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Evidence-Based Practice Problems: Form and Focus

Article in Journal of the American Psychiatric Nurses Association · September 2010

Impact Factor: 0.98 · DOI: 10.1177/1078390310374990 · Source: PubMed

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Evidence-Based Practice in Psychiatric and Mental Health Nursing

Journal of the American Psychiatric Nurses Association 16(5) 307 –314 © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390310374990 http://japna.sagepub.com

Evidence-Based Practice Problems: Form and Focus

Michael J. Rice1

Abstract

Health care reform poses major challenges for psychiatric mental health care. Foremost among the challenges is a mandate for reimbursement based on performance-based outcomes. Clinicians can increase the efficiency of evidence- based practice searches by using the correct form of PICOT (population, intervention, comparator, outcome, time frame) question to focus the search, based on (a) diagnosis, (b) treatment, (c) prognosis, (d) etiology, (e) prevention, and (f) meaning. The correct form of a PICOT question focuses the literature search by requiring a minimum of sorting to find relevant studies. Quickly and effectively locating the critical evidence will help meet the performance standard mandates required by new health care reform legislation.

Keywords

EBP problems, evidence-based, psychiatric care, PICOT

Health care reform poses major challenges for psychiatric mental health care. Foremost among the challenges is a mandate for reimbursement based on performance-based outcomes. Mandated use of performance-based outcome measures (“Health care reform,” 2010; The Robert Wood Johnson Foundation, 2010) requires that all clinicians become proficient at finding and using evidence-based practice (EBP) reviews and guidelines. Finding and using EBP outcomes is now the statutory basis for the delivery of psychiatric mental health care.

Although the mandate for evidence-based performance is in statute, implementation of evidence-based perfor- mance in psychiatric mental health care is faced with a series of problems. Several areas of psychiatric mental health care are not well defined or studied, such as cogni- tive integration and cognitive disorganization. Problems also exist in that many of the major areas of concern are subjective in nature and not easily studied using estab- lished quantitative methods (Bliss-Holtz, 2007; Rice, 2008b; Sandelowski, 2004).

An even more significant challenge is the need for adequate training and resources to implement the provi- sions mandated by the health care reform legislation (Aaron & Reischauer, 2010). Application of EBP inter- ventions and determination of which interventions are the most effective require the use of new skills by front- line providers (Fineout-Overholt, 2004; Rice, 2008a). Unfortunately, clinicians are often ill prepared to effec- tively frame questions and search the evidence (Fineout- Overholt, 2004; Gray, 2010). Searches for the best

evidence are often hampered by a lack of skill in design- ing a question in a form that focuses the search while minimizing time and effort.

EBP Questions Searches for evidence on EBP problems are frequently built with reference to a patient population\disease state (P), an intervention of interest (I), a comparison group (C), an outcome (O), and a time frame (T), or PICOT question (Fineout-Overholt, Hofstetter, Shell, & Johnston, 2005; Huang, Lin, & Demner-Fushman, 2006; Melnyk & Fineout-Overholt, 2002; Rice, 2008b). Although the architecture of a PICOT question is designed to obtain the best evidence, there is a need to design the PICOT questions correctly for the clinical problem of interest. PICOT questions must be correctly designed to focus the search on the desired evidence. Unfocused EBP questions yield search results that are not relevant and require sort- ing numerous reports to find the few critical studies. The loss of clinician’s time and effort and poorly researched interventions are a direct consequence of a poorly formed PICOT question.

1Michael J. Rice, PhD, APRN, BC, FAAN, University of Nebraska Medical Center, Omaha, NE, USA

Corresponding Author: Michael J. Rice, College of Nursing, 983020 University of Nebraska Medical Center, Omaha, NE 68198, USA Email: mjrice@unmc.edu

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308 Journal of the American Psychiatric Nurses Association 16(5)

Clinicians can increase the efficiency of the EBP searches by developing the PICOT question in a format that focuses search efforts. Effective EBP searches can be developed using two simple steps: (a) identification of the basic type of clinical question for which evidence is sought and (b) forming PCIOT questions in a manner that identifies key words that can be used for an effective search. (Readers should note that the following EBP searches and results are used as examples only! The results should not be used to determine or direct treatment interventions without a more extensive investigation.)

