Quantitative Evidence Research Article Appraisal Sample

Quantitative Evidence Research Article Appraisal

Critical appraisal of research involves evaluation of the research study for worthiness in application to clinical practice. Different types of research vary in the hierarchical level of evidence. I selected a quantitative research study by Shea et., (2006) aimed at comparing telemedicine against the usual care in case management for diabetics. My rationale for selecting this article is because the clinical issue addressed are relevant to my practice. I am a case manager in caring for diabetic patients. The study participants were unprivileged with distance and care access adversities making the application of telemedicine relevant.

I am currently a nurse case manager in a community-based clinic. As a nurse case manager, I reach out to patients that have uncontrolled diabetes and assist them in developing smart goals that will help improve their diabetes. I reach out to them by phone and spend time speaking with them regarding their diabetes and sometimes I meet them in the clinic to do the same. Meeting them in person is not easy because our clinic does not have spare rooms for us to meet in, so most all communication is done by telephone. Now because of COVID 19, many of our clinic providers are utilizing telehealth methods utilizing smart phones and computers to see patients. This would be of great benefit for case managers to do the same, have a face-to-face encounter where the case manager can visualize the patient’s environment, watch them take their blood pressure or check their blood sugar and glance at their logs. I believe this would make the visit more comprehensive and beneficial

