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  • Published: 31 January 2022

The fundamentals of critically appraising an article

  • Sneha Chotaliya 1  

BDJ Student volume  29 ,  pages 12–13 ( 2022 ) Cite this article

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We are often surrounded by an abundance of research and articles, but the quality and validity can vary massively. Not everything will be of a good quality - or even valid. An important part of reading a paper is first assessing the paper. This is a key skill for all healthcare professionals as anything we read can impact or influence our practice. It is also important to stay up to date with the latest research and findings.

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Chambers R, 'Clinical Effectiveness Made Easy', Oxford: Radcliffe Medical Press , 1998

Loney P L, Chambers L W, Bennett K J, Roberts J G and Stratford P W. Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can 1998; 19 : 170-176.

Brice R. CASP CHECKLISTS - CASP - Critical Appraisal Skills Programme . 2021. Available at: https://casp-uk.net/casp-tools-checklists/ (Accessed 22 July 2021).

White S, Halter M, Hassenkamp A and Mein G. 2021. Critical Appraisal Techniques for Healthcare Literature . St George's, University of London.

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  • Volume 25, Issue 1
  • Critical appraisal of qualitative research: necessity, partialities and the issue of bias
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  • http://orcid.org/0000-0001-5660-8224 Veronika Williams ,
  • Anne-Marie Boylan ,
  • http://orcid.org/0000-0003-4597-1276 David Nunan
  • Nuffield Department of Primary Care Health Sciences , University of Oxford, Radcliffe Observatory Quarter , Oxford , UK
  • Correspondence to Dr Veronika Williams, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; veronika.williams{at}phc.ox.ac.uk

https://doi.org/10.1136/bmjebm-2018-111132

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  • qualitative research

Introduction

Qualitative evidence allows researchers to analyse human experience and provides useful exploratory insights into experiential matters and meaning, often explaining the ‘how’ and ‘why’. As we have argued previously 1 , qualitative research has an important place within evidence-based healthcare, contributing to among other things policy on patient safety, 2 prescribing, 3 4 and understanding chronic illness. 5 Equally, it offers additional insight into quantitative studies, explaining contextual factors surrounding a successful intervention or why an intervention might have ‘failed’ or ‘succeeded’ where effect sizes cannot. It is for these reasons that the MRC strongly recommends including qualitative evaluations when developing and evaluating complex interventions. 6

Critical appraisal of qualitative research

Is it necessary.

Although the importance of qualitative research to improve health services and care is now increasingly widely supported (discussed in paper 1), the role of appraising the quality of qualitative health research is still debated. 8 10 Despite a large body of literature focusing on appraisal and rigour, 9 11–15 often referred to as ‘trustworthiness’ 16 in qualitative research, there remains debate about how to —and even whether to—critically appraise qualitative research. 8–10 17–19 However, if we are to make a case for qualitative research as integral to evidence-based healthcare, then any argument to omit a crucial element of evidence-based practice is difficult to justify. That being said, simply applying the standards of rigour used to appraise studies based on the positivist paradigm (Positivism depends on quantifiable observations to test hypotheses and assumes that the researcher is independent of the study. Research situated within a positivist paradigm isbased purely on facts and consider the world to be external and objective and is concerned with validity, reliability and generalisability as measures of rigour.) would be misplaced given the different epistemological underpinnings of the two types of data.

Given its scope and its place within health research, the robust and systematic appraisal of qualitative research to assess its trustworthiness is as paramount to its implementation in clinical practice as any other type of research. It is important to appraise different qualitative studies in relation to the specific methodology used because the methodological approach is linked to the ‘outcome’ of the research (eg, theory development, phenomenological understandings and credibility of findings). Moreover, appraisal needs to go beyond merely describing the specific details of the methods used (eg, how data were collected and analysed), with additional focus needed on the overarching research design and its appropriateness in accordance with the study remit and objectives.

Poorly conducted qualitative research has been described as ‘worthless, becomes fiction and loses its utility’. 20 However, without a deep understanding of concepts of quality in qualitative research or at least an appropriate means to assess its quality, good qualitative research also risks being dismissed, particularly in the context of evidence-based healthcare where end users may not be well versed in this paradigm.

How is appraisal currently performed?

Appraising the quality of qualitative research is not a new concept—there are a number of published appraisal tools, frameworks and checklists in existence. 21–23  An important and often overlooked point is the confusion between tools designed for appraising methodological quality and reporting guidelines designed to assess the quality of methods reporting. An example is the Consolidate Criteria for Reporting Qualitative Research (COREQ) 24 checklist, which was designed to provide standards for authors when reporting qualitative research but is often mistaken for a methods appraisal tool. 10

Broadly speaking there are two types of critical appraisal approaches for qualitative research: checklists and frameworks. Checklists have often been criticised for confusing quality in qualitative research with ‘technical fixes’ 21 25 , resulting in the erroneous prioritisation of particular aspects of methodological processes over others (eg, multiple coding and triangulation). It could be argued that a checklist approach adopts the positivist paradigm, where the focus is on objectively assessing ‘quality’ where the assumptions is that the researcher is independent of the research conducted. This may result in the application of quantitative understandings of bias in order to judge aspects of recruitment, sampling, data collection and analysis in qualitative research papers. One of the most widely used appraisal tools is the Critical Appraisal Skills Programme (CASP) 26 and along with the JBI QARI (Joanna Briggs Institute Qualitative Assessment and Assessment Instrument) 27 presents examples which tend to mimic the quantitative approach to appraisal. The CASP qualitative tool follows that of other CASP appraisal tools for quantitative research designs developed in the 1990s. The similarities are therefore unsurprising given the status of qualitative research at that time.

Frameworks focus on the overarching concepts of quality in qualitative research, including transparency, reflexivity, dependability and transferability (see box 1 ). 11–13 15 16 20 28 However, unless the reader is familiar with these concepts—their meaning and impact, and how to interpret them—they will have difficulty applying them when critically appraising a paper.

