Read & critical appraisal a

scientific article
Phùng Khánh Lâm, MD, PhD
27/03/2021
Outline
1. Evidence-Based Medicine
2. Example
3. Ask – Acquire – Appraise – Apply
4. Recap

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Reference

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Evidence-Based Medicine

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Evidence-Based Medicine (EBM)
• “conscientiously working with patients to help them resolve
(sometimes) or cope with (often) problems related to their
physical, mental, and social health”

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Evidence-Based Medicine (EBM)
• “conscientiously working with patients to help them resolve
(sometimes) or cope with (often) problems related to their
physical, mental, and social health”
• 3 fundamental principles

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Evidence-Based Medicine (EBM)
• “conscientiously working with patients to help them resolve
(sometimes) or cope with (often) problems related to their
physical, mental, and social health”
• 3 fundamental principles
• optimal decision requires awareness of the best available evidence
(ideally will come from systematic summaries of that evidence)

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Evidence-Based Medicine (EBM)
• “conscientiously working with patients to help them resolve
(sometimes) or cope with (often) problems related to their
physical, mental, and social health”
• 3 fundamental principles
• optimal decision requires awareness of the best available evidence
(ideally will come from systematic summaries of that evidence)
• EBM provides guidance to decide whether evidence is more or less
trustworthy

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Evidence-Based Medicine (EBM)
• “conscientiously working with patients to help them resolve
(sometimes) or cope with (often) problems related to their
physical, mental, and social health”
• 3 fundamental principles
• optimal decision requires awareness of the best available evidence
(ideally will come from systematic summaries of that evidence)
• EBM provides guidance to decide whether evidence is more or less
trustworthy
• Evidence alone is never sufficient to make a clinical decision.

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Evidence-Based Medicine (EBM)
• “conscientiously working with patients to help them resolve
(sometimes) or cope with (often) problems related to their
physical, mental, and social health”
• 3 fundamental principles
• optimal decision requires awareness of the best available evidence
(ideally will come from systematic summaries of that evidence)
• EBM provides guidance to decide whether evidence is more or less
trustworthy
• Evidence alone is never sufficient to make a clinical decision.
• Trade-off between: benefits, risks, burden, costs
(patients’ values and preferences)

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 Principles: 5As

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
 Principles: 5As
• Ask: identified the problem

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
 Principles: 5As
• Ask: identified the problem
• Acquire: search for the best relevant evidence

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
 Principles: 5As
• Ask: identified the problem
• Acquire: search for the best relevant evidence
• Appraise:
• Are the results valid?/How serious is the risk of
bias?
• What are the results?

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
 Principles: 5As
• Ask: identified the problem
• Acquire: search for the best relevant evidence
• Appraise:
• Are the results valid?/How serious is the risk of
bias?
• What are the results?
• Apply: How can I apply these results to patient care?
• Can you generalize the results to your patient?
• The significance of the results for your patient?
• Measured all patient-important outcomes?

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
 Principles: 5As
• Ask: identified the problem
• Acquire: search for the best relevant evidence
• Appraise:
• Are the results valid?/How serious is the risk of
bias?
• What are the results?
• Apply: How can I apply these results to patient care?
• Can you generalize the results to your patient?
• The significance of the results for your patient?
• Measured all patient-important outcomes?
• Act:
• Shared decision making

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
Scientific Article

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 Example

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Lancet 2012; 380: 1066-74. DOI: 10.1016/S0140-6736(12)61082-4
 Example

DOI: 10.1016/S0140-6736(12)61082-4

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Lancet 2012; 380: 1066-74. DOI: 10.1016/S0140-6736(12)61082-4
Practice: Digital Object Identifier (DOI)
• Search on Google: “DOI: 10.1016/S0140-6736(12)61082-4”
• Go to the webpage of this article

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Structure

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Structure
• What is the structure of this article?
• https://jamboard.google.com/d/1KY28NhugBJWRqvnnpMljQJa
E4LGE0W3KRdKyFMIxZR0/edit?usp=sharing

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Structure
• Abstract/Summary
• IMRAD
• Introduction
• Methods
• Results
• Discussion
• Others
• Contributors
• Conflict of interest
• Acknowledgments
• References

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Practice: Structure

• Conflict of interest?

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Ask

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Clinical question

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Clinical question
• Background questions
• Normal human physiology
• Pathophysiology of disease

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Clinical question
• Background questions
• Normal human physiology
• Pathophysiology of disease
• Foreground questions
• Specific questions raised in
caring for patients

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 Clinical question
• Background questions
• Normal human physiology
• Pathophysiology of disease
• Foreground questions
• Specific questions raised in
caring for patients

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
The structure of clinical question

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The structure of clinical question: PICO

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The structure of clinical question: PICO
• Patients or Population:
• Who are the relevant patients?

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The structure of clinical question: PICO
• Patients or Population:
• Who are the relevant patients?
• Intervention(s) or Exposure(s):
• What are the management strategies of interest?

