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How to Read a Paper: The Basics of Evidence-Based Medicine, 4th Edition



How to Read a Paper: The Basics of Evidence-Based Medicine, 4th Edition

Trisha Greenhalgh

ISBN: 978-1-444-39036-0 November 2010 BMJ Books 256 Pages

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How to Read a Paper describes the different types of clinical research reporting, and explains how to critically appraise the publications. The book provides the tools to find and evaluate the literature, and implement the findings in an evidence-based, patient-centered way. Written for anyone in the health care professions who has little or no knowledge of evidence-based medicine, it provides a clear understanding of the concepts and how to put them into practice at the basic, clinical level.

Changes for the 4th edition
The fourth edition will include two new chapters on important developments in health care research and delivery, but otherwise retains its original style, size, and scope.

  • New chapter on quality improvement – describing papers on quality improvement projects using ebm methods;  this will extend the readership to non clinical health care professionals working in hospitals and family practice, and to nurse specialists and practice nurses working in this field
  • New chapter on complex interventions - how to set up research projects involving both qualitative and quantitative methodology (known as mixed methods)
  • Thorough revision and updating of existing chapters and references
  • New illustrations – diagrammatic representations of ebm concepts
Foreword to the First Edition by Professor Sir David Weatherall.

Preface to the First Edition: do you need to read this book?

Preface to the Fourth Edition.


1 Why read papers at all?

1.1 Does 'evidence-based medicine' simply mean 'reading papers in medical journals'?

1.2 Why do people sometimes groan when you mention EBM?

1.3 Before you start: formulate the problem.

2 Searching the literature.

2.1 What are you looking for?

2.2 Levels upon levels of evidence.

2.3 Synthesised sources: systems, summaries and syntheses.

2.4 Pre-appraised sources: synopses of systematic reviews and primary studies.

2.5 Specialised resources.

2.6 Primary studies – tackling the jungle.

2.7 One-stop shopping: federated search engines.

2.8 Asking for help and asking around.

3 Getting your bearings – what is this paper about?

3.1 The science of 'trashing' papers.

3.2 Three preliminary questions to get your bearings.

3.3 Randomised controlled trials.

3.4 Cohort studies.

3.5 Case-control studies.

3.6 Cross-sectional surveys.

3.7 Case reports.

3.8 The traditional hierarchy of evidence.

3.9 A note on ethical considerations.

4 Assessing methodological quality.

4.1 Was the study original?

4.2 Whom is the study about?

4.3 Was the design of the study sensible?

4.4 Was systematic bias avoided or minimised?

4.5 Was assessment 'blind'?

4.6 Were preliminary statistical questions addressed?

4.7 Summing up.

5 Statistics for the non-statistician.

5.1 How can non-statisticians evaluate statistical tests?

5.2 Have the authors set the scene correctly?

5.3 Paired data, tails, and outliers.

5.4 Correlation, regression and causation.

5.5 Probability and confidence.

5.6 The bottom line.

5.7 Summary.

6 Papers that report trials of drug treatments and other simple interventions.

6.1 ‘Evidence’ and marketing.

