Discussion 5.2: Quantitative Critique
Name
Institution
Course
Date
Nurses are expected to understand, engage, and contribute to evidence-based practice to provide the best quality and standards of care to the patients. Part of the process of adopting evidence-based practice is being able to appraise the current evidence. Before applying the available research in improving the theoretical and clinical skills and base their practice on it, they are required to assess its quality (Galvan & Galvan, 2017). This implies evaluating all parts of the research study from the title to the conclusion noting the strengths and limitations of the evidence. This essay provides an evaluation and critique analysis of a quantitative research article that could be applicable in the nursing practice especially since it involves implementing a Clinical Decision Unit (CDU) to improve congestive heart failure care.
Title
The title does not provide enough details regarding the study’s variables, and the population of the study. However, the title “Improving Congestive Heart Failure Care with a Clinical Decision Unit” provides a hint of what the study is about. A reader understands that the objective of the study is to improve congestive heart failure through the use of a clinical decision unit. This title also represents the hypothesis of the study that the implementation of the Clinical Decision Unit leads to significant improvement of Congestive heart failure outcomes indicating better care. Nevertheless, this understanding can only be achieved by someone aware of research techniques however; a less aware reader will require reading the article to understand the title. Also, the title fails to include the approach used in the research; it could be argued that the title was no inefficient in indicating the nature of the study.
Abstract
According to Fain, the abstract is a very important part of any article since it summarizes the research and provides an overview of the most important points in the study (2020). The abstract in the study by Carpenter and others (2015) provides an effective summary of the identified variables and the outcomes. The abstract also highlights the design of the study as a pre-post design. it also hints at the results and recommendation stating that the intervention leads to better clinical outcomes without an increase of financial cost and hence CDC should be implemented in the health institutions. However, the abstract does not provide a summary of the research tools, collection of data techniques, and study sample used in the research. Hence it does not help readers decide whether the article is relevant and useful in research the topic.
Introduction: Statement of the Problem
The authors present the state of the problem in the introduction part stating that the programs introduced by Medicare that is the Readmission Reduction Program (RRP) have been affecting hospitals since their implementation in 2012 (Carpenter et al., 2015). The presented statement of the problem provides a good explanation of why the study is needed for the population of the study. The study states that about 26.9 cases of readmission cases feature patients with Congestive Heart Failure (CHF) making it the most common risk factor for readmission. The authors note that about 19.6% of patients get readmitted before a month ends. High readmission rates lead to a reduction of the Centers for Medicare & Medicaid Services (CMS) reimbursement. The authors, therefore, argue that improving CHF care is going to improve clinical outcomes hence reducing the rates of readmission and saving the institution from losing funds. The authors also provide an overview of the scope of the study that is; Norton Audubon Hospital (NAH) a 275-bed non-profit community health center. They stated that the rate of readmission in CHF patients was 25.35% and although the rate is less than the national average for health institutions focusing on the health condition and hence it was not labeled as excess. However, the hospital cannot afford an increase in the rate, and hence investigating the CDUs was integral to the institution and also other related health facilities. The research is relevant to the administration and to health providers who provide CHF care including nurses. Additionally, according to the factors discussed in the problem statement, using a pre-post design is efficient.
Introduction: Literature Review
The authors gathered literature from various scopes and time to support the study. The literature review contains articles that support the implementation of CDUs or some parts of it. The authors summarized the content of the articles in three simple columns; citations, relevance, and the supported elements for CDU Design. Although the literature review provided a solid basis and an extraordinary synthesis of the current evidence, some of the articles like Daly, Campbell, & Cameron (2003), were old. A more detailed literature analysis is needed. This could be seen as a limitation as some readers will feel the need to assess the matter and determine the research quality upon which they base their perception and conclusions.
