Evidence Based Medicine for Practicing Physicians

WORKSHEET 1
THE RESEARCH QUESTION

Name : ____________________________________ Date: _____________

Objective/s:
1. Identify a problem/s in his/her area of practice
2. Formulate a focused and well- constructed clinical research question/s

1. Enumerate at least two (2) clinical dilemnas.

a. ___________________________________________________
___________________________________________________
___________________________________________________
b. ___________________________________________________
___________________________________________________
___________________________________________________

2. Translate the above dilemnas into a focused QUESTION.

PECOM Sample 1 Sample 2

Population of Interest

Exposure or Intervention

Control or Comparator

Outcome of Interest

Method Filter

Please write the clinical question for sample 1 using the PEO (Population,
Exposure, Outcome) format based on the clinical case scenario.

Please write the clinical question for sample 2 using the PEO (Population, Exposure ,
Outcome) format based on the clinical case scenario.

*NA, Not Applicabe; P – Population of Interest; E- Exposure or Intervention; C –

Control or Comparator; O – Outcome; M – Method Filter/Study Design
 Evidence Based Medicine for Practicing Physicians

WORKSHEET 2
SEARCHING THE EVIDENCE

Name : ____________________________________ Date: _____________

Objective/s:

1. Search for the current best evidence using the MEDLINE as the main search
engine.

1. IDENTIFY the concepts (KE Y TERMS) in your focused clinical question.

Please write the clinical question for sample 1 using the PEO (Population, Exposure,
Outcome) format based on the clinical case scenario.

Please write the clinical question for sample 2 using the PEO (Population, Exposure,
Outcome) format based on the clinical case scenario.

PECOM KEY TERMS KEY TERMS

Sample 1 Sample 2
P
E
C
O
M
NA, Not Applicabe; P – Population of Interest; E- Exposure or Intervention; C –
Control or Comparator; O – Outcome; M – Method Filter/Study Design

2. PRIORITIZE the key terms from the MOST to the LEAST important.

PECOM KEY TERMS RANK KEY TERMS RANK

Sample 1 Sample 2
P
E
C
O
M
NA, Not Applicabe; P – Population of Interest; E- Exposure or Intervention; C –
Control or Comparator; O – Outcome; M – Method Filter/Study Design
 3. EXPAND/ BROADEN and INTERSECT/NARROW down each key term
sequentially, until you a manageable number of articles.

What are the possible key term combinations? Search Manageable?

Yield Yes No

4. Examine the yield for MISHITS AND MISSES. Revise the search if
necessary.

a. “Mishits’’ are articles yielded that aren’t relevant to our needs. If there are too
many mishits, you can:
i. Expand or intersect more concepts
ii. Insert more stringent method filters
b. “Misses’’ are articles relevant to your search that the present search strategy did
not find. When there are too many misses, you can:
i. Reduce the number of key terms
ii. Use less stringent method filters
iii. Look for more synonyms by going through the initial yield

What are the possible key term combinations? Search Manageable?

Yield Yes No
 Evidence Based Medicine for Practicing Physicians

WORKSHEET 3
CRITICAL APPRAISAL OF AN ARTICLE ON THERAPEUTICS

Name : ____________________________________ Date: _____________

Objective/s:

1. Critically appraise an article on therapy and prevention as to relevance of

directness, validity, treatment effects/results and applicability.

Please write the clinical question for using the PEO (Population, Exposure,
Outcome) format based on the clinical case scenario.

Population : ____________________________________
Exposure : _____________________________________
Outcome : _____________________________________

Write the question below. Please write legibly

Please write your search strategy below.

Journal

Name of Journal : __________________________________________________

Title of Research : __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Author/s: __________________________________________________
___________________________________________________
___________________________________________________
Date of Publication: __________________________________________________

Step 1: APPRAISING DIRECTNESS REMARKS

Does the study provide a direct enough Option: yes/No/Not Shown/Not Sure
answer to your clinical question in terms Write the page number, section or part of the
of the type of patients, paper or journal.
exposure/intervention and outcome?

