Critique of Systematic Research Review

Heart failure is a serious issue facing the medical profession, including nursing, due to the continued prevalence of the problem in the general population. In particular, the number of patients diagnosed with heart failure is increasing in the United States, as the most recent statistics report over 600,000 new cases annually (Graven et al., 2014). Additionally, this condition often results in death, but at the minimum it typically involves hospitalization and/or some type of physical limitations. Therefore, it is important for those in the nursing profession to be aware of the various treatment and intervention options available to those with heart failure.

This paper is a critique of the systematic review conducted by Jovicic, Holroyd-Leduc, & Straus (2006) regarding self-management interventions for patients with heart failure. According to Melnyk and Fineout-Overholt (2011), a systematic review is “a summary of evidence, typically conducted by an expert or expert panel on a particular topic, that uses a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific clinical question and draw conclusions about the data gathered” (p. 582). While taking medication is the minimum intervention that patients suffering from heart failure will encounter, there are other options suggested that may provide additional benefits, and Jovicic and colleagues (2006) reviewed some of these. In particular, their systematic review examined previous research related to patients’ use of interventions in addition to medication, such as diet, physical activity, and monitoring their own symptoms as they engage in daily activity.

The purpose of the self-management techniques reviewed by Jovicic et al (2006) is to allow the patient with heart failure to gain more control over their own health management. Not only do they administer their own medications, but they also engage in other activities that can contribute to improved health conditions. Encouraging patients to engage in self-management provides benefits not only to the patient but also aids the healthcare system by reducing the need for additional resources during this time of higher costs and decreasing medical benefits. The self-management process is different from the typical disease management program which places much less emphasis on the personal activity of the patient. The systematic review critiqued in this paper started with a significant number of articles to begin the review, eventually narrowed the potential review down just 58 studies, and finally selecting six articles for the systematic review (Jovicic et al., 2006). The studies that were excluded from the final review were rejected primarily because they did not address the types of interventions that were being reviewed. In addition, all of the studies had to involve patients engaged in interventions at home and in addition to just taking their medication.

The studies reviewed by Jovicic et al. (2006) were all randomized controlled trials and included participants diagnosed with heart failure and that were 56 years old to 76 years old. In all cases, the patients in the reviewed studies had been hospitalized at least once as a result of their condition and were now engaged in self-management programs. In all of the studies reviewed, males outnumbered females and the difference ranged from 76% to 53% depending on the study. Other demographic information was not consistently reported in the included studies, including race, education and income levels. Conversely, one of the studies reported a significant number of white males who were college graduates and another noted that the majority of participants had not attended college. In general, however, the studies were content with merely providing a male/female breakdown of participants. Finally, the reviewers noted that the quality of the studies varied (Jovicic et al., 2006). While not directly criticizing any of the studies they reviewed, it appeared that the authors would have preferred more consistency across all the studies regarding the collection of demographic data. Such information could be very beneficial.

In all cases, the studies included in the systematic review involved patients monitoring their health condition with the goal of being able to recognize when they need to call for medical assistance. The process of self-management also involved education by medical professionals (including nurses) as well as limited follow up in some cases. Education provided to the patients included understanding everything about their medication dosage and timing, in addition to weight maintenance (often through exercise) and a diet considered proper for a person with heart failure (Jovicic et al., 2006). In some of the studies reviewed, there was a greater emphasis placed on the relationship between medication, diet, and health behaviors that included exercise. While some studies included researchers who provided a greater degree of direction to the patient participants, others only provided basic educational materials and relied on the patients themselves to understand what types of actions they should take. In any event, all of the reviewed studies were in contrast to patients with heart failure who, following a return to home after hospitalization rely primarily on medication alone.

Importantly, all of the studies reviewed were based on some sort of time limitation which is necessary for answering any PICOT question. The follow-up timing ranged from as little as three months to as long as one year. In all cases, the reviewed studies took into consideration whether or not patients need to be hospitalized a second time after participation in the interventions included in the study (Jovicic et al., 2006). Half of the studies evaluated the quality of life of the patients included by means of self-reported scoring. These assessments were based on changes in health and life-style behavior of some patients, including changes in diet and exercise as part of the self-management behavior that the patients learned following hospitalization. When Jovicic and associates (2006) analyzed all of the results from studies that included such scoring, they found that rate of hospitalization was significantly reduced and the patients’ wellbeing improved in numerous ways. Significantly, based on a funnel plot utilized by the authors, it was determined that there was no publication bias identified.

