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A Graduate Critical Appraisal Assignment for Athletic Training
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  • Informal – ask questions Progressive better word

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  • 1. Graduated Critical Appraisal in AT Education John T. Parsons, MS, ATC, AT/L Tamara Valovich McLeod, PhD, ATC, AT/L A.T. Still University
  • 2. Objectives
    • Discuss the need critical analysis of published research studies.
    • Identify and discuss the main components of a graduated critical appraisal
      • Appropriately constructed clinical question (PICO) to direct patient care.
      • Levels of evidence or strength of recommendations of research articles
      • Critically appraisal of evidence.
    • Identify “behavioral markers” from student participation in a graduated critical appraisal assignment
  • 3. ASSIGNMENT CONTEXT
  • 4. Presentation Activities
    • Demonstration and discussion of the evolution of the critical appraisal assignment over time.
    • Demonstrate and discuss critical appraisal assignment grading criteria (e.g., grading matrix)
    • Demonstration of process of crafting a clinical question using PICO format: P atient, i ntervention, c omparison, o utcome.
    • Demonstration of CATs (Critically Appraised Topics) in athletic training and compare to purpose critical appraisal assignment and discuss value of CATs contribution to the profession
    • Demonstrate critical appraisal of article, including discussion of critical elements of appraisal for a given article type (i.e., intervention study; systematic review / meta-analysis; RCT)
    • Discussion Level of Evidence (LOE) component of critical appraisal assignment, including appropriate choice of LOE scale for athletic trainers.
    • Discuss student progression and maturation following regular engagement in critical appraisal assignment
  • 5.  
  • 6.  
  • 7. Best Research Evidence
    • Valid
    • Clinically relevant
    • Basic / clinical research
    • Patient-centered
    • Diagnostic efficacy
    • Prognostic markers
    • Treatment efficacy
  • 8. Patient-Oriented Evidence
    • Morbidity, mortality
    • Symptom improvement
    • Cost reduction
    • Quality of life
    • Highest quality evidence
  • 9. Patient-Oriented Evidence That Matters (POEM)
  • 10. (Hurwtiz et al, JBJS , 2000) Common Problem Uncommon Problem Patient-Oriented Evidence Best Best source of POEMs Relevance: I Only if Time May not be relevant to everyday practice Relevance: II Disease-Oriented Evidence Danger Can be misleading Relevance: III Worst Read only if extremely interested Relevance: IV
  • 11. Necessary Skills of Future Clinicians
    • Information mastery
    • Clinical epidemiology
    • Learn skills; not information
  • 12. Prescription for EBP
      • Craft a clinical question
      • Search the best evidence
      • Critically appraise the evidence
      • Integrate the evidence
      • Evaluate effectiveness
  • 13. ASSIGNMENT STRUCTURE
  • 14. Progressive Assignment Components
    • Identify & construct clinical question
    • Article annotation
    • LOE analysis
    • Clinical “bottom line”
    • Statement of clinical relevance
    • Identify & complete critical appraisal
  • 15. General Guidelines
    • Article <5 yrs. old
    • Relevant to course focus
    • Single-spaced, 1-page limit
    • Hard-copy submitted + article
  • 16. Grading Form
  • 17. AT 5070
  • 18. Later Assignments
  • 19. Annotation Clinical Relevance Clinical Question LOE Analysis “ Bottom Line” Patient Education Critical Appraisal AT 5070 AT 5120 AT 5220
  • 20. Annotation Components
    • Problem / purpose
    • Methods
    • Results
    • Page limit requirements
  • 21. Clinical Question Citation Problem & purpose Methods & results LOE, applicability, & patient education
  • 22. Annotation Clinical Relevance Clinical Question LOE Analysis “ Bottom Line” Patient Education Critical Appraisal AT 5070 AT 5120 AT 5220
  • 23. CRAFTING A CLINICAL QUESTION
  • 24.  
  • 25. If Well-Formulated. . .
  • 26. P I C O ATIENT NTERVENTION OMPARISON UTCOME
  • 27. Patient or Problem How would you describe a group of patients similar to yours? What are the most important characteristics of the patient?
    • Are Football athletes…
    • In ice hockey athletes…
    P
  • 28. Intervention Which main intervention, prognostic factor or exposure are you considering What do you want to do for the patient? What factor may influence the prognosis of the patient?
    • … with a history of multiple concussions…
    • … does the use of full face shields…
    I
  • 29. Comparison What is the main alternative to compare with the intervention?
    • … compared to those with no concussion history ...
    • … compared to half face shields…
    C
  • 30. Outcomes What can you hope to accomplish, measure, improve or affect? What are you trying to do for the patient? Relieve or eliminate the symptoms?
