Alcohol misuse as defined by the World Health Organization (WHO) is the alcohol use that places people at risk for problems, including “at-risk use,” “clinical alcohol abuse,” and “dependence.” Although the use of alcohol brings with it a number of pleasures, alcohol increases the risk of a wide range of social harms, generally in a dose dependent manner (WHO 2011).

Alcohol misuse is one of the most devastating non-communicable deceases that contributes, or directly causes chronic ill-health, high mortality, violent crime, and anti-social behaviour (Alcohol Concern, 1997). According to the global status report on alcohol and health published in 2011 by World Health Organisation (WHO), the harmful use of alcohol results in 2.5 million deaths each year globally (WHO 2011). According to the same report, by 2011, alcohol misuse is the world’s third largest risk factor for disease burden, and it is the leading risk factor in the Western Pacific and the Americas and the second largest in Europe. Alcohol is associated with many serious social and developmental issues, including violence, child neglect and abuse, and absenteeism in the workplace (Harvey, 2000).

Excessive alcohol consumption is a major cause of different types of diseases and conditions, including injuries, mental and behavioural disorders, gastrointestinal conditions, cancers, cardiovascular diseases, immunological disorders, lung diseases, skeletal and muscular diseases, reproductive disorders and pre-natal harm, including an increased risk of prematurity and low birth weight (Moore and, Pearson, 1986). For most conditions, alcohol increases the risk in a dose dependent manner, with the higher the alcohol consumption, the greater the risk. For some conditions, such as cardiomyopathy, acute respiratory distress syndrome and muscle damage, harm appears only to result from a sustained level of high alcohol consumption, but even at high levels, alcohol increases the risk and severity of these conditions in a dose dependent manner. The frequency and volume of episodic heavy drinking are of particular importance for increasing the risk of injuries and certain cardiovascular diseases (Moore and Pearson 1986).

The causes of alcohol misuse can be traced to many factors including family history, psychological factors such as anxiety or depression, the addictive pharmacology of alcohol, and the environment in which people live. Some research works show that genes could influence people drinking habits and their susceptibility to alcohol addiction. For others who drink alcohol above the guidelines, at ‘hazardous’ and ‘harmful’ levels, alcohol misuse may be due to habit, lifestyle, lack of awareness of the health effects and an absence of obvious symptoms.

This assignment seeks to discuss the problems associated with alcohol misuse, and the collective efforts currently being put in place in term of research and government policies to address it. The understanding of local, national and global trends of alcohol misuse and the associated deceases will be demonstrated using the available statistical data from the Public Health Observatory.

Following the introductory section, where background of alcohol misuse, the justification for chosen it, and the importance of alcohol misuse as a public health concern are provided, Section 2 will discuss the epidemiology and trends of alcohol misuse. In Section 3, the social determinants of alcohol misuse will be explored, while Section 4 will address how the issues and problems of alcohol misuses are tackled at both national and global level. Section 5 will be devoted to the local public health. Specifically, the problems associated with alcohol misuse in Bradford will be discussed. The last section will provide some recommendations and strategies to address the issue of alcohol misuse.

Methodology

The research methods used for this assignment included reviewing poster, televisions adverts, internet research on alcoholism and journals. The main website was the national institute of alcohol abuse, but others included healthy living, NHS Stockport. These research methods were very useful as they provided a wealth of information which resulted in a through investigation in to alcoholism and the effects on an individual’s lifestyle

2. Epidemiology of Alcohol Misuse

The alcohol misuse is a global phenomenon, which hinders both individual and social development. On a global level, World Health Organization (WHO 2011) reported that:

The harmful use of alcohol results in 2.5 million deaths each year.

320 000 young people between the age of 15 and 29 die from alcohol-related causes, resulting in 9% of all deaths in that age group.

Alcohol is the world’s third largest risk factor for disease burden; it is the leading risk factor in the Western Pacific and the Americas and the second largest in Europe.

Researchers in numerous countries have conducted analyses of alcohol consumption and general population surveys to ascertain the level and consequences of alcohol use. In recent years, investigators also have made attempts to compare drinking rates and other drinking variables across different countries. One reason for researching across national borders is the need for descriptive epidemiology (Room and Makela1988).

The total economic cost of alcohol to the EU was estimated to be €125 billion (WHO Europe, 2009), while the government of United Kingdom estimated the cost of alcohol related harms to the National Health Service (NHS) to be £2.7 billion in 2006/07 prices (NHS 2012).

Alcohol consumption is a major cause of ill-health in England. More than 10 million people (31 per cent of men and 20 per cent of women) are now regularly drinking above the guidelines set by Government (NAO, 2008), and many of these are likely to suffer ill-health or injury as a result.

In England, it is estimated that 18 per cent of the adult population (7.6 million) are drinking at ‘hazardous’ levels; another seven per cent (2.9 million) are showing evidence of harm to their own physical and mental health, including approximately 1.1 million people who have a level of alcohol addiction (NAO, 2008).

Social Determinant on Health

Alcohol use and abuse is a major preventable public health problem. To be able to do this, we must be able to understand the social determinant of alcohol misuse and abuse. Different factors such as gender difference, race, culture, ethnicity, social class, poverty levels are among the most important factors that have been found to influence the level of alcohol consumption. According to the research findings reported in the Alcohol Needs Assessment Research Project (ANARP), 2004, about 38% of men and 16% of women (age 16-64) have an alcohol use disorder , which is equivalent to approximately 8.2 million people in England.

It has also been reported in the literature that alcohol use disorders generally decline with age. In relation to ethnicity, black and minority ethnic groups have a considerably lower prevalence of hazardous/harmful alcohol use but a similar prevalence of alcohol dependence compared with the white population (ANARP, 2004).

Another important social determinant of alcohol misuse is the family background. The family plays a central role in the use of alcohol by children and adolescents. Early drinking and much subsequent use of alcohol by children and adolescents is sanctioned and sometimes encouraged by their families. Unlike experimentation with alcohol, problem drinking is associated with low levels of family social support and with dysfunctional coping strategies of families that may lead children to use drinking as an adaptive behavior.

Addressing Alcohol Misuse Issues

The harmful use of alcohol is a serious health burden, and it affects virtually all individuals on an international scale. Both the government policy (NHS) and the scientific literature have recognized the necessity to control the general population’s alcohol consumption. According to the World Health Organisation (WHO), the global strategy to control the misuse of alcohol will focuses on ten key areas of policy options and interventions at the national level and four priority areas for global action. The ten areas for national action are summarized as follows:

Leadership, awareness and commitment;

Health services’ response;

Community action;

Drink-driving policies and countermeasures;

Availability of alcohol;

Marketing of alcoholic beverages;

Pricing policies;

Reducing the negative consequences of drinking and alcohol intoxication;

Reducing the public health impact of illicit alcohol and informally produced alcohol;

Monitoring and surveillance.

The four priority areas for global action are:

public health advocacy and partnership;

technical support and capacity building;

production and dissemination of knowledge;

resource mobilization

At national level, Government policy continues to place emphasis on the primary care setting to undertake health promotion. Prior to 1995, the sensible drinking policy in the UK was that men should drink no more than 21 units (168 g) and women 14 units (112 g) per week (Department of Health 1992). However, by 1995, the Department of Health in UK has put in place guidelines for the responsible consumption of alcohol (UK Department of Health 1995). The comparison of UK units/day and grams of pure alcohol/day in light/moderate/heavy drinking is summarized in Table 1.

Table 1: comparison of UK units/day and grams of pure alcohol/day in light/moderate/heavy drinking

Local Public Health

Of most concern to public health is the number of local people drinking excessively. In this work, the public health of Bradford will be discussed. National data suggests around 20,000 residents of the Bradford district are dependent drinkers. According to the Bradford and Airedale Health and Lifestyle Survey 2007-2008, the national average consumption in Bradford district is significantly greater than the national average. In all adult, the mean units alcohol consumed by drinkers in a typical week in Bradford is 23% for men and 14.5% for woman as compared to national average of 21% for men and 11% for woman (BJSNA 2010).

The Bradford and Airedale Healthy Lifestyle Survey (BJSNA 2010) shows that 9% of men and 7% of women are drinking at a harmful (higher risk) level. For men, this finding is in line with the national average; for women, the finding as nearly double (England 4%). Amongst men, this problem is concentrated in the 35-64 age groups; amongst women, the under 24s and 45-54s exceed the district average.

