Critical Appraisal: An Introduction

Melanie Browne HBHSc, MLIS Information Specialist

Agenda
Introduction Define Evidence-based clinical practice How to read a research article Search for best evidence Apply critical appraisal in your library Our new role Case presentation Resources

Evidence-Based Medicine
"...the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. from Sackett, DL, et al. "Evidence based medicine: What it is and what it isn't." (BMJ 1996; 312: 71-2)

 "Evidence based medicine (EBM) is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgements" (McKibbon et al 1995).

Why EBM?
A clinician needs to read 17 peer reviewed articles per day, every day of the year, to stay current (Haynes 1993).
Haynes, R. (1993) Where's the meat in clinical journals? ACP Journal Club, 119: A23-4.

There are 20 million pieces of 'evidence' of varying quality and sometime of contradictory conclusions.

How Can You Access, Distil and Apply Research/Evidence?

Develop summaries Train clinicians and other health care decision makers to find and appraise relevant evidence Decision support systems

Summaries With Rigorous Methodologies

Cochrane Collaboration National Centre for Clinical Excellence Centre for Clinical Effectiveness at Monash University

The Argument for Evidence-Based Medicine

Stay up to date with the current literature Communicate effectively Make the best use of information from the history, physical examination, and diagnostic testing Avoid common pitfalls of clinical decision-making

Critical Appraisal
The assessment of evidence by systematically reviewing its relevance, validity and results to specific situations. - Chambers, R. (1998).

What is best evidence?

Using critical appraisal skills you can understand the methods and results of the research and then be able to assess the quality of the research.

Critical appraisal Critical appraisal

Exact science right answer

Information Mastery
Slawson and Shaughnessy Formula Usefulness of Medical Information = Relevance x Validity ____________________ Work to Access

 Smith R. What clinical information do doctors need? Br Med J 1996; 313: 1062-8.

 When doctors see patients they usually generate at least one question Most of the questions concern treatment Many of the questions are highly complex, simultaneously asking about individual patients and particular areas of medical knowledge

 Often doctors are asking not simply for information but for support, guidance, affirmation, and feedback Doctors are most likely to seek answers to these questions from other doctors The best information sources provide relevant, valid material that can be accessed quickly and with minimal effort

Basic elements of clinical decision making

Haynes RB. Loose connections between peer-reviewed clinical journals and clinical practice. Ann Intern Med 1990;113:724-8.

Why Should we Critically Appraise?

Published research is not always reliable Published research is not always relevant To improve clinical effectiveness, we need a systematic framework to interpret research

Difficulties with Critical Appraisal

Can be time consuming initially Doesnt provide an easy answer It could show a lack of good evidence in a particular topic

Key Steps to Effective Critical Appraisal

1. Are the results valid? 2. What are the results? 3. How will these results be relevant to the patient?

Validity and Reliability

A test is valid when it measures what its supposed to. If a test is reliable, it yields consistent results. A test can be both reliable and valid, one or the other, or neither. Reliability is a prerequisite for measurement validity.

Reliable, but Not Valid!

Not Reliable, Not Valid!

Reliable and Valid

Mark Newman - Middlesex University updated 04/2001

What a Physician can be Faced With on a Daily Basis?

~1 - 2 questions per patient (clinics) 15/patient/day (wards)

~30% of questions are followed People Books Electronic resources

40% easy to answer 30% tough to answer 30% cannot answer
Source: Dawes M, Sampson U. Knowledge management in clinical practice: a systematic review of information seeking behaviour in physicians. Int J Med Inform. 2003 Aug; 71(1):9-15. Review. PMID: 12909153

Steps to EBM
1. Formulate a clear, focused clinical question 2. PICO model 3. Search the literature for the best external evidence 4. Critically appraise the evidence for its validity and usefulness 5. Implement the useful evidence in clinical practice 6. Evaluate the results

Question Formulation
Not easy but EXTREMELY important Good questions will
Focus/clarify your information need Give you some idea of where to look for information Give you searching concepts and terms

Background Questions
Often broad in nature Often not patient-specific but fact based May not need to integrate knowledge More common early in training/new situations

Foreground Questions
Often for a specific patient or clinical situation Narrow in focus Need to integrate external information with clinical/situational data

PICO Structure
Patients Intervention

Comparison
Outcome

P I C O

Clinical Scenario
What therapeutic agents can be used for rate control of atrial fibrillation (AF) in a patient with congestive heart failure (CHF)?

Starting Point
Department: Emergency Population: Patients with atrial fibrillation and congestive heart failure Intervention: Rate control Comparison: N/A Outcome: Mortality, effectiveness of rate control

PICO Schematic Model

Rate control Patient w/ Atrial Fibrillation in congestive heart failure Effectiveness of rate control

Comparison

Rhythm control / No treatment

Clinical problem

General Search Strategy

Define the search question Try another relevant resource Choose a resource/database Create a search strategy Create a search strategy Summarize the evidence

Poor yield

Summarize the evidence

Apply the evidence

Try another relevant resource

Adapted from: Sackett, D. et al. 2000. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd Edition. Toronto: Churchill Livingstone.

