Drevenhorn et al (2007), Article Critique Example

Drevenhorn, E., Kjellgren, K. I., Bengtson, A. (2007).Outcomes following a programme for lifestyle changes with people with hypertension. Journal of Nursing and Healthcare of Chronic Illness, in association with Journal of Clinical Nursing, 16 (7b), 144-151. doi: 10.1111/j.1365-2702.2005.01493.x

Introduction

This study investigated the effectiveness of a nurse-led intervention of lifestyle changes in people with hypertension. The idea behind the study was to use a non-pharmacological approach to address hypertension in patients by counseling the patients on issues of weight control, smoking, alcohol consumption, diet, physical activity, and control of stress. The authors cite prior research that has demonstrated that control of hypertension can be very effective at reducing hospital readmissions after cardiovascular events. They note such control programs can also reduce mortality from cardiovascular disease. In particular the authors noted that while lifestyle changes can be very effective at hypertension control, it is very hard to implement such changes over the long-term. The authors also noted that prior research showed that patient-centered counseling in which the patient was an active participant was more likely to succeed than other types of interventions.

The paper’s introduction provided a useful background on the subject of the research topic and explains why the authors chose to investigate this type of intervention for the control of hypertension. With hypertension, cardiovascular disease so prevalent in Western society, the study is highly appropriate and of interest.

The justification of the study is more than sufficient to perform the study. Hypertension is an important problem in the Western world, and it is of value to research ways that may help control this problem, particularly when they are non-pharmacological in nature. Improving lifestyle has been shown by prior studies to positively impact hypertension. However, as the authors noted in their introduction, such lifestyle changes are difficult to bring about and even harder to sustain over the long term.

The purpose of the study is clearly articulated in the introduction: to determine if nurse-led, patient-centered counseling on lifestyle changes can be effective in control of hypertension. Patients in this study were typically receiving pharmacological treatments for their hypertension at the start of the study, although in many cases (detailed in the paper), those medications were changed during the 15 months of the study. Again, while not explicitly stated, the foreground question of this paper was, can patient-centered counseling on lifestyle changes can be effective in control of hypertension? While not explicitly stated, the implicit hypothesis was that such an intervention could be effective at control of hypertension via lifestyle changes.

PICO provides a way of constructing an effective clinical or research study question. The PICO analysis of this study is:

Patient or Problem: 100 adults in southern Sweden diagnosed with hypertension; some had other conditions such as diabetes (21);

Intervention: a structured, nurse-led, patient-centered counseling program on lifestyle changes to control hypertension;

Comparison: using a pre-test vs. post-test design due to the lack of alternative nurse-led clinics to act as a control group;

Outcomes: measured improvement in any of blood pressure, smoking alcohol consumption, weight, BMI, cholesterol levels (HDL & LDL), triglycerides.

It should be noted that this was a structured intervention and patients received counseling only for those aspects of lifestyle that were relevant to their individual health challenges (i.e., nonsmokers did not receive advice on how to stop smoking, etc.).

During the 15 months of the study, 17 of the initial 100 participants dropped out and were lost to follow-up. The sample size is thus too small to provide good generalization to larger populations. Also, the study lasted only 15 months, thus whether the lifestyle changes found in the participants may or may not be permanent. Despite these limitations, noted by the authors, this study provides an indication that patient-centered counseling can assist patients in changing their lifestyles at least in the short term, and can get good results. For example, many patients increased their activity levels, and the women generally lost weight (though their waist sizes increased). Moderate improvements were also seen in some clinical measures. Less successful were interventions on smoking (only 2 of 14 quit smoking), alcohol consumption (no change), weight in men (weight increased slightly), total cholesterol (increased), and triglycerides (increased). Only 7 of the 100 patients received no medication for hypertension at the start of the study, and at the end, only 2 still were unmedicated. Thus, this study does not provide strong evidence for the success of the nurse-led intervention.

The working hypothesis of this study is that the nurse-led counseling intervention on lifestyle alterations can assist with the control of hypertension. This study was an experimental one in that it performed an intervention and then measured the outcomes associated with that intervention. The experimental design did not isolate the variables because the patients were nearly all on hypertension medications at the start and throughout the course of the study. Furthermore the medications prescribed were not held constant, but changed throughout the study in accordance with patient clinical conditions. Thus, isolating the impact of the intervention from that of the medications is virtually impossible in this case.

The level of evidence of this study is Level III, a pre-post study using a single group. However, the strength and consistency of the evidence is rated at a C because the results were inconsistent. One of the problems with this study is that the patients had their hypertension medication adjusted during the course of the study. Thus, it is unclear whether improvements in the patients’ clinical measures were due to the lifestyle changes and intervention, or due to receiving more appropriate medications. The short term of the study is also insufficient to determine if the lifestyle changes implemented by the participants would become permanent or would fade after the study ended. An additional problem was that patients had different combinations of lifestyle issues (smoking, diet, alcohol consumption, etc. ). It might be more effective to isolate the participants into separate groups rather than trying to cover all lifestyle changes in a single study.

While this paper does not produce high-quality evidence, it does provide a hint that similar counseling interventions may be effective. A better designed, more focused, and larger scale study would be of value to determine if such lifestyle counseling is of long-term value. Because of the relatively low quality of the evidence presented in this paper, it is unclear whether applying it in clinical practice would be beneficial. The paper presented little convincing evidence that the counseling had a significant impact on the lifestyle choices of the participants or significant improvement in overall patient outcomes. Thus, this paper is not recommended as being sufficiently evidentiary to use in support of an evidence-based practice.

References

Drevenhorn, E., Kjellgren, K. I., Bengtson, A. (2007).Outcomes following a programme for lifestyle changes with people with hypertension. Journal of Nursing and Healthcare of Chronic Illness, in association with Journal of Clinical Nursing, 16 (7b), 144-151. doi: 10.1111/j.1365-2702.2005.01493.x