Critical Analysis of a Quantitative Article on Nurse Care Management

This report presents a critical analysis of a quantitative research article titled "Augmented nurse care management in CKD stages 4 to 5: a randomized trial" published in the American Journal of Kidney Diseases. The study investigated the impact of augmented nurse care management on patients with end-stage renal disease (ESRD). The analysis assesses the article's title, abstract, introduction, research question, literature review, framework, methods (including human rights, research design, population and sample, data collection, and procedures), results, discussion, and limitations. The report evaluates the study's strengths, weaknesses, and overall contribution to nursing practice, particularly concerning the reduction of hospitalization rates and improved patient outcomes. The report emphasizes the importance of the study design, methodology, and the implications of the findings for clinical practice and future research in the field of nephrology nursing.

Running head: NURSING RESEARCH
Critical analysis of a quantitative article
Name of the Student
Name of the University
Author Note

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Critical appraisal refers to the process of systematic and careful examination of a
particular research for judging the value, relevance and trustworthiness of the article with regards
to the particular research context (Crowe, Sheppard & Campbell, 2012). This essay will contain
a critical appraisal of a quantitative article on augmented nurse care management for end stage
renal disease.
Article-
Fishbane, S., Agoritsas, S., Bellucci, A., Halinski, C., Shah, H. H., Sakhiya, V., & Balsam, L.
(2017). Augmented nurse care management in CKD stages 4 to 5: a randomized
trial. American Journal of Kidney Diseases, 70(4), 498-505.
Title- The title of the article is comprehensive and specific in the fact that it suggests the
key phenomenon, augmented nurse care management (in this context) and clearly mentions that
target population and the kind of study (randomized controlled trial) that was conducted. The
target group or community comprises of patients suffering from chronic kidney disease, stage 4
and 5. Thus, the title was succinct.
Abstract- Although there was no specific heading for abstract of the study, before the
introduction section, the entire proceedings of the research were summarized under
corresponding headings such as study design, intervention, outcome, results, and limitations,
among others. This summarized information was adequately presented and were successful in
giving an overview of the main features of the research. It suggested that the trial was a
randomized controlled one, conducted at three sites and mentioned about the study sample and
the results of augmented nurse care management on them.

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Introduction- The problem of end stage renal disease is presented unambiguously and is
easy to identify from the introduction section. The section clearly establishes the fact that end
stage kidney disease occurs as a transition of CKD and has huge prevalence as suggested from
reports published in the previous year (Saran et al., 2017). It is able to establish the fact that
providing adequate care for this health abnormality requires sufficient amount of care and
education for dialysis, and kidney transplantation (Coca, Singanamala & Parikh, 2012).
The problem statement is able to build a cogent and persuasive argument for new studies
as it is able to address all related variables and provides clear prevalence rates and data for the
same. The problem is presented in a way that convinces the readers of the truth of the
proposition.
The problem holds great significance for nursing because all patients suffering from
ESRD are hospitalized at least twice a year. 30% of these hospital admissions are unplanned and
create a huge financial and societal burden (Eckardt et al., 2013). Thus, the research would
contribute to nursing practice significantly by providing a sound understanding of taking care for
the patients.
A good fit has been observed between the research problem and the paradigm in which it
was conducted. The study accurately fits in the method of quantitative research focused on
positivist paradigm. The research abundantly contains empirical data and controls all essential
variables involved in the study. Initially 130 participants were meticulously searched across three
nephrology offices located in the district and were randomly assigned to the intervention. The
participants were screened based on predetermined eligibility criteria and voluntary participation.

