Guest Editorial
Writing a Clinically Appraised Topic
Is a Team Sport
Carolyn M. Rutter, PhD, Susan M. Shortreed, PhD
Evidence-based practice requires clinicians to understand the
current research relevant to clinical decisions. This is a tall
order, given both the number of clinical decisions made
each day and the large and ever-increasing number of research
articles published each year. The Cochrane Collaboration
(www.cochrane.org) provides systematic reviews that are
meant to guide both health care and health policy. Although
Cochrane has more than 5000 such reviews, it cannot possibly
explore every clinical question. In addition, a systematic
review does not necessarily focus on specific, real-world clin-
ical situations. A critically appraised topic (CAT) can fill these
gaps, providing clinicians with the information necessary for
their specific clinical decisions and enabling effective commu-
nication with patients. Such communication is the foundation
of patient-centered care and is the first step in shared decision-
making. A well-written CAT may even be directly useful to
motivated patients who are seeking information on their own.
Sadigh, Parker, Kelly, and Cronin are to be congratulated
for their comprehensive description of the process of writing
a high-quality CAT, which appears in this issue of Academic
Radiology. As they demonstrate, writing a high-quality CAT
is a complex task that requires a broad knowledge base. For
a clinician planning to write a CAT, the article by Sadigh
and colleagues outline key steps in gathering and describing
the evidence on a chosen clinical topic and includes many
relevant and important references. In this editorial, we address
a key step neglected by their tutorial: building a strong, multi-
disciplinary CAT writing team. Only a few, rare individuals
possess both the clinical and statistical expertise needed to
write a CAT without assistance. For this reason, writing
a CAT provides an excellent opportunity for collaboration
between clinicians and statisticians.
The first step identified by Sadigh and colleagues is to
clearly articulate the clinical question to be addressed in the
CAT. Clinicians are certainly able to identify important and
relevant clinical questions, yet statisticians can provide impor-
tant support at this stage. Specifically, statisticians can assist in
refining and focusing the question of interest to ensure that it
can be addressed given the available evidence. This is an
important component of statistical training and is analogous
Acad Radiol 2012; 19:777–778
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98103. Received April 12, 2012; accepted April 13, 2012.
ªAUR, 2012
doi:10.1016/j.acra.2012.04.007
to consulting with a statistician in the early phases of a research
project.
The next step in writing a CAT is identification of articles
that are potentially related to the clinical question at hand. In
most cases this search will yield many published articles. A
single high-quality study is rarely comprehensive enough to
completely answer a clinical question: conditions need to be
varied, subgroups examined, and findings replicated. A CAT
article provides an essential link in the evidence chain, yet
a synthesis of available evidence is only as informative as the
quality of the literature review at its base. As Sadigh et al point
out, a good literature search requires a broad familiarity with
various types of studies and the strength of evidence each
provides. A multidisciplinary CAT writing team that includes
statistical expertise helps ensure a comprehensive examination
of the literature.
After potential articles have been identified, each one must
be critically appraised—that is, evaluated for study quality and
relevance. The quality of a study is determined by a collection
of factors including study design, how the data are analyzed,
and how the results are reported and interpreted. Although
many clinicians are statistically savvy, the skills required to
evaluate study quality are particularly aligned with the skills
and training of a statistician. Statisticians are trained in study
design, selection of appropriate analytic methods, and appro-
priate interpretation of results, making them well-equipped to
identify potential problems and biases. Just as a clinician
develops clinical insights with experience in clinical practice,
a statistician continues to gain insights, beyond his or her
classroom training, in study validity, generalizability, and bias
with experience collaborating with research teams studying
different types of diseases and populations. Statisticians are
better able to identify potential problems in specific clinical
areas after learning about the disease process through discus-
sions with clinician-collaborators. Thus, the task of assessing
study quality builds partnerships between clinicians and
statisticians, with both contributing unique expertise required
for assessing the importance and rigor of a scientific study.
Although study quality is critical to weighing the available
evidence in a CAT, threats to study quality can be subtle. For
example, although randomized controlled trials are consid-
ered the gold standard for estimating treatment efficacy,
analytic issues can still arise in randomized trials, such as the
proper estimation of standard errors or bias from missing
data or low compliance. Statisticians regularly wield statistical
tools to minimize bias in these settings, so they know what to
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look for in the statistical analysis section of a high-quality
study. Observational studies are useful for providing evidence
beyond randomized trials and can answer scientific questions
that cannot be addressed in a randomized setting (eg, for
ethical reasons). However, as Sadigh and colleagues note,
observational studies have much greater potential for bias
than randomized studies. Although statistical approaches can
be used to minimize bias in observational studies, these
methods can be highly technical and often involve assump-
tions that must be validated in the context of a particular study.
Statisticians are trained to be cognizant of the assumptions
necessary for various statistical methods, the appropriate
ways to validate these assumptions, and the red flags that can
indicate problems with an analysis.
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We strongly support the efforts of Sadigh and colleagues in
promoting and clearly explaining the writing of CATs to
support evidence-based practice. Most high-quality health
care research is the result of a cross-disciplinary effort
involving a team whose members each contribute unique
specialized skills. Similarly, a high-quality CAT writing team
should include members who bring the skills necessary for
a thorough critical appraisal and synthesis of the available
evidence. An experienced, multidisciplinary team can provide
a cohesive description of the available knowledge providing
more comprehensive finding than could possibly result from
any single study. Statisticians and clinicians both play essential
roles in this process and their collaboration can strengthen the
quality of the conclusions of a CAT.