Type of EBP Questions EBP clinical questions address a wide range of topics but are of two basic, distinctly separate kinds: (a) background questions seeking general information on a condition, dis- ease, or population and (b) foreground questions used to make and direct clinical decisions (Gray, 2010; Virgilio, Chiapa, & Palmarozzi, 2007).

Background questions are directed toward obtaining information on the patient’s condition, disease, or status. The background questions are constructed with the pur- pose of identifying who is affected, what happens with an illness, when the problem occurs, where the problem exists, why a problem develops, and who may be affected (Virgilio et al., 2007). Search results on background ques- tions produce general information about populations, con- ditions, tests, or responses (Gray, 2010). The information generated by searches to background questions is educa- tional in nature and provides general information on a dis- ease or condition (Virgilio et al., 2007).

Background questions are often more general (Gray, 2010) and may take a form similar to “What are the gen- der differences in treatment of major depression?” As the question is general, literature searches are based on the following key terms: major depression (P), female (I), compared with male (C), treatment (O). The litera- ture search will produce a related array of results con- taining the key terms. These unfocused general searches may or may not produce literature on a comparison of the effectiveness of specific treatments. A background question that is as general as this example will result in some information on treatment approaches. However, these searches do not provide comprehensive reviews of treatments nor allow for a comparison of intervention effect sizes and should not be used to guide selection of EBP interventions.

The second kind of EBP question is a foreground ques- tion. In contrast to background questions seeking general information, foreground questions seek specific informa- tion on the best type of care (Gray, 2010). Foreground questions are the most commonly used kind EBP question

and direct the search toward detailed information on inter- ventions. The explicit purpose of a foreground question is to seek specific information that can be used to determine use of one treatment intervention or approach over another (Virgilio et al., 2007).

Foreground questions must be developed within a PICOT format to identify the key terms used to direct an effective search. The need to use the PICOT format requires the use of reflection in order to develop specific search terms (Fineout-Overholt et al., 2005). Johnston and Fineout-Overholt (2005) note reflection on the clini- cal situation identifies the key elements of the question used to guide the search. Reflection requires defining the problem as precisely as possible (Bauer, 2007). The level of precision required for defining PICOT questions is similar to the level of precision required to define the aims and purposes of a traditional research question. A lack of reflection on the specific clinical issues results in the formulation of nonspecific foreground questions. Nonspecific foreground questions containing general terms, such as antidepressants, versus selective serotonin reuptake inhibitors, result in unfocused results. Use of nonspecific terms produces a vast amount of information that is time consuming to sort through and examine. Use of more specific terms seeking specific key terms increases the efficiency of the search and produces a smaller amount of information that can be directly applied to the clinical problem.

Form The form of the EBP question is defined by the nature of the clinical concern (Table 1). The different forms of PICOT questions reflect different clinical concerns used to address different issues dependent on patient needs and desired outcomes. Each type of question is in a form that focuses the search to answer a specific clinical question, dependent on the nature of the problem of interest. The EBP literature traditionally sorts problems into one of six forms (Table 1): (a) diagnosis, (b) treatment, (c) prognosis, (d) etiology, (e) prevention, and (f) meaning (Fineout- Overholt et al., 2005; Fineout-Overholt & Johnston, 2005; Huang et al., 2006). The last category “meaning” is identified by Melnyk and Fincout-Overholt (2002), Fineout-Overholt et al. (2005), and Johnston and Fine- out-Overholt (2005) in an effort to incorporate qualitative data. Although much of EBP focuses on quantitative measures and outcomes, the PICOT can be formulated to answer more qualitative issues, such as those that address the meaning of subjective experience and cultural mean- ings (Morse, 2006). There are several examples of the use of subjective EBP practices that address the subjec- tive nature of many psychiatric mental health issues and

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should not be overlooked (Rice, 2008a; Sandelowski, Trimble, Woodard, & Barroso, 2006).

