Discussion: Systematic Review Paper

Discussion: Systematic Review Paper ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Systematic Review Paper Write a 260-word summary of the article in which you: Provide a short summary of the review (research questions, number and type of studies reviewed, and major findings). Discussion: Systematic Review Paper Identify if theory was used to guide the data collection and analysis. Identify if the authors included theory as part of findings. State the major strengths and limitations of the study utilizing the evaluation guide in Box 29.1: Guidelines for Critiquing Systematic Reviews located on p. 666 in Ch. 29 of Nursing Research. Comment on the contributions of systematic reviews to evidence-based practice as contrasted with individual studies. Identify the level for the study in the hierarchy of evidence located in Figure 2.1 on p. 26 in Ch. 2 of Nursing Research. Include a reference page identifying the article you selected and format according to APA guidelines. Evidence-Based Practice Symptom Recognition and Healthcare Utilization in Adult Patients with Heart Failure: An Integrative Review of the Literature Michael M. Evans eart failure (HF) is a debilitating disease that impacts patients, caregivers, healthcare providers, and the nation as a whole (American Heart Association [AHA], 2016). However, symptom recognition is a poorly understood phenomenon. Patients with HF often have difficulty distinguishing HF exacerbations from other conditions, such as age-related changes or changes associated with other comorbidities (Jurgens, Lee, & Riegel, 2016). Without symptom recognition, patients with HF may delay lifesaving measures. Moreover, limited literature exists on symptom recognition in HF. The question that guided this integrated review of the literature is as follows: In adult patients with HF, does symptom recognition predict healthcare utilization? H Statement of the Problem HF is the most common primary diagnosis in hospitalized adults over age 65 (Liu, 2011). Approximately 6 million individuals live with HF in the United States, a number only expected to grow. More than 8 million individuals are expected to have HF by 2030 (Go et al., 2015). Discussion: Systematic Review Paper Although HF is classified as a chronic disease, it has a major impact on mortality rates in this country. HF is a contributing cause in one of nine deaths, and half of all individuals with HF die within 5 years of diagnosis (AHA, 2016). According to the AHA (2016), HF has a negative impact on patients’ lives. It has no known cure and a Heart failure (HF) is a complex chronic condition that impacts approximately 6 million Americans. The purpose of this integrative review of the literature is to understand how symptom recognition impacts healthcare utilization in adult patients with HF. variety of debilitating symptoms, including shortness of breath, cough, weight gain, and nausea. Moreover, it progresses over time as the heart muscle continues to weaken. Disease progression impacts an individual’s ability to work and perform activities of daily living, leading to frustration, deceased quality of life, and caregiver burden. HF also costs an estimated $32 billion annually. This includes the cost of healthcare services, medications, and missed days of work (Centers for Disease Control and Prevention, 2013). This number is expected to increase to $70 billion by 2030 (Heindenreich et al., 2013). It thus is vital for healthcare providers and scientists to understand the current state of knowledge surrounding HF so treatment efforts and patient outcomes can be maximized. Search Strategy A literature review was conducted of the most current relevant information related to the search question. Accessed computerized research databases included CINAHL, MEDLINE, Proquest Nursing & Allied Health Source, The Cochrane Library, and The Web of Science. Keywords were heart failure and symptom recognition and healthcare utilization; heart failure and symptom recognition; heart failure and healthcare utilization; and heart failure and somatic awareness. Included were all study designs, peer-reviewed articles, adult participants, and a focus related to the search question. Secondary sources and non-peer reviewed publications were excluded. No date range was specified because the goal was to include all related literature. Limitations that caused articles to be excluded included small sample sizes and lack of control for internal and external validity issues. Table 1 shows a sampling of the extracted data from each study and the study’s level of evidence. Relevant Literature From the 26 saved articles, 10 studies were descriptive or qualitative, 13 used observational designs, one was a randomized controlled trial, and two were systematic reviews. All except four studies were conducted in the United States. Discussion: Systematic Review Paper The Michael M. Evans, PhD, MSEd, RN, ACNS, CMSRN, CNE, is Assistant Chief Academic Officer and Instructor of Nursing, The Pennsylvania State University, College of Nursing, Worthington Scranton Campus, Dunmore, PA. September-October 2016 • Vol. 25/No. 5 319 320 Describe careseeking delay times; factors associated with prolonged delay; patients’ thoughts, actions; adults hospitalized with ADHF. Examine factors of care seeking among patients with HF. Determine efficacy of a HF training program on patients’ ability to recognize, respond to changes in HF symptoms; compare event-free survival at 90 days. Jurgens, 2006 Jurgens et al., 2013 Explore factors related to patients seeking care for worsening chronic HF. Purpose of Study Darling et al., 2013 Patel et al., 2007 Author/Year of Publication 99 patients with HF randomized to HF symptom training intervention or usual care group; convenience sample from NY 201 patients with HF admitted to three sites in MA, NY 1,271 patients hospitalized with ADHF at eight U.S. urban medical centers (20072010) 88 semi-structured interviews; hospital in Sweden Sample/Setting RCT/ Level II Descriptive, exploratory/Level VI Cross-sectional/Level IV Qualitative: Semistructured interviews, Level VI Research Design/ Level of Evidence Self-Care of HF index; HF Somatic Perception Scale Median pre-hospital delay 5.3 hours; patients who waited longer were more likely to have diabetes mellitus, peripheral edema, symptoms that began in the afternoon; and to have contacted the HCP. Prolonged-care seekers were less likely to have attributed symptoms to ADHF, less likely to want to bother their doctors or families, and more likely to be concerned about missing work due to illness (p<0.05). 58% patients sought Emergency Department care due to symptoms; 42% were sent by their relatives or referred from outpatient clinics. Delays in seeking care – 71% “wait & see” strategy; 10% reluctant to use healthcare system; 11% felt it was futile to seek care; 50% were uncertain about their current deteriorating status. Discussion: Systematic Review Paper Results September-October 2016 • Vol. 25/No. 5 Small convenience sample, low instrument reliability, no power analysis A qualitative component would have improved ability to understand statistics. No discusion of how the instrument was developed, reliability, or validity No bracketing, discussion of saturation, or feedback from participants; interviews not recorded; possible validity issues Limitations continued on next page Intervention group had significantly improved self-care maintenance, management, confidence scores. Usual care group had significantly improved self-care maintenance, management. Improvements in self-care maintenance, confidence were higher in intervention group. Uncertainty correlated with somatic HF Somatic awareness but did not predict delay. Awareness Scale; Mishel Uncertainty in Illness Scale Community Form 24-page survey None Instruments TABLE 1. Literature Review and Level of Evidence Evidence-Based Practice September-October 2016 • Vol. 25/No. 5 Examine research on self-reported patterns of symptom recognition, an antecedent of selfcare management, and treatmentseeking behaviors in patients with HF. Lam & Smeltzer, 2013 14 studies, 335 articles found Integrative review/ Level I Correlational design/ Level IV Research Design/ Level of Evidence Review of the SR/Level I literature: MEDLINE, CINAHL, Cochrane Library, reference lists from studies. Eligible studies: RCT, qualitative, quantitative, mixedmethods (20022012); 94 articles reviewed, 9 met inclusion criteria Acute HF (n=64) Chronic HF (n=148) Acute care hospitals in Western NY Sample/Setting Guidelines from Whittemore & Knafl None Preadmission Illness Behavior Questionnaire Instruments Dyspnea was most frequently reported symptom across all reviewed studies; dyspnea associated with treatment-seeking delay; older adults and newly diagnosed patients more likely to delay seeking treatment. Self-care themes: patient education; telemonitoring; barriers to self-care (agerelated symptoms, cognitive factors, social issues); interventions: patient education, telemonitoring Fatigue greater in chronic HF group. HCP advised patients with chronic HF to call 911 more frequently than those with acute HF. Patients with acute HF were more likely to be told to make an appointment or to come to the office. Results ADHF = acute decompensated heart failure, HCP = healthcare provider, HF = heart failure, RCT = randomized controlled trial, SR = systematic review Each article level of evidence graded using Melnyk’s Grading Pyramid (Melnyk & Fineout-Overholt, 2011). For more info, see http://guides.lib.umich.edu/content.php?pid=25673&sid=1946060 Notes: Overall Level of Evidence: B. This is based on the criteria provided by the GRADE guidelines. Examine evidence specific to self-care in adults over age 65 with HF; identify best nursing practice interventions in this group. Compare patients newly diagnosed with HF to patients with chronic HF who had been hospitalized (presenting symptoms, treatment delay times, who notified and when, advice given, action taken). Purpose of Study Zavertnik, 2014 Friedman & Quinn, 2008 Author/Year of Publication TABLE 1. (continued) Literature Review and Level of Evidence No clear questions to be answered by review, no discussion of bias, no recorder used in interviews, no use of checklists for critique Relied on patient recall; may not have been accurate Limitations Symptom Recognition and Healthcare Utilization in Adults Patients with Heart Failure: An Integrative Review of the Literature 