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Research question- The article does not contain a specific research question. However,
the primary purpose of conducting the study is well implied throughout the sections of
introduction and study design. However, the authors were able to provide a clear rationale for the
research objective by correlating healthy Transition care management programs with reduced
hospitalization rates and improved education among patients.
The research objective was appropriately worded and provided a succinct explanation of
the target population (ESRD patients) and the major variables (transition nursing care
management) involved in the study.
The authors did not conduct any literature review for the proposed research objective.
However, the conceptual framework on which the study was based was completely in
accordance with the objective and determined effects of the augmented nursing care management
program on hospitalization rates among ESRD patients.
Literature review- The research article did not contain a separate section for literature
review. However, most articles included in the introduction section that illustrated ESRD care
and associated hospitalization rates. Although the authors included only seven sources, none of
them were published prior to 2009.
Lack of appropriate literature review makes it difficult to state whether the articles
provided a state-of-the-art synthesis of relevant evidence in this context. However, the included
sources were able to note the major problems associated with hospitalizations of ESRD patients
and the nursing care required for the same.

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Due to lack of adequate research in the area, the article fails to provide a solid foundation
for the study. The included articles were able to provide limited background information on the
research topic.
Framework- The key concepts related to rates of hospitalization of patients suffering
from end stage renal disease were conceptually defined. The authors were able to establish the
fact that ESRD among patients are associated with substantial societal costs, most of which can
be attributed to high hospitalization rates. The authors were also successful in providing an
explanation that nursing care for ESRD patients encompass resource-consuming activities and
are also related with increased hospitalization rates due to impairment of renal functions.
Moreover, the research framework also indicated presence of co-morbid conditions in the case
scenario that increases risks of focused nursing care. Rates of hospitalization were assessed as
the number of times each patient got admitted to a hospital while suffering from ESRD.
Percentage of home-based dialysis therapy and type of access for those working with
arteriovanous grafts were also measured.
The researchers used a study design that was based on Good Clinical Practice guidelines,
Declaration of Helsinki, and the International Conference on Harmonisation of Technical
Requirements for Registration of Pharmaceuticals for Human Use. Under this study design, the
patients involved in the study were allocated on a 1:1 basis. The nursing professionals involved
in the study were given prior training for effective implementation of the augmented
management program. This created provisions for the staff to be more prepared and get
completely involved in accurate research methodology and data collection process.
Methods-

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Human rights- Appropriate measures were taken for safeguarding the rights of the all
study participants that included obtaining an ethical approval from the institutional review board.
This approval was imperative for protecting the ethical rights of the respondents. Participants
meeting the eligibility criteria were made to understand about the intervention and were provided
considerable amount of time for taking their decision and clarifying their doubts. Each
participant signed consent forms, followed by their random allocation to the intervention and
sample group by using a computer-generated schedule.
The study was designed in a way that minimized all risks and maximized the potential
benefits of the nursing intervention program to the participants. Only adult participants, with
consecutive GFR estimates around 0-30 Ml/MIN/1.73 m2 were recruited for the study. However,
exclusion criteria focused on patients suffering from cognitive impairment. This prevented bias
in the results as cognitively impaired participants might not be able to understand implications of
the intervention, thereby failing to show willingness for their participation.
Research design- The study used a randomized controlled trial that aimed to show effects
of the augmented nurse care management program on hospitalization rates of ESRD patients.
This kind of trial aims to reduce selection bias while testing a particular intervention.
Appropriate comparisons were made by the authors between the intervention and the
control group for enhancing interpretability of their findings. The researchers measured all
primary and secondary outcomes between the two groups in detail and gave adequate description
of the measurement techniques.
Data collection point numbers were appropriate for the same as primary and secondary
outcomes encompassed hospitalization rates and home dialysis percentage, and AVF or dialysis

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catheter access, respectively, for all participants. The figures and tables provided were able to
provide evidence for interpretability of all findings.
The researchers stated that allocation of the study group was concealed from the nursing
professionals involved in the research by performing the randomization process by independent
and separate biostatistics department of the Feinstein Institute for Medical Research of Northwell
Health. This attempt was taken to minimize research bias. However, there was no mention of
internal or external threats to validity.
Population and sample- The authors described and identified the population as adults
suffering from end stage renal disease (stage 4 and 5), across three nephrology offices in the
region. Only adult participants, with consecutive GFR estimates around 0-30 Ml/MIN/1.73 m2,
without cognitive impairment were found eligible for the study. The results were presented for
130 participants. Data for baseline characteristics of the participants were presented in table 1.
On the other hand, table 2 contained information on the number of hospitalization for the control
and intervention group. After being informed about the potential of the intervention, all
participants were given the opportunity to reflect on their thoughts and provide consent only if
they were willing to participate. Following receiving their informed consent, they were
randomized using a computer generated randomization program. This facilitated reduction of
research bias during randomization.
A random sample of end-stage kidney disease patients was used for the same. This study
design was appropriate as it assisted researchers to select their subjects in both the groups,
without any sample bias.