Recommendations and Strategies

Current Strategies

There have been various current strategies currently being put in place both by the local and national government. Some of the current strategies are aimed to:

reduce the number of people who drink alcohol above recommended limits, thus reducing the adverse health impact of alcohol.

reduce alcohol-related crime, disorder, intimidation, nuisance and anti-social behaviour.

develop a comprehensive range of effective treatment, support, rehabilitation and reintegration services for alcohol victims, with easy access and clear care pathways.

reduce the harm caused by alcohol misuse within families and relationships, including domestic abuse and the “hidden harms” caused to the children of alcohol- misusing parents.

reduce the number of babies born with a disorder in the Foetal Alcohol Spectrum Disorder range, and to decrease the risk of related problems experienced by children born with one of these disorders.

reduce alcohol-related accidents and fires, thus reducing avoidable premature death, disability and less serious injuries.

reduce the economic costs of alcohol misuse.

ensure that information and services are accessible and welcoming to all sections of Bradford’s diverse population.

Recommendations

In other to address the problem of alcohol misuse at local, national, and global level, the following recommendations are provided:

Education is on of the general way to address the issue of alcohol misuse. Government can make sure that all local schools have programs in place to educate children about the risks posed by alcohol misuse. It is important to arm young people in community with knowledge about the consequences of abusing drink and drugs.

Government at both local and national level should fund youth clubs, art facilities and other activities to give young people alternative things to do instead of spending time on the streets drinking.

The general practitioners as well as nursing practitioners should continue to provide better support/consultancy services to the victims of alcohol.

Provision of support group at different localities to provide improved counselling services and treatment programs for those with substance abuse problems in the community. Discussion should be established with schools, colleges, local employers, government and policy makers to see if they have any facilities in place to identify and help those struggling with alcohol misuse.

Conclusion

The public health issues on alcohol misuse are discussed in this work. Alcohol misuse is found to be one of the most devastating non-communicable deceases that contributes, or directly causes chronic ill-health, high mortality, violent crime, and anti-social behavior. The epidemiology and trends of alcohol misuse was discussed, while the social determinants of alcohol misuse based on gender difference, age, ethnicity, and family background was addressed. The policies put in place by both the local and national government to address the issues and problems of alcohol misuses are assessed. The last section provided some recommendations and strategies to address the issue of alcohol misuse.

Critical Appraisal Skills Programme/CASP (Public Health Resource Unit, 2007) a reader should equip with in order to make sense of scientific research. The CASP is to help a reader develops critical skills so as to be sensitive of scientific research and, therefore, to think reasonably about any research encountered (Public Health Resource Unit, 2007). Both quantitative and qualitative researches can be appraised by using the CASP. Each of the CASP guidelines has ten questions in which validity, relevance and results of appraised research have been covered. This assignment has been divided into two parts. The first part quantitative paper written by Ho et al, (2006) will be appraised. The second part qualitative paper written by Liu and Liehr (2009) will then be appraised. All findings will be summarized finally.

1. Did the study ask a clearly focused question?

PICOT is used for answering the question 1 and it is a framework that healthcare professionals can use to formulate effective clinical questions in a step-by-step manner (Melnyk & Fineout-Overholt, 2010). The population of the study was all the subjects should have one tattoo at least. 120 Chinese subjects with 144 tattoos were recruited for the study. The intervention of the study was half of the subjects were applied Contractubex gel while others were applied nothing. The purpose to do so was to check the efficacy of the gel. The comparison of the study was study and control groups are used for comparison as a result of finding out the efficacy of Contractubex gel. The outcome of the study was the gel should be effective in preventing scarring after the subjects receiving laser removal of tattoos. The research has shown that the number of subjects in Contractubex group with scarring were significantly lower than in control group. The time of the study was the treated areas were assessed 3 months after the last treatments. In short, the research has asked a clearly focused question- Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. So the answer is “Yes”.