While there were various measures included in these reviewed studies, the most significant interventions in light of the question under consideration consisted of changes designed to directly impact the health outcomes of patients with heart disease. In particular, the greatest improvements were identified among patients who had definitive action plans for self-management of their health. These interventions included regular exercise, strict diet adherence, monitoring weight, as well as properly taking medications (Jovicic et al., 2006). In comparison to the control groups, which did not participate in any of these interventions and typically just took their medication as prescribed, the groups involved with self-management performed much better in all health-related measurements. As a result of these results, the systematic review indicated a clear benefit for heart failure patients who engaged in self-management programs that included activities such as dieting, exercise and proper management of medications based on monitoring daily health.

There are many similarities between the conclusions drawn by the systematic review conducted by Jovicic et al. (2006) and other, similar, reviews designed to determine the effectiveness of specific interventions for patients with heart failure. For example, the results of this review were similar to those of Gonseth et al. (2004) and Gwadry-Sridhar et al. (2004); two systematic reviews which also examined similar interventions for patients with heart failure and. Both of these studies reviewed earlier studies that addressed ways that patients can manage their symptoms, including some of the same methods mentioned by Jovicic et al. (2006). The basic conclusion of these reviews is that there is a much greater advantage to heart patients from engaging in multiple interventions as opposed to simply being content with taking medications and having regular doctor visits. In other words, self-management programs, which include patients monitoring their diets, engaging in moderate exercise, as well as maintaining their normal medication regimen, are able to improve the overall health conditions of patients with heart failure.

The critique of any systematic review involves making an assessment of the quality of the articles and the data included in the studies that are part of the review. Unfortunately, complete data was not available for half of the studies included in this systematic review because the patients died as a result of heart failure. While there was no implication that participation in the studies involved contributed in any way to mortality, this fact still limits the overall quality of some of the studies included in the review. As mentioned earlier, another limitation was the lack of consistent regarding demographic data such as socioeconomic status and race, which could be important factors in assessing the value of self-management interventions for heart failure.

In conclusion, the systematic review used for this critique provided a foundation for the support of self-management programs among heart failure patients. While little can be done to completely eliminate mortality in this patient group, due to the severity of the disease, there is significant evidence that interventions such as moderate exercise, appropriate diet, and monitoring health conditions at home following hospitalization for heart failure-related symptoms contributes to a higher quality of life for the patient. This knowledge helps nurses to understand additional ways to provide care for patients, even if the patient eventually needs to be hospitalized again. Additionally, the results of this review indicate the importance role nurses can play in encouraging patients to participate in their treatment, especially by taking part in activities beyond mere compliance with a medication regimen.

References

Gonseth, J., Guallar-Castillón, P., Banegas, J. R., & Rodriguez-Artalejo, F. (2004). The effectiveness of disease management programs in reducing hospital readmissions in older patients with heart failure: A systematic review and meta-analysis of published reports. European Heart Journal 25, 1570-1595. doi:10.1016/j.ehj.2004.04.022.

Graven, L., Grant, J. S., Vance, D. E., Pryor, E. R., Grubbs, L., & Karioth, S. (2014). Coping styles associated with heart failure outcomes: A systematic review. Journal of Nursing Education and Practice, 4(2), 227-242. doi: 10.5430/jnep.v4n2p227.

Gwadry-Sridhar, F., Flintoft, V., Lee, D. S., Lee, H., & Guyatt, G. H. (2004). A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure. JAMA Internal Medicine 164(21), 2315-2320. doi:10.1001/archinte.164.21.2315.

Jovicic, A., Holroyd-Leduc, J. M., & Straus, S. E. (2006). Effects of self-management intervention on health outcomes of patients with heart failure: A systematic review of randomized controlled trials. BMC Cardiovascular Disorders 6(1), 43-50. doi:10.1186/1471-2261-6-43.

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare (2nd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.