The main issue concerning currently available checklist and framework appraisal methods is that they take a broad brush approach to ‘qualitative’ research as whole, with few, if any, sufficiently differentiating between the different methodological approaches (eg, Grounded Theory, Interpretative Phenomenology, Discourse Analysis) nor different methods of data collection (interviewing, focus groups and observations). In this sense, it is akin to taking the entire field of ‘quantitative’ study designs and applying a single method or tool for their quality appraisal. In the case of qualitative research, checklists, therefore, offer only a blunt and arguably ineffective tool and potentially promote an incomplete understanding of good ‘quality’ in qualitative research. Likewise, current framework methods do not take into account how concepts differ in their application across the variety of qualitative approaches and, like checklists, they also do not differentiate between different qualitative methodologies.

On the need for specific appraisal tools

Current approaches to the appraisal of the methodological rigour of the differing types of qualitative research converge towards checklists or frameworks. More importantly, the current tools do not explicitly acknowledge the prejudices that may be present in the different types of qualitative research.

Concepts of rigour or trustworthiness within qualitative research 31

Transferability: the extent to which the presented study allows readers to make connections between the study’s data and wider community settings, ie, transfer conceptual findings to other contexts.

Credibility: extent to which a research account is believable and appropriate, particularly in relation to the stories told by participants and the interpretations made by the researcher.

Reflexivity: refers to the researchers’ engagement of continuous examination and explanation of how they have influenced a research project from choosing a research question to sampling, data collection, analysis and interpretation of data.

Transparency: making explicit the whole research process from sampling strategies, data collection to analysis. The rationale for decisions made is as important as the decisions themselves.

However, we often talk about these concepts in general terms, and it might be helpful to give some explicit examples of how the ‘technical processes’ affect these, for example, partialities related to:

Selection: recruiting participants via gatekeepers, such as healthcare professionals or clinicians, who may select them based on whether they believe them to be ‘good’ participants for interviews/focus groups.

Data collection: poor interview guide with closed questions which encourage yes/no answers and/leading questions.

Reflexivity and transparency: where researchers may focus their analysis on preconceived ideas rather than ground their analysis in the data and do not reflect on the impact of this in a transparent way.

The lack of tailored, method-specific appraisal tools has potentially contributed to the poor uptake and use of qualitative research for informing evidence-based decision making. To improve this situation, we propose the need for more robust quality appraisal tools that explicitly encompass both the core design aspects of all qualitative research (sampling/data collection/analysis) but also considered the specific partialities that can be presented with different methodological approaches. Such tools might draw on the strengths of current frameworks and checklists while providing users with sufficient understanding of concepts of rigour in relation to the different types of qualitative methods. We provide an outline of such tools in the third and final paper in this series.

As qualitative research becomes ever more embedded in health science research, and in order for that research to have better impact on healthcare decisions, we need to rethink critical appraisal and develop tools that allow differentiated evaluations of the myriad of qualitative methodological approaches rather than continuing to treat qualitative research as a single unified approach.

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  • ↵ CASP (Critical Appraisal Skills Programme). date unknown . http://www.phru.nhs.uk/Pages/PHD/CASP.htm .
  • ↵ The Joanna Briggs Institute . JBI QARI Critical appraisal checklist for interpretive & critical research . Adelaide : The Joanna Briggs Institute , 2014 .
  • Stephens J ,

Contributors VW and DN: conceived the idea for this article. VW: wrote the first draft. AMB and DN: contributed to the final draft. All authors approve the submitted article.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Correction notice This article has been updated since its original publication to include a new reference (reference 1.)

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The following video (4 min 5 sec.) considers the background knowledge needed to critically appraise a qualitative study. Includes what critical appraisal means, and the tools available to help carry out critical appraisal.

Appraisal of qualitative research using a CASP checklist

The following video (3 min. 5 sec.) summarizes what to look for in a piece of qualitative research, and an introduction to the CASP checklist for qualitative research. 

Critical appraisal of qualitative research (webinar)

The following is a recording of a webinar, based upon the critical appraisal of qualitative research, using a CASP checklist:

'Focus on' videos (qualitative research)

The following videos (all approx. 4-9 min.) focus on particular aspects of critical appraisal methodology for qualitative studies.

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Appraisal of a Qualitative paper : Top tips

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Critical appraisal of a qualitative paper

This guide aimed at health students, provides basic level support for appraising qualitative research papers. It's designed for students who have already attended lectures on critical appraisal. One framework  for appraising qualitative research (based on 4 aspects of trustworthiness) is  provided and there is an opportunity to practise the technique on a sample article.

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To practise following this framework for critically appraising a qualitative article, please look at the following article:

Schellekens, M.P.J.  et al  (2016) 'A qualitative study on mindfulness-based stress reduction for breast cancer patients: how women experience participating with fellow patients',  Support Care Cancer , 24(4), pp. 1813-1820.

Critical appraisal of a qualitative paper: practical example.

  • Credibility
  • Transferability
  • Dependability
  • Confirmability

How to use this practical example 

Using the framework, you can have a go at appraising a qualitative paper - we are going to look at the following article: 

Step 1.  take a quick look at the article, step 2.  click on the credibility tab above - there are questions to help you appraise the trustworthiness of the article, read the questions and look for the answers in the article. , step 3.   click on each question and our answers will appear., step 4.    repeat with the other aspects of trustworthiness: transferability, dependability and confirmability ., questioning the credibility:, who is the researcher what has been their experience how well do they know this research area, was the best method chosen what method did they use was there any justification was the method scrutinised by peers is it a recognisable method was there triangulation ( more than one method used), how was the data collected was data collected from the participants at more than one time point how long were the interviews were questions asked to the participants in different ways, is the research reporting what the participants actually said were the participants shown transcripts / notes of the interviews / observations to ‘check’ for accuracy are direct quotes used from a variety of participants, how would you rate the overall credibility, questioning the transferability, was a meaningful sample obtained how many people were included is the sample diverse how were they selected, are the demographics given, does the research cover diverse viewpoints do the results include negative cases was data saturation reached, what is the overall transferability can the research be transferred to other settings , questioning the dependability :, how transparent is the audit trail can you follow the research steps are the decisions made transparent is the whole process explained in enough detail did the researcher keep a field diary is there a clear limitations section, was there peer scrutiny of the researchwas the research plan shown to peers / colleagues for approval and/or feedback did two or more researchers independently judge data, how would you rate the overall dependability would the results be similar if the study was repeated how consistent are the data and findings, questioning the confirmability :, is the process of analysis described in detail is a method of analysis named or described is there sufficient detail, have any checks taken place was there cross-checking of themes was there a team of researchers, has the researcher reflected on possible bias is there a reflexive diary, giving a detailed log of thoughts, ideas and assumptions, how do you rate the overall confirmability has the researcher attempted to limit bias, questioning the overall trustworthiness :, overall how trustworthy is the research, further information.

