The Critical Appraisal of Research Articles on Health and Social Care - Essay Example

?The Critical Appraisal of Research Articles on Health and Social Care Technological and research advancements allow people to secure better and safer health care for everyone to enjoy life with optimum level of health. To fulfil this need, scholars pursue researches to provide reliable information on various aspects of health care to set evidence based parameters on safety of innovations in health care. Unfortunately, not all research is unbiased, truthful, and reliable and of good quality (Burls, 2009, pp. 1-8) which may lead to confusion or false conclusions. When confusion on contradicting conclusions between common researches occurs or when a stated conclusion is inconsistent or untrustworthy, critical appraisal may be done. Critical appraisal is “the process of carefully and systematically examining research to judge its trustworthiness, and its value and relevance in a particular context” (Burls, 2009, pp. 1-8). Its practice in medical field is highly relevant to delineate the useful discoveries from the harmful ones. A quality research is not just one that reflects good composure or format rather it is one that has internal validity which is being free from bias. Therefore, the research must be reviewed particularly in the selection, performance, detection and attrition where bias commonly occurs. Analysis must be conducted from data gathering, collation, down to analysis. In this paper, the author aims to clinically appraise two researches on health and social care. The first is entitled “Efficacy and safety of hyaluronic acid in treatment of leg ulcers: a double-blind randomised controlled trial (Dereure, Czubek and Combemale, 2012, pp. 131-139)” while the other is “The experience of patients with complex wounds and the use of negative pressure wound therapy in a home-care setting (Moffatt, et al. 2011, pp.512-527).” Both are in pursuit of a reliable and sustainable practice caring for patients with chronic wound. The first is a method to hasten healing of chronic wounds through the use of a topical medicine and the other is regarding the social and psychological needs patients with chronic wound under pressure treatment. Each will be presented separately and both research design and methodology will be critiqued. There will be no comparison between the two researches since they differ completely in design and methodology. After discussions and analysis, conclusion of what transpired will be stated. The author elected these studies on chronic wound care as it poses great demand on the current health care system. With the world directing to an aging population, health problems related to obesity, immobility, chronic illness such as diabetes become rampant. These health problems commonly results to chronic wounds that has poor healing and required vast attention from clinicians. In 2009, it was declare to be a great public threat to health and economy as it results to government expenditure of at least 25 billion dollars per annum (Landro, 2012, par.5). Chronic wounds, particularly on the lower extremity, have high prevalence, high cost, and poor clinical outcome. They are often managed by a non-integrated healthcare system which consequentially resulting in an erratic healthcare arrangement. This challenges scholars and scientist to discover and create better technology and technique to better manage chronic wounds in a more sustainable and cost-effective manner (American Society of Plastic Surgeons, 2007, pp.1-8). For years, several methods have reached popularity in the medical scene of managing these type of wounds such as debridement and other surgical procedures, compression dressing, wound dressing with a variety of topical medicines, negative pressure wound therapy, cultured skin cells, pressure redistribution mattress, oxygen chambers, etc. (Landro, 2012, par.4); all of which acclaims to be effective in the healing process of complex wounds. Efficacy and safety of hyaluronic acid in treatment of leg ulcers: a double-blind randomised controlled trial (RCT) (Dereure, et al. 2012, pp. 131-139) Leg ulcer is a chronic non-healing wound presenting tissue damage and even necrosis. Eighty percent of the leg ulcers are venous in nature caused by long term venous hypertension eventually resulting to skin and tissue breakdown. The common underlying cause of venous hypertension includes diabetes, vasculitis such as in rheumatoid arthritis or lupus, trauma, malignancy, immobility, and obesity just to name a few (Bergan and Shortell, 2007). The elderly are more prone to acquire this as they have the most degenerative conditions and poor arterial and venous sufficiency. In United Kingdom alone, an estimated prevalence of leg ulcers are between 1.5 and 3 per 1,000 people (Adeyemi, et al., 2009, pp. 21-28). Several treatments are available and others are still under research to determine its effectiveness and efficacy. Some invasive treatments are endovenous lase ablation, radiofrequency ablation, foam schlerotherapy, perforating vein ligation, and deep vein reconstruction. But the most common and conservative treatment involved compression therapy and superficial wound remedy (Coleridge-Smith, 2009). He further declared that there was no particular dressing that hastens leg ulcer healing. Dereure, et al. (2012) aims to search for a topical medication to promote healing of leg ulcers. This gave birth to their evaluation on the efficacy and safety of utilizing hyaluronic acid in treating leg ulcers. Local wound treatment remains beneficial and important in managing all types of wound especially with leg ulcers. This practice is done to disinfect and maintain cleanliness of the wound, hasten healing, and protect it from further infection. This belief led Dereure, et al. (2012) to experiment on the