Please ensure that the Discussion includes more than 400 words with scholarly articles, and the plagiarism level must remain below 20%.
MSN5300: Advanced Nursing Inquiry, Research, and Evidence-Based Practice
Section:__________
Team:____________
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Critical Appraisal Worksheet for Individual Project 2, Part b |
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Elements of Appraisal |
Discussion |
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Study Design |
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Was the study a qualitative or quantitative design? Explain. |
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Practice Problem |
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State the practice problem/issue that is the focus of the study. How does this practice problem/issue affect your nursing practice? |
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Study Purpose |
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State the purpose of the study. Discuss whether this study was feasible to conduct in terms of money commitment; the researchers' expertise; availability of subjects, and ethical considerations. |
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Review of Literature |
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Was the literature review organized to show the progressive development of evidence from previous research? Was a clear, concise summary presented of the current empirical and theoretical knowledge in the area of the study? Did the literature review summary identify what was known and not known about the research problem? Did it logically direct the research purpose? |
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Theoretical Framework |
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Is a conceptual model or theoretical framework used? If so, is it presented with clarity? Does it adequately explain the phenomenon of concern? Is the framework linked to the research purpose? If not, would another framework fit more logically with the study? If a proposition or relationship from a theory is to be tested, is the proposition clearly identified and linked to the study hypothesis? |
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Research Question(s) and Hpothesis(es) |
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What is the research question? Is it clearly stated? Does the research question match the purpose of the study? What is the research hypothesis? Is it clearly stated? Does the hypothesis match the purpose of the study? Formulate a null hypothesis for this study. Were the objectives, questions, or hypotheses logically linked to the concepts and relationships (propositions) in the framework? Explain. |
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Variables |
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List all research variables with corresponding levels of measurement on the NOIR scale. Do variables represent the concepts identified in the framework? How is each study variable defined (both conceptually and operationally)? Are conceptual definitions of variables consistent with operational definitions? |
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Study Design |
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What was the design was used in the study? Was it the most appropriate design to answer the study question? Explain. Was the design logically linked to the sampling method and statistical analyses? Did the design provide a means to examine all objectives, questions, or hypotheses? If there was an intervention (treatment) in the study: · what was the intervention? was it clearly described? · was the treatment appropriate for examining the study purpose and hypotheses? · did the study framework explain the links between the treatment (independent variable) and the proposed outcomes (dependent variables)? · were subjects randomly assigned to the treatment group, or were the treatment and comparison groups dependent? · were the treatment and comparison group assignments appropriate for the purpose of the study? · was a protocol developed to promote consistent implementation of the treatment to ensure intervention fidelity? · did the researcher monitor implementation of the treatment to ensure consistency? How might this impact findings? |
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Study Sample |
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Were any subjects excluded from the study because of age, socioeconomic status, or ethnicity? If so, explain. Was sound rationale provided? Did the sample include an understudied or vulnerable population, such as young, elderly, pregnant, or minority subjects? What sampling criteria (inclusion and exclusion) were used? Was sampling criteria appropriate for the type of study conducted? Explain. Were the rights of human subjects protected? Explain. Was the refusal rate for the study provided? If so: · was it greater than 20%? · how might this have affected the representativeness of the sample? · did the researchers provide rationale for the refusals? Was the attrition rate for the study provided? If so: – what was it? – did the researchers provide a rationale for the attrition of study participants? – how did attrition influence the final sample as well as study results and findings? How large is the sample? How was sample size determined? |
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Research Instruments |
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Did the measurement methods selected for the study adequately measure the study variables? What instruments or tools were used to collect data? How did you determine if the instruments are valid? reliable? Respond to the following questions that are relevant to the measurement approaches used in the study: 1. Scales and questionnaires (a) Were the instruments clearly described? (b) Were techniques for completion and scoring of the instruments provided? (c) Were validity and reliability of the instruments described? (d) Did the researcher reexamine the validity and reliability of instruments for the present sample? (e) If an instrument was developed for the study, was the instrument development process described? 2. Observation (a) Were phenomenon that were to be observed clearly identified and defined? (b) Was interrater reliability described? (c) Were techniques for recording observations described? 3. Interviews (a) Did interview questions address concerns expressed in the research problem? (b) Were interview questions relevant for the research purpose and objectives, questions, or hypotheses? (c) Did the design of the questions tend to bias subjects' responses? (d) Did the sequence of questions tend to bias subjects' responses? 4. Physiological measures (a) Were physiological measures clearly described? If appropriate, are brand names (ex., Hewlett-Packard) of instruments identified? (b) Were accuracy, precision, and error of physiological instruments discussed? (c) Were physiological measures appropriate for the research purpose and objectives, questions, or hypotheses? (d) Were methods for recording data from physiological measures clearly described? Was recording of data consistent? |