See Useful resources  for links, books and LibGuides to help with Critical appraisal.

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critical appraisal essay using casp

“The purpose of critical appraisal is to determine the scientific merit of a research report and its applicability to clinical decision making.” 1 Conducting a critical appraisal of a study is imperative to any well executed evidence review, but the process can be time consuming and difficult. 2 The critical appraisal process requires “a methodological approach coupled with the right tools and skills to match these methods is essential for finding meaningful results.” 3 In short, it is a method of differentiating good research from bad research.

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  • AMSTAR 2 The original AMSTAR was developed to assess the risk of bias in systematic reviews that included only randomized controlled trials. AMSTAR 2 was published in 2017 and allows researchers to “identify high quality systematic reviews, including those based on non-randomised studies of healthcare interventions.” 4 more... less... AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews)
  • ROBIS ROBIS is a tool designed specifically to assess the risk of bias in systematic reviews. “The tool is completed in three phases: (1) assess relevance(optional), (2) identify concerns with the review process, and (3) judge risk of bias in the review. Signaling questions are included to help assess specific concerns about potential biases with the review.” 5 more... less... ROBIS (Risk of Bias in Systematic Reviews)
  • BMJ Framework for Assessing Systematic Reviews This framework provides a checklist that is used to evaluate the quality of a systematic review.
  • CASP Checklist for Systematic Reviews This CASP checklist is not a scoring system, but rather a method of appraising systematic reviews by considering: 1. Are the results of the study valid? 2. What are the results? 3. Will the results help locally? more... less... CASP (Critical Appraisal Skills Programme)
  • CEBM Systematic Reviews Critical Appraisal Sheet The CEBM’s critical appraisal sheets are designed to help you appraise the reliability, importance, and applicability of clinical evidence. more... less... CEBM (Centre for Evidence-Based Medicine)
  • JBI Critical Appraisal Tools, Checklist for Systematic Reviews JBI Critical Appraisal Tools help you assess the methodological quality of a study and to determine the extent to which study has addressed the possibility of bias in its design, conduct and analysis.
  • NHLBI Study Quality Assessment of Systematic Reviews and Meta-Analyses The NHLBI’s quality assessment tools were designed to assist reviewers in focusing on concepts that are key for critical appraisal of the internal validity of a study. more... less... NHLBI (National Heart, Lung, and Blood Institute)
  • RoB 2 RoB 2 “provides a framework for assessing the risk of bias in a single estimate of an intervention effect reported from a randomized trial,” rather than the entire trial. 6 more... less... RoB 2 (revised tool to assess Risk of Bias in randomized trials)
  • CASP Randomised Controlled Trials Checklist This CASP checklist considers various aspects of an RCT that require critical appraisal: 1. Is the basic study design valid for a randomized controlled trial? 2. Was the study methodologically sound? 3. What are the results? 4. Will the results help locally? more... less... CASP (Critical Appraisal Skills Programme)
  • CONSORT Statement The CONSORT checklist includes 25 items to determine the quality of randomized controlled trials. “Critical appraisal of the quality of clinical trials is possible only if the design, conduct, and analysis of RCTs are thoroughly and accurately described in the report.” 7 more... less... CONSORT (Consolidated Standards of Reporting Trials)
  • NHLBI Study Quality Assessment of Controlled Intervention Studies The NHLBI’s quality assessment tools were designed to assist reviewers in focusing on concepts that are key for critical appraisal of the internal validity of a study. more... less... NHLBI (National Heart, Lung, and Blood Institute)
  • JBI Critical Appraisal Tools Checklist for Randomized Controlled Trials JBI Critical Appraisal Tools help you assess the methodological quality of a study and to determine the extent to which study has addressed the possibility of bias in its design, conduct and analysis.
  • ROBINS-I ROBINS-I is a “tool for evaluating risk of bias in estimates of the comparative effectiveness… of interventions from studies that did not use randomization to allocate units… to comparison groups.” 8 more... less... ROBINS-I (Risk Of Bias in Non-randomized Studies – of Interventions)
  • NOS This tool is used primarily to evaluate and appraise case-control or cohort studies. more... less... NOS (Newcastle-Ottawa Scale)
  • AXIS Cross-sectional studies are frequently used as an evidence base for diagnostic testing, risk factors for disease, and prevalence studies. “The AXIS tool focuses mainly on the presented [study] methods and results.” 9 more... less... AXIS (Appraisal tool for Cross-Sectional Studies)
  • NHLBI Study Quality Assessment Tools for Non-Randomized Studies The NHLBI’s quality assessment tools were designed to assist reviewers in focusing on concepts that are key for critical appraisal of the internal validity of a study. • Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies • Quality Assessment of Case-Control Studies • Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group • Quality Assessment Tool for Case Series Studies more... less... NHLBI (National Heart, Lung, and Blood Institute)
  • Case Series Studies Quality Appraisal Checklist Developed by the Institute of Health Economics (Canada), the checklist is comprised of 20 questions to assess “the robustness of the evidence of uncontrolled, [case series] studies.” 10
  • Methodological Quality and Synthesis of Case Series and Case Reports In this paper, Dr. Murad and colleagues “present a framework for appraisal, synthesis and application of evidence derived from case reports and case series.” 11
  • MINORS The MINORS instrument contains 12 items and was developed for evaluating the quality of observational or non-randomized studies. 12 This tool may be of particular interest to researchers who would like to critically appraise surgical studies. more... less... MINORS (Methodological Index for Non-Randomized Studies)
  • JBI Critical Appraisal Tools for Non-Randomized Trials JBI Critical Appraisal Tools help you assess the methodological quality of a study and to determine the extent to which study has addressed the possibility of bias in its design, conduct and analysis. • Checklist for Analytical Cross Sectional Studies • Checklist for Case Control Studies • Checklist for Case Reports • Checklist for Case Series • Checklist for Cohort Studies
  • QUADAS-2 The QUADAS-2 tool “is designed to assess the quality of primary diagnostic accuracy studies… [it] consists of 4 key domains that discuss patient selection, index test, reference standard, and flow of patients through the study and timing of the index tests and reference standard.” 13 more... less... QUADAS-2 (a revised tool for the Quality Assessment of Diagnostic Accuracy Studies)
  • JBI Critical Appraisal Tools Checklist for Diagnostic Test Accuracy Studies JBI Critical Appraisal Tools help you assess the methodological quality of a study and to determine the extent to which study has addressed the possibility of bias in its design, conduct and analysis.
  • STARD 2015 The authors of the standards note that “[e]ssential elements of [diagnostic accuracy] study methods are often poorly described and sometimes completely omitted, making both critical appraisal and replication difficult, if not impossible.”10 The Standards for the Reporting of Diagnostic Accuracy Studies was developed “to help… improve completeness and transparency in reporting of diagnostic accuracy studies.” 14 more... less... STARD 2015 (Standards for the Reporting of Diagnostic Accuracy Studies)
  • CASP Diagnostic Study Checklist This CASP checklist considers various aspects of diagnostic test studies including: 1. Are the results of the study valid? 2. What were the results? 3. Will the results help locally? more... less... CASP (Critical Appraisal Skills Programme)
  • CEBM Diagnostic Critical Appraisal Sheet The CEBM’s critical appraisal sheets are designed to help you appraise the reliability, importance, and applicability of clinical evidence. more... less... CEBM (Centre for Evidence-Based Medicine)
  • SYRCLE’s RoB “[I]mplementation of [SYRCLE’s RoB tool] will facilitate and improve critical appraisal of evidence from animal studies. This may… enhance the efficiency of translating animal research into clinical practice and increase awareness of the necessity of improving the methodological quality of animal studies.” 15 more... less... SYRCLE’s RoB (SYstematic Review Center for Laboratory animal Experimentation’s Risk of Bias)
  • ARRIVE 2.0 “The [ARRIVE 2.0] guidelines are a checklist of information to include in a manuscript to ensure that publications [on in vivo animal studies] contain enough information to add to the knowledge base.” 16 more... less... ARRIVE 2.0 (Animal Research: Reporting of In Vivo Experiments)
  • Critical Appraisal of Studies Using Laboratory Animal Models This article provides “an approach to critically appraising papers based on the results of laboratory animal experiments,” and discusses various “bias domains” in the literature that critical appraisal can identify. 17
  • CEBM Critical Appraisal of Qualitative Studies Sheet The CEBM’s critical appraisal sheets are designed to help you appraise the reliability, importance and applicability of clinical evidence. more... less... CEBM (Centre for Evidence-Based Medicine)
  • CASP Qualitative Studies Checklist This CASP checklist considers various aspects of qualitative research studies including: 1. Are the results of the study valid? 2. What were the results? 3. Will the results help locally? more... less... CASP (Critical Appraisal Skills Programme)
  • Quality Assessment and Risk of Bias Tool Repository Created by librarians at Duke University, this extensive listing contains over 100 commonly used risk of bias tools that may be sorted by study type.
  • Latitudes Network A library of risk of bias tools for use in evidence syntheses that provides selection help and training videos.