Introduction: Conceptual/Theoretical Framework
The Quantitative study investigated the effectiveness of the CDU in reducing the number of patients with congestive heart failure who are readmitted within 30 days of discharge. The framework was based on the supporting research and the experiences of the cardiologists and supported the argument to establish a CDU in NAH (Carpenter, et al., 2015). The authors of this research paper provide a detailed explanation of the conceptual basis of this research, including how researchers decided to develop the CDU mentioned above. He briefly described other research concepts, like why Norton Healthcare and how predictive scores will be calculated (Carpenter, et al., 2015). Norton Healthcare has considered a variety of treatment options for chronic diseases. One option includes a nurse-run outpatient CHF clinic (Carpenter et al., 2015). The NAH Patient Management and Management Group has also discovered a successful CHF clinic and is currently using CDU to enhance the program (Carpenter et al., 2015). Members of the major cardiologists were interested in the “CHF of the CDU based on previous experience and knowledge of trends in healthcare delivery in their section” (p.256). This project is designed to make a difference in the caring of patients with chronic heart failure and lay the foundation for leadership to initiate change towards quality patient care (p.256). It provides the basis for future projects aimed at CHF disease management (Carpenter et al., 2015).
Introduction: Hypothesis or Research questions
The article did not provide the precise research questions, however; the readers understand the objective is to improve CHF care. Additionally, the need for change implementation has been discussed and the literature review supports why CDU is the best strategy. The authors did not provide a hypothesis; however, they stated that they were not surprised by the outcome of the study implying their hypothesis could be that there is a significant improvement of CHF care due to CDUs. Stating the research question or hypothesis could have been more effective.
Method
Research Design
Carpenter et al. (2015) applied a pre-post design in assessing the impact of the implementation of the Clinical Decision Unit in the Norton Audobon Hospital. This gave the authors the advantage of observing the process of changing and overseeing the outcomes. They provided the dates for the CDU implementation and the pre and post data. The noise related to CHF management was reduced or eliminated by comparing the NAH data with that of another hospital under the Norton system. However, there is no enough and clear information regarding the design or the reasons for choosing it; the only provided information is that NAH was the experiment group and the intervention being CDU, and the control group being a hospital still in the Norton style.
Population and Sample
There are no details regarding the population or the sample of the study. The authors include hints on the methodology used in the results part; this is not a clear way to present the methodology since the reader might get confused. There is no demographic information on the sample such as gender, mean age, demographic, marital status, etc. Additionally, there is no indication of the sample size or the sampling technique applied which makes it difficult to determine the quality of evidence. Also, the authors do not state how they protected the rights of the participants.
Data Collection and Measurement
The authors had two phases for data collection that is before and after implementation. They collected data through the pre-post design and the Microsoft Amalga Readmissions Manager. The latter was a computer system that Norton Healthcare was using to gather data and predict the likelihood of being readmitted within thirty days after discharge for each patient. These tools of data collection intertwine with the research objectives. The data was then entered into statistical software for analysis.
Procedures and Rigor of Instruments
The experiment involved assessing the effectiveness of CDU in CHF clinics as an integrated approach aimed at improving patient outcomes for patients diagnosed with CHF by NAH and reducing the overall 30-day readmission rate. The procedure of the study involved assessing taking the data before the implementation, the actual implementation, and the final collection of data. The resources used to facilitate the success of this study included Physical space, budgetary needs, and capital. Stakeholders were identified and a representative project team was used to ensure effective implementation. Evidence-based admission/discharge criteria, practice sets, nursing practices, and documentation tools were developed. Recruitment of experienced nurses to facilitate implementation was carried out with a 1: 5 ratio of nurses to patients (Carpenter et al, 2015). Also, training of nurses was important to guide discharge planning, identify high-risk patients, and identify those who require additional follow-up.
Results
Data analysis
The study used the involved comparison of data from the experiment and control group. The collected data was entered in SAS and analysis have done on readmission rates. However, the analysis was limited since the individual factors of the patients were not considered to influence the results.
Findings
The authors ensure to present the results clearly with the help of a table showing the Clinical Decision Unit analysis with the presentation of the data from both hospitals for pre and post-implementation and the observed change. The overall results of this study confirm that hospital readmission rates are absolute and are not easily affected by a single intervention, such as the implementation of a CDU. The readmission rate did not decrease during the active analysis period and did not show statistical differences from the comparative hospitals. Treatment costs for CHF patients increased in both comparative hospitals, but the cost increase was smaller in NAHs, and there was no statistically significant difference. Comparing prognostic scores showed a slight increase in NAH scores, but a slight decrease in hospital comparisons, showing no statistical significance. Statistically, the implementation of the CDUs did not have any effect on readmission rates, as they remain relatively high with no significant change when comparing with the situation before the implementation. However, the authors insist that the intervention is promising and will reduce readmissions over time.
