Research is an imperative activity aiming to guide nursing practice in providing evidence-based care (Reviriego et al., 2014). Research helps to enhance the quality and efficiency in healthcare, but developing a critical eye for valid research is equally paramount. Critical appraisal of research studies is a determinant factor of decision-making in evidence-based nursing practice. Critical appraisal of research articles is meant to help nurses apply credible knowledge to practice.
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The critical appraisal process seeks to determine the validity and representativeness of results. Thereby, the discussion herein takes one through the steps of critically appraising the journal article: “Impact of a Fast-Track Esophagectomy Protocol on Esophageal Cancer Patients and Hospital Charges” by Jitesh B. Shewale and others published in the 2015 Annals of Surgery. The appraisal process utilizes a critical appraisal tool from the Critical Appraisal Skills Programme (CASP) (2013).
Shewale’s et al. (2015) article does not have a literature review section and an associated theoretical or conceptual framework. The incorporation of empirical literature occurs in the discussion section, as the authors discuss the results.
Purpose of the Study
The study’s objective is clear by merely looking at the title. The title states the population under study, the intervention of focus, and outcomes of interest. On a different note, the title does not meet the requirements if a PICOT question. The title does not indicate a comparator and the duration of the study/intervention. In order to improve surgery outcomes, the study indicates the effectiveness of an FTEP by having a comprehensive look at pertinent outcome measures.
The need for the study is apparent; usually, lengthy hospital stays and high hospital costs are a typical phenomenon after patients undergo esophagectomy and get admitted to the ICU. The FTP entails a modification in the care of esophagectomy patients after surgery. Instead of admission to the ICU after surgery, the new protocol (FTEP) advocates for the transfer of esophagectomy patients to the telemetry unit directly. In addition, the FTEP encourages the inclusion of family and friends in the care of the patient a few hours after esophagectomy. The new protocol yields benefits because of the associated alleviation of both physiological and psychological stress. The study is not intrusive because there is no direct contact with the participants, but the benefits are irrefutable.
Shewale’s et al. (2015) study’s results are a reflection of a cancer medical center; thereby, the results are relevant to similar institutions and population. The results inform practice in cancer departments performing esophagectomy to individuals confirmed with adenocarcinoma or squamous cell carcinoma esophagus (Shewale et al., 2015). Based on the study results, transferring patients directly to the telemetry unit instead of the ICU, immediately after surgery, is more beneficial.
In spite of the authors’ failure to articulate indicate the study’s research design, the design qualifies as a quasi-experimental study. The study is retrospective in nature and evaluates the effect of an intervention in two groups. In one group, the fast-track esophagectomy protocol (FTEP) prevails, but in the other group (the control), the FTEP is missing. Since the research design is quasi-experimental, there is no randomization of subjects into the two groups (Dutra & Reis, 2016).
However, similarities between the two groups in terms of age, gender, and medical background for coronary artery disease, chronic obstructive pulmonary disease, and diabetes, are indicated. Participants in group A underwent esophagectomy before the introduction of the FTEP, while the second group (group B) underwent surgery after the institution of the FTEP.
Even though there are similarities in the baseline characteristics mentioned above, the number of participants in both groups is different. The researchers include 322 participants in group A and 386 participants in group B. Also, there is variation in tumor histology, pathological stage, tumor location, tumor grade, and distribution in clinical staging of the tumor (Shewale et al., 2015, 1117-1118).
The article does not indicate the concealment of the intervention because the research method is retrospective in nature and relied on secondary data. In addition, in comparison to true experimental studies: the randomized controlled trials (RCTs), there is no blinding in quasi-experimental studies (Misra, 2012). The research eliminates bias associated with recall and the researcher because the Esophageal Department Database is the source of research data.
Thereby, there is no manipulation of results in favor of the research. The kind of medical care given to the two groups is lacking; thus, there is difficulty in determining equality in the treatment given to the two populations. Since the researchers rely on a database, the kind of treatment received by the patients after esophagectomy is not known. Yet, the skills and professionalism of the medical team tend to influence health outcomes. Under such circumstances, the treatment effect is affected as well as the preciseness of the results.
