Critical Appraisal Paper

CriticalAppraisal Paper

Institution`

CriticalAppraisal Paper

Thisresearch paper is based on the PICO question, ‘in schizophrenicpatients taking anti psychotic medications, is consistent follow-upcommunication in addition to standard care more effective inincreasing patient medication adherence when compared with standardcare alone’? The PICO question answers one of the basic questionsin evidence based practice in the modern medical practice. Adherenceto medication is an essential factor that influences theeffectiveness of the treatment. However, statistics indicates thatthere is poor adherence to medication among mentally ill patients(McCabe et al, 2012). The paper also critically analysis the evidencebased practice guideline in the management of schizophrenia. Thispaper gives a critical evaluation of a research paper related to thePICO question. Selected tools have been used in the criticalappraisal and evaluation of the PICO related article and the evidencebased practice guideline.

Background of the question

Adherenceor compliance with medication among mentally ill patients is animportant concern among nurses and other medical workers. It has beenan elusive subject for many years in the treatment and management ofschizophrenia. There is a need for evidence based interventions thatimprove compliance or adherence among patient is an important steptowards full recovery of the patients. There are several programsthat have been proposed as effective measures to promote increasedadherence to medication. Key among them has been secondary careprogram in addition to the primary care and constant communication(Dawn &amp Peter, 2006). This forms the bases of the PICO questionthat guides this study.

Asystematic and critical appraisal is essential in the analysis of aPICO question article. Due to the nature of the PICO question asystematic review article which gives a wide range of replicated datais appropriate. A systematic review tool can be used to analyze thearticle. It identifies the strengths, weaknesses, biasness and theknowledge gaps in the research article in order to the usefulness ofthe findings to the nursing profession. According to Young andSolomon (2009), “the most important components of a criticalappraisal are an evaluation of the appropriateness of the studydesign for the research question and a careful assessment of the keymethodological features of this design”. Evidence based medicalpractice is based on the findings of research studies in making keydecisions. A critical appraisal of research studies is therefore anessential aspect of medical practice. There are points that areessential in the appraisal of a research article, which is dependenton the nature of the research or study design. In this particularstudy, systematic review article has been used to answer the PICOquestion. Therefore, some of the key questions in the criticalappraisal includes the relevance of the primary sources used, andtheir appropriateness, level of biasness as well as whether all theavailable primary sources were included in the study. Due to the widerange of data collected from different studies by the researchers,the results of the study are fairly accurate.

Systematicreview of PICO related article

Asystematic review tool was used to critically analyze the PICOrelated article. The appraisal worksheet is provided in appendix 1.The questions in the systematic review tool include whether the mainquestion is clear and related to the outcome of interest, whether allrelevant studies were identified, inclusion criteria, data extractionand clinical importance. The article seeks to review articles onfactors affecting adherence to psychotic medication. In addition tobeing related to the PICO question, the intentions and outcomes ofinterest of the article are clearly stated in the introduction andabstract. The study method in the research involve the retrieval ofjournal article ( in English and Chinese languages) from PubMed andPsycINFO followed by a review of the article for inclusion in thesystematic analysis. To increase the scope of the study, the help ofpsychologists dealing with Asian studies were sought in order toaccess more articles not access through the online databases. Apredetermined criterion was used to review the articles forinclusion. The criteria were based on the aims of the study, measuredoutcome, the subjects in the study and the relevance of the data. Thestudy selection involved an independent selection and screening ofthe research articles by the researchers. However, consensus wasrequired in cases where there were disagreements. All the studiesincluded in the research were accessed for biasness to avoidinaccurate conclusions. Additionally, data from each of the researchwas extracted in duplicate to enhance the authenticity and accuracyof the information obtained. The most important outcome of the studywas the finding that intervention increased the level of complianceby for example, ensuring that no change of dose or medication time bythe client (Fancer et al, 2014). This indicates the clinicalimportance of the study and the results are valid and can be verifiedusing studies from other populations rather than Asians. Ameasurement tool to assess systematic reviews (AMSTAR) worksheet ofthe article is also provided in appendix 2.

Evaluationof the EBP guidelines

Evidencebased guidelines in the management of Schizophrenia is essential inanswering the PICO question. The guidelines, “Management ofSchizophrenia, A nation clinical guideline” (U.S.DHHS, 2014),provide an expert view that gives the basic interventions to aparticular medical issue. Although majority of guidelines in thenursing profession are related to nursing and medical ethics, someclinical procedure have evidence based practices guidelines. Theguidelines are intended to guide all medical workers to adoptevidence based evidence in the management of Schizophrenia.Additionally, the generalized recommendation of family interventionto improve medication adherence is also recommended in theguidelines. The supports the postulations of the PICO questionenhanced communication and secondary care giving increases adherenceto medication among schizophrenia patients. Ameasurement tool to assess systematic reviews (AMSTAR) was used inthe critical appraisal of the evidence based guideline to determinethe relevance to the quality and relevance of the guidelines toclinical practice. A measurement tool to assess systematic reviews(AMSTAR) worksheet of the guideline is provided in appendix 3.

Processand outcome measures

Processand outcome measures of the PICO questions are very essential.Process refers to how the process works while the outcomes refer tothe results or the final outcome. In regard to the PICO questions,the process and outcome measures refer to measuring the processesinvolved and their outcomes (NCJP, 2014). In the evidence basedguideline, the process involves all interventions and practicesrecommended in the management of Schizophrenia. They include accessto treatment, pharmacological interventions and treatment of acuteexacerbation and prevention of relapses. Other processes includeaddressing perinatal issues, specific clinical issues and provisionof psychological therapies. On the other hand, the guidelinesproposes some outcomes including control of the psychotic symptoms,adherence to medication, reduced length of hospitalization andimproved quality of life (U.S.DHHS, 2014). Specifically, in referenceto the role of consistent of communication and secondary care inimproving medication adherence among schizophrenic patient, this willinvolve the measure of what has been done and the outcomes. Forexample, studies points towards provision of home based secondarycare through close members of the family. This will involve psychoeducation and sensitization of the family members to improve theirknowledge and attitude towards on the condition of the patient(U.S.DHHS, 2014). How this has been done or not done will involve theprocess measures. The outcome measures will involve the effects orresult of facilitating or not facilitating the secondary careprogram. In this regards, not facilitating involves relying on theprimary or standard care alone.

Applicationof the article finding

Thefindings of the article in relation to the PICO question as well asthe recommendations in the evidenced based practice guidelines arevery applicable in nursing practice. I would therefore apply both inthe management of schizophrenic clients. Evidence based practicefocuses on medical practices that are supported by research. Thecritical appraisal of the PICO related article and evidence basedpractice guidelines proves the validity of the findings andrecommendations. Although the studies referred in the article focusedon a specific population, Asian adults suffering from mentalillnesses, the finding are applicable to the general population. TheEBP guideline gives comprehensive guidelines in the management ofschizophrenia. Generally, with limited secondary care giving, theadherence and compliance to medication among mentally ill patient isa major concern. Focusing on education family members and engagingsupport groups in the management of schizophrenia and other mentalillnesses is a major step towards increased adherence (Dawn &ampPeter, 2006).

Revisionof the question

ThePICO question will not require to be revised. In addition to beingrelevant in the modern day practice, there are credible and expansiveresearch based materials on the topic. The PICO question as well asthe relevant studies seeks to answer pertinent questions in themodern society. Although cultural and societal factors have aninfluence on medication adherence, the question addresses all theunderlying factors. However, the systematic review suggests thatthere are some research gaps that need to be addressed in futurestudies. Some of the key steps in furthering the PICO questioninclude collecting primary evidence of the effectiveness of secondarycare giving and follow ups in increasing adherence from patients aswell as care givers. Application of the findings of the PICO questionin nursing will also be a key step in furthering the question.

