Criticallay Appraised Topics (CATs)

Critically Appraised Topics (CATs) - What are they?

Critically appraised topics (CATs) are summaries of the latest medical evidence, helping health professionals make better decisions for their patients - when theres not quite enough evidence to conduct a systematic review!This page teaches you how to write CATs, covering four steps: forming a clear question, searching for evidence, evaluating it critically, and applying it to your patients.

Why are they Useful?

Here's why Critically Appraised Topics (CATs) are useful:

High-Quality, Up-to-Date Evidence: CATs focus on the best available research, ensuring your decisions are based on solid science.
Manageable Information: They summarise vast amounts of information into clear summaries, making it easier to find what you need.
Critical Thinking Skills: Using CATs helps you develop the ability to analyse research effectively.
Practical Tool: CATs are quicker and cheaper than systematic reviews, making them ideal for everyday clinical questions.
Addressing Gaps: They cover areas not yet addressed by systematic reviews, providing valuable insights.
Integration of Research: Like systematic reviews, CATs bridge the gap between research and real-world practice.
Reduced Bias: CATs help avoid biases found in narrative reviews or simple internet searches.

Step 1

Formation of a question for Quantitative Studies

When dealing with daily clinical questions, Critically Appraised Topics (CATs) rely on a structured approach called PICO to ensure you find the most relevant evidence for your patients.

PICO helps you formulate a clear and focused question:

P (Patient/Population): Define the specific group you're interested in. This includes details like age, sex, disease they have, and its severity. Think: are you treating children with a specific illness, or adults with a particular condition at an advanced stage?
I (Intervention): Specify the treatment, diagnostic test, or potential risk factor you're considering. Are you evaluating a new medication, a diagnostic tool for a certain disease, or an environmental factor contributing to a health problem?

While not always necessary, PICO can be further refined for a more targeted search:

C (Comparator): This becomes relevant when comparing different interventions or tests. What's the alternative to your chosen treatment? Is it a different medication, a placebo, or no treatment at all? For diagnostic tests, the comparator could be a well-established test already in use.
O (Outcome): Define the positive or negative results you're looking for. Are you interested in the treatment's effectiveness in reducing symptoms, potential side effects, or how accurate a test is in diagnosing a condition? Outcomes can be short-term or long-term, and you might consider multiple outcomes depending on your specific question.

By structuring your clinical question with PICO, CATs ensure your search for evidence remains focused on the real-world scenario you're facing, ultimately leading to better patient care.

Formation of a question for Quantitative Studies

PICo Framework (Qualitative Adaptation of PICO):

P (Population/Problem): This represents the group of people or the issue that is the focus of the research. Instead of a specific clinical population, it could refer to any group with a shared experience, such as patients with a certain condition, healthcare professionals, or members of a community.
I (Interest): This refers to the central issue, experience, or phenomenon you're interested in studying. It could be anything from the perception of a particular treatment, the experience of a health condition, or attitudes toward a healthcare policy.
Co (Context): The context refers to the setting or environment where the research is conducted or where the phenomenon is occurring. This could include cultural, institutional, geographical, or historical factors that might influence the issue or experience being studied.

Example of a PICo Research Question:

P: Nurses working in intensive care units (ICU)
I: The experience of stress in the ICU
Co: Hospital setting

Link to: Further guidance on research questions

Step 2: Finding the Evidence

Once you've formulated your research question, the next step is to search for relevant evidence in online databases using well-defined keywords.

Start with P (Population/Problem) and I (Interest):

P (Population/Problem): Identify the specific population or issue you are focusing on. This could be a group of individuals with a particular condition, or a problem that a specific group is facing. In qualitative research, this often refers to the lived experiences, perceptions, or challenges related to the issue. e.g Healthcare workers
I (Interest): This represents the central phenomenon, experience, or issue you wish to explore. It could be individuals’ views on a healthcare policy, the impact of a disease, or their coping mechanisms with a specific condition. e.g Experience of burnout

Refine with C (Comparator) and O (Outcome) if Needed:

If you find that your initial search results are too broad, adding C (Comparator) and O (Outcome) can help narrow your focus.

C (Comparator): Use this if you're comparing different interventions or groups. It helps provide an alternative treatment, intervention, or group to contrast against the primary population or phenomenon.
O (Outcome): This defines the expected results you’re looking to find in your research. In qualitative research, this could be themes, insights, or impacts related to the issue.

Include Variations:

To ensure that you capture all relevant studies, consider using synonyms and alternative spellings for diseases, tests, treatments, or concepts related to your research. This helps broaden your search to include all relevant evidence.

Consult Medical Subject Headings (MeSH) for Specialized Databases:

In specialized databases, such as PubMed, using MeSH terms ensures you are using standardized, widely accepted terminology to find the most relevant studies. MeSH terms help refine your search to focus on high-quality studies that are categorized under specific topics.