    • … at greater risk for long term sequelae?
    • … decrease the risk of facial fractures?
    O
  • 31. Example
    • A 46 year old male had been moving rocks for his rock garden when he felt a twinge and his low back became excruciatingly painful. He's come into the ER and is extremely unhappy and demanding an MRI. You thought CT was the standard for diagnosis. P : patient with acute low back pain I : MRI C : CT Scan O : Diagnostic effectiveness Answerable Question : in patients with low back pain, is MRI more effective than CT scanning for diagnostic purposes?
  • 32. (Melnyk & Fineout-Overholt, 2005)
  • 33. LEVELS OF EVIDENCE
  • 34. Levels of Evidence vs. Strength of Recommendation
    • Levels of Evidence
      • Used with individual studies to help clinicians to determine the value of the results reported
      • Usually ranks from 1-5, with 1 being the highest quality
    • Strength of Recommendation
      • Used with a body of literature to grade the recommendation for evidence to be used in clinical practice
  • 35. Levels of Evidence / Strength of Recommendation
    • Oxford Centre for Evidence Based Medicine
    • Strength of Recommendation Taxonomy (SORT)
    • American Academy of Orthopaedic Surgeons (AAOS)
    • Grading of Recommendations, Assessment, Development and Evaluation (GRADE)
  • 36. SORT Ebell et al, Am Fam Phys , 2004
  • 37. SORT
  • 38. AAOS
  • 39. Anecdotal Animal / Bench research Unpublished clinical observations Case series Poorly designed cohort / case-control Case-control Cohort Well-designed RCTs / prospective studies Level 5 Level 4 Level 3 3a: SR of case-control studies 3b: Individual case-control Level 2 2a: SR of cohort studies 2b: Individual cohort studies 2c: Outcomes research Level 1 1a: SR of RCTs 1b: Individual RCTs 1c: All or none studies
  • 40. Annotation Clinical Relevance Clinical Question LOE Analysis “ Bottom Line” Patient Education Critical Appraisal AT 5070 AT 5120 AT 5220
  • 41. CRITICAL APPRAISAL
  • 42. Why Appraise? Current Literature Quantity concerns Quality concerns
  • 43. General Appraisal Questions
    • Are the results of this study valid ?
    • Are these valid results important ?
    • Are the valid, important results applicable to my patient?
  • 44. Applicable Evidence?
    • Is our patient so different that the results cannot apply?
    • Is the treatment feasible in our setting?
    • What are our patient’s potential benefits and harms from the therapy?
    • What are our patient’s values and expectations ?
  • 45. Systematic Reviews
    • Is the evidence from this SR valid ?
    • Is the valid evidence from the SR important ?
    • Are the valid, important results from the SR applicable to my patient?
  • 46. Critical Appraisal Worksheets
    • CEBM website
      • Links to appraisal worksheets
        • http://www.cebm.utoronto.ca/teach/materials/caworksheets.htm
      • Stats calculators (EBM toolbox – right side)
        • http://www.cebm.utoronto.ca/
        • Downloadable to a PDA
    • PEDro
      • http://www.pedro.fhs.usyd.edu.au/scale_item.html
  • 47.  
  • 48. STUDENT BEHAVIORAL MARKERS
  • 49. Student Evaluations: From Class 2005-2006
  • 50. Student Evaluations From Class 2006-2007
  • 51. Behavioral Markers Annotation Clinical Relevance
    • Connection to practice is difficult
    • Writing style & efficiency
    Patient Education
  • 52. Behavioral Markers
    • 1-page limit
    • Purpose / problem ID
    • Question structure
    • Study design required for LOE
    • Prioritizing study factors that speak to question
    Clinical Question LOE Analysis “ Bottom Line” Summary
  • 53. Behavioral Markers
    • Choosing proper tool
    • Demonstrating work
    • Study characteristics (i.e., blinding, random assignment)
    Critical Appraisal
  • 54. Future Modifications
    • Collaboration
    • Critically Appraised Topic (CAT)
  • 55. http://clinques.nlm.nih.gov/JitSearch. html The ClinicalQuestions Collection is a growing repository of questions that have been collected from healthcare providers in clinical settings across the country. The questions have been submitted by investigators who wish to share their data with other researchers.  http ://www.cebm.utoronto.ca / Main CEBM site  http ://www.pedro.fhs.usyd.edu.au/scale_item. html PEDro http ://ebmlibrarian.wetpaint.com / EBM Librarian - has info on appraisals and CATS http://www.cche.net/usersguides/ebm.aspHas info on the Users' Guides  http ://pubs.ama-assn.org/misc/usersguides. dtl Users' Guides  http ://www.ebmny.org/cats. html CATS  http ://www.otcats.com / OT CATS