Article critique
The article critically analyzes the diseases by pointing out some of their characteristics giving readers more information regarding them. These diseases are initially treated in the ED; they are common and associated with significant mortality and morbidity. They have evidence based time sensitive therapies which affect mortality. The objectives of this article is
The objective is clearly pointed out in the abstract and introduction of the article where the authors explain their mission to concentrate on establishing how the health care system has lagged in handling AMI and PNA, specifically in the hospital EDs. The hypothesis of the research was specified. The researchers have stated their position on the outcome of their study, and their two objectives ‘measure’ and ‘estimate’ indicated a direction they expected the findings to expose. The conclusion of the article clearly satisfies the researcher’s motive by giving a final result of the situation. It finalizes that national quality of ED care in patients with AMI and PNA is below the expected standards, and also admits some of the limitations in the research that may have effect on the conclusion. When a reader connects the title of the article to the final conclusion, it becomes clear that a final position is reached, and any additional recommendations should be made from this stand point.
The researchers supported their work with numerous references, more than 30 in number and, which were fairly mixed, with some dating very current and some up to fifteen years ago. Though, despite the numerous references, the researchers did not include in-text citation making it difficult for any reader to identify where they might have gotten specific information. The researchers have used an extremely effective way of giving explanations concerning their work and directing the reader to particular tables where they can obtain the information they need. This enables the reader to make better interpretation of the factors being discussed. The study includes 36 citations mostly between 2000-2003, and a balance between primary and secondary materials. The table below summarizes the details of the references.
The emergency department(ED) was cited by the institute of Medicine as among the areas that need improvement. The ED forms a vital part of the health system since it is common for receiving care for persons with medical emergencies. It tends to have a much higher probability for medical errors, and it is referred to as a ‘safety net’ in health care due to its importance. This justifies the importance the researchers of this article attach to the ED.
Methods
The study entirely adopted a cross sectional design, where the researchers performed a cross sectional study of visits to ED with diagnosis of PNA and AMI from 1998 to 2004. They used data from National Hospital Ambulatory Medical Care Survey (NHAMCS). The study comprised 544 EDs across the entire United States. Authors measured proportion of patients receiving the recommended therapies for AMI and PNA and established it as the primary outcome. In addition, they estimated deaths associated with current care. This section went deeper regarding how data was used from the National Hospital Ambulatory Medical Care Survey (NHAMCS).
The article elaborates how NHAMCS is administered to give the reader clear specifics regarding the reliability of the data obtained. The authors extracted data pertaining to patient age, race, gender, and ethnicity, source of payment and provider type seen for every visiting patient. These variables were further broken down into other categories to give the reader a more detailed understanding. For example, ethnicity involved either Hispanic or non-Hispanic. Race included white and non-white.
Definition of ED Quality Indicator Variables
One could conclude that the variables offer sufficient validity.
Sample
The NHAMCS from which the authors obtained their data is administered by centers for disease control and prevention National Center for Health Statistics. It is a nationwide probability sample of visits to the EDs of short –stay acute and non-institutional hospitals located in the District of Columbia and the 50 states. One understands that data was collected from a reliable source that is administered by government departments, implying more trustworthy data. The authors elaborate on how NHAMCS uses its sampling design to give the reader a wider perspective on how NHAMCS arrives at its values. NHAMCS uses a four stage probability sampling design, whereby samples are collected from primary sampling units, EDs, hospitals within primary sampling units, and patient visits within EDs. Every single patient visit is assigned a weight. The weight assigned is used to make national estimates. The selection process is developed in a manner to provide nationally representative sample of ED visits.
Study Design
The research design was more concentrated on the therapy received by both AMI and PNA patients in EDs, this study got its approval from the institutional review board of National Center for Health Statistics. The researchers performed a national cross sectional study of ED visits in the United States between 1998-2004 with the diagnosis of AMI or PNA.
NHAMCS four stage probability sampling design is well described in the article. The authors also estimated preventable deaths as the number of deaths per year associated with not receiving therapy, this was the number that did not conform to the primary outcome of the paper. The authors also give a clear description of how they calculated preventable deaths giving the relevant ratios of ARR and BBs used.
The comparison group comprised of 3955 PNA and 1492 AMI, representing the number of individuals from the samples who demanded therapy from the EDs across the country. This study did not explicitly address the conditions in EDs in terms of facilities and expertise that should be used. It concentrated on the quality of medication received by patients when the visit EDs. The complete NHAMCS database was obtained and extrapolated into Stata. The study combined data from seven years to provide more reliable estimates. Then it adopted survey sampling analysis to account for the four stage survey design. The researchers adopted the “svy” set of commands from Stata in their analysis.
There was no indication of how active or inactive the chosen sample was, 19 descriptive statistics were used to describe predictor variables. The study performed multivariate analysis to assess the effect of predictor variables after controlling for factors known to be associated with quality of care. The study compared statistical differences using chi-square test for categorical variables and the t-test for continuous variables.
Data Collection
Data was collected from NHAMCS and extrapolated into Stata. The data collected came from a national probability sample of visits to the EDs of short stay acute care hospitals and non-institutional hospitals in the fifty states and the District of Columbia. The researchers assumed that individuals in institutional hospitals received proper care, and they were not grouped into the category of those who needed to be evaluated in this research.
Data Analysis and Deduction
Complete NHAMCS database was obtained and extrapolated into Stata. The study performed a bivariate analysis using predictor variables to explore the differences in subjects who received recommended therapy and those who did not. All along this paper, the authors give the reader reference tables where they can access various data and values that have been used in the research to give readers clear procedures and how values have been arrived at. The model used in the research included twenty races and 21 sources of payment. Chi square test was used to compare statistical differences for categorical variables.
