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Critical Appraisal Assignment Writing Service

Introduction

The aim of this critical appraisal is to examine the research systematically and carefully that was conducted on the implementation of falls and fracture prevention programs. Since the element of this program is the administration of the calcium, and/or vitamin D supplements to the clients, this critical appraise is conducted to examine the trustworthiness and value of the identified research articles relevant in the specific context. The research article chosen for the program are“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” and“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial”. In order to make a comprehensive academic search, specific terms were used including falls and fracture, vitamin D and calcium supplements on falls and randomized controlled trial while“AND” was used as the important Booleans in the database for nursing and healthcare article database. Students were given a chance to write dissertation on the topic. Many students ended up with buy assignment writing. The reason to choose the specific articles is that they both represent the research on the effects of vitamin D on the falls and fracture, which can be effective in finding the best practice research in the context of the implementation of falls and fracture prevention programs.

The Purpose of the Study

The purpose of the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial” is to determine if single annual dose of 500 000 IU of cholecalciferol administered orally to older women in autumn or winter is effective in terms of improving the adherence and reducing the risks of falls and fracture. On the other hand, the purpose of the study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” is to identify the effects of vitamin D and calcium supplement on falls and hypothesized that vitamin D and calcium supplementation improves musculoskeletal function and reduces falls.

The Study Design (Hypothesis)

The study design of the article“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial” is based on predictive design in which the improvement of single annual dose of 500 000 IU of cholecalciferol administered orally to older women in autumn or winter would be predicted based on the observation. In addition, the participants for the research study were first recruited between 2003 and 2005 and were randomly given a single oral dose of cholecalciferol 500 000 IU or matched placebo each year for 3 to 5 years.  The study design of“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial”, on the other hand, is based on the explanatory design in which data is already available and will be tested for proving hypothesis of the study. 

Sample

The sample of the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial” consists of a double blind placebo-controlled trial of 2256 community-dwelling women, aged 70 years or older. These women are greatly considered to be vulnerable and at higher risk of falls and fractures. On the other hand, the sample of the study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” consists of 122 elderly women (mean age, 85.3 years; range, 63–99 years) in long-stay geriatric care. To test and prove the hypotheses, participants were given 1200 mg calcium plus 800 IU cholecalciferol (Cal+D-group; n= 62) or 1200 mg calcium (Cal-group; n= 60) per day over a 12-week treatment period.

Types of Intervention

The intervention used in the article“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial” is 500 000 IU of cholecalciferol or placebo while“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” used 1200 mg calcium plus 800 IU cholecalciferol (Cal+D-group; n= 62) or 1200 mg calcium (Cal-group; n= 60). 

Measurement Tools

The measurement tool used in the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial” is based on the recruitment of 70 years elderly women from June 2003 to June 2005. Profile of participants were collected using their age, calcium intake and fracture risks through questionnaire. Their falls and fractures were found by monthly calendar while other details were confirmed through telephonic interviews. Moreover, 137 participant were selected randomly for serial blood sampling for 25-hydroxycholecalciferol and parathyroid hormone levels. On the other hand, the measurement tool used in the study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” is based on the comparison between the treatment groups of the number of falls per person (0, 1, 2–5, 6–7,>7 falls).

Outcomes of Interest and Measurement of Outcome

The outcome of the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial”, which is based on the observation between 2003 to 2005 was concluded in 2008 and outcomes of the interest was found 171 fractures vs. 135 in the placebo group. Moreover, 2892 times fall recorded for 837 women in the vitamin D group while2512 times fall was recorded for 769 women in the placebo group. A temporal pattern was observed in a post hoc analysis of falls and in the sub-study, the median baseline serum was observed 25 - hydroxycholecalciferol that was 49 nmol/L. The outcomes of interest of the study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” were achieved through comparing the crude excessive fall rate among the fallers during the treatment period between treatment groups. Furthermore, alterations in the function of musculoskeletal were observed as the secondary outcome. Students were asked to craft thesis paper on the effects of vitamin D and calcium Supplementation on Falls, many students contactedthesis writing service provider to get help. Eventually, they succeeded in gaining the high marks in their thesis paper.

