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What is Critical Appraisal

What is Critical Appraisal

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05/11/2014

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q
Critical appraisal
is the process of 
systematically
examiningresearch evidence to assess its
 validity, results
and
relevance
before using it to inform a decision.
q
Critical appraisal is an essential part of 
evidence-basedclinical practice
that includes the process of systematically
finding, appraising 
and
acting 
on evidence of effectiveness.
q
Critical appraisal allows us to make sense of research evidenceand thus begins to close the gap between research and practice.
q
Randomised controlled trials
can minimise bias and usethe most appropriate design for studying the effectivenessof a specific intervention or treatment.
q
Systematic reviews
are particularly useful because theyusually contain an explicit statement of the objectives,materials and methods, and should be conducted accordingto explicit and reproducible methodology.
q
Randomised controlled trials and systematic reviews arenot automatically of good quality and should beappraised critically.
1
Volume 3,number 2
www.evidence-based-medicine.co.uk
What is criticalappraisal?
Sponsored by an educational grant from AVENTIS Pharma
Alison Hill
BSCFFPHM FRCP
Director,and
ClaireSpittlehouse
BSc
Business Manager,Critical AppraisalSkills Programme,Institute of HealthSciences,Oxford
Prescribing information is on page 8
 
Critical appraisal is one step in the process of evidence-based clinical practice. Evidence-based clinical practice is ‘an approach todecision making in which the clinician usesthe best evidence available, in consultationwith the patient, to decide the option whichsuits the patient best’.
1
To determine what isthe ‘best’ evidence, we need critical appraisalskills that will help us to understand themethods and results of research and to assessthe quality of the research. Most research isnot perfect, and critical appraisal is not anexact science – it will not give us the ‘right’answer. But it can help us to decide whetherwe think a reported piece of research is goodenoughto be used in decision making.There are many factors that come into playwhen making healthcare decisions – researchevidence is just one of them. If research hasflaws, it is up to readers to use their criticalappraisal skills to decide whether this affectsthe usefulness of the paper in influencingtheir decision.
Pros of critical appraisalin practice
q
Critical appraisal provides a systematic wayof assessing the validity, results andusefulness of published research papers.
q
Together with skills in finding researchevidence and changing practice as aresult of research, critical appraisal isthe route to closing the gap betweenresearch and practice
1
and as such makesan essential contribution to improvinghealthcare quality.
q
Critical appraisal encourages objectiveassessment of the usefulness of information – critical appraisal skills areapplied to published research, but allevidence should be appraised to weighup its usefulness.
q
Critical appraisal skills are not difficult todevelop. Critical appraisal is a commonsense approach to reading, and user-friendly tools are available to help anyonedevelop these skills.
Cons of critical appraisalin practice
q
Critical appraisal can be time-consuminginitially, although with time it becomes theautomatic way to look at research papers.
q
Critical appraisal does not always providethe reader with the ‘easy’ answer or theanswer one might have hoped for; it mayhighlight that a favoured intervention is infact ineffective.
q
Critical appraisal can be dispiriting if ithighlights a lack of good evidence – it maytake determination to persist with an areaof interest when access to good research inthe area is limited.
Appraising randomisedcontrolled trials
Box 1
3
(opposite) provides a checklist of questions for critically appraising
randomised controlled trials (RCTs).
The RCT is the mostappropriate research design for studying theeffectiveness of a specific intervention ortreatment.
2
In an RCT, participants arerandomly assigned to two (or more) groups:one (or more) experimental group(s)receiving the intervention that is being tested,and a comparison or control group receivinga placebo or an alternative treatment. The two(or more) groups are then followed up to seewhat differences result. Randomisationensures that the groups differ only in theintervention given, so any difference betweenthe outcomes in each group can be attributedto the intervention.RCTs’ methodology
can
minimiseaccidental or intentional bias, but this doesnot automatically mean that every RCT is of good quality. We must
critically appraise
individual studies to assess the validity of their methods. Once we are happy that themethods were sound, then we can look atwhat the results tell us and consider whetherwe can apply them to our own population.This method of critically appraising anRCT can be applied to the paper about theHeart Outcomes Prevention Evaluation
What is critical appraisal?
2
What iscritical appraisal
 
3
What iscritical appraisal
Box 1.
12 questions to help you make sense of a trial.Adapted from Guyatt
et al 
3
A. Are the results of the study valid?
Screening questions
1.Did the trial address a clearly focused research question? 
Tip:a research question should be ‘focused’ in terms of:
q
The population studied
q
The intervention given
q
The outcomes considered.
2.Did the authors use the right type of study
Tip:the right type of study would:
q
Address the research question
q
Have an appropriate study design.
Is it worth continuing?Detailed questions
3. Was the assignment of patients to treatments randomised? 
Tip:consider if this was done appropriately.
4.Were all of the patients who entered the trial properly accounted for at its conclusion? 
Tip:look for:
q
The completion of follow-up
q
Whether patients were analysed in the groups to which they were randomised.
5.Were patients, health workers and study personnel ‘blind’ to treatment? 
Tip:this is not always possible,but consider if it was possible – was every effort made to ensure ‘blinding’?
6.Were the groups similar at the start of the study
Tip:think about other factors that might effect the outcome such as age,sex,social class.
7.Aside from the experimental intervention, were the groups treated equally? 
Tip:for example,were they reviewed at the same time intervals.
B. What are the results?
8.How large was the treatment effect9.How precise was the estimate of the treatment effect
Tip:look for the confidence limits.
C. Will the results help locally?
10.Can the results be applied to the local population?Tip:consider whether the patients covered by the trial are likely to be very different from your population.11.Were all clinically important outcomes considered?12.Are the benefits worth the harms and costs?
© Critical Appraisal Skills Programme
(HOPE) study,
4
which investigates theeffects of ramipril on cardiovascular eventsin high-risk patients. A brief criticalappraisal of the methods of the HOPE paper(addressed by questions 1–7) is includedto demonstrate how critical appraisal toolscan be used.
How should thesequestions be used?
Questions one and two are screeningquestions, and any research paper should givethe reader the answers to these two questionson the first page, ideally in the abstract. If it isnot possible to answer ‘yes’ to both these

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