Critical Appraisal of Research Evidence

Type 2 diabetes is regarded as one of the leading causes of chronic-related deaths. According to Azami et al. (2018), more than 25% of the global population reports multiple chronic conditions, which significantly contribute to their higher mortality rates. Older adults aged 50 to 70 years represent the most vulnerable group due to ageing and metabolic changes, which predispose them to develop chronic conditions such as diabetes and hypertension. Additionally, due to their age, they suffer reduced quality of life and may experience difficulties participating in activities of daily living. Various pharmacological and nonpharmacological interventions have been prescribed for such older diabetic patients, including medications and self-management strategies. While diabetic medications have shown significant efficacy, other approaches, such as diabetes education to enhance medication adherence for such patients, have been regarded as a vital treatment approach (Azami et al., 2018). The clinical PICOT question of interest states; In elderly patients aged 50 to 70 years with type 2 diabetes mellitus, how does patient education compare with no education in improving medication adherence?

The PICOT question has been developed following concerns over medication noncompliance in elderly patients. Of note, older adults experience multiple chronic illnesses which may accompany diabetes, such as hypertension and Alzheimer’s disease, which imply that they are prescribed multiple medications. Further, the adult’s experience memory decline, which means they may encounter challenges remembering when to take their medications (Azami et al., 2018). Therefore, such patients may demonstrate noncompliance due to polypharmacy and cognitive decline. While current evidence highlights the benefits of patient education to promote adherence, this paper appraises current research on the clinical issue, investigating the validity, impact, and applicability of current evidence.

Evidence Appraisal

Current research highlights the benefit of various patient education interventions in elderly patients with type 2 diabetes mellitus to improve their adherence to medications. As Azami et al. (2018) argue, much of the research has not focused on the clear differences in the quality of services rendered to patients. Still, research studies name nurses, pharmacists, and registered nutritionists to be critical for patient education. Specifically, nurses are regarded as one of the most important healthcare professionals responsible for educating patients regarding medication compliance. They comprise the largest and most trusted healthcare professionals due to their mutual relationship with the patients and their families. Also, they are uniquely positioned to champion change and transform the continuum of healthcare delivery. The following is an appraisal of qualitative studies, randomized controlled trials, and systematic reviews on the effectiveness of patient education to promote diabetes medication adherence using the Critical Appraisal Skills Program (2020).

Kvarnström et al. (2018) investigate the challenge of medication adherence among patients with chronic illnesses which is relevant to the clinical question of interest. The study focuses on the general practitioner’s role in medication adherence using the subjective experience of the research participants. The study utilizes a qualitative study design to investigate the current concern on non-adherence and assess the attitudes of general practitioners towards patient education to enhance compliance. The researcher adequately outlines how the participants were selected, although the discussions around their recruitment are less adequate as issues such as inclusive and exclusive criteria have not been outlined. The study uses focus group discussions but does not justify the chosen data collection method. Further, the researcher does not outline any potential bias the author may have towards the recruitment or data collection process.

The research study outlines adherence to ethical standards as it highlights compliance with the Finnish ethical principles of research. The study also obtained ethical approval from the ethical committee on the setting in which it was conducted. The study does not outline an in-depth description of the data analysis process, how sufficient data was presented to support the findings, or the extent to which the researcher accounted for contradictory data (Kvarnström et al., 2018). The research findings are explicit and have been categorized into key themes such as poor adherence during medication management and better medication information for the patient, which includes sub-topics such as more patient empowerment, continuity of care, and more professional practices. Although the researcher does not outline the credibility of research findings, such as respondent validation, the study adequately discusses the evidence. Further, the researcher argues that the study adds to the existing body of literature on the role of general practitioners in diabetes self-management and medication adherence. However, the research does not identify opportunities for further research.

Presley et al. (2019) conducted a systematic review focused on elderly patients with diabetes using pharmacy-led interventions. To select the best available studies for the review, the research employed a rigorous search strategy utilizing various research databases and keywords such as EMBASE, JSTOR, and PubMed. The search keywords were “pharmacists,” “diabetes,” and “medication adherence.” To assess the rigor of the studies retrieved from the research databases, the researcher included studies that were based on a randomized controlled trial evaluating the proposed intervention. However, the studies were excluded if the intervention was administered to children or adolescent patients. The researcher does not document whether published and unpublished studies were distinguished. The researcher found 1181 studies after searching the databases. After screening their titles and abstracts, only 135 studies were found relevant. Further, the researcher conducted a further screening, after which they were left with only 30 studies.

