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Section A

1. Yes, the trial addressed the clearly focused issue. Here, in the research, the issue is investigating the effectiveness of the telemonitoring system for improving the health status of older people, who have been suffering from heart failure. Therefore, the focused issue is heart failure among older adults and the specific intervention telemonitoring that is being considered in the study (Pedone et al. 2015).

2. The allocation of patients, i.e. samples to the treatment was randomised, according to the methods of randomized controlled trial research. For instance, among total 186 patients, 96 participated in the trial and the patients were randomly assigned to either control group or intervention group. The total was 46 patients in control group and 50 patients in intervention group.

3. The trial was not stopped initially. The trial continued with the analysis of maximum participants. Although initially 186 patients met the inclusion and exclusion criteria, but 90 refused to participate and the rest 96 patients were randomized in control and intervention group. However, all the patients, who participated, were not analyzed for final results; because, in the control group, 3 patients and in the intervention group, 3 patients lost to follow up; moreover, 4 patients were dropped out from the intervention. The rest were analyzed for final results (Pedone et al. 2015).

4. No, not all the members participating in the research were blind. Instead of that the patients, who are participating in the research were informed about the research, its purpose, benefits and risks. The health care workers were also having enough information regarding the research. However, the study personnel were blinded to their study allocation, for reducing the risk of research bias.

5. Yes, the groups were similar at the start of their trial. Initially, the trials included 186 patients, but finally 96 patients were randomly distributed through two groups, intervention and control. All the patients were more than 65 years old, irrespective of their sex and religions. However, the sample size was slightly different within two groups, i.e. 46 in the control group and 50 in the intervention group (Clarke et al. 2011).

6. Yes, except the intervention implementation, the control and intervention groups were treated equally, to eliminate differences in results and ethical bias. Moreover, differences among the treatment of two groups may mask the actual efficacy of the telemonitoring intervention.

7. The treatment effect represented significant positive outcomes for the patient studied under the research context. The primary outcomes were clearly specified by the authors. The intervention group received standard care along with a multidimensional assessment. Outcome measures were hospital admissions for any reason or death 180 days from enrolment. The information was gathered from clinical records, when available, or from in person or telephone interviews. For instance, people experiencing composite outcomes were 42 %, which is 21 % for the intervention group, who received telemonitoring as an intervention. 10 outcome events were recorded in the intervention group, two of which occurred in people, who drop out of the study and two participants had poor adherence. Overall, the treatment has been proved to be effective for the sample group. In addition, the treatment was also cost effective (Pedone et al. 2015). For each outcomes, specific results were revealed, including a decline or instability of oxygen saturation preceded three; alteration in heart rate preceded two; and oxygen desaturation, decline in blood pressure, and weight gain preceded one. Moreover, it has been revealed that the treatment has also improved the vital signs of the patients, while enhancing their self esteem.

Section B

8. The intervention and results were precise enough to make the results justified and the study to be credible. For instance, though the incidence rate ratio is different, but the confidence interval was 95 % for the results of both of the control as well as test or intervention group. All the positive outcomes as well as deaths or any negative consequences resulted from the study had confidence level of 95 % (Hindricks et al. 2014).

9. Yes, the trial and its effects can be applied upon the current clinical research, which has been focused upon the older people, who have undergone heart failure. In the randomized trial conducted by Pedone et al. (2015) was focused upon the target group, i.e. the older adults, who are more than 65 years old, irrespective of gender, religion or class discrimination. Moreover the intervention identified and implemented by the author was the telemonitoring system, which is similar to the intervention of selected for the current research work. Therefore, it can be interpreted that the results of this randomized controlled trial are significant to be applied upon local population, i.e. the current research work’s population.

10. Overall, it can be interpreted that all of the visible important research outcomes have been considered by the authors, in the context of clinical research. However, the authors only focused upon representing only the medical outcomes, but the evaluation of economic or societal implications were not represented in the study outcomes, which are needed to establish the effectiveness of the model of telemonitoring.

11. Yes, the benefits worth the harms and costs of the research. It is because, the results revealed a significant positive impact of this telemonitoring tool to improve the overall health outcomes of the target group. In addition, it has also been represented that the tool is significantly cost effective, which would be able to save the cost of hospitalization and frequency of fatality related to the chronic disorders like heart failure. Although, the presence of publication bias may affect the results, but the reduced risk of death of the chronically ill patients as well as reduced visit to clinic or hospital has also improved their psychological health (Inglis et al. 2011). Therefore, overall the research interventions and results were significantly important for the public health.

1. Yes, the study potentially included a clear statement related to the aim of the study. For instance, the aim of the qualitative study provided by Fairbrother et al. (2014) was “The aim of the research study was to understand the views of patients and professionals on the acceptability and perceived usefulness of telemonitoring in CHF in the context of day-to-day care provision”.

Section C

2. Yes, the qualitative methodology is appropriate, because, the research seeks to explore the views and opinions of the participants, which needs the interpretation or illumination of the actions or subjective experiences gained by the participants, i.e. the patients, who have experienced heart failure and managed with telemonitoring system; which is also addressing the key goal of the research (Munn et al. 2014).

