Essay: Smoking Cessation's Impact On COPD Hospital Admissions.

1- Does negative pressure wound therapy lead to improved wound healing when compared to standard moist wound therapy in elderly patients with stage three foot ulcer

2-Does an intensive lifestyle intervention reduce weight and cardiovascular risk factors in overweight patients with type 2 diabetes.

3- Does non touch technique dressing approach reduce wound infection compared to clean dressing approach in a continuing care home patient.

Evidence-Based Nursing Practice and Research Question Development

Evidence-based nursing practice encompasses the scientific procedure that is most commonly adopted by all healthcare professionals, specifically physicians, and nursing professionals, which in turn provides them assistance during clinical decision making process (Greenhalgh, Howick and Maskrey 2014). This improves the delivery of optimal healthcare services to all patients, regardless of the health abnormality they are suffering from. EBN process is often supported by an appraisal of maximum quality of research articles that are statistically significant. Hence, EBN involves the judicious, conscientious, and explicit utilization of scientific evidences that are best available (Melnyk et al. 2014). This facilitates the process of clinical decision making that will enhance patient outcomes.

Research evidences have established strong correlation between smoking and high prevalence of chronic obstructive pulmonary disease (COPD) (Hessel et al. 2014). This refers to a chronic inflammatory lung disease that occurs due to obstruction of airflow in the lungs. Owing to the fact that tobacco smoking is a primary risk factor that increases the likelihood of an individual to suffer from COPD, keeping people away from smoking has been identified as a major aspect of preventing worsening of symptoms due to COPD (Camp et al. 2014). Moreover, the acute exacerbations of COPD have been found to act as major causes of recurrent hospitalizations, which in turn is associated with significantly high mortality and morbidity (Bollu et al. 2013). This report will critically evaluate an article that measures the effectiveness of smoking cessation on hospital admissions of COPD patients.

Development of an appropriate research question is an integral part of EBN. The research question was kept specific and comprehensive, which facilitated the retrieval of articles, relevant to the research objective. The research question that this EBN will address is given below:

Does smoking cessation reduce rate of hospital admissions among COPD patients?

The aforementioned question has been separated into several elements, based on the PICO model/framework. The PICO format can be defined as a technique that is widely used in EBN, with the aim of providing relevant clinical answers to a healthcare question (Costantino, Montano and Casazza 2015). The primary objective of the PICO framework is to assist the process of literature search. These elements of the PICO question encompass population/problem, intervention, comparison and outcome (Cooke, Smith and Booth 2012). The developed research question is often categorized into these four elements. This facilitates in extracting relevant clinical information that are relevant to the context of the research question. In this EBN, the population encompasses patients suffering from COPD. The intervention will encompass the non-therapeutic procedure of smoking cessation programs, to which the patients will be subjected. The outcome element will encompass a comprehensive analysis of the impact of smoking cessation on rates of hospitalization. In this context, the article selected will not compare the rates of hospitalization, upon implementation of two different procedures.

P	Population	COPD patients
I	Intervention	Smoking cessation
C	Comparison	NA
O	Outcome	Rates of hospitalisation

PICO Framework and Search Methodology

Table 1- PICO search format

The search strategy formed an organized structure of the search terms that were used to search for relevant articles from databases. The search strategy combined major concepts of the PICO question in order to extract accurate results. Two electronic databases namely, PubMed and CINAHL were searched for retrieving peer reviewed high quality articles that were published in English, relevant to the research question.

Several search terms such as, ‘smoking’, ‘cessation’, ‘withdrawal’, ‘COPD’, ‘chronic’, ‘obstructive’, ‘lung’, ‘disease’, ‘disorder’, ‘hospital’, ‘hospitalisation’ were used in conjunction with three boolean operators namely, ‘AND’, ‘OR’, and ‘NOT’. These boolean operators helped in either narrowing or broadening the search results. The operator ‘AND’ helped in narrowing the retrieved hits by presenting all of the search items that were fed as an input, in the retrieved records. The ‘OR’ operator broadened the search results by forming a connection between two or more synonyms that were used as key terms such as, ‘disease OR disorder’, and ‘cessation OR withdrawal’. In addition, the ‘NOT’ operator facilitated exclusion of all irrelevant terms from the search results (McGowan et al. 2016).  Truncations (*) or wildcard searches were used with the aim of finding variations of the predetermined key terms. Truncation proved useful in retrieving singular or plural forms of the variant endings and words. Owing to the fact that the databases use asterisk as the truncation symbol, ‘hospita*’ helped in finding articles with ‘hospitals’, ‘hospitalization’, or ‘hospitalization’. Furthermore, use of wildcards proved useful in finding articles that contained search terms with both American and British spellings. Use of the wildcard ‘hospitali?ation’ in the database yielded results with both ‘hospitalization’, and ‘hospitalization’.