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Data Collection |
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State the data collection procedures. How often were data collected and for how long? Was the data collection process conducted in a consistent manner? Did any adverse events occur during data collection? If adverse events did occur, how were they managed? |
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Data Analysis |
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Were data analysis procedures clearly described? What statistical tests were used to analyze data? Were statistical tests suitable to the types of data collected/levels of measurement? Explain. What assumptions in the data must be met for the type of statistical tests used? How do you know if these assumptions were met? Were data analysis procedures clearly described? Did the researcher address any problems with missing data and if so, how was this problem managed? Were data analysis techniques consistent with the study purpose research objectives, questions, and/or hypotheses? Explain. Were data logically organized/presented in tables, graphs and/or charts? Describe. What was the alpha for each statistical test? Describe how statistical significance was demonstrated (or not) for each variable. |
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Study Results and Interpretation |
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Were study results statistically significant? How did you determine statistical significance? What is your statistical interpretation of study results? Were findings discussed in relation to each objective, question, or hypothesis? In other words, was the research question/hypothesis answered? Describe. Were study findings clinically significant? If so: · discuss implications of the study for nursing practice. · what changes could you make in your practice based on the results of this study? What were the study conclusions? Did conclusions fit the results from the data analyses? Were the conclusions based on statistically significant and clinically important results? Explain. Were study limitations described? Discuss. Do you think the study had weaknesses not identified by the researcher? If so, explain. Did the researcher generalize the findings appropriately? Who will benefit from results of the study? Discuss. Were there any unexpected findings? Discuss. |
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Recommendations for Future Research |
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Discuss study recommendations. Is need for further research identified? |
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Study Rigor |
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Discuss elements of rigor based on study design. In your opinion, did the researchers address these aspects adequately in the published report? Why or why not? How does rigor impact study results? |
Adapted from: Gray, J.R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s The practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St.
Louis: Elsevier.
MSN5300 Rev. 1.2020
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ORIGINAL RESEARCH
Differences in Hypertension Medication Prescribing for Black Americans and Their Association with Hypertension Outcomes
Hunter K. Holt, MD, MAS, Ginny Gildengorin, PhD, Leah Karliner, MD, MAS, Valy Fontil, MD, MAS, MPH, Rajiv Pramanik, MD, and Michael B. Potter, MD
Background: National guidelines recommend different pharmacologic management of hypertension (HTN) without comorbidities for Black/African Americans (BAA) compared with non-BAA. We sought to 1) identify if these recommendations have influenced prescription patterns in BAA and 2) identify the differences in uncontrolled HTN in BAA on different antihypertensive medications.
Methods: We constructed a linked retrospective observational cohort using 2 years of electronic health records data, comprising of patients aged 18 to 85 with HTN on 1- or 2-drug regimens, includ- ing angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), thiazide diu- retics, or calcium channel blockers (CCB). We examined prescribing differences and HTN control in BAA versus non-BAA.
Results: Among 10,875 patients identified, 20.6% were identified as BAA. 46.4% of BAA had uncon- trolled HTN (≥140/90 mmHg) compared with 39.0% of non-BAA (P< .001). 61.8% of BAA were treated with 1-drug compared with 68.4% of non-BAA. Of BAA on monotherapy: 41.3% were on thiazide, 40.1% on CCB, and 18.6% on ACE/ARB. Of non-BAA on monotherapy, 27.7% were on thiazide, 30.1% were on CCB, and 42.3% were on ACE/ARB. Of BAA patients on 1 drug, 45.2% had uncontrolled HTN compared with 38.0% of non-BAA (P< .001). Of BAA on 2 drugs, 48.2% had uncontrolled HTN compared with 41.1% non-BAA (P< .001). For each drug regimen, there was more variation in HTN control within each group than between BAA and non-BAA.
Conclusions: Providers seem to be following race-based guidelines for HTN, yet HTN control for BAA remains worse than non-BAA. An individualized approach to HTN therapy for all patients may be more important than race-based guidelines. ( J Am Board Fam Med 2022;35:26–34.)
Keywords: Health Equity, Hypertension, Precision Medicine, Prescriptions, Primary Health Care,
Retrospective Studies
Background Race-based guidelines for medical care have recently become controversial.1–7 Skin color is increasingly
recognized as a poor proxy for precision medicine, and many have highlighted the potential harms of using race as a factor in clinical decision-making.4,7–10
For example, well-intentioned medical organizations, relying on data from clinical trials, have long recom- mended different standards for interpreting kidney and pulmonary function testing for Black/African
This article was externally peer reviewed. Submitted 6 July 2021; revised 24 August 2021; accepted
25 August 2021. From the Department of Family and Community Medicine
at the University of Illinois at Chicago (HKH); Department of Family and Community Medicine, University of California San Francisco (MBP); Division of General Internal Medicine, Department of Medicine, University of California San Francisco (GG, LK, VF); Multiethnic Health Equity Research Center, University of California San Francisco (LK, VF); UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA (VF); Contra Costa Health Services, San Francisco, CA (RP).
