Assessment 3 - Critical Appraisal Literature Review

This document is a critical appraisal literature review on the effectiveness of graduated compression stockings for prevention of venous thromboembolism in orthopedic and abdominal surgery patients requiring extended pharmacologic thromboprophylaxis. It discusses the review purpose, inclusion criteria, types of studies included, search engines used, data abstraction and synthesis, critique of the studies reviewed, and the levels of evidence reported. The document also provides recommendations for applying the information from the review in clinical practice.

Running head: ASSESSMENT 3 - CRITICAL APPRAISAL LITERATURE REVIEW
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Assessment 3 - Critical Appraisal Literature Review
Student’s Name
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Running head: ASSESSMENT 3 - CRITICAL APPRAISAL LITERATURE REVIEW
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Assessment 3 - Critical Appraisal Literature Review
1. What is the review purpose, objective or question?
The objective of Milinis, Shalhoub, Coupland, Salciccioli, Thapar & Huw (2018) study was
to determine how effectively venous thromboembolism in abdominal and orthopaedic
patients that needed pharmacological thromboprophylaxis through graduated compression
stockings.
2. Was there a published protocol for this review?
This study had a published protocol that was published in the PROSPERO database
(CRD42017062655). This is because systematic review reporting guidelines require that such
studies are published to recognize the use of previous study knowledge and at the same time
to authenticate the knowledge gathered from the study as the original. This also reduced the
duplication of research knowledge by ensuring that other researchers do not repeat the same
research will lead to similar knowledge of the study.
3. What are the inclusion criteria for this review?
The inclusion for this research was any randomized control trial that had pharmacologic
thromboprophylaxis patients or this was done in conjunction with CGS. Studies that qualified
to be included in this study were the ones that had a minimum of 21 days of pharmacologic
thromboprophylaxis, those with low weight molecular heparin, direct oral anticoagulants,
fondaparinux, patients that received prophylactic-dose pharmacologic thromboprophylaxis
only, studies with proper GCS documentation, had adults above years, studies where the
Pharmacologic thromboprophylaxis was done according to manufacturer instructions, studies
that were based on VTE confirmed by imaging and the ones where patients were undergoing
orthopaedic or abdominal surgery. Those studies that did not meet this criterion were
excluded and were mostly the ones that had younger patients, participants were pregnant, and

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patients had clotting disorders and those that had a combination of contraindications to GCS
or pharmacologic thromboprophylaxis
4. What types of studies were included?
This study utilized randomized control since they offer the best outcomes through the use of
controls to establish the differences in the indicators. According to Ernest, Jandrain, &
Scheen (2015) suggests that randomized control trials are the best since are the cornerstone of
evidence-based medicine since they allow testing the cause and effect relationships between
the treatment and the outcome. Thus studied based on this approach offer the best outcome
since they measure the differences in the studies. The exclusion-inclusion criteria was based
on studies that met the required study criteria and did not involve patients with contradictions
to GCS, a combination of two mechanical methods of thromboprophylaxis, patient with
clotting disorders, patient with participants younger than eighteen years and pregnancy.
5. What databases/search engines were searched?
The study search was based on a literature search of MEDLINE, Embase, Cochrane Library,
and Clinical Trials.gov since they are the common studies that publish health-related studies.
These studies are mostly relevant since they are updated every time now and then and are
regarded as peer-reviewed thus the research studies published here are peer-reviewed journals
that have been analysed and approved as meeting the conditions before being published.
6. Were the search terms suitable for the purpose of this review?
The search terms for the study were randomised controlled trials and pharmacologic
thromboprophylaxis. The search was further refined by adding the duration period of 21 days
so that the ones that had longer or shorter periods could be removed. These search terms were
refined to allow the researchers to generate the appropriate articles by reducing the ones that
were not relevant in the study.

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7. What search limits were applied?
The search limit was based on studies that were randomized control trials and include
postoperative patients receiving prolonged (21 days or longer) pharmacologic
thromboprophylaxis. This also determined the search criteria that was used for the study to
ensure that only relevant searches were found.
8. Does the Prisma flowchart adequately describe how articles were identified,
screened, assessed for eligibility, appraised and selected for inclusion in the review?
Stovold, Beecher, Foxlee, & Noel-Storr (2014) suggests that PRISMA charts are used by the
researcher to present the study resources that were found and how the researcher excluded the
references one by one until the studies that were appropriate or the research were found. The
researchers presented the PRIMA chart well because it presents from the initial 1226 until the
final 19 studies that were used for the study were used.
9. What critical appraisal instrument(s) was/were used to determine the methodological
quality of the articles? Were these instruments appropriate?
The methodological quality of the studies was done through the Cochrane risk bias tool.
Higgins, et al. (2011) suggests that this tool is effective for analysing the methodological
quality of randomized control studies since it avoids use of quality scales, focusses on
internal validity of the study, assesses the risk of bias in the trails and the data presented, and
finally reporting of outcome-specific evaluation of risk and bias.
10. Are the included studies summarised adequately? (Study type, study population,
location, interventions, outcomes, results)
The studies included in the research were adequately summarised in a table based on author
names, date of publication, study arm, country, total sample size, population, short
pharmacologic and long pharmacologic. This table gives a brief overview of each article thus