Keyword (P)	AND	Keyword (I)	AND	Keyword (C)	AND	Keyword (O)
‘COPD’		‘smoking cessation’				‘hospitalisation’
OR		OR				OR
‘chronic obstructive pulmonary disease’		‘smoking prevention’				‘hospital admission’
OR		OR				OR
‘chronic obstructive pulmonary disorder’		‘smoking withdrawal’				‘physical functioning’
						OR

Table 2- Boolean operators and truncations

INCLUSION CRITERIA	EXCLUSION CRITERIA	RATIONALE
English	Non-English articles	To prevent translation difficulties
Young and older smokers with COPD	Animal models	To retrieve maximum hits
Published on or later to 2013	Published before 2013	To ensure congruency of search hits with the PICO question
Full text articles	Abstracts or manuscripts or abstracts	To avoid poor credibility and reliability

Table 3- Inclusion and exclusion criteria

Search ID	Search terms	PubMed	CINAHL
S1	smoking	46337	35211
S2	cessation	12677	10964
S3	withdrawal	8550	7531
S4	COPD	15643	13249
S5	“chronic obstructive lung disease”	14728	15633
S6	hospital	866111	758207
S7	hospitalisation	63291	55194
S8	S1 AND S2	8264	6314
S9	S1 AND S2 OR S3	16398	11743
S10	S1 AND S2 AND S4	400	372
S11	S1 AND S2 OR S3 AND S4 AND S6	192	117
S13	S1 AND S2 OR S3 AND S4 AND S7	43	31
S12	S1 AND S2 OR S3 AND S4 AND S6 OR S7	32	23

Table 4- Electronic database search hits (after applying filters)

A refined search of 55 articles from two electronic databases, to assess their full text eligibility, gave 13 articles. The selected article was found in both the databases. It met all aspects of the PICO question.

This is defined as the process that involves a systematic and careful examination of the strengths and weaknesses of a research article, with the aim of evaluating the validity and usefulness of the research findings (LoBiondo-Wood and Haber 2017). The article selected for the critical appraisal is given below:

Hassan, H.A., Aziz, N.A., Hassan, Y. and Hassan, F., 2014. Does the duration of smoking cessation have an impact on hospital admission and health-related quality of life amongst COPD patients?. International journal of chronic obstructive pulmonary disease, 9, p.493.

Critical Appraisal of Selected Article

6 critical questions that trigger critical thinking will be used for appraising the article (Aveyard and Sharp 2013). The questions are given below:

TRIGGER QUESTIONS	RATIONALE
Where	Where did the relevant information come from?
What	What were major findings?
How	How were the conclusions made?
Who	Who wrote them and what is their credibility?
When	When was the article published and what is the validity?
Why	Why was it written and what is its objective?

Table 5- 6 Questions that trigger critical thinking

The aforementioned article was published in the year 2014. Validity of the article can be established by the fact that it has been cited several times in other articles and published in an international journal of repute.

Credibility of the authors can be ascertained as the information on their affiliations and credentials suggest their association with the Ministry of Health Malaysia.

The researchers conducted this study to investigate the awareness among smokers with COPD, regarding effectiveness of smoking cessation programs on their overall quality of life and hospital admission rates. Previous findings have established the fact that patients admitted to healthcare units for COPD exacerbation are often found at an increased rate of re-hospitalisation and subsequent death (Baker, Zou and Su 2013). Thus, COPD increases the rate of hospitalization and associated mortality rates, from other co-morbidities. Furthermore, researchers have identified COPD as the third highest cause of global deaths, in the year 2020 (López?Campos, Tan and Soriano 2016). Owing to the fact that smoking cessation programs have been found effective in reducing exposure to all forms of tobacco smoke and have proved beneficial for patients suffering from COPD, the researchers were accurate in identifying their objective (Warnier et al. 2013).

The research title is succinct and self-explanatory in reflecting the actual purpose or aim of the article. The abstract provides detailed information on the overview of the research study and also contain relevant information on the methods used for determining the effects of the cessation programs. Furthermore, adequate information is also provided on the findings. Formulation of an appropriate research objective can be attributed to the fact that previous findings have established correlation between cessation programs and improved health of COPD patients (Zuo et al. 2014). Thus, the researchers demonstrated an accurate approach in investigating the impact of smoking cessation duration on hospital admission and health related QoL of COPD patients.  

