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DECLARATION:

This written dissertation is my own unaided work. Signed:.. Dated: 8 September, 2011 Word count: 14,550
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Acknowledgements

To begin with, I would like to thank God for how far He has brought me on my journey in a foreign land. I express my sincere gratitude to my supervisor, Fiona Bath-Hextall for her support and guidance in the process of this dissertation and especially for her support during the entry of data. I could not achieve an experience of nurse-led dermatology clinics in the UK without the support of my mentor Sandra Lawton, Nurse Consultant, Dermatology Department- Queen's Medical Centre.

I would also like to show appreciation to my course leader Linda East for her assistance throughout the various modules of the course. I would like to acknowledge the help of Wendy Stanton, Faculty Team Librarian in Greenfield Medical Library with my searching strategy. Last but not least I would like to thank my sweetheart, Ivan Afram Attafuah, my family and course mates for their support and useful criticisms during this year of the course.

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Contents
DECLARATION: ...................................................................................................... i Acknowledgements ................................................................................................ ii List of Figures ....................................................................................................... v List of Tables ........................................................................................................ v Chapter 1 Introduction ........................................................................................ 1 Aim and Objectives ............................................................................................. 2 1.2 Background .................................................................................................. 4 1.2.1 Epidemiology of dermatology conditions and nurse-led clinics ....................... 4 1.2.3 Impact of dermatological conditions on patients ...................................... 5

1.2.4 Nurse-led Clinics(NLC) in Ghana ............................................................... 6 1.3 Literature Review .......................................................................................... 6 1.3.1 Quality of Life (QOL) ................................................................................ 6 1.3.2 Rationale and Assessment of QOL ............................................................. 7 1.3.3 Dermatology and Quality of Life ................................................................ 8 1.3.4 Patient satisfaction .................................................................................. 8 1.3.5 Severity of condition .............................................................................. 10 1.3.6 1.3.7 Adherence to treatment ................................................................. 11 Cost effectiveness ........................................................................... 12

1.4 Rationale and Justification for this Review ...................................................... 13 1.5 Summary of Chapter ................................................................................... 17 Chapter 2 Methodology ..................................................................................... 18 2.1 Evidence-based Practice (EBP) ...................................................................... 18 2.2 The Place of Systematic Reviews in Evidence-based Practice ............................ 19 2.3 Justification of the Review Question .............................................................. 22 2.4 Protocol ..................................................................................................... 23 2.5 Search Strategy .......................................................................................... 24 2.6 Selection of Studies..................................................................................... 25 iii

2.7 Selection of studies ..................................................................................... 26 2.7.1 2.7.2 2.8 Assessment of Methodological Quality ..................................................... 26 Data Extraction .................................................................................. 26 Summary of Chapter ............................................................................... 27

Chapter 3 Results ............................................................................................. 28 3.1 Description of studies .................................................................................. 28 3.1.1 Search Results ...................................................................................... 28 3.1.2 Characteristics of included studies ........................................................... 29 3.1.3 3.2 Characteristics of excluded studies ....................................................... 32 Methodological quality of included studies .............................................. 32

3.2.1 Risk of bias in included studies ................................................................ 33 3.3 Effects of nurse-led/nurse follow-up clinics: Primary and Secondary Outcomes 35 Primary Outcome: Quality of Life ........................................................ 35 Secondary outcomes ......................................................................... 37 Summary of Chapter ............................................................................ 38

3.3.1 3.3.2 3.4

Chapter 4 Discussion ........................................................................................ 39 4.4 Limitations and strengths of the Review .................................................. 43

Chapter 5 Conclusions....................................................................................... 45 5.1 5.2 Implications for Advancing Nursing Practice .......................................... 46 Reflection on the Process ................................................................... 47

REFERENCES: ..................................................................................................... 50 INCLUDED STUDIES ............................................................................................ 50 Appendix I- Systematic Review Protocol ....................................................................I APPENDIX II Search Strategy: .............................................................................. X

Appendix III ...................................................................................................... XIV Appendix IV ........................................................................................................ XV Appendix V ........................................................................................................ XVI

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List of Figures
Fig. A Hierarchy of evidence ................................................................................................................................. 22 Fig. B Flow diagram of search strategy ................................................................................................................. 29 Fig. C: Forest plots-Quality of life (nurse-led vs dermatologist/general practitioner-led) ................................... 36 Fig. D: Forest plots-severity of condition (nurse-led vs. dermatologist/general practitioner-led) ....................... 38 Fig. E: Forest plots-Patient Satisfaction (nurse-led vs dermatologist/general practitioner-led) .......................... 37 Fig. F: Driscoll's cycle ............................................................................................................................................ 47

List of Tables
Table 1: Characteristics of included studies ........................................................................................................ 31

ABSTRACT Aims and Objective: The existence of nurse-led clinics in developed countries is well known and documented. However, the effectiveness of these clinics in dermatology has not been systematically reviewed. The aim of this dissertation was to determine the effectiveness of a nurseled/follow-up dermatology clinic on the quality of life, adherence to treatment, severity of skin condition, and cost of the service to both clients of the dermatology clinic and the hospital. Background: Most dermatology conditions fall into the criteria of chronic diseases as they are mainly managed and not cured. Although various types of skin conditions affects a large proportion of the Ghanaian community along with the low number of available dermatologists (8), nothing has been done to improve the situation. It hoped that an alternate or additional model of care could be implemented. Design: Systematic review [Meta-analysis] Methods: Search was conducted through databases, journals, dissertations, theses and discussions with experts in dermatology to retrieve published as well as grey literature. 5 RCTs were included in this study with a total of 735 participants. Participants in the trials were randomly allocated to a dermatologist/general practitioner or a nurse (initial assessment or follow-up). They were all assessed at baseline and at various intervals of the trials. Extracted data was analysed using Revman 5.1. Results: Participants who received care from the nurse-led clinic demonstrated significantly improved outcomes in severity of condition(p=0.03) and patient satisfaction rate. Care was however comparable between the two clinics regarding the outcome quality of life (p=0.11) Conclusion: In this review the nurse-led/follow-up dermatology clinic shows potential to improve the health and well-being of clients who have dermatological conditions.

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KEYWORDS: Nurse-led, nurse follow-up, dermatology, dermatologist, general practitioner, Randomised Controlled trial.

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LIST OF ABBREVIATIONS

Atopic Eczema Atopic Dermatitis Body Surface Area British Association of Dermatology Central Intelligence Agency Centre for Review Dissemination Childrens Dermatology Life Quality Index Client Satisfaction Questionnaire-8 Cochrane database of Systematic Reviews Database of Abstracts and Reviews of Effects Dermatology Index of Disease Severity Dermatology Quality of Life Index Ear, Nose and Throat Eczema Area and Severity Index European Dermato-Epidemiological Network European Task Force on Atopic Dermatitis Evidence-based Practice General Practitioner Incremental Cost Effectiveness Ratio Infants Dermatitis Quality of Life Index Intention To Treat International Council of Nurses Joanna Briggs Institute Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument Mean Difference Medical Event Monitors Objective Severity Assessment of Atopic -Dermatitis Patient population, Intervention, Comparator, Outcome Quality of Life Randomised Controlled Trial Review Manager 5.1 SCORing Atopic Dermatitis Scottish Dermatological Society Short-Form Health Survey-36 item Six-Area, Six-Item Atopic Dermatitis severity score

AE AD BSA BAD CIA CRD CDLQI CSQ-8 CDSR DARE DIDS DQLI ENT EASI EDEN ETFAD EBP GP ICER IDQOL ITT ICN JBI JBI-MAStARI MD MEMS OSAAD PICO QOL RCT RevMan 5.1 SCORAD SDS SF-36 SASSAD
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Systems for Information on Grey Literature Tema General Hospital United Kingdom United States of America Visual Analogue Scale World Health Organization

SIGLE TGH UK USA VAS WHO

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Chapter 1 Introduction

The skin is one of the most important organs of the body responsible for protection of all internal organs. Being an external organ it is exposed to physical, chemical and environmental harm and needs to be assessed regularly. Most skin diseases may be overlooked by medical professionals despite being essential indicators of some underlying internal diseases (Mgonda, and Chale, 2011). Every individual has had one skin condition or the other, in their lifetime and may have needed medical attention. However, dermatologists who are trained in this field of medicine are not enough to care for the entire population. Furthermore, general practitioners do not have the requisite skills for dermatology care and support (Kernick, Cox, Powell, Reinhold et al., 2000). The ratio of dermatologists available to the population warrants for an alternative model of care (Brown, 2005; Richardson and Cunliffe, 2003). A doctor- led and nurse-led/nurse follow-up clinics are two common clinics in most developed countries specifically the UK and USA. It is anticipated that nurse-led dermatology clinics are as efficient as doctor-led clinics by providing safe, effective, and economical front line management of patients. Both clinics have been said to provide comparable services (Kinnersley et al., 2000; Miles et al., 2003; Venning et al., 2000).It is important to support this notion by appropriate evidence gathered through quality research (Niu and Li, 2005).

Dermatologist-led clinics are the only options available in my hospital and home country (Ghana) though the available doctors are not sufficient to meet the demands of the ever growing population. This result in long queues and a reduction in the quality of services provided. Waiting times for specialty consultations in public healthcare systems worldwide are lengthy and impose undue stress on patients waiting for further information and management of their conditions (Sarro, Rampersaud and Lewis, 2010). Negotiations are being made to set up a nurse-led dermatology clinic at the Tema General Hospital (TGH)-Ghana. Setting up a nurse-led dermatology clinic fits in with the
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trend of developing programs for patients with chronic diseases to optimise patients self-management (Barlow et al., 2002; Warsi et al., 2004). Measurement of productivity is important in determining the worth or value of a nurseled clinic. The development of a nurse-led service that could provide continuity of care with a nurse who is already part of the patients care pathway could be seen as beneficial. Critiques however do not see the nurse as suitable for the medical role (Keyzer, 1997). A critical review of the potential pros and cons of developing a nurseled clinic is necessary to ensure that significant benefit would be gained by patients, the organisation and the service provider (Winter, Lavender, Blesing, 2011). This systematic review is therefore appropriate to inform future development of the nurse-led dermatology clinic in Ghana.

Aim and Objectives This dissertation presents a systematic review that seeks to investigate the effectiveness of nurse-led dermatology clinics in comparison to dermatologist/general practitioner led clinics, when assessed through patient satisfaction, severity of disease condition, quality of life of clients, adherence to treatment and cost effectiveness for both clinics and clients. The objectives are to: I. Critically review literature on nurse-led dermatology clinics and their impact on clients II. III. Appreciate the role of systematic review in evidence based practice Undertake a systematic review of studies that compare nurse-led clinics to dermatologist/general practitioner led clinic in terms of patient satisfaction, severity of disease condition, quality of life of clients, adherence to treatment and cost effectiveness

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Reflect on how the findings of the systematic review will advance nursing practice

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Make recommendations based on the findings of the systematic review

In the following sections of this chapter, a broad background to dermatological conditions and nurse-led clinics, including its epidemiology and impact is given. Literature on quality of life, patient satisfaction, severity of conditions, adherence to treatment and cost effectiveness encompassing their assessment and relationship with dermatological conditions, is then reviewed. Finally, the rationale and justification for this review is provided.

Chapter 2 focuses on the methodology, beginning with a brief discussion of evidencebased practice, its strengths and its limitations. This is followed by a section on the role of systematic reviews in evidence-based practice. A justification for the review question is provided, followed by the protocol for the various stages of this systematic review.

Chapter 3 presents the findings of the systematic review while chapter 4 discusses these findings. The later sections of chapter 4 discuss the limitations of the review as well as recommendations for future research. Lastly, I discuss the implications of the findings to advancing nursing practice, and a reflection on the processes and learning that has taken place through carrying out this systematic review in chapter 5.

1.2 Background
1.2.1 Epidemiology of dermatology conditions and nurse-led clinics About 23-33% of the worlds population, at any one time, have a skin condition that requires medical attention (Schofield, Grindlay and Williams, 2009). In Europe a quarter of the population experience skin diseases at any one time (European DermatoEpidemiological Network [EDEN], 2007). A study in the United Kingdom shows that, dermatological conditions affects between a quarter and a third of the populace at any point in time (Lawton, 2004). A number of other studies confirm that dermatological conditions are among 15% of cases seen by general practitioners (GPs) in the region everyday (British Association of Dermatology (BAD) Guidelines, 2008; McCormick, Buchman and Maki, 2000; Peters, 2001; Scottish Dermatological Society (SDS), 2010). Schofield et al., (2009), in their service guidelines, also recorded that about 54% of the UK population experience a skin condition in a year.

Skin conditions are among the common diseases seen in clinics in the tropical areas ( Hay, Bendeck, Chen, Estrada, Haddix, McLeod and Mah, 2006). Hot and humid climates contribute to the circulation of skin conditions. World Health Organizations 2001 report (WHO, 2005) on the global burden of disease indicated that skin diseases were associated with mortality rates of 20,000 in Sub-Saharan Africa in 2001. The prevalence of skin diseases in developing countries ranges from 20% to 80% (Hay, et al., 2006). This is due to the level of poverty in this region which creates overcrowding in available places of accommodation. Dermatological diseases affect all age groups of both sexes; nevertheless, children are more susceptible. Ghana has a population of about 24,791,073 (CIA, 2011) serviced by about 8 dermatologists, most of them practicing in urban areas mainly in secondary and tertiary healthcare facilities. A large percentage of the rural areas population do not benefit from dermatological care. In fact dermatological diseases are often ineffectively managed. Efforts need to be made to address this current situation.

Nurse-led clinics, also known as nurse managed clinics or nurse-run clinics, are managed and operated by professional nurses with experience and expert skills in advanced nursing roles. Nurse follow-up clinics provide services which complement or extend those provided by doctors (Laurant, Reeves, Hermens, Braspenning, Grol and Sibbald, 2004). The title of advanced nurse practitioner is however non-existent in my country and this is a challenge. For this reason, the issue of complete autonomy in leading a clinic is pending. A review of nurse-led follow-up clinics in addition is relevant in this situation. The development of nurse-led clinics has increased because it provides an opportunity to challenge the traditional medical model (Richardson and Cunliffe, 2003): dermatologist/general practitioner clinic. Hitherto, a systematic review of the effectiveness of these clinics in dermatology has not been conducted. However, as the nurse-led clinics have spread, their presence and services have been noticed by service users and providers in various countries.

In Ghana, these clinics have not been set up despite the low number of dermatologists available. Medical personnel statistics recorded in 2009 shows that Ghana had 2,033 doctors and 24,974 nurses (WHO, 2011). Notwithstanding the recorded shortage of nurses in the UK (Bradshaw, 1999; Meadows et al., 2000), nurse led clinics exist. Considering the number of nurses available, it is eminent that recruiting nurses in Ghana to deliver nurse-led care in dermatology would not drastically reduce nursing workforce available to provide some of the essential nursing care; thus maintaining overall care standards.

1.2.3

Impact of dermatological conditions on patients

It may be argued that skin conditions are not usually life threatening, however, the resultant disfigurement of the body can negatively impact on ones sense of being in relation to the world (Watson & de Bruin, 2006). Skin disease is often visible to others and social factors in coping and adjustment are highly relevant. Patients, especially
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females, tend to be stressed and depressed about negative changes in their physical looks. Stress on its own affects the disease condition (Al'abadie, Kent and Gawkrodger, 1994). The outward look of females forms an integral part of the self-esteem. Therefore a low self-esteem as a result of the physical aspect will have a trickledown effect on other facets of self such as the spiritual and social aspects (Watson & de Bruin, 2006). The itch-scratch-itch cycle (Cork and Danby, 2009) which is brought about as a result of most skin conditions, causes sleep disturbances in both children and adults. As mentioned earlier, dermatological conditions are important indicators of some underlying internal diseases. These include chronic renal failure, endocrine disorders, lymphomas, nutritional deficiencies and HIV/AIDS which are life threatening. Some long term effects may leave an individual deformed for life.

1.2.4 Nurse-led Clinics(NLC) in Ghana In Ghana, nurse-led clinics exist in the rural areas of the country where the availability of doctors is scarce. However, there is none in the field of dermatology. Furthermore, nurses leading these clinics cannot be said to be qualified to take those roles. It is necessary in this day and age to have nurse-led clinics in the urban as well as rural areas. Nevertheless, inadequate or incomplete evidence seriously impedes policy formulation and implementation (Tranfield, Denyer and Smart, 2003).

1.3 Literature Review


1.3.1 Quality of Life (QOL) The term quality of life has been extensively used however a hypothetical and intangible elusiveness still persists (Draper and Thompson, 2001) as there has not been a consensus on its definition (Bowling, 1997). In the health sector, quality of life refers to the patients perception of the effects of an illness and its treatment on his/her physical, social, emotional and spiritual well being.

1.3.2 Rationale and Assessment of QOL A patient is the best person to provide information regarding his/her quality of life. However, to minimise bias and subjectivity, tools have been designed as a guide in assessing this accurately (Finlay, 1997). Methods The concept of QOL could be explored either quantitatively (statistically) or qualitatively. The quantitative approach to assessing QOL is more concrete as numerical values are generated and bias and interpretation are minimised. It is therefore useful for clinical trials. Instruments and tools have rapidly emerged as the issue of quality of life of patients is assessed. Like all others, these tools need to have desirable measurement properties such as validity, reliability, sensitivity and responsiveness to change over time (Cox et al., 1992; Fayers and Machin, 2000). Kinds of Tools QOL tools are of various kinds. These include the generic (e.g. 36-item Short-Form Health Survey (SF-36), speciality- specific (e.g. Dermatology Life Quality Index (DLQI) or SKINDEX, and disease-specific measures (e.g. Quality of Life Index for Atopic Dermatitis) [Chren, Lasek, Sahay and Sands,2001; Holm, Wulf, Stegmann and Jemec, 2006;Tobita and Hyde, 2007]. Generic tools measure broad aspects of quality of life and can be used for several types of diseases at different locations and for different cultural groups while disease-specific tools are for specific types of diseases or patient groups (Patrick and Deyo, 1989). A specialty-specific (dermatology) quality of life tool was used to measure quality of life in the studies analysed.

DLQI The Dermatology Life Quality Index (DLQI), was developed in 1994. It became the first dermatology-specific Quality of Life instrument. It is a simple 10-question validated questionnaire and currently, the most frequently used instrument in studies of randomized controlled trials in dermatology. The DLQI has been successfully used in 33
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different skin conditions in 32 countries. Its use has been described in over 500 publications including 30 multinational studies. 1.3.3 Dermatology and Quality of Life Itch, which is a major symptom of most skin conditions, has a profound effect on an individuals quality of life. From personal experience, itching can be really unbearable especially if you have to scratch certain parts of the body in public. Furthermore, a condition such as acne can affect social and psychological functioning especially for adolescents. Generally, dermatological conditions can decrease an individuals quality of life by interfering with achievement in school, influencing or limiting career choices and social life (Voegeli, 2010). In addition, they are a common cause of morbidity in developing countries and account for a high proportion of hospital visits (Nnoruka, 2005; Morrone, 2007). Morbidity among a countrys population minimises productivity (SDS, 2010). 1.3.4 Patient satisfaction Patient satisfaction is the major indicator of quality of care provided by a health facility. Subsequently, the issue of patient satisfaction has been on the rise in this era of patient-centred care because of the pressure of accountability (Larsen, Attkisson, Hargreaves, Nguyen, 1979; Thompson, 2006). Patient satisfaction can best be known by enquiring of the patient group involved and this is necessary to develop or improve on a service (White, 1999). However, it may be argued that what patients want may be harmful to their health and some patients have a distorted judgement. Most often patients consider medical care and information, nursing care and physical environments of the service when answering questions on satisfaction. The amount of time the patient spends in the waiting area plays a very significant part in determining the outcome of patient satisfaction (Prakash, 2010). Patient satisfaction is itself a desirable outcome, directly related to other positive outcomes. On the other hand, this may result in unrealistic expectations from answers to questions.

Assessment of patient satisfaction This can be assessed anecdotally (general perceptions on issues) or systematically (questionnaires). Unreliable results are a main criticism of patient satisfaction surveys but this can be prevented when surveys that meet the standards for statistical reliability are conducted. Kinds of patient satisfaction assessment tools Phone surveys, written surveys, focus groups or personal interviews are many ways of assessing patient satisfaction. Most institutions prefer to use written surveys, because it is the most cost-effective and reliable approach. The questionnaires used are most often than not tested and validated. Question types however do vary. Examples could be either reports or ratings (e.g. The Likert five-point scale: Agree, disagree, strongly agree, strongly disagree or neutral). It is important in designing a survey questionnaire that is concise, precise and consistent (White, 1999). The study (Schuttelaar et al., 2009) included in this review used a simple survey instrument (Client Satisfaction Questionnaire-8, CSQ-8) to ascertain patient satisfaction. CSQ-8 To begin with, parallel, 18-item scales of the CSQ were developed from the initial very large item set. These scales are designated as the CSQ-18A and CSQ-18B. This went through a series of tests and retests for reliability before the CSQ-8 was decided on. The CSQ-18B contains all the items that comprise the CSQ-8 plus 10 additional items. The CSQ-8 is a self-report statement of satisfaction with health and human services and can be used in a wide variety of settings. This self administered questionnaire takes approximately 3-8 minutes to complete. It has 8 items answered on a 4-point Likert. However, response descriptors differ.To come out with the total score, responses are summed up. Total score ranges from 8-32, with a higher score indicating higher satisfaction.