References & Recommended Reading

1.     Kolaski, K., Logan, L. R., & Ioannidis, J. P. (2024). Guidance to best tools and practices for systematic reviews .  British Journal of Pharmacology ,  181 (1), 180-210

2.    Portney LG.  Foundations of clinical research : applications to evidence-based practice.  Fourth edition. ed. Philadelphia: F A Davis; 2020.

3.     Fowkes FG, Fulton PM.  Critical appraisal of published research: introductory guidelines.   BMJ (Clinical research ed).  1991;302(6785):1136-1140.

4.     Singh S.  Critical appraisal skills programme.   Journal of Pharmacology and Pharmacotherapeutics.  2013;4(1):76-77.

5.     Shea BJ, Reeves BC, Wells G, et al.  AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both.   BMJ (Clinical research ed).  2017;358:j4008.

6.     Whiting P, Savovic J, Higgins JPT, et al.  ROBIS: A new tool to assess risk of bias in systematic reviews was developed.   Journal of clinical epidemiology.  2016;69:225-234.

7.     Sterne JAC, Savovic J, Page MJ, et al.  RoB 2: a revised tool for assessing risk of bias in randomised trials.  BMJ (Clinical research ed).  2019;366:l4898.

8.     Moher D, Hopewell S, Schulz KF, et al.  CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting parallel group randomised trials.  Journal of clinical epidemiology.  2010;63(8):e1-37.

9.     Sterne JA, Hernan MA, Reeves BC, et al.  ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.  BMJ (Clinical research ed).  2016;355:i4919.

10.     Downes MJ, Brennan ML, Williams HC, Dean RS.  Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS).   BMJ open.  2016;6(12):e011458.

11.   Guo B, Moga C, Harstall C, Schopflocher D.  A principal component analysis is conducted for a case series quality appraisal checklist.   Journal of clinical epidemiology.  2016;69:199-207.e192.

12.   Murad MH, Sultan S, Haffar S, Bazerbachi F.  Methodological quality and synthesis of case series and case reports.  BMJ evidence-based medicine.  2018;23(2):60-63.

13.   Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J.  Methodological index for non-randomized studies (MINORS): development and validation of a new instrument.   ANZ journal of surgery.  2003;73(9):712-716.

14.   Whiting PF, Rutjes AWS, Westwood ME, et al.  QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.   Annals of internal medicine.  2011;155(8):529-536.

15.   Bossuyt PM, Reitsma JB, Bruns DE, et al.  STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies.   BMJ (Clinical research ed).  2015;351:h5527.

16.   Hooijmans CR, Rovers MM, de Vries RBM, Leenaars M, Ritskes-Hoitinga M, Langendam MW.  SYRCLE's risk of bias tool for animal studies.   BMC medical research methodology.  2014;14:43.

17.   Percie du Sert N, Ahluwalia A, Alam S, et al.  Reporting animal research: Explanation and elaboration for the ARRIVE guidelines 2.0.  PLoS biology.  2020;18(7):e3000411.

