DNP 852A Module 2 Interpreting the Findings Against the Literature Example

Larger Than the Trials, and Why: Interpreting a Pediatric Asthma Program's Findings Against the Evidence

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 852A: Project Manuscript

Instructor Name

Month Day, Year

Larger Than the Trials, and Why: Interpreting a Pediatric Asthma Program's Findings Against the Evidence

Findings mean little until they are set beside what is already known. This paper drafts the interpretation section of chapter five for my DNP project, the clinic's nurse visit for children whose asthma was poorly controlled. After 12 weeks, many more children had well-controlled asthma and fewer needed emergency or urgent care. The paper compares those findings with systematic reviews of action plans, inhaler technique and school programs, asks why the project's effects appear larger than those in trials, and identifies what the project adds. Each comparison uses the reviews' own reported findings and wording.

Agreement With the Evidence on Action Plans

The direction of the project's findings matches the best available evidence. Pooling randomized pediatric trials, one systematic review linked written plans with fewer acute care visits, fewer missed school days and less waking at night, and that plans based on symptoms worked better than plans based on peak flow (Zemek et al., 2008). The project used symptom-based plans and found fewer acute visits and better control. The reviewers were cautious, noting that few trials compared a plan with no plan at all; most compared one kind of plan with another. The project cannot resolve that uncertainty either, since every child received a plan. What it can add is evidence that plans delivered by nurses in a busy safety-net clinic, in two languages, are followed by improvement of the kind the trials suggest.

Agreement on Inhaler Technique

The project's technique findings track the literature closely. Before coaching, fewer than one child in five used the inhaler and spacer correctly, consistent with a systematic review of 28 studies that described children's technique as generally very poor and found counseling associated with improvement (Gillette et al., 2016). The project also saw technique slip by 12 weeks in some of the earliest children and hold better once a check was added to follow-up contacts. That pattern matches a review of educational inhaler interventions that found them effective in the short term, with effects that waned over time and a need for periodic reinforcement (Klijn et al., 2017). The project's contribution is practical: it shows that reinforcement can be built into existing contacts at low cost, and that doing so is associated with better retention.

Why Are the Effects Larger Than in Trials?

The project's changes are large. The share of children in good control more than doubled, while acute care use dropped below half its earlier level. School-based self-management programs, reviewed in a Cochrane synthesis, probably reduce unplanned visits and may reduce emergency visits, but by modest amounts, for example from 7.5% to 5.4% of children visiting an emergency department over 12 months (Harris et al., 2019). Four explanations for the difference deserve weight. The project's children started with worse control than many trial populations, leaving more room to improve. The project had no concurrent comparison group, so regression to the mean and the attention of being in a program are included in the change. Some children began controller medicine during follow-up, a co-intervention that trials often hold constant. And 12 weeks is short, so the effect may shrink over a longer period, as the fading of technique suggests. Together these reasons caution against treating the project's effect as the size another clinic should expect.

Where the Project Adds to the Literature

The project adds three things the reviews note as gaps. First, it reports results separately for Spanish-speaking families and finds them similar to results for English-speaking families, in a field where many trials enrolled mostly English speakers. Second, it describes implementation in detail, including the administrative steps that failed until someone owned them, which reviews rarely report. Third, it shows a clinic-wide shift in action plan coverage, not only change among enrolled children, suggesting that the program changed routine practice. None of these contributions is definitive, but each is useful to a clinic deciding whether to try a similar program.

A clinic similar to this one is the audience these contributions serve best.

Reading the Clinic-Wide Change

The rise in action plan coverage across the whole registry deserves its own interpretation. Enrolled children account for most of it, but not all: once the template, the monthly registry flag and the front-desk process existed, clinicians began writing plans at routine visits for children who never enrolled. In the language of implementation research, the project changed the clinic's routines as well as delivering a service. That matters for interpretation, because a routine that outlasts the project is more likely to sustain benefit than a service that depends on a student's presence. It also means that the clinic-level acute care comparison measures a mix of the enrolled program and this wider change, and the two cannot be fully separated.

Findings That Were Not Expected

Two findings were unexpected. Acute care visits at the clinic level fell less than among enrolled children, which is expected on reflection because most registry children did not enroll, but it shows that the program's reach, not only its effect, limits its impact on the clinic. And children whose plans reached school did better than those whose plans did not, a difference larger than the literature on school sharing would predict. Because families chose whether to share, that difference is probably partly self-selection, and it is interpreted as a question for future work rather than a finding.

Conclusion

The project's findings agree in direction with systematic reviews of written action plans, inhaler technique education and school programs, and they fit the literature's warning that technique gains fade without reinforcement. The effects are larger than trials would predict, for reasons the design cannot rule out, so they should be read as encouraging rather than definitive. The project's clearest contributions are its bilingual results, its detailed account of implementation and its evidence of change across the clinic.

The limitations section that follows examines those design constraints one at a time.

Chapter five will present the comparison in this order.

References

Gillette, C., Rockich-Winston, N., Kuhn, J. A., Flesher, S., & Shepherd, M. (2016). Inhaler technique in children with asthma: A systematic review. Academic Pediatrics, 16(7), 605-615. https://doi.org/10.1016/j.acap.2016.04.006

Harris, K., Kneale, D., Lasserson, T. J., McDonald, V. M., Grigg, J., & Thomas, J. (2019). School-based self-management interventions for asthma in children and adolescents: A mixed methods systematic review. Cochrane Database of Systematic Reviews, 2019(1), Article CD011651. https://doi.org/10.1002/14651858.CD011651.pub2

Klijn, S. L., Hiligsmann, M., Evers, S. M. A. A., Román-Rodríguez, M., van der Molen, T., & van Boven, J. F. M. (2017). Effectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: A systematic review. NPJ Primary Care Respiratory Medicine, 27, Article 24. https://doi.org/10.1038/s41533-017-0022-1

Zemek, R. L., Bhogal, S. K., & Ducharme, F. M. (2008). Systematic review of randomized controlled trials examining written action plans in children: What is the plan? Archives of Pediatrics & Adolescent Medicine, 162(2), 157-163. https://doi.org/10.1001/archpediatrics.2007.34