CASP Checklist: 12 questions to help you make sense of a Cohort Study

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

Are the results of the study valid? (Section

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

The 12 questions on the following pages are designed to help you think about these issues
systematically. The first two 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. Cohort 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-
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Paper for appraisal and reference:.........................................................................................................

1.Section
Did theA:study
Are the results
address a of the study valid?
Ye HINT: A question can be ‘focused’
clearly focused issue?
in terms of
s Can’t • the population studied
 the risk factors studied
Tell
• is it clear whether the study tried to
No detect a beneficial or harmful effect
• the outcomes considered

Comments:

2. Was the cohort recruited in

Ye HINT: Look for selection bias which
an acceptable way?
might compromise the generalisability
s Can’t of the
findings:
Tell
 was the cohort representative of a
No defined population
 was there something special about the
cohort
 was everybody included who should
have been

Comments:

Is it worth continuing?

2
3. Was the exposure accurately Ye HINT: Look for measurement or
measured to minimise bias?
classification bias:
s Can’t • did they use subjective or objective
measurements
Tell • do the measurements truly reflect what
you want them to (have they been
No validated)
 were all the subjects classified
into exposure groups using the
same procedure

3
 Comments:

4. Was the outcome accurately Ye HINT: Look for measurement or

measured to minimise bias? classification bias:
s Can’t • did they use subjective or objective
measurements
Tell • do the measurements truly reflect what
you want them to (have they been
No validated)
 has a reliable system been
established for detecting all the cases (for
measuring disease occurrence)
 were the measurement
methods similar in the different groups
 were the subjects and/or
the outcome assessor blinded to
exposure (does this matter)

Comments:

4
5. (a) Have the authors identified Tell
Ye
all important confounding
factors? No
s Can’t

Tell

No

Comments:

5. (b) Have they taken account

of the confounding factors in
the design and/or analysis?
Ye

s Can’t

Tell
Comments:
No

6. (a) Was the follow up of

subjects complete enough?

Ye

s Can’t

Tell
6.(b) Was the follow up of
subjects long enough? No

Ye

s Can’t

5
 HINT:
• list the ones you
think might be
important, and ones the
author missed

HINT:
• look for
restriction in design, and
techniques e.g. modelling,
stratified-, regression-, or
sensitivity analysis to
correct, control or adjust
for confounding
factors

HINT: Consider
• the good or bad effects
should have
had long enough to reveal
themselves
• the persons that are
lost to follow-up
may have different
outcomes than
those available for
assessment
• in an open or
dynamic cohort, was
there anything special
about the outcome of
the people leaving, or
the exposure of the
people entering the
cohort

6
 Comments:

Section B: What are the results?

7. What are the results of this study? HINT: Consider
 what are the bottom line
results
 have they reported the rate or
the proportion between the
exposed/unexposed, the
ratio/rate difference
 how strong is the association
between exposure and
outcome (RR)
 what is the absolute risk
reduction (ARR)

Comments:
8. How precise are the results? HINT:
 look for the range of the confidence
intervals, if given

Comments:

7
 9. Do you believe the results?
HINT: Consider
 big effect is hard to ignore
 can it be due to bias, chance or
confounding
Yes
 are the design and methods of this
study sufficiently flawed to make
Can’t
the
results unreliable
Tell
 Bradford Hills criteria (e.g.
time sequence, dose-response
No
gradient, biological plausibility,
consistency)

Comments:

Section
10. C: Will
Can the theberesults
results help
applied to locally?
Ye HINT: Consider whether
the local population?
 a cohort study was the appropriate
s Can’t method to answer this question
 the subjects covered in this study could
Tell be sufficiently different from
your population to cause concern
No  your local setting is likely to
differ much from that of the
study
 you can quantify the local benefits and
harms

Comments:

11. Do the results of this study

Ye
fit with other available
evidence?
s Can’t

Tell

No

Comments:

8
12. What are the implications of
Ye HINT: Consider
this study for practice?
 one observational study rarely
provides sufficiently robust
s Can’t
evidence to recommend changes
to clinical practice or within
Tell health
policy decision making
 for certain questions,
No
observational studies provide the
only evidence
 recommendations from
observational studies are always
stronger when supported by other
evidence

Comments: