Chapter 9Posing an evidence-based practice question using PICO or SPICE

Alan Glasper and Colin Rees

Sue and Sam have been asked to pose an EBP question

I’m really worried about

this!

now isn’t it all beginning to make sense

How to Write Your Nursing Dissertation, First Edition. Alan Glasper and Colin Rees.© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.

Sue and Sam struggle to develop an answerable question.

Why evidence based practice?• 1747 – first experiment

demonstrates that lemon juice can prevent scurvy

• 1790s – experiment repeated

• 1795 – becomes Royal Navy policy

• 48 year gap between knowledge and practice

• Evidence-based practice aims to link what is known with what clinicians do

Limeys or Rosie’s • Why the English are called Limeys?

• It would have been logical to have nick named the English Lemonies after their conquest of scurvy. However by the mid nineteenth century the British government thought fit to spend its resources on West Indian Limes believing the fruit to be every similar to lemons rather than by Mediterranean lemons. Tragically the amount of vitamin C in limes is significantly less than lemons and scurvy returned to haunt the Royal Navy. Although the North Americans still refer to the British as Limeys, had a true randomised controlled trial have been conducted, they would in all probability now be called Rosie’s. WHY?

• Rose hips contain vast amounts of vitamin C and are freely available in the British country side!

What is evidence-based practice?Evidence-based health care is the integration of

• individual clinical expertise

with the

• best available external clinical evidence from systematic research

and

• patient’s values and expectations

Straus, S. (2005) Evidence-based medicine. How to practise and teach EBM Edinburgh: Churchill Livingstone

What is evidence?Hierarchy of research evidence

1. Systematic reviews

2. Randomised controlled trials

3. Non-randomised controlled trials

e.g. cohort studies, case-control studies

4. Consensus statements from respected authorities

5. Individual/expert knowledge

6. Anecdotal evidence – “a guy in the pub told me”What about grey

literature?

Finding the evidence

Ask focussed, answerable questions

NOT

Are febrile seizures in babies dangerous?

Finding the evidence

INSTEAD

Does a febrile seizure in a 6-month old infant increase the likelihood that s/he will develop epilepsy?

Finding the evidence

Use the PICO framework:

P – patient/problem

I – intervention

C – comparison

O - outcome

P= any population e.g. • Population of ?

• Disease or condition

• Stage of disease

• Gender

• Age group

• Socioeconomic group

• Healthcare setting

I= Intervention/What is being done?e.g.

• Drug therapy, surgery, radiotherapy

• Level of intervention: frequency, dosage

• Stage of intervention: prevention, secondary or prevention; advanced

• Delivery of intervention: self-medication etc.

C=Comparison• E.g. What could be done instead?

N.B. Sometimes in a PICO question there will be no comparison

O=Outcome• What happened to the Population being studied as

a result of the intervention (I) ?

? Patient oriented: quality of life; reduction in severity of symptoms; adverse effects etc.

? NHS Provider oriented: cost-effectiveness, reduction in levels of trained staff etc.

Is acupuncture effective in inducing labour?

P = Pregnant women >40 weeks, age?

I = Acupuncture: duration of treatment, frequency etc

C = No intervention

O = + - onset of labour?- adverse effects?

A biblical exampleThe first recorded clinical trial which features in the Old Testament which

clearly shows an allocation of children to a dietary group, one group eating the royal foods and wine of the King Nebuchadnezzar namely meat and the other a vegetarian diet in the form of pulses with water only. The aim of this trial was to ascertain differences in “countenance”. (Usually referring to appearance, but especially related to the face and how it is perceived by onlookers)

• Population = Israeli children and Israeli children from the royal families. (N= unknown) who were blemish free, wise, able to learn a language and with an understanding of science ( importantly gender was not stated! )

• Intervention = A new diet consisting of the Kings meat (not stated but? lamb, chicken or possibly goat or even camel) and wine (this is not stipulated but was it red or white, what was the grape variety, was it grown on south facing vineyards and importantly what percentage of alcohol did it contain and how much did they drink—was it more than 28 units per week?

• Comparison = 4 children including Daniel who had a diet of pulses (not

stated in the old testament but it may have been broad beans or perhaps Fava beans) and water (not stated in the old testament but was it still or sparkling or just well water?)

• Outcome = countenance. (Is this a valid measure of health and how is it measured?)

Exercise or antidepressants for depression?

P= Depressive patients: severity? Socioeconomic factors; in a healthcare setting? (type e.g. inpatient unit)

I= Exercise: type? how strenuous? How often?

C= Antidepressants: type? Dose? Frequency? Duration?

O= + Cure? Symptom reduction? Quality of life? or - Adverse effects

Antibiotics for middle ear infectionP = Acute otitis media; pre-school; socioeconomic

factors?

I = Antibiotics: which antibiotic? Dose? Frequency? How administered?

C = No intervention

O = + spontaneous remission? -Adverse effects? Mastoiditis?Cost effectiveness

What is the SPICE model? The use of the mnemonic SPICE. The SPICE model framework

has five components which students not posing a specific clinical question might find helpful. This mnemonic is structured as:

• Setting. (Where and what is context?)

• Perspective. (For whom? who are users /potential users of service?)

• Intervention. (What is being done to them/for them?)

• Comparison. (Compared with what. What are alternatives?)

• Evaluation. (With what result and how will you measure whether the intervention will succeed?)

The SPICE modelAlthough the SPICE structure is similar to that of

PICO, Booth (2009) points out that by separating the traditional medical type population aspect of the PICO model into firstly a setting and secondly a perspective that this enables SPICE to be used for posing non medical type questions i.e. more of a social scientific approach. Similarly by substituting the term outcome with the term evaluation the SPICE model of posing a question facilitates other elements of research which are broader and incorporate concepts such as outputs or impacts.

Example of a SPICE formulated questionHow does it feel to wait for your relative (child, spouse/partner or parent) to return to the ward after emergency surgery and await the results?

Setting: Hospital surgical wards

Perspective: Relatives of patients requiring emergency surgery.

Intervention: Dedicated waiting area with refreshments and tangible levels of distraction such as flat screen televisions or contemporary topical magazines.

Comparison: no special area or levels of distraction

Evaluation: by questionnaire given to relative when leaving the hospital or on return home.

USING THE SPICE MODELAccess The Belgian Health Care Knowledge Centre

(KCE).on http://www.kce.fgov.be/index_en.aspx?SGREF=5225

And investigate the various research questions hosted there using the SPICE model

Finding the evidenceWhere is the evidence?

• New generation EBP resources

– E.g. the Cochrane Library, Clinical Evidence, TRiP Plus, Bandolier

– EBP pages: University data bases • Large scale, traditional databases

– E.g. Medline, Embase– Is Google scholar any good?– What about the internet?

The EBP cycleIdentify/define the problem

Formulate a focused clinical question

Identify the appropriate resources

Search for valid and relevant information

Critically appraise/review this information using a tool

Implement in practice-AND THEN

Clinical audit ...FOR COMPLIANCE

Sam Gets to Grips With PICO

and Sue has decided to use the SPICE

model