DEVELOPMENT OF A PICO QUESTION 2
Research Proposal: Development of a PICO Question
Every year, hospitals struggle with continued growth in the number of patients evaluated
and treated in their emergency departments (Schoolmeester & Keiser, 2023). With overcrowding
increasing and hospitals focusing more on value-based care as a quality care indicator
(Bilazarian et al., 2021), it is important to identify and understand problems affecting an
emergency department’s return on investment. One patient population that depletes both the
financial and physical resources of an emergency department is that of high-need, high-cost
patients. High-need, high-cost (HNHC) patients are identified as those seeking repetitive medical
care more than 9 times within a 12-month (Schoolmeester & Keiser, 2023).
Significance of the Problem
Emergency departments lose millions of dollars in unpaid healthcare costs each year due
to visits by this group of patients. Additionally, the strain of caring for these repeat consumers
leads to decreased quality of care for all consumers and reduces the department's efficiency
(Powers & Modarai, 2020). With more payors turning away from fee-for-service reimbursement
and favoring a value-based care payment system, healthcare organizations feel pressure to
prevent repeat visits and admissions (Berkman et al., 2021).
Research indicates that clinicians must gain the trust of their patients to create a
relationship that provides more effective behavior change. Ineffective follow-up care and poor
case management have been identified as causes of readmission (Chang et al., 2021). Nurses
must evaluate and understand the root cause of the need for these patients, taking time to actively
listen and show compassion to make a difference in their lives (King James Bible, 1769/2024,
James 1:19, Jude 22). This example should come from the top down, beginning at the highest
level of leadership, understanding that humble, servant leadership (King James Bible,
DEVELOPMENT OF A PICO QUESTION 3
1769/2024, Philippians 2:3-9) will positively impact both clinician and consumer. While the
intervention to aid HNHC patients in obtaining the thorough care needed will require a multi-
disciplinary approach, nursing leaders in the emergency department will play an important role
in creating, evaluating, and managing this patient-centered approach.
Clinical Question
Once a gap in clinical practice is identified, it is essential to formulate a question to guide
nursing research (Gray & Grove, 2020). In this project, a patient, intervention, comparison, and
outcome (PICO) question will be written to guide the development of this research proposal. The
writing of a PICO question is a common practice in evidence-based practice and is used to
narrow a research project to an appropriate level (Schiavenato & Chu, 2021). After using PICO
to narrow the scope of the study, the researcher should determine if that identified question is a
priority at that time. This ensures that resources are allocated most effectively to further the
organization’s stated mission and values. If this does not occur, it is unlikely that the researcher
will obtain the support and resources needed to complete the study and implement findings into
clinical practice (Buckwalter et al., 2017).
PICO Question Development
When developing a PICO question for this research proposal, it is important to identify
key words relating to HNHC patients and their effect on the emergency department. After
reading available scholarly resources, consideration should be given to what the researcher
believes contributes to the problem. In this case, the intervention should be patient-centered and
attempt to identify the root causes of repeated visits (Berkman et al., 2021). Key words identified
for this proposal include: emergency department, overcrowding, resources, unreimbursed care,
case management, high-need, high-cost, and chronic disease.
DEVELOPMENT OF A PICO QUESTION 4
After identifying the problem of HNHC patients creating a strain on emergency
department resources resulting from an increased number of unnecessary visits and causing an
increase in unreimbursed care, the researcher determined it was a high-priority concern for their
organization. The suggested intervention is creating a robust case management program that uses
a multi-disciplinary approach to identify patients with increased healthcare needs and provide the
necessary education and resources to fulfill their medical needs. The comparison situation would
be the current state of not having a program or resources available to these patients and
continuing with the status quo of general emergency triage, evaluation, and management during
a single visit to the emergency department. The desired outcome is to decrease the number of
unnecessary emergency department visits, reducing the amount of unreimbursed medical care.
The following PICO question has been formulated to guide this research proposal. In high-need,
high-cost patients presenting to the emergency department routinely for care, does an aggressive
case management program, compared to no additional resources provided, decrease the number
of unnecessary visits and reduce the amount of unreimbursed dollars?
Conclusion
High-need, high-cost patients routinely overwhelm and burden an already taxed
emergency department (Schoolmeester & Keiser, 2023). Many times, these visits result from a
consumer’s chronic illness and inability to find follow-up care in a timely manner. Additionally,
these patients often have difficulty finding the specialized care needed to manage their
conditions and are often uneducated on the best way to manage them (Berkman et al., 2021). It is
important to identify those patients needing this additional help and provide the education and
resources necessary to improve their quality of life by not needing recurrent visits to the
emergency department. Research is necessary to determine if a robust, multi-disciplinary case
DEVELOPMENT OF A PICO QUESTION 6
References
Berkman, N. D., Chang, E., Seibert, J., Ali, R., Porterfield, D., Jiang, L., Wines, R., Rains, C., &
Viswanathan, M. (2021). Management of high-need, high-cost patients: A "best fit"
framework synthesis, realist review, and systematic review (AHRQ Publication No.
21(22)-EHC028). Agency for Healthcare Research and Quality.
https://effectivehealthcare.ahrq.gov/products/high-utilizers-health-care/research
Bilazarian, A., Hovsepian, V., Kueakomoldej, S., & Poghosyan, L. (2021). A systematic review
of primary care and payment models on emergency department use in patients classified
as high need, high cost. Journal of Emergency Nursing, 47(5), 761–777.e3.
https://doi.org/10.1016/j.jen.2021.01.012
Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A., Rakel, B., Steelman, V.,
Tripp‐Reimer, T., & Tucker, S. (2017). Iowa model of evidence‐based practice:
Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175–182.
https://doi.org/10.1111/wvn.12223
Chang, E. T., Asch, S. M., Eng, J., Gutierrez, F., Denietolis, A., & Atkins, D. (2021). What is the
return on investment of caring for complex high-need, high-cost patients? Journal of
General Internal Medicine, 36(11), 3541–3544. https://doi.org/10.1007/s11606-021-
07110-y
Gray, J. R., & Grove, S. K. (2020). Burns and Grove's the practice of nursing research:
Appraisal, synthesis, and generation of evidence (9th ed.). Elsevier.
King James Bible. (2024). King James Bible Online. https://www.kingjamesbibleonline.org/
(Original work published 1769)
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Powers, B. W., & Modarai, F. (2020). Impact of complex care management on spending and
utilization for high-need, high-cost Medicaid patients. The American Journal of Managed
Care, 26(2), e57–e63. https://doi.org/10.37765/ajmc.2020.42402
Schiavenato, M., & Chu, F. (2021). PICO: What it is and what it is not. Nurse Education in
Practice, 56, 103194. https://doi.org/10.1016/j.nepr.2021.103194
Schoolmeester, A., & Keiser, M. (2023). Use of care guides to reduce emergency department
visits by high-frequency utilizers. Journal of Emergency Nursing, 49(6), 863–869.
https://doi.org/10.1016/j.jen.2023.07.007
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