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A critique: The good and bad of a review

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DOI: 10.5667/tang.2015.0008

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Review

A critique: The good and bad of a review

Debbie McMullen, Rhett McClean, Sok Cheon Pak*

School of Biomedical Sciences, Charles Sturt University, Bathurst, NSW 2795, Australia

ABSTRACT
Evidence based medicine involves using both the individual clinician’s expertise and the current best
available external clinical evidence from systematic research in deciding on the appropriate care for
individual patients. The current approach to evidence based practice in healthcare adds a third component
which is patient values. Evidence based practice is thus a triad, in which the practitioner’s expertise,
research evidence and the patient’s values are all given consideration. The balance to be struck between
them depends on the individual case. The literature indicates that complementary medicine practitioners
are moving away from traditional knowledge and towards the use of evidence based practice in their
clinical discussions. In the context of the daily practice of complementary medicine practitioners and their
continuing development of their knowledge base of evidence based practice, this short review discusses
the good and bad of a review journal article.

Keywords critique, review, methodology, bias, evidence

INTRODUCTION selecting articles or their validity (Collins and Fauser, 2005;

Green et al., 2006). This review shows some degree of
It is crucial that all health professionals uphold current best selection bias as many of the results are taken from previously
practice standards. In evidence based practice, this is founded published studies by or involving the author, nevertheless, this
in quality research. Time poor practitioners often opt to use has been balanced with a review of other clinical trials and
reviews to achieve this. Therefore, the ability to objectively observational studies. Yuan’s review is relatively unsystematic
critique a review journal article to determine its strengths and despite the use of studies ranking high on the evidence
weaknesses and its value to clinical practice is essential. Not all hierarchy (Green et al., 2006; MeInyk and Fineout-Overholt,
reviews are created equal; hence, it is important to recognize 2011). An unsystematic method with subjective selection of
the advantages and disadvantages of a review. This short articles leaves a review open to a greater potential for selection
review looks at some of these features based on a published bias and the possibility of the omission of valuable studies that
review article by Yuan (2013) entitled ‘Cancer prevention by could result in a different conclusion, hence, a non-objective
green tea: Evidence from epidemiologic studies’. review. Further, the use of good methodology is vital to a good
quality review such as data extraction and analysis identifying
how the findings were achieved; producing valid results and
Methodology and bias allowing the reader to judge the merit of the paper (Abalos et
al., 2001; Green et al., 2006; MeInyk and Fineout-Overholt,
Yuan’s article published in 2013 is a narrative review with a 2011; Rother, 2007). In contrast to Yuan’s review, a similar
critical evaluation which describes and discusses the evidence review by Hou et al. (2013) regarding green tea and gastric
from a compilation of previously published papers relating to cancer, provided full details on searching and methodology;
the efficacy of green tea and/or green tea polyphenols and identifying the three search engines and keywords used,
extracts for the prevention of human cancers (Green et al., inclusion/exclusion criteria and data extraction methods, also
2006). This type of review uses qualitative rather than including a ‘flow diagram of identification of relevant studies’
quantitative methods and although there are limitations in which made it easy to identify their method. Thereby, making
qualitative studies they can help to produce hypotheses and pin- their review more systematic and less prone to bias gives the
point variables for future quantitative studies (Creswell, 2013; reader more confidence in the quality and validity of the review
Ho et al., 2008). Details identifying data bases and search (Ho et al., 2008).
strategy, inclusion/exclusion criteria and data extraction
methods are not usually included in this type of review. The
author has not included these strategies and methods, hence, the Importance of the title, abstract, aim and keywords
reader cannot be certain of the author’s motives or biases when
Green et al. (2006) point out that the title and abstract are
*
Correspondence: Sok Cheon Pak
important components used by data base indexing. Marshall
E-mail: [email protected] (2005) notes that including keywords and capturing the main
Received April 1, 2015; Accepted August 6, 2015; Published topic are essential for computer literature searches. By omitting
August 31, 2015 keywords, this review may miss out on being included in
doi: http://dx.doi.org/10.5667/tang.2015.0008 search results. Therefore, the title, abstract and keywords are
© 2015 by Association of Humanitas Medicine crucial aspects involved to ensure an article appears in the
This is an open access article under the CC BY-NC license. search results. A good title allows the reader to clearly interpret
(http://creativecommons.org/licenses/by-nc/3.0/)

