Critique of Systematic Research, Article Critique Example

The importance of evidence based practice principles has been overemphasized in recent years. Without substantial evidence, it is incorrect to initiate a therapeutic modality without conclusive proof of its efficacy. A nursing professional therefore must not only be familiar with criteria for accepting a modality as therapeutically effective based on rigorous research, but should also be well aware of research designs which prove any therapeutic intervention to be sound. Hypertension is a frequently encountered condition which needs immediate attention upon diagnosis due to its implications on overall cardiovascular health. The earlier hypertension is detected, the more are the chances of initiating appropriate measures to prevent it, thereby excluding chances of subsequent cardiovascular complications. Pharmacological control of hypertension is definitely based on scientific evidence, but is replete with side effects and complications which might jeopardize a patient’s health. Alternative techniques and modalities available for controlling hypertension need to be tried at the initial stage of diagnosis, especially in young patients as the chances of development of cardiovascular pathology in such patients are better than older patients, the latter generally being afflicted with multiple comorbidities. Systemic reviews and meta-analyses are two techniques which extract the crux of research from multiple studies, in order to arrive at an evidence based conclusion. The subject of hypertension and the non conventional approaches for its prevention has been adequately researched in recent years but offers only speculative inferences. The research article by Rainforth et al (2007) is a systematic review combined with meta-analyses in order to adequately wean out the specific and actually effective non conventional approaches for handling freshly diagnosed hypertension. Based on their inferences, a nursing professional can better equip herself to handle clinical situations encountered in this field and suggest prevention measures to affected patients.

In the systematic review and meta-analysis carried out by Rainforth et al (2007), the authors have thoroughly searched the literature pertaining to hypertension control by non-conventional methods and analysed past systematic reviews on the topic as well. Analyses of past reviews assisted the authors in reducing the errors in gleaning relevant information from the studies by avoiding mistakes and irrelevant analytical methods. The soundness of previous systematic studies and meta-analyses has been questioned by the authors based upon non-randomization techniques employed, non reportage of results for specific treatments, variability in criteria for inclusion of the subjects, selection of variable end points for data generation such as net BP change, BP changes only within the intervention group, inadequacy of baseline protocols, lack of control for attentional factors and non-usage of adequate control groups. The authors began their analysis by citing the accepted benefits of lifestyle changes in preventing hypertension and the methodological limitations in past reviews on the subject as a pretext for their venture. The role of psychosocial stress as a major independent risk factor for the occurrence of hypertension has received validation and reduction of such stress therefore automatically becomes the first line of treatment for a preventive approach. The authors have quoted past studies and reviews done in the United States and Europe which linked hypertension with psychosocial stress. Such stress definitely affects the sympathetic or autonomic nervous system thereby producing changes in the hypothalamic-pituitary-adrenocortical axis with the resultant cardiovascular anomalies (Rainforth et al, 2007). Non pharmacological approaches for attaining autonomic balance in patients subject to psychosocial stress have been shortlisted as relaxation, meditation and biofeedback by the authors, on the basis of which they have conducted this systematic review. Armed with the information from past reviews the authors scoured the Medline databases as well conducted direct searches for related literature by short listing specific terms and phrases for conducting a computer based search. Relevant information which cropped up from the search yielded 107 pooled studies out of which the authors selected only 20 trials making available 27 comparisons satisfying the strict criteria prepared by the authors and offering data for analyses. Their strict criteria included studies exclusively satisfying the following conditions: 1) random allocation of subjects to experimental or control interventions; 2) comparison of BP changes for a stress reduction program versus a minimally treated or attention-control group; 3) assessment baseline BP levels over multiple clinic visits or used 24-hour ambulatory BP recording in lieu of multiple clinic visits; 4) duration of at least 8 weeks from baseline to post-test or follow-up assessment;5) publication in peer-reviewed English-language journals only and; 6) inclusion of pre-hypertensive and/or hypertensive subjects. The authors therefore eliminated the confounding factors which, according to them, might have influenced the previous systematic reviews in drawing inferences. The authors however confess that they did employ some techniques with proven success used by the previous researchers who conducted systematic reviews on the topic with the contention that they modified the search criteria according to their own prescribed standards shortlisted above. The rationale of their criteria appears to be sound, especially the 6^th criterion, as inclusion of pre-hypertensive subjects in a study can better meet the objectives of this analysis. The other criteria allows for comparison of data obtained from subjects who had been under observation as well as being subjected to blood pressure measurements over a standardized span of time i.e. 8 weeks. Limitations in past reviews which impose bias in such behavioural trials during interpretation, lack of including studies incorporating baseline BP measurements, lack of control groups, non incorporation of trials conducted on adolescents and youth, non usage of single blinding technique appropriate for such studies were eliminated by the authors while conducting the present systematic review. Two or more appropriate studies with the same intervention were analyzed for each intervention, and appropriate and valid software (Review Manager 4.2) was employed by the authors to conduct the meta-analysis to yield level of significance values for individual interventions, which were then compared for their beneficial effect, or none. The analyses has been well presented in the form of two tables from where at a glance, one can evaluate the rigor of a particular study, the methodology/intervention employed as well as the level of significance of the reduction in both systolic as well as diastolic blood pressure.

The clarity with which the authors have conducted this SRR is remarkable. The introductory approach enables the reader to identify with the objective of the review and the gradual build up of the rationality for searching this vital area of preventive medicine can contribute significantly in identifying the non conventional approaches for preventing hypertension, which is gradually attaining the status of a scourge at an early stage of life in both sexes. The authors have carefully dissected the shortcomings in previous systematic reviews and modified the criteria scientifically to conduct a fresh search in order to arrive at some conclusive evidence. The literature search has been conducted with meticulous detail and only the studies satisfying strict criteria have been selected for the meta-analyses. The data generation and presentation is appropriate and the authors convincing in making claims for the deduced inference.

The authors have been able to deduce that transcendental meditation is the only non conventional approach that has succeeded in lowering both the systolic as well as the diastolic blood pressure successfully. Other techniques such as relaxation, biofeedback and stress management training although claimed to succeed in many other studies have been discovered to be insignificant as a result of this systematic review, in lowering blood pressure in hypertensive subjects. The authors have recommended the incorporation of transcendental meditation programmes in the preventive therapeutic repertoire for hypertensive patients with a claim that it can assist in reducing the incidence of subsequent cardiovascular disorders. They have recommended the administration of this form of therapy only under the guidance of qualified practitioners in the art.

The authors conclusion is based on sound, evidence based principles. They have been careful enough to remove factors for bias while conducting this study and have been able to identify the most appropriate non conventional technique to control hypertension. There is no doubt that psychosocial factors play a role in the early occurrence of hypertension and the current lifestyle factors precipitate an early onset. A nursing practitioner should be thoroughly familiar with conventional as well as non conventional approaches to most medical ailments. As the nursing profession is in direct contact with the general public, knowledge of such non conventional approaches and subsequent mastery by additional educational efforts can certainly strengthen professional commitments and delivery of services.

Reference

Rainforth, M.V., Schneider, R.H., Nidich, S.I. et al (2007). Stress Reduction Programs in Patients with Elevated Blood Pressure: A Systematic Review and Meta-analysis, Curr Hypertens Rep. 9(6), pp.520–528.