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Critical Appraisal

Unit Pengembangan & Evaluasi Pendidikan ( UPEP ) FacultY of MedicinE UniversitY of SriwijayA Palembang

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Clinical appraisal
The Utility of

Diagnostic The effect of Therapy Prognosis of disease Causative / Harm (etiology of disorders)

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How to appraisal ?
Valid

? Important ? Aplicable ?

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Evidence-Based Guidelines Effectiveness of Clinical Intervention


Level
Ia Ib IIa IIb III IV V

Type of evidence
Meta-analysis of randomized trial At least one randomized trial Well-designed, controlled study Well-designed, quasi-experimental study Descriptive and comparative studies. Non random study. Case serial, expert panel / committee

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Recommendations On Clinical Intervention


Grade
A B C D E

Nature of Recommendation
Ia + Ib / ( > I ) Ia / Ib IIa / IIb III IV / V

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Appraisal

Prognosis

Is this evidence about prognosis valid ?

1. Was a defined, representative sample of patients assembled at a common (usual early) point in the course of their disease ? 2. Was patient follow-up sufficiently long and complete ? 3. Were objective outcome criteria applied in a blind fashion ? 4. If sub groups with different prognosis are identified: - Was there adjustment for important prognostic factors? - Was there validation in an independent group of test-set patients?

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Is this evidence about therapy (from an individual randomized trial) valid?


1. Was the assignment of patients to treatment randomized? 2. Was the randomization concealed? 3. Were the groups similar at the start of the trial? 4. Was follow-up of patients sufficiently long and complete? 5. Were all patients analyzed in the groups to which they were randomized?
Some finer points: 6. Were patients, clinicians, and study personnel kept blind to treatment? 7. Were groups treated equally, apart from the experimental therapy?
Elsevier Ltd 2005. Straus et al.: Evidence-based medicine

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Valid ?
1. Was a defined, representative sample of patients assembled

at a common (usual early) point in the course of their disease ?

Ideally : entire population who ever live who developed the disease

How Close the report approaches to Ideal ? How the disease was defined ? How the participants were assembled ? From what point in the disease should patients be followed ? Inception cohort Exception if only learn about late stage in the disease

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Valid ?

2. Was patient follow-up sufficiently long and complete ?


Ideally : every patient in the inception cohort would be followed until they fully recover or develop one of the other disease outcomes Study prognosis 100 patients, 4 die, 16 lost to follow up A Crude case-fatality rate 4,8 % (4/84 x100%)

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Valid ?

3. Were objective outcome criteria applied in a blind fashion ?


Diseases affect patients; some are easy to spot and some are more subtle. Extreme outcomes ; death or full recovery. (easy to detect) More difficult between them; rediness to work, intensity of residual paint.

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Valid ?

4. If sub groups with different prognosis are identified: - Was there adjustment for important prognostic factors? - Was there validation in an independent group of test-set patients?

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Is This valid evidence about prognosis important ?


How

likely are the outcomes over time ?

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Important ?

How

pricise are the prognostic estimates ? The text, tables, graphis of a proper prognostic study include the confidence intervals for estimates of prognosis

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Can we apply this valid, important evidence about prognosis to our patient?
Are

the study patients similar to our own ?

Are the study patients so different from ours that we should not use the result at all in making prediction for our patients?

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Apply ?

Will

this evidence make a clinically important impact on our conclusions about what to offer or tell our patient ?

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