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Critical Appraisal Worksheets 1
Critical Appraisal Worksheets
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Critical Appraisal Worksheets 2
壹 ..Primary Studies
CRI TI CAL REVI EWFORMFOR THERAPY
I . Are the Resul ts Val i d?
1. Was the assi gnment of pati ents to treatments randomi zed?
2. Were al l pati ents who entered the tri al properl y accounted for
and attri buted at i ts concl usi on?
a. Was fol l ow-up compl ete?
b. Were pati ents anal yzed i n the groups to whi ch they were
randomi zed?
3. Were pati ents, cl i ni ci ans, and study personnel "bl i nd" to
treatment?4. Were the groups si mi l ar at the start of the tri al ?
5. Asi de f romthe experi mental i nterventi on, were the groups
treated equal l y?
I I . What Are the Resul ts?
1. How l arge was the treatment effect?
2. How preci se i s the esti mate of the treatment effect?
I I I . Wi l l the Resul ts Hel p Me i n My Pati ent Care?
1. Can the resul ts be appl i ed to my pati ents?2. Were al l cl i ni cal l y i mportant outcomes consi dered?
3. Are the benef i ts worth the harms and costs?
References: J AMA 1993; 270: 2598-2601, J AMA 1994; 271: 59-63
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Critical Appraisal Worksheets 3
CRI TI CAL REVI EWFORMFOR A D AGNOSTIC TEST
I . Are the Resul ts Val i d?
1. Was there an i ndependent, bl i nd compari son wi th a reference
standard?
2. Di d the pati ent sampl e i ncl ude an appropri ate spectrumof
pati ents to whomthe test wi l l be appl i ed?
3. Di d the resul ts of the test bei ng eval uated i nf l uence the
deci si on to performthe reference standard?
4. Were the test methods descri bed cl earl y enough to permi t
repl i cati on?
I I . What Are the Resul ts?
1. What are the l i kel i hood rati os for the test resul ts?I I I . Wi l l the Resul ts Hel p Me I n My Pati ent Care?
1. Wi l l the test be reproduci bl e and wel l i nterpreted i n my
practi ce sett i ng?
2. Are the resul ts appl i cabl e to my pati ents?
3. Wi l l the resul ts change my management?
4. Wi l l my pati ents be better of f because of the test?
References: J AMA 1994; 271: 389-391, J AMA 1994; 271: 703-707
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Critical Appraisal Worksheets 4
CRI TI CAL REVI EWFORMFOR HARM
I . Are the Resul ts Val i d?
1. Except for the exposure under study, were the compared groups
si mi l ar to each other?
2. Were the outcomes and exposures measured i n the same ways i n
both groups?
3. Was the fol l ow-up of pati ents suf f i ci entl y l ong and compl ete?
4. I s the temporal rel ati onshi p correct?
5. I s there a dose-response gradi ent?
I I . What Are the Resul ts?
1. Howst rong i s the associ ati on between exposure and outcome?
2. How preci se i s the esti mate of ri sk?I I I . Wi l l the Resul ts Hel p Me I n My Pati ent Care?
1. Are the resul ts appl i cabl e to my pati ents?
2. What i s the magni tude of the ri sk?
3. Shoul d I attempt to stop the exposure?
Reference: J AMA 1994; 271: 1616-1619
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Critical Appraisal Worksheets 5
CRI TI CAL REVI EWFORMFOR PROGNOSI S
I . Are the Resul ts Val i d?
1. Was there a def i ned representati ve sampl e of pati ents
assembl ed at a si mi l ar poi nt i n the course of the di sease?
2. Was fol l ow-up suf f i ci entl y l ong and compl ete?
3. Were obj ecti ve and unbi ased outcome cri teri a used?
4. Was there adj ustments for i mportant prognost i c factors?
I I . What Are the Resul ts?
1. How l i kel y are the outcomes over t i me?
2. How preci se are the esti mates of prognosi s?
I I I . Wi l l the Resul ts Hel p Me I n My Pati ent Care?
1. Were the study pati ents si mi l ar to my own?2. Wi l l the resul ts l ead di rectl y to sel ecti ng or avoi di ng
therapy?
3. Are the resul ts useful f or counsel i ng pati ents?
Reference: J AMA 1994; 272: 234-237
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Critical Appraisal Worksheets 6
CRITICAL REVIEW FORM ON APPLICABILITY
I . BI OLOGI C:
1. Ar e t her e pat hophysi ol ogi c di f f er ences i n t he
i l l ness under st udy that may l ead t o a di mi ni shed
t r eat ment r esponse?