Conclusion

Thelack of medication adherence among schizophrenic client is a realthreat to the treatment of the condition as well as other mentalillness. There is a need for evidenced based approaches to increaseadherence to medication. The critical appraisal of the PICO questionsuggests that family based secondary care giving can effectivelyincrease the compliance with medication. The analysis involves theapplication of the systematic review of the PICO related question andameasurement tool to assess systematic reviews (AMSTAR) ofthe EBP guidelines. This critical analysis and tools are essential indetermining the appropriateness of the article and evidence basedguidelines in reference to the PICO question. The paper also includespossibility of application of the findings and recommendationsfollowing the critical appraisal.

References

DawnI. V. &amp Peter J. W. (2006). “Interventions to Improve Adherenceto Antipsychotic Medications”. Schizophrenia,Addiction, Cognitive Behavioral Therapy,Vol. XXIII, No. 9

FancerT. L., Lee, D, Cheng, J. K. &amp Yang, M. S. (2014). “Interventionsto improve adherence to psychotropic medication in clients with Asiandescent: a systematic review”. AsianAmerican Journal of psychology,5(1), 22-34.

NCJP.(2014). Processand Outcome Measure,National Center for Justice Planning.

McCabeR, Bullenkamp J, Hansson L, Lauber C, Martinez-Leal R, et al. (2012).“The Therapeutic Relationship and Adherence to AntipsychoticMedication in Schizophrenia”. PLoSONE7(4): e36080. doi:10.1371/journal.pone.0036080

U.S.DHHS.(2014). Managementof schizophrenia.A national clinical guideline. U.S. Department of Health &amp HumanServices http://www.guideline.gov/content.aspx?id=43956

Young,J. M. &amp Solomon, M.J. (2009). “How to critically appraise anarticle”, NatureClinical Practice Gastroenterology &amp Hepatology(2009) 6, 82-91.

Appendix1

CriticalAppraisal Worksheet: Systematic Review/Meta-analysis

FancerT. L., Lee, D, Cheng, J. K. &amp Yang, M. S. (2014). “Interventionsto improve adherence to psychotropic medication in clients with Asiandescent: a systematic review”. Asian American Journal ofpsychology, 5(1), 22-34.

1. What question did the systematic review address?

The main question should be clear and focused. It should describe the population, intervention/exposure, and outcomes of interest.

YES

The main question and intentions are clearly stated in the abstract and the introduction of the paper.

2. Is it likely that all relevant studies (published and unpublished) were identified?

Look for a comprehensive search forstudies in relevant bibliographic databases (e.g. MEDLINE, Cochrane, EMBASE) a search of reference lists from relevant studies contact with experts search for unpublished studies. The search should not be limited to English language only. The search strategy should include both controlled vocabulary terms (e.g. MeSH) and text words.

YES

The research article is an expert analysis of relevant studies in the past obtained from a wide range of databases.

3. Were the criteria used to select articles for inclusion predetermined, clearly stated, and appropriate?

The inclusion or exclusion of studies should be a clearly defineda priori. The eligibility criteria should specify the patients, interventions or exposures, outcomes of interest, and study designs.

YES

The researchers have provided an inclusion and exclusion criteria to ensure that the studies referred are relevant to the main question.

4. Were the included studies sufficiently valid?

Was themethodological quality of each study assessed using predetermined criteria appropriate to the type of study (e.g. randomization, allocation concealment, and follow-up for randomized controlled trials)

YES

The quality of the methodology was one of the inclusion criteria.

5. Were studies selected and data extracted by 2 or more individuals?

There should be at least 2 independent selectors/extractors and a tie-breaking procedure for disagreements.

YES

Data from all the sources was extracted by more than one researcher and disagreements resolved through consensus.

6. Were the results similar from study to study?

Ideally, the results of the included studies should be similar (homogeneous). If heterogeneity exists, the authors may estimate whether the differences are significant (chi-square test). Possible reasons for the heterogeneity should be explored.

YES

The results of all the studies included were homogeneous although there were some acceptable statistical differences.

7. Conflict of interest

Sources of support and other potential conflicts should be acknowledged and addressed.