2. Was this a randomized controlled trial (RCT) and was it appropriately so?

A type of scientific experiment most commonly used in validating the effectiveness of health issue, say, pharmaceuticals (e.g. gel), can be regarded as RCT (Gallin & Ognibene, 2007). It involves the random allocation of different interventions to the subjects. Furthermore, as long as the numbers of subjects are adequate, randomization is an effective method to produce a random and unpredictable sequence of allocations. Regarding to the Ho et al (2006) research, they must adopt RCT. Two evidences can be shown to support my stance. First, it was testing the efficacy of Contractubex gel intervention (health issue) provided by doctors to subjects with tattoo. Second, the 120 subjects were randomly assigned to either Contractubex or Control group at equal probabilities. In suitability, it was the right research approach for the researched question because it was going to compare result after receiving Contractubex gel with a control group. In short, RCT is the appropriate method and correct approach to conduct this research, as there were two groups that were allocated randomly, the study group received intervention and the control group did not receive intervention and the answer is “Yes”.

3. Were participants appropriately allocated to intervention and control groups?

The answer is “Yes”. Answer of question 2 has mentioned that the 120 subjects were allocated into the two groups randomly. In research term, complete randomization has been adopted. Complete randomization means each tattooed subject was randomly assigned to either of the groups. It is simple and optimal in the sense of validity to prevent accidental bias (Gallin & Ognibene, 2007). In randomization procedure, the researchers adopted fifty-fifty basis allocation (60 subjects in Contractubex group and 60 subjects in Control group). In this research stratification can be observed. Stratification means developing strata for sampling (Gallin & Ognibene, 2007). 60 subjects in control group and 60 subjects in study group is a typical example of stratification. The purpose to do so is that since most statistical tests, say, the paired student’s t test are most reliable when the groups being compared have equal subjects (Gallin & Ognibene, 2007), it is desirable for the randomization procedure to generate similarly-sized groups. In short, as all participants were assigned to Contractubex and Control groups appropriately.

4. Were participants, staff and study personnel ‘blind’ to participants’ study group?

The above parties understood the details of the research. Ho et al (2006) paper mentioned that “informed consent” was obtained from all subjects. “Informed consent” is a process of communication between a subject and doctor that results in the subject’s authorization or agreement to undergo a specific medical intervention (Berg et al, 2001). On the one hand, blinded research can avoid bias. However, it is impossible for some treatments. For example, treatments where active participation of the subjects are necessary (e.g. regularly receiving laser therapy with the application of the gel). In research personnel, certainly they understood the details of the research, for instance, employing Q-switched laser systems as well as its spot size and repeat rate and pulse duration. They were unable to perform the research successfully otherwise. Nonetheless, whether the control group received placebo gel and the assessor of the scars knew the research details or not did not mention. In brief, open trial (the above parties understood the details of the treatment) instead of blind trial was employed and the answer seems “No”.

5. Were all of the participants who entered the trial accounted for at its conclusion?

Originally, there were 60 subjects in the control group and 60 subjects in the study group. However, there were 8 out of 60 subjects in the study group quitted the research. 5 out of 8 simply defaulted follow-up and 3 out of 8 stopped using the gel due to adverse effect. In the control group, there were 5 out of 60 subjects quitted the research. 4 out of 8 simply did not follow-up and 1 out of 8 stopped using the gel due to have a baby. Although, there were a few subjects quitting from the research due to personal affairs, the groups’ size still remained similar (52 in Contractubex and 55 in Control groups) and the researchers have already reported such discrepancy. In other words, intention to treat was used as it is a strategy for the analysis of RCT that compares subjects in the groups to which they were originally randomly assigned (Gallin & Ognibene, 2007) and the answer is “Yes”.

6. Were the participants in all groups followed up and data collected in the same way?

In the former, the subjects were followed up from 13 to 20 months with a mean of 15.5 + 2.6 months. The importance of the follow up was to review the probability of scar formation after applying the gel. Likely, the research personnel followed up the subjects after the last laser treatment. However, the same amount of attention to the subjects from the research personnel becomes questionable because the researchers did not describe how to review the subjects. More elaborately, how much time the researchers spend on each subject for review? In addition, performance bias may occur. For instance, if research personnel know which group subjects are in, they may treat subjects differently (Gallin & Ognibene, 2007). In this aspect, “can’t tell” seems appropriate. In the latter, “Yes” in terms of data collection in the same way, the researchers should collect the data during clinical observation. Clinical observation is the research personnel directly observe any changes during the study period and then record the changes. Data analysis can be done by using statistical software (e.g. SAS). In short, the answers were “Yes” in the way of data collection only. The amount of attention to the subjects needs the research personnel further clarification otherwise performance bias may be suspected.

