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Of these, six were developed for use on both experimental and observational studies [ 9 , 91 — 95 ], whereas 11 were purported to be useful for any qualitative and quantitative research design [ 1 , 18 , 41 , 96 — , ] see Figure 1 , Table 1. One thousand, four hundred and seventy five items were extracted from these critical appraisal tools. The most frequently reported items across all critical appraisal tools were:.
Eighty-seven different items were extracted from the 26 critical appraisal tools, which were designed to evaluate the quality of systematic reviews. These critical appraisal tools frequently contained items regarding data analyses and issues of external validity Tables 2 and 3. Items assessing data analyses were focused to the methods used to summarize the results, assessment of sensitivity of results and whether heterogeneity was considered, whereas the nature of reporting of the main results, interpretation of them and their generalizability were frequently used to assess the external validity of the study findings.
Moreover, systematic review critical appraisal tools tended to contain items such as identification of relevant studies, search strategy used, number of studies included and protocol adherence, that would not be relevant for other study designs. Blinding and randomisation procedures were rarely included in these critical appraisal tools.
One hundred and twenty thirteen different items were extracted from the 45 experimental critical appraisal tools. These items most frequently assessed aspects of data analyses and blinding Tables 1 and 2.
Data analyses items were focused on whether appropriate statistical analysis was performed, whether a sample size justification or power calculation was provided and whether side effects of the intervention were recorded and analysed. Blinding was focused on whether the participant, clinician and assessor were blinded to the intervention.
Forty-seven different items were extracted from the seven diagnostic critical appraisal tools. These items frequently addressed issues involving data analyses, external validity of results and sample selection that were specific to diagnostic studies whether the diagnostic criteria were defined, definition of the "gold" standard, the calculation of sensitivity and specificity Tables 1 and 2. Seventy-four different items were extracted from the 19 critical appraisal tools for observational studies.
These items primarily focused on aspects of data analyses see Tables 1 and 2 , such as whether confounders were considered in the analysis, whether a sample size justification or power calculation was provided and whether appropriate statistical analyses were preformed. Thirty-six different items were extracted from the seven qualitative study critical appraisal tools.
The majority of these items assessed issues regarding external validity, methods of data analyses and the aims and justification of the study Tables 1 and 2. Specifically, items were focused to whether the study question was clearly stated, whether data analyses were clearly described and appropriate, and application of the study findings to the clinical setting. Qualitative critical appraisal tools did not contain items regarding sample selection, randomization, blinding, intervention or bias, perhaps because these issues are not relevant to the qualitative paradigm.
Forty-two different items were extracted from the six critical appraisal tools that could be used to evaluate experimental and observational studies.
Seventy-eight different items were contained in the ten critical appraisal tools that could be used for all study designs quantitative and qualitative. The majority of these items focused on whether appropriate data analyses were undertaken such as whether confounders were considered in the analysis, whether a sample size justification or power calculation was provided and whether appropriate statistical analyses were preformed and external validity issues generalization of results to the population, value of the research findings see Tables 1 and 2.
We found no critical appraisal instrument specific to allied health research, despite finding at least seven critical appraisal instruments associated with allied health topics mostly physiotherapy management of orthopedic conditions [ 37 , 39 , 52 , 58 , 59 , 65 ]. One critical appraisal development group proposed two instruments [ 9 ], specific to quantitative and qualitative research respectively. The core elements of allied health research quality specific diagnosis criteria, intervention descriptions, nature of patient contact and appropriate outcome measures were not addressed in any one tool sourced for this evaluation.
We identified different ways of considering quality reporting of outcome measures in the critical appraisal tools, and 81 ways of considering description of interventions. The critical appraisal instrument that seemed most related to allied health research quality [ 39 ] sought comprehensive evaluation of elements of intervention and outcome, however this instrument was relevant only to physiotherapeutic orthopedic experimental research. This was achieved by one of two methods:.
A weighted system, where fulfilled items were allocated various points depending on their perceived importance. However, there was no justification provided for any of the scoring systems used. This left the research consumer to summarize the results of the appraisal in a narrative manner, without the assistance of a standard approach.
Few critical appraisal tools had documented evidence of their validity and reliability. Face validity was established in nine critical appraisal tools, seven of which were developed for use on experimental studies [ 38 , 40 , 45 , 49 , 51 , 63 , 70 ] and two for systematic reviews [ 32 , ].
Intra-rater reliability was established for only one critical appraisal tool as part of its empirical development process [ 40 ], whereas inter-rater reliability was reported for two systematic review tools [ 20 , 36 ] for one of these as part of the developmental process [ 20 ] and seven experimental critical appraisal tools [ 38 , 40 , 45 , 51 , 55 , 56 , 63 ] for two of these as part of the developmental process [ 40 , 51 ]. Our search strategy identified a large number of published critical appraisal tools that are currently available to critically appraise research reports.
There was a distinct lack of information on tool development processes in most cases. Many of the tools were reported to be modifications of other published tools, or reflected specialty concerns in specific clinical or research areas, without attempts to justify inclusion criteria. Less than 10 of these tools were relevant to evaluation of the quality of allied health research, and none of these were based on an empirical research approach.
However, consumers of research seeking critical appraisal instruments are not likely to seek instruments from outdated Internet links and unobtainable journals, thus we believe that we identified the most readily available instruments. Thus, despite the limitations on sourcing all possible tools, we believe that this paper presents a useful synthesis of the readily available critical appraisal tools.
This finding is not surprising as, according to the medical model, experimental studies sit at or near the top of the hierarchy of evidence [ 2 , 8 ]. In recent years, allied health researchers have strived to apply the medical model of research to their own discipline by conducting experimental research, often by using the randomized controlled trial design [ ].
