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.

©CASP this work is licensed under the Creative Commons Attribution – Non-Commercial-
Share A like. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-
sa/3.0/ www.casp-uk.net

Critical Appraisal Skills Programme (CASP) part of Oxford Centre for Triple Value Healthcare Ltd www.casp-uk.net
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: P: Pasien dengan usia 66 tahun atau lebih tua dengan menerima terapi glyburide, digoxin, atau ACE
inhibitor.
I: Penerimaan obat lain yang menyebabkan adanya interaksi obat dengan terapi yang diterima pasien
C: obat-obatan yg tidak berinteraksi dengan terapi yg diterima pasien
O: Angka masuk RS karena adanya interaksi obat

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: case control merupakan metode yang tepat karena dalam jurnal ini membahas mengenai
interaksi obat terhadap pasien yang sudah lanjut usia. Jika menggunakan metode RCT, maka
penelitian harus melakukan "harm" kepada pasien. Kemudian jika menggunakan cohort, pasien
harus dilakukan percobaan terlebih dahulu agar dapat menyimpulkan penelitian. Hal ini berbeda
dengan case control dimana hal pertama yang dapat dilakukan adalah menilai dari outcomenya.

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
3a. Database yang digunakan adalah linking system for selecting all the cases
multiple health case databases • are they incident or prevalent
3b. • is there something special about the
3c. cases
3d. Timeframe panjang: 7 tahun (1 jan 1994 • is the time frame of the study
sampai 31 des 2000) relevant to disease/exposure
3e. Kejadian drug interaksi pada pasien lansia • was there a sufficient number of
disebut index date 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
4a. Database yang digunakan adalah linking multiple health case • was the non-response high, could
databases non-respondents be different in
4b. Peneliti menggunakan perbandingan case:control -> glyburide any way
with cotrimoxazole = 909:43.766 (1:48) ; digoxin with clarithromycin
= 1051:51.896 (1:49 ; ACE inhibitors with K-sparing diuretics = • are they matched, population
523:25.807 (1:49) -> u/ menghindari bias, control dibesarkan. based or randomly selected
4c. matching:
- age, sex, lamanya medication, ada atau tidak adanya penyakit • was there a sufficient number of
ginjal sebagaimana ditentukan oleh pemeriksaan rinci dari semua controls selected
klaim dokter, penerimaan rumah sakit, dan perawatan dialisis rawat
inap atau rawat jalan di rumah sakit.
4d.

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
5a. they been validated)
5b. analisis pengobatan dikurangi dari 6 bulan menjadi 3 bulan,
kemudian perpanjangan periode pengamatan diubah setelah resep • were the measurement methods
terakhir dari 2 bulan menjadi 1 bulan sampai 3 bulang. sensivity similar in the cases and controls
analysis diulangi untuk menyesuaikna paparan obat lain dalam
2,4,6,8 minggu dari index date. exposure dianggap valid apabila
• did the study incorporate blinding
dalam analisis primer mempertimbangkan resep dalam seminggu where feasible
sebelum index date, dan analisis sekunder mempertimbangkan • is the temporal relation correct
resep dalam 2 dan 3 minggu sebelum index kemudian dilakukan
analisis tambahan bagi pasien yang memiliki pengobatan jangka (does the exposure of interest
panjang, exposure valid pada waktu 30 hari sebelum index date 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: cukup

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: - confounding factor dijelaskan pada tabel 1, dimana tabel ini mengelompokkan obat-obat
yang dapat menjadi bias berdasarkan mekanismenya.
- dilakukan sensivity analysis untuk mengetahui durasi exposure dari index date.
-
-

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
- Hasil penelitian dibahas di tabel 3-5
between exposure and
- Odds ratio dihitung dengan prinsip unadjusted dan adjusted outcome (look at the odds
- Confounding yang dihitung terlampir pada tabel 1 ratio)
- Selisih OR adjusted dan adjusted cukup besar -> kurang baik. • are the results adjusted for
Contoh: Cotrimoxazole within 1 week of exposure to second confounding, and might
drug confounding still explain the
OR = (35x43577)/(189x874) = 9,23 association
Resiko interaksi obat tinggi thdp amoxicillin, cefuroxime,
• has adjustment made a big
indapamide.
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: confidence interval cukup lebar, kurang precise

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: 9a. hasil yang diperoleh kurang dapat dipercaya karena menurut nilai unadjusted dan adjusted, resiko interaksi obat
cukup kecil (bahkan tidak ada). selain itu, interaksi obat tidak diketahui
9b. confounding factor mempengaruhi hasil, karena nilai unadjusted dan adjusted yang memiliki range cukup besar.
9c.

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: Penelitian ini tidak dapat direkomendasikan kepada pasien lansia

mengingat interaksi obat yang cukup kecil bahkan tidak diketahui

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: dari referensi, banyak studi mengenai interaksi obat yang digunakan namun tidak ada
yang menjelaskan mengenai pemberian obat-obatan yg dapat menyebabkan interaksi
pada pasien lansia yang menerima pengobatan glyburide, digoxin dan ACE inhibitor
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.