3. The authors adopted a qualitative design, where semi-structured interviews were arranged for the participants, i.e. both the patients, who experienced heart failure as well as the physicians, to explore their views related to the effectiveness of CHF telemonitoring service in the context of the focused health issue, i.e. heart failure among the target population, i.e. the aged patients (Fairbrother et al. 2014).

4. Yes, the researchers potentially demonstrated the selection or recruitment strategy for participants in the research. For instance, the patients sample included two parts, i.e. patients, telemonitored by their GP and patients’ telemonitored by the CHF nurse service; Postal invitations to interview were issued to all patients. Then the reminder letters were sent to the participants, who did not responded initially, one month after the dispatch of the first invitation (Jones et al. 2011). Then, prior interview, written consents were taken and in some cases, patient’s family members were also allowed to be present. In addition, the heath care professionals involved in the telemonitoring service were interviewed, including GPs and CFH nurses either in the workplace or via telephone. Moreover, authors also demonstrated the suitability of the samples in the study, i.e. how well the

5. Yes, the research settings as well as the details of the data collection methods have been demonstrated in the research context. The data collection was done via face-to-face interview either via telephone or within the person’s home. The time duration of the interviews were also conveyed. The type of the interview was also conveyed, which was open discussion. To justify the ability of the interviewers, the authors demonstrated and justified the professional background of the interviewers along with the benefits of including them in the research (Fairbrother et al. 2014).  Authors also demonstrated the how these collected data were processed and stored. The form of data was clearly demonstrated, i.e. audio recording, field notes and interview transcripts. Methods were not modified during the research, but they did not discuss the saturation of data.

6. Through discussion, consent collection and interview guide provision, a significant relationship with the participants was developed by the researchers. Although, researchers have not demonstrated their own role in the research clearly, during the research question formulation, data collection or sample recruitment (Munn et al. 2013). In addition, no information related to researcher’s response to events during the study has been addressed in the study.  

Appraisal of Your Qualitative Article

7. Yes, ethical considerations have been demonstrated potentially by the researchers. For instance, the ethical approval was demonstrated, which was granted by the Lothian Research Ethics Committee (ref 08/S1101/34). Moreover, Authors also demonstrated the informed consent for participants and assured the confidentiality of their data. They also addressed how the participants would be handled with the effect of the research.  

8. The data analysis was sufficiently rigorous. It is because, an in-depth description of the data analysis process have been demonstrated. For instance, they demonstrated the approach, which was used for the data analysis. Authors also demonstrated why the method of data analysis was selected. They selected framework approach. The method facilitated the qualitative data synthesis in applied research, provides a strong framework for data management and supports the readers to critically analyze findings through highlighting the process of data interpretation and analysis method (Fairbrother et al. 2014). They used thematic  analysis, where themes were identified two researchers independently through interviews. Researchers also explained the presentation of data from original sample to demonstrate the findings. Possible bias was identified, while presenting sufficient data for supporting findings.

9. Yes, authors presented a clear statement of findings, which were explicit to the researchers as well as the readers. The authors included a thorough discussion part, where the previous evidences in the research field have been discussed to strengthen the findings. In the discussion part, the authors demonstrated some key aspects found from the results, aligning with the previous research, which demonstrating the scope for future practice. Moreover, a clear statement for the strength and weaknesses of the study has also been demonstrated (Bolton et al. 2011). The findings were also discussed related to the original research question. Researchers also discussed about the validity of the findings. Therefore, the findings were appropriate for demonstrating its credibility.

10. Finally, reviewing and appraising the article, it can be stated that the study findings have significantly contributed to the health care technology and its adaption in the health care sector. The previous findings demonstrated the positive aspects of telemonitoring in health care context. This study demonstrated why telemonitoring is necessary to reduce the rate of hospitalization, fatality rates; and how satisfied the patients and physicians are, by implementing the telemonitoring tool in the care context. Researchers have demonstrated a relevant base of literature, while identifying and demonstrating the scope of new research in this area (Seto et al. 2012). Researchers also demonstrated the implementation and relevance of the findings in clinical practice, in other populations, through a short term targeted approach and towards telemetric supported self-management.

The main clinical question for this research is as follows:

In patients with chronic heart failure does remote telemonitoring compared with routine care management of chronic heart failure/reduction of hospital visits?

In the article provided by Pedone et al. (2015), the key objective was to evaluate how the innovative models with telemonitoring affect the 6-months survival and hospital admission of elderly adults experiencing heart failure. The objective and title of the article is directly linked with the research question in the current research, i.e. “In patients with chronic heart failure does remote telemonitoring compared with routine care management of chronic heart failure/reduction of hospital visits?” The research design is a randomized-controlled trial. The research was conducted in the geriatric acute ward and outpatient clinic at Policlinico Campus Biomedico. The author selected participants, who are more than 65 years old and have undergone episodes of heart failure and distributed in two groups, i.e. test and control (Pedone et al. 2015). The key intervention that was implemented was telemonitoring system and office-hours telephonic support by a geriatrician. Authors revealed the incidence of the main outcome as 42% for the control group and 21% for the intervention group. Therefore, from this article, it has been revealed that it is feasible to introduce telemonitoring system in the care plan of elderly people with heart failure, as it reduced the risk of fatality and hospitalization. However, the article is not unbiased, which tend to overestimate the treatment effect (Pedone et al. 2015). The findings helped to address the clinical research question.