Quantitative Article Evaluation

Evaluation Table with descriptors, as per Fineout-Overholt 2007

	Critical appraisal
Citation At minimum- Author, Title, Year	Shea, S., Weinstock, R. S., Starren, J., Teresi, J., Palmas, W., Field, L., Morin, P., Goland, R., Izquierdo, R. E., Wolff, L. T., Ashraf, M., Hilliman, C., Silver, S., Meyer, S., Holmes, D., Petkova, E., Capps, L., & Lantigua, R. A. (2006). A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. Journal of the American Medical Informatics Association: JAMIA, 13(1), 40–51. https://doi.org/10.1197/jamia.M1917
Conceptual Framework The theoretical basis for the study	There was no conceptual or theoretical framework provided by the authors of the research study
Design/Method Indicate design and briefly describe what was done in the study	The researchers used a quantitative research design involving randomized control trial methods. Participants were assigned randomly and interventions were administered. Study participants who met the inclusion criteria were randomly selected and assigned randomly into intervention and nonintervention or control groups. The assignment into intervention and control groups was done in the ratio of 1:1 after proving their eligibility to participate through screening through phone before baseline examination of desired endpoints. The intervention in this research study was the use of telemedicine in the care and follow-up of patients in the intervention group. The primary care providers cared for the control and intervention groups. The control group was also followed for the same period after which comparisons were made. The double blinding method was used such that the follow-up examiners and evaluators were not aware of the group of the participant. A follow-up examination took place exactly one year after the baseline examination. Outcomes were compared and analysis was done. The researchers also acquired ethical approval to conduct this research from the State University of New York (SUNY) Upstate Medical University and Columbia University Medical Center institutional review boards among other related participating healthcare institutions and providers. Written consents were used to ensure participant autonomy
Sample/Setting	The study was carried in New York. The participants in this study were patients who were diabetic through physician’s diagnosis, were aged (55 years and above) who resided in the medically underserved in New York. These regions, that are federally designated also have a shortage of healthcare professionals. The initial enrollment of participating through random sampling yielded 9597 participants who could potentially patriate in the study; but after bassline examination and eligibility check and randomization, the final population of participants reduced 1665 against the expected sample size of 1500. Random assignment allocated 821 participants to the control group, those who would receive the usual care; and 844 to the intervention group, those who would receive the care through telemedicine. After allocation, participants’ numbers reduced in both groups due to the patients changing their mind, family and physician refusal, and other exclusion systems. The final number to be analyzed reduced to 717 for control and 700 for the intervention group. However, 815 participants in the control group and 842 participants in the intervention group were analyzed. Those who dropped out from the study after the administration of the intervention were also analyzed. The study assumed overall attrition rates of twenty percent.
Major Variables Studies and Their Definitions Independent variables (may list IV1, IV2, etc.) and Dependent variables (DV1, DV2, etc.)	The independent variable in the study was the type of care for aged diabetic patients; the usual care by primary care providers and care by the use of telemedicine. The dependent variable included the mean blood pressure, urine microalbumin, lipid levels, and HbA1c levels. These were measured at baseline and the evaluation, one year after baseline measurements.
Measurements What scales were used to measure the outcome variables (name of scale, author, reliability info)	Primus CLC 385 by Primus, Kansas City. which is a boronate-affinity chromatography analytical tool that was used to measure the hemoglobin A1c. Enzymatic calorimetric scales using reagents from (Vitros, Johnson & Johnson, New Brunswick, New Jersey, were used to measure the total cholesterol, high-density lipoprotein, and triglycerides and the results used to derive the low-density lipoprotein (LDL) levels in milligrams per deciliter. The Dinamap Monitor Pro 100 (Critikon, Tampa, Florida) was used to measure blood pressure in millimeters of mercury (mmHg). Before the baseline examination of the outcome variables, reliability tests were conducted on these instruments. The overall reliability of outcomes variables was 0.90.
Data Analysis	The studies involved various interrelated data types where others were assumed to have more data weight than others and therefore, that necessitated cluster data analysis. Statistical data analysis using Analysis of covariance was used to adjust various data clusters in the baseline examination outcome data findings. The cluster intercorrelations ranged from 0.05 to 0.2. there was no need for p-value adjustments. Analysis of central tendencies and measures of association were also analyzed. Result presentation in tables was prepared. The final participant number was 1665 that was analyzed. Even though 248 participants did not complete the study, the analysis for completers and dropout was analyzed.
Findings	The baseline data of the control and intervention groups did not differ significantly. The mean age of participants was 71 years. the overall mean reduction in hemoglobin A1c was 0.18% when compared with the control group with a p-value of 0.006. the net adjusted reduction in mean blood pressure was 3.4mmHg and 1,8 mmHg for systolic and diastolic blood pressure respectively at p valise of 0.001 for both pressures. Net reduction in mean adjusted LDL levels were 11.06 mg/dL (p, 0.001) and 9.5 mg/dL (p, 0.001). however, the reduction in mean blood pressure and cholesterol for the control was not significant over the one year of follow-up. There were no significant differences in the reduction values between the dropouts and the completers of the study at p-values of 0.05 or greater. To minimize the geographical factor as a confounding factor in the reduction of outcome variables, the values from the two centers were analyzed separately. Comparisons showed no statistically significant change; even though the bassline results differed by very small values. It can, therefore, be implied from this research study that telemedicine was responsible for the significant reductions in LDL cholesterol, blood pressure, and hemoglobin A1c.
Appraisal: Worth to Practice -Strengths and limitations of the study -Risk or harm if study intervention or findings implemented -Feasibility of use in your practice -Consider the level of evidence and quality of evidence	The study was ethically approved by more than two institutional review boards. This makes the study findings clinically safer and more applicable to my nursing practice. The sample sizes, 1665 diabetic participants in an area of about 30000 square miles, used makes the study more ‘powerful.’ The reliability of the measurement tools used were at 0.90 making the findings more reliable as well. The study used noninvasive interventions that can be safely applied to my practice. The risk for harm to patients in my practice cannot be inferred from the study methodology. Being a randomized control trial with comparisons using control groups, this research findings fall under level II evidence in the evidence hierarchy (Winona State University, n.d.). The use of double-blinding and randomization in the sample section reduced chances of bias making the study findings more real and applicable to clinical practice. The control group was relevant as they were also diabetic patients from the same region and of the same age brackets who had met all the inclusion criteria. The interventional treatments used to apply to my clinical practice. The fact that current and future nursing practice is inclined more towards using technology including telehealth to provide accessible care in the shortest possible time (Bashir & Bastola, 2018) makes the study methodology and findings feasible to my practice. The use of telemedicine in chronic management and monitoring of patients with chronic conditions reduces the impact of the high patients to the nursing ratio (Rutledge et al., 2017). The intervention outcomes are relevant endpoints that are used daily in monitoring diabetes management. The reduction in hemoglobin A1c is a good indicator of good chronic diabetic control. Diabetes is also a risk factor for cardiovascular control. Managing diabetes mellitus reduces the risk for cardiac pathologies including hypertension. Telemedicine improved diabetic management. My patients prefer when the interaction time with the clinician is increased. This would be improved through telemedicine to reach more clients who are geographically disadvantaged.