The question can be rephrased as:

Is the objective of the article comparing

therapeutic interventions similar to your
clinical dilemma?

Step 2: APPRAISING VALIDITY REMARKS

(Primary)
Was the assignment of patients to Option: yes/No/Not Shown/Not Sure
treatment groups randomized? Write the page number, section or part of the
paper or journal.

Were all the patients who entered the Option: yes/No/Not Shown/Not Sure
trial properly accounted for and Write the page number, section or part of the
attributed at its conclusion? See paper or journal.
questions below.

a. Was follow-up rate adequate?

What is the drop-out rate?
Compute if necessary.
b. Were all patients analysed in the
group to which they were originally
randomized? (Intention-to-treat analysis)

Step 2: APPRAISING VALIDITY REMARKS

(Secondary)
Were the baseline characteristics similar Option: yes/No/Not Shown/Not Sure
at the start of the trial) Write the page number, section or part of the
paper or journal.

Were patients blinded to the treatment Option: yes/No/Not Shown/Not Sure

assignment Write the page number, section or part of the
paper or journal.

Were caregivers blinded to the treatment Option: yes/No/Not Shown/Not Sure

assignment? Write the page number, section or part of the
paper or journal

Were outcome assessors blinded to the

treatment assignment?

OVER-ALL, IS THE STUDY VALID? Options: Yes/No

Step 3: APPRAISING THE RESULTS REMARKS

How large was the treatment effect?
Outcome Event Measures on Effect
Rates
Rc Rt RR RRR ARR NNT
Event Rates : Risk in Control (Rc) Please show computation below.
Event Rates : Risk in Treatment (Rt)
Relative Risk (RR)
Relative Risk Reduction (RRR)
Absolute Rusk Reduction (ARR)
Number Needed to Treat (NNT)
Was the estimate of the treatment of effect Option: yes/No/Not Shown/Not Sure
precise? (Confidence Interval and p- value) Write the page number, section or part of
the paper or journal

Step 4: APPRAISING APPLICABILITY Remarks

Can the results be applied to my patient Options : Yes/No/Not Sure/Why
care?

Are there biologic issues that may effect Options : Yes/No/Not Sure/Why
applicability of treatment?

Are there socio-economic issues affecting Options : Yes/No/Not Sure/Why

applicability of treatment?

Were all clinically important outcomes Options : Yes/No/Not Sure/Why

considered?

Are the likely treatment worth the potential Options : Yes/No/Not Sure/Why
harm and costs?

RESOLUTION OF THE CLINICAL REMARKS

DILEMNA
Can the results of this appraisal be applied Options : Yes/No/Not Sure/Why
to my patient?
 Evidence Based Medicine for Practicing Physicians

WORKSHEET 4
CRITICAL APPRAISAL OF AN ARTICLE ON SYSTEMATIC REVIEWS OR META - ANALYSIS

Name : ____________________________________ Date: _____________

Objective/s:

1. Critically appraise an article on systematic review/meta- analysis as to relevance

or directness, validity, results and applicability.

Please write the clinical question using the PEO (Population, Exposure,
Outcome) format based on the clinical case scenario.

Population : ____________________________________
Exposure : _____________________________________
Outcome : _____________________________________

Write the question below. Please write legibly

Please write your search strategy below.

Journal

Name of Journal : __________________________________________________

Title of Research : __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Author/s: __________________________________________________
___________________________________________________
___________________________________________________
Date of Publication: __________________________________________________

Step 1: APPRAISING DIRECTNESS REMARKS

Does the study provide a direct enough Option: yes/No/Not Shown/Not Sure
answer to your clinical question in terms Write the page number, section or part of the
of the type of patients, paper or journal.
exposure/intervention and outcome?

The question can be rephrased as:

Is the objective of the article comparing

therapeutic interventions similar to your
clinical dilemma?