18.   O'Connor AM, Sargeant JM.  Critical appraisal of studies using laboratory animal models.   ILAR journal.  2014;55(3):405-417.

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  • v.11(5); 2017 May

Critical Appraisal of Clinical Research

Azzam al-jundi.

1 Professor, Department of Orthodontics, King Saud bin Abdul Aziz University for Health Sciences-College of Dentistry, Riyadh, Kingdom of Saudi Arabia.

Salah Sakka

2 Associate Professor, Department of Oral and Maxillofacial Surgery, Al Farabi Dental College, Riyadh, KSA.

Evidence-based practice is the integration of individual clinical expertise with the best available external clinical evidence from systematic research and patient’s values and expectations into the decision making process for patient care. It is a fundamental skill to be able to identify and appraise the best available evidence in order to integrate it with your own clinical experience and patients values. The aim of this article is to provide a robust and simple process for assessing the credibility of articles and their value to your clinical practice.

Introduction

Decisions related to patient value and care is carefully made following an essential process of integration of the best existing evidence, clinical experience and patient preference. Critical appraisal is the course of action for watchfully and systematically examining research to assess its reliability, value and relevance in order to direct professionals in their vital clinical decision making [ 1 ].

Critical appraisal is essential to:

  • Combat information overload;
  • Identify papers that are clinically relevant;
  • Continuing Professional Development (CPD).

Carrying out Critical Appraisal:

Assessing the research methods used in the study is a prime step in its critical appraisal. This is done using checklists which are specific to the study design.

Standard Common Questions:

  • What is the research question?
  • What is the study type (design)?
  • Selection issues.
  • What are the outcome factors and how are they measured?
  • What are the study factors and how are they measured?
  • What important potential confounders are considered?
  • What is the statistical method used in the study?
  • Statistical results.
  • What conclusions did the authors reach about the research question?
  • Are ethical issues considered?

The Critical Appraisal starts by double checking the following main sections:

I. Overview of the paper:

  • The publishing journal and the year
  • The article title: Does it state key trial objectives?
  • The author (s) and their institution (s)

The presence of a peer review process in journal acceptance protocols also adds robustness to the assessment criteria for research papers and hence would indicate a reduced likelihood of publication of poor quality research. Other areas to consider may include authors’ declarations of interest and potential market bias. Attention should be paid to any declared funding or the issue of a research grant, in order to check for a conflict of interest [ 2 ].

II. ABSTRACT: Reading the abstract is a quick way of getting to know the article and its purpose, major procedures and methods, main findings, and conclusions.

  • Aim of the study: It should be well and clearly written.
  • Materials and Methods: The study design and type of groups, type of randomization process, sample size, gender, age, and procedure rendered to each group and measuring tool(s) should be evidently mentioned.
  • Results: The measured variables with their statistical analysis and significance.
  • Conclusion: It must clearly answer the question of interest.

III. Introduction/Background section:

An excellent introduction will thoroughly include references to earlier work related to the area under discussion and express the importance and limitations of what is previously acknowledged [ 2 ].

-Why this study is considered necessary? What is the purpose of this study? Was the purpose identified before the study or a chance result revealed as part of ‘data searching?’

-What has been already achieved and how does this study be at variance?

-Does the scientific approach outline the advantages along with possible drawbacks associated with the intervention or observations?

IV. Methods and Materials section : Full details on how the study was actually carried out should be mentioned. Precise information is given on the study design, the population, the sample size and the interventions presented. All measurements approaches should be clearly stated [ 3 ].

V. Results section : This section should clearly reveal what actually occur to the subjects. The results might contain raw data and explain the statistical analysis. These can be shown in related tables, diagrams and graphs.

VI. Discussion section : This section should include an absolute comparison of what is already identified in the topic of interest and the clinical relevance of what has been newly established. A discussion on a possible related limitations and necessitation for further studies should also be indicated.

Does it summarize the main findings of the study and relate them to any deficiencies in the study design or problems in the conduct of the study? (This is called intention to treat analysis).

  • Does it address any source of potential bias?
  • Are interpretations consistent with the results?
  • How are null findings interpreted?
  • Does it mention how do the findings of this study relate to previous work in the area?
  • Can they be generalized (external validity)?
  • Does it mention their clinical implications/applicability?
  • What are the results/outcomes/findings applicable to and will they affect a clinical practice?
  • Does the conclusion answer the study question?
  • -Is the conclusion convincing?
  • -Does the paper indicate ethics approval?
  • -Can you identify potential ethical issues?
  • -Do the results apply to the population in which you are interested?
  • -Will you use the results of the study?

Once you have answered the preliminary and key questions and identified the research method used, you can incorporate specific questions related to each method into your appraisal process or checklist.

1-What is the research question?

For a study to gain value, it should address a significant problem within the healthcare and provide new or meaningful results. Useful structure for assessing the problem addressed in the article is the Problem Intervention Comparison Outcome (PICO) method [ 3 ].

P = Patient or problem: Patient/Problem/Population:

It involves identifying if the research has a focused question. What is the chief complaint?

E.g.,: Disease status, previous ailments, current medications etc.,

I = Intervention: Appropriately and clearly stated management strategy e.g.,: new diagnostic test, treatment, adjunctive therapy etc.,

C= Comparison: A suitable control or alternative

E.g.,: specific and limited to one alternative choice.

O= Outcomes: The desired results or patient related consequences have to be identified. e.g.,: eliminating symptoms, improving function, esthetics etc.,

The clinical question determines which study designs are appropriate. There are five broad categories of clinical questions, as shown in [ Table/Fig-1 ].

[Table/Fig-1]:

Categories of clinical questions and the related study designs.

2- What is the study type (design)?

The study design of the research is fundamental to the usefulness of the study.

In a clinical paper the methodology employed to generate the results is fully explained. In general, all questions about the related clinical query, the study design, the subjects and the correlated measures to reduce bias and confounding should be adequately and thoroughly explored and answered.

Participants/Sample Population:

Researchers identify the target population they are interested in. A sample population is therefore taken and results from this sample are then generalized to the target population.