effectiveness of a topical medicine in healing leg ulcers. They used the hyaluronic acid for the trial group and a neutral vehicle for the control group. A highly purified form of this chemical is currently utilized in treating acute and chronic wounds and researches were done in determining its mechanism of action and safety perimeters (Dereure, et al., 2012, p.131). Hyaluronic acid is a major component of the extracellular matrix. Its moisture absorption and viscoelastic properties play a pivotal role in the wound healing process, through complex interactions with cells and other extracellular components. Hyaluronic acid is actively involved in all stages of wound healing, from promotion of early inflammation and granulation tissue formation, through facilitation of cell migration into the wound matrix, to re-epithelialisation, through its free radical scavenging function, and role in keratinocyte proliferation and migration (Anderson, 2001). The researchers gathered patients with leg ulcers and subjected them to a double-blind, randomised, controlled trial for sixty days. The evaluative criteria are the percentage of wound size reduction, change in pain intensity, rate of complete ulcer healing, and aspect of the wound and peri-ulcer skin. After forty five days of treatment, they discovered a significant improvement on leg ulcers for those exposed to hyaluronic acid compared with the control group. They claim that the pain intensity decreased significantly with the trial group and that the treatments were tolerated. Although there was no significant difference on terms of rate of complete healing and changes in the characteristic of wound and peri-ulcer skin, they concluded that hyaluronic acid is significantly more effective compared to the neutral vehicle in wound treatment (Dereure, at al., 2012). To test the validity of this study, the appropriateness of research design utilized to the question posed is scrutinized. Here, Dereure, et al. (2012) used the RCT which is acclaimed to be the most apposite design to measure effectiveness (Burls, 2009). RCT provides an opportunity to gather useful evidences on the efficacy of an intervention to the patient population (Polit and Beck, 2004). The principal lead of proper randomization is that it diminishes allocation bias where both known and unknown prognostic factors are balanced in the assignment of treatments (Moher, et al., 2010). Randomization was observed in selection of participants in the study at hand. The total research population of one hundred one is categories into a control group and trial group. They kept in mind that both groups have the same demographic and wound characteristics at the baseline. The control group composed of fifty one participants who received neutral vehicle for wound care while the other fifty received hyaluronic acid in the trial group. Control groups are created in order to validate its outcome if the result is due to treatment or to a natural cause. As believed by scholars that some disease conditions are self limiting and can therefore cure itself without any intervention (Burls, 2009). This became the basis of utilizing a control group in research. Dereure, et al. (2012) ensured a “double-blind” randomization where the participant and practitioner are kept uninformed on the participant’s category. Keeping the knowledge of who is in treatment and who is not ascertains unbiased treatment and evaluation. After randomised selection, nurses apply the provided cream application and assigned dressing and covered by sterile gauze afterwards. For patients with multiple leg ulcers, only one ulcer is selected and evaluated. The evaluation is done by a physician and debridement was done prior to application of treatment to remove necrotic tissues. Compression bandages were allowed to be applied on daytime and removed at night. Systemic antibiotics and analgesics were also allowed but high-dose systemic corticosteroids, cytostatic and immunosuppressive drugs and proteolytic enzymes were not permitted (Dereure, at al., 2012). This research design and methodology chosen by the researcher fits their query of effectiveness and comparison between the hyaluronic acid treatment and neutral treatment of wound. Accepting this as valid points, the author then critics the results and relevance to further appraise this research study. Statistical treatment was determined with a hypothesis that “a superiority of the hyaluronic acid cream, compared with the neutral vehicle, regarding clinical efficacy evaluated through the primary endpoint of percentage of wound size reduction at day 45, could be considered as a valid surrogate endpoint for leg ulcer healing” (Dereure, at al., 2012, p.135). Analysis of variance (ANOVA) was used to compare the evaluation criteria between the two groups. Qualitative variables such as pain were compared with a Chi-square test while last observation carried forward (LOCF) was used in cases where there were missing values in the hyaluronic acid group analysis for all evaluation criteria. The results reflected “significant difference” referring to the statistical results and not to necessarily to the relevance of the notion (Burls, 2009, p.5). Researchers utilized statistical treatment to compute for the progress in wound size of the patients and to weigh the difference on the secondary criteria of pain and characteristics of wound. They were accurately reflected with relative risks and can therefore be accepted as valid. As with other experimental researches, this study also poses ethical issues on the difference on treatment received between the trial and control groups. Yet they managed to secure permit from independent ethics committees to ensure that their study protocol is in accordance with the provisions of the French Ministry of Health (International Standard, 2003). It was also noted that patients