7. Did the study have enough participants to minimize the play of chance?

The meaning of the play of chance can be explained by the following example, taking a comparison of the Contractubex group with the control group in which 4 subjects scar formation with the Contractubex group and 6 subjects scar formation with the control group. It would be incorrect to conclude that the Contractubex group was better than the Control group. It is because if the comparison was repeated, the numbers of subjects who formed scar might be same (5 against 5). However, 7 subjects scar formation with the gel and 16 subjects without the gel, chance becomes a less likely explanation for the difference. In Ho et al (2006) study, numbers of subjects were enough to lessen the play of chance. Sample size can be determined by a formula by inputting population size and confidence level as well as margin of error and response distribution. On the one hand, significant difference between the two groups was observed. Power calculation can facilitate the research personnel determines how large of a sample the research personnel needs to make precise statistical conclusions (Gallin & Ognibene, 2007). Therefore, statistical significance was the robust evidence to prove the play of chance impossible.

8. How are the results presented and what is the main result and

9. How precise are these results?

Comparison of the intervention and control groups using the p-value has been presented. The main finding was that the application of the gel was useful to prevent scar formation after laser removal of tattoos. In accuracy of the results, p-value <.05 can be regarded as statistically significant that scar removal with the application of the gel was not by chance. The results can be considered to be quite precise.

10. Were all important outcomes considered so the results can be applied?

The research proved that the gel was effective, safe, and easy to apply in the prevention of scarring in Chinese subjects having laser removal of tattoos. Nonetheless, 100% scar removal is not guaranteed after using the gel. The results revealed that there were a few subjects who still have scarring. In addition, permanent hypopigmentation and transient hyperpigmentation can be noted. On the other hand, you may argue that the results may be affected by a political factor, that is a pressure from the pharmaceutical company, Ho et al (2006) have indicated that no significant interest with commercial supporters at the beginning of the research. In short, the research provides a reliable reference to healthcare professionals that the gel is recommended to be used in dark skin patients receiving laser treatments of tattoos.

Ten questions have been answered to help me make sense of quantitative research. Also, ten questions are used to help me make sense of qualitative research. Qualitative research is a generic term for investigative methodologies described as ethnographic, naturalistic, field, or participant observer research. It underscores the importance of looking at variables in the natural setting in which they are found (Sliverman, 2004).

1. Was there a clear statement of the aims of the research?

Qualitative PICOT is a framework that healthcare professionals can use to formulate effective clinical questions in a step-by-step manner (Melnyk & Fineout-Overholt, 2010).The population of the study was the six nurses who had experiences in taking care of SARS patients. The issue of the study was identifying instructive messages to guide nursing practice in future epidemics by in-depth interview of the six Chinese nurses who cared for SARS patients. The context of the study was where the study takes place. The research mainly takes place in Beijing. The outcome of the study was the research gave specific direction to enhance potential for a well-prepared nursing workforce in future epidemics. The time of the study was the SARS outbreaks between 11/2002-5/2004 and data were collected in 2003 within the three months following the nurses’ quarantine necessitated by caring for SARS patients.. In brief, the answer is “Yes”.

2. Is a qualitative methodology appropriate?

Qualitative research is to study things in their natural settings, attempting to make sense of, or to interpret, phenomena in terms of the meanings people bring to them. It is intended to penetrate to the deeper significance that the subject of the research ascribes to the topic being researched (Denzin, 2005). Interviews, observations and case studies are commonly used for data collection and then analyse the data. Samples are usually small and are often selected purposively. Qualitative research uses detailed descriptions from the participants as ways of examining specific issues under study. The research method employed by the researchers was appropriate because the following criteria were matched- detailed description instead of statistical software were used and number of participants was quite small- only six. In addition, the researchers adopted phenomenology. The phenomenological approach is to describe accurately a person’s ‘lived’ experience in relation to what is being studied (i.e. the six Chinese nurses caring for SARS patients) (Denzin & Lincoln, 2005). In short, the answer is “Yes”.

