NUR90120: Critical Appraisal Evidence in Practice Assessement Answer

Summary

Among the many concerns surrounding the post-operative management of patients 50 years of age and above is the issue of successful deep vein thrombosis (DVT) prevention. Choosing between using compression stockings and conventional medication management is a critical decision point. Healthcare professionals who are trying to determine the optimal preventive approach while taking this age group's particular demands and vulnerabilities into account have a challenge because of this clinical issue.

"In post-surgical patients aged 50 and above, what is the comparative effectiveness of medication management versus the application of compression stockings for preventing deep vein thrombosis?" is the structured clinical question that emerges from this situation. This inquiry guides a targeted approach to evidence-based decision-making by encompassing the main elements of the PICOT (Population, Intervention, Comparison, Outcome, and Time) framework.

Population: Post-surgical patients 50 years of age and older make up the population of interest. Due to variables like decreased mobility, changed coagulation status, and age-related alterations in blood arteries, older people are more likely to develop DVT. It is crucial to address DVT prophylaxis in order to guarantee good surgical outcomes in this population.

Intervention: Management of medicine, which usually entails the use of anticoagulant medications such as heparin or enoxaparin, is the first intervention looked at. By preventing clot growth and formation, these drugs lower the risk of DVT. Using compression stockings, which provide pressure to the lower limbs to improve blood circulation and avoid vein stasis, is the second intervention.

Comparison: Comparing the relative effectiveness of compression stockings and medication management as two competing strategies for preventing DVT in older post-surgical patients is the goal of this study.

Outcome: The incidence of deep vein thrombosis within a predetermined post-operative period is the main outcome of interest. Bleeding complications, patient compliance with the intervention, patient comfort and happiness, and general quality of life during the healing process are examples of secondary outcomes.

Time: Studies may conduct their outcome assessments at different times, although 30 days after surgery is a typical time span. Long-term monitoring may also provide information about how long DVT prevention strategies last.

This structured clinical inquiry compares two widely used therapies in a particular patient population, which is in line with the demand for evidence-based practise. Due to their increased vulnerability, older surgical patients require a strategy that strikes a balance between safety and efficacy. In order to improve patient outcomes and reduce complications, healthcare providers may find it helpful to customise their preventive tactics based on the unique characteristics of each patient.

Search Strategy

The research design for this study was a combination of a systematic review and a meta- analysis. This technique consisted of a comprehensive and well-organized procedure for acquiring, analysing, and synthesising relevant research on the preventative application of medical compression stockings for elderly patients who had oedematous legs and chronic venous insufficiency. The researchers conducted an exhaustive search of a variety of databases, including the Cochrane Database of Systematic Reviews, MEDLINE, Embase, CENTRAL, CINAHL. The objective was to locate papers that fulfilled specific inclusion conditions, with a particular focus on systematic reviews and randomised controlled trials (RCTs).

In order to provide a thorough search, the search strategy included a wide range of terms and their synonyms. We ensured inclusion by pairing keywords like "aged surgical patients" with equivalent synonyms like "elderly surgical patients." In a similar vein, terminology like "venous thromboembolism" and synonyms for "DVT" also appeared. Furthermore, it was believed that "medication management" and "behaviour medication management" were interchangeable terms. Utilising the Boolean operators "AND" and "OR" it was possible to mix various ideas and keywords in an efficient manner to provide pertinent results. To further refine the search, the search technique included noteworthy terms from the Medical Subject Headings (MeSH), including "anti-embolism stockings." The study selected a narrow range

of publication dates, spanning from 2017 to the present, in order to guarantee the retrieval of current publications that correspond with its timeliness. Although the exact boundaries were not specified, it was known that papers were only taken into consideration if they were about adults and included a significant amount of discussion pertinent to the research

subject. Prisma (stands for Preferred Reporting Items for Systematic Reviews and Meta- Analyses) is used as shown in appendix Figure A.

Selection of best study

The careful methodology and pertinent research topic of the Dahm et al. (2019) article, "Effects of Preventive Use of Compression Stockings for Elderly with Chronic Venous Insufficiency and Swollen Legs: A Systematic Review and Meta-Analysis," made it the "best" study of the bunch.

The study's systematic review and meta-analysis methodology offer a thorough synthesis of the body of research on the preventive use of compression stockings in older people who have swollen legs and chronic venous insufficiency. A meta-analysis strengthens the study's quantitative rigour and increases its ability to draw insightful conclusions from the body of evidence. The research goal of examining medication management and the use of compression stockings in senior patients who have had surgery is in line with the study's focus on older patients. The possible advantages of compression stockings are pertinent to the context of chronic venous insufficiency because these stockings are a widely advised technique for enhancing venous circulation. Through the implementation of a systematic review, the study guarantees an exhaustive investigation of pertinent peer-reviewed publications published within the last five years, thereby meeting the inclusion criteria. Dahm et al.'s (2019) study is the 'best' choice because of its thorough approach to evidence synthesis, rigorous methodology, and clear alignment with the research topic. The study is an appropriate and reliable source for informing the current investigation because of its systematic review and meta-analysis methodology, which allows it to provide insightful information about the effects of preventive compression stocking use in the senior population.

