Conventional Medical Follow Up in Management of Patients with Lung Cancer - Essay Example

Introduction In a study conducted by Moore et al (2002, pp. 1145-7) en d “Nurse Led Follow Up and Conventional Medical Follow Up in Management of Patients with Lung Cancer: Randomised Trial,” the researchers concluded that nurse led follow up care didn’t increase cost or risk to patient, yet delivered higher patient satisfaction and decreased burden on hospitals. A careful look into the specifics of the study reveals some weaknesses as well as basis for further investigation. Study purpose A collaborative study was used to determine whether a nurse led follow up service for lung cancer patients was more effective than the conventional medical follow up services offered through the outpatient clinics. The hypothesis was that this type of service would enhance care, reduce costs and increase patient quality of life. According to Van Tulder et al (1997, p. 2324), outcomes measuring patient care should include pain, functional status, ability to work and satisfaction with treatment, all of which are addressed in this study. Although this isn’t clearly stated, it is relevant in that it addressed a number of these variables. Some subsequent studies into the effectiveness of home care versus outpatient clinic care such as “Routine hospital admission versus outpatient or home care in children at diagnosis of type 1 diabetes mellitus” (Clar, Waugh, Thomas, 2003) yielded inconclusive results regarding the benefits of in-home care versus outpatient care while others, such as “Care home versus hospital and own home environments for rehabilitation of older people” (Ward, Severs, Dean, Brooks, 2003), suggest there is still not enough completed research to provide accurate, reliable results. Study design The study utilized an experimental approach which was exploratory and causal and appropriate to the purpose as it uses three properties – randomization, control and manipulation – to allow other explanations for a phenomenon to be ruled out and therefore strengthen cause-and-effect relationships (Schneider, Elliott, LoBiondo-Wood, Haber, 2003, p. 317). According to Schneider et al, “the primary focus [of experimental designs] is on assessing the validity of the finding that the intervention (independent variable) caused the desired effect on the outcome (dependent) variable” (p. 317). “Randomized trials distribute confounding variables equally, making it safer to conclude that differences across groups reflect the intervention in question” (BMJ USA, 2002, p. 137). Sample size The sample size was determined by the number of patients available who both fit the criteria for the study and who were willing to volunteer for this type of research. In this case, 203 patients with lung cancer who had completed initial treatment and were expected to survive for at least three months accepted the invitation to participate and were divided nearly equally between conventional and nurse led follow up care. Campbell, Julious and Altman claim “maximum power is usually achieved by having equal numbers in the two groups” (1995, p. 1145). An independent trials office was used for the randomization of patients and an independent data monitoring committee was consulted on the design of the study. However, by not elaborating on how sample size was determined, this study leaves itself open to criticism that they took a logistical approach rather than clinical approach to this calculation (Torgerson & Campbell, 2000, p. 697). The small sample size limits generalisability considerably. Coupled with a high rate of attrition due to death and ill health, more study would be required to support the findings. Sampling is closely associated with the issue of generalisability (Mays & Pope, 1995, p. 109). Data collection Data was collected at 3, 6 and 12 month intervals from the patients by the use of a questionnaire based on the European Organisation for Research and Treatment of Cancer’s (EORTC) core questionnaire and module about lung cancer. The methods for obtaining results regarding physical health, use of services and other factors are described in detail as well, making it possible to determine that the variables of interest were addressed. David Lane says dependent variables are measured while independent variables are manipulated by the experimenter (2003). In this study, the nurse led follow up care program was the independent variable while the effects on both patients and practitioners were dependent variables. “Although the importance of quality of life is broadly acknowledged, skepticism and confusion remain about how quality of life should be measured and its usefulness in medical research. These responses may reflect important conceptual and methodological limitations of the current concept of quality of life” (Muldoon, Barger, Flory, Manuck, 1998, p. 542). Regardless of the doubts regarding the specifics of how quality of life should be measured, the results of these tests were sufficient to demonstrate that nurse led follow up care is “safe, acceptable, and cost effective” (Moore et al, 2002, p. 1147). Schneider et al (2003) say reliability is the extent to which a measure, procedure or instrument yields the same result in repeated trials. “It is involved with consistency, precision, stability, equivalence and homogeneity” (p. 35). These tests are deemed reliable because they were previously tested in a pilot study. Although there is strong internal validity in that the only difference in treatment plans was the use of conventional or nurse led care so the results had to be a consequence of the more individualized treatment, external validity is weak because the sample size was small to begin with, did not range over a wide section of the population and contained a high attrition rate. Data analysis Statistics were reported in the form of charts regarding patient characteristics, patient recruitment and follow up, quality of life mean test results, patient satisfaction, use of services and cost per patient. Median scores for the quality of life and satisfaction tests between the groups were compared using the