Home

Welcome

What is EBP?

ASK
Clinical Question

ACQUIRE
Literature Search

APPRAISE
Evaluate Evidence

Test
Your Knowledge

Glossary (CEBM)

References

Feedback

Testing Your Knowledge

Case 3: Nursing staff and Cardiac Surgery Patients

This is a self-correcting exercise. Click on Answer for a pop-up box with the response.

Note: If you do not see a pop-up box, check your pop-up blocker settings in the browser. If that is not the problem, try closing the previous pop-up box or check to see if the pop-up box is behind your browser window.  If you still do not see the pop-up box, you may need to update your browser.

ASSESS
the patient

1. Start with the patient -- a clinical problem or question arises out of the care of the patient

The setting is a large community hospital.  The transition from discharge to home is a high-risk period for patients.  This is a time when patients experience complications and adverse drug effects, often many weeks before they can access their primary care provider.  As the Assistant Head nurse, you have been assigned to a process improvement group looking at ways to increase medication compliance and decrease adverse events and hospitalizations for these patients. 

In talking to your colleagues in other units, you find out that the hospital has recently purchased an interactive voice response (IVR) system for reminding patients about upcoming appointments.  You think this might be helpful in tracking cardiac surgical patients. 

You want to request additional budget support to use this system with discharged patients.  However, hospital administration wants to see a justification for this and information about its potential effectiveness before providing additional funding.  You have been tasked with reviewing the research on IVR.

 

 ivr patient

ASK
the Question

2. Construct a well-built clinical question derived from the case

Based on this scenario, choose the best, well-built clinical question:

A. What is the best way to follow patients for compliance and reporting adverse effects?

B. Is an interactive voice response system useful to follow discharged surgical or hospitalized patients?

C. In patients discharged after surgical procedures, is an IVR system more effective at reducing adverse effects and medication non compliance than following standard care?

ACQUIRE
the Evidence

3. Select the appropriate resource(s) and conduct a search

Based on question C, choose the best search strategy to address the question.

A. Search: ivr AND hospitalizations OR adverse reactions

B. Search: (ivr OR interactive voice response) AND (medication compliance OR hospitalization OR adverse effects) Limits: Randomized Controlled Trial

C. Search: Cardiac Surgical Procedures AND (ivr OR interactive voice response) AND (medication compliance OR hospitalization OR adverse effects) Limits: Randomized Controlled Trial

APPRAISE
the Evidence

4. Appraise the evidence for its validity (closeness to the truth) and its applicability (usefulness in clinical practice)

Read the following article to determine if the article meets the criteria for validity. As stated previously, evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question.

Article: Sherrad H. Using technology to create a medication safety net for cardiac surgery patients: a nurse-led randomized control trial. Canadian Journal of Cardiovascular Nursing, 2009 19(3):9-15. PDF file.

Are the results valid?

1. Randomization: Were patients randomized?

2. Concealed allocation: Was group allocation concealed?

3. Similar baseline characteristics of patients: Were patients in the study groups similar with respect to known prognostic variables?

4. Blinding: To what extent was the study blinded?

5. Follow-up: Was follow-up complete?

6. Intention to Treat: Were patients analyzed in the groups to which they were first allocated?

7. Was the trial stopped early?

What are the results?

How large was the treatment effect?
What was the relative risk reduction?
What was the absolute risk reduction?

How precise was the estimate of the treatment effect?
What were the confidence intervals?

An analysis of the composite primary outcome of increased compliance with medications and decreased AEs (emergency room visits and hospitalization) at six months revealed that patients in the IVR group were significantly different from the patients in the UC group (RR and 95% CI: 0.60 [0.37, 0.96], p = 0.041) as shown in Table 4.

In the IVR group, 51.1% remained compliant with their medications and did not have an AE, compared to 38.5% in the UC group.

 

Positive composite outcome YES

Positive composite outcome NO

 

Totals

IVR Group

70

67

137

Usual care Group

55

88

143

Experiment Event Rate: 70 / 137 = 51%
Control Event Rate: 55/143 = 38.5%

Absolute Reduction Risk (compliant with their medications and did not have an AE): 51% - 38.5% = 12.5%. 

Relative Risk Reduction: 12.5% / 38.5% = 32%.

Number Needed to Treat: 1 / 12.5% = 8 patients

The number of cardiac surgical patients that would need to be treated with (use) the IVR in order to prevent one additional bad outcome is 8 patients.

Analysis of the discreet secondary outcomes determined a significant difference for medication compliance (RR: 0.34 [0.20, 0.56], p < 0.0001), whereas there was no impact on the emergency room visits (RR: 1.04 [0.63, 1.73], p = 0.897) and hospitalization (RR: 0.77 [0.41, 1.45], p = 0.519)

How can I apply the results to patient care?

Were the study patients similar to my population of interest?
Does your population match the study inclusion criteria?
If not, are there compelling reasons why the results should not apply to your population?

Were all clinically important outcomes considered?
What were the primary and secondary endpoints studied?
Were surrogate endpoints used?

Are the likely treatment benefits worth the potential harm and costs?
What is the number needed to treat (NNT) to prevent one adverse outcome or produce one positive outcome?
Is the reduction of clinical endpoints worth the increase of cost and risk of harm?

 

APPLY:
talk with patient

5. Return to the patient -- integrate the evidence and clinical expertise, patient preferences and apply it to practice

 

The intervention is something that is available within the hospital.  And while the study was not as rigorous as we would have liked, the intervention is reasonable, cost effective and relatively harmless.

 ivr patient 2

Please take a few minutes to give us feedback about this tutorial. Thank you!

Previous References Next

 

Revised July 2010