Reliability of the smoking cessation program can be established by the fact that it was based on previous findings that demonstrated the role of cessation program in lowering hospital admission rates among patients suffering from diseases such as, COPD (Vestbo et al. 2013). Furthermore, the researchers also took into account the fact that a reduction in lung function might lead to an increase in rates of hospital admissions due to manifestation of symptoms that are related to respiratory dyspnea, thereby creating significant negative impacts on the patient health status (Paddison et al. 2013). Due to the fact that the authors conducted an interview, in addition to collecting information on demographic variables, previous admissions, medication and smoking cessation history, it can be stated that results of the intervention was reliable.

Findings of the Article

The study recruited 198 subjects (smokers and non-smokers), based on COPD diagnosis by physicians. Furthermore, patients who reported problems of asthma, congestive cardiac failure, long term oxygen supplementation and exacerbation, 4 weeks before QoL measurement were excluded. This can be considered as the best approach for recruiting participants to the two groups, smokers and non-smokers. Owing to the fact that COPD is found to affect males and females in almost equal proportions, more number of females should have been recruited for the study, to avoid any selection bias.

The researchers did not use a blinding approach in the study. Blinding or concealment of group allocation is generally followed for one or more individuals who are involved in a clinical research (Hróbjartsson et al. 2013). This was a study where there was no blinding approach used and all the parties were aware of the intended purpose of the study. Hence, this might be called an open label study.

The participants recruited at the beginning of the study were not similar due to the fact the sample contained smokers as well as non-smokers. Ensuring that the population contained a mixture of participants, the authors were able to obtain significant results regarding effects of smoking cessation.

They addressed a clearly focused issue related to effects of smoking cessation and its duration on hospital admissions and subsequent quality of life of the smokers. Reliability of the study can be established by the fact that in addition to the primary effects of hospitalization rates, they also measured the health related quality of life, before and after smoking cessation programs, in addition to demographic variables. This can be considered significant as demographics acts as major indicators of the QoL (Fayers and Machin 2013).

Of the 198 participants who were initially recruited, 117 were accounted for at the end of the study, according to the inclusion criteria. A total of 41 sustained quitters, 36 smokers and 40 quitters were evaluated at the end of the study. 82.9% participants reported smoking cessation with non-pharmacological treatment. Comorbidities were reported among 50% of the subjects that included dyslipidemia, hypertension, osteoporosis, diabetes, hormonal disorder, and obesity. An evaluation of the hospitalisation rates suggested a presence of statistically significant mean annual hospitalization among quitters, upon comparison to smokers (odds ratio 4.5, confidence interval 1.91–10.59; P=0.005). However, no significant differences were observed in the length of hospitalisation. Statistically significant improvements were obtained in sustained quitters, upon comparison to smokers, in the symptom domain (odds ratio 0.02, confidence interval 0–0.12; P=0.001).

The precision of the obtained results can be established by the fact that the odds ratio acted as a direct measure of the association between the exposure to smoking cessation and reduced hospitalization and improved quality of life. The odds ration represented the odds that the outcomes would occur given the smoking cessation program is implemented appropriately (Grant 2014). The odds ratio of 4.5 for increased annual hospitalization rates indicates high probability of the event to occur. Hence, it overestimates the relative risks.

Moreover, the smoking cessation program can be easily implemented in the local context, upon smokers suffering from COPD. However, the fact that smoking quitters demonstrated an increased rate of hospital readmissions than smokers, without any significant changes in their health related quality of life, calls for the need of increasing the duration of the cessation program. This reconfirms the fact that implementation of cessation for a longer period might help in achieving the intended goals of reduced rates of annual hospital admissions of COPD patients.

The findings from the research have been disseminated by using the results in clinical practice. Adequate funding from health organizations was followed by selection of the target population. Implementation of smoking quitting programs for longer time period was found to reduce the high hospitalization rates. Cost-effectiveness of the program also validated the need of adopting this approach, for a longer time period, to find an enhanced quality of life.

Conclusion

Hence, it can be concluded that there is a lack of adequate literature that investigated the effects of quitting smoking and its direct impacts on readmission rates and health related QoL. The positive effects of smoking cessation on the morbidity and mortality of smokers have already been well established. Moreover, a range of studies have been conducted that determined the association between quality of life and COPD symptoms. It can be concluded that smoking status acts as a potential contributor to the changes that influence the overall quality of life of all patient suffering from COPD. This helps in drawing a conclusion that smoking acts as an important trigger for flare-ups related to COPD.

Direct damages to the airways, air sacs, and lining of the lung brings about a deterioration of the overall patient condition and significantly increases risks of morbidities that creates difficulties for the injured lungs in facilitating passage of air. Difficulty in breathing increases the likelihood of the COPD smokers to get repeatedly admitted at hospitals. Hence, efforts must be taken to educate the target population about the benefits of quitting smoking to protect the lungs and prevent recurrent hospital admissions. However, there is a need to increase the period of cessation to exert direct benefits on quitters and sustained quitters.