The studies varied significantly in their findings as different methodologies were applied. For instance, while assessing the effect of follow-up on outcome measures, the researcher found that most studies utilized a combination of educational and behavioral elements to enhance medication adherence. One limitation of the review is that it lacks the numerical appropriateness of study findings while it does not clearly outline how the results were expressed, including odd ratios or intervals are given. The study considered elderly patients as part of the selection criteria, implying that the study findings would be relevant in my local setting.

Greenwood et al. (2017) conducted a systematic review of technology-based educational interventions for elderly type 2 diabetic patients. The review addresses a focused clinical question as to its objective addresses the population, intervention administered, and the outcomes to be considered. The author searched studies from various databases such as CINHAL, Medline Complete, and PubMed. The author removed duplicates after screening the abstracts of 265 papers, where only 145 papers met the inclusion criteria. Further, studies conducted in school sites and those conducted within classrooms were excluded. Also, studies that focused on diabetes devices as the mode of intervention, including insulin pumps and those published older than 2013 were excluded. Based on the keywords and the databases searched, almost all available research studies must have been included in the review. The author did not consider the rigor of the studies analyzed. However, the study findings were documented in tables for data analysis to identify the effect of diabetes education on key clinical outcomes such as glycated hemoglobin levels. Although the study findings varied from one study to the other, the researcher did not outline the reason for such variabilities.

The patient population considered for selection in the review are not different from those available in my locality. Therefore, the study findings are valid and could apply to my locality. The study findings from all the analyzed research papers have been displayed in tables for comparison (Greenwood et al., 2017). The findings have been adequately outlined, and no missing information can alter the validity of the research evidence.

Tan et al. (2019) examine various research evidence on the effectiveness of diabetes education on medication adherence. The study argues that poor medication adherence is a key challenge among elderly patients with low health literacy levels resulting in poor health outcomes. Hence, building their health literacy through education efforts has been determined to be an effective strategy. To effectively address the clinical issue of interest, the study objective was to assess the effectiveness of educational interventions in improving medication adherence among diagnosed patients. The study design points highlight the selection of the right papers in assessing the intervention. Specifically, the researcher conducted the search strategy from various databases such as CINAHL, EMBASE, CENTRAL, and Web of Science. Science Direct, and PubMed. The search strategy included studies from 2003 to 2016. The studies assessing medication adherence were included because the outcome measure aligned with the purpose of the review.

Based on the search strategy and the search criteria, all the relevant studies were included in the systematic review. The selected studies were further independently reviewed for rigor and methodological quality using the Cochrane Collaboration Tool for assessing the risk of bias. Further, discrepancies between the reviewers were solved through discussions. The Cochrane Handbook for Systematic Reviews of Interventions was also used for data extraction. Regarding the study findings, the outcome of the review was medication adherence, and thus, relevant statistical techniques were used to calculate the report as an odds ratio with a confidential interval of 95% (Tan et al., 2019). The studies exhibited significant differences in overall outcomes, although some outcome measures were similar across studies. The overall results of this study indicated that diabetes education was important in promoting medication adherence among elderly patients. One key concern from the review was that medication adherence with educational intervention could not be pooled into a meta-analysis and was thus presented narratively. The study participants across the studies included older diabetic patients, which implies that the study findings are relevant to a typical location population that usually has a higher diabetes prevalence among the elderly. All the important outcomes regarding diabetes prognosis were considered, including glycated hemoglobin to assess glycemic control. Because no invasive intervention has been administered to the patients, the benefits of conducting the review override the potential harm that may be imposed.