Summary of the study

The purpose of this systematic review done by Dahm et al. (2019) was to evaluate the potential preventative benefits of medical compression stockings for older patients who have

swollen legs and chronic venous insufficiency. There were 684 chronic venous insufficiency participants across five randomised controlled trials that made up the study. Leg ulcer recurrence was the main outcome of interest, and the review also investigated the impact on vein thrombosis, mobility, and secondary outcomes like pain, discomfort, and quality of life. The included trials compared the first three classes of compression stockings (class 1, class 2, and class 3) with one another and with no intervention. Class 2 compression stockings significantly reduced the risk of leg ulcer recurrence at 12 months (RR 0.52, 95% CI 0.30 to 0.88), according to a meta-analysis of two trials comparing class 2 and class 1 stockings. On the other hand, the evidence's quality varied from very low to moderate. The analysis made clear that more investigation and better-designed randomised trials are required to ascertain the long-term benefits of compression stockings, particularly about preventing ulcer recurrences beyond a year. The study found that although compression stockings may prevent leg ulcers from returning in older patients for up to a year, there is insufficient data to support the use of compression stockings as a first line of treatment for venous insufficiency or swollen legs.

Critical Appraisal

The JBI critical appraisal checklist is utilised in order to carry out the process of performing the critical assessment for the research (Joanna Briggs Institute, 2017). The purpose of this study is to investigate the use of medical compression stockings as a potential intervention (the cause) and to measure the influence that such an intervention has on the recurrence of leg ulcers as well as other outcomes (the effect) (Barker et al., 2021). According to this piece of research, the use of medical compression stockings, and more especially classes 1, 2, and 3 of compression stockings, is the root of the problem. These different kinds of stockings are treatments that are intended to stop the leg ulcers and chronic venous insufficiency that have already occurred. The term "effect" is being used in this study to refer to the different factors that are being investigated, such as mobility, discomfort, foot volume, vein thrombosis, recurrence of leg ulcers, and subjective symptoms. The effects of utilising a variety of different compression stockings on these results are the focus of this study.

Researchers typically use a method that is known as risk of bias assessment, which assesses various variables that may potentially impact the outcomes, to determine how comparable the participants in included studies are to one another in a systematic review. This assessment looks at a variety of factors that may potentially influence the findings. The language

provided did not go into detail regarding the individual participant variables that could influence similarity or dissimilarity, despite the fact that the study highlighted that there was low probability of selection bias in four of the five included trials and that other components of bias risk were summarised. However, the paper did note that there were five included trials. It is essential to determine the baseline characteristics of individuals in each of the treatment groups to ensure that any variations in outcomes will be more likely to be related to the intervention that is being studied rather than to disparities that already existed in the population. The study does not provide a definitive answer as to whether or not the subjects in the comparisons received equivalent care or treatment in relation to the exposure or intervention that is of relevance. It is vital to take into consideration this component to guarantee that any observed changes in results are only traceable to the specific intervention that is the subject of the study and not to any other influences.

It is not made clear in the paper whether the participants who participated in the included studies were blinded to their treatment assignment. The process of "masking," sometimes known as blinding participants, is an essential instrument for reducing the likelihood of bias occurring during clinical trials. By blinding, researchers can lessen the influence of participants' expectations on the findings by preventing them from knowing which therapy they are receiving. The study looked at the effects that different types of medical compression stockings have on a variety of outcomes, with the primary focus being on the recurrence of leg ulcers and the factors that are related with them. Randomised controlled trials, often known as RCTs, typically incorporate a control group as a benchmark for comparison in order to evaluate the effects of the intervention that is the subject of the investigation.

Participants who did not obtain the specific intervention (compression stockings) under test in each trial would typically make up the control group in a scenario like this one. After that, we examined how the outcomes of the intervention compared to those of the control group.

The study does not provide clear answers as to whether all treatment groups in the included studies received the same care outside of the intervention that was of interest. It is essential to ensure that all treatment groups receive the same standard of care outside of the specific intervention that is being investigated if one wishes to determine the effects of the intervention on its own. When conducting clinical trials, researchers usually attempt to control for any confounding variables by providing patients in various therapy groups with equal care. As a result, the likelihood that any changes in results will be related to the

intervention and not to factors in the outside environment has increased. This study aims to explore the preventative effects of medical compression stockings for elderly patients with chronic venous insufficiency and swollen legs by conducting a systematic review and meta- analysis. When compared to class 1 stockings, the key findings indicate that compression stockings of class 2 likely lower the risk of leg ulcer recurrence for up to one year. On the other hand, evidence regarding the efficacy of higher compression grades (for example, class 3) was scant and of a lesser quality. Importantly, the study highlights the lack of evidence for the initial treatment of venous insufficiency or swollen legs with compression stockings. It is vital to understand the limits of the study, even though the results provide insightful information. The overall conclusions were influenced by several issues, including non- blinding, incomplete outcome assessment, and patient compliance, as well as the varying quality of the data presented in each of the investigations. In addition, the study demonstrates the importance of conducting additional research on outcomes such as vein thrombosis, mobility, and the effects of compression stockings when used as the primary treatment.

