Evidence-Based Clinical Question Search Assignment

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Evidence based clinical question

Heart failure morbidity and mortality rates in the world have been on the rise. In the United States alone, it affects approximately 5. 1 million people and, at the same time, accounts for more than 1 million hospitalizations. It is estimated that $32 billion have been utilized in the management of diseases in the country. Within the United States, heart failure remains one of the conditions in the United States with high rates of readmissions meaning that increased costs associated with the above condition are likely to increase in this yearly budget. The health sector in the United States and other countries have utilized different approaches in an attempt to reduce readmission cases. Some approaches commonly utilized include proper and adequate care of the patient within the clinical setting ensuring that the patient receives the required care and is only discharged when the disease condition has been fully managed. Other approaches have focused on the use of home-based care in reducing readmission rates. The discharge instructions across various settings have been utilized to decrease readmission cases. Two common methods that have been applied are based on the use of video-based discharge instructions and the use of oral or written instructions. The two methods have different efficacy levels. Evidence-based research could provide information on the effectiveness of the two methods and, as a result, in the readmission cases. Thus, in CHF patients discharged from the hospital (P), how does video discharge instructions (I) compared to just written and verbal discharge instructions (C) affect patient outcomes regarding readmissions to the hospital (O) within 30 days after discharge (T)?

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Systematic Review

A systematic review identified all relevant articles that could provide requisite information regarding the subject under investigation. In this case, information was searched across specific databases including the Cochrane Database and Pubmed. The inclusion criteria focused on articles that had relevant information relating to any form of video based discharge instructions including the use of telehealth services, those containing readmission of the patient in 30 days, and congestive heart failure. The search was limited to randomized controlled trials in the past ten years. Cochrane Databases revealed a total of 23 articles while Pubmed provided a total of 34 articles. All these articles were saved in a reference manager. Abstract information from the mentioned articles was then evaluated to ensure that the articles contained the required information relating to the PICOT question. Consequently, nly relevant articles selected. This reduced the number of articles to only ten. Data was searched from the remaining unpublished databases such as Google Scholar to ensure that there was no bias in the selection of the article to be utilized in analyzing the above PICOT information. One article was then selected from the remaining three articles since it had recently updated information on the use of video-based instructions in clinical settings. The article was published in 2004 and had relevant information relating to the topic under investigation.

Literature Summary

According to Bradley et al. (2013), the rates at which patients are readmitted in any clinical setting are dependent on several factors. Adherence to discharge information is mentioned as one of the factors. However, this is affected by a number of factors including the educational level of the patient and the type of discharge information. Written instructions are considered essential and would be preferred by patients with high educational levels. Video based instructions are preferred by both educated and illiterate patients because they provide visual instructions on how discharge instructions should be followed. According to Regalbuto, Maurer, Chapel, Mendez, & Shaffer (2014), standard bodies such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) indicated that it was important for hospital settings to provide discharge information to patient using a method that is simple and could be applied in their specific home settings. Elaborate discharge instructions were to be provided on aspects related to the management of heart failure including weight monitoring, diet, medication, exercise, and follow-up appointments. The findings showed that patients who understood the information provided on how they were supposed to manage the disease condition deal with it in a better manner. This showed the importance of adhering to patient discharge information. Lee, Yang, Hernandez, Steimle, & Go (2016) state that the rate of readmission is largely based on numerous aspects including the quality of treatment provided to the patient, and follow-up of post-charge information. Healthcare providers who permanently check whether the patients adhered to all standards indicate fewer readmission cases compared to cases where healthcare providers were never involved in the management of disease conditions. Patients who followed the discharge information were less likely to be readmitted in the clinical setting because the information provided is requisite in controlling the effects of the aforementioned condition in any setting. In essence, it meant that they could apply postdischarge information relating to the following treatment regiment medications, dietary plans, and consulting their healthcare providers in case of any associated new symptom that was not indicated during their prognosis. All of the above aspects are critical in dealing with the management of heart failure.

Annema, Luttik, and Jaarsma (2009) provide specific reasons why there are high readmissions cases in heart failure patients. One basic reason is the inability of individuals to understand post-discharge instructions provided by the medical practitioners. Ideally, most patients across various clinical settings adhere to the provided prescriptions and, as a consequence, decrease the risk of elevating the disease condition, which ultimately results in readmission in clinical settings.

