The Effective Health Care Program Stakeholder Guide

Appendix C. Research Questions and PICO(TS)

Systematic reviews are a type of research review that synthesizes the available scientific evidence on the comparative effectiveness, benefits, and harms for a variety of diagnostic, treatment, and health care delivery decisions. They provide syntheses of relevant evidence to inform real-world health care decisions for consumers, clinicians, and policymakers.

Systematic reviews are designed to answer a set of questions. The questions may be about how different tests or treatments work, or how they compare with one another. These Key Questions direct the researchers on what to look for in the evidence. Key questions help to ensure that the research stays focused on the findings that consumers, clinicians, and health care policymakers need to make good decisions.

For example, investigators studying the evidence about different treatments available for people with acid reflux disease will engage a team of patients, clinical experts, researchers, and others to think through the important issues for people with this condition. The team then develops a list of questions that are most relevant to consumers, clinicians, and policymakers. They will make sure the questions reflect as many of the available treatments for acid reflux disease as possible, the benefits of these treatments for different groups of people, and the possible side effects of each treatment for different groups of people.

Typically these questions are generated during the topic refinement process. However, Key Questions can be suggested as part of a topic nomination. Key Questions generally use a patient, intervention, comparison, outcomes (treatment and setting) [PICO(TS)] format to maximize the usefulness of the final report. Public comment on a set of draft Key Questions helps researchers continue to think about what is most important to ask so that the research report can be as useful as possible. PICO(TS) stands for the following:

  • Patient, Population, or Problem: The "P" in PICO(TS) is a description of the patient(s) of interest. It includes the condition(s), populations or subpopulations, disease severity or stage, comorbidities, and other patient characteristics or demographics.
  • Intervention or Exposure: The "I" in PICO(TS) refers to the specific treatments or approaches with the patient or population. It includes dose, frequency, method of administering treatments, and so on.
  • Comparison: The "C" in PICO(TS) describes what is being compared with the intervention. It includes alternatives such as placebo, drugs, surgery, and lifestyle changes.
  • Outcome: The "O" in PICO(TS) describes the specific results of interest. It refers to short, intermediate, and long-term outcomes, and includes specific areas such as quality of life, complications, mortality, and morbidity.
  • Timing (If Applicable): The "T" in PICO(TS) describes the duration of time that is of interest for the particular patient outcome, benefit, or harm to occur (or not occur).
  • Setting (If Applicable): The "S" in PICO(TS) describes the setting or context of interest. Setting can be a location (such as primary, specialty, or inpatient care) or health policy that frames or restricts the important questions to be answered.

The carefully drafted questions for a systematic review are strengthened by incorporating stakeholders and end-users in their development. For example, patients can offer specific and important insights about the benefits and harms of a treatment or drug. Clinicians or policymakers can describe real-world treatment and coverage dilemmas that the review may help to resolve. These points of view are invaluable in the early phases of research and help ensure that the final products are relevant and useful.

When developing Key Questions, investigators use the PICO(TS) approach described above, as well as the involvement of stakeholders, to help them identify three to five specific well-defined questions. A strong question is one that helps guide the research and can be addressed by a review of the evidence. Questions inappropriate for systematic reviews include those that involve clinical judgment, seek recommendations for an individual patient, are vague or limited to a single procedure, or ask about general approaches to treatment.

The examples in Figure C-1 are listed to illustrate the difference between questions that are considered "strong" or "weak" in their appropriateness for systematic reviews. Examples are listed for clinical questions, as well as for the organization and delivery of health care.

Figure C-1. Guidance for Key Questions

Figure C-1 lists five suggestions for developing Key Questions. They are: Use questions that ask about indications for multiple procedures, ask questions that are specific about effectiveness and evidence, be specific about the aspect of health care that is of interest, ask questions that are specific to reviewing available evidence, and ask questions that will provide a basis for determining relative performance.

Page last reviewed February 2014
Internet Citation: Appendix C. Research Questions and PICO(TS). Content last updated February 2014. Agency for Healthcare Research and Quality, Rockville, MD.