The process of developing a clinical question is divided into four categories:
The practice of evidence-based veterinary medicine (EBVM) starts with forming a clinical questions. Forming a question that is highly specific, particularly in outcomes is very important in retrieving relevant research.
Forming the PICO by Dr. Dan Fletcher
Dr. Fletcher discusses the importance of writing good clinical questions by referencing the trials and tribulations of the RECOVER initiative, an ambitious endeavor published in 2012 to create Cardiopulmonary resuscitation (CPR) guidelines.
"it is very easy, we've learned, to write bad questions."
PICO allows us to make specific question because it is easy to be distracted:
P – Patient or population for most clinically based questions. You think it would be easy, but it is not. RECOVER we started with dogs and cats with cardiopulmonary arrest seems easy but there are so many factors like what CPA is, how long, did it happen before, etc...
I – Intervention must be specific, like antibiotics is too vague, but specific antibiotics.
C- comparative group, thought needs to go to what you want your control group to be, it does not have to be perfectly healthy animals.
O- Outcome, Dr. Fletcher felt was the area for the most improvement from RECOVER. The outcome needs to be clearly defined which is a big part of focus for RECOVER 2.0, each outcome will have a different evaluation. ROSC, survival to discharge, and survival 30 days after ROSC will each be independently evaluated (or independent PICOs) . You should have a separate PICO for all different outcomes (same PIC and different Os) and re-evaluate.
Studies are not necessarily poorly designed but may not answer the PICO properly, Every paper needs to be read in the context of the PICO question.
GRADE is a very useful tool to help alleviate subjectivity and bias in systematic reviews that will become an important part of RECOVER 2.0.
Librarians are important tools in developing PICOs and developing effective search strategies to find evidence.
Erik mentions a lot of people think comparisons are placebos but that is not necessarily what you want to compare. Dr. Fletcher states that PICOs in the first RECOVER found that many comparators create a more subjective environment. Comparative groups in CPR will never be healthy animals. Unfortunately we pool all of these studies that have unfair comparators and comes to the reality that we have to create multiple questions and address the multiple comparators.
Reducing Overlap and Better PICO Formation
Dr. Pratt mentions that developing PICOs with overlapping information became a challenge. Dr. Fletcher stated that PICO limitations become more obvious when you start reading the papers, the big "bifs" happened with evidence evaluation after the PICOs were formed. Round 2, they are committed to utilizing a different evaluation process, GRADE. Limitations of PICOs often become apparent in the evaluative process. Highly specific PICOs will result in better return of relevant evidence, whereas vague PICOs will slow the researcher down because of extraneous content.
Utilizing Human Medicine to Develop Better PICOs
ILCOR is the human equivalent to the RECOVER initiative that has been utilizing evidence to update CPR guidelines since the 1990s. The RECOVER initiative reached out and learned a great deal from ILCOR. ILCOR suggested the utilization of GRADE criteria and utilization of librarians, who are experts in search strategy, to help develop PICOs.
Be a Splitter, Not a Grouper
It is clear that many specific PICOs are far more valuable than fewer vague ones. Dr. Fletcher points out that whether 100 doctors or one doctor are performing EBVM, the strategy is the same.
● Dan Fletcher, PhD, DVM, DACVECC
● Chap Pratt, DVM, DACVECC
●Erik Fausak, MSLIS, CVT, RLAT