1.3.5 Severity of condition Severity of condition primarily affects symptoms and feelings, leisure time activities, treatment, and daily activities (El-Mongy, El-Shahat, and El-Bahaey, 2006).

Assessment of severity of condition A wide range of outcome measures have been used to evaluate the severity of dermatological conditions. Despite their widespread use, many measures have received little attention with regards to their reliability and validity. Selecting an appropriately developed measurement tool is therefore of critical importance.

Kinds of severity assessment tools The Dermatology Index of Disease Severity (DIDS) , Eczema Area and Severity Index (EASI), Six-Area, Six-Sign Atopic Dermatitis severity score (SASSAD), Objective Severity Assessment of Atopic Dermatitis (OSAAD) score and SCORing Atopic Dermatitis (SCORAD) are a few of the assessment tools. DIDS focuses on two factors, the percentage of involved body surface area (BSA) and functional limitation, in forming a five-stage scale ranging from stage 0 to stage IV: 0, no evidence of clinical disease; I, limited disease; II, mild disease; III, moderate disease; IV, severe disease. The OSAAD which is comparable to the SCORAD (Sugarman, Fluhr, Fowler, Bruckner, et al., 2003) is however argued not to be reliable and valid (Williams, 2003). The details of the SCORAD index are given below.

SCORAD The 2 studies (Moore et al., 2009; Schuttelaar et al., 2009) included in this review both used the SCORing Atopic Dermatitis (SCORAD) tool to assess the severity of atopic dermatitis. The European Task Force on Atopic Dermatitis (ETFAD) has developed the SCORAD index to create a consensus on assessment methods for AD, so that study results of different trials can be compared. However, modification of the SCORAD index has led on several occasions to wrong and incorrect use of the system. To measure the extent of AD, the rule of nines is applied on a front/back drawing of the patients inflammatory lesions. The extent can be graded 0100. The intensity part of the
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SCORAD index consists of six items: erythema, oedema/papulation, excoriations, lichenification, oozing/crusts and dryness. Each item can be graded on a scale 03. The subjective items include daily pruritus and sleeplessness. Both subjective items can be graded on a 10-cm visual analogue scale. The maximum subjective score is 20. All items should be filled out in the SCORAD evaluation form. The SCORAD index formula is: A/5 + 7B/2 + C. In this formula A is defined as the extent (0100), B is defined as the intensity (018) and C is defined as the subjective symptoms (020). The maximum SCORAD score is 103. Based on training sessions by the ETFAD, the SCORAD index was modified by excluding the subjective symptoms. If these are excluded, the SCORAD is known as objective SCORAD (score range 083).The objective SCORAD consists of just the extent and intensity items, the formula being A/5 + 7B/2. A higher score indicates more severe disease. The following cut-off points for objective SCORAD have been suggested for classification of disease severity: mild AE, score < 15; moderate AE, score 1540; and severe AE, score >40. The maximum objective SCORAD score is 83 (plus an additional 10 bonus points). 1.3.6 Adherence to treatment

The term adherence is also known as compliance. It refers to an agreement between the patient and physician to achieve the primary goal of optimal treatment outcome. Low level of compliance to prescribed medical interventions has always been a problem, especially for patients with a chronic condition (Feldman, Camacho, Krejci-Manwaring, Carroll, and Balkrishnan, 2007; Greenlaw, Yentzer, O'neill, Balkrishnan, and Feldman, 2010; Hodari, Nanton, Carroll et al., 2006 ; Jones-Caballero, Pedrosa and Peas , 2008 ; Richards, Fortune and Griffiths, 2006). Very little literature is available on assessing adherence in dermatology (Greenlaw et al., 2010). There are many treatment options for patients with skin conditions, varying from simple topical medication to oral therapy. Assessing adherence to treatment Measures of medication adherence such as the pill count and interview methods are subjective and mostly unreliable in clinical trials. If a pill is reduced by one in the container does not mean it has been taken. Furthermore, assessment by interviews only provides results which clients know the health personnel would be content with:
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complete adherence. Until recently, the most precise measures of adherence to treatment were associated with determining blood levels of the prescribed drug or measuring urinary excretion of the medication or a metabolic by-product. In the event that neither the medication nor its by-product can be detected easily in the urine, a readily detected marker or tracer substance can be added to the prescribed medication (Zaghloul, and Goodfield, 2004). However, objective adherence assessment has been improved by electronic monitoring (Hodari et al., 2006; Feldman et al., 2007; Greenlaw et al., 2010).

Electronic monitoring devices Electronic monitoring devices, or electronic medication event monitors, use microprocessors to measure and record data such as the date and time of medication events. For example, Medical Event Monitors (MEMS, Aardex Corp., Fremont, CA, USA) have microprocessors in the bottle cap of a standard medication bottle that, each time the bottle is opened; record the time, date, and interval since the last bottle opening. MEMS caps can be used to monitor adherence to topical therapy, not just pills. MEMS caps offer a way of accurately recording missed doses and decreased likelihood of reporter bias. Nevertheless, a dermatology-specific instrument for the measurement of adherence would contribute to improved outcomes (Greenlaw et al., 2010).

1.3.7

Cost effectiveness

Cost effectiveness is an important factor to consider when planning the implementation of a current healthcare intervention such as nurse-led clinics, in a different locality. Unfortunately, not all questions can be answered by a randomised controlled trial and this was the situation of the outcome cost effectiveness. An audit evaluation or economic evaluation may be a better way to assess cost effectiveness of a clinic to the hospital or institution. For cost accrued by patients, it is argued that a qualitative approach to know their views is the best (Kernick et al., 2000). Most studies looking at costs or cost effectiveness are done in parallel with RCTs looking at quality of life of
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patients or accessibility of clinics to patents (Kernick et al., 2000; Coast, Noble, Horrocks, Asim, Peters, Salisbury et al., 2005).

1.4 Rationale and Justification for this Review


Dermatology is an aspect of medicine which has been under researched. In the UK, about 15% of the cases seen by GPs are of dermatological conditions (British Association of Dermatology (BAD) Guidelines, 2008; Scottish Dermatological Society (SDS), 2010) this is exclusive of those seen by the few dermatologists available. Although statistics of dermatology conditions in developing countries have not been generalised, this figure could even be higher. Dermatologists are a precious restricted resource and their numbers are unlikely to increase in the same proportion as the incidence of dermatology conditions or public demand for access to investigation and specialist advice. Considering the current socio-economic factors which have led to poor hygienic conditions compounded by the fact that dermatology services in this region have not been developed (Masawe and Samitz, 1976; Doe , Asiedu, Acheampong and Payne, 2001), a large number of the population have had one dermatological condition or the other .This is as a result of the small number of dermatologists available (Brown, 2005; Courtenay and Carey, 2006) in addition to general practitioners not having the requisite skills for dermatological care and support (Kernick, Cox, Powell et al., 2000). It will therefore not be surprising, if excellent outcomes are not achieved from their consultations. In the UK, it has been noted that the demands on dermatologists have led to certain aspects of their consultation, especially education, being ignored and this has affected patient outcomes (Brown, 2005). This situation is not different from what can be witnessed in most developing countries. The issue of waiting times, quality of care, treatment outcomes all arise out of this situation. It is surprising to know that in affluent countries like the USA and UK where there are many doctors, nurse-led clinics exist but are absent in deprived countries. This is attributed to the low number of dermatologists available and policies need to be drawn to make dermatology more attractive to doctors. Furthermore, with the impact of dermatological services on
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individuals in the community, having one type of service is not sufficient in meeting the needs of the growing population (Brown, 2005). Nurses with expertise and training are available to bridge this gap in dermatology services (Chinn, Poyner and Sibley, 2001; Carter and Chochinov, 2007). This necessitated the emergence of nurse-led clinics (Brown, 2005). Nurse-led clinics sprung up to assist in the management of a variety of conditions presented by these clients (Hatchet, 2008). These are clinics where nurses have the upper hand in the management of clients from initial assessment through till follow-up. However, in some of these clinics, the nurse only sees a client after the doctor has had the initial assessment and has provided prescriptions. In such cases, the nurse then does the follow-up of the client. These clinics are usually led by nurses in advanced level practice.

Although the area of a Nurse Practitioners practice varies, he or she must possess the knowledge and skills to make self-directed decisions regarding selected patient populations as well as be accountable for his or her actions (Carter and Chochinov, 2007).

However, in Ghana my home country, though there is the existence of nurse-led clinics in other specialties of medicine (ear, nose and throat [ENT], Eye and General Nursing) there is none set up in dermatology. Moreover, nurses who lead these clinics do not have the education/qualification required to act in such a capacity. Therefore, most of their actions are not justifiable. Also, these are only seen in the rural areas where there is the shortage of general practitioners. These nurses assess, diagnose and prescribe for the clients who come to see them. The license to prescribe is not rigid in Ghana as compared to the situation in the U.K.

In Tema General Hospital, situated about 15 minutes drive from the point of intersection of the Greenwich Meridian in Ghana, there is a visiting dermatologist who
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comes once a week or sometimes every other week for 3 hours per visit. Clients have to wait weeks to see the dermatologist or make do with prescriptions given by General Practitioners who do not have the required skills for dermatological care. In Ghana, most clients who visit the hospitals do not have a preference of who sits in the consulting room when they enter. For this reason, a nurse-led clinic to cater for the needs of these clients will be well appreciated. Nevertheless, other nurses and those in managerial positions may not readily succumb to this idea.

In most developed countries like the United States of America and United Kingdom, nurse-led clinics (Welwyn Hatfield PCT, 2011) and nurse-led follow-up (Gradwell, Thomas, English and Williams, 2002) clinics have helped minimize the cascade of workload on dermatologists Research over the last couple of years suggests that nurseled clinics improve the quality of life of clients with chronic conditions (example being most dermatological conditions) as there is the shift from the busy nature of general hospital setting (Mundinger, Kane, Lenz, Totten et.al, 2000).

Currently, studies have been conducted on the effectiveness of nurse led clinics with the focus on one outcome or the other but have not looked at it in terms of the synthesis of outcomes. An intervention review of specialist outreach clinics in primary care and rural hospital settings was conducted by Gruen, Weeramanthri, Knight, Bailie in 2003 looking at improving access to care, quality of care, health outcomes, patient satisfaction and use of hospital services, is one of such. Efforts have been made to find evidence on which model of service is better in terms of any of the above outcomes. Most reviews have been qualitative in nature reflecting the reviewers impression of the issue. A case study conducted by Appleby and Lawrence (2001) which looked into reducing waiting times in a dermatology out-patient department in Newcastle upon Tyne, is one out of the lot. They acknowledged that, maximising the use of nursing skills and a willingness to accept innovative models of services, are critical factors in reducing waiting times. However, a randomized trial by Mundinger, Kane, Lenz et.al (2000) which
15

compared primary care outcomes in patients treated by nurse practitioners or physicians, did not conclude on which model had a better outcome but just stated that with all parameters being equal, these models are comparable.