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The structure of clinical question: PICO
• Patients or Population:
• Who are the relevant patients?
• Intervention(s) or Exposure(s):
• What are the management strategies of interest?
• Comparator:
• What are alternative management strategies?

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The structure of clinical question: PICO
• Patients or Population:
• Who are the relevant patients?
• Intervention(s) or Exposure(s):
• What are the management strategies of interest?
• Comparator:
• What are alternative management strategies?
• Outcome:
• What are the patient-relevant consequences of the exposures?

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Practice: What is the clinical question?
• Where to find the information?
• What are the information?

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5 Types of Foreground Clinical Questions
• What types of foreground clinical questions?

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5 Types of Foreground Clinical Questions
1. Therapy
• The effect of interventions on patient- important outcomes

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5 Types of Foreground Clinical Questions
1. Therapy
• The effect of interventions on patient- important outcomes
2. Harm:
• The effects of potentially harmful agents on patient-important outcomes

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5 Types of Foreground Clinical Questions
1. Therapy
• The effect of interventions on patient- important outcomes
2. Harm:
• The effects of potentially harmful agents on patient-important outcomes
3. Differential diagnosis:
• Frequency of the underlying disorders in patients with a particular clinical
presentation

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5 Types of Foreground Clinical Questions
1. Therapy
• The effect of interventions on patient- important outcomes
2. Harm:
• The effects of potentially harmful agents on patient-important outcomes
3. Differential diagnosis:
• Frequency of the underlying disorders in patients with a particular clinical
presentation
4. Diagnosis:
• Power of a test to differentiate between those with and without a condition

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5 Types of Foreground Clinical Questions
1. Therapy
• The effect of interventions on patient- important outcomes
2. Harm:
• The effects of potentially harmful agents on patient-important outcomes
3. Differential diagnosis:
• Frequency of the underlying disorders in patients with a particular clinical
presentation
4. Diagnosis:
• Power of a test to differentiate between those with and without a condition
5. Prognosis:
• Patient’s future course

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Practice: Type of question
• What is the type of question in this article?

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Acquire

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Evidence-based resources

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Evidence-based resources

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Evidence-based resources

PubMed

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Evidence-based resources

Cochrane

PubMed

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Evidence-based resources

UpToDate

Cochrane

PubMed

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Appraise

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Appraise
• Are the results valid?
• What are the results?

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Why Study Results Mislead: Bias and Random Error

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Why Study Results Mislead: Bias and Random Error

• Systematic error (bias)

• Random error

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Why Study Results Mislead: Bias and Random Error

• Systematic error (bias)

• Have flawed in design or conduct
• Random error

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Why Study Results Mislead: Bias and Random Error

• Systematic error (bias)

• Have flawed in design or conduct
• Selection bias
• Non-comparable groups: randomization, adjustment
• Lost to follow-up: ensuring complete follow-up
• Random error

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Why Study Results Mislead: Bias and Random Error

• Systematic error (bias)

• Have flawed in design or conduct
• Selection bias
• Non-comparable groups: randomization, adjustment
• Lost to follow-up: ensuring complete follow-up
• Information bias
• Placebo effects: blinding, objective outcomes
• Random error

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Why Study Results Mislead: Bias and Random Error

• Systematic error (bias)

• Have flawed in design or conduct
• Selection bias
• Non-comparable groups: randomization, adjustment
• Lost to follow-up: ensuring complete follow-up
• Information bias
• Placebo effects: blinding, objective outcomes
• Random error
• “No matter how powerful and well designed a study, we will never be
sure of the truth”
• Remedy: Sample size
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Practice: How serious is the risk of bias?
• Where to find information?
• What are the information?

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What are the results?

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What are the results?
• How strong is the association?
• How precise was the estimate?

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Practice: What are the results?

• Where to find information?

• What are the information?

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Apply

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How can I apply these results to patient care?

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How can I apply these results to patient care?

• Can you generalize the results to your patient?

• The significance of the results for your patient?

• Measured all patient-important outcomes?

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Practice: Measured all patient-important outcomes?

• Where to find information?

• What are the information?

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RECAP

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 Principles: 5As
• Ask: identified the problem
• Acquire: search for the best relevant evidence
• Appraise:
• Are the results valid?/How serious is the risk of
bias?
• What are the results?
• Apply: How can I apply these results to patient care?
• Can you generalize the results to your patient?
• The significance of the results for your patient?
• Measured all patient-important outcomes?
• Act:
• Shared decision making

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AMA (2015) Users; Guides to the Medical Literature. McGraw-Hill Education
Structure
• Abstract/Summary
• IMRAD
• Introduction
• Methods
• Results
• Discussion
• Others
• Contributors
• Conflict of interest
• Acknowledgments
• References

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Feedback
• https://forms.office.com/Pages/ResponsePage.aspx?id=-
Miz6oh0D0aitEEurd6ov5n02b8-
tohPqXmBIVH6UQxUOVEwQkJQSTBVMkpZTUxDUk9OQ0Yx
R1dEMi4u

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