Mapping real life clinical questions to guideline PICOs

Authors: Van de Velde S, Brandt L, Leysen P, Kristiansen A, Vandvik P


Physicians ask and seek answer for many questions during a normal workday. Previous literature and research have found it useful to conceptually divide these questions into foreground and background questions (1). Forground questions deal with options and actions in a specific situation, while background questions deal with questions about etiology, prognosis and knowledge about a specific conditiion or situation.

From yet other studies we have learned that few physicians’ clinical questions followed the recommended PICO structure for EBP (2). Current methodology for the production of trustworthy guidelines (eg. GRADE) base themselves on structured questions like the PICO format to be underlying every recommendation made.

If the questions physicians want answers for do not fit with the advices given in these guidelines dissemination and uptake of guidelines may very well fail.

Looking at this in a practical manner, we theorize that although clinicians do not think in terms of PICO questions themselves, it might be that a PICO structured clinical question made by a guideline panel nevertheless could give clinicians answers they are looking for. We therefore believe that instead of purely looking at the question asked by the clinician, as previous studies have done, it is useful to look at what answer the question would require. In the setting of guidelines this would require a question to be answered with a recommendation or another component in the guideline structure.


To explore how well questions asked by clinicians during a normal workday could fit into a PICO structure made by a guideline panel. We further want to explore:

  1. if there is a difference between the foreground and background questions in terms of their possibility to be made into a PICO question.
  2. in the cases where the PICO question framework cannot be used, are there more suitable frameworks (eg. PESICO, COPES, ECLIPSE, SPICE).
  3. which part of a guideline will give an answer to the various questions


We have a set of 365 clinical questions collected from Belgian physicians in 2003 by Van Duppen et al (3). The two main researchers (SvdV, LB) will independently take this set and:

  1. Classify the Questions as foreground and background questions
  2. Find a suitable PICO questions that match the questions possible answer
  3. In cases where that is not possible, try to make it fit with the PESICO, COPES, ECLIPSE, SPICE – framework
  4. Specify what part of an guideline that would ideally answer the various questions.

For part (4) we will use the framework of multi layered guidelines developed through the DECIDE project (4), as that provides a well-structured model of guideline content.

After going through the material independently the two researchers met to compare the results. The goal was through comparing and discussion to produce one list of results they could both agree upon. In cases they did not agree, they clearly stated so. The meeting was overseen by a third party (PL), to ensure it’s validity


  1. Ely………1999/1991?
  2. Huang, X., Lin, J. & Demner-Fushman, D. (2006). Evaluation of PICO as a knowledge representation for clinical questions. In Proceeding of the 2006 Annual Symposium of the American Medical Informatics Association (AMIA 2006), pp. 359-363, Washington, D.C.
  3. Online on-the-spot searching increases use of evidence during consultations in family practice Dirk Van Duppen, Bert Aertgeerts, Karin Hannes, Jasna Neirinckx, Lieve Seuntjens, Filip Goossens, Annelies Van Linden Patient Education and Counseling – September 2007 (Vol. 68, Issue 1, Pages 61-65, DOI: 10.1016/j.pec.2007.04.008)
  4. Treweek S, Oxman AO, Alderson P, Bossuyt P, Davoli M, Flottorp S, Harbour R, Hill S, Liberati A, Liira H, Schünemann HJ, Rosenbaum S, Thornton J, Vandvik PO, Alonso-Coello P and the DECIDE Consortium. Title: Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence (DECIDE): Protocol and preliminary results. Implementation Science. 2013,8, Early Online January 2013