In Brown and Grimes (1995) meta-analysis of nurse practitioners and nurse midwives in primary care, an outcome measure: cost-effectiveness was not concluded on. In this systematic review, however, a conclusion on this measure will be drawn considering the fact that many more studies have been conducted after 1995. Horrocks, Anderson and Salisbury, (2002) performed a systematic review to find out whether nurses working in primary care could provide care equal to that of physicians, with quality of care and patient satisfaction as outcomes. Both randomized controlled trials and observational studies were included in this review. It could be argued, however that, observational study designs have certain attributes that mar the quality of evidence generated by them. They are postulated to have a potential for biases because the association between an effect and outcome is not known (Hoffman and Lim, 2007).

Further examination of a review done by Courtenay and Carey (2007) on the impact and effectiveness of nurse-led care in dermatology shows that, though it was intended to be a systematic review it was not rigorously carried out. Search strategy was not indicated and makes it impossible for another author to carry out the same review. In addition the scope of review was limited to studies between 1990 and 2005 with 5 of these studies describing activities of the nurses in these clinics. This review looked at a description of the activities of nurses and evaluation of nursing interventions in nurse-led dermatology clinics. Focus was placed on the treatment options nurses used in the clinic. This review found out that nurses working in primary care are not confident enough to manage certain conditions especially when invasive

16

procedures like scalp scaling are needed. Also, though these nurses know the importance of education, their educational needs are not met. In contrast with Courtenay and Carry (2007), this systematic review seeks to find out the impact of nurses on clients who attend their clinics irrespective of what interventions they carry out. Furthermore, the former fails to be classified as a systematic review as it was not rigorously done.

1.5 Summary of Chapter


Dermatology and nurse-led clinics and the impact of dermatological conditions on the life of clients have been discussed. The concept of quality of life, patient satisfaction, severity of disease condition, adherence to treatment modalities and the costeffectiveness of nurse-led and nurse follow up clinics has been elaborated. A justification for this systematic review has been given. The next chapter discusses the role of systematic reviews in evidence-based practice, justifies the question for this systematic review, and elaborates the steps involved in the process.

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Chapter 2 Methodology
This chapter focuses on the use of quality clinical evidence to enhance patient care. The strengths and limitations of evidence-based practice are discussed. Particular attention is given to the role of systematic reviews in evidence-based practice. The question for this systematic review is then justified, making use of the PICO (Patient population, Intervention, Comparator, Outcome) framework. The steps for this systematic review, up to the data extraction process, are explained.

2.1 Evidence-based Practice (EBP)


Evidence-based practice began in the health sector over 20 years ago with medical doctors being at the fore of its inception (Biesta, 2007; Wall, 2008). In recent times, evidence-based practice has become a critical concept for liability among other health professionals (Tranfield, Denyer and Smart, 2003; Avis and Freshwater, 2006; Benton, 2009) such as nurses because of demands by service users for better and individualised care. The term evidence-based practice has been identified synonymously with research utilisation (Estabrooks, 1998; Scott-Findlay and Pollock, 2004) over the years. Nevertheless, there are varying opinions on what should constitute evidence. The positivist opinion argues that science is the only reliable source of evidence while the empiricists beg to differ. Science has become an important means by which evidence is generated and efforts are being made to increase its reliability (Avis and Freshwater, 2006). Avis and Freshwater (2006), who are of the empiricist opinion, suggest that evidence generated by science should be open to questions to ensure its validity. Nonetheless, it may be argued that in contexts where there is incomplete or inadequate research evidence, application of critical reflection in practice is helpful in this era of EBP. Evidence-based practice involves the rigorous use of current best evidence from quality studies, clinicians experience, and patients preferences to resolve clinical problems (Fineout-Overholt, Melnyk, Schultz, 2005). An integration of scientific evidence and clinical expertise promotes individualised patient-centred care (Rosenfeld, 2004). Evidence-based practice is intended to help health professionals understand and utilize
18

evidence in the context of patients situation (Lipman, 2004). However, the debate on what is considered evidence is ongoing (Gupta,2003). The concept of evidence based practice has its limitations. Not every area of nursing has been researched into and the few available ones may be under researched. This makes it difficult to conclude on few valid interventions. Furthermore, using evidence in practice can sometimes be taunting because the contexts may vary and what worked well on a group of patients may not be the solution for the patient in question (Lipman, 2004). Another criticism of EBP is that it suppresses critical and creative research while controlling professional practice (Gough, 2004). In severe cases, healthcare practitioners may be coerced to follow specific guidelines of which nonconformity may result in punishment (OHalloran et al., 2010). Other critics argue that knowledge gained from the basic sciences, and clinical judgement derived from healthcare personnels previous experience may be ignored (Mickenautsch, 2010). Amidst the deliberations of best evidence to be used in practice, there has been an elaborate system of hierarchical differentiation of evidence. Highly approved research designs in this ladder are the quantitative in nature with RCTs labelled the gold standard (Polit and Beck, 2010). It is therefore argued that evidence obtained from systematic review of relevant randomised controlled trials (RCTs) which provides the highest quality of evidence on effectiveness, and is regarded as a cornerstone of EBP ( Fineout-Overholt et al., 2005; JBI, 2008; Polit and Beck, 2010) is the best source of evidence. Randomised controlled trials are the best means of determining if one service is better than the other (Avis and Freshwater, 2006). This hierarchical ladder is however not without criticisms.

2.2 The Place of Systematic Reviews in Evidence-based Practice


Systematic reviews espouse a replicable, scientific and apparent process that aims to minimize bias (Tranfield et al., 2003). They have some advantages over traditional literature reviews and single studies. For instance, traditional literature reviews are more subjective, making them liable to bias whereas systematic reviews allow for objective appraisal of evidence (Egger, Dickerson and Smith, 2001). Single isolated
19

studies, on the other hand, may not provide convincing evidence to fully answer a research question of interest or detect relevant differences (Jensen and Allen, 1996 cited in Evans and Pearson, 2001; Egger, Smith and ORourke, 2001). To be able to effectively implement an evidence based practice, there are five sequential steps to follow with the initial step being asking the clinical question (Fineout-Overholt et.al, 2005). Without a researchable question there cannot be a research. Polit and Beck (2008) suggest the use of the PICO framework Patient population, Intervention, Comparator and Outcome; to assist in the formulation of the research question. The four subsequent steps to undertake are searching for best evidence; critically appraising found evidence; analysing evidence in relation to the question and deciding to implement or not; finally evaluating the outcome of evidence implementation (FineoutOverholt et.al, 2005).

After a researchable question has been framed, the search for best evidence follows. However, there is still an ongoing debate as to which evidence is best. Evidence can be classified as best if it is consistently and systematically identified and evaluated. Although RCTs are considered the gold standard (Polit and Beck, 2008), they are not void of the effects of chance (Webb and Roe, 2008). Intervention bias is a potential problem of most RCTs (Lindsay, 2004). For this reason an adequate methodological assessment of their quality is necessary for excellent results. Research done under this method could either be quantitative (where there is statistical involvement Meta-analysis) or qualitative (meta-synthesis/meta-summary) [Polit and Beck, 2008]. For this reason, a systematic review could be a summary of quantitative studies where similar methods of research have been used on a common clinical question (LoBiondo-Wood & Haber, 2006; Burns & Grove, 2007). Generally, it is an overview which integrates primary research on a particular question and tries to identify, select, synthesize and appraise almost all research evidence, with similar methodology, relevant to that question in order to answer it. When this is done, bits of evidence generated from various research conducted is compiled in one form using a predefined, explicit methodology, which is reproducible (Tranfield, Denyer and Smart,
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2003; Polit and Beck, 2008; Webb and Roe, 2008). Meta-analysis offers a statistical approach for synthesizing findings in order to obtain overall consistency which cannot be derived from any single study alone. Primary research carried out are usually of small sample sizes therefore they are most often not able to answer adequately the research question or questions the user of the research might have (Webb and Roe, 2008). However, a systematic review carried out analyses these small sample sizes and inconclusive studies into a more precise one (Cook, Mulrow and Haynes, 1997). Relatively, it is cheaper to conduct a systematic review when compared with other methods of research. It also identifies gaps in practice and prompts further research. Systematic reviews, in which the relevant research is sought, appraised, summarised and, if appropriate, meta-analysed, provide the best way to ensure that current evidence is available (Tharyan and Jebaraj, 2006) because potential for bias is minimal. Nevertheless, searching has to be efficiently done to retrieve relevant data because of publication bias as selective reporting of trials do occur. Whilst not a perfect system, systematic reviews are far superior to the traditional narrative approach, which often allows a lot of good research to be discarded because of inappropriate methodology. It is therefore not surprising that systematic reviews are argued to be the most efficient and highest quality method for identifying and evaluating extensive literatures.

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Hierarchy of evidence I-I Systematic review and meta-analysis of two or more double blind randomized controlled trials. I-2 One or more large double-blind randomized controlled trials. II-1 One or more, well-conducted cohort studies. II-2 One or more, well-conducted case-control studies. II-3 A dramatic uncontrolled experiment. III Expert committee sitting in review; peer leader opinion. IV Personal experience.
Fig. A Hierarchy of evidence

Source: reproduced by kind permission of the publisher from Davies, H. T. O. and S. M. Nutley (1999). The Rise and Rise of Evidence in Health Care, Public Money & Management, 19 (1), pp. 916.r 1999 Blackwell

2.3 Justification of the Review Question


In view of the low number of medical practitioners training to become dermatologists, nurses are being urged to take up these vacant positions to help meet the rising demands of health consumers. Nurse-led clinics have been in operation for decades now and nurses in advanced practice who lead these clinics have been generally suggested to act effectively (Mundinger et al., 2000; Pinkerton and Bush, 2000; Courtenay and Carey, 2007; Courtenay, Carey and Stenner, 2009). However, a systematic review of the effectiveness of nurse-led dermatology clinics is necessary for identifying its contribution within the health care system and for justifying its institutionalization in places where they are none existent (Sidani and Irvine, 1999).

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Therefore, is a systematic review of quantitative studies that compare nurse-led or nurse follow-up dermatology clinics with care led by a medical practitioner (dermatologist/general practitioner), with either of these outcomes: adherence to treatment, quality of life, patient satisfaction and cost involved. Studies that met the inclusion criteria were critically appraised and the findings reviewed. Using the PICO framework, the clinical question for this proposed systematic review is: How effective is a nurse-led/ nurse-follow-up dermatology clinic, compared to usual care (dermatologist/general practitioner) in relation to clients adherence to treatment, satisfaction, quality of life and cost involved (both for health facility and clients)?.