The study compared the proportion receiving recommended therapy with the national goal proportion, with the goal being set at 90% for both AMI and PNA therapies. Though, 100% of patients were eligible to receive a therapy. The study recognized limitations in its database, which would exclude some ineligible subjects. Recognizing limitations is vital in this study because it enables any reader to understand the conditions for consideration in arriving at the final conclusion, which can at times be affected by certain limitations experienced in a study. The goal was adjusted to the best estimate of that proportion. In addition, the researchers also performed a logistical regression treating each year as a category.
This study reported in a number of sentences the statistical analysis performed in the whole research, roughly about three paragraphs. No adjustments were made for multiple comparisons. The researchers calculated the power to detect a difference between proportions receiving the appropriate therapy and the national goal proportion. The minimal difference of clinical importance between groups was considered to be 10% absolute difference.
Modes of Data Analysis and Interpretation
The study discovered that, in the national study, patients with AMI and PNA received recommended ED treatment half the time or less. Less than one third of the patients received all recommended therapies. The study also relates this deficiency with the number of deaths, to signify to the reader the importance of this research in reducing the number of deaths. The study discovers that the deficiency led to a significant number of excess deaths. The study also inspected how healthcare disparities varied and discovered that there were health disparities based on race because white patients more likely received recommended treatments.
The study provided quantitative data to support the recent report card from the American College of Emergency Physicians, suggesting that the national emergency health care system indeed needed urgent attention to improve the health standards in the whole country. These findings are consistent with other studies touching on quality care of patients with AMI. The study evaluated one national study which discovered that between 1992 and 1996, patients with AMI received ASA and BBs only half the time. Additionally, the study confirmed a single institutional ED study finding, that only 45% of patients with AMI received ASA. This study also supported the studies concerning quality of PNA care. From the researcher’s knowledge, there have been no studies that have evaluated appropriate antibiotic treatment of PNA in the ED.
An estimate 88% of hospitalized patients with Medicate received appropriate antibiotics within 12 hours, which the study concluded as an approximate comparison group for ED patients because the majority of ED stays did not exceed 12 hours. Making comparisons, the reader can, therefore, analyze that the results suggest ED patients receive appropriate antibiotic treatment 69% of the time. 89% of hospitalized patients with PNA, on the other hand, received measurement of pulse oximetry. Comparing, 46% of ED patients received pulse oxim.
Theory data alignment
The statistical results were clearly reported and displayed in visualization tables. There was a thorough and detailed discussion regarding the quality of EDs in hospitals around the United States of America, with data obtained from the NHAMCS. The limitations section addressed a number of factors that could have hindered the results obtained from the research.
The validity of this study was based on the validity of quality indicators. The researchers chose indicators that have strong empirical evidence from quality studies conducted in the past to minimize this limitation. The researchers, though, used evidence endorsed by professional societies; they admitted they might still have been some controversy concerning the value of some indicators. This is particularly notable because it sends a signal to the reader, that though the study was conducted and conclusions made there might still have been some inconsistencies which are common with any research work. The study also points out that due to the quality of ED documentation, there is potential for misclassification. Some therapies might not have been documented despite being administered in the ED. The study expected therapies that require a physician order to be better documented, and the misclassification is predicted to underestimate ED performance.
Limited information available in the NHAMCS was noted as another source of potential for misclassification as the study discovered it does not give information concerning patients out of hospital lifestyle. This made it difficult for the study to establish if patients had a contraindication to a therapy or they received the therapy before arriving in hospital. The researchers decreased their national goal to 90%, in part, to accommodate for this. Additionally, the study identifies that there is potential misclassification in diagnosing AMI and PNA. The study used the most conservative estimate.
Estimation of patient harm was limited by treatment received in the ED section of the hospitals. The study could not establish whether patients received these therapies after leaving the ED. Though, these therapies represent standard ED care and should be administered in the ED. The researchers compared prior research and discovered that in hospital treatment is not better than ED treatment. Improvement opportunities and the excess deaths resulting from AMI and PNA represented opportunities for improvement of ED and reduction in the near term mortality. The study’s estimates of harm used risk reduction figures based on efficacy trials in specific areas. Therefore, the extent to which the results apply to general practice could not be established. Though, there are implications from the results of the study. EDs should create a mechanism which ensures receipts of these therapies before leaving the ED because these therapies are time-sensitive. The ED priority should be focusing on these therapies.
Therefore, the author’s conclusions can be easily termed as predictions based on guidelines for determining the quality of EDs in providing recommended therapies to AMI and PNA patients across the United States. There was indeed adequate discussion of the methodological limitations, and the conclusions were consistent with empirical findings.
Feed back
This paper outstandingly focused on the main research objective which was to measure the quality of emergency department (ED) care for patients with acute myocardial infarction (AMI) and pneumonia (PNA), and to estimate the number of preventable deaths in these patients. The results of the research indicate that national quality of ED care in patients with AMI and PNA is low below the expected goals in the entire country. In addition, there are likely significant excess deaths that are attributed to these deficiencies in care. Therefore, the study proposes that future efforts should aim at understanding why such deficiencies occur in health care, and efforts should be aimed at developing meaningful measurable performance indicators that are ED-specific. The main agenda should be to research on strategies that can improve the quality of care for these patients. This paper was published in 2007 by the Society for Academic Emergency.
References
D.F Polit, C. B. (2012). Nursing research: Generating and assessing evidence for nursing practice. Philadelphia: Lippincott Williams & Wilkins.
Julius Cuong Pham, G. K. (2007). National Study on the Quality of Emergency Department Care in the Treatment of Acute Myocardial Infarction and Pneumonia. 856-862.