321 Evidence-Based Practice majority of studies focused on heart failure symptoms and how they influenced healthcare decisions and utilization. ing patients and healthcare providers about lesser-known symptoms of HF increased self-care and patient outcomes (Jurgens, Lee, Reitano, & Riegel, 2013). awareness when examined for age, sex, and treatment. Jurgens (2006) found uncertainty to be associated with lack of symptom recognition. Results Self-Care Reviewed literature suggested the number of patients affected by HF can be even higher if individuals with HF delay treatment. The average delay in time for seeking treatment for HF exacerbations is 2-3 days (Nieuwehnuis et al., 2011). Main reasons for the delay in healthcare access included uncertainty concerning health deterioration, desire to “wait and see” what would happen, lack of trust in the healthcare system (Patel, Shafazand, Schaufelberger, & Ekman, 2007), desire not to bother their families or healthcare providers, desire not to miss work (Darling et al., 2013), on vacation (White, Howie-Esquivel, & Caldwell, 2010), and new diagnosis with HF and age over 65 (Lam & Smeltzer, 2013). Main reasons for using healthcare services included urging of healthcare providers and family members (Riegel et al., 2013) and history of myocardial infarction or stroke (Nieuwehnuis et al., 2011). Dyspnea, edema, and fatigue were the most commonly reported symptoms in patients seeking healthcare services (Evangelista, Dracup, & Doering, 2000). Finally, Friedman and Quinn (2008) found healthcare providers advised persons with chronic HF to call 911 more frequently than those with acute HF. Patients with acute HF were more likely to be told to make an appointment or come to the office. This is a concerning finding as lack of action could delay needed emergency services. Symptoms of Heart Failure Most individuals with HF and healthcare providers are aware of common symptoms of HF, such as shortness of breath and weight gain (AHA, 2016). However, the reviewed literature suggested they need to be more aware of other related symptoms. While still the most commonly reported symptom (Lam & Smeltzer, 2013), dyspnea was only one of many reported symptoms. Friedman and Quinn (2008) found fatigue, difficulty sleeping, decreased functional ability, edema, increased urination, tight clothes, coughing, anorexia, paroxysmal nocturnal dyspnea, tachycardia, chest discomfort, and nausea as symptoms associated with heart failure. Study of symptom clustering is a more recent area of research in HF. Hertzog, Pozehl, and Duncan (2010) identified three different sets of symptom clusters in participants in their descriptive study. The higher the patient’s New York Heart Association level (levels III and IV) of HF, the more symptoms reported (e.g., shortness of breath at rest and when lying down, difficulty sleeping, forgetfulness, dizziness, bloating, heart palpitations, depression). In addition, this cluster of participants had a lower education level and greater functional impairment. Lee and colleagues (2010) found no difference among symptom clusters between men and women but did find the emotional/cognitive symptom cluster (worrying, feeling depressed, and cognitive problems) was associated with higher risk of a cardiac event (e.g., rehospitalization, or Emergency Department visit, death). Discussion: Systematic Review Paper Researchers’ physical symptom cluster of dyspnea, fatigue, low energy, and sleep disturbances was very similar to the findings by Hertzog and co-authors (2010). Research has found educat- 322 The majority of reviewed studies used Riegel and Dickson’s (2008) definition of self-care: “self-care is a rational process, involving purposeful choices and behaviors, reflecting knowledge and thought” (p. 192). Their situational-specific theory of heart failure self-care also was used as a conceptual framework to guide the search strategy in one study (Zavertnik, 2014) and in others to describe methods and/or results correlating with the conceptual definitions of self-care maintenance and/or self-care management (Jurgens et al., 2013; Nieuwehnuis, Jaarsma, van Veldhuisen, & van der Wal, 2011; Riegel, Dickson, & Topaz, 2013). Regarding patient self-care practices, Jaarsma and colleagues (2013) found adult patients with heart failure were least concerned with symptom monitoring and management (e.g., exercise, weight monitoring) and most concerned with taking their prescribed medications. In addition, Lee and co-authors (2015) found more highly educated and symptomatic patients were more likely to participate in self-care activities. However, they found higher levels of anxiety were associated with worse consulting (contacting the healthcare provider) and self-care behaviors. Symptom Recognition Symptom recognition is the ability of individuals with HF to recognize symptoms related to the disease (Jurgens, 2006). Multiple studies have found older adults have difficulty differentiating symptoms of HF from age-related changes; cognitive changes also can cause treatment delays and symptom exacerbation (Lam & Smeltzer, 2013; Riegel et al., 2010; Zavertnik, 2014). Sex was not associated with any significant differences in symptoms recognition (Bass, Beery, Allen, Wizer, & Wagoner, 