Evidence-Based Clinical Question – Congestive Heart Failure

Congestive Heart Failure (CHF) remains one of the diseases with high mortality and morbidity rates in both developed and developing countries (Ross et al., 2010). As a result, it is necessary to identify and utilize effective methods of the management of the disease conditions for reducing the effects of CHF. Since most people affected by CHF are considered to be outpatients, it is necessary to equip them with adequate information that could be used to reduce the effects of the disease condition. Effective methods of providing information to these patients can be used to reduce cases of readmission. Currently, there are two common methods commonly used to provide instructions across various health settings with the most common methods being the use of video, written, and verbal discharge information. The different methods have different efficacy levels. Thus, considering the previous discharging from the hospital (P), how does video discharge instructions (I) compared to just written and verbal discharge instructions (C) affect CHF patient outcomes regarding re-admissions to the hospital (O) within 30 days after discharge (T)?

Systematic Review

A search for the relevant articles was conducted in both the PubMed and Cochrane databases to identify the list of eligible pieces that could be utilized to provide adequate information on the area under investigation. The inclusion criteria involved the use of articles that had specific keywords. The keywords that were to be used included “video-based instructions”, “written or oral based discharge instructions”, “congestive heart failure”, “readmission”, and “30 days”. The search was previously restricted to the use of articles based on the site. The inclusion criteria in PubMed resulted in 104 articles while from the Cochrane database 63 articles were chosen. The search was restricted to the use of specific articles that had been published in the last five years. All the articles matching the above inclusion criteria were collected and saved in a database. The abstracts of all articles were then read to determine if the paper discussed the topic under investigation. All the articles that were off the required topic were excluded from the list. This substantially reduced the number of articles that were examined in the end. Since the number of articles utilized had substantially decreased, it was necessary to include other articles that might have been missed and contain relevant information when investigating the aforementioned variables. Articles within fifteen years of the study were included with specific information covering the comparison of both video based and written or oral instructions. Most articles collected were mainly randomized controlled trials and systematic reviews as they contained higher levels of information compared to other articles. This was to ensure that information collected largely came from valid sources and could maily be reliable.

Most of the articles revealed that patient discharge information had a fundamental role in the readmission process. Ideally, if patients understood the type of information that was provided during their discharge, they would more likely follow the information provided and reduce the issues to readmission of the disease condition (Jingbo & Guangwei, 2014). In addition, several articles noted that there were specific guidelines to be followed in each of the discharge plans. Some utilized a checklist to ensure that the patient understood all the necessary components that were supposed to be followed to the latter (Showalter, Rafferty, Swallow, DaSilva, & Chuang, 2011). This checklist was critical as it outlined how different regimen had to be applied. The oral information was also utilized though the instructions provided were simple, clear, and elaborate. The age is considered as one of the main predisposing factors associated with CHF (Eapen et al., 2013; Showalter et al., 2011). Older uneducated people preferred a different form of instruction, and, in most cases, family members decided to engage themselves in providing specific information on how the management of the disease condition will be effected. In cases where telehealth practices have been utilized to monitor the condition, the outcomes have been positive indicating that the technology could be utilized to reduce instances of readmission (Jingbo & Guangwei, 2014; Morrow, Weiner, Steinley, Young, & Murray, 2007). In one unpublished study comparing the effectiveness of the two methods, the results indicated that the video-based instruction with the use of tablets, for example, was preferred compared to the use of written or oral instructions that have been provided by the medical practitioner (Annema, Luttik, & Jaarsma, 2009; Lee, Yang, Hernandez, Steimle, & Go, 2016; Showalter et al., 2011). The rates were even higher in cases where the sampled population was mostly uneducated. Most papers indicated that the use of videos was preferred because it provides the illustrative visual effect and does not require the use of more information as compared to other methods such as oral based instructions that were easily forgotten and written based instructions that were largely based on an educational level.

Determination of Quantitative Articles

Quantitative articles contain relevant information relating to the collection of information based on measurable characteristics. Most articles contained the above information, though there were specific papers that presented the use of the difference between two diverse methods of patient discharge. The measurable variables or characteristics in these cases were primarily based on testing self-education and, more specifically, the perception of patients diagnosed with CHF on the efficient method that could be utilized to reduce readmissions among the patients. The two methods under investigation were the video-based instruction strategies and the oral or written instruction used for reducing readmission cases of chronic heart failure.

