Critically-Appraised Topics (CAT)

David Luce, MMS, PA-C Research Seminar PASS 0527 Monday, January 7, 2013

Critically Appraised Topics (CAT)

Brief Evidence-based assessment of one or two of the most relevant studies retrieved to answer a focused clinical question Generally written as a one-page summary
Your CAT may be 1-2 pages in length

Steps in Preparing a CAT

Formulate a clinical question Efficiently and effectively search the literature Critically appraise the literature Apply the evidence to the patient

CAT Example, pg. 62

Physician Assistants Guide to Research and Medical Literature, J. Dennis Blessing

Scenario
Author: Barbara A. Porter Date: October 31, 1997

Crilically appraised topic: Chamydial screening to prevent pelvic inflammatory disease (PID) 1
Scenario: An asymptomatic 22-year-old female presents to clinic for a routine physical exam. She is sexually active, I had two sexual partners in the last year. Never treated for an STD. Will screening her for chlamydia at today's visit decrease her risk of developing PID in the future?

Clinical Bottom Line

In women thought to be at increased risk for chlamydial infection, cervical screening reduced the risk of subsequent PID by 58% relative to women who were not screened. Eighty-three women at increased risk for chlamydial infections need to be screened by cervical testing in order to prevent one case of PID.

The Evidence
Randomized controlled trial of 2,607 women identified as being at increased risk for chlamydial infection. Women were assigned to receive either screening for cervical chlamydial disease or usual care. The diagnosis of PID within one year of onset of study was the outcome measured, and was determined by patient report, review of inpatient and outpatient diagnostic databases. and medical record review. Randomization into groups occurred before inclusion/exclusion criteria sought. Except for marital status, the two groups were similar in baseline characteristics.

The Evidence
Endpoint* Screened Usual Care 33/1598 Absolute Risk Reduction 0.012 Relative Risk 0.42 Relative Risk Reduction 0.58 NNS**

PID

9/1009

83

*Calculations based on rates expressed as cases of PID per

number of women: paper's rates are per women months. **Number needed to screen.

Comments
1. Results are strained by several flaws in study design: *Randomization style, that is, because of study design, subjects randomized to screening group were more intensely recruited. which may have introduced behavior changes in this population. *Thirty-six percent of women in the screening group did not receive the intervention, which seems like a large percentage; however. data was analyzed by "intention to screen." Subjects and health workers were not blinded. *Were the seven women diagnosed with chlamydia in the screened population also diagnosed with PID during the screening test, or were these subsequent diagnoses? 2 Although this study set out to evaluate the usefulness of screening for chlamydia in PID, the paper did not provide a detailed evaluation of the screening tool. Is the prevalence of chlamydia known in this population? What are the sensitivity and specificity of the two screening tests? Why did they use two diagnostic tests? Is one a "gold standard"? The fact that screening required a pelvic exam makes cervical testing less attractive as a screening tool.

Comments
3. First-void urine testing with ligase chain reaction assay for chlamydia may be a more appropriate screening tool,2 and its utility in the prevention of PID should be studied. 4. Some PID is caused by gonorrhea. were subjects with chlamydia treated for gonorrhea as well? 5. Besides decreasing the risk of PID secondary to indolent infection. does making a diagnosis of chlamydia lead to education and behavioral changes? Is there a way to measure this?

References (1-3)
1 Scholes D. Stergachis A. Heidrich FE. et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydia! infection. N Engl J Med 1996;334: 1362-1366. 2. Marrazzo JM. WI1Ue CL. Kreke!er B. eta!. community-based urine screening for Chlamydia trachomatis with a ligase chain reaction assay Ann lnternal Med 1997: 127:796-803. Used with permission from: Porter BA. Critically-appraised topic: Chamydial screening to prevent pelvic inflammatory Disease. UNC Critically Appraised Topics. Online CAT Bank. October 31, 1997. Cited date: August, 2004. Available from: hffp:llwww.med.unc.edu/ rnediclneledursrcltve/corne