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The Pocket Guide to
Critical Appraisal
The Pocket
Guide to Critical
Appraisal
SECOND EDITION
Iain K. Crombie
University of Dundee
Dundee, UK
This second edition first published 2022
© 2022 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
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The right of Iain K. Crombie to be identified as the author of this work has been asserted in
accordance with law.
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Library of Congress Cataloging-in-Publication Data Applied for
Paperback ISBN: 9781119835240
Cover Design: Wiley

Cover Image: © Govindanmarudhai/Getty Images
Set in 10.5/13pt STIXTwoText by Straive, Chennai, India

Contents
Acknowledgements ix
Preface to the First Edition xi
Preface to the Second Edition xiii
CHAPTER 1 Introduction to Critical Appraisal 1

The aims of critical appraisal 1
Three stages of critical appraisal 2
CHAPTER 2 Do Not Read the Paper 4

The initial interrogation 5
The in-depth interrogation 6
CHAPTER 3 Identifying the Research Design 7

Surveys 7
Cohort studies 9
Case–control studies 10
RCTs 11
Cohort studies that evaluate the
effectiveness of interventions 12
Systematic reviews 14
CHAPTER 4 Interpreting the Results 16

The effect size 17
Taking the play of chance into account 19
Factors that distort the effect size 22
Questionable research practices 24
Conclusion 25
v
vi Contents
CHAPTER 5 The In-Depth Interrogation 26

Bias 26
Critical questions for bias 27
Important questions for bias 27
Indicative questions for bias 33
Questions about value 36
Conclusion 39
CHAPTER 6 Appraising Surveys 40

The critical bias questions for bias 40
The complete list for appraising surveys* 43
CHAPTER 7 Appraising Cohort Studies 45

The critical questions for bias 45
The important questions for bias 49
The indicative questions for risk of bias 50
The complete list for the appraisal of
cohort studies* 51
CHAPTER 8 Appraising Case–Control Studies 53

case–control studies* 58
CHAPTER 9 Appraising Randomised Controlled

Trials 60
The questions of value 67
clinical trials* 68
CHAPTER 10 Cohort Studies That Evaluate the

Effectiveness of Interventions 70
Overview of advantages of cohort
treatment studies and challenges
for critical appraisal 71
Contents vii

Conclusion 78
cohort studies that evaluate
interventions 79
CHAPTER 11 Appraising Systematic Reviews 81

The critical questions for risk of bias 81
The important questions for risk of bias 86
systematic reviews* 89
CHAPTER 12 Summarising Risk of Bias 91

Identify the risk of bias of the research
designs 91
Review the biases in study design,
conduct, and interpretation 92
Derive an overall rating 93
Summary 95
CHAPTER 13 Certainty of Evidence 96

The nature of certainty of evidence 96
Downgrading the certainty of evidence 97
Factors that increase certainty 100
Overall assessment of certainty 102
Conclusion 103
CHAPTER 14 Assessing Value 104

Measuring potential benefit 105
Harm and the balance between benefit
and harm 106
Costs and cost effectiveness 107
Feasibility of implementation of a
treatment 109
Health equity 109
Summary 111
Appendix: Further Reading 113

Index 131
Acknowledgements
I am grateful to the University of Dundee for providing the facilities

to research and write the second edition of this book. The success of
the first edition was due in no small part to my colleagues for their
support and encouragement. As the style and much of the content
of this new edition follows the original, I am pleased to be able to
thank them again for their help. Special thanks are due to Geraldine
Fardon whose constructive comments highlighted imprecise, vague,
and confusing text. I take full responsibility for any remaining flaws.
ix
Preface to the First
Edition
This book was written to meet the needs of health professionals as

medicine moves to be evidence-based. The initial idea arose during
discussion with younger colleagues and students on difficulties of
interpreting the medical literature. It quickly became apparent that
their needs would be best met by a short book detailing criteria for
critical appraisal.
The book is organised in two parts. The first five chapters
provide an introduction to critical appraisal of quantitative research,
indicating how papers can be read and how the results can be inter-
preted. Experienced researchers could easily omit these chapters.
The final six chapters provide annotated checklists for critical
appraisal. The first of these contains the general questions which
can be asked of any study using a quantitative methodology. The
succeeding five chapters review in turn the questions which are
specific for each quantitative method. For convenience each of these
five chapters concludes with a combined list of general and specific
questions.
The book has been written to be simple and quick to use.
Technical terms are avoided where possible, and the assessment
criteria are explained but not justified. A larger and less accessible
text would have been needed to give a proper rationale for each
the checklists. To keep this a pocket guide, it was also decided
to omit evaluations of other topics such as qualitative methods,
health economics, clinical audit, decision analysis, and screening
tests. An argument could be made for the inclusion of each, but to
include them all would nearly double the size of the book. I hope
the checklists prove useful.
xi
Preface to the Second
Edition
Several developments have highlighted the need for a second edition

of this book. Recent work, particularly from the new discipline
of meta-research, has provided important evidence for critical
appraisal. By examining and comparing large numbers of studies,
this research has clarified the nature of and impact of many sources
of bias. A separate development is the recognition that critical
appraisal should distinguish between the risk of bias and the value
of the findings to individuals, health care systems, and the wider
society. Critical appraisal checklists should provide separate sets
of questions for the two issues. Finally, many years of teaching
critical appraisal skills have provided the author with an under-
standing of the difficulties that students and health professionals
encounter when evaluating papers. These developments have led to
improvements in the guidance given in this book.
This new edition follows the format and the spirit of the first:
it is written to be easy to use and, where possible, technical terms
are avoided. However, substantial modifications have been made.
A new Introduction clarifies the aims of critical appraisal. The
second chapter, entitled ‘Do Not Read the Paper’, is also new; it
provides a simple method for eliciting the information needed
for critical appraisal from published studies. This is supported by
Chapter 5, ‘The In-Depth Interrogation’, which is a much-amended
version of the original ‘Standard Appraisal Questions’. In addition,
Chapter 4 on ‘Interpreting the Results’ has been updated in line
with current views on the nature of statistical significance and the
interpretation of confidence intervals.
xiii
xiv Preface to the Second Edition
All of the chapters that provide checklists for critical appraisal

of specific research designs have been revised and updated, partic-
ularly Chapter 9, ‘Appraising Randomised Controlled Trials’, and
Chapter 11, ‘Appraising Systematic Reviews’. A new chapter for
the critical appraisal of cohort studies that evaluate interventions
has been added. This research design is now being frequently used
in medical research (the separate chapter on conventional cohort
studies has been retained). All the checklists distinguish between
critical and important sources of bias and they evaluate risk of bias
separately from value.
Two new chapters at the end of the book provide methods for
synthesising the findings of critical appraisal. One provides a method
for summarising risk of bias. The second explores the important
concept of certainty of evidence and describes how it is assessed.
A further new chapter reviews the wide range of factors that
determine the value of research findings to society as a whole. This
second edition provides a much-needed update to the guidance on
critical appraisal.
CHAPTER 1
Introduction to Critical
Appraisal
Critical appraisal is the process of assessing the strengths and weak-

nesses of published studies. It involves a structured and rigorous
evaluation of all the stages of the research, from design to analysis
and interpretation. All studies have imperfections, so the question
is not if there are flaws, but whether they are likely to be important.
Critical appraisal is a method of systematically examining research
studies to determine the worth of their findings.
The aims of critical appraisal
Critical appraisal assesses two issues: bias in study design or

conduct, and the value that the findings have for clinical practice.
Bias occurs when systematic errors distort the results of a study.
For example, a clinical trial should provide a good estimate of the
benefit of a treatment, but weaknesses in design or conduct could
produce a misleading estimate. There are many types of bias and
The Pocket Guide to Critical Appraisal, Second Edition. Iain K. Crombie.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
1
2 Chapter 1 Introduction to critical appraisal
these are explored through a series of questions that examine the

main deficiencies in research.
The value of findings is the extent to which they will provide
benefits for patients or the general population. Many factors con-
tribute to the value of research findings. For a clinical trial, this would
include the size of the treatment benefit, the importance of the out-
come measure to patients, and whether the patients to be treated in
a clinical setting are similar to the participants in the study. As with
bias, there are sets of questions that assess value.
Three stages of critical appraisal
The critical appraisal of a paper is conducted in three stages: identify

the research design, select the appropriate appraisal tool for that
study, and apply the tool to assess the bias and the value of the
research. This section introduces these stages, with subsequent
chapters explaining in detail how to carry them out.
Identify the research design

Research studies can ask different types of questions. Some may be
concerned with the effectiveness of treatments; others may investi-
gate the likely prognosis of an illness. The research design should be
matched to the research question. To evaluate treatment effective-
ness a randomised controlled trial would be used, whereas progno-
sis would be investigated by a cohort study. The other designs are
surveys, case–control studies, cohort studies that test interventions,
and systematic reviews. Chapter 3 of this book provides guidance on
identifying the correct design.
Select the appropriate appraisal tool

