An easy-to-use template and guide for Critical Appraisal

1. Sudan Evidence-Based Medicine Association Template
Developed by:
Dr. Imad Salah Ahmed Hassan
MD (UK) FACP FRCPI MemAcadMEd (UK) MSc (UK) MBBS (U of K)
EBM: Critical Appraisal of an Article on Diagnosis

3. Clinical Scenario

4. Formulate a Well-Built Clinical
Question
Patient
Intervention
Comparison
Outcome

5. Outline your Search Strategy:
Search Terms/Keywords/Mesh terms
Search site/Search Engine
Pubmed via PICO
Pubmed Search Box & Limits
Pubmed Clinical Queries
Pubmed Advanced Search
Cochrane Library
Other

6. Outline Current Practice
 Tip: From the Introduction Section or from a
Guideline

7. Select a Reasonable Piece of
Research
Tip:
Paste the title, authors, journal details
here
Type of Study: Prospective, blind comparison to a gold standard
 Other:
Date published:
Number of Pages:
Quality of journal i.e. impact factor (get from Google!)
Linked-In: Author Details/Picture

8. Reason(s) for Selecting this Piece of
Research
 Tip: Common Reasons
Answers my QUESTION
Free article
Recent Article
Reputable Journal
Other

9. Summarize the Results of your
Article
 Tip: Paste the Abstract/Conclusion from the
Abstract here
 Paste Abstract here: use several slides if it is
long-remember the 6X6 rule in power-point
presentations!

10. My Appraisal Map
 Appropriateness of chosen Title?
 Trustworthy Authors?
 Truthful Abstract?
 Comprehensiveness of Introduction section?
 Relevance: Importance for Practice
 Validity: Appropriate Methodology (Validity:
Internal)?
 Results: Trustworthy Results?
 Applicability?
 Impact of Findings on Current Practice and
Future Recommendations?

11. Apply Your Appraisal Scheme
 Tip: Use the RVRA Scheme: Based on the National & Gulf
Center for Evidence-based Health Practice
Relevance
Validity
Results
Applicability

12. Apply Your Appraisal Scheme
 Tip: Use the RVRA Scheme
Relevance Personal Knowledge
Validity Methods Section
Results Results Section
Applicability Personal
Interpretation/
Experience

13. Apply Your Appraisal Scheme
Relevance
Important outcome:
• Is target disorder
dangerous if left
Undiagnosed?
• Does effective treatment
exists?
Common Problem:
Is target disorder common
enough?
Will change the practice?
Will information from test
lead to change of
management beneficial to
patients?

14. Apply Your Appraisal Scheme
Validity
Was there an
independent, blind
comparison with a
reference standard?
 Is reference standard
used acceptable?
 Blind interpretation
 Independent: Index
test is not part of
Gold standard test.

15. Apply Your Appraisal Scheme
Validity
Did the patient sample
include an appropriate
spectrum of patients to
whom the test will be
applied? (Spectrum
Bias)
Tip: From Method Section or Copy the Method
Summary from the Abstract.
 Copy the Inclusion & Exclusion Criteria
 Copy the Study Flow Chart to your
Presentation
Copy the Inclusion &
Exclusion Criteria

16. Apply Your Appraisal Scheme
Validity
Interventions: Were
the test’s method
described
clearly enough to permit
replication?
 Preparation of
patient?
 Performance of test?
 Analysis and
interpretation of
results?
 Test precision and
correctness
 Reproducibility: Inter
& Intra-observer
Bias)

17. Apply Your Appraisal Scheme
Validity
Did investigators
perform the same
reference standard to all
patients regardless of
the results of the test
under investigation?
 Were both reference
standard and test
applied to all
patients?
 Verification (workup)
Bias

18. Apply Your Appraisal Scheme
Results clinical significance (in MP : Magnitude &
Precision)
What likelihood
ratios are
associated
with the range of
possible test
results?
Calculate and interpret LR, Sn and Sp
(Diagnostic and Treatment Thresholds)

19. Summarize the Study Biases
Selection, Attrition, Performance,
Detection Biases, Conflict of
Interest etc.

20. Summarize the Study Strength
Tip: From the Discussion or
Letter to the Editor/Editorial
Comment etc.
E.G.: Number of Patients, Randomization Method,
Least Biases, Statistical Tests used, Outcome
Measures, Ascertainment, Drop-outs, Length of
Follow-up etc.

21. Summarize the Study
Weaknesses
Tip: From the Discussion or
Letter to the Editor/Editorial
Comment etc.
E.G.: Number of Patients, Randomization Method,
Least Biases, Statistical Tests used, Outcome
Measures, Ascertainment, Drop-outs, Length of
Follow-up etc.

22. Summarize the Study
Tip: From the Discussion or
Letter to the Editor/Editorial
Comment etc.

23. Unanswered Questions from the
Study
Tip: From the Discussion or
Letter to the Editor/Editorial
Comment etc.

24. Apply Your Appraisal Scheme
Applicability I (in IPPP: Intervention – Population -
Preferences-Potential Benefits - Harm
Will the test be applicable
and well interpreted in my
practice setting?
 Feasible test
 Trained operator
Are the results applicable
to patients in my practice?
 Similar distribution of
disease severity?
 Compelling reasons
why the results should
not be applied?

25. Apply Your Appraisal Scheme
Applicability I (in IPPP: Intervention – Population -
Preferences-Potential Benefits - Harm
What are your patients
preferences?
 Invasive vs. non
invasive tools
 Costs
Will the reproducibility of
the test result and its
interpretation be
satisfactory in my setting?

26. Applicability
System
Preparedness:
Availability, Cost
etc
Staff Preparedness:
Knowledge, Skill
etc
Patient Factors &
Acceptability:
Similar to study
population,
Preferences, Values
etc

27. Resolution of your PICO
Question
Narrate/Write your PICO Question &
Why is it important.
Summarize the Study Findings
Summarize the weaknesses, biases,
Sens., Specif., LR etc.
Indicate the Level of Evidence &
whether you are going to apply the
findings to your patient.

28. Resolution of your PICO Question:
Recommendations
New Research: Is there a need to do more
research of the subject? Y□ N □
Suggested research if the answer is yes:
Audit: Is there a need to audit your practice?
Y□ N □
Suggest an audit cycle.
Publication: Is it worth publishing your Journal
Club presentation in an EBM CAT journal or
website? May be start your own JC website?

30. Useful Links
 EBM Glossary of Terms: http://www.cebm.net/glossary/
 EBM Calculators:
http://ktclearinghouse.ca/cebm/practise/ca/calculators
 EBM NNT, LR etc. Websites:
 http://ktclearinghouse.ca/cebm/toolbox
 http://www.thennt.com/
 EBM Critical Appraisal Worksheets:
http://ktclearinghouse.ca/cebm/practise/ca/worksheets
 Diagnosis worksheet
 Harm worksheet
 Prognosis worksheet
 Systematic review (of therapy) worksheet
 Therapy worksheet