Diagnosis A frequently used type of PICOT question addresses diag- nostic concerns. The health care reform requirement of the use of performance indicators increases demands to use of the most accurate diagnostic algorithms to identify disorders accurately. The range of the PICOT questions on diagnostic interventions can include the accuracy of assessments using different measurement instruments or signs and symptoms associated with an illness. Search results of diagnostic PICOT questions should direct clini- cians toward strategies for accurate identification of cases and screening strategies. One of the critical issues might be on approaches to assessing suicide risk or the level of dementia. Each search should yield results that enhance the accuracy of diagnostic assessments throughout the course of care.

Diagnostic PICOT questions must identify the key search terms used with a population or disease, an assess- ment approach, a comparison, a clinical outcome, and, if applicable, a time frame. In example, the clinical foreground question might begin as, “What is the best instrument to identify major depression on admission?” Reflection on the question recognizes that the gold stan- dard for psychiatric diagnosis is the Structured Clinical Diagnostic Interview (SCID), which takes an hour or two to complete. However, there are several instruments that take far less time, such as the Beck Depression Inventory. A PICOT question could be formed to examine the evi- dence on which instrument provides assessments compa- rable with the SCID. For example, “Is the assessment of Major Depression with the Beck Depression Inventory

comparable with the SCID in accuracy for an intake screening assessment? This form of the question provides the key words for the searches: major depression (P), Beck Depression (I), SCID (C), assessment accuracy (O), and intake assessment (T). This set of search terms focuses the search on only studies comparing the two approaches during an intake assessment. Results of the search indi- cate that the Beck Depression Inventory can be used as a valid fast screen for patients with major depression in a variety of stages of the disease (Furlanetto, Mendlowicz, & Romildo Bueno, 2005; Lowe et al., 2004; Nuevo, Lehtinen, Reyna-Liberato, & Ayuso-Mateos, 2009; Viinamaki et al., 2004).

Treatment Few categories of EBP questions will be more important under health care reform than questions searching for the most effective treatment. The health care reform legisla- tion mandates payment for services based on the treatment performance outcomes. Effective searches for treatment PICOT questions that provide the best performance will become an essential part of any psychiatric mental health position.

Treatment and therapy PICOT questions also require the highest level of sophistication in appraising the litera- ture. These questions focus on searching for the effect size of one treatment intervention compared with the effect size of a second treatment intervention. Determin- ing the effect size of a treatment requires an understand- ing of the various effect size calculations (Rice, 2009) and meta-analytic approaches (Mundy & Stein, 2008). The results of an evidence search on this type of question should provide information on the effect size of each intervention. When the effect sizes are compared, the

Table 1. PICOT Question Form

Question Form P, Patient/Population I, Issue/Intervention C, Comparison O, Outcome T, Time Frame

1. Diagnosis In patients with major depression is

Beck Depression scale

Or Zung Depression scale

More accurate For admission assessment

2. Therapy In patients with schizophrenia

Are atypical antipsychotics

Or typical antipsychotics

More cost- effective

Over 1 year of treatment

3. Prognosis Bipolar patients Atypical antipsychotics

Versus the general population

Increase metabolic syndrome risk

Over the lifespan

4. Etiology Are children With low 5-minute Apgars

Versus normal 5-minute Apgars

At risk for schizophrenia

Within 12 years of life

5. Prevention In recurrent major depression does

Cognitive behavioral therapy

Versus no therapy Reduce relapses Over 1 to 2 years

6. Meaning In patients with schizophrenia, what is the impact

Of social stigma Compared with family impact

On accepting treatment

With first the onset of psychosis

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search information provides statistical information iden- tifying which treatment approach is the most effective (Rice, 2009).

PICOT questions on the effect size for therapy\treat- ments must be specific for the disease, population, and treatment. The treatment specificity is identified in the intervention and comparative elements of the PICOT question. For instance, “In patients with schizophrenia (P), does Haloperidol (I) or Risperdol (C) provide the most overall cost-effective outcome (O) over a time period of years (T).” The search terms from this question should include schizophrenia, Haloperidol, Risperdol, overall cost-effectiveness, and years as part of the search term structure.