Shewale et al. (2015) do not indicate the reason for choosing a quasi-experimental study over an RCT is not clear because there is no indication of negative ethical implications associated with the RCT. In reference to CASP (2013), the reader prefers the use of an RCT. An RCT is more beneficial and yields more valid and reliable results if used in a similar study but a different location. The nature of the study’s research design is cost-effective, but the study is worth the effort.
The study informs future RCTs and advocates for a look at other parameters, such as patient approval and satisfaction. Various measures are of interest, including the length of stay, duration of days of using a mechanical ventilator immediately after surgery, ventilator days before discharge, all days spent in the ICU (SICU), days spent in the telemetry unit, postoperative complications to indicate overall outcomes of the surgery. The MDACC’s enterprise information warehouse provided information on hospital charges.
The results include all the participants targeted at the start of the study; there is no attrition or non-response because the study extracts data from a database. The article talks of significant differences in the length of stays, some postoperative complications including acute respiratory distress syndrome, and days spent in the ICU and telemetry units between the two groups. But, the treatment effect of the FTEP compared to no FTEP is not shown.
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In reference to McGough and Faraone (2009), the application of effect size is dependent on the type of research methodology, and Shewale et al. (2015) does not guarantee the rigor of the research method used. After regression analysis, the indication of the confidence interval for the length of stays, pulmonary complications, and hospital charges helps to determine the precision of the study results. Confidence limits help to indicate the preciseness of results; a higher limit is associated with a low level of preciseness while the converse is true.
The results show significantly longer length of stays, significantly higher number of days spent in the ICU and telemetry units, a higher number of days with the ventilator in group A as opposed to group B. Postoperative complications, such as admission in the ICU, is significantly higher in group A than B. Other postoperative complications like pneumonia, aspiration, anastomotic leak, reoperation, readmission in the ICU, discharging patients while on patient oxygen, and atelectasis is not significantly different between the two groups.
Also, there is no significant difference in 30-day mortality and 90-day readmission between the two groups. The confidence interval for the effect of the FTEP in reducing the length of stays indicates a low level of preciseness, as shown by an association coefficient of -6.415 at a confidence interval of 8.294 to -4.536. However, the association between the FTEP and pulmonary complications is more precise, as shown by a correlation coefficient of 0.655 at a confidence interval of 0.456 to 0.942.
Overall, hospital charges for group A, compared to group B, are significantly higher, and a multivariate analysis shows a negative association. There is selective reporting because among the postoperative complications of interest, discharging a patient with a jejunostomy tube is among the outcomes of interest. Unfortunately, the article does not give details about the provision of a jejunostomy tube and one’s ability to feed after surgery. Thereby, in such studies, discussing the feeding abilities of the patient is paramount. A patient’s feeding abilities is one of the major reasons for readmission.
Critical appraisal of results is important in decision-making and future research. Future researchers are able to gain insight into ideal strategies for minimizing bias likely to affect the validity and reliability of results. Based on the appraisal of Shewale’s et al. (2015) study, quasi-experimental studies lack the rigor and credibility present in randomized controlled trials. As a researcher, giving the use of RCTs priority is imperative.
Critical Appraisal Skills Programme (CASP). (2013). CASP checklists. Web.
Dutra, H. S., & Reis, V. N dos. (2016). Experimental and quasi-experimental study designs: definitions and challenges in nursing research. Journal of Nursing, 10(6), 2230-2241.
McGough, J. J., & Faraone, S. V. (2009). Estimating the Size of Treatment Effects: Moving Beyond P Values. Psychiatry (Edgmont), 6(10), 21–29.
Misra, S. (2012). Randomized double-blind placebo control studies, the “Gold Standard” in intervention-based studies. Indian Journal of Sexually Transmitted Diseases, 33(2), 131–134.
Reviriego, E., Cidoncha, M. A., Asua, J., Gagnon, M., Mateos, M., Garate, L., … Gonzalez, R. M. (2014). Online training course on a critical appraisal for nurses: adaptation and assessment. BMC Medical Education, 14(136). Web.
Shewale, J. B., Correa, A. M., Baker, C. M., Villafane-Ferriol, N., Hofstetter, W. L., Jordan, V. S., … The University of Texas MD Anderson Esophageal Cancer Collaborative Group. (2015). Impact of a Fast-Track Esophagectomy Protocol on Esophageal Cancer Patient Outcomes and Hospital Charges. Annals of Surgery, 261(6), 1114–1123.