Funding: This research was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (UL1 TR001872). JKH was supported
by the National Research Service Award (NRSA) grant (T32HP19025).
Conflict of interest: The authors declare that they have no conflicts of interest.
Availability of data and materials: The study protocol, raw data, and/or programing code supporting the conclusions of this article are available from the corresponding author on reasonable request.
Corresponding author: Michael B. Potter, MD, University of California, San Francisco 505 Parnassus Ave, San Francisco, CA 94143; Phone: 415-476-1000 (E-mail: [email protected]).
26 JABFM January–February 2022 Vol. 35 No. 1 http://www.jabfm.org
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Americans (BAA) compared with others, even as many have suggested that relying on such guidelines may lead to delayed diagnosis and treatment for BAA populations. 2,6,11–14 In this context, it may be valua- ble to reevaluate widely accepted race-based guide- lines for managing hypertension (HTN) in BAA.15
The Eighth Joint National Committee in 2014 (JNC8), the American College of Cardiology/ American Heart Association in 2017 (ACA/AHA), and European Society of Cardiology 2018 guidelines all recommend a unique approach to initial therapy for BAA, stating that individuals in this group without comorbidities should receive either a thiazide diuretic or a calcium channel blocker (CCB) as initial therapy, whereas angiotensin-converting enzyme inhibitors (ACE) and/or angiotensin receptor blockers (ARB) should be considered as initial therapy only for BAA with certain comorbidities while non-BAA individuals can be prescribed any of those 3 classes of medicines regardless of comorbidities.16–18 These guidelines ech- oed sentiments in the International Society on Hypertension in Blacks (ISHB) consensus statement in 2010 that recommended that first-line treatment consist of a thiazide diuretic or CCB over an ACE/ ARB in BAA populations, but not other populations.19
Race-based HTN treatment guidelines have been based on evidence from clinical trials and intended to rectify disparities in HTN control in BAA popula- tions.20,21 However, the interpretation of this evi- dence has come under scrutiny.15 JNC8 and ACA/ AHA recommendations are based on results from the Anti-HTN and Lipid-Lowering treatment to Prevent Heart Attack Trial (ALLHAT) and the African American Study of Kidney Disease and Hypertension study (AASK). ALLHAT found in the primary outcome of coronary heart disease there was no difference for BAA when using thiazide, CCB, or ACE. While based on a prespecified secondary out- come of strokes, there was a significant benefit from using CCB/thiazide medications compared with ACE for BAA. However, this finding has been chal- lenged, as the treatment regimen for patients on ACE included a b blocker, which is no longer con- sidered an appropriate regimen for any patient with HTN and no other comorbidities.15,22 The AASK Trial evaluated BAA populations with chronic kidney disease and the effects of medications in those popu- lations. While ACE was not as effective at lowering blood pressure (BP) in BAA, it was found that they did prevent the progression of kidney disease.23 It has been pointed out that avoiding ACE to treat
BAA with uncomplicated HTN could lead to worse outcomes for those whose progression of kidney dis- ease is not immediately recognized in primary care.15,24
Given the current concerns about health equity in the United States, we must examine whether and how race-based guidelines for HTN treatment have influenced the practice patterns of primary care clinicians and whether there is evidence of a beneficial impact from following such guidelines on clinical outcomes for BAA with HTN. In this study, our objective was to evaluate electronic health re- cord (EHR) data to identify if these race-based guidelines have influenced health care provider pre- scribing practices in BAA groups and evaluate the HTN control for BAA and non-BAA patients with uncomplicated HTN who were prescribed 1 or 2 drugs. We additionally examined predictors of uncontrolled HTN among BAA patients.
Methods Study Design
This study is a retrospective, observational cohort analysis using 2 years of linked EHR data from 3 health systems affiliated with the San Francisco Bay Collaborative Research Network (sfbaycrn.org). The 3 health systems were comprised of 1 academic and 2 county-run systems with a total of 31 primary care clinics. The study included all patients aged 18 to 85 years at the beginning of the study period with a hypertension diagnosis and at least 1 primary care provider care visit between October 15, 2013, and October 14, 2015, for 2 of the 3 health systems, and between May 1, 2014, and April 30, 2016, for the third health system. These 2-year periods were different due to local constraints and Health System 1 to pull data retrospectively to match the dates from the other 2 health systems. All the data were collected using a 1-time extraction of EHR data. HTN diagnosis in each was defined using the Ninth International Classification of Disease visit diagnosis codes 401 and 405 during the study pe- riod or a problem list diagnosis indicating “hyper- tension.&#