Hospital Pharmacy - July/August 2017 - 489

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Thornby

Journal Clubs as a Means of Efficient
Critical Appraisal
It is not surprising to see why organizations and schools/colleges of pharmacy support the concept of a journal club.
When searching the online database PubMed6 for the year
2016, there were 23, 206 citations indexed that were clinical
trials (located by combining 11 trial-type article limits such
as clinical study, clinical trial, and comparative study) or
meta-analyses (used meta-analysis and systematic reviews as
article types) which equates to approximately 63 articles per
day. It would be impossible for someone to independently
critically analyze that many articles to stay abreast of the
changes in medicine. Implementing journal clubs in practice
has been shown to instill habits of lifelong learning, promote
critical appraisal skills, improve understanding of current
health topics, and encourage debate among and across other
health care professions.7

Journal Club Best Practices
Even if there is buy-in regarding the need for journal clubs,
many health care practitioners need guidance on conducting
such a review. Deenadayalan and colleagues published a systematic review of what constitutes an effective journal club.
They found that "using established critical appraisal processes and summarizing journal club findings" were key to
determining effectiveness.8 A considerable number of articles have been published showcasing various goals, journal
club templates, and best practices for conducting journal
clubs in diverse medical disciplines.9 Although there may be
subtleties among each of them, many templates incorporate
core questions asked in the Consolidated Standards
Of Reporting Trials (CONSORT) checklist.10 While the
CONSORT and other similar reporting guidelines serve as
tools for the reader to be aware of research reporting requirements, there is little emphasis on how to analyze, appraise,
and distill the information. In the health care literature, there
are a few recommendations for evaluating journal clubs, and
limited templates to assist the reader.5,11-19 The Center for
Evidence-Based Medicine provides access to a clinical trial
appraisal tool termed "CATmaker."16,20 A study that surveyed
medical residents showed that only 39% found the software
to be useful; however, they did find that having a process
helped to add structure to the presentations to allow for better
dialogue. The type of resources utilized will vary based on
the different health care settings. With so many journal club
templates to choose from, it may be difficult to ensure consistency with regard to questions asked, details of statistics
included, length of assignment, and expectations of timing
for discussions. Depending on the practice setting and the
number of students, residents, or pharmacists participating,
time dedicated to the journal club may be limited. Reviews
have shown that the duration of a journal club ranges from 1
to 2 hours,21,22 with some stating that the entire process
should be about 15 minutes23 per article while others suggest

15 minutes for presentation and 15 minutes for a questionand-answer session.12 Often a concern for facilitators of journal clubs is the limited emphasis to which presenters
communicate the clinical relevance of an article. Literature
has shown that a key characteristic of effective journal clubs
is critically appraising the article by discussing the article's
strengths and limitations, external validity, and recommendations to current practice.22,24 Simply reciting detailed facts
of the article is not enough to foster critical thinking to apply
the results in practice. Deenadayalan and colleagues suggest
using structured journal club worksheets which can promote
participation and discussion among the audience.8
Although CONSORT provides information and a checklist of what should be in clinical trials, it may be cumbersome
to use for those desiring to conduct a journal club.10 Other
examples of journal club documentation forms are equally
difficult and may be too time-consuming to complete.19

ROOTs Journal Club Format
An acronym was designed to help readers critically evaluate
the clinical relevance of research articles using the adage of
not losing sight of the forest for the trees. Often, it is easy for
readers to get caught in the details of the article (ie, tree)
which distracts them from observing the entire clinical picture (ie, forest). After analyzing a research article, the reader
should be prepared to articulate the bottom line messages (ie,
roots) to the audience by discussing the article's place in
therapy compared with current evidence-based medicine
practices. The ROOTs journal club is intended to be an
efficient and succinct format which can be delivered in 15
minutes (See online appendix/supplemental material). This
template can be used by both the novice and skilled expert. It
is designed to help each individual navigate an article without missing key features, and it also helps to provide consistency to the journal club process among its members.
In an effort to not muddle the main take-away messages
from original research, this journal club template focuses on
4 major "ROOT" sections to structure the critical appraisal.
These ROOT sections, showcased in Figure 1, are relevance,
observe validity, obtain clinically significant results, and
translate results to clinical practice. A discussion of pertinent
information to address in each respective section is discussed
below, and a summary is provided in Table 1. The ROOTs
journal club format is best suited to appraise experimental
and observational studies, in superiority, noninferiority, and
equivalence models, such as randomized controlled trials,
cohort studies, and case-control studies. Analyzing systematic reviews and meta-analyses requires special considerations, and readers are referred elsewhere for guidance on
their appraisal.25,26 The intent of this article is to highlight
key elements of study design, statistical analysis, and clinical
practice guideline recommendations that should be considered in determining potential application to clinical practice.
An in-depth explanation of study design and interpretation of
study results are outside the scope of this article. Also,
http://journals.sagepub.com/doi/suppl/10.1177/0018578717721104
Table of Contents for the Digital Edition of Hospital Pharmacy - July/August 2017