3. Was the research design appropriate to address the aims of the research?

Appropriate method (i.e. in-depth interview) for conducting the research was used. In-depth interview is a kind of qualitative research technique that involves conducting intensive individual interviews (i.e. the six nurses) with a small number of respondents to explore their views on a particular idea (i.e. sharing in caring SARS patients). In the study, the researchers asked participants about their experiences and insights regarding to the caring for SARS patients, the thoughts they have concerning nursing care, challenge, and outcomes as well as about any changes the participants perceive in themselves as a result of their involvement in the study (Denzin & Lincoln, 2005). In addition, rich contextual information can be obtained and the research personnel can ask the six nurses to elaborate their sharing in details through the in-depth interview. So the answer is “Yes”

4. Was the recruitment strategy appropriate to the aims of the research?

Six nurses were invited to share their experiences in caring for SARS patients. The six nurses were no objections and voluntary to share their encounter after enquired by research personnel. In other words, a reader should not suspect their willingness of participation. The recruitment strategy was appropriate, because if reward-based (e.g. bonus to interviewees) and compulsory-based recruitment were offered to potential interviewees, the accuracy and reliability of data should be suspected. To achieve the aims of the research, nurses were voluntary to share their stories and they provided detailed descriptions with little prompting were important to the aims of the research. In other words, it starts with a purpose in mind and the sample is selected to include interested party (i.e. nurses with experience in caring of SARS patients) and exclude those who do not suit the purpose and purposive sampling was used (Denzin & Lincoln, 2005). So the answer is “Yes”.

5. Were the data collected in a way that addressed the research issue?

To collect data, a storypath approach was used. Research personnel recorded what the six nurses presented by a tape recorder. Seven inquiry phases were associated with storypath approach, including gathering the story, reconstructing the story, connecting it to the literature, naming the complicating challenge, describing the story plot, identifying movement toward resolving, and gathering additional stories (Denzin & Lincoln, 2005). In application, specific questions were asked by the research personnel, for instance, challenge the nurses were facing during caring for SARS victims, how the experience influence your hopes and dreams in the coming future. The data collection methods must observe the ethical principles of research. In short, the answer is “Yes”.

6. Has the relationship between researcher and participants been adequately considered?

This research paper mentioned that the stories of the six nurses were collected by two Chinese investigators, It was hard to say that any potential bias and influence occurred because the research personnel simply mentioned that they were responsible for gathering the stories from the participants and supporting activities, say, properly use of tape recording. Apparently, the relationship between the research personnel and participants were nothing, but participants may be influenced by the research team or in professional term- reflexivity. Reflexivity requires an awareness of the researcher’s contribution to the construction of meanings throughout the research process, and an acknowledgment of the impossibility of remaining ‘outside of the six nurses’ while conducting research. In short, the answer of this question is “Yes”.

7. Have ethical issues been taken into consideration?

Oral consent is a kind of ethical issue. Kozier et al, 2004 define the consent is an essential part of the research process, and as such entails more than obtaining a signature on a form (Kozier et al, 2004). Research personnel must educate potential subjects to ensure that they can reach a real informed choice about whether or not to participate in the research. Consent must be given freely and with no coercion as well as based on a clear understanding of what participation involves. On the one hand, the above study has been approved by the University’s ethics committee. The committee is responsible for reviewing, on request, ethical or moral questions that may come up during the study. In brief, the answer is “Yes”.

8. Was the data analysis sufficiently rigorous?

In-depth description of the analysis process was shown in Liu & Liehr (2009) paper. The authors described every phase elaborately and in step-by-step pattern. There were total 5 phases of the content analysis for the nurses caring for SARS patients. The content shared by the six nurses was similar because of geographical reason and the consistent format of the interview. Such arrangement provided convincing analysis to a reader. In fact, thematic analysis was employed by the researchers. It means focuses on identifiable themes (i.e. sharing of nursing care of SARS patients) and data is analysed by theme. This type of analysis is highly inductive, that is, the themes emerge from the data and are not imposed upon it by the research personnel (Denzin & Lincoln, 2005). In short, the answer is “Yes”.