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 Critiquing a review article

the topic of the study and should catch the attention of the of research in complementary medicine (Ernst et al., 2004), this
reader to enable them to determine the relativity of the topic review’s inclusion of research mostly from the past ten years is
and/or interest to either inspire them to read or reject it reasonable. Generally, study design is the main measure of
(Caldwell et al., 2005; Marshall, 2005). In Yuan’s paper the title validity of the findings. Within this context, the hierarchy of
accurately reflects the focus of the paper, green tea and cancer evidence is the most widely used grading system placing
prevention, together with the words ‘evidence from studies in order of scientific rigor (Ho et al., 2008). For
epidemiologic studies’ indicating other publications are example, expert opinion is relegated to the bottom of the
summarized in this review, therefore allowing the reader to hierarchy because it is has the most risk of bias, therefore, more
interpret the content of the study and enable data bases to prone to threats of internal validity and therefore providing the
include the review in search results; an unclear or confusing weakest evidence. Systematic review, meta-analysis and
title can mislead the reader (Caldwell et al., 2011). According randomized controlled trials (RCTs) are considered least prone
to Green et al. (2006), an abstract should present a brief to bias, have the most sound design providing the strongest
summary of the main components including the aim and/or evidence, accordingly, are top of the hierarchy (Hess, 2004;
objective of the study, methodology and main findings. MeInyk and Fineout-Overholt, 2011). Yuan’s review includes
Marshall (2005) concurs by adding that readers use an abstract mostly quality evidence, according to the evidence hierarchy,
to judge its relevance to their particular needs. In Yuan’s review and includes large cohort studies, randomized, placebo-
the abstract is brief, summarizing the content. However, there is controlled trials including several phase 2 clinical trials, several
no clear or specific statement of aims and/or objectives meta analyses and systematic reviews, and a couple of case
presented in this review which is a critical factor to focus the studies. Case studies can provide information not always
study and clearly identify what the research is attempting to reported in other studies such as clinical trials and can add to a
achieve (Marshall, 2005). Boswell and Cannon (2014) note that practitioner’s knowledge (MeInyk and Fineout-Overholt, 2011).
in qualitative research a broad question rather than an
hypothesis is usual. The closest to, but far from, a statement of
aim is found in the introduction ‘the results of green tea Critical appraisal
consumption on the protection/risk of various cancer sites in
humans assessed here are’. After reading Yuan’s abstract the Yuan’s paper is categorized into the specific cancers and their
reader has to assume the aims but does get a general idea of the relevant studies. Within the categories each study reviewed has
direction of the review. This contrasts with the Hou et al. (2013) a brief description, results, discussion and recommendations
study which makes a very clear statement about the aim of their with an overall analysis, main findings and recommendation for
study with ‘The aim of this systematic and up-to-date review each cancer. A review should not just describe the studies
was to critically evaluate all epidemiological studies published included, but make a critical appraisal (Marshall, 2005). Yuan
so far to report an association between green tea consumption has given a critical examination, such as evidenced by noting in
and GC risk’. Yuan does, however, provide a foundation for the esophageal cancer that the inconsistencies in results across
review, noting previous research in animal models consistently studies may be due to confounding effects, particularly in Asian
showed positive results in prevention in contrast to the mixed populations where there are high rates of this cancer as well as
results in human studies so far. According to Caldwell et al. high consumption of hot green tea. Further, noting the
(2011), the research should be placed in context by presenting a association between green tea consumption and a greater
rationale for the research within current knowledge of the focus likelihood of smoking and alcohol. To clarify any association
topic. Hence, the title and abstract should correctly represent between green tea and esophageal cancer, Yuan recommends
the paper. The abstract identifies the cancers included in the studies controlling these factors. Study descriptions are,
review as oral/digestive tract cancers (oral, esophageal, gastric, however, inconsistent. For example, the study sample
colorectal), liver, lung, prostate and breast cancers and a brief populations are included for some Chinese and Japanese
overview of the study types used has been identified here, for populations, and not for others. It is important to clarify the
some cancers. A very brief summary of findings for each cancer sample population in order for the reader to decide if the
is included in the abstract with the main findings of the review research is relevant to their agenda (Boswell and Cannon,
reported as well as recommendations for further research. 2014). Further, data such as relative risk and confidence
Therefore, given the information included in the abstract, it intervals appropriate for study types such as RCTs and cohort
basically conforms to what is expected in an abstract of a studies were not reported for all (MeInyk and Fineout-Overholt,
narrative review except for the important statement of aims 2011). Therefore, the reader is unable to make fair comparisons
and/or objectives and omission of methodology not usually between studies. A summary table of the data would improve
included in a narrative review (Caldwell et al., 2011; Green et the review by ensuring all relevant data is included promoting
al., 2006). clarity, making it easy and fast for the reader to assimilate the
data without having to refer to the article as was presented in
the Hou et al. (2013).
Sources, relevance and rigour of studies included in a
review
A good conclusion
The quality of a paper is a reflection of the relevance, recency
and design of studies used including whether primary or Boswell and Cannon (2014), and Caldwell et al. (2011) concur
secondary sources are used (Ho et al., 2008; Marshall, 2005). that conclusions must be based on the results of the included
As the author has a considerable amount of previously studies and should not make exaggerated claims. Further, that
published research on this topic, it would be remiss to exclude author recommendations for future study often arise from the
them, however, it is a matter of perspective in considering if conclusions (Marshall, 2005). The evidence provided in this
they are primary or secondary studies, although technically review supports Yuan’s conclusions confirming green tea as a
they are secondary. The literature included should be up-to-date preventative in cancer in humans is inconclusive, in contrast to
and comprehensive (Caldwell et al., 2011). Given the paucity strong positive animal studies. However, he does surmise from