6.2 Making decisions about therapy.

6.3 Surrogate endpoints.

6.4 What information to expect in a paper describing an RCT: the CONSORT statement.

6.5 Getting worthwhile evidence out of a pharmaceutical representative.

7 Papers that report trials of complex interventions.

7.1 Complex interventions.

7.2 Ten questions to ask about a paper describing a complex intervention.

8 Papers that report diagnostic or screening tests.

8.1 Ten men in the dock.

8.2 Validating diagnostic tests against a gold standard.

8.3 Ten questions to ask about a paper that claims to validate a diagnostic or screening test.

8.4 Likelihood ratios.

8.5 Clinical prediction rules.

9 Papers that summarise other papers (systematic reviews and meta-analyses).

9.1 When is a review systematic?

9.2 Evaluating systematic reviews.

9.3 Meta-analysis for the non-statistician.

9.4 Explaining heterogeneity.

9.5 New approaches to systematic review.

10 Papers that tell you what to do (guidelines).

10.1 The great guidelines debate.

10.2 How can we help ensure that evidence-based guidelines are followed?

10.3 Ten questions to ask about a clinical guideline.

11 Papers that tell you what things cost (economic analyses).

11.1 What is an economic analysis?

11.2 Measuring the costs and benefits of health interventions.

11.3 Ten questions to ask about an economic analysis.

11.4 Conclusion.

12 Papers that go beyond numbers (qualitative research).

12.1 What is qualitative research?

12.2 Evaluating papers that describe qualitative research.

12.3 Conclusion.

13 Papers that report questionnaire research.

13.1 The rise and rise of questionnaire research.

13.2 Ten questions to ask about a paper describing a questionnaire study.

14 Papers that report quality improvement case studies.

14.1 What are quality improvement studies – and how should we research them?

14.2 Ten questions to ask about a paper describing a quality improvement initiative.

14.3 Conclusion.

15 Getting evidence into practice.

15.1 Why are health professionals slow to adopt evidence-based practice?

15.2 How much avoidable suffering is caused by failing to implement evidence?

15.3 How can we influence health professionals' behaviour to promote evidence-based practice?

15.4 What does an 'evidence-based organisation' look like?

15.5 How can we help organisations develop the appropriate structures, systems and values to support evidence-based practice?

15.6 Why is it so hard to get evidence into policymaking?

Appendix 1 Checklists for finding, appraising and implementing evidence.

Appendix 2 Assessing the effects of an intervention.


"It becomes phenomenal in the transition of empirical medicine to evidence-based medicine
(EBM) ... Even though the book titles the word ‘basics' it is fit enough for advanced level of EBM. (Riper Pdic Bulletin, 1December 2011)

"It is an essential read for all occupational health practitioners in training and those participating in a systematic evidence review or the development of evidence-based practice guidelines." (Occupational Medicine, 11 December 2011)

"To some extent forget the "evidence-based medicine" tag; while some chapters are specific to medical research, many others have generic value for any field of research ... This is a useful supplement that will aid anyone new to the assessment game." (Online Information Review, 2011)

"In summary, this book presents with not only some interesting research material itself, but also provides valuable insight into the reading and interpretation of technical and research papers. As a laboratory professional, this text can help to move you from merely a reader to papers to a user of papers. This step can take you to a new level in your laboratory career. Definitely worth the read or at least the scan." (Advance for Medical Laboratory Professionals, 10 October 2011)

"It will be a great tool for students, teachers and others in the world of academia, as well as patients who want to find out more about their condition, and who are new to reading journal papers and other documents which consider evidence-based medicine . . . It is good to see this book in its 4th edition and this reviewer hopes it continues to be revised as it really does provide a basic one-stop shop if you are new to evidence-based medicine." (The Encephalitis Society, 2011)

"Writing for health students and professionals, and anyone wanting to assess the validity of articles, Greenhalgh (primary health care, Queen Mary, U. of London, UK) explains the principles of evidencebased medicine and how to critically evaluate clinical research papers. She details how to evaluate different types of papers, such as papers on drug treatments and simple interventions, diagnostic and screening tests, those that summarize other papers, guidelines, economic analyses, and qualitative research." (Book News, September 2010)Trisha Greenhalgh is a doctor, not a statistician, and she is writing about a topic, Evidence-Based Medicine (EBM) that might appear at first to be irrelevant to us statisticians. It is not irrelevant. Any statistician who works extensively with health care professionals should embrace the EBM movement." (Journal of Biopharmaceutical Statistics , 2011)

"The book does show you how to put your brain into thinking gear and not just absorb information without thinking about it making this an excellent book. If I can react so strongly in this review, then it has to be worth something." (, July 2010)