References

Aveyard, H. and Sharp, P., 2013. A beginner's guide to evidence-based practice in health and social care. McGraw-Hill Education (UK), pp.109-141.

Baker, C.L., Zou, K.H. and Su, J., 2013. Risk assessment of readmissions following an initial COPD-related hospitalization. International journal of chronic obstructive pulmonary disease, 8, p.551.

Bollu, V., Ernst, F.R., Karafilidis, J., Rajagopalan, K., Robinson, S.B. and Braman, S.S., 2013. Hospital readmissions following initiation of nebulized arformoterol tartrate or nebulized short-acting beta-agonists among inpatients treated for COPD. International journal of chronic obstructive pulmonary disease, 8, p.631.

Camp, P.G., Ramirez-Venegas, A., Sansores, R.H., Alva, L.F., McDougall, J.E., Sin, D.D., Paré, P.D., Müller, N.L., Silva, C.I.S., Rojas, C.E. and Coxson, H.O., 2014. COPD phenotypes in biomass smoke-versus tobacco smoke-exposed Mexican women. European Respiratory Journal, 43(3), pp.725-734.

Cooke, A., Smith, D. and Booth, A., 2012. Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qualitative Health Research, 22(10), pp.1435-1443.

Costantino, G., Montano, N. and Casazza, G., 2015. When should we change our clinical practice based on the results of a clinical study? Searching for evidence: PICOS and PubMed. Internal and emergency medicine, 10(4), pp.525-527.

Fayers, P.M. and Machin, D., 2013. Quality of life: the assessment, analysis and interpretation of patient-reported outcomes. John Wiley & Sons, pp.3-45.

Grant, R.L., 2014. Converting an odds ratio to a range of plausible relative risks for better communication of research findings. Bmj, 348, p.f7450.

Greenhalgh, T., Howick, J. and Maskrey, N., 2014. Evidence based medicine: a movement in crisis?. Bmj, 348, p.g3725.

Hassan, H.A., Aziz, N.A., Hassan, Y. and Hassan, F., 2014. Does the duration of smoking cessation have an impact on hospital admission and health-related quality of life amongst COPD patients?. International journal of chronic obstructive pulmonary disease, 9, p.493.

Hessel, J., Heldrich, J., Fuller, J., Staudt, M.R., Radisch, S., Hollmann, C., Harvey, B.G., Kaner, R.J., Salit, J., Yee-Levin, J. and Sridhar, S., 2014. Intraflagellar transport gene expression associated with short cilia in smoking and COPD. PloS one, 9(1), p.e85453.

Hróbjartsson, A., Thomsen, A.S.S., Emanuelsson, F., Tendal, B., Hilden, J., Boutron, I., Ravaud, P. and Brorson, S., 2013. Observer bias in randomized clinical trials with measurement scale outcomes: a systematic review of trials with both blinded and nonblinded assessors. Canadian Medical Association Journal, pp.cmaj-120744.

LoBiondo-Wood, G. and Haber, J., 2017. Nursing Research-E-Book: Methods and Critical Appraisal for Evidence-Based Practice. Elsevier Health Sciences, pp.2-66.

López?Campos, J.L., Tan, W. and Soriano, J.B., 2016. Global burden of COPD. Respirology, 21(1), pp.14-23.

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Melnyk, B.M., Gallagher?Ford, L., Long, L.E. and Fineout?Overholt, E., 2014. The establishment of evidence?based practice competencies for practicing registered nurses and advanced practice nurses in real?world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence?Based Nursing, 11(1), pp.5-15.

Paddison, J.S., Effing, T.W., Quinn, S. and Frith, P.A., 2013. Fatigue in COPD: association with functional status and hospitalisations. European Respiratory Journal, 41(3), pp.565-570.

Vestbo, J., Hurd, S.S., Agustí, A.G., Jones, P.W., Vogelmeier, C., Anzueto, A., Barnes, P.J., Fabbri, L.M., Martinez, F.J., Nishimura, M. and Stockley, R.A., 2013. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American journal of respiratory and critical care medicine, 187(4), pp.347-365.

Warnier, M.J., van Riet, E.E., Rutten, F.H., De Bruin, M.L. and Sachs, A.P., 2013. Smoking cessation strategies in patients with COPD. European Respiratory Journal, 41(3), pp.727-734.

Zuo, L., He, F., Sergakis, G.G., Koozehchian, M.S., Stimpfl, J.N., Rong, Y., Diaz, P.T. and Best, T.M., 2014. Interrelated role of cigarette smoking, oxidative stress, and immune response in COPD and corresponding treatments. American Journal of Physiology-Lung Cellular and Molecular Physiology, 307(3), pp.L205-L218.