Step 2: APPRAISING VALIDITY REMARKS

Were the criteria for inclusion of articles Option: yes/No/Not Shown/Not Sure
clear and appropriate? Write the page number, section or part of the
paper or journal.

Was the search for eligible studies Option: yes/No/Not Shown/Not Sure
thorough? Write the page number, section or part of the
paper or journal.

Were the criteria for selecting articles for Option: yes/No/Not Shown/Not Sure
inclusion and exclusion explicit and Write the page number, section or part of the
credible? paper or journal.
Were the included studies appraised? Option: yes/No/Not Shown/Not Sure
Write the page number, section or part of the
paper or journal.

Were the assessments of the studies Option: yes/No/Not Shown/Not Sure

reproducible? Write the page number, section or part of the
paper or journal.

OVER-ALL, IS THE STUDY VALID? Options : Yes/No

What are the overall results of the Option: yes/No/Not Shown/Not Sure
review? (Forest plot) Write the page number, section or part of the
paper or journal.

Were the results similar from the Option: yes/No/Not Shown/Not Sure
study to study> Write the page number, section or part of the
*Heterogeneity (Meta-Analysis) paper or journal.
I2 Statistics= [(chi square-df)/chi
square]x 100%
Interpretation:
 25% - low
 50% - moderate
 75% - high
STEP4:APPRAISING APPLICABILITY REMARKS
Are the study patients similar to my Option: yes/No/Not Shown/Not Sure
own? Write the page number, section or part of the
paper or journal.

Is the result of the review relevant to my Option: yes/No/Not Shown/Not Sure

patient?

RESOLUTION OF THE CLINICAL REMARKS

DILEMNA
Can the results of this appraisal be Options: Yes/No/Not shown/Not Sure
applied to my patient?
 Evidence Based Medicine for Practicing Physicians

WORKSHEET 5
CRITICAL APPRAISAL OF AN ARTICLE DIAGNOSIS

Name : ____________________________________ Date: _____________

Objective/s:

1. Critically appraise an article on diagnostic tests as to relevance or directness,

validity, results and applicability.

Please write the clinical question using the PEO (Population, Exposure,
Outcome) format based on the clinical case scenario.

Population : ____________________________________
Exposure : _____________________________________
Outcome : _____________________________________

Write the question below. Please write legibly

Please write your search strategy below.

Journal

Name of Journal : __________________________________________________

Title of Research : __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Author/s: __________________________________________________
___________________________________________________
___________________________________________________
Date of Publication: __________________________________________________

Step 1: APPRAISING DIRECTNESS REMARKS

Does the study provide a direct enough Option: yes/No/Not Shown/Not Sure
answer to your clinical question in terms Write the page number, section or part of the
of the type of patients, paper or journal.
exposure/intervention and outcome?

The question can be rephrased as:

Is the objective of the article comparing

therapeutic interventions similar to your
clinical dilemma?

Step 2: APPRAISING VALIDITY REMARKS

Was the reference standard an Option: yes/No/Not Shown/Not Sure
acceptable one? Write the page number, section or part of the
paper or journal.

Was the reference standard interpreted Option: yes/No/Not Shown/Not Sure

independently from the test in question? Write the page number, section or part of the
paper or journal.

OVER-ALL, IS THE STUDY VALID? Options: Yes/No

 Step 3: APPRAISING THE RESULTS REMARKS
What likelihood ratios were associated with
the range of possible test results? Test Sensitivity Specificity LR+ LR-
Result
Test Reference Standard
Result Disease Disease
Present Absent
Test A B
Positive True Positive False Positive
Test C D
Negative False Negative True Negative

Sensitivity: A/ (A+C)
Specificity: D/ (B+ D)
LR+ :Sensitivity/ (1-Specificity)
LR- : 1-Sensitivity / Specificity *LR, Likelihood Ratio

Others: Please show your computation below.