The sample should be representative of the target population from which it came. Knowing the baseline characteristics of the sample population is important because this allows researchers to see how closely the subjects match their own patients [ 4 ].

Sample size calculation (Power calculation): A trial should be large enough to have a high chance of detecting a worthwhile effect if it exists. Statisticians can work out before the trial begins how large the sample size should be in order to have a good chance of detecting a true difference between the intervention and control groups [ 5 ].

  • Is the sample defined? Human, Animals (type); what population does it represent?
  • Does it mention eligibility criteria with reasons?
  • Does it mention where and how the sample were recruited, selected and assessed?
  • Does it mention where was the study carried out?
  • Is the sample size justified? Rightly calculated? Is it adequate to detect statistical and clinical significant results?
  • Does it mention a suitable study design/type?
  • Is the study type appropriate to the research question?
  • Is the study adequately controlled? Does it mention type of randomization process? Does it mention the presence of control group or explain lack of it?
  • Are the samples similar at baseline? Is sample attrition mentioned?
  • All studies report the number of participants/specimens at the start of a study, together with details of how many of them completed the study and reasons for incomplete follow up if there is any.
  • Does it mention who was blinded? Are the assessors and participants blind to the interventions received?
  • Is it mentioned how was the data analysed?
  • Are any measurements taken likely to be valid?

Researchers use measuring techniques and instruments that have been shown to be valid and reliable.

Validity refers to the extent to which a test measures what it is supposed to measure.

(the extent to which the value obtained represents the object of interest.)

  • -Soundness, effectiveness of the measuring instrument;
  • -What does the test measure?
  • -Does it measure, what it is supposed to be measured?
  • -How well, how accurately does it measure?

Reliability: In research, the term reliability means “repeatability” or “consistency”

Reliability refers to how consistent a test is on repeated measurements. It is important especially if assessments are made on different occasions and or by different examiners. Studies should state the method for assessing the reliability of any measurements taken and what the intra –examiner reliability was [ 6 ].

3-Selection issues:

The following questions should be raised:

  • - How were subjects chosen or recruited? If not random, are they representative of the population?
  • - Types of Blinding (Masking) Single, Double, Triple?
  • - Is there a control group? How was it chosen?
  • - How are patients followed up? Who are the dropouts? Why and how many are there?
  • - Are the independent (predictor) and dependent (outcome) variables in the study clearly identified, defined, and measured?
  • - Is there a statement about sample size issues or statistical power (especially important in negative studies)?
  • - If a multicenter study, what quality assurance measures were employed to obtain consistency across sites?
  • - Are there selection biases?
  • • In a case-control study, if exercise habits to be compared:
  • - Are the controls appropriate?
  • - Were records of cases and controls reviewed blindly?
  • - How were possible selection biases controlled (Prevalence bias, Admission Rate bias, Volunteer bias, Recall bias, Lead Time bias, Detection bias, etc.,)?
  • • Cross Sectional Studies:
  • - Was the sample selected in an appropriate manner (random, convenience, etc.,)?
  • - Were efforts made to ensure a good response rate or to minimize the occurrence of missing data?
  • - Were reliability (reproducibility) and validity reported?
  • • In an intervention study, how were subjects recruited and assigned to groups?
  • • In a cohort study, how many reached final follow-up?
  • - Are the subject’s representatives of the population to which the findings are applied?
  • - Is there evidence of volunteer bias? Was there adequate follow-up time?
  • - What was the drop-out rate?
  • - Any shortcoming in the methodology can lead to results that do not reflect the truth. If clinical practice is changed on the basis of these results, patients could be harmed.

Researchers employ a variety of techniques to make the methodology more robust, such as matching, restriction, randomization, and blinding [ 7 ].

Bias is the term used to describe an error at any stage of the study that was not due to chance. Bias leads to results in which there are a systematic deviation from the truth. As bias cannot be measured, researchers need to rely on good research design to minimize bias [ 8 ]. To minimize any bias within a study the sample population should be representative of the population. It is also imperative to consider the sample size in the study and identify if the study is adequately powered to produce statistically significant results, i.e., p-values quoted are <0.05 [ 9 ].

4-What are the outcome factors and how are they measured?

  • -Are all relevant outcomes assessed?
  • -Is measurement error an important source of bias?

5-What are the study factors and how are they measured?

  • -Are all the relevant study factors included in the study?
  • -Have the factors been measured using appropriate tools?

Data Analysis and Results:

- Were the tests appropriate for the data?

- Are confidence intervals or p-values given?

  • How strong is the association between intervention and outcome?
  • How precise is the estimate of the risk?
  • Does it clearly mention the main finding(s) and does the data support them?
  • Does it mention the clinical significance of the result?
  • Is adverse event or lack of it mentioned?
  • Are all relevant outcomes assessed?
  • Was the sample size adequate to detect a clinically/socially significant result?
  • Are the results presented in a way to help in health policy decisions?
  • Is there measurement error?
  • Is measurement error an important source of bias?

Confounding Factors:

A confounder has a triangular relationship with both the exposure and the outcome. However, it is not on the causal pathway. It makes it appear as if there is a direct relationship between the exposure and the outcome or it might even mask an association that would otherwise have been present [ 9 ].

6- What important potential confounders are considered?

  • -Are potential confounders examined and controlled for?
  • -Is confounding an important source of bias?

7- What is the statistical method in the study?

  • -Are the statistical methods described appropriate to compare participants for primary and secondary outcomes?
  • -Are statistical methods specified insufficient detail (If I had access to the raw data, could I reproduce the analysis)?
  • -Were the tests appropriate for the data?
  • -Are confidence intervals or p-values given?
  • -Are results presented as absolute risk reduction as well as relative risk reduction?

Interpretation of p-value:

The p-value refers to the probability that any particular outcome would have arisen by chance. A p-value of less than 1 in 20 (p<0.05) is statistically significant.

  • When p-value is less than significance level, which is usually 0.05, we often reject the null hypothesis and the result is considered to be statistically significant. Conversely, when p-value is greater than 0.05, we conclude that the result is not statistically significant and the null hypothesis is accepted.

Confidence interval:

Multiple repetition of the same trial would not yield the exact same results every time. However, on average the results would be within a certain range. A 95% confidence interval means that there is a 95% chance that the true size of effect will lie within this range.