Critical appraisal tools have been developed to enable a forensic eval-
uation of research studies. They provide lists of questions that probe
all aspects of the methods used and the results obtained. Judgements
can then be made about the bias and value of the research. This book
Three stages of critical appraisal 3
presents appraisal tools for the six most common research designs in
medical research (Chapters 6–11).
A key feature of the questions on bias is that they distinguish
between critical and important sources of bias. For each research
design there are a few crucial steps which, if conducted poorly, are
very likely to lead to misleading findings. Flaws in the other steps
are less likely to cause serious bias. Only when several of these flaws
occur are serious concerns raised.
Value, the usefulness or worth of a finding to individuals and to
society, is more difficult to assess. Assessing the potential for improv-
ing health is usually straightforward, but often some pieces of infor-
mation, such as the importance of the findings to patients, are not
available. Decisions about value can use information from several
sources and require judgement to balance many complex issues.
Apply the tool to assess the bias and the value of the
research
The critical appraisal questions can only be answered by identifying
key pieces of information from relevant sections of a paper. Chapter 2
provides a simple method for extracting the key pieces of information
from a research paper. Careful reflection on what the questions reveal
enables an assessment of the quality of the research study.
The appraisal questions presented in this book are structured
to lead to one of three answers: yes, no, or not enough information
to decide. Selecting the appropriate option is not a simple tick
box process. Critical appraisal involves pausing to think about the
implications of each limitation, and whether it could seriously affect
the interpretation of the study’s findings. Sometimes there will
be insufficient information to answer a question. As decisions in
medicine affect patients, it is usually better to be cautious in drawing
conclusions.
In summary, critical appraisal assesses the bias and the value of
research studies. By identifying the research design, the appropriate
appraisal tool is selected. It asks probing questions about the design
of the study and the way it was conducted, analysed, and interpreted.
Chapter 2 describes a simple method for extracting the information
from published papers to facilitate critical appraisal.
CHAPTER 2
Do Not Read the Paper
The most important piece of advice when appraising a scientific

paper is: do not read the paper. Scientific papers are complicated,
information dense, and full of technical jargon – they cannot be read
like a newspaper article. They are written for experts and prioritise
technical correctness over ease of understanding. The research
design is often complex, and the statistical analysis sophisticated.
Papers are written with the assumption that the reader is familiar
with the scientific terms and the methodologies used. Reading every
word from the Introduction to the Discussion may lead to confusion.
A better approach is to interrogate the paper, asking questions
to make it reveal the information about study design and conduct.
Unlike reading, which is a passive process, critical appraisal searches
out the key pieces of information about a study. Interrogation puts
the reader in charge, directing questions at different sections of the
paper, identifying and checking the information in the paper. This
approach provides a quicker appraisal of a paper because it focuses
on the important features of research studies. It probes not just what
was done, but how well it was done. Sometimes the authors of papers
try to gloss over weaknesses in their study. Interrogation will identify

4
The initial interrogation 5
flaws that reading may miss. It provides all the information needed
to evaluate the risk of bias and value of the results.
The initial interrogation
The initial interrogation involves delving into some sections of the

paper to get a feel for what the study is about. The aim is to start
constructing a mental map of the study, not to engage in a serious
appraisal. The main benefit of the map is that it allows you to slot
subsequent pieces of information into a mental framework. This sim-
plifies the task of understanding the paper and helps you organise the
information it contains. The process uses four questions.
What does the title reveal about the study?

The interrogation begins with the title. Good titles should indicate
the patient group being investigated, the research design used, and
why the study is being done. Sometimes titles are written to be catchy
rather than informative, but even then, they should provide one or
two facts about the study. The title provides the first indication of
what the study is about.
Does the abstract help in constructing the mental

map?
The Abstract usually gives key information about the four main
sections of the paper: the Introduction, Methods, Results, and
Discussion. Ideally it will clarify the study aim, the research
design that was used, the main findings and their implications.
Together with the title, the Abstract should enable you to construct
a provisional map of the paper. However, this is not guaranteed.
Information in the Abstracts may be presented to impress rather
than to be informative. The provisional map should be tested by
comparing what it says with the information presented in the
Introduction and the Methods sections.
6 Chapter 2 Do not read the paper
Does the introduction confirm the aims?

The aims of the study are usually presented towards the end of the
Introduction. They may be phrased as hypotheses to be tested or as
questions to be answered. The absence of a clear statement of aims
could mean that the authors had no real idea of what they were trying
to find out. Research studies with unclearly stated aims are often of
poor quality.
Does the methods section explain how the study aims

will be achieved?
The Methods section should explain how all aspects of the study
were carried out. The descriptions in this section are often brief and
difficult to follow. This section should clarify how participants were
recruited, the data that were collected, and the statistical techniques
that were used. Often, the research design, which should explain
how the study aims will be achieved, is not clearly stated. To assist
with this limitation, Chapter 3 provides guidance on identifying the
research design. It outlines the main features and the key terms
indicative of the six most common research designs.
The in-depth interrogation
The initial interrogation should provide a provisional map of the

paper into which information about the sources of bias and the
value of the study findings can be fitted. This process requires an
in-depth interrogation using detailed questions which probe the
quality of the study. These questions are described in Chapters 5–11.
Before reading these chapters, it may be helpful to review Chapter 3
‘Identifying the Research Design’ and Chapter 4 ‘Interpreting the
Results’.
CHAPTER 3
Identifying the
Research Design
The first step in critical appraisal is to identify the research design

used in a study so the appropriate appraisal checklist can be selected.
This chapter provides an outline of the common research designs to
aid their identification. It does not provide a full description of each
method, but instead gives sufficient detail to confirm which design
was used.
Surveys
Surveys are often used to estimate how common something is:

how many people have high blood pressure, or how many suffer
from chronic pain. They can also investigate associations between
factors: is it more common in men or women; does the frequency
of high blood pressure vary with age? Surveys can study whole
populations; for example, to establish the proportion of people who
currently smoke cigarettes. Or they can investigate specific groups;
7
8 Chapter 3 Identifying the research design
for example, they could explore the health beliefs of pregnant

women, or the frequency of loneliness in persons aged between 65
and 90 years.
Essential features
Surveys take samples from a target group or population. The idea
behind this is that a well-taken sample contains almost as much
information as would come from studying the whole population.
In principle, surveys obtain a complete list of the group or population
of interest from which a sample of individuals is selected for further
study. The selection is carried out randomly (not haphazardly),
such that each individual has an equal chance of being chosen.
In practice, a complete list may not be available and alternative
approaches such as cluster sampling can be used (these more
complicated designs are not described here). The important points
are that selection of individuals uses random sampling and that the
sample obtained is representative of a target population.
Complications
Surveys usually do not have a separate control or comparison group,
so studies that have them are not surveys. However, in the analy-
sis of surveys one subgroup in the sample may be compared against
another (e.g. men versus women, or old versus young). Comparisons
are being made, but there is no sense in which one group is acting as
a control to another group. All the individuals have been selected at
the same time and an internal comparison is made.
Terms of identification
Use of the term survey in a paper should identify the method,
but sometimes the term is used for what is really a cohort study.
Cross-sectional is a helpful term because it is seldom used with any
other research method. Prevalence, the frequency of something in
a sample, also suggests that a study is a survey. The terms sample
Cohort studies 9
and random sample are unhelpful because they often appear in the
description of the other research designs. The terms simple, cluster,
or systematic can be used with the word sampling to describe differ-
ent ways of drawing a sample, e.g. cluster sampling. These terms are
seldom used with the other research designs. The phrase stratified
sampling is also used in surveys, but the word stratified can also be
used in randomised controlled trials (RCTs).
Cohort studies
Cohort studies are used to find out what happens to study partic-
ipants over time. It is the method of choice for studying disease
prognosis, or for investigating the consequences of exposure to
potentially harmful agents. For example, studies could investigate
how long patients with acute low back pain take to recover, or
how many people who smoke subsequently develop lung cancer.
Whatever the topic, a group of individuals is identified and followed
up to see what events befall them. Most commonly the aim is to
determine whether exposure to a potentially noxious substance
leads to an increased risk of a disease. Sometimes the interest is in
whether potentially beneficial substances, such as dietary vitamins
or fish oils, reduce the risk of disease.
Essential features
The defining characteristic of cohort studies is the element of time: in
cohort studies time flows forwards. A set of individuals is identified at
one point in time and followed up to a later time to ascertain what has
happened. These studies are called prospective cohort studies. When
studying the impact of some exposure, cohort studies often have a
comparison or control group. The controls are usually identified at
around the same time and followed for the same length of time. This
type of cohort study is called a concurrent cohort study.
Many cohort studies do not have a control group; instead they
can make internal comparisons. For example, a cohort could recruit
a large sample from the general population and identify who smoked
and who did not. The whole sample would be followed up for several
years to determine whether lung cancer occurs more frequently in
smokers than in non-smokers.
Complications
Some cohort studies identify the group from some time in the past
and follow them up to the present. These studies might at first appear
to be looking backwards in time, but they are not. Historical records
are used, and time flows forwards from the point at which the indi-
viduals are identified. This type of design is usually called a retrospec-
tive cohort study. (Note the term historical cohort study is used when
the exposed group is recruited from one period and the comparison
group comes from an earlier period.)
The terms prospective and longitudinal suggest a cohort study,
although these terms are also used in clinical trials. The term
retrospective is used for one type of cohort study, but is also used
with case–control studies.
Case–control studies
Case–control studies ask what makes a group of individuals different