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 Critiquing a review article

the reviewed articles possible reasons for inconsistency and

recommends further RCTs to provide more conclusive evidence Caldwell K, Henshaw L, Taylor G. Developing a framework
on the effects of green tea on carcinogenesis and prevention in for critiquing health research: an early evaluation. Nurse Educ
defined populations and particular cancers. Today. 2011;31:8:e1-e7.

Collins JA, Fauser BC. Balancing the strengths of systematic

CONCLUSION and narrative reviews. Hum Reprod Update. 2005;11:103-104.

Health professionals need to recognize that the synthesis of Creswell JW. Qualitative inquiry and research design:
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and that another review will not necessarily return the same Sage Publications Inc), 2013.
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best available evidence with the least likelihood of bias should Ernst E, Cohen MH, Stone J. Ethical problems arising in
be used in guiding clinical decisions (MeInyk and Fineout- evidence based complementary and alternative medicine. J
Overholt, 2011). From a complementary medicine practitioner Med Ethics. 2004;30:156-159.
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ACKNOWLEDGEMENTS Hou IC, Amarnani S, Chong MT, Bishayee A. Green tea and
the risk of gastric cancer: epidemiological evidence. World J
None. Gastroenterol. 2013;19:3713-3722.

Marshall G. Critiquing a research article. Radiography.

2005;11:55-59.
CONFLICT OF INTEREST
Melnyk BM, Fineout-Overholt E. Evidence-based practice in
The authors have no conflicting financial interests. nursing and healthcare. 2nd ed. (Philadelphia, USA: Wolters
Kluwer Health/Lippincott Williams & Wilkins), 2011.

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