8- Statistical results:

  • -Do statistical tests answer the research question?

Are statistical tests performed and comparisons made (data searching)?

Correct statistical analysis of results is crucial to the reliability of the conclusions drawn from the research paper. Depending on the study design and sample selection method employed, observational or inferential statistical analysis may be carried out on the results of the study.

It is important to identify if this is appropriate for the study [ 9 ].

  • -Was the sample size adequate to detect a clinically/socially significant result?
  • -Are the results presented in a way to help in health policy decisions?

Clinical significance:

Statistical significance as shown by p-value is not the same as clinical significance. Statistical significance judges whether treatment effects are explicable as chance findings, whereas clinical significance assesses whether treatment effects are worthwhile in real life. Small improvements that are statistically significant might not result in any meaningful improvement clinically. The following questions should always be on mind:

  • -If the results are statistically significant, do they also have clinical significance?
  • -If the results are not statistically significant, was the sample size sufficiently large to detect a meaningful difference or effect?

9- What conclusions did the authors reach about the study question?

Conclusions should ensure that recommendations stated are suitable for the results attained within the capacity of the study. The authors should also concentrate on the limitations in the study and their effects on the outcomes and the proposed suggestions for future studies [ 10 ].

  • -Are the questions posed in the study adequately addressed?
  • -Are the conclusions justified by the data?
  • -Do the authors extrapolate beyond the data?
  • -Are shortcomings of the study addressed and constructive suggestions given for future research?
  • -Bibliography/References:

Do the citations follow one of the Council of Biological Editors’ (CBE) standard formats?

10- Are ethical issues considered?

If a study involves human subjects, human tissues, or animals, was approval from appropriate institutional or governmental entities obtained? [ 10 , 11 ].

Critical appraisal of RCTs: Factors to look for:

  • Allocation (randomization, stratification, confounders).
  • Follow up of participants (intention to treat).
  • Data collection (bias).
  • Sample size (power calculation).
  • Presentation of results (clear, precise).
  • Applicability to local population.

[ Table/Fig-2 ] summarizes the guidelines for Consolidated Standards of Reporting Trials CONSORT [ 12 ].

[Table/Fig-2]:

Summary of the CONSORT guidelines.

Critical appraisal of systematic reviews: provide an overview of all primary studies on a topic and try to obtain an overall picture of the results.

In a systematic review, all the primary studies identified are critically appraised and only the best ones are selected. A meta-analysis (i.e., a statistical analysis) of the results from selected studies may be included. Factors to look for:

  • Literature search (did it include published and unpublished materials as well as non-English language studies? Was personal contact with experts sought?).
  • Quality-control of studies included (type of study; scoring system used to rate studies; analysis performed by at least two experts).
  • Homogeneity of studies.

[ Table/Fig-3 ] summarizes the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses PRISMA [ 13 ].

[Table/Fig-3]:

Summary of PRISMA guidelines.

Critical appraisal is a fundamental skill in modern practice for assessing the value of clinical researches and providing an indication of their relevance to the profession. It is a skills-set developed throughout a professional career that facilitates this and, through integration with clinical experience and patient preference, permits the practice of evidence based medicine and dentistry. By following a systematic approach, such evidence can be considered and applied to clinical practice.

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Evaluating Sources: Critical Appraisal

  • Introduction
  • Test Yourself
  • Critical Appraisal
  • Other useful resources

The second stage to the evaluative process is critical appraisal. This involves a careful examination of the author's arguments and the evidence they provide to support their claims. Even if you are reading an article published in a top academic journal or a book by a leading authority in your field of study, you should start from a position of neutrality and take the approach that the author (whoever they are) must make a case to persuade you of the validity of their arguments.

Ask questions...

  • Do I find the author’s arguments persuasive?​
  • Are the aims of the study clear?​
  • How strong is the evidence supporting the claims?​
  • What are the strengths and weaknesses of the study? ​
  • What are the limitations of study design? Have these been acknowledged? ​
  • What has research by other authors shown?​
  • Do any factors cause me to doubt the validity or reliability of the research? ​

In addition to the facts and analysis offered by the authors, think about the context of their research, the appropriateness and limitations of study design, and any external factors that may impact the relevance or the importance of their approach.   

Look at the bigger picture

When consulting the literature, seek out the different points of view, set them against each other, test them by questioning them, and see how well they stand up when you raise objections and expose them to opposing views by other authors.

Critical appraisal checklists

There are a number of critical appraisal checklists which can help you evaluate particular kinds of studies. Though primarily intended for healthcare clinicians, these checklists are excellent tools for researchers in any discipline  Here  are a few examples:

CASP  

CONSORT  

TREND 

Keep in mind that most studies have imitations and will rarely tick every box. When a study fails to satisfy one or more criteria on a checklist, consider the  extent to which this impacts the evidence (if at all).These considerations can inform the critical discussion in your essay. 

Video: Using the CASP checklist for appraisal of qualitative research

Introduction to critical appraisal.

Critical thinking

Critical thinking is the foundation for good academic writing. It should inform every stage of the journey from planning your essay to embarking on your research project to writing the final draft of your paper. Evaluating and critically appraising sources is a key stage in this process,

  • Critical engagement with the idea or topic 
  • Critical appraisal of each piece of evidence we encounter
  • Comparing competing sources of evidence​
  • Developing an argument on the idea or topic informed by our research

critical appraisal essay using casp

Diagram: Monash University (2022) What is critical thinking? Available at:  https://www.monash.edu/learnhq/enhance- your-thinking/critical-thinking/what-is-critical-thinking  (Accessed: 16 June 2023)

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  • Next: Other useful resources >>
  • Last Updated: Aug 8, 2023 2:32 PM
  • URL: https://uws-uk.libguides.com/evaluating_sources

COMMENTS

  1. Critical Appraisal of a Qualitative Journal Article

    This essay critically appraises a research article, Using CASP (critical appraisal skills programme, 2006) and individual sections of Bellini & Rumrill: guidelines for critiquing research articles (Bellini &Rumrill, 1999). The title of this article is; 'Clinical handover in the trauma setting: A qualitative study of paramedics and trauma team ...