from a control or comparison group. Often the study group will have
a disease, which the control group do not have. For example, the cases
could be women with breast cancer and the controls could be women
of similar age who do not have the disease. The study compares the
characteristics of the cases and controls to identify the factors from
the past that might have caused the disease. The control group is
often selected to be similar to the cases in factors such as age, gen-
der, and life circumstances. This type of study can also explore why
some people behave in a particular way. For example, a study could
RCTs 11
explore why some patients miss clinic appointments, by comparing

those who fail to attend with those who do attend.
Essential features
Case–control studies look backwards in time from some event
(e.g. the diagnosis of breast cancer or failing to attend a clinic)
to try to identify factors in the past that might explain why that
event occurred. The direction of time is crucial for distinguishing
between cohort studies and case–control studies: cohort studies look
forwards; case–control studies backwards.
Complications
The use of a control group is not a defining characteristic, since RCTs
always have one, and cohort studies often do.
Several terms are used for this type of study including: case–control,
case-referent, case-comparator, and case-comparison. Because the
method looks backwards in time it is sometimes called a retrospective
study, but this term can be used with cohort studies.
RCTs
The RCT should be the easiest method to identify. This design is used
to test whether one health care intervention is superior to another.
RCTs are most often used to test drugs, but they can be used to inves-
tigate many different types of health care interventions: surgery,
vaccination, anti-pressure sore mattresses, and health education.
RCTs often compare a new treatment against the currently accepted
best treatment. If there is no existing treatment, the new one is com-
pared against a placebo (an inert substance or a dummy procedure).
Essential features
RCTs are always concerned with effectiveness. The key element of
this design is that patients are randomly allocated to receive a new
treatment or to the conventional one (or a placebo). The outcome of
the new treatment is compared with that of the conventional one,
identifying which is superior. RCTs are also concerned with the
side effects of treatments. Most RCTs compare two treatments, but
sometimes more than two treatments can be investigated. This adds
complexity to the conduct and analysis of the study, although the
resulting study is a valid RCT.
Complications
The phrase clinical trial is often used as shorthand for an RCT.
However, clinical trial can refer to studies in which patients are
allocated treatment in a non-random way (non-randomised studies).
For example, cohort studies can be used to assess effectiveness: a
group of treated patients and an independent control group are
followed up to see which group gains most benefit.
The term randomisation almost always identifies an RCT, as does the
equivalent phrase random allocation. (Note that the term random
selection may refer to a survey.) The terms blinding, placebo, effec-
tiveness, efficacy, and evaluation, or phrases like assess the value of or
improve the outcome, can be used in both RCTs and non-randomised
studies.
Cohort studies that evaluate the effectiveness

of interventions
An increasingly common research design is a special type of cohort

study that evaluates the effectiveness of treatments. It compares
Cohort studies that evaluate the effectiveness of interventions 13
the outcomes among a group of patients given one treatment with

outcomes in other patients who have the same disease but were
given a different treatment. The difference from a conventional
RCT is that patients are not randomised to treatments. Instead
the clinician responsible for the patient decides which treatment
should be given. This type of study evaluates treatments as they
are used in routine clinical practice. A common form of this design
uses electronic health records to identify patients with a defined
disease and the treatments that they were given. The effects of
the treatments on the outcome measures are also obtained from
electronic data. When the two groups are recruited and followed
up in the same time period, this design is called a concurrent cohort
study. In a different form of this design, recently diagnosed patients
are given the new treatment and are compared with patients from
the past who were given a different treatment. These studies are
called historical cohort studies.
Essential features
The essential feature of this design is that the treatment patients
receive is selected by the doctors who are responsible for their
care, based on an assessment of their specific clinical circum-
stances. Rather than being randomised to treatment groups, clinical
judgement is used to decide which treatment will be best for each
patient. As a result, the patients given one treatment may differ
systematically from those given the other treatment. This is the
major weakness of the research design, as the two groups of patients
will be different at the start of the study (i.e. before they receive their
treatment).
Complications
A special type of cohort treatment study is the quasi-randomised
study. In this design patients are assigned by the researchers to
treatment groups using a non-random method such as date of
clinic appointment (assignment by alternate days) or date of birth
(assignment by odd or even dates). Because the assignment process

is predictable, it could be tampered with, creating a risk of bias. This
design is best viewed as similar to an RCT, but one at high risk of
bias due to poor concealment of treatment allocation.
There are no specific terms which identify this research design.
The terms concurrent cohort study and historical cohort study could
refer to this design, but they could also refer to conventional cohort
studies (those which do not evaluate the effectiveness of treatments).
The term non-randomised study is often used for this type of study,
although that label refers to a group of research designs which
include case–control studies, surveys, interrupted time series, and
case series.
Systematic reviews
Systematic reviews seek to identify all the papers published on a

specific health topic to obtain a summary of the findings from all
the relevant studies. They commonly use the statistical technique
of meta-analyses to combine the findings from each study. In effect,
meta-analysis produces results which are comparable with those
from one very large study. This approach overcomes the weakness of
individual studies, which, because of their small size, can be greatly
affected by the play of chance.
Essential features
Systematic reviews search electronic databases of research studies,
such as MEDLINE, EMBASE, and CINAHL, to locate published
studies, using carefully chosen combinations of key terms. Papers are
carefully screened to identify the relevant ones. The chosen papers
are commonly referred to as the primary studies. Key data items,
such as effect size, standard deviation, and sample size, are extracted
from each study. These data are usually, but not always, combined
to provide an overall estimate of effect size using meta-analysis.
Systematic reviews 15
Complications
There are no complications. The design of a systematic review differs
substantially from all other types of study, so that an inspection of the
methods used should identify it.
Either of the terms systematic review or meta-analysis identifies the
design. If there is doubt, then the use of a search strategy should
provide confirmation. The terms review and narrative review can
refer to a systematic review or to a study with a less complete collec-
tion of primary studies. An overview usually indicates a collection of
systematic reviews, but it can be used for a set of primary studies.
CHAPTER 4
Interpreting the Results
Interpreting the results presented in a paper can be challenging.

Large amounts of information from the statistical analyses can be
spread across the text, tables, and figures. To simplify the process
of interpretation, the initial focus should be on the findings most
relevant to the aim or hypothesis being evaluated. This is usually
the result highlighted in the Abstract. For example, the key item for
a randomised controlled trial (RCT) would be the size of the benefit
(or the harm) of the new treatment. It should be accompanied by a
test for statistical significance and a confidence interval (these topics
are described in the text that follows). Having established the key
items, each table and figure can be then approached by asking ‘How
will these results influence the interpretation of the main findings?’
This sequential approach simplifies the process, making it easier to
review the large amount of information presented.
The interpretation of the analyses needs an understanding of
several important ideas from statistics and epidemiology. These
may seem daunting, but they are really quite straightforward.
This chapter presents a simple introduction to the following

16
The effect size 17
terms: measures of effect size, probability, p-values and confidence,

bias, and confounding. It also describes some common questionable
research practices.
The effect size
In most quantitative research designs the key item is the effect size,
the observed difference between two groups. For example, cohort
studies compare the frequencies of the outcomes in exposed and
non-exposed groups, and clinical trials do so for the treated and
the control groups. Case–control studies identify the factor(s) that
distinguish cases from controls. What matters is the magnitude
of the effect size, how much the two groups differ, with large
differences usually being more important than small ones. Several
measures are used to quantify the differences between groups, and
these are described in the text that follows.
The relative risk

In cohort studies and clinical trials, the effect size is often presented
as a relative risk. It compares the frequency of the outcomes in two
groups, dividing the rate in the exposed (or treated) group by the
rate in the control group. For example, in a cohort study of the risk
among women of dying from heart disease, the rate among those who
smoked >25 cigarettes per day was 27 deaths per 100 000 per year, and
the rate among non-smokers was 5 per 100 000 per year. The relative
risk was 27 ÷ 5 = 5.4. Therefore, heavy smoking caused a fivefold
increase in the risk of heart disease.
The relative risk takes the value 1.0 if there is no difference
between the two groups (if the frequency of the outcome was the
same in the two groups, dividing the exposed by the non-exposed
will yield 1.0). For cohort studies, with an exposure that increases
the risk of disease, the relative risk will be greater than 1.0. As a
rough guide, a relative risk of 1.2 would be regarded as a small
increase in risk, whereas 2.0 is moderate, 5.0 is large, and >10 is very
large.
18 Chapter 4 Interpreting the results
Relative risks can also be less than 1.0. For exposures such as reg-
ular aerobic exercise, which decrease the frequency of heart disease,
the relative risk could be 0.8, corresponding to a 20% reduction in
risk. In clinical trials the interest lies in whether the new treatment
reduces the frequency of an outcome compared to the control. Thus,
a relative risk of 0.8 indicates that the new treatment was slightly bet-
ter than the control treatment, whereas one of 0.2 would suggest it
was much better and 0.1 would show it was very much better. In con-
trast, a relative risk of 1.2 would mean that the treatment could be
harmful.
Other ratio measures of risk