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making it easy for the reader to understand the weight of each study for the whole article.
Donald (2014) by summarising the studies in the table, the reader is able to understand the
nature of the nature that were included like the region, sample of the population and the
pharmacologic type. This means that the table gives an overview of the items that were
included in the study process thus allowing the reader to understand the specific articles that
were used in the research.
11. Are excluded studies listed with reasons for their exclusion?
Yes, in the PRISMA table, the researcher excluded 1160 studies that failed to meet the
criteria. These studies were mostly republication articles, duplicate articles, and articles based
on animal studies. These studies were excluded since, despite the fact that they appeared in
the search process, they were not relevant to the research topic.
12. How was the data abstracted and synthesized?
The data was extracted and stored in Excel 2016 and summarised using descriptive statistics.
To assess the data, the Freeman-Turkey transformation and random effect were used to
measure the heterogeneity of the studies. This means that the proportion of heterogeneity
across the studies was determined to determine the validity of the fixed effects model or the
invalid random effects model. The studies were validated using VTE through the random-
effect model.
13. Is there an adequate critique of the studies reviewed, including discussion of study
limitations?
Yes, the articles were adequately critiqued as seen from the presentation where the authors
presented the analysis of the articles in different ways. The data was analysed in different
tables to present descriptive statistics and then the studies analysed in the discussion to

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determine the validity of the articles and the relationship between different articles that were
used in the study.
14. Were the levels of evidence reported in this systematic review? What is your
assessment of the level of evidence included in this review?
The level of evidence used in this study is the randomized control trial which is based on
testing treatments in research to assess the benefits of such studies. According to Burns,
Rohrich, & Chung (2012), the participants in these studies are randomly allocated in groups
where one group receives treatment under investigation while the other receives standard
treatment so that the differences in the measures can be determined. Since the random
allocation is used, bias is reduced in these studies allowing the researcher to determine any
effects of the treatment as compared with other non-treatment groups. Thus the reason why
this treatment method is best is suited for studies that seek to generate new evidence for the
study. Thus by using randomized controlled trials. This study used one of the best levels of
evidence for meeting the needs of the research. Thus this level of evidence is the best because
the research used in this type study entails a comparison of controlled and non-controlled
groups to select the best evidence of the study.
15. How should the information from this systematic review be applied in clinical
practice (knowledge transfer)?
According to Colquitt & George (2011), good grand research is supposed to add knowledge
to the existing literature about the research topic. This means that it should propose new
theories or new directions of research by proposing ways that can be used to resolve the gaps
that the research has presented. Since this was a systematic review, it thus presented the need
for new research that focusses on addressing the similar gaps that were identified in all the
studies. This means that new research is needed to focus on a new clinical trial that seeks to

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determine the benefits, costs and adverse events of GCS when used in conjunction with
extended pharmacoprophylaxis.

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References
Burns, P. B., Rohrich, R. J., & Chung, K. C. (2012). The Levels of Evidence and their role in
Evidence-Based Medicine. Plastic Reconstructive Surgery, 128(1), 305–310.
Colquitt, J., & George, G. (2011). 2011. From the editor publishing in amj—Part 1: Topic
Choice. Academy of Management Journal, 54(3), 432-435.
Donald, H. M. (2014). Research Methods. London: Cengage Learning.
Ernest, P., Jandrain, B., & Scheen, A. (2015). Strengths and Weaknesses of Randomised
ClinicaL Trials: Evolving Changes According to Personalized Medicine. Revue
Medicale DE Liege, 70(5), 232-236.
Higgins, J. P., Altman, D. G., Gøtzsche, P. C., Jüni, P., Moher, D., Schulz, K. F., . . . Sterne,
J. A. (2011). The Cochrane Collaboration’s tool for assessing risk of bias in
randomised trials. BMJ, 343.
Milinis, K., Shalhoub, J., Coupland, A. P., Salciccioli, J. D., Thapar, A., & Davies, A. H.
(2018). The effectiveness of graduated compression stockings for prevention of
venous thromboembolism in orthopedic and abdominal surgery patients requiring
extended pharmacologic thromboprophylaxis. Journal of Vascular Surgery: Venous
and Lymphatic Disorders, 6(6), 766-778.
Stovold, E., Beecher, D., Foxlee, R., & Noel-Storr, A. (2014). Study flow diagrams in
Cochrane systematic review updates: an adapted PRISMA flow diagram. Systematic
Reviews, 3(54).

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