2.4 Protocol
A protocol is a detailed set of activities for a proposed project and these activities are supported by evidence from other research and preliminary investigations (Polit and Beck, 2008). The review question, inclusion and exclusion criteria, search strategy, data extraction, quality assessment, data synthesis and information on dissemination of final results are all made available in the protocol. It shows some foresight into what the systematic review is trying to achieve. Above all, it shows evidence of planning, including anticipation of potential problems and how they would be dealt with. However, a protocol is not meant to be rigid. If modifications are made from clearer understanding of the review, it is permitted but it should be justified and not be made on the bases of results of individual studies (Centre for Review Dissemination [CRD], 2009).

The protocol for this review has been provided (appendix I). Some modifications were, however, made to the protocol after a clearer understanding of the review question and discussions with some methodological experts. For instance, the topic for the systematic review was changed from the effectiveness of nurse-led dermatology clinics when compared with care provided by a medical practitioner to the effectiveness of nurse-led and nurse follow-up dermatology clinics in comparison with dermatologist/general practitioner led dermatology clinics to reflect a clearer understanding of the review question. As stated earlier, autonomy of a nurse in Ghana
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is not firmly established; therefore the possibility of having a nurse-led follow-up clinic to start with is high. The rest of the protocol was, however, maintained with some specific details provided in the subsequent sections.

2.5 Search Strategy


The review was rigorously begun by searching the Database of Abstracts of Reviews of Effects (DARE) and the Cochrane Database of Systematic Reviews (CDSR) for the existence of this proposed review. A thorough literature search of the databases and hand searching of journals for relevant studies was carried out as this is significant in reducing the impact of publication bias in the systematic review process (CRD, 2009). It is suggested that limiting searches to English can introduce language bias (CRD, 2009). However, to prevent translation problems because of the time span for this review, the search strategy for this systematic review was limited to English. Furthermore, it is sometimes difficult to have correct translations as not all words have meanings within every language and this may introduce some extent of bias. The search was carried out using a variety of search methods to ensure that both published and grey literature is searched for. As the first step, electronically relevant data was extracted from databases such as MEDLINE, SCOPUS, CINAHL, and Cochrane Library from their inception till June, 2011. Alternative spellings (British and American English) as well as words in relation to the topic such as nurse led and nurse managed were taken into account during the search. Text words in the titles and abstract were then examined. Search strings (synonyms, wild cards) specific to each database were employed to ensure that relevant studies were retrieved. Subsequently, identified keywords and index terms were keyed into the databases. Hidden studies from reference lists of retrieved studies were searched then searched. Experts in the field of dermatology specifically nurse led clinics were contacted to identify any missing studies (CRD, 2009). Hand searching through journals, conference reports, dissertation abstracts and theses of other students was carried out with the intention of retrieving grey literature that meets the inclusion criteria, however, this was uneventful. The database Systems for
24

Information on Grey Literature (SIGLE) was also searched. Full text for potentially relevant studies was then retrieved and compiled.

2.6 Selection of Studies


Extensive searching resulted in a large number of potentially eligible studies being found. However, only a small number was included after assessment for inclusion was carried out. Articles were selected for inclusion based on the predesigned protocol containing inclusion criteria specifying the type of subjects, outcomes and type of study (Tak, Meijer, de Jonge, and Rosmalen, 2010). Studies were included if they: I. II. III. IV. V.
VI.

RCTs Outpatient cases Adults and children A nurse clinic in the intervention group Dermatologist or general practitioner in the control group Evaluated either of the following: patient satisfaction, severity of condition, quality of life, adherence to treatment and cost effectiveness of clinics. As a primary or secondary outcome with a validated measure, whether generic, disease-specific or both. Studies were excluded if they:

I. II.
III.

Did not specify tools for measurement of outcomes Had any other intervention aside a nurse Were not in English

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2.7 Selection of studies


One reviewer (PYA) assessed the titles and abstracts of the search results and excluded articles that clearly did not meet the inclusion criteria for this review. Full text articles that were retrieved were, again, compared with the inclusion and exclusion criteria by PYA.

2.7.1

Assessment of Methodological Quality

The quality of a systematic review is defined by the quality of primary studies included in the study. The existence of bias in included primary studies will mar the quality of the review. Randomised controlled trials if conducted appropriately, are suggested to be the most unbiased form of study designs (Herkner, 2006; CRD, 2009). Two independent reviewers (PYA and FB-H) appraised the quality of the selected studies. This was done using the standardised critical appraisal checklist from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument JBIMAStARI (Appendix II). Following discussion, both reviewers were in agreement on the final papers to be included in the review. 2.7.2 Data Extraction

Full text articles of studies that met the inclusion criteria were retrieved and reviewed by two independent reviewers for methodological validity before inclusion in the review. Standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) will be used for this purpose. Data was extracted by two reviewers (PYA and FB-H) independently and entered into a modified Cochrane Skin Group data extraction form. The data extracted included participant numbers and characteristics, place of study, patients demographics, diagnosis, nature of the intervention, loss to follow-up rates and rationale. Discrepancies were resolved between the two review authors. Review authors were not blinded to the names of trial authors, journals or institutions, specific information on the study methods, populations, interventions and outcome measures.

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The extracted data was then entered into the Cochrane collaboration software -Review Manager (Revman 5.1).

2.8

Summary of Chapter

This chapter has focussed on evidence-based practice and systematic reviews. A justification for the review question has been provided, using the PICO framework. The processes involved in this systematic review, up to data extraction, have also been presented. The subsequent chapter presents the findings of the search strategy in detail.

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Chapter 3 Results
The findings of the systematic review are presented in this chapter. It begins with the results of the search strategy, then characteristics of the included studies as well as their findings. Figures and tables are used, where necessary, to give a pictorial presentation of the findings

3.1 Description of studies


3.1.1 Search Results The literature search resulted in the identification of 160 studies: 157 from the electronic databases and 3 through searching references of key articles. However, none was found from grey literature. After examining the titles and abstracts, 9 studies appeared eligible for this review and, thus, the full articles were retrieved. However, after comparing those with the eligibility criteria for this review, 4 studies were excluded (See Table 1). The methodological quality of the remaining 5 studies was assessed by two independent reviewers and these eventually met the inclusion criteria (Figure B). The flow diagram for the searches retrieved throughout this review is shown on the ensuing page.

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FLOW DIAGRAM OF SEARCH STRATEGY

Potentially relevant papers identified by literature search (n= 160) Papers excluded after evaluation of abstract (n=151) Papers retrieved for detailed examination (n=9)

Papers excluded after review of full paper (n=4) Papers assessed for methodological quality (n=5)

Papers included in systematic review (n=5)

Fig. B Flow diagram of search strategy

3.1.2 Characteristics of included studies


As detailed in Table 1, only randomised controlled trials were considered in this systematic review. Four of the included trials were randomised parallel group trials with a minimum interval assessment of one month. The other study (Moore, Williams, Manias et al,2009) which did not state what RCT design was used had a trial duration of four weeks with assessment being done at the fourth week. The total length of these trials was 34 months and 2 weeks. It was noted that all included studies were undertaken in developed countries. One study was conducted in Melbourne, Australia (Moore, Williams, Manias, Varigos and Donath, 2009), another in the Netherlands (Schuttelaar, Vermeulen, Drukker, and
29

Coenraads, 2009) and the remaining in England. Among the included studies, there was none from Ghana or any African country. The studies all looked at various skin diseases with some limiting their trials to specific conditions while others made it open (irrespective of which skin condition). All the included studies had at least a diagnosis of eczema as an inclusion criterion. Two of these considered a diagnosis of psoriasis for inclusion. One study included patients seeking repeat prescriptions for a diagnosis of eczema. Anyone who had a previous treatment of eczema, has been involved in similar studies or has relatives involved in similar studies was excluded from most of the included studies. However, 2 studies did not state any exclusion criteria. The total number of randomised participants in the 5 trials was 735 and 593 were analysed. Participants ages ranged from 0 to 65 years. In the studies which categorized participants according to their gender, the total number of males involved in all the studies outnumbered that of the females. Nonetheless, total number of females was more in the nurse-led clinic than the dermatologist/ general practitioner led clinic. Almost all the studies recruited participants irrespective of the severity of their condition and did not state this except Gradwell, Thomas, English and Williams (2002) who despite randomization had participants with moderate to severe skin diseases in the nurse led group. None of the studies included the duration of the participants condition. Most of the studies (n=4) compared the quality of life of participants attending a nurseled clinic with a dermatologist or usual clinic (which could be led by a general practitioner). Two looked at the severity of eczema among these participants. Surprisingly, only one (Schuttelaar, Vermeulen, Drukker, and Coenraads, 2009) looked at the patients satisfaction as an outcome assessment.

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Table 1: Characteristics of included studies Study Method Country Number of participants Beginnig Chinn, Poyner, and Sibley, (2002). RCT Middlesbrough, UK 235 Completion 197 0.5 -16 2002 12 QOL DQLI Age of participants (years) Year of publication Duration of study (months) Outcome measure of interest Tool for measuring outcome

Gradwell, Thomas, English, and Williams (2002) Kernick, Cox, Powell, et.al.(2000)

RCT (randomised parallel group)

Nottingham, UK

66

64

14

2002

1.5

QOL

DQLI

RCT

Exeter, UK

109

81

18 x 65

2000

QOL, Cost effectiveness

DQLI,

Schuttelaar, Vermeulen, RCT Drukker, and Coenraads,( 2009)

Groningen, Netherlands

160

152

16

2009

12

QOL, Eczema severity,


Patient satisfaction

DQLI, SCORAD, CSQ-8 Objective SCORAD

Moore, Williams, Manias, Varigos, and Donath, (2009)

RCT

Melbourne, Australia

165

99

16

2009

Eczema severity

QOL- Quality Of Life; DQLI- Dermatology Quality of Life Index; SCORAD- Scoring Atopic Dermatitis; CSQ-8- Client Satisfaction Questionnaire-8

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3.1.3 Characteristics of excluded studies Of the 4 studies excluded after retrieving full papers of 9, one was a cohort study ( Cork, Britton, Butler, Young et.al, 2003) and another a literature review (Courtenay and Carey, 2007). None of these qualified as a randomised controlled trial. The other 2 studies although were RCTs were excluded because the intervention in one was being given by a senior medical student and not a nurse(Shaw, Morrel and Goldsmith, 2008) and the other did not have any of the expected characteristics for included studies (van OsMedendorp H, Ros WJ, Eland-de Kok PC, et al.,2007). A complete list of the excluded studies and reasons for their exclusion has been provided in Appendix III: Table 2. 3.1.4 Ongoing studies

After search was conducted, there have been ongoing studies on one of the outcomes of interest: cost effectiveness (Schuttelaar, Vermeulen and Coenraads, 2011). In this study, Schuttelaar et al., (2011) estimated the healthcare costs, family costs and general costs in other sectors in relation to the quality of life and patient satisfaction to determine incremental cost effectiveness ratio (ICER). They concluded that substituting NPs for dermatologists in the treatment of eczema in children provides savings in both healthcare costs and family costs.

