Introduction
This paper is based on a critical appraisal of studies regarding medical care. The importance of performing this task is to be able to examine and judge the trustworthiness, value, and relevance of this particular healthcare activity. Critical appraisal is a very critical skill that is used in evidence-based medicine since it allows clinical technicians to come up with research evidence that is reliable and effective (Polit and Beck, 2008).
It is believed that many people with coronary heart disease live long but their long life is dilapidated due to other symptoms such as dyspnea (Cullum et al, 2008). Due to the high increase of the effects of coronary heart disease the fit for surgery agenda or program was done. This program was conducted basing its procedures and outcomes on various studies which were done earlier. This research and the critical appraisal aim to evaluate the outcomes of the program and make recommendations or conclusions on the same. The paper will critically analyze the randomization process of these patients who were to undergo coronary artery surgery. Finally, the paper will discuss in detail the costs implications of the interventions made to the patients.
Randomization of patients
The study shows that there was a randomized system of choosing the patients with coronary heart disease who underwent surgery. The randomized group had a steady improvement on all the risk factors compared to the other group which is the control group. This process of randomization of the patients was considered unusual because the patients were assigned to groups before recruitment. The intervention group of patients was trained in physical exercise twice a week and was treated to a monthly education through phone calls made by nurses. Through the randomization nurses ensured that the patients had reduced the anxiety of the surgery and had improved their control factors which are related to the progress of the coronary heart disease, this is an advantage compared to the patients who had routine care in the control group. It is categorical that the patients were allocated to control and experimental groups randomly.
Was randomization concealed?
The randomization process included just two groups that were quasi-experimental in design: this was done with groups being assigned randomly. Though it is not clear if the nurses were blindfolded while performing these random choices the process can be considered to be concealed, this is because the activity was done by a computerized system (Caroci and Lareau, 2004).
Analysis of the patients according to groups
The analysis done to the patients was done according to their respective groups. The analysis according to groups can be proved since there was the relocation of a member who was one of the six members who withdrew from the control group; this was done to have a proper balance between the control group and the intervention group (Caroci and Lareau, 2004). There were independent tests and data distribution in the two different groups for both the categorical and skewed information the data. The data was further scrutinized to see whether there were differences within groups on baseline and admission, this was done by the use of computerized tests which compared variations in means.
Similarities or differences in groups
The groups are considered to be similar because all the patients had the same illness and the same clinical characteristics. The groups used the same targeted population but they differed in their training criteria because each group used different methods and techniques of training protocol (Vibarel et al, 2002). However, all the outcomes were not the same when put in comparison across the groups hence making the conclusions to be unjustified. The differences across the groups occurred in the weight of the patients and ejection factor; however the statistics within the control and intervention groups was not much, since they had a difference in the intervention levels.. Moreover the Borg scale values which were collected across the groups have not been presented in the paper hence the differences cannot be obtained (Larson et al, 2002). Both groups showed a great improvement in blood pressure and total cholesterol from the baseline to surgery.
Patients’ knowledge of the group allocations
The nurses were involved in counseling the patients and through these activities, they may have hinted to the patients’ about the groups, although this is difficult to prove since the authors do not report whether there was blindfolding of the patients hence making it difficult to know whether the patients were blinded. This report was not elaborate on whether the patients knew the arrangements of the group in advance or even the trials and therefore was not aware of the nature of the control group. There is a possibility that some patients consider that they were wrongly placed in the control group while they thought that they were supposed to be in the treatment or intervention group.
Awareness of clinicians on the group allocations
Clinicians were more involved in educating the patients on the surgery procedure to counter anxiety and control the risk factors. Further, the clinicians were more involved in the identification of the subjects the patients will undertake thus making it difficult for the clinicians to be aware of the allocations (Vibarel et al, 2002). The allocation of the groups was rather unusual and this made it difficult for the clinicians to be aware of the allocations, moreover, it was done randomly. In addition, the randomization process was done after the patients have been screened. The person who may have been aware of this process was the clinician who is also the research nurse. Finally, the patients had manuals and they were also able to refer to the advertisements thus increasing the probability of their knowledge of the allocation process.
Awareness of the outcome assessors on the group allocations
The outcome assessors had a high chance in the knowledge of the allocation of the groups because the author does not indicate that they were blinded in the overall design. As earlier indicated the control groups were using placebo as their training method thus giving the clinicians a high chance of knowing the allocation process. Despite these occurrences, there was a significant amount of data about ostensible treatment on the treatment group which may have given the clinicians prior knowledge of this procedure.
The follow-up
We categorically say that the follow-up was not complete, for example, there was a withdrawal of three subjects between weeks six and nine hence leaving a hanging data outcome since the clinicians did not finish the analysis. This information could not be completed unless the patients agreed to go ahead with the process outside the group which could now shift from the group analysis to individuals hence rendering the follow-up inconsistent. As the report indicates that all the other patients had followed the guidelines and the data collected was compliant with the required standards.