Positive Predictive Vale : A / (A+B)
Negative Predictive Value : D/ (C+D)

Step 4: APPRAISING APPLICABILITY REMARKS

Are the biologic issues that may effect Options: Yes/No/Not Sure/Why
applicability and accuracy of the test in
question?

Are there socio-economic issues affecting Options: Yes/No/Not Sure/Why

applicability of treatment?

How will the test results affect the Estimate POST – test probability using a
probability of disease in your patient? NOMOGRAM.
Plot the values below.
Steps:
1. Establish (by consensus) PRE-test
probability
2. Compute likelihood ratios using the 0.1 99
sensitivity and specificity values.
3. Determine the post-test probability 0.2 98
using the Fagan’s Nomogram.
(1975 TJ Fagan)
0.5 95

1 90

2 2000 80
100
5 500 70
100
10 50 60
20
20 10 50
5
30 2 40
1
40 0.5 30
0.2
50 0.1 20
0.05
60 0.02 10
0.01
70 0.005 5
0.002
80 0.001 2
0.0005
90 1

95 0.5

0.2
98
0.1
99
Pre – Test Likelihood Post - Test
Probability (%) Ratio Probability (%)

RESOLUTION OF THE CLINICAL REMARKS

Can the results of this appraisal be
applied to my patient?
 Evidence Based Medicine for Practicing Physicians

WORKSHEET 6
CRITICAL APPRAISAL OF AN ARTICLE PROGNOSIS

Name : ____________________________________ Date: _____________

Objective/s:

1. Critically appraise an article on prognosis as to relevance or directness, validity,

results and applicability.

Please write the clinical question using the PEO (Population, Exposure,
Outcome) format based on the clinical case scenario.

Population : ____________________________________
Exposure : _____________________________________
Outcome : _____________________________________

Write the question below. Please write legibly

Please write your search strategy below.

If a journal has been found using the above search strategy, please write the
necessary details below.

Name of Journal : __________________________________________________

Title of Research : __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Author/s: __________________________________________________
___________________________________________________
___________________________________________________
Date of Publication: __________________________________________________
 Step 1: APPRAISING DIRECTNESS REMARKS
Does the study provide a direct enough Option: yes/No/Not Shown/Not Sure
answer to your clinical question in terms Write the page number, section or part of the
of the type of patients, paper or journal.
exposure/intervention and outcome?

The question can be rephrased as:

Is the objective of the article comparing

therapeutic interventions similar to your
clinical dilemma?

Step 2: APPRAISING VALIDITY REMARKS

Was the sample of patient’s Option: yes/No/Not Shown/Not Sure
representative? Write the page number, section or part of the
paper or journal.

Were patients (or subgroups of patients) Option: yes/No/Not Shown/Not Sure

sufficiently homogeneous with respect to Write the page number, section or part of the
prognostic risk? paper or journal.

Were unbiased criteria used to detect the Option: yes/No/Not Shown/Not Sure
outcome in all patients? Write the page number, section or part of the
paper or journal.

Was follow-up rate adequate? Option: yes/No/Not Shown/Not Sure

Write the page number, section or part of the
paper or journal.
Total number of dropouts x 100
Total number of subjects
Over-all, is the study valid?
Step 3: APPRAISING THE RESULTS REMARKS
How likely are the outcomes overtime? Option: yes/No/Not Shown/Not Sure
Write the page number, section or part of the
Look for: paper or journal.
 Event rates (e.g. Mortality rate,
stroke rate, hospitalization rate,
etc)
 Event-free rates (e.g. store-
free survival rate, symptom-free
survival rate, etc.)
 Average survival ( e.g. Mean
survival, median survival, average
time to event, etc.)
How precise are the estimates of the Option: yes/No/Not Shown/Not Sure
likelihood? (95% confidence level; p- Write the page number, section or part of the
value) paper or journal.
Step 4:APPRAISING APPLICABILITY REMARKS
Are there biologic issues (age, sex, race Option: yes/No/Not Shown/Not Sure
or ethnic, comorbids, pathology, etc.) Write the page number, section or part of the
affecting applicability? paper or journal.

