Utilization of the PICO framework to improve searching PubMed for clinical questions

Supporting 21st century health care and the practice of evidence-based medicine (EBM) requires ubiquitous access to clinical information and to knowledge-based resources to answer clinical questions. Many questions go unanswered, however, due to lack of skills in formulating questions, crafting effective search strategies, and accessing databases to identify best levels of evidence.
Practicing evidence-based medicine (EBM) requires integration of clinical experience, the best available research evidence, and the values and preferences of the patient into the clinical decision-making process [1]. The steps in practicing EBM are centered on the patient and involve asking well-focused questions, searching for the best available evidence, appraising that evidence for validity, and then applying the results to the care of the patient. Supporting 21st century health care and the practice of EBM requires ubiquitous access to clinical information and to knowledge-based resources. Clinicians and educators currently utilize a variety of resources and interfaces to search the biomedical literature to answer clinical questions. PubMed is a service of the U.S. National Library of Medicine (NLM) that provides access to over 16 million citations from MEDLINE and other life science journals dating back to the 1950s [2]. Since 1997, PubMed has been freely available to physicians, researchers, and the public. The information obtained from literature searches in PubMed can have a significant impact on patient care and clinical outcomes. Crowley et al reported on a study of 625 clinical questions asked by residents during an in-hospital general medicine rotation. Seventy-seven percent of the answers to these questions came from MEDLINE and the information from the articles changed patient management 47% of the time [3]. Klein et al. showed that conducting a MEDLINE search early in the hospitalization of a patient could significantly lower costs, charges, and lengths of stay [4]. Westbrook et al reported that the use of an online information retrieval system improved the quality of clinicians' answers to clinical questions by 21% [5]. The literature also reports that many clinical questions go unanswered due to difficulties formulating a relevant question [6], forgetting the question [7], lack of access to information resources, and lack of skills in searching [8].
Formulating a well-focused question is the first and arguably the most important step in the EBM process. Without a well-focused question, it can be very difficult and time consuming to identify appropriate resources and search for relevant evidence. Practitioners of EBM often use a specialized framework, called PICO, to form the question and facilitate the literature search. PICO stands for Patient problem, Intervention, Comparison, and Outcome. [9] The PICO framework can be expanded to PICOTT, adding information about the Type of question being asked (therapy, diagnosis, prognosis, harm, etc.) and the best Type of study design for that particular question. Using this framework helps the clinician articulate the important parts of the clinical question most applicable to the patient and facilitates the searching process by identifying the key concepts for an effective search strategy. [10,11]
PubMed includes a feature called Clinical Queries, which helps identify citations with appropriate study design by linking the type of question (therapy, diagnosis, etiology and prognosis) to a stored search strategy that retrieves the appropriate research methodology. The Clinical Queries are based on extensive research by the Hedges Study Team at McMaster University [12] and have been shown to improve searching results. Combining the PICO framework with the PubMed Clinical Queries has the potential to improve the efficiency of literature searching. Bergus et al reported that questions with at least a defined intervention (I) and outcome (O) were more likely to be answered than questions with one or none of these parameters [13]. The objectives of this pilot study were to measure the relevancy or precision of PubMed search results when using a PICO search framework, to test feasibility of the study design and to identify possible trends.
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