Study Types for Question Types

Diagnosis Prospective cohort study with good quality validation against Gold Standard Randomized controlled clinical trial (RCT)

Therapy

Etiology/ Harm Prognosis

RCT, cohort or case-control study (probably retrospective)

Prospective cohort study

Does this treatment work?

systematic review, RCT

How good is a diagnostic test?

(prospective) cohort study

Should we screen?

RCT

What causes this disease?

RCT, prospective cohort study, case control study (rare diseases)

What did people think or do?

cohort study, cross-sectional survey, qualitative study

How can we do Critical Appraisal?

Use common sense Use simple checklists Use different checklists depending on the different types of studies (i.e., RCTS, systematic reviews etc) Checklists help you focus on the important parts of the article

Research Methodology
Who were the participants of the study? How were they recruited? Was there bias in the recruiting methods? How was the data collected? What statistical tests were used? Where the data collection methods accurate?

Critical appraisal questions

What is the paper about? Why was the study done? What type of study was done? Was it primary research (experiment, RCT, cohort, case-control, crosssectional, longitudinal, case report/series)?

Critical appraisal questions

Was it secondary research (overview, systematic review, meta-analysis, decision analysis, guidelines development, economic analysis)? Was the design appropriate (for study on treatment, diagnosis, screening, prognosis, or causation)?

Critical appraisal questions

Was the study ethical? Is the design right?

(BMJ Editor's checklists)

How to Read a Research Article? First Glance.

Purpose of reading the paper. Do not read the abstract. Read the title, find out who the authors are and where they work, look for sources of funding and conflicts of interest Look at the tables and figures Is there a diagram to show the flow of participants through each stage of the study Why was the study done and what hypothesis were the authors testing? What is broadly the topic of research? Therapy, Diagnosis, Screening, Prognosis, Causation? What type of study was done? Is this a primary (experimental, clinical trial, survey) or a secondary paper (review, meta-analysis, guideline, economic analysis)? Was the study design appropriate? Now proceed to a critical appraisal of the paper

Case Presentation
Read the Ray et al(2008) paper and divide the group into 2 for a debate on the paper Breast size and risk of type 2 diabetes mellitus. CMAJ

 Ray and colleagues studied data from 92 106 women in conjunction with the Nurses' Health Study II and found that breast size at age 20, assessed by recall of bra cup size, correlated positively with the incidence of type 2 diabetes

 After adjustment for relevant factors, such as body mass index, waist circumference and family history of diabetes, the hazard ratio dropped to 1.58 but remained significant.

 Nurses' Health Study II population data emanates from women who were mainly of white ancestry, and that their analysis is based on recall and self-report.

New Role of Health Sciences Librarians

Teaching access to the literature and other information resources Teaching use of technology as a means to access and manage information Teaching skills in information organization and critical appraisal

Role of Librarians as Information Clinicians

Information Clinician Medical Informatics Tutor EBM Educator

Informationist
A discipline requiring a combination of the skills of a librarian, a clinical epidemiologist and a medical scientist

Davidoff, F. & Florance,V. (2000) The Informationist: A New Health Profession? Annals of Internal Medicine, 132: 996998.

Effective INFORMAtician
Knows categories of information resources
therapy, diagnosis, prognosis synthesized resources vs original studies

Knows strengths/weaknesses of information resources Knows when to use each category Knows that some resources are better than others in certain situations
Cochrane diagnostic accuracy data?

Knows what to do with the results

 Practical solutions - Librarian as a partner on the teaching team; teachable moments Formal hospital library educational programs have focused on orientation and instruction in the use of bibliographic tools. i.e.- LATCH (Literature Attached to Charts) and clinical medical librarianship

Critical Appraisal Skills Training

Research methodology Statistical techniques

Courses for Librarians Out There

CILIP: the Chartered Institute of Library and Information Professionals Critical appraisal skills for healthcare librarians: building on the basics http://www.cilip.org.uk/training/trainin g/2008/libinfo/criticalappraisalskillsforhe althcarelibrariansbuildingonthebasics.htm

General Resources:
CASP (Critical Appraisal Skills Programme) - part of the Public Health Resource Unit based at Oxford, CASP runs training workshops on critical appraisal skills. Evidence-Based Medicine Toolkit - hosted by the University of Alberta, this is an online "box" of handy tools to help you find, appraise, and apply in practice, evidence-based research How to read a paper - a set of ten guides from the BMJ (individual links given in the relevant section below). Levels of Evidence - a ranking system used to rank various study designs in order of evidence-based merit: systematic reviews/meta-analyses and well conducted randomised controlled trials (RCTs) are usually seen as the best form of "evidence", with research based on the outcome of a case series placed somewhere near the bottom Netting the Evidence - search for the keyword "appraisal" to find a quality assessed list of appraisal resources User's guides to evidence based practice - based on a series of articles published in JAMA, these guides give comprehensive advice on how to find, appraise and apply research in practice

Keeping Current
Daily InfoPOEMs http://www.infopoems.com/ bmjupdates+
http://bmjupdates.mcmaster.ca/index.asp

Tables of contents of journals (e.g. JAMA)

From journal itself My NCBI from PUBMED

Predictive Value of tests

Relative Risk Reduction

P Value