Two other measures of risk, the odds ratio and the hazard ratio, are
commonly presented in research papers. These are interpreted in the
same way as the relative risk: the further the estimate is away from
1.0 (either larger or smaller), the greater the effect size. Case–control
studies use the odds ratio because, for technical reasons, they cannot
calculate relative risks. The hazard ratio is a more sophisticated ver-
sion of measuring risk for cohort studies and clinical trials. It takes
account of the fact that participants may have been followed up for
different lengths of time.
The absolute risk reduction

The absolute risk reduction does not use ratios; it looks at the arith-
metic difference in the frequency of outcomes in the two groups.
In a clinical trial this would be the frequency of the outcome in the
control group minus that in the treated group. This measure can be
more informative than the relative risk because it conveys a better
sense of the potential importance of an exposure or a treatment.
Suppose a new treatment for a serious disease was shown to have
a relative risk of 0.5, reducing the chances of dying by half. If the
disease was had a low mortality, with only 2% of patients dying
from it, then the treatment would reduce the rate from 2 to 1%.
However, if the disease had a mortality rate of 20%, treatment would
reduce the rate to 10%, preventing many more deaths. This example
shows that the potential impact of the relative risk depends on the
mortality rate of the disease.
Effect size for surveys

Surveys differ from the other research designs in that they only pro-
vide estimates of the frequency of certain characteristics in the group
studied. For example, it could be the frequency of asthma in a region
of England; or it could be the proportion of people who smoke. Thus,
the equivalent of the effect size is the size of the proportion. Surveys
often compare the frequency among different subgroups, for example
the proportion of men and women with asthma. They could also
investigate how the frequency of smoking varies by age.
Taking the play of chance into account
All study results are subject to the play of chance. Suppose when
one study was completed, a second identical one was carried out.
It is very likely that the effect sizes from the two studies would
be similar but not identical. (The characteristics of the patients
included might differ, and the data collected could contain different
measurement errors.) If the study could be replicated hundreds of
times, then taking an average of all the effect sizes would remove
the impact of the play of chance. In effect, the average would be very
close to the true value. Many of the individual effect sizes will be
close to the average value, but by chance a few will be far away from
it. Thus, when a study produces an interesting finding we need to
know whether it could be real or just due to the play of chance. This
involves probability and statistical testing, which sound difficult but
are fairly straightforward.
Probability
The probability of throwing a six (with a fair six-sided dice) is one
in six. The probability of a single ticket winning the national lottery
is 1 in 14 million. Probabilities are simply a way of describing how

likely it is that an event will happen. They are commonly expressed
as decimal fractions, where one in six becomes 0.167. The interpre-
tation of probabilities is straightforward. When an event has a very
small probability, e.g. 0.0001, it is very unlikely to happen. When the
probability is large, say 0.9, the event is very likely to happen.
Probabilities vary between 0.0 and 1.0, where 0.0 means an event
will never happen and 1.0 means it is certain to happen. Thus, the
probability that a healthy adult will eventually die is 1.0, because
we all die sometime. In contrast the probability of that adult dying
tomorrow is less than one in 100 000, i.e. <0.00001. It is not quite
zero because some unlikely event, such as being run over by a bus,
might just happen. It is very small because rare events are unlikely
to happen.
Probabilities are often termed p-values, in which the letter p
stands for probability. They can be written as p = 0.003 indicating
that an event has a 3 in 1000 chance of occurring. Sometimes these
probabilities are rounded up to specific thresholds: p < 0.05, p < 0.01,
and p < 0.001, corresponding to significant, very significant, and
highly significant. For example, p = 0.003 would be expressed as
p < 0.01. This practice is discouraged. It is better to give the exact
p-value, as rounding up introduces an approximation that wastes
information.
Statistical tests and p-values

Probabilities lie at the heart of statistical tests. The logic behind the
calculation of p-values can seem a bit strange, but the approach is
chosen because it is the only one that is valid. Consider a clinical
trial comparing a new treatment with a conventional one. The first
step is to propose that any difference between the treatments is
solely due to the play of chance, i.e. that there is really no difference
between the treatments. This is commonly called the Null Hypothe-
sis. (It is not what we are hoping for – everyone would want a new
treatment to be superior to the conventional one – however, it is the
way the logic leads us.) The statistical test then calculates how likely
it is that, by chance alone, we would see a difference at least as big
as that observed. The test provides us with a probability, a p-value,

which tells us how likely it is that the result is due to chance. When
this is small (e.g. p = 0.003), the result is unlikely to be due to chance.
The Null Hypothesis can be rejected, and we can conclude that one
treatment is likely to be better than the other. In contrast p = 0.65
suggests that chance could be the explanation and we accept the
Null Hypothesis.1
There is a convenient threshold for the interpretation of p-values:
when the p-value is less than 0.05 (i.e. p < 0.05) we conclude that
chance is not the explanation. The observed effect size is said to
be statistically significant. Smaller p-values, say p < 0.01 or even
p < 0.001, indicate it is even less likely that the result was due
to chance. These are termed highly and very highly significant,
respectively.
The p < 0.05 threshold does not correspond to a guarantee. It is
sometimes incorrectly used to decide whether a treatment is effec-
tive. Such a rule would mean that a treatment with p = 0.049 would
be judged effective, whereas in another study, one with p = 0.051
would be ineffective. The difference between the p-values is tiny, so
it would be absurd to claim that one treatment was effective and the
other was not. Statistical testing was developed as way of identifying
findings that could be interesting, not to prove effectiveness.
When multiple tests of significance are conducted p-values lose
their meaning. Suppose many trials were conducted to evaluate a
treatment which, in reality, was not effective. Then, by chance alone,
a spuriously significant result would occur, on average, once for every
20 significance tests that were conducted. This is because p = 0.05
actually says that the observed result could occur by chance one time
in 20.
1
Technical note. All statistical tests make assumptions about the nature of the
data being analysed. Commonly these are that the data points are independent
and that they follow a defined distribution, such as the normal distribution.
The interpretation of statistical tests and p-values requires that these assump-
tions are met. Published papers generally do not provide sufficient information
to assess the validity of the assumptions, leaving no option but to take it on trust
that the statistical tests are being used appropriately.
Confidence intervals
Because of the play of chance, research studies only provide an esti-
mate of the true effect size. With a large study the estimate should be
close to the true value, but it is unlikely to be identical to it. The con-
fidence interval indicates a range within which the true value might
lie. Conventionally the 95% confidence interval is used: it shows the
range within which we are 95% sure that the true size of effect might
lie. This can be helpful when deciding whether a treatment is clini-
cally important. For example, a relative risk of 0.4 might have a 95%
confidence interval 0.3–0.55. This shows that the true value is most
likely in the narrow range 0.3–0.55. However, if the same relative risk
had a confidence interval 0.05–0.95, there is considerable uncertainty
about what the true value might be. The confidence interval conveys
more useful information than p-values.
Factors that distort the effect size
Bias
Bias is the bane of medical research. It occurs when the observed
effect size differs from the true value because of systematic flaws
in the design or conduct of a study. Unlike random chance, which
sometimes pushes the effect size up, and sometimes down, bias
consistently pushes it in one direction. The difference between
random and systematic errors can be illustrated by considering a
digital thermometer that makes errors. If it produces random errors,
then some patients will have too high a reading, and for others it
will be too low. But when calculating the average for a group of
patients, the falsely high and low readings will tend to cancel each
other out, so the group average will be close to the true value. If the
errors are systematic, either high or low, then the group average will
be consistently pushed in one direction.
Random errors become important when comparing two groups.
Usually they bias the effect size towards the null (i.e. towards no dif-
ference between the groups); the effect appears smaller than it really
Factors that distort the effect size 23
is. In contrast, systematic errors can either inflate or underestimate

the estimated effect size. Most often it is unclear which way the bias
will push the effect size. This uncertainty makes it difficult to inter-
pret the study findings.
A large number of biases afflict medical research; a website
hosted by the University of Oxford (https://catalogofbias
.org) identifies over 60 of them. They can occur in the design,
conduct, analysis, and interpretation of studies. Although there are
many types of bias, they all act to distort estimates of effect sizes. The
biases most common in the different research designs are described
in Chapters 6–11.
Confounding
Confounding occurs when part, or all, of the observed associa-
tion between two variables is due to the action of a third factor.
A well-known example of this is the relationship between birth order
and Down’s syndrome. Studies show that first- and second-born
children have a much lower risk of the disease than children further
down the birth order. In fact, the relationship is due to the age of
the mother, as women having a third or fourth child will usually be
older than mothers having a first or second child. Older mothers
are at much higher risk, even if they are having their first child.
Similarly, the association between alcohol consumption and lung
cancer is due to confounding by smoking. Smokers on average drink
more, and it is smoking that causes lung cancer.
Confounding is a common feature of surveys, case–control
studies, and cohort studies, and even RCTs can be affected. It
occurs because many aspects of human health and behaviour are
interrelated. For example, with increasing age blood pressure tends
to rise, and older people may need glasses to help them read. This
does not mean that hypertension causes difficulties in reading.
Instead, both are a consequence of ageing. Reducing the impact of
confounding is one of the major challenges in medical research.
Confounding is a particular problem for modest relative
risks in the range 0.5–2.0. Research has shown that such effect
sizes could easily be produced by confounding. In contrast, large
effects (relative risks <0.2 or >5) are unlikely to be due solely to

confounding. As modest treatment effects are the ones commonly
reported in research studies, confounding is often a serious problem.
Questionable research practices
There is substantial evidence that research findings can be distorted

by the manipulation of data or the statistical analysis. This may be
motivated by the desire to produce more interesting (statistically sig-
nificant) findings. Three techniques that are commonly used to man-
ufacture spurious p-values are described.
Hypothesising after the analysis