Consistency of the intervention
The subjects who were being trained were required to follow certain procedures and the nurses ensured they do the same. Furthermore, the clinicians were supposed to follow certain guidelines to ensure that they train the patients well. The report is categorical on the matter regarding the attention of the subjects because it is reported that the patients normally stayed at the hospital
for half a day receiving training, to add to that, patients were also given reading manuals to get more informed about heart disease. A study was also conducted on the reading of the manual and there was a tremendous change of attitude in patients which led to a significant decrease in blood pressure (Larson et al, 2002). The patients also appreciated the way of living since they were feeling fitter. The intervention increased the self-confidence of the patients and they were also able to make more friends within and outside the groups. There was also an order that all patients should keep a record of what they are doing in the hospital on daily basis (Vibarel et al, 2002).
Description of the measurement instruments that were used
The measurements which are included in the data are precise and accurate and this can only be done by the use of proper measuring tools, for example, the measurement of the blood pressure and the heartbeat rate can only be done by using proper instruments. The OMRON machine was used to measure the blood pressure in the baseline changes and the body mass index was calibrated and calculated using computers. The measure and description of machines are positively described and the methods of data collection are well explained.
Validity and reliability of the instruments used
The instruments used in this study have explicitly provided similar data that was collected by the clinicians. The instruments assisted the nurses in the collection of important data in a sequential and well-arranged manner. This ensured that the nurses collected data in the required procedures and standards and without the use of these instruments the data collected would have been faulty and erroneous. Furthermore, to justify that the instruments used were valid the data collected was done equivalently among or the groups and to all members or subjects of the groups (Vibarel et al, 2002).
However, due to the lack of blinding the patients and the clinicians, the data collected may be correct thus making measurements to be unreliable. The data collected by the patients by use of the diaries was also inconsistent thus making the measurements unreliable.
Effects of intervention
There were larger numbers of patients who received surgery and the waiting list was substantially reduced. Within the groups, there were tremendous enhancements from baseline through surgery, and the total cholesterol for the patients’ reduced. There was also an improvement in the physical quality of the patients which was calculated and measured by SF36 (Vibarel et al, 2002). The patients also appreciated the way of living since they were feeling fitter. The intervention increased the self-confidence of the patients and they were also able to make more friends within and outside the groups. The intervention also shows that the patients can utilize health resources adequately.
The precision of the intervention effect
The intervention effect is not perfect since the patients were seen to have attempted to improve their compliance and behaviors before the surgery. It is important to note that the intervention created a substantive effect on the lives of the patients and also the way they live (Caroci and Lareau, 2004). Insistency in the intervention is brought about by the time duration of the study which was not enough. The report indicates that in the future the effects of the intervention will be adversely felt across the medical fraternity. Though intervention was essential it did not prove to be important in improving the risk factors in the waiting period. The intervention may have been unsuccessful because of the new nurses who were hired, thus affecting the interviewing techniques.
Similarities of the patients
The percentages of the demographic representation were small and the study could not have captured the general view of patients and doctors. Moreover, the numbers of patients randomized were not many enough to give the option to the general public (Zigmond and Snaith, 1983). These shortcomings of the study make it undesirable to be used in my clinical setting. However, the study has some substantive similarities for example the use of well-explained subjects can be compared to those of my clinical setting.
Consideration of all outcomes
The study did a quality job by collecting enough data from as many patients as possible thus putting most of the outcomes into consideration. The analysis of the study included the evaluation of the clinical baseline variables which were vital to the study. Although many outcomes were included in this report there was incomplete information of the results. Some of the data collected did not go, beyond the baseline for example the data on lung sounds, blood pressure, and weight of the patients. All the outcomes of the patients could not be included in the data analysis because the data was being collected according to a certain geographical area. Nurses also considered the post operations outcomes, therefore, making it difficult to include all the outcomes of the patients (Padula and Yeaw, 2001).
The worthiness of the Interventions and cost implications
The results as evaluated in the study suggest that intervention had a direct impact on healthcare utilization thus leading to a reduction of costs for the admission of the inpatients. This impact was recorded during the waiting period of the intervention arm; this was mainly because of the homecare visits which were done regularly. The intervention results were affected by the time allocated and availability of nurses, hence giving improper results and increasing the cost of intervention.
Conclusion
In conclusion, the study has helped patients reduce the risk factors and hence helped in curbing coronary heart disease. The study has also helped nurses and clinicians to monitor their patients by measuring their cholesterol and blood pressure levels thus the nurses can offer better and appropriate medication. However, researchers should engage in doing more studies that will include a larger sample size to get a better review. When doing their research, researchers should involve patients more so as they can share the most intimate things affecting them i.e. things they write in diaries.
References
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