who encountered adverse effects from both the trial method and the neutral vehicle received apt treatment from physicians and some were even excluded from the study population to receive prescribed medications that were not permitted in the study (Dereure, at al., 2012). The research paper also reported the adverse reactions that were experienced by their subjects with the use of hyaluronic acid such as application site burn, eczema, erythema, pain, and aggravated condition. But stated that the number affected were statistically insignificant and were just mild to moderate. In conclusion, usage of hyaluronic acid can be acknowledged as effective and safe in use for treating leg ulcers with low risk for developing mild to moderate adverse effects. The experience of patients with complex wounds and the use of negative pressure wound therapy in a home-care setting (Moffatt, et al. 2011, pp.512-527) As clinicians pursue on discovering strategies and techniques to hasten wound healing, little attention were given to address the psychosocial problems of the patients related to chronic wound and its treatment. The best way to treat chronic wound it through comprehensive holistic approach (Landro, 2012, par. 8) that is by not just treating the physiologic aspects of the wound and infection but by also attending to the social and psychological troubles of the person. This drove Moffatt, et al. (2011) to engage in a research exploring on the experience of patients with chronic complex wound and their notions on negative pressure wound therapy at rendered at home. Negative pressure wound therapy involves the controlled application of sub-atmospheric pressure to the local wound environment using a sealed wound dressing connected to a vacuum pump. A dressing is fixed to the surrounding skin of a wound then is sealed with a transparent dressing and connected to a vacuum source via a drainage tube. The wound will be a controlled close wound where excess fluid volume will be eliminated thus resulting to better circulation, moist healing environment, lesser oedema, and faster healing (Lillis, 2003, p.32). “The biophysics behind the success of this treatment largely have focused on increased wound blood flow, increased granulation tissue formation, decreased bacterial counts, and stimulation of wound healing pathways through shear stress mechanisms” (Thompson and Marks, 2007). This method has been utilized for years as its effectiveness to heal Stage III and Stage IV pressure ulcers were already confirmed (Gupta, et al., 2004, pp.1-17). Limb preservation is parallel in priority with allowing the patient to perform activities of daily living on his optimum level of health (Wu and Armstrong, 2008). Home health care agencies as well as community nurses and care givers are challenged with providing wound treatment at home setting to reduce cost of hospitalization, lessen risk of nosocomial infection, and promote self preservation on the part of the patient (Schwien, et al., 2005, pp. 47-60). Unfortunately, follow up have been challenging for those in remote locations such as in urban areas. Recurrence of pressure sores or ulcers oftentimes happen due to poor follow up. Resources need to be combined and collaboration among health care providers, patient, and family members are needed to synergize their daily activity performance with accomplishment of treatment (Wu and Armstrong, 2008). The researchers opted to use qualitative research design to better investigate on the feelings and perception of the subjects on the topic at hand. Qualitative research design is applied for in-depth understanding of human behaviour and feelings and the reasons for such manners. The complexity and depth of this design limits the study population to a smaller size compared to a quantitative research (Holloway and Wheeler, 2009). Here, they made use of semi-structured interviews as tool in assessing eight patients. The participants were purposively selected from a primary care trust and using stratified sampling elected the study population considering their wound types, age and gender (Moffatt, et al. 2011, p.512). It is a well thought decision to use this sampling type as it is most appropriate to answer their query that deals with thoughts and feelings. Stratified purposive sampling generated credibility to a research study especially when the characteristics of the research subjects have already been identified (Cohen, 2006). After selection of subject, each was interviewed in the comforts of their home after ten days of NPWT using a semi-structured interview guide and was digitally recorded (Moffatt, et al. 2011, p.514). Semi-structured interviews allow the subjects to explore on their thoughts and feelings even outside the prepared questions as long as it remains relevant to the topic (Parahoo, 2006). As this research involves a more personal aspect of a person dealing with their experience and insights, the researchers acquired permission for the conduction of this study from the ethical commission of United Kingdom. All participants signed a well explained informed consent prior to interview and were allowed to have a relative or companion during interview. All digital and written records of interview were treated with utmost confidentiality according to the researchers (Moffatt, et al. 2011, p.514). The transcribed interview were analysed using the Framework method polished by the National Centre for Social Research (Ritchie, et al., 2003). This allows transparent treatment of data through categorizing them in systematic groups of idea. This is one of the arduous parts of a qualitative research as this requires ample time and patience. After meticulous analysis, the researchers created five categories with sub-categories they referred as themes. They are: (1) developing a wound through crisis, with themes of a failing