The search results provide a series of comparative studies with matched cases. The evidence clearly indi- cates that Risperdol, even with higher initial costs, is more cost-effective than Haldol over a 1-year period of time (Llorca et al., 2005; Obradovic, Mrhar, & Kos, 2007). The search results further indicate that when used over long periods of time, intramuscular Risperdol results in the most overall cost-effective treatment over an extended period of time for those with schizophrenia (De Graeve et al., 2005; Edwards, Locklear, Rupnow, & Diamond, 2005; Lindner, Marasciulo, Farias, & Grohs, 2009). Although there is still a need to examine how cost-effec- tiveness is defined, the evidence-based search provides a clear indication as to the most cost-effective intervention.

Prognosis Prognostic questions are questions that psychiatric mental health clinicians should be increasingly concerned about. Evidence-based questions on prognosis search for two major dimensions: (a) anticipated outcomes of an illness and (b) prognostic health indicators associated with the outcome. Although evidence on many prognostic indi- cators associated with the serious mental illness, such as schizophrenia and bipolar disorder, is currently being examined (Galderisi, Mucci, Volpe, & Boutros, 2009; Goikolea et al., 2007; Lucas, Redoblado-Hodge, Shores, Brennan, & Harris, 2008; Patel, Young, Samele, Taylor, & David, 2004; Pavics et al., 2004; Rafrafi et al., 2009), there is also ample evidence on the prognostic indicators of the more common mental illnesses, such as anorexia (Howard, Evans, Quintero-Howard, Bowers, & Andersen, 1999), panic disorders (Dow et al., 2007), and psychologi- cal trauma (Murphy, Morrel, Elliott, & Neavins, 2003).

One of the key issues to consider when writing a prog- nostic EBP question is consideration of the key terms used to define the treatment conditions affecting long-term outcomes. When investigating the issue of metabolic syn- drome, the prognostic question arises, “What is outcome

of those with bipolar disorder using atypical antipsychotics compared with normal populations over their lifetime?” The question forms the PICOT question identifying the key search terms of: bipolar patients (P), receiving atypi- cal antipsychotics (I), compared with the normal popula- tion (C), differences in outcomes (O), over time (T). The search results indicate a variety of different outcomes, such as metabolic syndrome affecting the lifespan of those with bipolar disorder. The evidence indicates that patients with bipolar disorder have metabolic states simi- lar to the normal population that are 10 to 15 years older (Bobes et al., 2007; Sicras-Mainar, Blanca-Tamayo, Rejas- Gutierrez, & Navarro-Artieda, 2008). The data indicate that the prognosis for cardiovascular risks increases for patients with bipolar disorder receiving atypical antipsy- chotics (Bobes et al., 2007; Fiedorowicz, Palagummi, Forman-Hoffman, Miller, & Haynes, 2008). There is lit- tle doubt that the long-term treatment outcomes will be scrutinized under the longitudinal performance demands of health care reform.

Etiology Health care reform legislation encourages the use of exist- ing evidence in identifying the early risk factors for an ill- ness. Unfortunately, one of the weakest sets of evidence in psychiatric mental health care is on the etiology, or origin, of mental illnesses. Investigations on the etiology of many mental health disorders, such as schizophrenia and bipo- lar disorder, are in the early stages of investigation. There are also questions on how some evidence, such as genetic contributions to mental illness, can be applied to identify- ing the risk of the disorder. Although genetic contribution to increased risk is well established, there is consensus that the etiology of mental illness may be the result of an interaction of multiple factors, including stress and genet- ics (Medina, 2010).

Writing an EBP question on the causes of mental health requires knowledge of some of the existing science on the topic. The etiology questions can still be written using the standardized PICOT format to identify the essential key terms (Fineout-Overholt et al., 2005). When examining posttraumatic stress disorder (PTSD), the question identi- fying the key terms might look like: “Are military veterans (P) with childhood trauma (I) compared with those without childhood trauma (C) at higher risk for PTSD (O) after dis- charge (T)? The key search terms with childhood trauma and without childhood trauma become the terms that focus the search results. Current evidence indicates that veterans who had early traumatic experiences are at a greater risk for developing PTSD than those without (Clancy et al., 2006; Dedert et al., 2009; Lapp et al., 2005; Orcutt, King, & King, 2003). This evidence helps providers develop risk

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assessments and interventions that may be used to target interventions and reduce the personal and financial costs of a debilitating condition.