Research studies often collect a large amount of data, although only
a small amount is published. The wealth of data means multiple
statistical tests can be conducted. Then a chance finding could be
presented as if it were a prior hypothesis that was being tested.
New study aims could be created, making it appear that the authors
showed good judgement in their selection of the research question.
This may not be the result of deliberate cheating: subconscious
biases could enable the researchers to persuade themselves that they
really knew in advance what would be found in the analysis. It can
then appear permissible to change the aims.
Detecting changes in the aims is difficult, as it requires access
to the protocol for the original study. The protocols of RCTs can be
published in journals, or the main study features can be posted on
an international register of clinical trials (e.g. International Clinical
Trials Registry Platform or clinicaltrials.gov). Checking these sources
can identify instances of hypothesis changing. However, for other
study designs, such as surveys or cohort studies, few protocols are
published and international registries, if available, are seldom used.
The only option for critical appraisal is gut feeling: if the hypothesis
being tested is somewhat unexpected, to the point of being bizarre,
then the study findings should be treated with caution.
Another random document with
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“Nothing but the five statutory questions,” said Ellen to the
rawboned man with big sagging eyes like oysters into whose long
shirtfront she was talking.
“And so the decree is granted?” he asked solemnly.
“Surely in an uncontested ...”
“Well I’m very sorry to hear it as an old family friend of both
parties.”
“Look here Dick, honestly I’m very fond of Jojo. I owe him a great
deal.... He’s a very fine person in many ways, but it absolutely had to
be.”
“You mean there is somebody else?”
She looked up at him with bright eyes and half nodded.
“Oh but divorce is a very serious step my dear young lady.”
“Oh not so serious as all that.”
They saw Harry Goldweiser coming towards them across the big
walnut paneled room. She suddenly raised her voice. “They say that
this battle of the Marne is going to end the war.”
Harry Goldweiser took her hand between his two pudgy-palmed
hands and bowed over it. “It’s very charming of you Elaine to come
and keep a lot of old midsummer bachelors from boring each other
to death. Hello Snow old man, how’s things?”
“Yes how is it we have the pleasure of still finding you here?”
“Oh various things have held me.... Anyway I hate summer
resorts.” “Nowhere prettier than Long Beach anyway.... Why Bar
Harbor, I wouldnt go to Bar Harbor if you gave me a million ... a cool
million.”
Mr. Snow let out a gruff sniff. “Seems to me I’ve heard you been
going into the realestate game down there, Goldweiser.”
“I bought myself a cottage that’s all. It’s amazing you cant even
buy yourself a cottage without every newsboy on Times Square
knowing about it. Let’s go in and eat; my sister’ll be right here.” A
dumpy woman in a spangled dress came in after they had sat down
to table in the big antlerhung diningroom; she was pigeonbreasted
and had a sallow skin.
“Oh Miss Oglethorpe I’m so glad to see you,” she twittered in a
little voice like a parrakeet’s. “I’ve often seen you and thought you
were the loveliest thing.... I did my best to get Harry to bring you up
to see me.”
“This is my sister Rachel,” said Goldweiser to Ellen without getting
up. “She keeps house for me.”
“I wish you’d help me, Snow, to induce Miss Oglethorpe to take
that part in The Zinnia Girl.... Honest it was just written for you.”
“But it’s such a small part ...”
“It’s not a lead exactly, but from the point of view of your
reputation as a versatile and exquisite artist, it’s the best thing in the
show.”
“Will you have a little more fish, Miss Oglethorpe?” piped Miss
Goldweiser.
Mr. Snow sniffed. “There’s no great acting any more: Booth,
Jefferson, Mansfield ... all gone. Nowadays it’s all advertising; actors
and actresses are put on the market like patent medicines. Isn’t it the
truth Elaine?... Advertising, advertising.”
“But that isn’t what makes success.... If you could do it with
advertising every producer in New York’d be a millionaire,” burst in
Goldweiser. “It’s the mysterious occult force that grips the crowds on
the street and makes them turn in at a particular theater that makes
the receipts go up at a particular boxoffice, do you understand me?
Advertising wont do it, good criticism wont do it, maybe it’s genius
maybe it’s luck but if you can give the public what it wants at that
time and at that place you have a hit. Now that’s what Elaine gave us
in this last show.... She established contact with the audience. It
might have been the greatest play in the world acted by the greatest
actors in the world and fallen a flat failure.... And I dont know how
you do it, nobody dont know how you do it.... You go to bed one
night with your house full of paper and you wake up the next morning
with a howling success. The producer cant control it any more than
the weather man can control the weather. Aint I tellin the truth?”
“Ah the taste of the New York public has sadly degenerated since
the old days of Wallack’s.”
“But there have been some beautiful plays,” chirped Miss
Goldweiser.
The long day love was crisp in the curls ... the dark curls ...
broken in the dark steel light ... hurls ... high O God high into the
bright ... She was cutting with her fork in the crisp white heart of a
lettuce. She was saying words while quite other words spilled
confusedly inside her like a broken package of beads. She sat
looking at a picture of two women and two men eating at a table in a
high paneled room under a shivering crystal chandelier. She looked
up from her plate to find Miss Goldweiser’s little birdeyes kindly
querulous fixed hard on her face.
“Oh yes New York is really pleasanter in midsummer than any
other time; there’s less hurry and bustle.”
“Oh yes that’s quite true Miss Goldweiser.” Ellen flashed a sudden
smile round the table.... All the long day love Was crisp in the curls of
his high thin brow, Flashed in his eyes in dark steel light....
In the taxi Goldweiser’s broad short knees pressed against hers;
his eyes were full of furtive spiderlike industry weaving a warm sweet
choking net about her face and neck. Miss Goldweiser had relapsed
pudgily into the seat beside her. Dick Snow was holding an unlighted
cigar in his mouth, rolling it with his tongue. Ellen tried to remember
exactly how Stan looked, his polevaulter’s tight slenderness; she
couldn’t remember his face entire, she saw his eyes, lips, an ear.
Times Square was full of juggled colored lights, crisscrossed
corrugations of glare. They went up in the elevator at the Astor. Ellen
followed Miss Goldweiser across the roofgarden among the tables.
Men and women in evening dress, in summer muslins and light suits
turned and looked after her, like sticky tendrils of vines glances
caught at her as she passed. The orchestra was playing In My
Harem. They arranged themselves at a table.
“Shall we dance?” asked Goldweiser.
She smiled a wry broken smile in his face as she let him put his
arm round her back. His big ear with solemn lonely hairs on it was on
the level of her eyes.
“Elaine,” he was breathing into her ear, “honest I thought I was a
wise guy.” He caught his breath ... “but I aint.... You’ve got me goin
little girl and I hate to admit it.... Why cant you like me a little bit? I’d
like ... us to get married as soon as you get your decree.... Wouldn’t
you be kinder nice to me once in a while...? I’d do anything for you,
you know that.... There are lots of things in New York I could do for
you ...” The music stopped. They stood apart under a palm. “Elaine
come over to my office and sign that contract. I had Ferrari wait....
We can be back in fifteen minutes.”
“I’ve got to think it over ... I never do anything without sleeping on
it.”
“Gosh you drive a feller wild.”
Suddenly she remembered Stan’s face altogether, he was
standing in front of her with a bow tie crooked in his soft shirt, his
hair rumpled, drinking again.
“Oh Ellie I’m so glad to see you....”
“This is Mr. Emery, Mr. Goldweiser....”
“I’ve been on the most exordinately spectacular trip, honestly you
should have come.... We went to Montreal and Quebec and came
back through Niagara Falls and we never drew a sober breath from
the time we left little old New York till they arrested us for speeding
on the Boston Post Road, did we Pearline?” Ellen was staring at a
girl who stood groggily behind Stan with a small flowered straw hat
pulled down over a pair of eyes the blue of watered milk. “Ellie this is
Pearline.... Isn’t it a fine name? I almost split when she told me what
it was.... But you dont know the joke.... We got so tight in Niagara
Falls that when we came to we found we were married.... And we
have pansies on our marriage license....”
Ellen couldnt see his face. The orchestra, the jangle of voices, the
clatter of plates spouted spiraling louder and louder about her ...
And the ladies of the harem
Knew exactly how to wear ’em
In O-riental Bagdad long ago....
“Good night Stan.” Her voice was gritty in her mouth, she heard
the words very clearly when she spoke them.
“Oh Ellie I wish you’d come partying with us....”
“Thanks ... thanks.”
She started to dance again with Harry Goldweiser. The
roofgarden was spinning fast, then less fast. The noise ebbed
sickeningly. “Excuse me a minute Harry,” she said. “I’ll come back to
the table.” In the ladies’ room she let herself down carefully on the
plush sofa. She looked at her face in the round mirror of her
vanitycase. From black pinholes her pupils spread blurring till
everything was black.
Jimmy Herf’s legs were tired; he had been walking all afternoon.
He sat down on a bench beside the Aquarium and looked out over
the water. The fresh September wind gave a glint of steel to the little
crisp waves of the harbor and to the slateblue smutted sky. A big
white steamer with a yellow funnel was passing in front of the statue
of Liberty. The smoke from the tug at the bow came out sharply
scalloped like paper. In spite of the encumbering wharfhouses the
end of Manhattan seemed to him like the prow of a barge pushing
slowly and evenly down the harbor. Gulls wheeled and cried. He got
to his feet with a jerk. “Oh hell I’ve got to do something.”
He stood a second with tense muscles balanced on the balls of
his feet. The ragged man looking at the photogravures of a Sunday
paper had a face he had seen before. “Hello,” he said vaguely. “I
knew who you were all along,” said the man without holding out his
hand. “You’re Lily Herf’s boy.... I thought you werent going to speak
to me.... No reason why you should.”
“Oh of course you must be Cousin Joe Harland.... I’m awfully glad
to see you.... I’ve often wondered about you.”
“Wondered what?”
“Oh I dunno ... funny you never think of your relatives as being
people like yourself, do you?” Herf sat down in the seat again. “Will
you have a cigarette.... It’s only a Camel.”
“Well I dont mind if I do.... What’s your business Jimmy? You dont
mind if I call you that do you?” Jimmy Herf lit a match; it went out, lit
another and held it for Harland. “That’s the first tobacco I’ve had in a
week ... Thank you.”
Jimmy glanced at the man beside him. The long hollow of his gray
cheek made a caret with the deep crease that came from the end of
his mouth. “You think I’m pretty much of a wreck dont you?” spat
Harland. “You’re sorry you sat down aint you? You’re sorry you had a
mother who brought you up a gentleman instead of a cad like the
rest of ’em....”
“Why I’ve got a job as a reporter on the Times ... a hellish rotten
job and I’m sick of it,” said Jimmy, drawling out his words.
“Dont talk like that Jimmy, you’re too young.... You’ll never get
anywhere with that attitude.”
“Well suppose I dont want to get anywhere.”
“Poor dear Lily was so proud of you.... She wanted you to be a
great man, she was so ambitious for you.... You dont want to forget
your mother Jimmy. She was the only friend I had in the whole damn
family.”
Jimmy laughed. “I didnt say I wasnt ambitious.”
“For God’s sake, for your dear mother’s sake be careful what you
do. You’re just starting out in life ... everything’ll depend on the next
couple of years. Look at me.”
“Well the Wizard of Wall Street made a pretty good thing of it I’ll
say.... No it’s just that I dont like to take all the stuff you have to take
from people in this goddam town. I’m sick of playing up to a lot of
desk men I dont respect.... What are you doing Cousin Joe?”
“Don’t ask me....”
“Look, do you see that boat with the red funnels? She’s French.
Look, they are pulling the canvas off the gun on her stern.... I want to
go to the war.... The only trouble is I’m very poor at wrangling
things.”
Harland was gnawing his upper lip; after a silence he burst out in
a hoarse broken voice. “Jimmy I’m going to ask you to do something
for Lily’s sake.... Er ... have you any ... er ... any change with you?
By a rather unfortunate ... coincidence I have not eaten very well for
the last two or three days.... I’m a little weak, do you understand?”
“Why yes I was just going to suggest that we go have a cup of
coffee or tea or something.... I know a fine Syrian restaurant on
Washington street.”
“Come along then,” said Harland, getting up stiffly. “You’re sure
you don’t mind being seen with a scarecrow like this?”
The newspaper fell out of his hand. Jimmy stooped to pick it up. A
face made out of modulated brown blurs gave him a twinge as if
something had touched a nerve in a tooth. No it wasnt, she doesnt
look like that, yes Talented Young Actress Scores Hit in the
Zinnia Girl....
“Thanks, dont bother, I found it there,” said Harland. Jimmy
dropped the paper; she fell face down.
“Pretty rotten photographs they have dont they?”
“It passes the time to look at them, I like to keep up with what’s
going on in New York a little bit.... A cat may look at a king you know,
a cat may look at a king.”
“Oh I just meant that they were badly taken.”
VII. Rollercoaster
T
he leaden twilight weighs on the dry
limbs of an old man walking towards
Broadway. Round the Nedick’s stand at
the corner something clicks in his eyes.
Broken doll in the ranks of varnished
articulated dolls he plods up with drooping
head into the seethe and throb into the
furnace of beaded lettercut light. “I
remember when it was all meadows,” he
grumbles to the little boy.
L
ouis Expresso Association, the red letters on the placard jig
before Stan’s eyes. Annual Dance. Young men and girls going
in. Two by two the elephant And the kangaroo. The boom and
jangle of an orchestra seeping out through the swinging doors of the
hall. Outside it is raining. One more river, O there’s one more river to
cross. He straightens the lapels of his coat, arranges his mouth
soberly, pays two dollars and goes into a big resounding hall hung
with red white and blue bunting. Reeling, so he leans for a while
against the wall. One more river ... The dancefloor full of jogging
couples rolls like the deck of a ship. The bar is more stable. “Gus
McNiel’s here,” everybody’s saying “Good old Gus.” Big hands slap
broad backs, mouths roar black in red faces. Glasses rise and tip
glinting, rise and tip in a dance. A husky beetfaced man with deepset
eyes and curly hair limps through the bar leaning on a stick. “How’s a
boy Gus?”
“Yay dere’s de chief.”
“Good for old man McNiel come at last.”
“Howde do Mr. McNiel?” The bar quiets down.
Gus McNiel waves his stick in the air. “Attaboy fellers, have a
good time.... Burke ole man set the company up to a drink on me.”
“Dere’s Father Mulvaney wid him too. Good for Father Mulvaney....
He’s a prince that feller is.”
For he’s a jolly good fellow
That nobody can deny ...
Broad backs deferentially hunched follow the slowly pacing group
out among the dancers. O the big baboon by the light of the moon is
combing his auburn hair. “Wont you dance, please?” The girl turns a
white shoulder and walks off.
I am a bachelor and I live all alone
And I work at the weaver’s trade....
Stan finds himself singing at his own face in a mirror. One of his
eyebrows is joining his hair, the other’s an eyelash.... “No I’m not
bejases I’m a married man.... Fight any man who says I’m not a
married man and a citizen of City of New York, County of New York,
State of New York....” He’s standing on a chair making a speech,
banging his fist into his hand. “Friends Roooomans and countrymen,
lend me five bucks.... We come to muzzle Cæsar not to shaaaave
him.... According to the Constitution of the City of New York, County
of New York, State of New York and duly attested and subscribed
before a district attorney according to the provisions of the act of July
13th 1888.... To hell with the Pope.”
“Hey quit dat.” “Fellers lets trow dis guy out.... He aint one o de
boys.... Dunno how he got in here. He’s drunk as a pissant.” Stan
jumps with his eyes closed into a thicket of fists. He’s slammed in the
eye, in the jaw, shoots like out of a gun out into the drizzling cool
silent street. Ha ha ha.
For I am a bachelor and I live all alone
And there’s one more river to cross
One more river to Jordan
One more river to cross ...
It was blowing cold in his face and he was sitting on the front of a
ferryboat when he came to. His teeth were chattering, he was
shivering ... “I’m having DT’s. Who am I? Where am I? City of New
York, State of New York.... Stanwood Emery age twentytwo
occupation student.... Pearline Anderson twentyone occupation
actress. To hell with her. Gosh I’ve got fortynine dollars and eight
cents and where the hell have I been? And nobody rolled me. Why I
havent got the DT’s at all. I feel fine, only a little delicate. All I need’s
a little drink, dont you? Hello, I thought there was somebody here. I
guess I’d better shut up.”
Fortynine dollars ahanging on the wall
Fortynine dollars ahanging on the wall
Across the zinc water the tall walls, the birchlike cluster of
downtown buildings shimmered up the rosy morning like a sound of
horns through a chocolatebrown haze. As the boat drew near the
buildings densened to a granite mountain split with knifecut canyons.
The ferry passed close to a tubby steamer that rode at anchor listing
towards Stan so that he could see all the decks. An Ellis Island tug
was alongside. A stale smell came from the decks packed with
upturned faces like a load of melons. Three gulls wheeled
complaining. A gull soared in a spiral, white wings caught the sun,
the gull skimmed motionless in whitegold light. The rim of the sun
had risen above the plumcolored band of clouds behind East New
York. A million windows flashed with light. A rasp and a humming
came from the city.
The animals went in two by two
The elephant and the kangaroo
There’s one more river to Jordan
One more river to cross
In the whitening light tinfoil gulls wheeled above broken boxes,
spoiled cabbageheads, orangerinds heaving slowly between the
splintered plank walls, the green spumed under the round bow as
the ferry skidding on the tide, gulped the broken water, crashed, slid,
settled slowly into the slip. Handwinches whirled with jingle of chains,
gates folded upward. Stan stepped across the crack, staggered up
the manuresmelling wooden tunnel of the ferryhouse out into the
sunny glass and benches of the Battery. He sat down on a bench,
clasped his hands round his knees to keep them from shaking so.
His mind went on jingling like a mechanical piano.
With bells on her fingers and rings on her toes
Shall ride a white lady upon a great horse
And she shall make mischief wherever she goes ...
There was Babylon and Nineveh, they were built of brick. Athens
was goldmarble columns. Rome was held up on broad arches of
rubble. In Constantinople the minarets flame like great candles round
the Golden Horn.... O there’s one more river to cross. Steel glass,
tile, concrete will be the materials of the skyscrapers. Crammed on
the narrow island the millionwindowed buildings will jut, glittering
pyramid on pyramid, white cloudsheads piled above a thunderstorm
...
And it rained forty days and it rained forty nights
And it didn’t stop till Christmas
And the only man who survived the flood
Was longlegged Jack of the Isthmus....
Kerist I wish I was a skyscraper.
The lock spun round in a circle to keep out the key. Dexterously
Stan bided his time and caught it. He shot headlong through the
open door and down the long hall shouting Pearline into the
livingroom. It smelled funny, Pearline’s smell, to hell with it. He
picked up a chair; the chair wanted to fly, it swung round his head
and crashed into the window, the glass shivered and tinkled. He
looked out through the window. The street stood up on end. A
hookandladder and a fire engine were climbing it licketysplit trailing a
droning sirenshriek. Fire fire, pour on water, Scotland’s burning. A
thousand dollar fire, a hundredthousand dollar fire, a million dollar
fire. Skyscrapers go up like flames, in flames, flames. He spun back
into the room. The table turned a somersault. The chinacloset
jumped on the table. Oak chairs climbed on top to the gas jet. Pour
on water, Scotland’s burning. Don’t like the smell in this place in the
City of New York, County of New York, State of New York. He lay on
his back on the floor of the revolving kitchen and laughed and
laughed. The only man who survived the flood rode a great lady on a
white horse. Up in flames, up, up. Kerosene whispered a
greasyfaced can in the corner of the kitchen. Pour on water. He
stood swaying on the crackling upside down chairs on the upside
down table. The kerosene licked him with a white cold tongue. He
pitched, grabbed the gasjet, the gasjet gave way, he lay in a puddle
on his back striking matches, wet wouldn’t light. A match spluttered,
lit; he held the flame carefully between his hands.
“Oh yes but my husband’s awfully ambitious.” Pearline was telling