body, missed diagnosis and failed professional intervention; (2) decreased control, with themes of poor communication, failed wound healing, poor discharge planning and failure to recover; (3) increased control, with themes of understanding what is happening, symptom control, positive professional relationships and returning to health; (4) using NPWT, with themes of information and understanding of NPWT and expectations and experience of NPWT; and finally entails (5) participant recommendations about the device with themes about device issues and improving professional practice (Moffatt, et al. 2011, pp. 518-526). Mofatt, et al. (2011) concluded that indeed these patients suffer from various psychosocial challenges caused by NPWT. One of the core findings is that “patients saw chronic wounds as developing through a process of crisis... (such as) underlying severe illness, missed diagnosis, failing treatment, fear, loss of self-esteem and reduced control over aspects of their lives.” The participants perceived NPWT as an effective intervention promoting improved wound healing and symptom control. Unfortunately, they also found that optimal achievement of goal is failed to be achieved due to poor discharge planning and poor communication with health care providers. This finding is significant in the improvement of the current practice as patient’s control on health generally promotes better recovery and healing (Chase, et al., 1997, pp.73-78). Furthermore, perception of pain and its management were also discussed as they concluded that pain is the most significant problem that a patient experiences with chronic complex wounds. NPWT therefore, reduces that painful experience and promotes faster healing as well. In addition, the patient’s vision of being healed helps with better recovery and less pain on their part. Being able to be treated at their home also helps with increasing the patients’ comfort during procedures thus allowing for better compliance to treatment (Moffatt, et al. 2011, p. 527). These results pose high relevance to the health care practice particularly in caring for patients with chronic complex wounds. The findings may serve as guide for physicians, nurses, and other clinician, in developing a treatment program for the patients. The need for better communication lines among the patients and health care providers must be addressed as well as the discharge planning and follow up to prevent recurrence of the complex wound. The strength of this research embraces the in-depth approach to the topic and the subjective treatment of data. The research reflects well transcribed interviews and carefully analyzed categories and themes that promoted better understanding and realisation for the readers. Research design and methodology together with the method of analysis were properly employed and directly answered the research problems that were identified. Summary and Conclusion Two types of research were explored in this paper; the first one is a quantitative research while the other is qualitative. Both involve management of patients with chronic and complex wound but the treatment modalities are different. Dereure, et al. (2012) sought after the effectiveness of hyaluronic acid in treating leg ulcers and used the experimental research design for this. They succeeded with this perusal and presented their results and findings in accordance to the principles of research. They study implies acceptance of hyaluronic acid ointment in treatment of leg ulcers over neutral vehicle or other ointments. On the other hand, Moffatt, et al. (2011) comprehensively explored the feelings and experiences of patients with complex wound and their perception regarding NPWT. They found a variety of issues involving the communication and treatment from physicians, nurses, and other health care workers, and NPWT. After hospital discharge, most of patients, especially those living in urban areas, have difficulty on follow-up (Landro, 2012, par.17). With regards to research design, methodology, statistical treatment or analysis, both made use of what is appropriate to answer the queries. Burls (2009) stated that only when these research components are accepted as valid and appropriate to the variables that the result of the investigation will matter. These findings generally imply that wound healing does not necessitate the most expensive technology available but mere proper management are proven efficient. Health care providers particularly nurse and caregivers who monitor and daily aid in treatment must ensure proper compliance to treatment regimen as prescribed by the physician. Nevertheless, the most important thing is prevention rather than cure, occurrence of chronic and complex wounds could be prevented with proper monitoring and assessment especially of the high risk population. With early detection and early treatment medical costs and physical and psychosocial burden will relatively be lessen. In conclusion, it can be stated that both researches are positively appraised and are considered valid form of evidence-based studies that can be a reliable guide for health care practice. Bibliography Adeyemi, A., et al. (2009) Leg Ulcers in Older People: A Review of Management. British Journal of Medical Practitioners, September 2(3), pp. 21-28. American Society of Plastic Surgeons. (2007) Evidence-based Clinical Practice Guideline: Chronic Wounds of the Lower Extremity [Internet] May. Available from < https://docs. google.com> [Accessed 18 October 2012] Anderson, I. (2001) The properties of hyaluronan and its role in wound healing. 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(2008) Clinical outcome of diabetic foot ulcers treated with negative pressure wound therapy and the transition from acute care to home care. International Wound Journal Special Issue: V.A.C.®, 5(2) June, pp. 10–16. Read More