Although the group agreed that the PICO elements should be core requirements for a research recommendation, intense discussion centred on the inclusion of factors defining a more detailed context, such as current state of evidence (E), appropriate study type (s), disease burden and relevance (d), and timeliness (t).
Initially, group members interpreted E differently. Some viewed it as the supporting evidence for a research recommendation and others as the suggested study type for a research recommendation. After discussion, we agreed that E should be used to refer to the amount and quality of research supporting the recommendation. However, the issue remained contentious as some of us thought that if a systematic review was available, its reference would sufficiently identify the strength of the existing evidence. Others thought that adding evidence to the set of core elements was important as it provided a summary of the supporting evidence, particularly as the recommendation was likely to be abstracted and used separately from the review or research that led to its formulation. In contrast, the suggested study type (s) was left as an optional element.
A research recommendation will rarely have an absolute value in itself. Its relative priority will be influenced by the burden of ill health (d), which is itself dependent on factors such as local prevalence, disease severity, relevant risk factors, and the priorities of the organisation considering commissioning the research.
Similarly, the issue of time (t) could be seen to be relevant to each of the core elements in varying ways—for example, duration of treatment, length of follow-up. The group therefore agreed that time had a subsidiary role within each core item; however, T as the date of the recommendation served to define its shelf life and therefore retained individual importance.