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Evidence Based Practice: 5 A's

This guide provides a step-by-step overview of the EBP process along with resources for each step of the process

The essential first step in EBP

ASK is the essential first step of EBP. 

Developing an answerable clinical research question can help to:

  1. Determine the essential elements of the question (Patient/Population/Problem, Intervention, Control, Outcome)
  2. Differentiate between background and foreground information needs; Identify gaps in knowledge
  3. Assist to develop synonyms for a comprehensive search
  4. Develop a structured search string 
  5. Determine the domain of the question (therapy/treatment, prevention, diagnosis, prognosis, etiology, meaning)

Background vs. Foreground Questions

Background questions: 

Are there elements of the question which require basic (background) research? Is there a gap in the clinician's/researcher's knowledge about specific elements of the question? 

  • What additional information does the clinician/researcher require to better understand the patient/population or problem? 
  • What additional information does the clinician/researcher require to better understand the intervention proposed? 
  • What additional information does the clinician/researcher require to better understand the control variable proposed? 
  • What additional information does the clinician/researcher require to better understand the desired outcome? 

Background questions are typically answered with textbooks, reference texts, summary/review articles, and point-of-care tools.

Background question example: 

Asian-American adult female with type 2 diabetes mellitus requests alternatives to insulin treatment. 

  • What is type 2 diabetes mellitus?
  • Is type 2 diabetes mellitus prevalent in the Asian-American community? 
  • What is the standard of treatment for adult women with type 2 diabetes?
  • What should be known about insulin treatments? 
  • What are the effects of untreated type 2 diabetes mellitus?

Foreground question: 

Foreground questions combine predetermined elements of the clinical problem to acquire specific knowledge. They are more complex and specific than background questions. 

Foreground questions combine the Patient/Population/Problem and the Intervention and the Control treatment and the desired Outcome into a PICO format. 

PICO format

PICO Elements Considerations
P Patient/Population/Problem Demographics, Problem type, Diagnosis
I Intervention/Exposure Therapeutic, preventative, diagnostic, time, exposure
C  Control/Comparison Placebo, Standard of care, Preventative measure, Not applicable
O  Outcome Measure Mortality rate, Measure of test, Rate of disease progression, Resolution

When forming your questions using PICO, consider: 

  • Demographic variables can include: age, gender, ethnicity, socioeconomic status in addition to health issue.
  • Comparison is not required
  • Outcomes measure a positive impact on the patient/population's wellbeing and should be measurable. Use validated instruments and assessments when possible.
  • Using the PICO format to develop a searchable & answerable question will provide the elements needed to obtain the best evidence from rigorous studies with statistically relevant findings. 

Question Domain/Type of Evidence

Question Domain

Patient/Population/

Problem

 Intervention Control Outcome Measure Level of Evidence

Therapeutic/

Treatment

 Disease or condition Therapeutic measures: Exercise, medication, surgical, life style change Standard of care, additional intervention, placebo, no control Measurable improvement in impairment/disease factors Randomized Control Trial (RCT)
Prevention Risk factors, Medical history Preventative measures Alternative preventative measures or no control Measurable improvement in impairment/disease factors RCT or Prospective study
Diagnosis Specific disease or condition Diagnostic test or procedure Standard of care  Measurable results of test/procedure utility/sensitivity/odds ratio RCT or Cohort Study
Prognosis Duration & sensitivity of main prognostic factor or clinical problem Typically time related Typically not applicable Mortality rates or rates of disease progression Cohort Study and/or Case-Control Series
Etiology Risk factors, health disorders, medical history Strength/dose/duration of intervention or exposure (risk factor) of interest Typically not applicable Mortality rates or rates of disease progression Cohort Study

Source: https://canberra.libguides.com/c.php?g=599346&p=4149722

PICO Format Worksheet

I. Determine Clinical Question Elements

PICO Question Elements Your PICO Elements                                                                  

P: Patient/Population/Problem

The most important element of this component

e.g. Diagnosis/disease/condition, age group, gender

  

I: Intervention/Prognostic factor/Exposure/Treatment

  

C: Comparison (if applicable)

e.g. Placebo, standard protocol, no treatment, alternative options

  

O: Outcome (measurable)

e.g. Reduce mortality/morbidity, improved symptoms, accurate/timely diagnosis

  
Your answerable & searchable clinical question:   

II. Match Question Domain with Study Type

Question Domain

  • Therapeutic/Treatment
  • Prevention
  • Diagnosis
  • Prognosis
  • Etiology/Harm

Type of Study

  • RCT
  • RCT, Cohort Study, Prospective
  • RCT, Prospective
  • Cohort Study, Case Control Series
  • RCT, Cohort Study, Case Control Series
Refer to the Evidence Pyramid: Meta-analyses & Systematic reviews will provide the best answers to clinical questions

III. Search strategy development

PICO Primary PICO Elements/Search terms Synonym(s)       MeSh term     
P      
I      
C      
O      

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