the blue gingham lady in the grocery-store. “Likes to have a good
time an all that but he’s much more ambitious than anybody I every
knew. He’s goin to get his old man to send us abroad so he can
study architecture. He wants to be an architect.”
“My that’ll be nice for you wont it? A trip like that ... Anything else
miss?” “No I guess I didn’t forget anythin.... If it was anybody else I’d
be worryin about him. I haven’t seen him for two days. Had to go and
see his dad I guess.”
“And you just newly wed too.”
“I wouldnt be tellin ye if I thought there was anythin wrong, would
I? No he’s playin straight all right.... Well goodby Mrs. Robinson.”
She tucked her packages under one arm and swinging her bead bag
in the free hand walked down the street. The sun was still warm
although there was a tang of fall in the wind. She gave a penny to a
blind man cranking the Merry Widow waltz out of a grindorgan. Still
she’d better bawl him out a little when he came home, might get to
doing it often. She turned into 200th Street. People were looking out
of windows, there was a crowd gathering. It was a fire. She sniffed
the singed air. It gave her gooseflesh; she loved seeing fires. She
hurried. Why it’s outside our building. Outside our apartmenthouse.
Smoke dense as gunnysacks rolled out of the fifthstory window. She
suddenly found herself all atremble. The colored elevatorboy ran up
to her. His face was green. “Oh it’s in our apartment” she shrieked,
“and the furniture just came a week ago. Let me get by.” The
packages fell from her, a bottle of cream broke on the sidewalk. A
policeman stood in her way, she threw herself at him and pounded
on the broad blue chest. She couldnt stop shrieking. “That’s all right
little lady, that’s all right,” he kept booming in a deep voice. As she
beat her head against it she could feel his voice rumbling in his
chest. “They’re bringing him down, just overcome by smoke that’s
all, just overcome by smoke.”
“O Stanwood my husband,” she shrieked. Everything was
blacking out. She grabbed at two bright buttons on the policeman’s
coat and fainted.
VIII. One More River to Jordan
A
man is shouting from a soapbox at
Second Avenue and Houston in front of
the Cosmopolitan Cafè: “... these fellers,
men ... wageslaves like I was ... are sittin on
your chest ... they’re takin the food outen
your mouths. Where’s all the pretty girls I
used to see walkin up and down the
bullevard? Look for em in the uptown
cabarets.... They squeeze us dry friends ...
feller workers, slaves I’d oughter say ... they
take our work and our ideers and our
women.... They build their Plaza Hotels and
their millionaire’s clubs and their million
dollar theayters and their battleships and
what do they leave us?... They leave us
shopsickness an the rickets and a lot of dirty
streets full of garbage cans.... You look pale
you fellers.... You need blood.... Why dont
you get some blood in your veins?... Back in
Russia the poor people ... not so much
poorer’n we are ... believe in wampires,
things come suck your blood at night....
That’s what Capitalism is, a wampire that
sucks your blood ... day ... and ... night.”
It is beginning to snow. The flakes are
giltedged where they pass the streetlamp.
Through the plate glass the Cosmopolitan
Cafè full of blue and green opal rifts of
smoke looks like a muddy aquarium; faces
blob whitely round the tables like illassorted
fishes. Umbrellas begin to bob in clusters up
the snowmottled street. The orator turns up
his collar and walks briskly east along
Houston, holding the muddy soapbox away
from his trousers.
aces, hats, hands, newspapers jiggled in the fetid roaring