2004). Authors also found no differences in body Healthcare Utilization Discussion Several high-quality studies focused on symptom recognition and healthcare utilization (Jurgens, 2006; Patel et al., 2007; Riegel et al., 2013). However, not all studies examined the two variables together. Thus symptom recognition cannot be correlated to healthcare utilization. Moreover, studies that September-October 2016 • Vol. 25/No. 5 Symptom Recognition and Healthcare Utilization in Adults Patients with Heart Failure: An Integrative Review of the Literature examined symptom recognition and reasons for healthcare utilization found family member and caregiver suggestions to seek medical advice as well as past medical history (e.g., anxiety) were more likely than symptom recognition to promote healthcare use (Lee et al., 2015; Riegel et al., 2013). However, Lee and colleagues (2015) found higher-educated and symptomatic patients were more likely to participate in self-care practices. A possible hypothesis is better-educated patients who are aware of less-common symptoms of HF might experience improved self-care. In addition, older adults appeared to struggle with symptom recognition (Riegel et al., 2010). Level of Evidence The quality of the current state of the science was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines (2007). The quality of the evidence related to the search question is level B (moderate). This is based on limitations in many of the articles (see Table 1). cognitive dysfunction as this group was at risk for not recognizing HF symptoms. In addition, educational efforts should be targeted at teaching patients about HF symptom clustering and how to monitor and intervene with these clusters. More studies also need to be conducted to examine symptom clusters in patients with HF among diverse populations. Finally, additional research should be conducted regarding symptom clustering as an emerging area of study in HF that can help healthcare providers and patients understand recognizable symptoms. The author would like to examine differences in symptom recognition in patients with acute versus chronic HF using the Heart Failure Somatic Awareness/Perception Scale (Jurgens et al., 2013). Results then can be used to develop educational tools for healthcare providers and patients concerning possible HF symptom differences. Symptom recognition also can be studied for possible association with healthcare utilization in these two groups. Finally, the author would like to examine patients with acute versus chronic HF to identify any perceived differences in living with the illness. Limitations Limitations of the review ranged from interviews not being recorded in qualitative studies to small sample sizes in quantitative studies (see Table 1). In addition, this integrative review has its own limitations. Time was a known limitation for this review as it was completed in 3 months. In addition, the author was the only reviewer of the articles. In future work, two reviewers would be used to enhance the validity of results. Finally, relevant articles may have been overlooked as only articles in English were included. Future Research With only one randomized controlled trial found in the literature search, future research needs to focus on interventional studies to explore how to help patients perceive their symptoms and then gain necessary healthcare access. Intervention studies also need to occur in patients with Conclusion Results of this integrative review indicate patients and healthcare providers should be aware of the more obscure symptoms of heart failure. In addition, it shows individuals often seek healthcare services based on family and caregiver urging and their past medical history rather than an exacerbation of their symptoms. More research needs to be done in this area to strengthen the evidence. Discussion: Systematic Review Paper REFERENCES American Heart Association (AHA). (2016). Heart failure. Retrieved from http://www. heart.org/HEARTORG/Conditions/Heart Failure/HeartFailure_UCM_002019 _SubHomePage.jsp Bass, L.S., Beery, T.A., Allen, G., Wizer, M., & Wagoner, L.E. (2004). An exploratory study of body awareness with heart failure treated medically or with transplantation. Journal of Cardiovascular Nursing, 19(1), 32-40. September-October 2016 • Vol. 25/No. 5 Centers for Disease Control and Prevention. (2013). Heart failure fact sheet. Retrieved from http://www.cdc.gov/dhdsp/data_ statistics/fact_sheets/fs_heart_failure.htm Darling, C., Scczynski, J.S., McManus, D.D., Lessard, D., Spencer, F.A., & Goldberg, R.J. (2013). Delayed hospital presentation in acute decompensated heart failure: Clinical and patient reported factors. Heart & Lung, 42(4), 281-286. Evangelista, L.S., Dracup, K., & Doering, L.V. (2000). Treatment-seeking delays in heart failure patients. The Journal of Heart and Lung Transplantation, 19(10), 932-938. Friedman, M.M., & Quinn, J.R. (2008). Heart failure patients’ time, symptoms, and actions before a hospital admission. Journal of Cardiovascular Nursing, 23(6), 506-512. Go, A.S., Mozaffarian, D., Roger, V.L., … Discussion: Systematic Review Paper Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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