Refine with Co (Context):

Co (Context): Consider the setting or conditions under which the phenomenon is being studied. This could include the geographical location, cultural, social, or political environment, or the time period in which the study was conducted.

Example:

P: Healthcare workers
I: Experience of burnout
Co: In intensive care units (ICU)

Adding Co helps provide a more specific search, focusing on studies conducted under particular conditions or settings that may be relevant to your research question.

If you're new to searching databases, seek help from your librarian or information specialist.

Document your search strategy: Keep a record of your search terms, filters, and dates to help you update your search later and for transparency.

Use Advanced Search Features:

Many online databases offer advanced search tools that can help refine your search. For instance:

Combining Terms: Use "OR" to combine related keywords or phrases.
Truncation: Use the asterisk (*) to capture variations in spelling (e.g., "burnout*" to include "burnout," "burnouts," etc.).

These features help you find a broader set of relevant studies, even if they use different terminology.

Check whether the journal is peer reviewed

Look at the example above, note the number of articles found during the S1-3 stages (over 1.5 million). Yet the find number found was 7. Never worry about the inittial figure when using 'OR'. The idea is that this number is as high as possible. The final search ends up with 7 articles which is much more managable a may mean reading all the articles. Imagine if this number was much higher! Using the column on hte left can help you quickly reduce this number in a transparent way. Such as:

By Date
Full Text
Subject Major headings
Publication
Databases.............And more.

The point here is to rationalise why you are doing something. For example limiting the date is often used but rarely done with a rationale. If you cant rationalise it simply note it as a limitation to your strategy.

NB if you do this using the method above it simply adds it to your list:

Using the example above this would become:

S5 Date 2010 - present day

S6 Journals only

S7 The subject major headings used were........these act like standardised tags for categorising research content.

The final part to a transparent search strategy would be to create a flow diagram. Here are a few examples:

PRISMA Flow Diagram: This refers to a specific type of flow diagram recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. It's a standardised way to visualise the search process for systematic reviews, particularly in healthcare research.
Search Strategy Flow Diagram: This is a more general term encompassing any flow diagram that documents a search strategy. It's not limited to systematic reviews and can be used for various research projects.

Here's an example:

Step 3 Critical Appraisal

Summarise Key Findings: Briefly restate the main results of each study, highlighting areas of agreement and disagreement.

Appraise the Methodology: Analyse the strengths and weaknesses of the studies' methodologies. Consider factors like sample size, study design (randomised controlled trial vs. observational study), potential biases, and generalisability of the findings.

Explain Inconsistencies: Discuss any discrepancies in findings across studies. Explore potential explanations for these differences, such as methodological variations or population characteristics.

Identify Limitations: Acknowledge the limitations of the reviewed research. This could include limitations inherent to the studies themselves or limitations in the search strategy used for the appraisal.

Consider the Broader Context: Discuss how the findings of the reviewed literature fit within the existing body of knowledge on the topic. Are there any relevant theoretical frameworks or real-world applications to consider?

Step 4 Interpreting and Applying the Results

Interpreting and Analysing Qualitative Studies in a CAT

Interpreting and Applying Results in CATs with Quantitative Studies:

Example: Let's say your CAT topic is "The Effectiveness of Exercise Programs for Weight Loss in Adults." You've reviewed multiple quantitative studies (randomised controlled trials, cohort studies, etc.) on this topic. Here's how you might approach interpreting and applying the results:

1. Interpreting the Findings:

Look for trends across studies. Do most studies show a significant weight loss with exercise programs compared to control groups?
Analyse the magnitude of effect. How much weight loss did the studies find on average with exercise programs?
Consider subgroup analyses. Did the effectiveness of exercise programs differ based on factors like age, gender, or baseline weight?

2. Applying the Results:

Based on the findings, can you draw conclusions about the overall effectiveness of exercise programs for weight loss?
How can these findings be applied in real-world settings? For example, can they inform recommendations for healthy weight management programs?
Are there any limitations to the generalisability of the findings? For instance, were the study participants representative of the broader population?

Here's a more specific example of applying the results:

Let's say your review found several studies showing an average weight loss of 5-7 pounds over 12 weeks in participants who engaged in regular exercise programs compared to control groups. This suggests that exercise can be a helpful tool for weight loss. However, the studies also found that the effectiveness varied depending on the intensity and duration of the exercise program. This highlights the importance of tailoring exercise programs to individual needs and preferences for optimal results.

Additional Points:

Pay attention to statistical significance (p-values) reported in the studies. A statistically significant finding suggests that the observed effect is unlikely due to chance.
Consider potential biases in the studies, such as selection bias (participants who may be more motivated to lose weight) or measurement bias (inaccurate weight measurement techniques).
Discuss the implications of the findings for future research. Are there unanswered questions or areas that need further investigation?