Type of Analysis Undertaken

For the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial”, statistical analysis method was used in which initial comparisons of outcome was measured between treatment groups. Moreover, the primary outcome was measured the numbers of falls and fractures and were analyzed through Poisson regression models. On the other hand, the study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” used a Poisson regression model to compare falls after controlling for age, number of falls in a 6-week pretreatment period, and baseline 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D serum concentrations.

Study Findings and Author’s Interpretation

 The findings of the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial” observed no clear difference between the treatment group in the proportion of the participants who withdrew. Moreover, findings of the study can be based on outcome of falls and outcomes of fracture. As the findings, 2256 participants experienced 5404 falls over 6925 person-years. There were 74% of 837 participants in the vitamin D group and 68% of 769 participants in the placebo experiencing one fall.

For outcomes of fractures, 155 participants receiving vitamin D sustained 171 fractures while 125 participants receiving placebo sustained 135 fractures.  The interpreted of the author is based on the findings that increased falls in the vitamin D group that was observed in each classification of falls such as falls with fracture, falls without fractures and falls with soft tissues injury. Overall findings show proportionate of falls between two groups that did not differ because 27.2% was observed in the vitamin D group and 26.1% in the placebo group.   The study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” found 49% reduction of falls in Cal+D treatment while the crude average number of excessive falls was  significantly higher in the Cal-group among the fallers of the treatment period. In addition, the function of musculoskeletal considerably improved in the Cal+D and single intervention with vitamin D and calcium over 3 months decreased 49% risk of falling compared with calcium alone. It is found in the short-term intervention that recurrent fallers are to help in improving through the treatment.

