The study by Mason et al. (2007) outlined the research question to a certain extent in the abstract and the introductory paragraph to the study. It was stated that the purpose of the study was to evaluate the effectiveness and safety of paramedic practitioners assessing and treating older people in the community after injury or illness. There was however no clear indication as to how effectiveness and safety were being assessed, in either the introduction or methodology of the paper. Although by the end of the paper there was a somewhat clearer idea could be gained of how safety was measured, it was still difficult to clearly understand how effectiveness had been measured. This may considerably impact on the value of the research study as a clear research question has been identified as an essential element in ensuring the legitimacy of findings in any study (Ioannidis, 2005).
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The study was a randomised controlled trial (RCT), with the control group being those receiving assistance from paramedic practitioners or not receiving these practitioners. Clustered randomisation was used and its use justified. This was a suitable approach to take to measure the size of a difference between the two groups in terms of the outcome of treatments (Sibbald & Roland, 1998) which was the aim of the study. The factors which may have affected the outcome were controlled for as part of the trial, for example the presenting complaint.
Participants were randomly allocated to control and intervention groups, but this was done in clusters rather than on an individual basis. The clusters which were used were each week that the 999 service was operating, with certain weeks receiving intervention and other weeks receiving normal service. This therefore may remove some of the issues identified in allocation procedures for RCTs (Webert, 2007). There have however been concerns over the analysis of these cluster trials, as there is evidence that analysis in many published studies has not taken account of this and therefore the results may be inaccurate (Campbell, Elbourne & Altman, 2004).
It was not possible to blind the study personnel in the trial as they were aware of whether they were the paramedic practitioner and whether they were being utilised. It was however possible to blind participants who did not need to know whether the service they were receiving was any different to normal. It was however not clear from the report whether participants were notified of which type of treatment they were receiving even though consent for the study was sought. This is apparently quite common practice in RCTs even though it calls into question the validity of findings (Montori, 2002). In this study it is possible that non-blinding may have slightly influenced the results if participants were notified of which service they received. Patient satisfaction was listed as one of the outcome measures, and it is possible that this may have been influenced by the quality of care that participants perceived in relation to having more qualified practitioners handling their care. If the patients were not blinded this could further call into question the validity of their satisfaction as a measure of quality, something which has already been questioned in the literature (Williams, 1994).
An intention to treat protocol was followed for the study which means that all participants were analysed according to the treatment group to which they were originally allocated. This is suggested to be the best protocol to use for measuring clinical effectiveness of a change in treatment (Hollis & Campbell, 1999). All those who initially entered the system were automatically allocated to treatment or control groups by virtue of the method of randomisation used. There were a significant number of eligible participants that were subsequently discounted however due to not giving consent for the study, death, or other reasons. Those who were included in the study from the stage of consent were those which were included in the data analysis.
There was no option for the participants to explicitly switch between intervention and control groups, although not all received the intended intervention. There were also a substantial number of participants which did not give consent for their participation in data collection through the survey, which meant that this element of quality measurement was based on lower numbers of responses than the measures using hospital notes. In addition, there were a significant number of those consenting to a survey which then did not complete the survey. All of these lost to follow-up were however included in the data analysis according to the intention to treat protocol. Given that there were large amounts of participants for which complete sets of outcome data were not available, this may have significantly influenced the results when they were treated using this protocol. This is especially true as it was not clear how the missing data were treated (Hollis & Campbell, 1999).
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Not all patients were approached in the same way to retrieve consent for collection of data, although it is not clear if there were significant differences between the two groups in terms of whether consent was collected in the community or in the emergency department. This may introduce performance bias to some extent (CASP, 2006a) even though the rest of the follow-up was conducted in the same manner. There was less opportunity for there to be bias introduced in the stages of actual data collection as this was done through postal survey and analysis of patient notes. Although there is mention given of obtaining consent after the treatment had been given it was not clear exactly what information was given to participants and whether they were given ample opportunity to withdraw at a later date. Therefore it is difficult to determine the extent to which they study was conducted in an ethical manner.
There was a power calculation which was included in the report. This showed that the intervention and control groups both needed to contain at least 1100 participants to produce results with 5% significance and 80% power. On the basis of using the intention to treat analysis, this was achieved by the study, with 1148 participants included in the intervention group and 1145 in the control group. This should then ensure that enough patients were included to minimise the risk of chance in the results.
The results are presented in the report as a series of statistical test results using the Poisson error distribution. The results indicated that less of those in the intervention group attended an A&E department on the day of attendance and over the next four weeks; they were also less likely to be admitted to hospital. This all indicates that the intervention was more successful in treating patients without them needing to go into hospital. The results also showed that patients were more satisfied when receiving the intervention rather than the control service. Patients also were shown to be attended to in over a shorter period of time than those receiving the control treatment.
There were no confidence intervals provided for the results, with percentages reported to only two significant figures. There were however p-values used, and these were all given as less than 0.001, which indicates substantial evidence that there was a significant difference in the outcomes between intervention and control groups.
There were some secondary findings which were also presented. This included the finding that those in the intervention group were also less likely to have services such as radiography, electrocardiography and pathology tests. They were however more likely to receive advice. They were also more likely to have subsequent unplanned contact with secondary care services in the 28 days post-intervention.
The main findings of the study may however be summed up as the use of the paramedic practitioner service providing better quality and more effective treatment than the conventional service.
Application of the Results
It would appear that the results of the study could be applied to the general population. The randomisation process which was used ensured that the study sample which was allocated to either group would be no different from the population which would usually use the ambulance service over the course of a year. There would also appear to be little which would separate the study sample which was used and the population from other areas of the United Kingdom. It is unlikely that there would significant impact on the results of the study from elements of the health service outside of the actual treatment given by the paramedic service. This should then indicate that the study may be applicable across the country. It would also be anticipated that with the initiation of a similar training course to that undergone by the personnel in this study, the same service should be possible in any area. Although this would involve considerable cost to the local authority, it is likely that resources would be spared by the reduction in the need for hospital treatment. This would then indicate that an investment in the program would be beneficial even despite the initial investment.
