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Talk on Critical Appraisal 17.08.11

Talk on Critical Appraisal 17.08.11

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Published by Akira Naito
Introductory talk on Critical Appraisal
Introductory talk on Critical Appraisal

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Published by: Akira Naito on Aug 18, 2011
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An introduction to Critical Appraisal for Psychiatry

Wednesday 17th Aug 2011
In an Academic Meeting at Department of Psychiatry, Eastbourne District General Hospital

Akira NAITO MD PhD CT1 to Dr. A. GALEA

‡ Psychiatry and neurology only became distinct medical specialities about a century ago. ‡ Antidepressants and antipsychotics were first evaluated in the 1960¶s. ‡ The efficacy of treatments (psychotherapies and biomedical treatments) could not be rigorously evaluated until the µinvention¶ of RCT. ‡ The EBM movement appears to offer some solutions, but requires adequate support.

Evidence-Based Practice (EBP)
‡ Definition of Evidence Based Medicine:
The µconscientious, explicit and judicious use of current best evidence in making decisions about the care of patients¶ (Sackett et all 2000)

‡ The goal of EBP is the integration of:
1. Clinical expertise 2. Scientific evidence, and 3. Client/patient/caregiver values


Information solutions
‡ Useful sources of information for clinical practice
± The Cochrane Library: http://www.thecochranelibrary.com/ ± The Evidence-Based Mental Health (EBMH):

‡ Other internet resources
± Clinical Evidence: http://clinicalevidence.bmj.com ± PubMed (MEDLINE): http://www.ncbi.nlm.nih.gov/pubmed ± National Institute of Clinical Excellence (NICE):


Why doing critical appraisal?
‡ Uncertainty is universal in clinical medicine. ‡ It takes practice to routinely identify areas of uncertainty and to ask clinical questions in a productive way. ‡ Such questions will be brief summaries of the clinical scenario and the information required, constructed in a way that makes searching for evidence likely to succeed.

Different types of question require different study designs
‡ Aetiology:
± What caused this illness? Cross-sectional surveys RCTs

‡ Diagnosis:
± What does this test result mean?

‡ Prognosis:
± What is likely to happen? Inception cohort studies RCTs

‡ Harm:
± Is being exposed to it likely to do harm?

‡ Effectiveness of therapy/treatment:
± Is this treatment likely to help? RCTs

‡ Qualitative:
± What are the outcomes that are most important?

Evidence levels (from NICE)
Ia. Systematic review / Meta-analysis of RCTs Ib. Randomised Controlled Trial (RCT) IIa. Non-randomised controlled study IIb. Quasi-experimental study III. Non-experimental descriptive study
± Comparative studies, Correlation studies ± Case controlled studies

IV. Clinical experience
± Expert-committee reports or opinions ± Evidence from expected authorities

Main types of bias
‡ Selection bias
± Sampling / Performance bias
‡ non-representative identification/recruitment of subjects ‡ Unequal provision of care apart from treatment under evaluation

± Response/ Attrition bias (non-/late- responders)
‡ unrepresentative participation differs from responders ‡ Biased occurrence and loss to follow up

‡ Observation / Detection bias
± Interviewer bias (blind to subject status or not):
‡ differential data recording in subject groups by researcher

± Recall bias
‡ historical data is selectively filtered

‡ Confounding correlations/associations (not causal links)

What is critical appraisal?
‡ The process by which a reader can assess whether a written material possesses:
± Validity (Is it close to the truth?), and ± Applicability (Is it clinically useful?).

‡ The process of carefully & systematically examining research to judge its:
± Trustworthiness, and ± Value and Relevance in a particular context.

Common ground inquiries
1. Is the study/research/guideline valid?
‡ Validity / Trustworthiness (Internal validity = free/minimum bias)

2. What does it show? & Is it important?
‡ Value and Relevance

3. Can I use this in caring for my patients?
‡ Applicability (for ones own decision making)

Structure of a paper
‡ Introduction/Background
± Clinical importance (Why do the study?) ± A review of previous work in the subject area ± Hypotheses to be tested: a null hypothesis

‡ Methods ‡ Results ‡ Discussion / Conclusions

‡ Research subjects
± Subjects: Representative sample? (who? where from? Inclusion & exclusion criteria?) ± Measures: Validated/published measures? (reliability and validity in manner and process) ± Statistical tests + Power calculation

‡ Types of a paper
± A hierarchy of evidence (see the previous slide)

‡ Check whether original research question or hypothesis was properly assessed?
± Appropriate tables and figures? ± Logical manner? ± Key findings?

‡ Any inconsistencies in the data?


Discussion / Conclusions
‡ Value and relevance of the study results ‡ Limitations of the study ‡ Implications of the study¶s findings
± Generalisability of positive findings ± Implication of negative results


Any question so far?
(References for writing a paper) ‡ Writing a case report

‡ Tips and Check-points for academic writing in English

‡ Using English for Academic Purposes

Example questions for therapy/treatment articles


What question did the study ask? + PICO ‡ Patients
‡ Intervention ‡ Comparison ‡ Outcome(s)


Are the results of the trial valid?
‡ Was the assignment of patients to treatments randomised? ‡ Were the groups similar at the start of the trial? ‡ Aside from the allocated treatment, were groups treated equally? ‡ Were all patients who entered the trial accounted for? ± and were they analysed in the groups to which they were randomised? ‡ Were measures objective or were the patients and clinicians kept ³blind´ to which treatment 18 was being received?

What were the results?
‡ How large was the treatment effect?
± Relative Risk (RR) ± Relative Risk Reduction (RRR) ± Number Needed to Treat (NNT) = 1 / ARR ± Coefficient of Intra-Cluster Correlation (ICC)

‡ How precise was the estimate of the treatment effect? (confidence intervals for each estimate)

Will the results help me in caring for my patient?
‡ The questions that you should ask before you decide to apply the results of the study to your patient are:
± Is my patient so different to those in the study that the results cannot apply? ± Is the treatment feasible in my setting? ± Will the potential benefits of treatment outweigh the potential harms of treatment for my patient?

‡ EBM Tools for Critical Appraisal

‡ What is critical appraisal?
http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/W hat_is_critical_appraisal.pdf

‡ EBP tutorials - Critical Appraisal Skills
http://www.brighton.ac.uk/ncor/tutorials/EBP_Tutorial_intro_Critical_ Appraisal_Skills.pdf

‡ Clinical Study Design and Methods Terminology

‡ Critical Appraisal for Psychiatry (MRCPsych Guides)

Thank you!


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