Critical Appraisal of the Chosen Studies
 

  1. The studies chosen ask the focus question as the focus question of the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women” is“what is the effect of a single annual dose of 500 000 IU of cholecalciferol if administered orally to older women in autumn or winter in terms of reducing the falls and fractures?”. While, the focus question identified in the study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” is“what is the effects of vitamin D and calcium supplement on falls?”.
  2. Both studies were randomized controlled trial and were conducted appropriately as in the both study, sample population was assessed for the eligibility and recruited for the intervention study and before the intervention were randomly allocated to receive one and other alternative treatments under the study. According to Jadad& Enkin (2007), randomized controlled trial is used for conducting a research that aims to compare two different interventions. Therefore, it can be stated that the reason to choose to randomized controlled trial for the chosen study is to comparae different interventions by applying them on two different sample recrutied groups. According to Jadad& Enkin (2008), there are controlled groups in the research under randomized controlled trial and such control may be conventional, placebo or no intervention (Jadad& Enkin, 2008). Since, in the study“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women”, the question was to identify the effects of cholecalciferol (vitamin D) supplementation on falls and fractures, the research sample was divided into groups such as treatment groups. Other study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” was also divided into treatment groups making it appropriate randomized controlled trial with the standardized groups such as experimental or treatment groups. However, both studies aim to conduct a comparative study that is effective to identify the more effective intervention for a treatment, both researches could be worth continuing because the first article“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women” was conducted on women as sample population, the further comparative research can be conducted on men. Moreover, the article“Effects of Vitamin D and Calcium Supplementation on Falls: Randomized Controlled Trial” was also conducted on women and findings of the research regarding the effectiveness of interventions for treatment is limited to only women. Further research based on comparative study for the interventions on men will be helpful in identifying the effects of interventions for men.
  3. With regard to appropriate allocation of participants to intervention and control groups, the first article“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women” allocated the women as participants if they were taken at the higher risk of hip fracture. However, allocation of the participants to intervention and control group was made by an independent statistician in which randomization was performed by computer-generated numbers allocated in blocks of 500. On the other hand, in the second article,“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial”, two groups were formed namely Cal-group and Cal+D-group. Cal-group was allocated to have calcium while Cal+D-group were allocated to have calcium with vitamin D. However, the article does not clearly indicate if the trial was made truly randomly, it was mentioned that it is double-blind randomized controlled trial, similarly the first article used computer-generated numbers which apparently indicates that sample was chosen randomly.
  4. As far as the blindness of participants and staff is concerned towards study group, in the first article“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women”, participants and study staff were blinded to intervention group and treatment allocation status was e-mailed directly to the hospital clinical trials pharmacist. Another study“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial” used randomized, double-blind, placebo-controlled trial, in which findings are produced in the form of knowledge free from bias. According to Watson (2008), in a double blind study in nursing, few participatns are given the treatment while others are given fake treatement called placebo and neither the researcher nor the participants know which is which as long as the study is finished (Grundy& Quinn, 2006).
  5. In the first reseach article,“Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women”, no intervention group got a control group option nor control group got intervention group and every participant was followed up in each study group while every participant was analyzed in the outcome of the study. In the article“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial”, each group was followed up in each study group while every participant was analyzed in the outcome of the study.
  6. As identified by Gray (2001), identifying the study groups being treated biased can change the outcome of the research in nursing. However, in the first study, almost all groups followed up and data collected in the same way with few exceptions. On different occasions, participants were treated in the same way as they were given dose of the study medication but continued to particpate in the study. The second article“Effects of Vitamin D and Calcium Supplementation on Falls: A Randomized Controlled Trial”, no study group was treated exceptionally and data was collected in the same way, thus no difference was introduced that could affect the performance bias.
  7. According to Brockopp& Hastings-Tolsma (2003), numbers of participants can be important in the determination of validity of research outcome. When considering the numbers of participants used in the selected study, it is found that both studies have used 2256 70 years old elderly women and 122 elderly women respectively. Comparatively, the first reearch included appropirate numbers of participants which would be helpful in attaining desired outcome. Other study, on the other hand, comparatively used small numbers of participants and less likely to achieve the goals of the study.
  8. According to LoBiondo-Wood& Haber (2006), results presented in the research can be helpful in comparing two studies to idenfity the effectiveness of their study. In the first study, the result is presented in proportion of groups experiencing an outcome, and large size of partiicpants increases the effectiveness of the research because large sample provides an oportunity to gather important and meaningful result (Polit& Beck, 2004). The findings of the first research was opposite to research hypothesis and participants receiving annual high-dose oral cholecalciferol experienced 15% more falls and 26% more fractures than the placebo group. Another study, on the other hand, used comparatively small sample for study and it found that short term intervention can benefit the treatment.
  9. The result of the first study is more precise than the second study as the result of the first study is efefctive in making a decision regarding. In regard to using the intervention, it is found that findings and result can affect in building the confidence level for making the decision and choosing the intervention (Macnee& McCabe, 2008).
  10. Comparatively to first study, second study did not consider all the outcomes its outcome cannot be applied. However, participants included in these studies are not different from the participants to be used in my study as they are also elderly participant with falls and fracture problems.

Implications for Practice

According to Burns and Grove (2005), the result and findings of research can be taken differently by different indivduals based on the needs and availability of the acceptance for the same setting (Burns& Grove, 2005). Thus, as a result, the interventions used the studies can be used for other study for same context but outcomes of the intervention is important to consider from different point of views. For an individual, applying the intervention inspiring from other studies may not be point of questions but it could be questionalbe for policy maker, family or carers and other community members. They could have different concerns regarding the outcome of the interventions and can related the outcome with the specific study. According to Dossey and Keegan (2008), identifying the needs of patient, and diagnose the problem is rather important in nursing practice while implementing an intervention without any assessment may affect the outcome of the intervention strategy. In this regard, outcome of the interventions proposed in the study can be applied for other studies but needs for assessment should not be ignored.

2/3/2017 4:06:00 PM
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