Theoretical integration
The rationale for researchers to use quantitative methodologies for this particular study was related to the need to collect data to confirm the value of introducing a CDU in care provision in CHF units. The framework in which this study was formatted was derived from various related studies that provided support for the design elements of the CDU.
Discussion and Recommendations
The authors interpreted all the results recorded under findings consistently while highlighting the study’s limitations. The authors stated that the lack of significant reduction of readmission rates was due to the lack of enough information and data collection period; the study requires a longer period of analysis to collect important data. However, the results showed that outpatient visits increased during this study, and the assessment of the number of patients admitted since CDU implementation showed a slight decrease when compared to the prior data. The CDU may look promising, but it takes time to fully understand and evaluate the value of the system. The authors explained why the observation encounters in both hospitals had increased and why the rate was higher in NAH. It also provided an interpretation of the volume analysis highlight the cost-benefit of CDU. The authors also stated what the results implied on cost-neutral staffing, cost avoidance calculations, and volume budget. The article also states the relationship between the implementation of CDU and the predictive index score, and hospital reimbursement.
Global Implications
This quantitative study shows that the use of CDU provides many opportunities for nursing leaders to have an encouraging impact on clinical care and financial performance in their environment. They are looking for ways to improve clinical outcomes, given current financial pressures. Carpenter et al. (2015) explain as follows; if a project such as the CDU provides margin support and some reduction in price pressure, the organization will have time to provide comprehensive community support and continue to develop the larger structures needed to survive (p.261). Interdisciplinary team involvement, satisfaction, and improvement of patient outcomes, comparison and evaluation of multiple aspects of work using robust arithmetic analysis, and improved financial performance through cost management are beneficial to nursing leaders around the world.
Implications, Strengths, and Weaknesses
This study had many of Norton Healthcare’s strengths that laid the foundation for the success of the CDU. To maintain a culture of transparency, the CDU staff, statisticians, and analysts worked together to ensure data integrity and provide analytical support. Norton Healthcare received the 2011 National Quality Forum Award for its commitment to quality improvement. Besides, the NAH CDU was recognized as good practice during the 2013 site visit. Besides, the analytical design was enhanced with access to data to compare NAH CDU results with comparative hospitals. The next step in Norton Healthcare is to reduce the need for hospitalization, readmission, and plan to continue working with cardiologists, and identify groups where the same process is appropriate to provide the desired result especially concerning reducing the cost
This project has some drawbacks. Increasing the readmission rate is a tedious effort that requires many factors. As a result, it takes time to understand the value of CDU to the organization and integrate it into a broader safety net for chronic disease management. It turns out that it is currently under development for Norton Healthcare. Also, Norton Healthcare has a lot of work to do to fully integrate with the pool of a wide range of people who use predictive indexing tools. A single site also restricted the project. And the authors found that another hospital is currently developing a plan to replicate the concept of CDU. Once this is complete, the organization’s vision of understanding the unit’s contributions and further investigating its impact on the care delivery model will be strengthened.
Summary
Patient care is a top priority for hospital staff. Using predictive indices and CDUs for congestive heart failure is another way to improve a patient’s quality of life. It may be difficult to fully integrate the processes of congestive heart failure and other comorbidities, however, it is effective in reducing the cost of readmission.
References
Carpenter, J. E., Short, N., Williams, T.E., Yandell, B., & Bowers, M.T. (2015). improving congestive heart failure care with a clinical decision unit. Nursing Economics, 33(5), 255–262.
Fain, J. A. (2020). Reading, understanding, and applying nursing research. FA Davis.
Galvan, J.L., & Galvan, M.C. (2017). Writing Literature Reviews: A guide for students of the social and behavioral sciences (7th ed.). New York, NY: Taylor and Francis.
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer, Philadelphia, PA.