Summary of Article

The article was a randomized controlled trial that was conducted in the year 2006 and later presented in one of the conferences that sought to outline the effect of patient education on the reducing the readmission of cases associated with congestive heart failure. The study took place in a hospital setting. The study searched for filling a gap that existed in literature and helping to bridge the difference that could reduce the number of cases associated with congestive heart failure. However, the limited research had been conducted on the use of videos in reducing the incidences of readmission in clinical settings. The study involved a total of 36 patients diagnosed with congestive heart failure (Laramee, 2006). The patients were provided with either written based or video based instructions that were to be followed to the latter. Before the patients were discharged, they were required to fill in a form based on the instructions that they had been provided during the course of the study. Health literacy levels were measured through the use of specific tests while the discharge information test were based on the utilization of existent test such as the Dutch Heart Failure Knowledge Scale (Laramee, 2006). The results indicated that there were no significant differences between the two groups though there were several variables that could help to explain the outcome of the results. Nonetheless, the use of the video was indicated to have a better effect compared to the use of written based instructions, especially in cases where the time span was moved from the 30 days to 60 days (Laramee, 2006). The study further recommended that more research be done on the application of video discharge instructions on extended readmission periods.

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Study Approach, Sample Size, and Population

A randomized controlled pilot research was conducted to examine whether thevideo discharge instruction or the written instructions can be used to reduce cases of readmissions and ultimately decrease cases of congestive heart failure. This method involved the collection of information from the patients who had previously been diagnosed with such a disease. The two variables under investigation were video based instructions and written discharge instructions. The participants of the study were randomly selected before being allowed to participate All those involved in the study were educated on what was supposed to be done to avoid instances of readmission within their hospital based setting. One group was confined to the use of written based instructions while another group was obliged to use video-based instructions (Laramee, 2006). At the end of the study, the participants were supposed to provide knowledge on discharge information and, more specifically, on discharge instructions. The total number of participants selected in the study were 36, and the methods used were probability sampling and random sampling. The inclusion criteria required individuals under investigation to have been diagnosed with congestive heart failure. In addition, the groups were classified based on the age to eliminate the effects of confounding variables in the study. The above study was referred to as a pilot one, that means that it is conducted on a specifically limited population before it can be utilized in a larger population sample.

Evidence Application

The information collected was further supported by evidence present in some of the articles collected in the review section. According to Bradley et al. (2013), hospital readmission, especially in the pretext of conditions such as congestive heart failure, was mostly determined by a number of factors, with discharge instruction being mentioned as one of the critical factors. Instructions provided to patients during their discharge sessions were identified as the key to the reduction of readmission cases, especially if the information was understood by the patients. The findings also identified other factors associated with the readmission of patients in clinical settings. According to Regalbuto, Maurer, Chapel, Mendez, & Shaffer (2014), the Joint Commission on Accreditation of Health Care Organizations (JC) required that all hospital settings across the country apply specific discharge instructions that addressed particular information that related to management of congestive heart failure in cases where patients were to manage the disease condition from their homes. The different aspects included diet, weight monitoring, follow-up appointments, medication, and exercise. Patients who understood the discharge instructions were less likely to be readmitted in the clinical settings compared to patients who did not understand the provided information. This study served to support the findings indicating the important role that patient discharge instructions played in the reduction of readmission cases. Lee, Yang, Hernandez, Steimle, & Go (2016) noted that readmission of patients suffering from congestive heart failure is determined by a number of factors including aspects such as post-discharge instructions. Patients who continuously receive this information are more likely to utilize it in the management of the disease condition compared to patients who fail to understand post-discharge instructions. Some of the key aspects of post-discharge instructions that are considered critical to any setting include aspects such as taking medication, identification of symptoms associated with the disease condition, the ways of managing the condition before visiting various clinical settings, actions in cases where there is any form of an attack, and observing diet and other instructions related to the management of congestive heart failure. According to Annema, Luttik, & Jaarsma (2009), there are several different reasons why there are higher readmission rates in cases associated with congestive heart failure. Some of the causes are related to the patient`s failure to understand discharge instruction. This implies that the patient fails to follow the required procedure set in the management of the disease and, as a consequence, the patient is more likely not to adhere to the required instructions. This would largely increase the number of readmissions of cases related to congestive heart failure. According to Jingbo & Guangwei (2014), non-adherence of medical instruction is one of the factors mentioned to increase the number of readmission cases associated with congestive heart failure. This study was conducted to investigate reasons associated with readmissions of congestive heart failure in many clinical settings across the United States.