2. Ar e t her e pat i ent di f f er ences t hat may di mi ni sh t he
t r eat ment r esponse?
I I . SOCI AL AND ECONOMI C:
1. Ar e t her e i mpor t ant di f f er ences i n pat i ent
compl i ance t hat may di mi ni sh t he t r eat ment
r esponse?2. Ar e t her e i mpor t ant di f f er ences i n pr ovi der
compl i ance t hat may di mi ni sh t he t r eat ment
r esponse?
I I I . EPI DEMI OLOGI C:
1. Do my pat i ent s have comorbi d condi t i ons t hat
si gni f i cant l y al t er t he pot ent i al benef i t s and
r i sks of t r eat ment ?2. Ar e t her e i mpor t ant di f f er ences i n unt r eat ed
pat i ent s at r i sk of adver se out comes t hat mi ght
al t er t he ef f i ci ency of t r eat ment ?
Ref erences: J AMA 1994; 271: 389- 391, J AMA 1994; 271: 703- 707
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Critical Appraisal Worksheets 7
貳 ..Integrative Studies
CRI TI CAL REVI EWFORMFOR SYSTEMATI C REVI EW
I . Are the Resul ts Val i d?
1. Di d thi s revi ew address a focused cl i ni cal questi on?
2. Were the cri teri a f or arti cl e i ncl usi on appropri ate?
3. I s i t unl i kel y that rel evant studi es were mi ssed?
4. Was the val i di ty of the i ncl uded studi es apprai sed?
5. Was the assessments of studi es reproduci bl e?
6. Were the resul ts si mi l ar f romstudy to study?
I I . What Are the Resul ts?1. What are the overal l resul ts of the revi ew?
2. How preci se are the resul ts?
I I I . Wi l l the Resul ts Hel p Me I n My Pati ent Care?
1. Can the resul ts be appl i ed to my pati ents?
2. Were al l cl i ni cal l y i mportant outcomes consi dered?
3. Are the benef i ts worth the harms and costs?
References: J AMA 1994; 272: 1367-1371
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Critical Appraisal Worksheets 8
CRITICAL REVIEW FORM FOR A PRACTICE GUIDELINE
I . Ar e t he Resul t s Val i d?
1. Wer e al l i mpor t ant opt i ons and out comes cl ear l y
speci f i ed?
2. Was an expl i ci t and sensi bl e pr ocess used t o
i dent i f y, sel ect , and combi ne t he evi dence?
3. Was an expl i ci t and sensi bl e pr ocess used t o
consi der t he rel at i ve val ue to di f f er ent out comes?
4. I s t he gui del i ne l i kel y t o account f or i mpor t ant
r ecent devel opment s?
5. Has t he gui del i nes been subj ect t o peer r evi ew andt est i ng?
I I . What are t he r ecommendat i ons?
1. Ar e cl ear , pr act i cal , and i mpor t ant
r ecommendat i ons made?
2. How st r ong are t he r ecommendat i ons?
3. Coul d t he uncer t ai nt y i n t he evi dence or val ues
change t he gui del i ne i s r ecommendat i ons?
I I I . Wi l l t he r esul t s hel p me i n car i ng f or my pat i ent s?
1. I s t he obj ect i ve of t he gui del i ne consi st ent wi t h
mi ne?
2. Ar e t he r ecommendat i ons appl i cabl e t o my pat i ent s?
Ref erences: J AMA 1995; 274: 570- 574, J AMA 1995; 274: 1630- 1632
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Critical Appraisal Worksheets 9
CRI TI CAL REVI EWFOR UTI LI ZATI ON REVI EW
I . Are the Cri teri a Val i d?
1. Was an expl i ci t and sensi bl e process used to i denti f y, sel ect,
and combi ne evi dence for the cri teri a?
2. What i s the qual i ty of the evi dence used i n f rami ng the
cri teri a?
3. I f necessary, was an expl i ci t, systemati c, and rel i abl e
process used to tap expert opi ni on?
4. Was an expl i ci t and sensi bl e process used to consi der the
rel ati ve val ues of di f ferent outcomes?
5. I f the qual i ty of the evi dence used i n ori gi nal l y f rami ng the
cri teri a was weak, have the cri teri a themsel ves beencorrel ated wi th pati ent outcomes?