In the article provided by Fairbrother et al. (2014) a qualitative study design was undertaken for understanding the patients and physician’s views related to the usefulness and acceptability of telemonitoring in chronic heart failure management in the context of day-to-day care provision. Therefore, the research objective is directly addressing the current clinical research question. In this context, the qualitative design is suitable to address the research aim and objectives. The authors undertook a semi-structured interview with 18 patients and five health care professionals.

Data were collected through audio record, then coded and analysed thematically with the help of framework approach. From the research, authors revealed 5 key themes, which are ‘compliance and dependence’, ‘‘information, support and reassurance’, ‘changes and challenges’, ‘determining the criteria for patient applicability to telemonitoring’ and ‘continuity of care’ (Fairbrother et al. 2014). Therefore, authors interpreted that patients as well as physicians have accepted the telemoitoring tool as a useful tool in managing heart failure among older patients. Therefore, this article also supported the efficiency of telemonitoring in managing the chronic disorder, i.e. HF among older patients. Moreover, this study has been represented as unbiased and significantly answered the research question of the current clinical research.

Analyzing the pre-existing literatures related to the research question, it can be interpreted that telemonitoring is a significant clinical tool to manage the clinical chronic conditions like chronic heart failure among the patients, who are older, i.e. more than 65 years old, in the home environment, while reducing the fatality and hospitalization rate. From both the articles, it has been revealed that the telemonitoring has significantly improved the daily living standards and self-esteem of the patients, which was also supported by the physicians (Fairbrother et al. 2014).

From both of these two articles, a high level of satidfaction with telemonitoring has been revealed. It is because, many patients claimed that they felt reassurance, while thinking that someone is ‘watching over them’. In addition, it has been revealed that the telemonitoring system is consistently helping the elderly people to monitor their vital signs constantly, thereby providing an aid to identify any kinds of change in vital signs immediately and consult with the physicians. It also reduced the necessity of being hospitalized, which sometimes poses additional pressure upon the patient, enhancing the risk of developing psychological issues (Pedone et al. 2015). Thus, the telemonitoring system helped in reducing these kinds of symptoms. In addition, from the thematic analysis, it has been revealed that this system helped promoting patient’s compliance with the therapeutic procedure, while built self esteem of the patients.

However, telemonitoring system has also been represented as a cost saving tool for the hospitals and entire health care authority. On the other hand, it has been revealed that the use of telemonitoring enhanced with age. But, it has been argued that it is important to select a model of care, instead of simply integrating a normal telemonitoring system.

Reference List

Bolton, C.E., Waters, C.S., Peirce, S. and Elwyn, G., 2011. Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD. Journal of evaluation in clinical practice, 17(6), pp.1216-1222.

Clarke, M., Shah, A. and Sharma, U., 2011. Systematic review of studies on telemonitoring of patients with congestive heart failure: a meta-analysis. Journal of telemedicine and telecare, 17(1), pp.7-14.

Fairbrother, P., Ure, J., Hanley, J., McCloughan, L., Denvir, M., Sheikh, A. and McKinstry, B., 2014. Telemonitoring for chronic heart failure: the views of patients and healthcare professionals–a qualitative study. Journal of clinical nursing, 23(1-2), pp.132-144.

Heyvaert, M., Hannes, K., Maes, B. and Onghena, P., 2013. Critical appraisal of mixed methods studies. Journal of mixed methods research, p.1558689813479449.

Hindricks, G., Taborsky, M., Glikson, M., Heinrich, U., Schumacher, B., Katz, A., Brachmann, J., Lewalter, T., Goette, A., Block, M. and Kautzner, J., 2014. Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial. The Lancet, 384(9943), pp.583-590.

Inglis, S.C., Clark, R.A., McAlister, F.A., Stewart, S. and Cleland, J.G., 2011. Which components of heart failure programmes are effective? A systematic review and meta?analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: abridged cochrane review. European journal of heart failure, 13(9), pp.1028-1040.

Jones, S.C., Crookes, P.A. and Johnson, K.M., 2011. Teaching critical appraisal skills for nursing research. Nurse Education in Practice, 11(5), pp.327-332.

Munn, Z., Moola, S., Riitano, D. and Lisy, K., 2014. The development of a critical appraisal tool for use in systematic reviews: Addressing questions of prevalence.

Pedone, C., Rossi, F.F., Cecere, A., Costanzo, L. and Antonelli Incalzi, R., 2015. Efficacy of a Physician?Led Multiparametric Telemonitoring System in Very Old Adults with Heart Failure. Journal of the American Geriatrics Society, 63(6), pp.1175-1180.

Seto, E., Leonard, K.J., Cafazzo, J.A., Barnsley, J., Masino, C. and Ross, H.J., 2012. Mobile phone-based telemonitoring for heart failure management: a randomized controlled trial. Journal of medical Internet research, 14(1), p.e31. 

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