This trend may be the reason for the development of experimental critical appraisal tools reported in allied health-specific research topics [ 37 , 39 , 52 , 58 , 59 , 65 ].
Systematic review critical appraisal tools contained unique items such as identification of relevant studies, search strategy used, number of studies included, protocol adherence compared with tools used for primary studies, a reflection of the secondary nature of data synthesis and analysis.
In contrast, we identified very few qualitative study critical appraisal tools, despite the presence of many journal-specific guidelines that outline important methodological aspects required in a manuscript submitted for publication [ — ]. This finding may reflect the more traditional, quantitative focus of allied health research [ ]. Alternatively, qualitative researchers may view the robustness of their research findings in different terms compared with quantitative researchers [ , ].
Hence the use of critical appraisal tools may be less appropriate for the qualitative paradigm. This requires further consideration. Whilst these types of tools potentially facilitate the synthesis of evidence across allied health research designs for clinicians, their lack of specificity in asking the 'hard' questions about research quality related to research design also potentially precludes their adoption for allied health evidence-based practice.
At present, the gold standard study design when synthesizing evidence is the randomized controlled trial [ 4 ], which underpins our finding that experimental critical appraisal tools predominated in the allied health literature [ 37 , 39 , 52 , 58 , 59 , 65 ]. However, as more systematic literature reviews are undertaken on allied health topics, it may become more accepted that evidence in the form of other research design types requires acknowledgement, evaluation and synthesis.
This may result in the development of more appropriate and clinically useful allied health critical appraisal tools. A major finding of our study was the volume and variation in available critical appraisal tools. We found no gold standard critical appraisal tool for any type of study design. Therefore, consumers of research are faced with frustrating decisions when attempting to select the most appropriate tool for their needs.
Variable quality evaluations may be produced when different critical appraisal tools are used on the same literature [ 6 ]. Thus, interpretation of critical analysis must be carefully considered in light of the critical appraisal tool used. The variability in the content of critical appraisal tools could be accounted for by the lack of any empirical basis of tool construction, established validity of item construction, and the lack of a gold standard against which to compare new critical tools.
As such, consumers of research cannot be certain that the content of published critical appraisal tools reflect the most important aspects of the quality of studies that they assess [ ].
Moreover, there was little evidence of intra- or inter-rater reliability of the critical appraisal tools. Coupled with the lack of protocols for use, this may mean that critical appraisers could interpret instrument items in different ways over repeated occasions of use. This may produce variable results []. Based on the findings of this evaluation, we recommend that consumers of research should carefully select critical appraisal tools for their needs.
The selected tools should have published evidence of the empirical basis for their construction, validity of items and reliability of interpretation, as well as guidelines for use, so that the tools can be applied and interpreted in a standardized manner. Our findings highlight the need for consensus to be reached regarding the important and core items for critical appraisal tools that will produce a more standardized environment for critical appraisal of research evidence.
As a consequence, allied health research will specifically benefit from having critical appraisal tools that reflect best practice research approaches which embed specific research requirements of allied health disciplines. Google Scholar. Joanna Briggs Institute. Critical literature reviews. J Allied Health Res Dec. Grimmer K, Bowman P, Roper J: Episodes of allied health outpatient care: an investigation of service delivery in acute public hospital settings. Disability and Rehabilitation.
Physiotherapy Canada. Greenhalgh T: How to read a paper: papers that summarize other papers systematic reviews and meta-analysis. Auperin A, Pignon J, Poynard T: Review article: critical review of meta-analysis of randomised clinical trials in hepatogastroenterology. Alimentary Pharmacol Therapeutics.
CAS Google Scholar. J Am Med Assoc. Beck CT: Use of meta-analysis as a teaching strategy in nursing research courses. J Nurs Educat. Can Med Assoc J. J Clin Epidemiol. Mount Sinai Journal of Medicine. Smith AF: An analysis of review articles published in four anaesthesia journals. Can J Anaesth. Ann Intern Med. PubMed Google Scholar. J Rheumatol. A method for grading health care recommendations.
Can J Public Health. The last 2 questions attract a negative score, which means that the range of possible scores is 0 bad to 5 good. Whislt developed to be used for the development of clinical guidelines they are excellent CATs for single study appraisals.
Although designed for use in systematic reviews, JBI critical appraisal tools can also be used when creating Critically Appraised Topics in journal clubs and as an educational tool.
Summary: This CAT presents questions to assist with the critical appraisal of randomised controlled trials and other experimental studies. Whilst developed to be used for the development of clinical guidelines they are excellent CATs for single study appraisals.
PDF: Roever Summary: critical appraisal tool that addresses study design and reporting quality as well as the risk of bias in cross-sectional studies, developed via an international Delphi panel of 18 medical and veterinary experts.
Summary: A critical appraisal tool that includes the criteria appropriate for criticizing cross-sectional study design developed through a Delphi survey of 15 academics. Summary: A CAT for evaluation of reporting quality from cross-sectional epidemiological studies employing biomarker data.
Summary: McMaster Critical Review Form for Qualitative studies contains a generic quantitative appraisal tool, accompanied by detailed guidelines for usage. Summary: The Evaluation Tool for Quantitative Studies contains 51 questions in six sub-sections: study evaluative overview; study, setting and sample; ethics; group comparability and outcome measurement; policy and practice implications; and other comments. Summary: A tool used to aid critical reading by general practitioners which can also be used to CAT an article.
Summary: This CAT developed through the University of Glasgow involves 13 questions that should be asked when reviewing a study involving educational interventions. Summary: MINORS is a valid instrument designed to assess the methodological quality of non-randomized surgical studies, whether comparative or non-comparative.
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