9. Is there a clear statement of findings?

It is crystal clear that there were three core qualities (personal challenge, essence of care and self-growth) the researchers found. Each quality was described in-details with concrete example of the original words from the six nurses. In addition, instructive messages for guidance during future epidemics were also provided. The findings were highly related to the research question. In brief, a clear statement of the findings was clear and evidences were provided to support each quality the answer is “Yes”.

10. How valuable is the research?

The researchers discovered three core qualities and instructive messages regarding to SARS patients caring. Such discovery greatly increases preparedness by attending the messages including structured support, disease/protection-related information systems and the power of military spirit. Maybe the above components can be further researched so as to obtain greater improvements. In addition to enhance preparedness and identify new areas where researches are necessary, the findings are universal applicable. Healthcare frontline staff may face the problems when caring for SARS patients, say, lack of resources. Clinical leader may find the importance of structured support and collaborative spirit to relieve the staff pressure. In short, the value of this research is valuable.

Conclusion

To sum up, the CASP guidelines can appraise both quantitative and qualitative researches. The guidelines include ten questions in which provide comprehensive evaluation of the above studies. The guidelines are particular useful in appraising health and social researches. Furthermore, the CASP guidelines aim to enable readers to develop the skills to find out and make sense of research evidence, helping them to put knowledge into practice. (Word count: 3212)

Introduction

The United States spends more money on healthcare than any other developed country with more than $10,000 spent in total health expenditures per capita in 2016 (Sawyer & Cox, 2018). Healthcare consumes more of the gross national product year after year at a rate that is unsustainable. Our health outcomes, however, do not reflect these rising costs suggesting that the U.S. is not using its healthcare dollars efficiently. Leaders in health policy have looked to cost containment as a strategy to reduce expenses and improve profitability. One specific initiative to contain costs is to optimize how healthcare is delivered to patients and how providers are paid. James C. Robinson said, “There are many mechanisms for paying physicians. The three worst are fee-for-service, capitation, and salary,” (Robinson, 2001). Very broadly, fee-for-service models generally result in overutilization and capitation the opposite. Salary models undermine productivity. In these systems, competition in healthcare is not aligned with value for patients. By focusing on value for patient, we can create a system that improves quality of health that is based on health outcomes, which will ultimately lower costs as well (Porter, 2009).

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Quality refers not only to health outcomes, but also quality of the provider and of the care delivered; the latter two of which are subject to the patient’s perceptions. Most patients focus on the doctor-patient relationship while experts focus on effectiveness of treatments or health outcomes (Coleman, 2014). Patient satisfaction was not even factored into pay incentives until CMS started its Hospital Inpatient Value-Based Purchasing program (HVBP). Starting in 2012, Medicare began withholding 1% of its payments to hospitals to be doled out as bonuses to hospitals that score above average on certain measures. A large chunk of the scores are based on patient satisfaction measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Centers for Medicare & Medicaid Services (CMS), HHS, 2011). The utility of these scores remains controversial since a happy patient isn’t necessarily one that received the best medical care and vice versa. Larger, tertiary care hospitals, especially those in urban areas oppose linking patient satisfaction to payment while smaller, community hospitals are more in favor. Teaching hospitals and larger hospitals tend to score lower than smaller community hospitals (Rau, 2011). CMS adjusts for some factors, but not all of them. Understanding the limitations of HCAHPS scores is an important step in determining the utility and validity of this value-based program.

Limitations of the HCAHPS Survey

Structural and Demographic Disparities

To start, safety-net hospitals tend to perform more poorly than other hospitals on almost every HCAHPS measure of patient experience. These hospitals are most likely to suffer from additional reimbursement cuts due to narrow operating margins and are disparately penalized for having lower scores (Chatterjee, Joynt, Orav, & Jha, 2012). In the first year of Medicare’s HVBP program, hospitals caring for more disadvantaged patients had significantly lower Medicare payment adjustments (Ryan, 2013). Academic medical centers, specifically, treat large number of disadvantaged patients because those centers tend to be the state hospitals or the large tertiary care centers in urban areas. These patients are likely to require multiple specialists and more complex coordination of care. Coupled with larger medical teams, this leaves room for more oversights and poorer communication likely resulting in a poorer patient experience.

