Table Of ContentCritical Appraisal
from Papers to Patient
A Practical Guide
Critical Appraisal
from Papers to Patient
A Practical Guide
DUNCAN BOOTLAND • EVAN COUGHLAN
ROBERT GALLOWAY • STEPHANIE GOUBET
EMILY MCWHIRTER
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2017 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
Version Date: 20161010
International Standard Book Number-13: 978-1-4822-3045-1 (Paperback)
This book contains information obtained from authentic and highly regarded sources. Reasonable efforts
have been made to publish reliable data and information, but the author and publisher cannot assume
responsibility for the validity of all materials or the consequences of their use. The authors and publishers
have attempted to trace the copyright holders of all material reproduced in this publication and apologize
to copyright holders if permission to publish in this form has not been obtained. If any copyright material
has not been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, trans-
mitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying, microfilming, and recording, or in any information storage or retrieval
system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com
(http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive,
Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registra-
tion for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate
system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Bootland, Duncan, author. | Coughlan, Evan, author. | Galloway, Robert,
author. | Goubet, Stephanie, author. | McWhirter, Emily, author. | Title: Critical
appraisal from papers to patient : a practical guide / Duncan Bootland, Evan
Coughlan, Robert Galloway, Stephanie Goubet, and Emily McWhirter. Description:
Boca Raton : CRC Press, [2017] | Includes bibliographical references. Identifiers:
LCCN 2016026644 (print) | LCCN 2016027455 (ebook) | ISBN 9781482230451 (pbk. :
alk. paper) | ISBN 9781482230475 () Subjects: | MESH: Evidence-Based Medicine |
Test Taking Skills | Statistics as Topic | Examination Questions Classification: LCC
R723.7 (print) | LCC R723.7 (ebook) | NLM WB 18.2 | DDC 616--dc23 LC record
available at https://lccn.loc.gov/2016026644
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents
Foreword ..................................................................................................................vii
Authors ......................................................................................................................ix
Introduction ...............................................................................................................xi
Section 1 Introduction to Critical Appraisal
1 Types of Papers and Grades of Evidence 3
2 An Approach to Appraising Papers 9
Section 2 Basic Statistics
3 Types of Data and Moving from Samples to Populations 21
4 The Statistics Used in Papers 33
5 Basic Probability 43
Section 3 Appraising Different Types of Papers
6 Observational Studies 55
7 Qualitative Papers 67
8 Therapeutic Papers 73
9 Diagnostic Papers and Screening Papers 91
10 Prognostic Papers 113
v
vi Contents
11 Economic Studies 119
12 Meta-Analysis 123
Section 4 Applying the Knowledge
13 Writing a Clinical Topic Review 129
14 Running a Journal Club 133
15 Creating a ‘Best Available’ Evidence-Based Clinical Environment 137
Section 5 Critical Appraisal Exams
16 An Approach to Critical Appraisal Exams 145
17 Practice Papers 153
Glossary 183
Index 197
Foreword
Professor Sir Cyril Chantler, a paediatrician and former chair of the Kings Fund,
once told a parliamentary patient safety committee that “Medicine used to be simple,
ineffective and relatively safe.” Today of course the reverse is true. As it has grown
in capability, medicine has also become more complex, expensive and dangerous.
A century ago, medicine was a thing of fine craft, delivered by individuals guided
as much by dogma as anything else. The efficacy of interventions was determined
largely by the response of individual patients to discrete interventions and an over-
valued sense of the causal connection between the two. Today we know better. We
understand our treatments and their consequences as a thing of statistical probability.
We improve our outcomes largely through marginal gains, finding our survival
advantage in small fractions has spread across large populations. And as a result, for
the inhabitants of high-income countries, life has never been safer or longer lived.
This is a far better world but, consequently, one in which the efficacy of our inter-
ventions is rarely obvious at the end of the bed. In medicine today, the benefits we
deliver and the harm we inflict are largely invisible.
In this world we save lives by knowing the evidence offered to us in published
research, by not being seduced by poorly or falsely constructed arguments, by
designing studies that can tease apart the differences in our outcomes and by under-
standing the limits of the foundation of knowledge on which we base our decisions.
Today, a working knowledge of statistics and the ability to appraise the medi-
cal literature intelligently is as essential to your practice as a knowledge of gross
anatomy. This text represents a brilliant primer and the tools and skills it equips
the clinician with are designed to help them navigate the uncertainties of medical
practice today.
Kevin J. Fong
vii
Authors
Duncan Bootland, MBBS, BSc, FRCEM (@dbootland)
Emergency Medicine Consultant, Brighton and Sussex University Hospitals
NHS Trust
Duncan Bootland trained at University College London and has worked in south-
east England since then. His specialist training was in Emergency Medicine and
Intensive Care, as well as working for Kent, Surrey, Sussex Helicopter Emergency
Medicine Service. He was appointed an emergency medicine consultant in 2012.
Bootland has an excellent reputation in teaching, especially for the Royal College of
Emergency Medicine examinations and in critical appraisal courses.
Evan Coughlan, MB Bch NUI, MRCSEd, DSEM, FRCEM, DipTox (@Evpco)
Emergency Medicine Consultant, Brighton and Sussex University Hospitals
NHS Trust
Evan Coughlan qualified in Ireland and finished his registrar training in the United
Kingdom. He was appointed as a consultant in 2010. His interests are in ultrasound,
trauma and toxicology. He is a passionate and established teacher of critical appraisal
courses. He has also written chapters for several textbooks.
Robert Galloway, MBBS, BSc, MRCP, FRCEM, PGCMedED (@drrobgalloway)
Emergency Medicine Consultant, Brighton and Sussex University Hospitals
NHS Trust, and Honorary Senior Lecturer and Sub-Dean, Brighton and
Sussex Medical School
Robert Galloway trained at St George’s Hospital Medical School, London. He dual
trained in Emergency Medicine and Intensive Care and was appointed an emergency
medicine consultant in 2011. He has a passion for education and has completed a
PGC in medical education. He is a Honorary Senior Lecturer, year five sub-dean
and leads for Emergency Medicine undergraduate education at Brighton and Sussex
Medical School. He has interests in a wide range of academic topics including resus-
citation and human factors. He teaches critical appraisal courses with the aim of
making them relevant to practicing clinicians.
Stephanie Goubet, MSc
Medical Statistician, Brighton and Sussex University Hospitals NHS Trust and
Brighton and Sussex Medical School
Stephanie Goubet came to the Brighton and Sussex University Hospital National
Institute for Health Research Clinical Research Facility from the Department of
Primary Care and Population Health, University College London. While there she
was a member of their Evidence-Based Medicine workshops. She shares her time
between Brighton and Sussex University Hospitals NHS Trust and Brighton and
Sussex Medical School.
ix