Jingbo and Guangwei (2014) indicate that non-adherence of patients to the provided medical instruction remains one of the major factors related to high readmission rates. In most cases, patients either failed to stick to the required treatment regimen by not taking the drugs or stopped taking any form of medication once they felt better. This information was provided by a study conducted in the United States that investigated the high readmission rates of the patients in clinical settings. The study showed that the mode of discharge instructions had an effect on the patient`s outcome. Video based instructions were indicated to be a better method for discharge instructions compared to the use of written or oral information. The paper recommended that most clinical setting should invest their resources in providing video based instructions since few settings adopted this form of instructions to patients. Most hospitals utilized oral and written based instructions and, at the same time, ignored any form of the follow-up method. Desai and Stevenson (2012) note that the discharge information can be used to improve services provided in the healthcare settings to make the patients understand the information that has been passed through this mode. The writers stated that clinical settings that utilized video based instructions were more likely to have fewer cases of readmissions compared to written or oral based instructions. However, the rates differed slightly and did not indicate that the use of written based method was not effective in the management of different conditions. Most articles report that patient discharge instructions had a direct role in determining the number of patients that were going to be readmitted in any clinical setting (O’Connor et al., 2016; Retrum et al., 2013). Some articles advocated for the use of a patient checklist to ensure that patients understood all information that had been provided through any form of writing; thus, other factors such as age were also supposed to be considered (Eapen et al., 2013). Age and the use of technology were also mentioned as some of the important components that need to be regarded before providing any form of discharge information (Corotto, McCarey, Adams, Khazanie, & Whellan, 2013; Dharmarajan et al., 2013).

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Determination of Quantitative Articles

Quantitative articles contain information based on a measurable quantity. It is largely based on the rational scale in the levels of measurements as compared to qualitative studies that are based on ordinal and normative measurement levels. Most of the articles above contained qualitative information and, therefore, could not be analyzed. Randomized controlled trials contain relevant information that has been collected in a quantitative manner since it bases its research on experimental studies. These studies attempt to measure specific variables and show the relations between all variables under investigation. In the above case, one quantitative article was selected. The article under invetsigation is “A Remote Monitoring and Telephone Nurse Coaching Intervention to Reduce Readmissions among Patients with Heart Failure: Study Protocol for the Better Effectiveness after Transition-Heart Failure (BEAT-HF) Randomized Controlled Trial”. The article was based on a randomized controlled trial in 2014 and sought to investigate information relation to the use of video-based instruction in discharging patients across various settings and its relation to readmission levels. The disease under investigation was heart failure.

Summary of Article

The given article provides information on a randomized controlled trial, which was utilized to investigate the effects of telemonitoring in managing a chronic condition such as heart failure. The objective of the study was to compare the effectiveness of two methods commonly used in managing a chronic condition (Black et al., 2014). The two investigated methods include the use of pre-discharge information or education on heart failure and the use of telephone nurse coaching after discharging patients. This method was to be combined with home telemonitoring of aspects such as weight, blood pressure, heart rate, and all common causes associated with the readmission of patients in a clinical setting within a period of six months. The sample population, in this case, was older patients diagnosed with heart failure. The study was conducted in six different healthcare settings.

Study Approach, Sample Size, and Population

The prospective study was to be conducted in the form of a two-arm randomized controlled trial across six different healthcare settings in California. It sought to compare the effectiveness of telehealth-based services as a transition intervention on older patients discharged from clinical setting. The study enrolled a total of 1500 patients. These patients had not been discharged from their clinical settings. The half of the sampled population was educated by the nurses while another was to undergo some form of telemonitoring intervention. Stratification was utilized as the main sampling method in classifying patients into the two different settings. The final design of the study had been based on randomizing the sampled population into three different categories including those who followed the telephones based help coaching method, the Tele-Hf method, and the concurrent controls before it was designed to fit the design described above. A change in design suggests that the above study was not adequately planned. In addition, the authors of the paper do not provide information on why they had to redesign the study to conform to the one defined above.

The study sample population was 1500 participants. These participants were selected randomly from their respective six healthcare facilities. Randomisation ensures that the bias is eliminated from the study. In addition , the specific exclusion criteria was utilized to identify patients who were to undergo the study. This ensured that only patients with specific variables were admitted to the study and reduced the effects of external factors from interfering with the results of the study. The patients were sampled from various populations in the process allowing for randomisation, which has been indicated to play an important role in reducing the bias. The inclusion criteria were specific requiring individuals to be above 50 years, actively treated for heart failure, and to have the ability to speak specific languages. In addition, exclusion criteria for all participants in the study were defined. A population of 31,500 were to be screened and, utilizing the inclusion and exclusion criteria, a sample of 1500 was received. In essence, the sample population utilized in the above case was above 30 and randomized meaning that it could adequately represent the population that was selected. Several assumptions have also been calculated in the sample response rate though the actual study has not been conducted and the numbers may rise depending on the nature of participants who have been recruited in the study. Patients who had refused to be the part of the study can also be readmitted. This affects the principle of randomization of the results and also increases the probability of having outliers.