Critique of Paper 2: Vydelingum (2000)
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The study aims and research questions are very clearly outlined, with a dedicated subsection given to their description. This detailed the aim of the study as being to describe and interpret the lived experience of the consumer of the hospital experience from the perspective of the Asian population. The associated research question then related to how South Asian patients and their carers perceived and described the hospital experience.
The importance of the study was also clearly detailed in the introduction of the study. This shows that there is sufficient evidence to suggest that the healthcare needs of non-native English people, i.e. those from ethnic minorities, may be very different from those which have been conventionally identified for the Caucasian English population. There is also significant evidence which is presented which shows that Asian patients show generally lower levels of satisfaction with health care services than other patients. There is however little evidence which is presented as to why this may be, and this is therefore the justification of the study. It is not clearly explicitly outlined as to why this is relevant, although it may be assumed that the study is relevant as there is a growing South Asian population in the UK.
The study design which was selected is entirely appropriate for answering the research question which was proposed. The study is interested solely in the lived experiences of the research participants, and qualitative research is far more appropriate for this type of data collection and analysis than quantitative methods (Munhall, 2001).
The Heideggerian tradition of hermeneutics is focused on the concept that humans are not separable from our physical world, but that instead every person is constantly finding significance in their surroundings. It is a method which is specifically aimed at finding the meaning underlying human experiences (Draucker, 2001). This therefore makes the research approach used appropriate for the study as the research aimed to understand the experience of the healthcare service from the South Asian perspective using data collected from their own perspective.
The study used interviews with participants that had previously been identified as hospital patients. This would appear to be an appropriate method of qualitative data collection to use, as observation would not have revealed the thoughts and feelings of the study sample as they went through the healthcare experience. What is not clear from the report is the format which was taken in the interviews. The use of a semi-structured interview is particularly suitable for the research question of interest as this helps to reveal the story of the patient from their own perspective (Parker, 2004). The researcher also has not explicitly justified their choice of research method, although this may be simply due to it being a relatively logical choice given the purpose of the study.
There is sufficient description given of the sampling techniques which were used to show the precise criteria which were fulfilled by participants of the study. This was justified, with certain criteria being included in sampling to reduce the bias which may be associated with certain characteristics of participants. For example only those South Asians who were born outside of the UK were included in the study as it was hypothesised that there may be significant differences in the experiences of those born inside or outside the UK. Participants which were identified as being suitable for the study were approached in the hospital for consent and then followed up at a later date. This approach was justified as being due to reluctance to speak out while in the hospital. There is no discussion given in the paper about how many patients chose to decline to take part in the research and reasons for this.
The interviews which were conducted for the study were performed in the patientsââ‚¬â„¢ own homes. There was no indication about why this was selected as the setting for the interviews, although it would be assumed that this was done to put the participants at ease. The researcher also detailed that the interviews were recorded and then transcribed at a later point in time. This is advised with qualitative interviews as it makes it less likely that important details would be missed than if notes were taken during the interview (Britten, 1995). It was also made clear that there was an interpreter present at the interviews. This may also have been important given that the participants were non-native English speakers, as it would ensure that the patients truly understood the purpose of the research, what they were consenting too and the questions asked.
It is not clear however whether the presence of the interpreters may have influenced the outcome of the study. It was recognised in the report that the translators may have been interpreting what was said as opposed to translating it word-for-word, and this may have significant implications to the interpretation applied to the findings. It is not clear from the report if the researcher adequately considered their own role. It would not appear that there was any other way that the researcher themselves may have influenced the findings, other than through their own interpretation of the data, but this was not explicitly mentioned. There was however a sound qualitative framework applied to analysing the data, which should have reduced the bias which was introduced during interpretation (Pope, Ziebland & Mays, 2000).
There is a very thorough description given of the data analysis procedure which was applied. This would allow for the study to be reproduced and also allows for better judgements to be formed relating to the validity of the findings. This description gives details about the units and processes which were used for the analysis and these appear to support the findings.
It is specifically mentioned in the report that permission for the study was sought from the local ethics committee. There also appears to have been adequate steps taken by the researcher to ensure that the participants truly understood what they were consenting to. This was achieved through the use of interpreters in meeting with the patients and carers, as well as information sheets to clearly show the purpose of the study. There was also ample opportunity given to patients to withdraw from the study at any point they chose. This all therefore supports that this study was conducted in an ethical manner.
The results of the study indicate that there is generally a low level of satisfaction with the health service from South Asian study participants. The main themes which were identified were those of communication difficulties and a lack of understanding of culture.
The results of the study were explicit. Each of the main themes of the interviews was presented in segregated subsections of the discussion. Each section also began with an overview of the findings relating to that theme, followed by a more in-depth description of how the data supported this finding. The findings which were discussed did however seem to focus very much on the themes which were discussed by a majority of patients. There was little mention of the data which contradicted or did not agree with this. It is however possible that the opinions of the minority may also be important even though the researchers here chose not to include it in their discussion. There is also little information given about validation of findings, it is simply stated that the views presented were those of the majority of the study sample.
Application of the Results
The researcher does evaluate the contribution which the research makes to the current body of knowledge. For example the researcher suggests that the research should highlight the need for health care staff to evaluate and reflect on their own practice in relation to those from South Asia. The researcher does however recognise that the findings may not be generalisable to other populations; instead they provide more of a conceptual prompt to change practice. There is also no mention given as to how the research may further proceed to improve on the knowledge generated from this study.