Outcomes, Reliability, and Validity

The results of the study indicated that video-based instructions were more effective compared to the written based or oral based instructions. The use of visual representation in the case of video instructions might have played an important role in increasing patients` levels of understanding compared to the use of oral based instructions that can be easily forgotten. It is imperative to note that though the use of patient-based information remained the most preferred method that was utilized to pass discharge information, the results were still insignificant since the differences between the two variables were not quite substantial. The results were also based on a 30 day readmission period, though similar results were indicated for the period of 2 months.

Reliability refers to the use of research methods that can be replicated across various settings and closer results deal with the once indicated in the above areas. In most cases, it focuses on the manner the study was conducted and, more specifically, the methodology that was applied in a specific study. In the above case, the methodology involved the collection of information through the use of random sampling that is considered to be an elaborate method of collecting information and minimizing biases in the outcome. The method also categorized the sample population on the age and other demographic attributes such as gender with the main aim of reducing the effects of confounding variables. These variables have been indicated to affect the dependent and independent variables in most studies indirectly. By ensuring that both of the aforementioned variables were examined without the effects of the other variables, the examined results were largely true and based on scientific principles. The methods utilized in the above study were, therefore, considered to be valid and within the domains of the scientific research.

Validity remains the important criterion utilized in defining the quality of tests. It is used to measure the closeness of the results to the test measure. In the above case, the method applied to compare the effectiveness of the two methods was considered elaborate and within the scientific measures defining the validity in the experimental research. First, the sampled population was enough to conduct a variance study between the two specific variables. The population under investigation was greater than thirty meaning that it could be analyzed and utilized to provide information about the specific population. In essence, when the number of participants is greater than thirty it can be used to represent the particular group. In this case, the sampled population consisted of 36 participants. The use of random sampling completely eliminated any form of biases that existed between the different variables. In addition, the data collection method utilized was based on the use of the valid and proven method. Ideally, the test that were given to the participants had been tested in different settings and utilized in the past in conducting trials that contain similar information. In addition, the data analysis method utilized was based on examining the relationship and the difference between the various variables. The chi-square test is identified as one of the tests that indicated the difference between the two variables. Therefore, the above method utilized can be considered valid.

Bias

Biases in the study are based on focusing on some tendency to prefer specific attributes of the populace. In the above case study, there are different methods that have been utilized to eliminate biases. The first method is the use of randomized controlled trials where the participants who took part in the study were randomly selected rather than being chosen on the basis of another method such as convenience sampling. Random sampling ensures that all the participants who wanted to take part in the study had an equal chance to be involved. In this case, the exclusion criteria utilized required all individuals participating in the study to be diagnosed with congestive heart failure. Data was also classified based on demographics to reduce the effects of confounding variables and other masking effects that could have allowed the occurance of biases. In essence, the study ensured that no information regarding methodology allowed for any form of biases. Nonetheless, the variables under investigation including the use of specific discharge methods could have been tested because they depend on various variables. For example, written instructions were largely based on the educational levels of individuals. This seemed to be a factor that could have promoted some form of biases to the results of the study.

Level of Evidence

The hierarchy of scientific evidence places the use of systematic reviews and meta-analysis on top of other forms of scientific methods. This method is then closely followed by the use of randomized controlled trials prior to the other methods such as case studies, descriptive studies, and cohort studies. In the above case, the study was based on randomized controlled trials meaning that the level of evidence was accepted. In the earlier sections, most of the articles utilized included those based on systematic reviews and meta-analysis as well as randomized controlled trials. The cohort and descriptive studies were also utilized to collect information regarding the above mentioned area.

Conclusion

The above study sought to answer the PIQOT question related to the CHF patients discharged from the medical settings based on video discharge instructions. These instructions were compared to simple written and verbal instructions and their effect on outcomes regarding re-admissions within 30 days after discharge were also investigated. The information collected from the randomized controlled pilot study indicated that the use of video-based instruction was a better method of reducing readmission cases as more patients were able to understand the information provided. The study was within the confines of the scientific research with certain aspects related to the validity and the reliability being within the specific confines. The study also limited the effects of biases that have been mentioned to affect the scientific research. Confounding variables were limited to the paper. The above paper also had a high level of evidence as it was classified primarily under randomized controlled trials and only then according to systematic reviews and meta-analysis.