F subway car like corn in a popper. The downtown express passed
clattering in yellow light, window telescoping window till they
overlapped like scales.
“Look George,” said Sandbourne to George Baldwin who hung on
a strap beside him, “you can see Fitzgerald’s contraction.”
“I’ll be seeing the inside of an undertaking parlor if I dont get out
of this subway soon.”
“It does you plutocrats good now and then to see how the other
half travels.... Maybe it’ll make you induce some of your little
playmates down at Tammany Hall to stop squabbling and give us
wageslaves a little transportation.... cristamighty I could tell em a
thing or two.... My idea’s for a series of endless moving platforms
under Fifth Avenue.”
“Did you cook that up when you were in hospital Phil?”
“I cooked a whole lot of things up while I was in hospital.”
“Look here lets get out at Grand Central and walk. I cant stand
this.... I’m not used to it.”
“Sure ... I’ll phone Elsie I’ll be a little late to dinner.... Not often I
get to see you nowadays George ... Gee it’s like the old days.”
In a tangled clot of men and women, arms, legs, hats aslant on
perspiring necks, they were pushed out on the platform. They walked
up Lexington Avenue quiet in the claretmisted afterglow.
“But Phil how did you come to step out in front of a truck that
way?”
“Honestly George I dunno.... The last I remember is craning my
neck to look at a terribly pretty girl went by in a taxicab and there I
was drinking icewater out of a teapot in the hospital.”
“Shame on you Phil at your age.”
“Cristamighty dont I know it? But I’m not the only one.”
“It is funny the way a thing like that comes over you.... Why what
have you heard about me?”
“Gosh George dont get nervous, it’s all right.... I’ve seen her in
The Zinnia Girl.... She walks away with it. That other girl who’s the
star dont have a show.”
“Look here Phil if you hear any rumors about Miss Oglethorpe for
Heaven’s sake shut them up. It’s so damn silly you cant go out to tea
with a woman without everybody starting their dirty gabble all over
town.... By God I will not have a scandal, I dont care what happens.”
“Say hold your horses George.”
“I’m in a very delicate position downtown just at the moment that’s
all.... And then Cecily and I have at last reached a modus vivendi.... I
wont have it disturbed.”
They walked along in silence.
Sandbourne walked with his hat in his hand. His hair was almost
white but his eyebrows were still dark and bushy. Every few steps he
changed the length of his stride as if it hurt him to walk. He cleared
his throat. “George you were asking me if I’d cooked up any
schemes when I was in hospital.... Do you remember years ago old
man Specker used to talk about vitreous and superenameled tile?
Well I’ve been workin on his formula out at Hollis.... A friend of mine
there has a two thousand degree oven he bakes pottery in. I think it
can be put on a commercial basis.... Man it would revolutionize the
whole industry. Combined with concrete it would enormously
increase the flexibility of the materials at the architects’ disposal. We
could make tile any color, size or finish.... Imagine this city when all
the buildins instead of bein dirty gray were ornamented with vivid
colors. Imagine bands of scarlet round the entablatures of
skyscrapers. Colored tile would revolutionize the whole life of the
city.... Instead of fallin back on the orders or on gothic or
romanesque decorations we could evolve new designs, new colors,
new forms. If there was a little color in the town all this hardshell
inhibited life’d break down.... There’d be more love an less
divorce....”
Baldwin burst out laughing. “You tell em Phil.... I’ll talk to you
about that sometime. You must come up to dinner when Cecily’s
there and tell us about it.... Why wont Parkhurst do anything?”
“I wouldnt let him in on it. He’d cotton on to the proposition and
leave me out in the cold once he had the formula. I wouldn’t trust him
with a rubber nickel.”
“Why doesnt he take you into partnership Phil?”
“He’s got me where he wants me anyway.... He knows I do all the
work in his goddamned office. He knows too that I’m too cranky to
make out with most people. He’s a slick article.”
“Still I should think you could put it up to him.”
“He’s got me where he wants me and he knows it, so I continue
doin the work while he amasses the coin.... I guess it’s logical. If I
had more money I’d just spend it. I’m just shiftless.”
“But look here man you’re not so much older than I am.... You’ve
still got a career ahead of you.”
“Sure nine hours a day draftin.... Gosh I wish you’d go into this tile
business with me.”
Baldwin stopped at a corner and slapped his hand on the
briefcase he was carrying. “Now Phil you know I’d be very glad to
give you a hand in any way I could.... But just at the moment my
financial situation is terribly involved. I’ve gotten into some rather
rash entanglements and Heaven knows how I’m going to get out of
them.... That’s why I cant have a scandal or a divorce or anything.
You dont understand how complicatedly things interact.... I couldnt
take up anything new, not for a year at least. This war in Europe has
made things very unsettled downtown. Anything’s liable to happen.”
“All right. Good night George.”
Sandbourne turned abruptly on his heel and walked down the
avenue again. He was tired and his legs ached. It was almost dark.
On the way back to the station the grimy brick and brownstone
blocks dragged past monotonously like the days of his life.
Under the skin of her temples iron clamps tighten till her head will
mash like an egg; she begins to walk with long strides up and down
the room that bristles with itching stuffiness; spotty colors of pictures,
carpets, chairs wrap about her like a choking hot blanket. Outside
the window the backyards are striped with blue and lilac and topaz of
a rainy twilight. She opens the window. No time to get tight like the
twilight, Stan said. The telephone reached out shivering beady
tentacles of sound. She slams the window down. O hell cant they
give you any peace?
“Why Harry I didnt know you were back.... Oh I wonder if I can....
Oh yes I guess I can. Come along by after the theater.... Isnt that
wonderful? You must tell me all about it.” She no sooner puts the
receiver down than the bell clutches at her again. “Hello.... No I
dont.... Oh yes maybe I do.... When did you get back?” She laughed
a tinkling telephone laugh. “But Howard I’m terribly busy.... Yes I am
honestly.... Have you been to the show? Well sometime come round
after a performance.... I’m so anxious to hear about your trip ... you
know ... Goodby Howard.”
A walk’ll make me feel better. She sits at her dressingtable and
shakes her hair down about her shoulders. “It’s such a hellish
nuisance, I’d like to cut it all off ... spreads apace. The shadow of
white Death.... Oughtnt to stay up so late, those dark circles under
my eyes.... And at the door, Invisible Corruption.... If I could only cry;
there are people who can cry their eyes out, really cry themselves
blind ... Anyway the divorce’ll go through....”
Far from the shore, far from the trembling throng
Whose sails were never to the tempest given
Gosh it’s six o’clock already. She starts walking up and down the
room again. I am borne darkly fearfully afar.... The phone rings.
“Hello.... Yes this is Miss Oglethorpe.... Why hello Ruth, why I
haven’t seen you for ages, since Mrs. Sunderland’s.... Oh, do I’d love
to see you. Come by and we’ll have a bite to eat on the way to the
theater.... It’s the third floor.”
She rings off and gets a raincape out of a closet. The smell of furs
and mothballs and dresses clings in her nostrils. She throws up the
window again and breathes deep of the wet air full of the cold rot of
autumn. She hears the burring boom of a big steamer from the river.
Darkly, fearfully afar from this nonsensical life, from this fuzzy idiocy
and strife; a man can take a ship for his wife, but a girl. The
telephone is shiveringly beadily ringing, ringing.
The buzzer burrs at the same time. Ellen presses the button to
click the latch. “Hello.... No, I’m very sorry I’m afraid you’ll have to tell
me who it is. Why Larry Hopkins I thought you were in Tokyo.... They
havent moved you again have they? Why of course we must see
each other.... My dear it’s simply horrible but I’m all dated up for two
weeks.... Look I’m sort of crazy tonight. You call up tomorrow at
twelve and I’ll try to shift things around.... Why of course I’ve got to
see you immediately you funny old thing.” ... Ruth Prynne and
Cassandra Wilkins come in shaking the water off their umbrellas.
“Well goodby Larry.... Why it’s so so sweet of both of you.... Do take
your things off for a second.... Cassie wont you have dinner with
us?”
“I felt I just had to see you.... It’s so wonderful about your
wonderful success,” says Cassie in a shaky voice. “And my dear I
felt so terribly when I heard about Mr. Emery. I cried and cried, didnt I
Ruth?”
“Oh what a beautiful apartment you have,” Ruth is exclaiming at
the same moment. Ellen’s ears ring sickeningly. “We all have to die
sometime,” gruffly she blurts out.
Ruth’s rubberclad foot is tapping the floor; she catches Cassie’s
eye and makes her stammer into silence. “Hadnt we better go
along? It’s getting rather late,” she says.
“Excuse me a minute Ruth.” Ellen runs into the bathroom and
slams the door. She sits on the edge of the bathtub pounding on her
knees with her clenched fists. Those women’ll drive me mad. Then
the tension in her snaps, she feels something draining out of her like
water out of a washbasin. She quietly puts a dab of rouge on her
lips.
When she goes back she says in her usual voice: “Well let’s get
along.... Got a part yet Ruth?”
“I had a chance to go out to Detroit with a stock company. I turned
it down.... I wont go out of New York whatever happens.”
“What wouldnt I give for a chance to get away from New York....
Honestly if I was offered a job singing in a movie in Medicine Hat I
think I’d take it.”
Ellen picks up her umbrella and the three women file down the
stairs and out into the street. “Taxi,” calls Ellen.
The passing car grinds to a stop. The red hawk face of the
taxidriver craning into the light of the street lamp. “Go to Eugenie’s
on Fortyeighth Street,” says Ellen as the others climb in. Greenish
lights and darks flicker past the lightbeaded windows.
She stood with her arm in the arm of Harry Goldweiser’s dinner
jacket looking out over the parapet of the roofgarden. Below them
the Park lay twinkling with occasional lights, streaked with nebular
blur like a fallen sky. From behind them came gusts of a tango,
inklings of voices, shuffle of feet on a dancefloor. Ellen felt a stiff
castiron figure in her metalgreen evening dress.
“Ah but Boirnhardt, Rachel, Duse, Mrs. Siddons.... No Elaine I’m
tellin you, d’you understand? There’s no art like the stage that soars
so high moldin the passions of men.... If I could only do what I
wanted we’d be the greatest people in the world. You’d be the
greatest actress.... I’d be the great producer, the unseen builder,
d’you understand? But the public dont want art, the people of this
country wont let you do anythin for em. All they want’s a detective
melodrama or a rotten French farce with the kick left out or a lot of