3.2

Methodological quality of included studies

Assessing the methodological quality of randomised controlled trials is an essential aspect of systematic reviews (Juni , Altman and Matthias , 2001; Moja, Telaro, D'amico, Moschetti, Coe and Liberati, 2005) as defects in the conduct of primary studies can result in bias (CRD, 2009). For this reason, the author assessed the individual studies included in this review for quality.

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3.2.1 Risk of bias in included studies

Randomisation and allocation concealment The method of randomisation and allocation concealment, was clearly specified in all (n=5) the studies included in this review. Four of the studies (Chinn, Poyner, and Sibley, 2002; Gradwell, Thomas, English, and Williams 2002; Kernick, Cox, Powell, et.al. 2000;Schuttelaar, Vermeulen, Drukker, and Coenraads, 2009) randomised participants using computer generated scheme with decodes placed in sealed, opaque envelopes which were opened by the participants in the presence of the investigator, while Moore et al., (2009) randomised using sequentially numbered sealed, opaque envelopes.

Blinding of participants, clinicians and outcome assessor In view of the nature of the comparison intervention (nurse-led/nurse follow-up vs. dermatologist/general practitioner clinic) double blinding was not possible. The two clinics have different styles of managing patients and it was almost impossible to blind participants and the clinicians involved to the treatment group. The dermatology nurse in two of the studies (Kernick, Cox, Powell, et al., 2000; Gradwell, Thomas, English, and Williams, 2002 ) was not aware of allocation. However, the outcome assessor was blinded in four of the studies.

Intention to treat (ITT) Intention to treat analysis helps to minimise biases in quantitative research but can only be performed when there is complete outcome data available from randomised participants(Hollis and Campbell, 1999). Four studies (Chinn, Poyner, and Sibley, 2002; Gradwell, Thomas, English, and Williams 2002; Kernick, Cox, Powell, et.al. 2000;Schuttelaar, Vermeulen, Drukker, and Coenraads, 2009), analysed their results on an ITT basis by taking into consideration the data of all randomised participants irrespective of whether they completed the trial or not. The other study (Moore et al., 2009) which did not state intention-to-treat analysis was found not to have included data of participants lost to follow-up.

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Loss to follow-up

121 participants out of the 735 randomised participants were lost to follow-up for one reason or the other. Studies identified indicated number lost to follow-up and gave reasons where possible. In all 5 studies, break down of follow-up reasons is: n=27[Did not want appointment], n=3[study demanding too much effort on the part of participants], n=10 [missed the triage of the study], n=4[migrated]. However, a large number of participants who dropped off before completion gave no reason [n=77].

Other potential sources of bias

Levels of severity of the various dermatological conditions between the two clinics varied in all the studies. Despite randomisation, some studies reported having participants with moderate to severe eczema in the dermatologist/general practitionerled clinic and this could be a bias. Some studies also failed to provide exclusion criteria and may have recruited participants who had been involved in similar trials and knew what was expected. Therefore such participants would provide responses they think would make the investigator happy.

Although most of the studies had a mixture of mainly eczema and psoriasis, they report a greater number of eczema participants and this may affect the generalization of their results.

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3.3

Effects of nurse-led/nurse follow-up clinics: Primary and Secondary

Outcomes
3.3.1 Primary Outcome: Quality of Life

Tools for measuring Quality Of Life The Dermatology Life Quality Index (DLQI) was used to assess quality of life across the studies. Where appropriate it was modified to suit the ages. Hence there was the Infants Dermatitis Quality of Life Index (IDQOL) for children aged 4 years, and by the illustrated version of the Childrens Dermatology Life Quality Index (CDLQI) for children aged 416 years. One study (Kernick, Cox, Powell, et al., 2000) used an additional instrument: the visual analogue scale (VAS) from the Euroqol instrument to detect changes in overall quality of life. A detailed description of the DLQI tool has been provided in the assessment of QOL section of the literature review.

Results for Quality of Life [QOL: nurse-led vs. dermatologist/general practitioner-led] A. Infants Using the infants dermatology quality of life tool, two studies (shown in the forest plot below) achieved no significant difference in quality of life of infants treated either by a nurse or a dermatologist/general practitioner. Their pooled estimate gave an evidence of this MD -0.62(95% CI, -2.05 to 0.81). [Illustrated in 1.1.1 IDQoL of Fig. C] B. Adults Quality of life of participants above 16 years from 3 studies using the CDQoL, was recorded under 1.1.2 in Fig. C. The individual studies showed no significant differences in the quality of life of the participants in either group. Overall score for the participants in the 3 studies showed no significant difference, MD -0.74 (95%CI, -1.82 to 0.34).

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C. Adults and Infants As illustrated in Fig. C, the pulled estimate in QOL scores between nurse led dermatology clinics and dermatologist/ general practitioner led clinics for both adults and children was not statistically significant in 3 of the studies MD -0.70 (95% CI, -1.56 to 0.16).

Forest plots- Quality of life (nurse-led vs. dermatologist/general practitioner-led)


Nurse dermatologist/medical pr Mean Difference Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI 1.1.1 IDQoL Chinn et.al, 2002 5.44 5.1 55 6.61 4.4 42 20.7% -1.17 [-3.06, 0.72] Schuttelaar et. al,2009 5.7 5.4 37 5.6 3.9 34 15.6% 0.10 [-2.08, 2.28] Subtotal (95% CI) 92 76 36.3% -0.62 [-2.05, 0.81] Heterogeneity: Chi = 0.74, df = 1 (P = 0.39); I = 0% Test for overall effect: Z = 0.85 (P = 0.39) 1.1.2 CDQoL Chinn et.al, 2002 9.74 3.5 50 9.98 Kernick et.al, 2000 4.6 4.7 35 6.2 Schuttelaar et. al,2009 4.9 3.5 35 5.6 Subtotal (95% CI) 120 Heterogeneity: Chi = 0.94, df = 2 (P = 0.63); I = 0% Test for overall effect: Z = 1.35 (P = 0.18) Mean Difference IV, Fixed, 95% CI

5.1 5.2 4.2

50 46 35 131

25.2% 15.8% 22.6% 63.7%

-0.24 [-1.95, 1.47] -1.60 [-3.76, 0.56] -0.70 [-2.51, 1.11] -0.74 [-1.82, 0.34]

Total (95% CI) 212 Heterogeneity: Chi = 1.70, df = 4 (P = 0.79); I = 0% Test for overall effect: Z = 1.59 (P = 0.11) Test for subgroup differences: Chi = 0.02, df = 1 (P = 0.90), I = 0%

207 100.0% -0.70 [-1.56, 0.16] -2 -1 0 1 2 nurse dermatologist/general pra

Fig. C: Forest plots-Quality of life (nurse-led vs dermatologist/general practitioner-led)

Results for Quality of Life [QOL: nurse follow-up vs. dermatologist/general practitioner-led] With only one study retrieved for a comparison of nurse follow-up clinics with dermatologist/ general practitioner led clinics a strong conclusion could not be drawn on the QOL scores. However, there was no statistically significant difference in quality of life of participants attending either clinic MD-0.30 (95% CI, -2.48 to 1.88) [Fig. Ci]

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Forest plots -Quality of life (nurse follow-up vs. dermatologist/general practitionerled)


Study or Subgroup Gradwell et.al, 2002

Nurse Mean SD Total 7.5 5.4 37

dermatologist/medical pr Mean Difference Mean SD Total IV, Fixed, 95% CI 7.8 3.9 34 -0.30 [-2.48, 1.88] -2

Mean Difference IV, Fixed, 95% CI -1 0 1 2 nurse dermatologist/general pra

Fig. Ci

3.3.2
I.

Secondary outcomes
Results for Severity of condition using the Objective SCORAD

For the 2 studies (Moore et al., 2009; Schuttelaar et al., 2009) that considered the severity of eczema, the objective Scoring of Atopic Dermatitis (SCORAD) was the tool for assessment (refer to Assessment of severity section in Chapter one for details of the SCORAD). There was a recorded significance in the objective SCORAD score between participants in the nurse-led clinics and those in the dermatologist/ general practitioner-led clinic (pooled estimates of 2 studies, MD-2.33 (95% CI, -5.60 to 0.93] )as per Fig. D. Forest plots Severity of condition (nurse -led vs. dermatologist/general practitionerled)
Study or Subgroup Moore et.al, 2009 Schuttelaar et. al,2009 Nurse Mean SD Total 38 11 49 19 11 73 dermatologist/medical pr Mean Difference Mean SD Total Weight IV, Fixed, 95% CI 42 15 50 34.6% -4.00 [-9.17, 1.17] 22.1 11.9 70 65.4% -3.10 [-6.86, 0.66] 120 100.0% -3.41 [-6.45, -0.37] -10 -5 nurse 0 5 10 dermatologist/general pra Mean Difference IV, Fixed, 95% CI

Total (95% CI) 122 Heterogeneity: Chi = 0.08, df = 1 (P = 0.78); I = 0% Test for overall effect: Z = 2.20 (P = 0.03)

Fig. D: II. Patient Satisfaction The study by Schuttelaar et al., (2009) was the only one that had patient satisfaction as an outcome. As illustrated in Fig. E below, between-groups comparison shows that, there were more participants satisfied with care provided by a nurse than a dermatologist/ general practitioner. Statistically significant difference is therefore seen in the 2 groups MD 2.10 (95%CI, 0.34 to 3.86).
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Forest plots-Patient satisfaction (nurse-led vs. dermatologist/general practitionerled)


Study or Subgroup Schuttelaar et. al,2009

Nurse Mean SD Total 26.9 4.9 53

dermatologist/medical pr Mean Difference Mean SD Total IV, Fixed, 95% CI 24.8 4.3 52 2.10 [0.34, 3.86]

Mean Difference IV, Fixed, 95% CI 10

-10 -5 0 5 dermatologist/general pra nurse

Fig. E

III.

Adherence to treatment

None of the trials reported on this outcome. IV. Cost effectiveness to health facility and patients None of the trials reported on this outcome.

3.4

Summary of Chapter

This chapter has recorded the characteristics and results of the 5 included studies looking at QOL, severity of condition and patient satisfaction as the outcomes. In summary, there is no statistically significant difference in care provided by a nurse or a dermatologist/general practitioner with respect to QOL of patients who have dermatological conditions (mainly eczema and psoriasis in the studies included). Nonetheless, there was significant difference in the severity of the patients condition and general satisfaction rates in favour of nurse-led/nurse follow-up clinics. No results were recorded for the outcomes adherence to treatment and cost effectiveness as there were imprecise conclusions or no trials reported on them. These findings are discussed further in the next chapter.