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A power calculation (1.2/year for control and 0.6/year for intervention group) was done
for determining the sample size (Wolf et al., 2013). An intention-to-treat principle was used for
the same. However, the sample size of 130 participants was not adequate for determining
effectiveness of the intervention.
Data collection and measurement- The conceptual and operational definitions of
included variables were congruent for the study. Appropriate descriptions were provided for the
rates of hospitalization, AVF and dialysis catheter access for both the intervention and the
control group. The outcomes were also ascertained by discussing with the physicians and the
patients.
The key variables were operationalized using a range of techniques for each. Similar data
collection methods were used with regards to hospitalization rates for both the groups.
The scale used for measuring rates of hospitalization and all secondary outcomes was
accurate for the study. It allowed the researchers to determine whether implementation of the
nursing management was successful in improving the health outcomes of ESRD patients.
The researchers analyzed the data on an intention-to-treat basis. Mean and standard
deviation were calculated for the collected data followed by a statistical analysis of the variables,
using t test.
Procedures- The intervention based on augmented nursing care management for ESRD
patients were adequately implemented during the study. Initial phase of the intervention
consisted of visits for the nurse-care managers to the participant’s homes, followed by sessions
that encompassed motivational interviewing for effective communication exchange. All patients
were provided with renal replacement and modality discussions. Home visits also comprised of

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proper medication reconciliation, dietary education, and home safety assessments. The nurses
focused on monitoring the sodium intake of all participants and also assessed their food patterns.
Their baseline characteristics were also measured. Following these home visits, the nephrologists
and care managers worked together to formulate a patient-centered care plan, specific to the
research goal. Three nurse care managers worked during conduction of the RCT. A 1:100 nurse
to patient ratio was followed for the same. Control patients suffering from ESRD were subjected
to usual care by their nephrologists, and were not administered upon the intervention. On the
other hand, the sample group patients were subjected to administration of the Healthy Transitions
care management program. Monthly assessments were conducted to determine reduction in
hospitalization rates (if any). Result collection was also continued for a follow-up period of 18
months.
Providing training to the concerned nurses and use of a protocol for guiding the steps that
were critical in receiving the intended primary and secondary outcomes helped in eliminating
possible bias. There was no direct explanation of the specific training, the nursing staff had
received.
Results
Data analysis- The researchers made use of statistical analysis for testing effects of the
intervention by utilizing the student’s t-test for the samples. Standard deviations and means were
calculated. The researchers conducted the study upon 59 patients (30 in the intervention group
and 29 in the control group). The results indicated absence of death in the intervention group
during the study period. However, three patients from the group were found to enter hospice and
two of them died subsequently. Death occurred due to malignancy in both the patients. In

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addition, the control group. Hospitalization rates were found to be significantly low in the
intervention group (0.6/year), upon comparison to the control group (0.92/year). Results also
showed that the number of hospitalization ranged from 0-5 over a period of 18 months. The
researchers were also able to identify congestive heart failure or volume overload. Significant
reduction in hospitalization rates were observed in this case in the intervention group. Rates of
ESRD initiation were found similar in the two groups. Moreover, more number of patients were
found to initiate the PD therapy in the intervention group, when compared to the control group.
Thus, it can be stated that the researchers undertook the study in a way that was successfully able
to address all research objectives.
The authors used accurate statistical methods based on descriptive statistics for
calculating the means, and standard deviation. The statistical method of using student’s t-test was
accurate due to the fact that the scaling term was not known and was replaced by estimates that
were based on the data.
Student’s t-test was the most powerful analytic method used for the study. Extraneous
variables were controlled by randomly picking up patients suffering from ESRD across three
nephrology offices, by concealing the allocation process. This process prevented bias in selecting
the participants for the intervention and the control group.
Type I and type II errors were minimized and avoided by performing the student’s t-test.
The data analysis for the study was conducted by utilizing the intention-to-treat approach.
There were 30 participants in the intervention group and 29 in the control group. Once the
randomization process was complete, the data corresponding to each participant was analysed.
This was followed by statistical analysis of the collected information.