Mann-Whitney U test. A Kaplan-Meier survival analysis was used to estimate disease progression. Data analysis techniques are determined by the research questions and the assumptions or biases brought into the research (Helberg, 1996). In analyzing the cost portion of the study, Moore et al (2002) failed to provide specific documentary evidence to support their conclusions as is suggested by Barber and Thompson (1998, p. 1195), but validity is strengthened by the use of Netten and Curtis (2000) as a base provider of information with reference to numbers provided by the Department of Health. In terms of quality of life, results showed patients’ needs in nurse led care were addressed on a more individual basis and more patients were able to receive the type of care they wished. The burden on hospitals and clinics was also reduced without a significant reduction in overall health of patients although care costs remained relatively equal. Mortality rate remained high, but most patients opted to continue with the nurse led program following the study’s conclusion, indicating a high rate of satisfaction. The validity of this study is backed up by similar findings in Grunfeld et al (1996, p. 669) in which 31 percent of breast cancer patients preferred nurse led follow up to the outpatient clinic. Limitations of the study include the limited study population, the high rate of attrition and the possibility that some of the outcomes included in the study might have happened by chance. “Problems relating to recruitment, attrition, and the vulnerability of the patient group make randomised controlled trials in palliative care difficult” (Grande, Todd, Barclay, Farquhar, 1999, p. 1472). If further research into this arena or further development of such programs result, nurses will have much greater responsibility in terms of managing care and determining when testing is required. Critical Thinking requirements To analyse research in this way, it is necessary to employ several critical thinking behaviors. In a study such as this one, it is necessary to be able to read through the material and clearly define the problems inherent in the literature. This is done by collecting and examining evidence to see where the holes are. For instance, in this study, 203 patients began the study, but only 61 were able to finish it. Some assumptions must have been made in determining the reported outcomes. In addition, for many, a bias toward more individualized health care may make them predisposed to see promise where there is none – no significant differences were reported in cost or survival of patients, yet it was optimistically suggested that nurse led follow up care should be continued. Furthermore, no background is given as to the standing of the researchers. Are they nurses, doctors, pharmacists, students? What is their scope of interest? Without knowing this, it is difficult to ascertain where their biases and assumptions might lie in approaching the study. However, regardless of these answers, there remains some truth to the argument that those patients participating in the study who had nurse led follow up opted to remain in the program even after the study was concluded. It is also reported that 40 percent of the patients in nurse led care who expressed a desire to die in their homes were afforded their wish compared with only 23 percent in conventional care. These harder numbers tend to substantiate the claims of the authors enough to encourage further research where other evidence was not as air-tight. Alternatives for these outcomes are few as there is only one other option, which was not selected by the patients, and that is conventional outpatient care. Once these alternatives and factors are identified, compared and considered, it is possible to synthesize the general meaning of the study enough to conclude that there is perhaps merit in conducting further research using a wider population base, a different population base or a different setting so as to exclude the supervision. Conclusion Rather than just reading through the research presented, it is necessary to actively read the document applying significant critical thinking skills such as problem definition, collecting and examining evidence, analyzing assumptions and biases, considering alternatives, comparing and contrasting results and synthesizing the information presented before one can determine whether the research in question did an adequate job of proving its results. In this case, the research was sufficient enough to show some correlation between patient satisfaction and nurse led follow up care, but was not sufficient to show that differences in mortality rates, cost per patient or other factors were affected one way or another depending upon treatment. References Barber J, Thompson S 31 October 1998, ‘Analysis and interpretation of cost data in randomised controlled trials: review of published studies’, British Medical Journal, vol. 317, pp. 1195-2000. 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Muldoon M, Barger S, Flory J & Manuck S 14 February 1998, ‘Education and debate: what are quality of life measurements measuring?’, British Medical Journal, vol. 316, pp. 542-45. Netten A & Curtis L 2000, Unit Costs of Health and Social Care, Canterbury: Personal Social Services Research Unit, University of Kent. Schneider Z, Elliott D, LoBiondo-Wood G & Haber J 2003, Nursing Research: Methods, Critical Appraisal and Utilisation. 2nd Ed. Sydney: Mosby. Torgerson D & Campbell MK 16 September 2000, ‘Economics notes: cost effectiveness calculations and sample size’, British Medical Journal, vol. 321, p. 697. Van Tulder MW, Assendelft WW, Koes BW, Bouter LM & the Cochrane Back Pain Editorial Board, 1997, ‘Method guidelines for systematic reviews in the Cochrane Back Review Group for spinal disorders’, Spine, vol. 20, pp. 2323-30. Ward D, Severs M, Dean T & Brooks N 22 April 2003, ‘Care home versus hospital and own home environments for rehabilitation of older people’, The Cochrane Database of Systematic Reviews 2003, issue 2, viewed 19 January 2006, < http://www.cochrane.org/cochrane/revabstr/AB003164.htm>. Read More