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Chapter 4 Discussion
This chapter discusses the findings of this review. The later sections present the limitations and strengths of this review, implications for future practice and research. 4.1 Summary of main results

To my knowledge this is the first meta-analysis (systematic review) on the effectiveness of nurse-led/nurse follow-up dermatology clinics compared to a dermatologist/general practitioner-led clinic. A critical finding of this review is that only 5 of the 160 studies retrieved were randomised controlled trials with the outcomes of interest (see Table 1). This meta-analysis has shown that care provided by a nurse compared to that given by a dermatologist/general practitioner is comparable in many ways although it was hypothesized that there would be much difference in favour of nurse-led clinics ( Schuttelaar et al., 2009). However, there was evidence of decreased severity of dermatological condition and greater patient satisfaction rates with care provided by nurses in the studies analysed. 4.2 Quality of evidence

Participants at the beginning of the trial were comparable in demographic characteristics in both groups. Despite the lack of blinding of participants and clinicians trials, most trials (n=4) had a strict exclusion criteria and had their outcome assessors blinded. However, low statistical power was reported for one study (Chinn et al.,2002) for QOL because non-responders to the study had a worse quality of life than those who did and sample size was also small. The quality of the evidence provided by this meta-analysis is therefore moderate.

4.3
4.3.1

Agreements/disagreements with other studies /reviews


Quality of life

With the above results, it is apparent that nurse-led/nurse follow-up clinics do not worsen the plight of patients. Moreover, there is an indication that information and
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care given to participants in the two groups are not conflicting but rather could be complementary. This can be accomplished through a concerted approach by nurses and dermatologists working together to develop nursing skills in the community (Ersser & Penzer, 2000). In the trial by Gradwell et al. (2002) which concluded that the quality of life of participants in the nurse follow-up clinic had no significant difference in comparison with the dermatologist/general practitioner-led clinic, it is recorded that the patients were assessed before being sent for a follow-up by the nurse. The method of assessment and expected outcomes of the assessment were however not revealed and makes the results on quality of life a bit dicey. However, a study by Ben-Gashir, Seed and Hay (2004) suggests that the impact in quality of life of individuals is greatest in moderate to severe conditions. It is therefore possible that only patients with moderate to severe conditions were sent to both study groups (Brown and Grimes, 1995) hence the resulting no significant difference. This meta-analysis provides validity for a systematic review [not meta-analysis] conducted by Horrocks , Anderson and Salisbury (2002) which reported that an analysis of seven RCTs comparing nurse-led clinics and general practitioner led clinics with quality of life or health status as an outcome revealed no significant difference in patients outcome.

It is argued that health education improves the quality of life (Ross and Willigen, 1997). However, in all 5 trials comparing nurse-led clinics to dermatologist/general practitioner led clinic, education was an aspect of the care provided by the nurse in the nurse-led clinic, yet quality of life in the two groups was not significantly different. 4.3.2 Severity of condition

The severity of eczema of participants in the nurse-led clinic was significantly improved at completion of the trials compared to those in the dermatologist/general practitioner
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led clinic. This adds to the review conducted by Courtenay and Carey (2005) which concluded that nurse-led clinics brought a reduction in the severity of conditions of dermatology patients. The duration of consultation for nurses in these clinics could be a contributing factor as education on condition and application of treatment is usually demonstrated unlike in the dermatologist/general practitioner clinic where there is pressure on the doctors because of time. For example in the UK where doctors are paid according to the number of consultations, this could be a problem. The problem exists in Ghana although for a different reason as salaries of doctors and nurses are fixed irrespective of the number of hours worked. Nevertheless, with the low number of dermatologists available and the high incidence of dermatological conditions, consultation time is never adequate for patients because the waiting queue is long and a lot of consultation must be done by the dermatologist within the allocated period. Therefore in Ghana and other developing countries, improved severity of dermatological conditions will take a longer time if an alternate dermatology clinic is not implemented. Generally, quality of life and severity of condition have been shown to have a positive correlation (Ben-Gashir, Seed and Hay, 2004) but this was not indicated by this metaanalysis. 4.3.3 Patient satisfaction

While it is commonly remarked that patient satisfaction scores opt in favour of nurseled clinics (Horrocks et al., 2002; Krothe and Clendon, 2006), only few RCTs have evidence of this. This meta-analysis shows proof of this as it had only one RCT with patient satisfaction as an outcome. In a cross-sectional survey of 741 patients carried out in Saudi Arabia by Alzolibani (2011) which assessed various aspects of patient satisfaction, satisfaction rate for overall quality of dermatology services was 66.1%. High levels of satisfaction were expressed about the general maintenance and hygienic conditions of the clinic. About 38% of patients indicated their dissatisfaction regarding the waiting time for appointment and about 40% were not satisfied with the information they received
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about their problems. About 48% felt that the consultation time was inadequate and 36.7% felt that they were not allowed to express their symptoms in detail. It is argued that nurses tend to have longer consultations than doctors, and patient satisfaction is higher with longer consultations (Freeman, Horder, Howie, Hungin et al., 2002). However, having health education during consultation helps the patients in the management of their condition and provides a form of psychological therapy. The results underscore the importance of proper psychological assessment and treatment of dermatological conditions in addition to the standard dermatological treatment. Poor communication with dermatologists/general practitioners and the lack of empathy could be a possible cause of low patient satisfaction rates in the dermatologists/general practitioner led clinic. Nonetheless, satisfaction rates in the nurse-led clinic could be related to the acuity of the patients condition. This meta-analysis gave an evidence of decreased severity of patients condition. It could however be criticised with the view that patients with more serious conditions would prefer to see a doctor tha n a nurse (Laurant et al., 2004).

No RCTs were identified that compared patients adherence to treatment after attending either a nurse-led/nurse-follow-up clinic or dermatologist/general practitioner led clinic. However, in a prospective study by Storm, Benefedt, Serup et al. (2008) on adherence of patients to topical drugs, they confirmed that studying adherence in dermatology is very complicated as it is difficult to determine especially in the case of topical treatments. It is arguable that with the incorporation of education in nurse-led/nurse follow-up clinics, demonstration of application of topical treatments would improve and increase adherence among patients. Nevertheless, RCTs are needed to help make a valid inference.

Evidence of cost effectiveness of nurse-led dermatology clinics when compared to dermatologists/general practitioner led clinics is imprecise and prevents a meta-analysis to be carried out on this outcome. This is a confirmation of the review conducted by Brown and Grimes (1995) which concluded that although some studies may have been conducted looking at costs and cost effectiveness, authors fail to provide data on their
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conclusions and for those who do have data, it cannot be used in a meta-analysis (Brown and Grimes, 1995). A cost analysis conducted by Lattimer, Sassi, George, Turnbull et al. (2000), was in favour of nurse telephone consultations out of hours. However, this result would be impractical as evidence in a developing country like Ghana because not every patient has access to a phone.

4.4

Limitations and strengths of the Review

This systematic review is not without its own limitations. The main limitation of this review is that the reviewer is inexperienced and may have faltered one way or the other. Secondly, in most of the studies participants and clinicians were not blinded. However, the studies which provided a protocol with precise inclusion and exclusion criteria would help to minimize this bias. Another limitation is that, some studies might have been missed because of the larger number of studies that are usually involved in systematic reviews, especially, of non-randomised studies. Nevertheless, the range of subject headings used across the included databases increased the sensitivity of the search strategy. It is noticed that studies were from developed countries where resources a readily available. Although implementation is possible in developing countries like Ghana the issue of inadequate resources can prolong this. Lastly, limiting the search strategy to articles published in English Language only might, also, have contributed to the exclusion of some eligible studies resulting in language bias. The main strength of this review is the fact that meta-analysis (statistical integration of several similar quantitative studies) is the best approach for this systematic review as it generates explicit conclusions that are convincing enough to be used as evidence in clinical practice.

4.5 Recommendations for Future research


Cost, particularly cost involved for patients, has not been well investigated despite the extensively held view that nurse-led care will generate savings. Future studies of effectiveness of nurse-led dermatology clinics need to give more attention to the financial aspects of care; taking into consideration cost of educating the nurse and that of the dermatologist/general practitioner.
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4.6 Summary of Chapter


The findings as well as limitations of this systematic review have been discussed extensively in this chapter. Studies which have been conducted in other health sectors looking at similar outcomes were compared with this meta-analysis, and some major recommendations have been made towards future research. The next chapter provides a conclusion to the whole review process and discusses its implications for advancing nursing practice. A personal reflection on the learning process that has taken place in conducting this systematic review, and on my journey for a degree of Master of Science in Advanced Nursing are, then, provided.

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Chapter 5 Conclusions
With the current practice of evidence-based practice, hearsay is not acceptable. Therefore decisions are made based on rigorous and valid research. There are many study designs as seen in Fig A. (Chapter 1). However, systematic reviews and better still meta-analysis of randomised controlled trials are preferred.

The main focus of this dissertation was to look at the impact of nurse-led dermatology clinics on quality of life, adherence to treatment, cost (for institutions as well as patients), severity of condition and satisfaction rate. There was a critical appraisal of randomised controlled trials involving nurses leading dermatology clinics and their medical counterparts (dermatologist/ general practitioner). There was a wide search of databases as well as hand searching through journals and other dissertations and theses to locate available and relevant data. Trials that compared the nurse and the dermatologist/general practitioner with reference to the quality of life of patients, their adherence to treatment modalities, severity of condition, cost involved or the patient satisfaction of either clinics, and met the inclusion criteria for this systematic review were critically analysed. A meta-analysis of their findings, showed no difference in the quality of life of patients in either clinics. However, the impact of the nurse was felt by patients in the nurse-led clinic as evidenced by a reduction in the severity of their skin condition hence a report of higher satisfaction rates in the same group. This implies that nurses leading dermatology clinics can work as effectively as doctors if not better (Rafferty,). Yet, threats to the development of nurse led dermatology clinic are marked doctors unwillingness to relinquish certain aspects of their role, such as decision making, the training and recruitment of nurses, identifying future sources of funding and expounding administrative preparations (Cable, 1995).
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5.1

Implications for Advancing Nursing Practice

For many years, the debate on the meaning and roles of advanced nursing practice (Carnwell and Daly, 2003; Mantzoukas and Watkinson, 2006) is still ongoing. As a result, there is no agreement on this concept; while some believe that it is the shifting of medical roles (McGee, 1998b; Tye and Ross, 2000; Pearson and Peels, 2002), others claim that it is the development of the nursing profession (Rolfe, 1998b; Fulbrook, 1998; Castledine, 1998a). The findings suggest that appropriately trained nurses can produce as high quality care as dermatologists/general practitioners and achieve good health outcomes for patients. For most of the studies, nurse practitioners (NP) were the leaders in the clinics. However, without a consensus on the definition of who a nurse practitioner is, the title could have just been conferred on the nurses involved in the trials. An advanced level practitioner according to the ICN (2002) is a registered nurse who has acquired the expert knowledge base, complex skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Masters degree is recommended for entry level Manley (1997) describes four sub-roles for the advanced nurse practitioner; expert practitioner, educator, researcher and consultant roles. My opinion on advancing nursing practice is that nurses are able to identify areas of care that need amendment, through reflection, and take the necessary actions, including research and collaboration to bring about successful changes in practice and improve patient outcomes. As an expert practitioner, I would now be a position to offer quality client-centred care to attendants of dermatology clinic. With the knowledge received through this review I hope to achieve improved adherence to treatment on the part of clients as a result of sufficient education on management thereby reducing severity of the condition.

