or problem of interest
  • the main intervention, defined very broadly, including exposure, a diagnostic test, a prognostic factor, treatment, a patient perception, and so on
  • the clinical outcome(s) of interest, including a time horizon, if applicable

Timeframe A format using the time factor (PICOT)4 may be used. The variable of time (T) is helpful if, for example, you are interested in looking at the effect of an intervention over time, such as wound healing time as an end point.

Evidence-Based Medicine and Advances in Skin & Wound Care

During the journal’s manuscript evaluation and peer-review process, the editors and reviewers sharply focus on whether articles contain important and answerable questions to the practice of wound care. Sequentially, the methods are evaluated by assessing the background (literature review and pilot research) that must be relevant to the question or hypothesis of interest, and the research methodology must be appropriately structured to achieve internal validity, construct validity, statistical conclusion validity, and external validity. The methods must be reproducible and generalizable in supporting a given conclusion. Measurement questions and logistical, administrative issues, such as recruitment of subjects, data collection, and data management, are all considered as a requirement to answer the question.

The hardest part of a research paper is asking the right question. If that’s done in a systematic way, an appropriate solution will develop.

Interrogating and appraising the literature to develop research questions is a team sport. “Developing the research question and study plan is an iterative process that includes consultations with advisors and friends,” stated Cummings.1 A growing familiarity with the burgeoning amount of wound care literature is essential, and using evidence-based frameworks, such as FINER and PICO, creates order and systemization5 to the process.

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REFERENCES

1. Cummings SR, Browner WS, Hulley SB. Conceiving the research question and developing the study plan. In: Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB, eds. Designing Clinical Research. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2013:24-42.
2. Guyatt G, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, IL: American Medical Association; 2002.
3. Stone PW. Popping the (PICO) question in research and evidence-based practice. Appl Nurs Res 2002;15:197-8.
4. Hastings C, Fisher CA. Searching for proof: creating and using an actionable PICO question. Nurs Manage 2014;45(8):9-12.
5. Medical Literature Searching Skills: Literature Searching Skills. http://learntech.physiol.ox.ac.uk/cochrane_tutorial/cochlibd0e84.php. Last accessed May 23, 2017.
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