Acuity of Care

Hospitals that treat more chronically ill patients for longer periods of time also tend to have worse satisfaction scores. One study found that in chronically ill Medicare patients, greater inpatient care intensity was associated with lower quality scores and lower patient ratings. Hospitals in regions with more-aggressive patterns of inpatient care are generally more inefficient in their resource utilization. Conversely, hospitals that use less inpatient care, tend have better scores in their chronically ill patients. Most of the questions of the HCAHPS survey are concerned with coordination of care and communication with patients. Regions with lower intensity care and greater patient satisfaction tended to have higher proportions of primary care providers who aid in care coordination both in and out of the hospital (Wennberg et al., 2009). Improving communication between PCPs and inpatient providers is critical in promoting conservative inpatient care. This not only improves care coordination from inpatient to the outpatient, but also reduces the number of providers involved in a patient’s care while in the hospital. More providers often lead to duplicate services, disorganized care, and higher chance of communication issues. Also patient often feel that when they have too many providers they are less likely to establish a rapport with any of them. Fewer providers and more thoughtful use of care leads to deeper provider-patient relationships and likely better patient satisfaction.

Patient Characteristics

Patient experience may also be confounded by factors that are not directly associated with their care. For example, patients may base their satisfaction scores on their health status regardless of the care they received, which can also explain why higher acuity hospitals have lower scores. One study showed that a better self-perceived health status was associated with greater patient satisfaction suggesting that characteristics external to the delivery of healthcare are also in play. Patient education, ethnicity, and primary language are among these characteristics that can influence patient satisfaction. Hospitals that treat a disproportionate percentage of non-English speaker, non-White, non-educated patients in large facilities report lower patient satisfaction scores (McFarland, Ornstein, & Holcombe, 2015). Both structural and demographic inequalities are often not adjusted for by CMS. Therefore, hospitals that serve indigent and elderly populations may be unjustly penalized under this HVBP reimbursement models.

Addressing the Entire Medical Team

Another limitation to the HCAHPS survey is its lack of focus on the patient-provider interaction. An analysis from the American Journal of Managed Care found that communication with physicians ranked fifth out of eight categories in order of degree of correlation with patient satisfaction. Communication with nurses, pain management and timeliness of assistance were the top three to correlate with overall satisfaction (Boulding, Glickman, Manary, Schulman, & Staelin, 2011). Patients value their interactions with the entire medical team and it is understandable that the members of the team with the most face time have the most influence over patient experience. However, when talking about outcomes, it is important to tie them to the physician order first and foremost.  Therefore, limiting the scope of the HCAHPS surveys to just the provider-patient interaction may provide greater insight into the aspect of care for which patient reported measures are most valuable.

Conclusion

Critically appraising the HCAHPS survey is an important step in validating its utility in the HVBP program. The biases and limitations of the survey show the consequences of using unadjusted models of scores to determine Medicare reimbursements. It also uncovers where hospitals can be held accountable for the things they can control while accepting that some patient perceptions may not change no matter what. Improving care coordination after discharge, reducing the size of medical teams, being thoughtful about utilization are all behaviors that any hospital can employ to improve their patient satisfaction. Teaching hospitals can invite social work students, pharmacy students and nursing students to be part of the medical team to create a better foundation and understanding of patient-centered care earlier on in their educations. Cleveland Clinic, for example, scored below average on 7 of 9 key patient-satisfaction questions according to their chief experience officer, Dr. James Merlino. They have analyzed their scores and improved physician communication by learning from their high-scoring physicians. According to the Dr. Merlino, the entire medical staff has attended a communication-training program taught by a team of peer physicians, which has already enhanced patient-physician conversations (Guadagnino, 2012). Any definition of high quality medical care must include the patient experience and if that is not always concordant with their outcomes then special care should be taken to understand why. Adjusting scores based on acuity of the hospital, as well as adjusting for teaching status and the demographics of the patients seen there is a start in recognizing nonrandom variance among satisfaction scores. CMS is taking these scores seriously for better or worse when distributing Medicare reimbursements, so a more productive strategy would be to focus on improving the patient experience. Listening carefully and employing empathy can go a long way, and at the end of the day, the value, in value-based medicine, should include the delivery of both high-quality and patient-friendly care.

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