Unclear

Not directly acknowledged or addressed in the article.

8. Clinical Importance

8a. What were the results of the review?

(Are the results of all included studies clearly displayed? Are the results similar from study to study? Is there a clinical bottom line? If the study results were combined, was it appropriate to do so?)

8b. How precise are the results?

(What is the confidence interval? P-value?)

8c. Did the interpretation of the review’s resultsaccurately reflect the results themselves? Are theresults generalizable?

YES

The results of the review are clear. All similar results are combined appropriately.

Unclear

Can not be accurately determined

YES

The results are accurately interpreted and can be generalized.

Appendix2

Ameasurement tool to assess systematic reviews (AMSTAR)

Fancer T. L., Lee, D, Cheng, J. K. &amp Yang, M. S. (2014). “Interventions to improve adherence to psychotropic medication in clients with Asian descent: a systematic review”. Asian American Journal of psychology, 5(1), 22-34.

1.

Was an ‘a priori’ design provided?

Yes

The research question and inclusion criteria are provided.

2.

Was there duplicate study selection and data extraction?

Yes

Data from each selected article were extracted by more than one researcher.

3.

Was a comprehensive literature search performed?

Yes

A comprehensive literature search from major databases mainly PubMed and PsycINFO was done.

4.

Was the status of publication (i.e. grey literature) used as an inclusion criterion?

Yes

The search was restricted to peer reviewed journal articles.

5.

Was the list of studies (included and excluded) provided?

No

List of all studies (included and excluded) not provided.

6.

Were the characteristics of the included studies provided?

No

Characterization of all the studies was not included.

7.

Was the scientific quality of the included studies assessed and documented?

Yes

The scientific quality of all articles was accesses before inclusion.

8.

Was the scientific quality of the included studies used appropriately in formulating conclusions?

Can’t answer

9.

Were the methods used to combine the findings of studies appropriate?

Yes

The findings of the studies were combined based on aims of the study, measured outcome, the subjects in the study and the relevance of the data.

10.

Was the likelihood of publication bias assessed?

Yes

Data being extracted by more than one researcher was used to identify and avoid bias.

11.

Was the conflict of interest stated?

No

Conflict on interest was not stated.

Appendix3:

Ameasurement tool to assess systematic reviews (AMSTAR), Appraisal ofthe EBP guideline

U.S.DHHS. (2014). Management of schizophrenia. A national clinical guideline. U.S. Department of Health &amp Human Services http://www.guideline.gov/content.aspx?id=43956

1.

Was an ‘a priori’ design provided?

Yes

The research question and inclusion criteria are provided. The question is provided in the scope while inclusion criteria include primary secondary and electronic sources and databases.

2.

Was there duplicate study selection and data extraction?

Yes

A systematic review of the studies based Scottish Intercollegiate Guidelines Network was used.

3.

Was a comprehensive literature search performed?

Yes

A comprehensive literature search from major databases mainly “Medline, Embase, Cinahl, PsycINFO and the Cochrane Library” was done. The year range covered was 2008-2011.

4.

Was the status of publication (i.e. grey literature) used as an inclusion criterion?

Can`t answer.

5.

Was the list of studies (included and excluded) provided?

No

List of all studies (included and excluded) not provided.

6.

Were the characteristics of the included studies provided?

No

Characterization of all the studies was not included.

7.

Was the scientific quality of the included studies assessed and documented?

Yes

The scientific quality of all articles was accesses before inclusion.

8.

Was the scientific quality of the included studies used appropriately in formulating conclusions?

Yes

The level of evidence was rated using a rating scheme. The levels of evidence in the scheme are 1++, 1+, 1-, 2++, 2+, 2-, 3, 4

9.

Were the methods used to combine the findings of studies appropriate?

Yes

The findings of the studies were combined based on level of evidence and recommendations.

10.

Was the likelihood of publication bias assessed?

Not Applicable

11.

Was the conflict of interest stated?

No

Conflict on interest was not stated.

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