Are there Socioeconomic issues affecting Option: yes/No/Not Shown/Not Sure

capability? Write the page number, section or part of the
paper or journal.

Did the article answer your clinical Option: yes/No/Not Shown/Not Sure
question? Write the page number, section or part of the
paper or journal.

RESOLUTION OF THE CLINICAL REMARKS

DILEMNA
Can the results if this appraisal be Options: Yes/No/Not Shown/Not sure
applied to my patient?
 Evidence Based Medicine for Practicing Physicians

WORKSHEET 7
CRITICAL APPRAISAL OF AN ARTICLE ON HARM

Name : ____________________________________ Date: _____________

Objective/s:

1. Critically appraise an article on harm as to relevance or directness, validity,

results and applicability.

Please write the clinical question using the PEO (Population, Exposure,
Outcome) format based on the clinical case scenario.

Population : ____________________________________
Exposure : _____________________________________
Outcome : _____________________________________

Write the question below. Please write legibly

Please write your search strategy below.

If a journal has been found using the above search strategy, please write the
necessary details below.

Name of Journal : __________________________________________________

Title of Research : __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Author/s: __________________________________________________
___________________________________________________
___________________________________________________
Date of Publication: __________________________________________________
 Step 1: APPRAISING DIRECTNESS REMARKS
Does the study provide a direct enough Option: yes/No/Not Shown/Not Sure
answer to your clinical question in terms Write the page number, section or part of the
of the type of patients, paper or journal.
exposure/intervention and outcome?

The question can be rephrased as:

Is the objective of the article comparing

therapeutic interventions similar to your
clinical dilemma?

Step 2: APPRAISING VALIDITY REMARKS

Were the patient groups being compared Option: yes/No/Not Shown/Not Sure
sufficiently similar with respect to Write the page number, section or part of the
baseline characteristics? If not, were paper or journal.
statistical adjustments made?

Were unbiased criteria used to determine Option: yes/No/Not Shown/Not Sure

exposure in all patients? Write the page number, section or part of the
paper or journal.

Were unbiased criteria used to detect the Option: yes/No/Not Shown/Not Sure
outcome in all patients? Write the page number, section or part of the
paper or journal.

Was follow-up rate adequate? Option: yes/No/Not Shown/Not Sure

Write the page number, section or part of the
paper or journal.
Total number of dropouts x 100
Total number of subjects
Over-all, is the study valid?
Step 3: APPRAISING THE RESULTS REMARKS
How strong is the association between Option: yes/No/Not Shown/Not Sure
exposure and outcome? Write the page number, section or part of the
paper or journal.
Look for odds ratios (OR), risk ratios
(RR), hazards ratios (RR), relative risk
(RR),
etc.
 If odds ratio is greater than1,
exposure is harmful/increases the
odds of unfavorable outcome.
 If odds ration (OR) is equal to 1,
inconclusive/no effect
 If odds ratio (OR) is less than 1,
decreases the odds of
unfavourable outcome.
How precise are the estimates of the Option: yes/No/Not Shown/Not Sure
likelihood? (95% confidence level; p- Write the page number, section or part of the
value) paper or journal.

STEP 4: ASSESSING APPLICABILITY REMARKS

Are there biologic issues (age, sex, race Options : Yes/No/Not Sure/Why
or ethnic, comorbids, pathology, etc.)
affecting applicability?

Are there Socioeconomic issues affecting Options : Yes/No/Not Sure/Why

applicability?

Did the article answer your clinical Options : Yes/No/Not Sure/Why

question? Can the results be applied to
your patient?

RESOLUTION OF THE CLINICAL REMARKS

DILEMNA
Can the results of this appraisal be Options: Yes/No/Not shown?Not sure
applied to my patient?