CASP Checklist: 11 questions to help you make sense of a Case Control Study

How to use this appraisal tool: Three broad issues need to be considered when appraising a
case control study:

Are the results of the study valid? (Section A)

What are the results? (Section B)
Will the results help locally? (Section C)

The 11 questions on the following pages are designed to help you think about these issues
systematically. The first three questions are screening questions and can be answered
quickly. If the answer to both is “yes”, it is worth proceeding with the remaining questions.
There is some degree of overlap between the questions, you are asked to record a “yes”,
“no” or “can’t tell” to most of the questions. A number of italicised prompts are given after
each question. These are designed to remind you why the question is important. Record your
reasons for your answers in the spaces provided.

About: These checklists were designed to be used as educational pedagogic tools, as part of a
workshop setting, therefore we do not suggest a scoring system. The core CASP checklists
(randomised controlled trial & systematic review) were based on JAMA 'Users’ guides to the
medical literature 1994 (adapted from Guyatt GH, Sackett DL, and Cook DJ), and piloted with
health care practitioners.
For each new checklist, a group of experts were assembled to develop and pilot the checklist
and the workshop format with which it would be used. Over the years overall adjustments
have been made to the format, but a recent survey of checklist users reiterated that the basic
format continues to be useful and appropriate.
Referencing: we recommend using the Harvard style citation, i.e.: Critical Appraisal Skills
Programme (2018). CASP (insert name of checklist i.e. Case Control Study) Checklist. [online]
Available at: URL. Accessed: Date Accessed.

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Paper for appraisal and reference
Section A: Are the results of the trial valid?

1. Did the study address a Yes HINT: An issue can be ‘focused’ In terms of
✓
clearly focused issue? • the population studied
Can’t Tell • Whether the study tried to detect a
beneficial or harmful effect
No • the risk factors studied

Comments:

2. Did the authors use an Yes HINT: Consider

✓
appropriate method to • Is a case control study an appropriate
answer their question? Can’t Tell way of answering the question under
the circumstances
No
• Did it address the study question

Comments:

2
Is it worth continuing?

3. Were the cases recruited in Yes HINT: We are looking for selection bias
an acceptable way? ✓ which might compromise validity of the
Can’t Tell findings
• are the cases defined precisely
No • were the cases representative of a
defined population (geographically
and/or temporally)
Comments: • was there an established reliable
system for selecting all the cases
• are they incident or prevalent
• is there something special about the
cases
• is the time frame of the study
relevant to disease/exposure
• was there a sufficient number of
cases selected
• was there a power calculation

4. Were the controls selected in Yes HINT: We are looking for selection bias
an acceptable way?
✓ which might compromise the
Can’t Tell generalisability of the findings
• were the controls representative of the
No defined population (geographically
and/or temporally)
• was there something special about
Comments: the controls
• was the non-response high, could
non-respondents be different in
any way
• are they matched, population
based or randomly selected
• was there a sufficient number of
controls selected

3
5. Was the exposure accurately Yes HINT: We are looking for measurement,
measured to minimise bias? recall or classification bias
Can’t Tell • was the exposure clearly defined and
accurately measured
No • did the authors use subjective or
objective measurements
• do the measures truly reflect what
Comments: they are supposed to measure (have
they been validated)
• were the measurement methods
similar in the cases and controls
• did the study incorporate blinding
where feasible
• is the temporal relation correct
(does the exposure of interest
precede the outcome)

6. (a) Aside from the HINT: List the ones you think might be
experimental intervention, important, that the author may have
were the groups treated missed
equally? • genetic
• environmental
• socio-economic

List:

6. (b) Have the authors taken Yes HINT: Look for

account of the potential ✓
• restriction in design, and techniques e.g.
confounding factors in the Can’t Tell modelling, stratified-, regression-, or
design and/or in their sensitivity analysis to correct, control or
analysis? No adjust for confounding factors

Comments:

4
Section B: What are the results?

7. How large was the treatment effect? HINT: Consider

• what are the bottom line
results
• is the analysis appropriate to
the design
Comments: • how strong is the association
between exposure and
outcome (look at the odds
ratio)
• are the results adjusted for
confounding, and might
confounding still explain the
association
• has adjustment made a big
difference to the OR

8. How precise was the estimate of the treatment HINT: Consider

effect? • size of the p-value
• size of the confidence intervals
• have the authors considered all the
important variables
• how was the effect of subjects
refusing to participate evaluated

Comments:

5
9. Do you believe the results? Yes HINT: Consider
• big effect is hard to ignore!
• Can it be due to chance, bias, or
No
confounding
• are the design and methods of this
study sufficiently flawed to make the
results unreliable
• consider Bradford Hills criteria (e.g. time
sequence, does-response gradient,
strength, biological plausibility)

Comments:

Section C: Will the results help locally?

10. Can the results be applied Yes HINT: Consider whether

to the local population? • the subjects covered in the study could
Can’t Tell be sufficiently different from your
population to cause concern
No • your local setting is likely to differ
much from that of the study
• can you quantify the local benefits and
harms

Comments:

11. Do the results of this study Yes HINT: Consider

fit with other available • all the available evidence from RCT’s
evidence? Can’t Tell Systematic Reviews, Cohort Studies,
and Case Control Studies as well, for
No consistency

Comments:

Remember One observational study rarely provides sufficiently robust evidence to recommend changes to
clinical practice or within health policy decision making. However, for certain questions observational
studies provide the only evidence. Recommendations from observational studies are always stronger
when supported by other evidence.