  2. Optimising the value of the critical appraisal skills programme (CASP

    It follows that quality appraisal is contingent on adequate reporting, and may only assess reporting, rather than study conduct. 17 Nevertheless, the CASP tool is the most commonly used checklist/criteria-based tool for quality appraisal in health and social care-related qualitative evidence synthesis. 16,23 Authors' reasons for using a ...

  3. PDF Critical appraisal of a journal article

    a good use of resources. (Bandolier 2004; Greenhalgh 2001) 3.3. Critical appraisal of different study designs To critically appraise a journal article, you would have to start by assessing the research methods used in the study. This is done using checklists which are specific to the study design. The following checklists are

  4. How to Critically Appraise a Research Paper

    In addition to our free checklists, CASP has developed a number of valuable online e-learning modules designed to increase your knowledge and confidence in conducting a critical appraisal. Introduction To Critical Appraisal & CASP. This Module covers the following: Challenges using evidence to change practice; 5 steps of evidence-based practice

  5. Critically appraising and utilising qualitative health research

    A qualitative health research study was selected and appraised using the Critical Appraisal Skill Programme (CASP) appraisal tool for qualitative research. Based on the results of the critical appraisal, the study quality is considered, and we discuss whether the qualitative evidence can be applied to practice. Results

  6. CASP Checklists

    Critical Appraisal Checklists. We offer a number of free downloadable checklists to help you more easily and accurately perform critical appraisal across a number of different study types. The CASP checklists are easy to understand but in case you need any further guidance on how they are structured, take a look at our guide on how to use our ...

  7. Critical Appraisal Tools & Resources

    Critical Appraisal is the process of carefully and systematically examining research to judge its trustworthiness, and its value and relevance in a particular context. It is an essential skill for evidence-based medicine because it allows people to find and use research evidence reliably and efficiently. Learn more about what critical appraisal ...

  8. Optimising the value of the critical appraisal skills programme (CASP

    Qualitative evidence synthesis, systematic review, critical appraisal, quality appraisal, Critical Appraisal Skills Programme Background Since the 1990s, the systematic review has been consid-ered to be the cornerstone methodology for informing healthcare policy and practice within the evidence-based medicine movement. Systematic review methods

  9. The fundamentals of critically appraising an article

    Here are some of the tools and basic considerations you might find useful when critically appraising an article. In a nutshell when appraising an article, you are assessing: 1. Its relevance ...

  10. A hands on introduction to using the CASP checklist to appraise

    This webinar is part of a series 'Systematic Reviews and Meta-analysis in Practice', hosted by Cochrane UK in September 2021.

  11. Critical appraisal of qualitative research

    Qualitative evidence allows researchers to analyse human experience and provides useful exploratory insights into experiential matters and meaning, often explaining the 'how' and 'why'. As we have argued previously1, qualitative research has an important place within evidence-based healthcare, contributing to among other things policy on patient safety,2 prescribing,3 4 and ...

  12. PDF Learning to Appraise the Quality of Qualitative Research Articles: A

    I drew upon the Critical Appraisal Skills Programme's (CASP) Making Sense of Evidence Tool: 10 Questions to Help You Make Sense of Qualitative Research to give the appraising assignment structure and to help students engage qualitative research articles efficiently. I have also found the use of the CASP tool provides students with the

  13. Full article: Critical appraisal

    What is critical appraisal? Critical appraisal involves a careful and systematic assessment of a study's trustworthiness or rigour (Booth et al., Citation 2016).A well-conducted critical appraisal: (a) is an explicit systematic, rather than an implicit haphazard, process; (b) involves judging a study on its methodological, ethical, and theoretical quality, and (c) is enhanced by a reviewer ...

  14. Critical appraisal of a qualitative study

    Includes what critical appraisal means, and the tools available to help carry out critical appraisal. Appraisal of qualitative research using a CASP checklist The following video (3 min. 5 sec.) summarizes what to look for in a piece of qualitative research, and an introduction to the CASP checklist for qualitative research.

  15. Critical Appraisal for Health Students

    Critical appraisal of a qualitative paper. This guide aimed at health students, provides basic level support for appraising qualitative research papers. It's designed for students who have already attended lectures on critical appraisal. One framework for appraising qualitative research (based on 4 aspects of trustworthiness) is provided and ...

  16. Systematic Reviews: Critical Appraisal by Study Design

    4. Singh S. Critical appraisal skills programme. Journal of Pharmacology and Pharmacotherapeutics. 2013;4(1):76-77. 5. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ (Clinical research ed). 2017;358:j4008. 6.

  17. PDF Critical appraisal of a journal article

    Critical appraisal is essential to: 1. combat information overload; 2. identify papers that are clinically relevant; 3. Continuing Professional Development (CPD) - critical appraisal is a requirement for the evidence based medicine component of many membership exams. Location and selection of studies 2.1. Bad science

  18. Critical Appraisal of Clinical Research

    Critical appraisal of systematic reviews: provide an overview of all primary studies on a topic and try to obtain an overall picture of the results. In a systematic review, all the primary studies identified are critically appraised and only the best ones are selected. A meta-analysis (i.e., a statistical analysis) of the results from selected ...

  19. Evidence-Based Practice Article Reviews Using CASP Tools ...

    The 17 articles were appraised for quality using the Critical Appraisal Skills Programme (Critical Appraisal Skills Programme UK, 2023) checklist, a widely used tool recognized for being succinct ...

  20. Library Guides: Evaluating Sources: Critical Appraisal

    Critical thinking is the foundation for good academic writing. It should inform every stage of the journey from planning your essay to embarking on your research project to writing the final draft of your paper. Evaluating and critically appraising sources is a key stage in this process, Critical engagement with the idea or topic.

  21. (PDF) Critical Appraisal of Quantitative Research

    ChapterPDF Available. Critical Appraisal of Quantitative Research. June 2018. DOI: 10.1007/978-981-10-2779-6_120-2. In book: Handbook of Research Methods in Health Social Sciences (pp.1-23 ...

  22. Exemplar Quantative Grade A

    Quantitative The author will use the Critical Appraisal Skills Programme (CASP) (2018) to critically appraise the quantitative study by Monaghan et al. (2017). CASP is a useful tool that should be utilised by both inexperienced and advanced healthcare professionals.