I I . Were the Cri teri a Appl i ed Appropri atel y?
1. Was the process of appl yi ng the cri teri a rel i abl e, unbi ased,
and l i kel y to yi el d robust concl usi ons?
2. What i s the i mpact of uncertai nty associ ated wi th evi dence
and val ues on the cri teri a-based rati ngs of process of care?
I I I . Can You Use the Cri teri a i n Your Practi ce Setti ng?
1. Are the cri teri a rel evant to your practi ce sett i ng?
2. Have the cri teri a been f i el d- tested for f easi bi l i ty of use
i n di verse sett i ngs, i ncl udi ng your own?
References: J AMA 1996; 275: 1435-1439
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Critical Appraisal Worksheets 10
CRITICAL REVIEW FOR HEALTH SERVICES RESEARCH
I . Thr ee I ni t i al Questi ons
1. Wer e t he outcome measur es accur at e and
comprehensi ve?
2. Wer e t her e cl ear l y i dent i f i ed, sensi bl e compar i son
groups?
3. How wel l di d t he compar ed groups mat ch up on
i mpor t ant f act or s t hat can af f ect t he out comes of
a heal t h ser vi ce:
4. Who pr ovi ded t he ser vi ce?
5. What ser vi ce was pr ovi ded?
6. When was t he ser vi ce pr ovi ded?7. Where was t he servi ce pr ovi ded?
8. How was t he servi ce pr ovi ded?
I I . Fur t her Quest i ons
1. Wer e al l i mpor t ant pr ognost i c f act or s measur e?
2. Wer e measur es of pat i ent s¡ ¦ pr ognost i c f act or s
r epr oduci bl e and accur at e?
3. Wer e pat i ent s si mi l ar wi t h r espect t o t hese
f actor s?4. How much di f f erence i n out come(s) r emai ns af t er
adj ust ment f or t he pr ognost i c f act or s?
Ref erences: J AMA 1996; 275: 554- 558
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Critical Appraisal Worksheets 11
CRITICAL REVIEW FORM FOR DECISION ANALYSIS
I . Ar e t he Resul t s Val i d?
1. Were al l i mport ant st r ategi es and out comes
i ncl uded?
2. Was an expl i ci t and sensi bl e pr ocess used t o
assembl e t he evi dence i nt o pr obabi l i t i es?
3. Wer e t he ut i l i t i es obt ai ned i n an expl i ci t and
sensi bl e way f r om credi bl e sour ces?
4. Was t he i mpact of uncert ai nt y i n evi dence expl or ed?
I I . What Ar e t he Resul t s?
1. Does one st r at egy yi el d a cl i ni cal l y i mpor t ant gai n
f or pat i ent s? I f not , i s t he r esul t a "t oss- up"?2. How st r ong i s t he evi dence used i n t he anal ysi s?
3. Coul d uncer t ai nt y i n t he evi dence change t he
r esul t s?
I I I . Wi l l t he Resul t s Hel p Me I n My Pat i ent Car e?
1. Do t he pr obabi l i t i es f i t my pat i ent s¡¦ c l i ni cal
f eat ur es?
2. Do t he ut i l i t i es r ef l ect my pat i ent s¡ ¦ val ues?
Ref erences: J AMA 1995; 273: 1292- 1295,
J AMA 1995; 273: 1610- 1613
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Critical Appraisal Worksheets 12
CRI TI CAL REVI EWFOR ECONOMC ANALYSI S
I . Are the Resul ts Val i d?
1. Di d the anal ysi s provi de a ful l economi c compari son of
heal thcare strategi es?
2. Were the costs and outcomes properl y measured and val ued?
3. Was appropri ate al l owance made for uncertai nti es i n the
anal ysi s?
4. Are est i mates of costs and outcomes rel ated to the basel i ne
ri sk i n the treatment popul ati on?
I I . What Were the Resul ts?
1. What were the i ncremental costs and outcomes of eachstrategy?
2. Do i ncremental costs and outcomes di f fer between subgroups?
3. Howmuch does al l owance for uncertai nty change the resul ts?
I I I . Wi l l the Resul ts Hel p Me I n My Pati ent Care?
1. Are treatment benef i ts worth the harms and costs?
2. Coul d my pati ents expect si mi l ar heal th outcomes?
3. Coul d I expect si mi l ar costs?
References: J AMA 1997; 277: 1552-1557