Conclusion

Shea et al., (2006) carried out their research study with clear methodologies and address their objectives precisely. The research provided a high level of evidence that applies to my clinical practice. The chances of bias were reduced through randomization and double-blinding. The analysis and findings are reliable because of the reliable tools of data collection used. The validity of the finding is supported by more recent studies using other chronic disease management.

References

Bashir, A., & Bastola, D. R. (2018). Perspectives of nurses toward telehealth efficacy and quality of health care: Pilot study. JMIR Medical Informatics, 6(2), e35. https://doi.org/10.2196/medinform.9080
Rutledge, C. M., Kott, K., Schweickert, P. A., Poston, R., Fowler, C., & Haney, T. S. (2017). Telehealth and eHealth in nurse practitioner training: current perspectives. Advances in Medical Education and Practice, 8, 399–409. https://doi.org/10.2147/AMEP.S116071
Shea, S., Weinstock, R. S., Starren, J., Teresi, J., Palmas, W., Field, L., Morin, P., Goland, R., Izquierdo, R. E., Wolff, L. T., Ashraf, M., Hilliman, C., Silver, S., Meyer, S., Holmes, D., Petkova, E., Capps, L., & Lantigua, R. A. (2006). A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. Journal of the American Medical Informatics Association: JAMIA, 13(1), 40–51. https://doi.org/10.1197/jamia.M1917
Winona State University. UC Library Guides: Evidence-Based Practice in Health: Hierarchy of Evidence. Canberra.libguides.com. Retrieved from https://canberra.libguides.com/c.php?g=599346&p=4149721

Appendix 1

Rapid Critical Appraisal Checklist for a Randomized Clinical Trial (RCT)

Are the study findings valid? Yes
Were the subjects randomly assigned to the experimental and control groups? Yes, the researchers ensured the subjects were randomized within clusters.
Were the follow-up assessments conducted long enough to fully study the effects of the intervention? Yes
Did at least 80% of the subjects complete the study? Yes, the actual percentage is actually 85.1% since 14.9 percent dropped out.
Was random assignment concealed from the individuals who were first enrolling subjects into the study? Unknown
Were the subjects analyzed in the group to which they were randomly assigned?

■ Yes

Was the control group appropriate?

■ Yes

Were the subjects and providers kept blind to the study group?

■ Yes

Were the instruments used to measure the outcomes valid and reliable?

■ Yes

Were the subjects in each of the groups similar on demographic and baseline clinical variables?

■ Yes

What are the results of the study and are they important? The study established that case management among diabetes patients, when delivered using telemedicine, resulted in improved A1c, blood pressure and LDL cholesterol levels.
How large is the intervention or treatment effect (NNT, NNH, effect size, level of significance)?

“The intervention effect on diabetes control was greater in the subgroup with hemoglobin A1c $7% at baseline, with an absolute change from 8.35% to 7.42% and a difference net of change in the usual care group of 0.32%.”

__________________

How precise is the intervention or treatment (Confidence interval)? Unknown
Will the results help me in caring for my patients? Yes, the study findings indicate that diabetic patients receive better care when telemedicine is incorporated into the care process.
Are the results applicable to my patients? Yes, care for diabetic patients still require extensive patient monitoring, presently supplemented by wearable gadgets that measure and relay patient vitals.
Were all clinically important outcomes measured?

■ Yes

What are the risks and benefits of the treatment? There are no known risks identified in this study. The benefits, however, include improved patient monitoring for timely intervention, hence better life outcomes for diabetic patients.

______________________

Is the treatment feasible in my clinical setting?

■ Yes

What are my patient’s/family’s values and expectations for the outcome that is trying to be prevented and the treatment itself?

Case needed to answer this question