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Set in 10.5/13pt STIXTwoText by Straive, Chennai, India

CHAPTER 1 Introduction to Critical Appraisal 1

CHAPTER 2 Do Not Read the Paper 4

CHAPTER 3 Identifying the Research Design 7

CHAPTER 4 Interpreting the Results 16

CHAPTER 5 The In-Depth Interrogation 26

CHAPTER 6 Appraising Surveys 40

CHAPTER 7 Appraising Cohort Studies 45

CHAPTER 8 Appraising Case–Control Studies 53

CHAPTER 9 Appraising Randomised Controlled

CHAPTER 10 Cohort Studies That Evaluate the

The questions of value 78

CHAPTER 11 Appraising Systematic Reviews 81

CHAPTER 12 Summarising Risk of Bias 91

CHAPTER 13 Certainty of Evidence 96

CHAPTER 14 Assessing Value 104

Appendix: Further Reading 113

I am grateful to the University of Dundee for providing the facilities

This book was written to meet the needs of health professionals as

Several developments have highlighted the need for a second edition

All of the chapters that provide checklists for critical appraisal

Critical appraisal is the process of assessing the strengths and weak-

The aims of critical appraisal

Critical appraisal assesses two issues: bias in study design or

these are explored through a series of questions that examine the

Three stages of critical appraisal

The critical appraisal of a paper is conducted in three stages: identify

Identify the research design

Select the appropriate appraisal tool

The most important piece of advice when appraising a scientific

The Pocket Guide to Critical Appraisal, Second Edition. Iain K. Crombie.

The initial interrogation

The initial interrogation involves delving into some sections of the

What does the title reveal about the study?

Does the abstract help in constructing the mental

Does the introduction confirm the aims?

Does the methods section explain how the study aims

The in-depth interrogation

The initial interrogation should provide a provisional map of the

The first step in critical appraisal is to identify the research design

Surveys are often used to estimate how common something is:

for example, they could explore the health beliefs of pregnant

Case–control studies ask what makes a group of individuals different