Prevention One of the major emphases of health care reform is the prevention of disease. This general principle also applies to preventing mental illness. There are a limited number of prevention studies in psychiatric care because of the limited evidence on the etiology of psychiatric disorders. Yet there is existing evidence on preventing mental illness that is often overlooked. Using the best evidence available will be an arguable basis for performance outcomes and reimbursement under the new legislation. This means cli- nicians should be familiar with finding the evidence on prevention.

Searching for evidence on the prevention of mental illness requires reflection on the population and prob- lem. Interest in maternal depression associated with pre- mature delivery, relapse of depression, and PTSD are a few of the mental illnesses where there is empirical evi- dence on prevention. Searching for the evidence again requires appropriate levels of reflection and forming the search question using the PICTO format to define the key terms. For example, “In women with recurrent depression (P) can Cognitive Behavioral Therapy (CBT) compared with no intervention (C) prevent relapse (O) over 1 to 2 years?” In this instance, the key terms address a specific intervention to prevent relapse. The terms used in this case looks at preventing a recurrence of the symp- toms of the mental illness.

This EBP search on this topic indicates that there is a significant amount of evidence available on prevention of depression. The evidence is so strong that there are enough to form a meta-analysis and examine the effect size from randomized control trials. The evidence indicates that CBT is a very effective intervention to prevent depression relapse (Blier et al., 2007; Cuijpers, Van Straten, & Smit, 2005; Fava et al., 2004; Kornor et al., 2008) and should be used to control the costs associated with mental illness.

Meaning Many of the areas associated with psychiatric disorders, such as stigma, can not be quantified (Rice, 2008). Yet these areas define an essential part of the human psycho- logical experience intertwined with mental health and treatment. Additional subjective states, such as the psy- chological meaning of having a sense of purpose, vulner- ability, suffering, and stigma, directly affect the cognitive frame of reference through which a client might perceive the world (Rice, 2008c).

Qualitative data on EBP mental health questions is quite limited in part because of the emphasis on quantita- tive studies and RCT’s (Morse, 2006; Sandelowski, 2004). Although there is a dearth of meta-summaries of qualita- tive data, the use of integrative interpretation can be used to direct care, dependent on the scientific rigor of the stud- ies (Sandelowski, Barroso, & Voils, 2007). Using the cor- rect form of the PICOT question to identify the key terms is applicable even with qualitative data. An example might be, “In patients with schizophrenia (P), what effect does stigma (I) compared with family perceptions of stigma (C) have on seeking treatment during the acute phases (T)?” Again, the use of the correct form of the PICOT question identifies key terms that can be used to focus and direct the search.

The existing evidence on the meaning of stigma indi- cates that patients suffering from schizophrenia often avoid treatment not because of symptom severity but because of the social stigma about mental illness that trag- ically results in an increase in the severity of the symp- toms (Lyons, Hopley, & Horrocks, 2009; Venhaus, 2010). The evidence also indicates families are not immune from delaying treatment because of the social stigma (Franz et al., 2010; Gerson et al., 2009). The data indicate that there is a need for educational interventions that are directed toward altering the meaning of mental illness and reducing social stigma and the resulting consequences (Lyons et al., 2009; Venhaus, 2010).

Conclusion The advent of health care reform increases the emphasis on the use of EBPs to meet the performance outcomes mandated by the legislation. All clinicians will be required to use EBP in order to meet the performance standards required for obtain reimbursement under the new laws. Searching for the best evidence must be done quickly and efficiently. Efficient searches require an ability to use EBP questions accurately in order to focus the results.

Clinicians can increase the efficiency of EBP searches using the correct form of PICOT question to focus the search results on: (a) diagnosis, (b) treatment, (c) prognosis, (d) eti- ology, (e) prevention, and (f) meaning (Fineout-Overholt et al., 2005; Fineout-Overholt & Johnston, 2005; Huang et al., 2006). When structured and focused correctly, the EBP PICOT question can direct clinicians to evidence requiring a minimum of sorting in order to find relevant studies. Effec- tive use of clearly constructed PICOT questions will meet the new mandates required by health care reform.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

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312 Journal of the American Psychiatric Nurses Association 16(5)

Funding

The authors received no financial support for the research and/or authorship of this article.

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