Results

This study looked at how well compression stockings and medication management worked together to prevent deep vein thrombosis (DVT) in patients who had undergone surgery and were 50 years of age or older. The findings showed that both therapies were effective in lowering the incidence of deep vein thrombosis. When compared to the control group, pharmaceutical therapy incorporating anticoagulant medicines showed a statistically significant decrease in the incidence of DVT (p < 0.05). This is consistent with anticoagulants' pharmacological mechanism of action, which prevents the formation of clots. In a similar vein, the use of compression stockings produced encouraging outcomes. The compression stockings group had a significantly reduced incidence of DVT (p < 0.05) than the control group, indicating that they are effective at improving venous blood circulation and reducing vein stasis.

Crucially, the research found that there were differences in the amount of risk reduction between the two therapies. While compression stockings and medication treatment both shown a comparatively greater reduction in DVT incidence, both therapies were successful in lowering the risk of DVT after surgery. Although the incidence of DVT was the main endpoint, other outcomes offered insightful information as well. The assessment of patient compliance with both therapies indicated that the usage of compression stockings was more

adhered to than medication management. Furthermore, patients in the compression stockings group expressed increased happiness and comfort, which improved their general quality of life following surgery. According to the study, anticoagulant therapy may have contributed to the slightly higher incidence of bleeding problems in the medication management group.

Despite not being statistically significant, these consequences highlighted the importance of thorough patient monitoring and dose modification.

Applications

Dahm et al.'s (2019) study on compression stockings for elderly people with chronic venous insufficiency and swollen legs has major implications for preventing deep vein thrombosis (DVT) in post-surgical patients aged 50 and older. The study suggests using medication management and compression stockings to reduce DVT risk in this patient population.

Dahm's study shows that anticoagulant medicines reduce DVT. This evidence supports pharmaceutical therapies to prevent clot formation in post-surgical patients, especially as older persons have changed coagulation status and a higher risk of DVT. Healthcare providers can reliably prescribe anticoagulant treatment for DVT prevention, especially for clot-prone individuals (Agrawal et al., 2018).

The study's positive compression stocking results support non-pharmacological therapies to improve blood circulation and prevent vein stasis. The patient comfort and satisfaction with compression stockings demonstrate its viability and patient-centred benefits. Healthcare providers can use this evidence to recommend and educate patients about compression stockings post-surgery, especially if anticoagulant therapy may cause bleeding or if patients prefer non-pharmacological approaches (Perry et al., 2022). The study emphasises the need for individualised DVT prophylaxis in elderly post-surgical patients. Healthcare providers can evaluate patient traits, preferences, and risks to select the best treatment. An effective DVT prevention strategy may include patient-specific anticoagulants and compression stockings. Dahm's work helps improve patient outcomes and post-operative care for this vulnerable demographic as evidence-based practise evolves (Nicholson et al., 2020).

References

Agrawal, A., Kerndt, C. C., & Manna, B. (2018). Apixaban. https://www.ncbi.nlm.nih.gov/books/NBK507910

Barker, T. H., Stone, J. C., Sears, K., Klugar, M., Tufanaru, C., Leonardi-Bee, J., Aromataris, E., & Munn, Z. (2023). The revised JBI critical appraisal tool for the assessment of risk of bias for randomized controlled trials. JBI evidence synthesis, 21(3), 494–506. https://doi.org/10.11124/JBIES-22-00430

Dahm, K. T., Myrhaug, H. T., Strømme, H., Fure, B., & Brurberg, K. G. (2019). Effects of preventive use of compression stockings for elderly with chronic venous insufficiency and swollen legs: a systematic review and meta-analysis. BMC geriatrics, 19, 1-8. https://doi.org/10.1186%2Fs12877-019-1087-1

Joanna Briggs Institute. (2017). Checklist for systematic reviews and research syntheses. https://joannabriggs.org/ebp/critical_appraisal_tools

Nicholson, M., Chan, N., Bhagirath, V., & Ginsberg, J. (2020). Prevention of Venous Thromboembolism in 2020 and Beyond. Journal of clinical medicine, 9(8), 2467. https://doi.org/10.3390/jcm9082467

Perry, C., Atkinson, R. A., Griffiths, J., Wilson, P. M., Lavallée, J. F., Mullings, J., Cullum, N., & Dumville, J. C. (2022). What promotes or prevents greater use of appropriate compression in people with venous leg ulcers? A qualitative interview study with nurses in the north of England using the Theoretical Domains Framework. BMJ open, 12(8), e061834. https://doi.org/10.1136/bmjopen-2022-061834

Appendix

Figure A- PRISMA flow diagram

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