By critically interpreting and applying the results of quantitative studies, your CAT will provide a valuable and nuanced understanding of the current evidence on the topic.

Interpreting and Analysing Quantitative Studies in a CAT

No, critically appraised topics (CATs) are not restricted to quantitative research questions. They can be effectively used for both quantitative and qualitative research questions.

Here's why:

Core Purpose: At its heart, a CAT aims to summarise the best available evidence on a specific topic. This evidence can come from various research methodologies, not just numbers and statistics. Qualitative studies, which explore experiences and perceptions, can offer valuable insights relevant to a CAT.
Focus on Evidence: Regardless of methodology, a CAT focuses on critically appraising the research that exists on a particular issue. It evaluates the quality of the studies, identifies key findings, and highlights any gaps in knowledge. This process can be applied to both quantitative and qualitative research.

However, there might be some adjustments:

Appraisal Techniques: The specific techniques used to analyse the research may differ depending on the research type. For quantitative studies, you might focus on sample size, statistical analysis, and generalisability. For qualitative studies, you might evaluate the research design, data collection methods, and trustworthiness of the findings.
Examples of Conclusions: The conclusions drawn in a CAT will also reflect the type of research reviewed. For quantitative studies, you might conclude with evidence supporting or refuting a hypothesis. For qualitative studies, you might highlight emergent themes or offer a deeper understanding of a phenomenon.

Step 5 Concluding the CAT

Draw conclusions and make recommendations

The final section of a critically appraised topic (CAT) focuses on synthesising the reviewed research and offering your informed interpretation. This section consists of two key parts: drawing conclusions and making recommendations.

Drawing Conclusions:

Summarise the Evidence: Briefly restate the main findings from the reviewed studies. Highlight areas of agreement and disagreement across the research.
Evaluate the Strength of the Evidence: Consider the methodological quality of the studies, sample size, potential biases, and consistency of findings. Is the evidence strong, moderate, or weak?
Address Limitations: Acknowledge any limitations in the reviewed research (e.g., small samples, specific populations) and how they might affect the generalisability of the conclusions.
Formulate Overall Statements: Based on the evidence synthesis, draw conclusions about the current state of knowledge on the topic. Can you support or refute a specific hypothesis?
Identify Gaps in Knowledge: Highlight areas where the research is lacking or inconclusive. This paves the way for future research recommendations.

Making Recommendations:

Translate Findings to Practice: Based on your conclusions, can you make recommendations for practice, policy, or future research? For example, if the evidence supports a specific intervention, recommend its use in clinical settings with appropriate considerations.
Consider Generalisability: Ensure your recommendations are realistic and applicable to broader populations or real-world settings, taking into account potential limitations identified in the reviewed studies.
Prioritise Research Needs: Highlight key areas for further research based on the gaps in knowledge identified in the CAT. This could involve specific research questions, methodologies, or populations that require further investigation.

Here's an example to illustrate this process:

Topic: The Effectiveness of Mindfulness Meditation for Reducing Anxiety

Conclusions:

This review identified several studies showing positive effects of mindfulness meditation on reducing anxiety symptoms.
However, the studies varied in methodology and sample size. Some studies also lacked long-term follow-up data.

Recommendations:

Based on the current evidence, mindfulness meditation appears to be a promising intervention for anxiety.
Healthcare professionals can consider recommending mindfulness practices to patients experiencing anxiety, alongside other evidence-based treatments.
Further research with larger, more rigorous study designs is needed to confirm the long-term efficacy of mindfulness meditation for anxiety and explore its effectiveness in different populations.

By following these steps, you can create a well-rounded concluding section for your CAT that provides a clear interpretation of the research evidence, along with actionable recommendations for future practice and research.

In addition to the core elements of drawing conclusions and making recommendations, here are a few extra tips for concluding a strong CAT:

Future Directions: Briefly discuss the potential future directions for research on the topic. This could involve exploring new research questions, methodologies, or populations not yet addressed in the reviewed studies.
Clinical Significance: If your CAT focuses on a clinical topic, emphasise the clinical significance of your conclusions and recommendations. How can the findings be translated into improved patient care or healthcare practices?
Limitations of the CAT: Acknowledge any limitations of your own CAT. This could include limitations in the search strategy used to identify relevant research or the scope of the review itself.
Concluding Statement: End your CAT with a concise and impactful statement that summarises the key takeaway from your analysis of the evidence.

By incorporating these suggestions, you can craft a comprehensive and insightful conclusion that leaves a lasting impression on your reader. Remember, the conclusion is your opportunity to showcase your critical thinking skills and offer valuable insights based on the research you have appraised.

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