Azami et al. (2018) consider the effectiveness of nurse-led diabetes education to improve glycemic control among older patients which is a focused research objective. The objective demonstrates the population of interest, the intervention, and the outcome to be considered. The study design was a single-center observer-blinded in which study subjects were randomized into the control and intervention groups. The eligibility criteria for participating in the study are comprehensive, with inclusion and exclusion criteria adequately discussed. For instance, the exclusion criteria included a diagnosis of hemolytic anemia or hearing impairment. The study participants were also excluded from the study if they expressed visual impairment or hemoglobinopathies. Participant recruitment was also conducted in two stages involving an initial advertisement which was followed by a screening and assessment process. Apart from the experimental intervention, both the control and the experimental group received a similar level of care, including follow-up intervals and additional tests.

The researcher did not calculate the power calculation but indicated the outcomes to be measured which were laboratory and clinical measures. The laboratory measures included glycated hemoglobin using whole blood. The clinical measures included weight and height measurements and a questionnaire that was used to assess diabetes self-efficacy expectations. The results were reported for each outcome, and there were no missing or incomplete data. Nonetheless, during the 24-week patient follow-up, six of them dropped out, of whom one was in the intervention group while the remaining five were in the control group (Azami et al., 2018). Due to the large number of remaining participants, the dropout rate did not significantly affect the validity of the study findings.

The study reported p values and statistical tests, which were used to arrive at the conclusions. Data collected by the researchers were analyzed using SPSS. Of note, the statistical significance of the study results was reported at 0.05 alpha level with two p values. The chi-square test was utilized for continuous variables, while the Fisher exact test was used for categorical variables. This experimental design is largely noninvasive and, thus, imposes limited potential risks to the study subjects. Additionally, the study did not document any harm or unintended effects on the study groups (Azami et al., 2018). The study participants are similar in demography to those in my care, implying that the research findings can positively influence my clinical practice. Differences between my population and the study participants cannot alter the outcomes reported. Besides, no study limitations reported can negatively impact my clinical decisions. To introduce this intervention to people in my care, it would be appropriate to publish health information documents such as brochures to educate the patients.

Conclusion

The evidence appraised in the research articles analyzed supports diabetes education as an effective strategy in enhancing medication adherence in elderly type 2 diabetic patients. Of note, the clinical question and study design differ across the studies, with one study focusing on nurse-led interventions while another study addressing the attitudes and practices of general practitioners. Whether it is a qualitative study design, a randomized controlled trial, or a systematic review, the study findings are relevant and support the PICOT question. Moreover, the results differ across multiple studies, especially when critiquing systematic reviews. However, the results agree on the administration of patient education to improve adherence. Lastly, the study population used in the five studies aligns with a typical local population of diabetes patients implying that the findings are relevant and applicable to local clinical practice.

References

Azami, G., Soh, K. L., Sazlina, S. G., Salmiah, M., Aazami, S., Mozafari, M., & Taghinejad, (2018). Effect of a nurse-led diabetes self-management education program on glycosylated hemoglobin among adults with type 2 diabetes. Journal of diabetes research, 2018.

Critical Appraisal Skills Program. (2020, November 20). Casp checklists. CASP – Critical Appraisal Skills Program. https://casp-uk.net/casp-tools-checklists/

Greenwood, D. A., Gee, P. M., Fatkin, K. J., & Peeples, M. (2017). A systematic review of reviews evaluating technology-enabled diabetes self-management education and support. Journal of diabetes science and Technology, 11(5), 1015-1027.

Kvarnström, K., Airaksinen, M., & Liira, H. (2018). Barriers and facilitators to medication adherence: a qualitative study with general practitioners. BMJ Open, 8(1), e015332.

Presley, B., Groot, W., & Pavlova, M. (2019). Pharmacy-led interventions to improve medication adherence among adults with diabetes: a systematic review and meta-analysis. Research in Social and Administrative Pharmacy, 15(9), 1057-1067.

Tan, J. P., Cheng, K. K. F., & Siah, R. C. J. (2019). A systematic review and meta‐analysis on the effectiveness of education on medication adherence for patients with hypertension, hyperlipidemia, and diabetes. Journal of advanced nursing, 75(11), 2478-2494.

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Question

Critical appraisal aims to identify potential threats to the validity of the research findings and make informed decisions about the quality of research evidence. Using a Critical Appraisal of Research Evidence Download Critical Appraisal of Research Evidence allows consistency when reviewing several studies.