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The problems related to missing values were accounted for and described by the authors.
They made a mention of the number of participants who initially refused to participate in the
RCT. Of the recruited 130 participants, initially equal number of participants was allotted to the
control and intervention group respectively (65 each). The researchers also formed a correlation
between less number of participants to withdrawal of consent, discontinuation of intervention,
immediate withdrawal, or moving out of the area. Thus, the problems of missing values were
adequately addressed.
Findings- The authors presented adequate information about the statistical significance
of the results. The authors reported 95% CI for incidence rate ratio related to hospitalization
rates. 95% CI was also calculated initiated RRT, HD vascular access and composite outcomes.
Thus, the authors were precise in stating their estimates. Presence of 95% CI indicates high level
of significance of the results, when a similar study is conducted in a larger population (Knol et
al., 2012).
The researchers accurately summarized the findings by using relevant texts, schematic
diagrams and tables. The recruitment of all participants was illustrated with a flow diagram.
Baseline characteristics of the participants were explained in terms of percentage values that
were represented in tables. The result summaries were also concise and supported by data
provided in their corresponding tables.
The researchers noted presence of negligible data on randomized controlled that focused
on studying effects of the Healthy Transitions intervention program on end stage CKD patients.
Thus, results of this study would be insufficient for conducting a meta-analysis. Further research
is required to be performed for a meta-analysis. However, the research article provided sufficient

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information on the positive effects of the proposed intervention on health outcome of ESRD
patients.
Discussion-
Interpretation- Major findings were discussed within the research context. The
researchers compared their findings of the intervention group with the control group to determine
positive impacts of the intervention. Due to absence of similar kinds of research studies, the
major findings could not be much correlated with previous trials.
The researchers did not provide any information on causal inferences. They did not
analyse response of the effect variables by changing the cause.
The interpretations were consistent with the results of the study and with its limitations.
Supportive data present in the tables were able to link themselves to the interpretation.
Limitations of the research and their probable effects on the results were also discussed.
The article stated that generalizability of the findings were strong and could be
implemented across large nephrology practices.
Implications-
The researchers discussed the importance of the information-guided care management on
ESRD patient outcomes. They also noted that further studies on larger sample population and
broader geographical range were needed to understand the effects.
Global issues-

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The report is well written in a detailed and organized manner and would facilitate a
clinician with working knowledge to perform an analysis and make informed decisions regarding
implementation of the intervention.
A CONSORT flow chart is provided for explaining the flow and recruitment of
participants.
The report would make the findings easily accessible to nurses because it has been
published in the AJKD journal, which is most often used for clinical research.
Researcher credibility- The credibility of the researchers and evaluation of the article by
2 external peer reviewers justify the interpretations and the findings.
Summary assessment- The limitations present difficulties in establishing validity of the
results. However, despite the potential limitations, confidence is established in the truth-value of
the results due to the 95% CI.
The study results present contribute meaningful evidences that suggest that informatics-
guided nursing care management are responsible for improving health outcomes of ESRD
patients. Thus, the findings of the study can be used in nursing practice and will assist
professionals working in the nursing discipline to implement the strategy across hospital settings
from improving health outcomes of their clients.

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References
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(2013). Evolving importance of kidney disease: from subspecialty to global health
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(2017). Augmented nurse care management in CKD stages 4 to 5: a randomized
trial. American Journal of Kidney Diseases, 70(4), 498-505.
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(2017). US Renal Data System 2016 annual data report: epidemiology of kidney disease
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Wolf, E. J., Harrington, K. M., Clark, S. L., & Miller, M. W. (2013). Sample size requirements
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