Evidence Application

The information collected from the above study will indicate the effectiveness of different approaches in reducing the cases of readmissions among patients suffering from deseases in the clinical settings. Considering that the above paper focuses on comparing the effects of educating and telemonitoring patients after their discharg from clinical settings and monitoring their levels of readmission after 7, 30, and 180 days, the study may provide essential information on the effectiveness of the two approaches. The use of telemonitoring applications will be classified as video based instrutions. It is important to mention that the results of the above study have not been indicated and, therefore, the best method among the two cannot be determined or concluded.

Outcomes, Reliability, and Validity

The study does not provide information about the outcome of the study indicating that it has probably not been conducted. Therefore, although the two compared methods have been described fully, the results of the study are missing, and, thus, no information can be concluded from the study. However, the researchers have predicted some of the outcomes that are expected in the different settings and, at the same time. provided information on why they support some of the expected views. This approach ensures that researchers only stick to specific methods of data analysis and may not consider some factors in specific conditions. In addition, some outcomes that might have been predicted and indentified under investigation could also appear in a different manner that is not anticipated by the researchers.

Reliability referred to the ability of another study being done using the provided methodology and similar conclusions or results that do not substantially differ from the analysis of the above article. Although the above-named study is quite elaborate with the specific exclusion and inclusion criteria that are the key in understanding the methodology of the above study, there are specific elements that are not reliable. First, the study allows for the reintroduction of participants who had already been deemed to quite from the study. In case the number of these participants is high, there will be an increase in the number of outliers in the study, and this would significantly affect the data collected from the participants since not all of them would have been subjected to the same treatment. Aspects that have been adequately addressed include the way information will be collected and the randomisation of all participants in the study. In addition, the study has identified its challenges and strengths making it easier to address issues that may arise during the study. However, the assumption determined by the researcher based on the response rate is wrong since the study has not been conducted.

The validity of any test defines the criteria used in conducting tests within the study. It defines the closeness of information collected in the study to the test measure. In this case, several important aspects were adhered to while conducting the above study. The first aspect was the use of the appropriate population and the huge sample size. The higher the sample size in any study is, the less number of an outlier and the more valid results are obtained. The study had indicated the specific control methods that are to be used to differentiate between the two interventions and the criteria that were utilized in selecting the sampled population. In addition, randomization of the sample population ensures that internal validity of the results is controlled. However, the study has not addressed confounding variables such as the effect of education levelss and previous experiences of the sampled population considering that some of the participants in the study are more likely to have an advantage over the others, and, in the process, it may affect the information collected at the end of the study.


Bias was reduced in the above study by ensuring that randomisation was utilized as the only approach in selecting the patients that were supposed to take part. Randomisation of the sampled population eliminates the bias since the researchers do not have the right to be biased in the selection of the sampled population. Nonetheless, the reintroduction of participants who had taken part in the study is based on no specific criteria that allow to do this. Since the researchers did not provide information on the exact method to be utilized in mediating the effects associated with confounding factors, there is an increased probability that this may affect the results.

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Level of Evidence

The above articles are based on randomized controlled trials. This level is classified just after the systematic levels and, therefore, it means that it is the second level in the hierarchy. Randomized controlled trials are commonly found in systematic reviews and meta-analysis. Ideally, information found in the randomized controlled trials is valid and reliable in the research.


Readmission of patients in clinical settings remains one of the major issues that affect the quality of health care services in any setting. Discharge information has been indicated to play a role in mediating some of the effects associated with readmission. The two most common methods that have been utilized include the use of video and written written based instruction. Evidence-based studies have been used in collecting this information. Critical analysis of the above article shows whether the information collected is credible, valid, and reliable so that it can be utilized as a background for many other studies. It addresses other aspects such as biases in studies and examines the effect of the article based on the level of evidence. This study shows that the above article was a randomized controlled trial, which is highly reliable and valid. However, the article under investigation has various issues that need to be addressed.

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