Evidence-Based Medicine

Background questions are those that may be best answered by information found in textbooks or narrative review articles in journals. Example: "What are the complications of gastroesophageal reflux?"

Foreground questions ask for specific knowledge to help make informed clinical decisions and usually concern a specific patient or population. They tend to be more specific and complex compared to background questions. These types of questions often investigate comparisons such as two drugs, two treatments, two diagnostic tests etc...

Example: In patients with primary hypertension, are beta-blockers more effective than other antihypertensive drugs for reducing myocardial infarction mortality?

The acronym PICO is the most common concept used as a bridge between a clinical question and a search strategy, and can be used to build a clinical foreground question. PICO stands for:

Patient/Population/Problem
Intervention, Prognostic Factor, Exposure
Comparison (optional)
Outcome

Example:
A 62-year-old patient's PSA blood test returned with a Level 4 reading. This falls within the normal range for the patient's age; however, the patient heard on the news that a PSA test misses 82% of tumors in men under the age of 60 and is concerned about the accuracy of the test.

P - Male patients over 60
I - PSA test (or prostate specific antigen)
C - None (the question is not looking at a comparison)
O - Accurate tool for diagnosing prostate cancer

Clinical Question: In male patients over 60 years old (P), is the PSA test (I) an accurate tool for diagnosing prostate cancer (O)?

In addition to PICO, there are other acronyms used to develop clinical questions, depending on the study's purpose. For instance, PICOT adds 'Time' to the equation and PICOTT adds Type of Question and Type of Study.

Point of Care vs. Comprehensive Research Resources

Point of care resources are typically secondary/background filtered resources that are used at the bedside to provide quick overviews of a topic and seminal research. More comprehensive searches typically use databases to retrieve unfiltered content.

Review the evidence for validity and applicability to your patient. Tools that guide critical appraisal:

AGREE II (Appraisal of Guidelines for Research and Evaluation II) Reporting Checklist
BMJ Best Practice EBM Toolkit
Centre for Evidence-Based Medicine EBM Tools
JAMAevidence Worksheets (requires personal profile sign-in)

Clinical Calculators

ClinicalKey (select the 'Calculators' link on the ClinicalKey landing page)
DynaMed
JAMAevidence
UpToDate

Step 4 - APPLY: Relate the Evidence to the Patient
Based on the critical appraisal, apply the best evidence to your patient. Remember to ensure that the evidence and recommendations incorporate patient values and preferences.

Step 5 - ASSESS: Evaluate the Outcome

Reflect on the result of incorporating your clinical expertise, the best evidence, and the patient's values and preferences into improving your patient's outcome. Self-evaluate and determine if further evidence is needed or how you could improve your process in the future.