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5.2

Reflection on the Process

Reflection is a teaching and learning process that allows individuals to critically analyse their experiences during a course or practical professional programme, and learn from them (Durgahee, 1996). The what-so what-now what reflective framework by Borton (1970) modified by Driscoll (2007) was used as a guide during this process.

Driscolls cycle

Fig. F: Driscoll's cycle What?

In my pursuit of personal and professional development, I enrolled in the MSc. Advanced Nursing program, and chose to focus on improving the quality of life of dermatology clients through setting up a nurse-led clinic (reasons are obvious in the preceding chapters). I first and foremost needed to find out if these clinics would be effective. This exposed me to many germane issues involved in the setting up and running of a nurse-led clinic as well as the requirements needed to lead such clinics and has fully prepared me for addressing such issues. So what?

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It is therefore appropriate that as an advanced nurse practitioner with an interest in this area, I know more about nurse-led clinics in general and specifically in the field of dermatology to initiate this project. I set out to carry out this systematic review to determine the effectiveness of existing nurse-led dermatology clinics and provide a reliable evidence to be used during the negotiation process of setting up the nurse-led dermatology clinic. The several advantages of systematic reviews over other sources of evidence imply that many healthcare professionals and service users will, at a point in time, rely on them for guiding practice and decision-making. Moreover, personal and professional development may imply that healthcare professionals should be conversant with generating and/or utilising quality evidence in their clinical practice. Now what? This systematic review not only contributes significantly to evidence-based practice but, also, serves as an indication of my personal and professional development. Undertaking this systematic review has given me a better understanding of research methods. It has also enhanced my ability to critique research articles and make sense of their findings. With these, the use of clinical evidence will be a kingpin in my nursing practice. I also believe that I can play significant roles in assisting other colleagues in the process of undertaking and utilising research. It is anticipated that the findings of this systematic review will influence the initiation of a nurse-led dermatology clinic in my hospital in Ghana. Some of the challenges that may be encountered have been discussed in the section on implications for advancing practice section. However, my belief is that its introduction may provide an alternative service of care for clients who have dermatology problems. In the course of this dissertation, I undertook visits to nurse-led dermatology clinics that enhanced my understanding on various activities that went on at such clinics. I also interacted with a nurse consultant dermatologist. I anticipate that all these experiences will make me very instrumental in leading a nurse-led dermatology clinic in Ghana. Now that the impact of the service has been established, several obstacles need to be overcome, including the issue of funding the clinic. As specialty clinics expand, on-going
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evaluation should be considered to ensure the quality of care and patient satisfaction with the consultation.

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Appendix I- Systematic Review Protocol

The Effectiveness of Nurse-Led/Nurse Follow-Up Dermatology Clinics

Background
With the impact of dermatological services on individuals in the community, just having one type of service is not sufficient in meeting the needs of the growing population (Brown, 2005). The issue of waiting times, quality of care, treatment outcomes is an evidence of this.

Nurses with expertise and training are available to bridge this gap in dermatology services (Chinn, Poyner and Sibley, 2001). This initiated the emergence of nurse-led clinics (Brown, 2005). Nurse-led clinics have been in the United States and the United Kingdom since the 19th century (Turkeltaub, 2004). Though these clinics have been in existence for decades, a rigorous search for evidence on their effectiveness in outpatient dermatology settings has not been carried out.

In Ghana my home country, though there is the existence of nurse-led clinics in other specialties of medicine (ear, nose and throat [ENT], Eye and General Nursing), there is none set up in dermatology. Also, these are only seen in the rural areas where there is the shortage of general practitioners. In the hospital where I work in Ghana, there is a visiting dermatologist who comes once a week or sometimes every other week for 3 hours per visit. Clients have to wait weeks to see the dermatologist or make do with prescriptions given by general practitioners who do not have the required skills for dermatological care.

Setting up a nurse-led dermatology clinic after my training as an advanced nurse practitioner, is one of the targets I look forward to achieve. It is therefore anticipated that this systematic review when carried out will identify available evidence from
I

randomised controlled trials, the pros and cons of nurse-led clinics in dermatology and if it is beneficial to start such a clinic. Review Question: How effective is a nurse-led outpatient dermatology clinic when compared to the usual care (dermatologist/general practitioner)? Objective To determine the effectiveness of nurse-led dermatology clinics on patients adherence to treatment, the quality of life, patient satisfaction, severity of condition and cost. Inclusion Criteria Types of participants I. II. Adults and children of either gender seen at dermatology Outpatient departments Nurse could be nurse practitioners, clinical nurse specialists and advanced practice nurses III. Medical practitioner could be a general practitioner or dermatologist Types of interventions All or part of care delivered by a nurse practitioner compared to the usual care (medical practitioner managed) in a dermatology clinic. Types of outcome measures I. II. III. IV. V. Adherence to treatment, Quality of life, Patient satisfaction Severity of condition Cost involved

II

Types of studies (study designs) Randomised controlled trials (RCTs) comparing nurse-led dermatology clinics to clinics run by a dermatologist/ general practitioner (usual care) with quality of life, adherence to treatment, patient satisfaction, severity of condition or cost involved as a primary or secondary outcome, will be considered for inclusion in this review. Other research designs such as non-randomised controlled trials and observational studies will be considered for inclusion in a narrative summary, in the absence of RCTs. This is to ensure that the current best evidence on the effectiveness of nurse-led clinics as compared to usual care in improving quality of life, adherence to treatment, waiting times and minimizing cost among patients in the dermatology clinic, is identified. Search strategy for identification of studies The search strategy (limited to English to prevent translation problems as this may be bias) will be in 3 steps to ensure that both published and grey literature is searched for. Electronically, relevant data will be extracted from databases such as MEDLINE, SCOPUS, CINAHL, and Cochrane Library as the first step. Text words in the titles and abstract will then be examined. Searching will be efficiently carried out by ensuring that inclusive search strings (synonyms, wild cards) specific to each database are employed. The second step involves keying in identified keywords and index terms into the databases. In the third step, hidden studies from retrieved references will be searched. Hand searching through journals, conference reports, dissertation abstracts and theses of other students will also be done to retrieve grey literature that meets the inclusion criteria. The database Systems for Information on Grey Literature (SIGLE) will also be searched. Full text for potentially relevant studies will be then retrieved. Initial keywords for the search will be: a. Nurse-led clinics b. Nurse managed clinic c. Nurse-led care

III

d. Dermatology e. Out Patient/ ambulatory care f. Effectiveness of care g. Quality of care h. Patient satisfaction i. Cost effectiveness

Methods of the review Eligibility Two independent reviewers will screen the articles for inclusion. Studies should involve clinics led by nurses in outpatient dermatology. Participants in these studies could be either children or adults. Any disagreement that arises between the reviewers will be resolved through discussion and a final consensus. Where relevant, authors of the studies will be contacted for clarification. Data extraction Data will be extracted by two reviewers independently and entered into a data extraction form. The extracted data will then be entered into the Cochrane collaboration software -Review Manager (Revman 5.1). Assessment of methodological quality

Full text articles of studies that meet the inclusion criteria will be retrieved and reviewed by two independent reviewers for methodological validity before inclusion in the review. Standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) will be used for this purpose. The two independent reviewers will assess the quality of the search results and exclude articles that do not meet the inclusion criteria of this review.
IV

For quality of the randomized controlled trials, the following will be noted: a. How was randomization done? b. Where participants comparable at baseline? b. Method of allocation concealment c. Which parties were blinded? d. Was there an indication of Intention to treat? e. Measurement tools used in defining outcome measures

Analysis Analysis will be done using the Review manager software. Studies with similar outcomes will undergo meta-analysis. The results will be expressed as odds ratio (OR) for dichotomous outcomes and weighted mean differences for continuous outcomes with 95% confidence intervals (CI) for either outcomes. Heterogeneity will be assessed using I2. The result will also be expressed as number needed to treat (NNT) where appropriate, for a range of plausible control event rates. Where it is not possible to perform a meta-analysis the findings will be summarized in a narrative form.

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Chinn, D. J., Poyner, T. and Sibley, G. (2002) Randomized controlled trial of a single dermatology nurse consultation in primary care on the quality of life of children with atopic eczema. British Journal of Dermatology 146: 432-439.

Courtenay, M. and Carey, N. (2007) A review of the impact and effectiveness of nurse-led care in dermatology. Journal Of Clinical Nursing 16:pp.122-128.

VI

Courtenay, M., Carey, N. and Stenner, K. (2009) Nurse prescriber-patient consultations: a case study in dermatology. Journal Of Advanced Nursing 65:pp.1207-1217.

Doe, P. T., Asiedu, A., Acheampong, J. W. and Payne, C. M. E. (2001) Skin diseases in Ghana and the Uk. International Journal Of Dermatology 40:pp.323-326.

Fineout-Overholt, E. and Johnston, L. (2005) Teaching Evidence based practice: A challenge for educators in the 21st century. Worldviews on Evidence-Based Nursing 2: pp. 37-39.

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Hoffman, R.G. and Lim, J.H. (2007) Observational study design. In: Ambrosius, W.T. (Ed). Methods in molecular biology: Topics in biostatistics. Humana Press Inc., Totowa: New Jersey, pp. 19-31

Horrocks, S., Anderson, E. and Salisbury, C. (2002) Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal 324:pp. 819-823.

International Council of Nurses (ICN) (2005) Definition and characteristics of the Advanced Practitioner Nurse role. In: Clinical Nurse Specialists and Nurse Practitioners in Canada :A Decision Support Synthesis ,June 2010 Kernick, D., Cox, A., Powell, R. et.al (2000) A cost consequence study of the impact of a dermatology-trained practice nurse on the quality of life of primary care patients with eczema and psoriasis. British Journal of General Practice 50:pp. 555-558.
VII

Lobiondo-Wood, G. and Haber, J. (Eds.) (2006) Nursing research, methods and critical appraisal for evidence-based practice. pp. 78-110. Philadelphia: Mosby Elsevier.

Masawe, A. E. J. and Samitz, M. H. (1976) Dermatology in Tanzania: a model for other developing countries. International Journal of Dermatology 15:pp. 680-687

Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W.-Y., Cleary, P. D., Friedewald, W. T., Siu, A. L. and Shelanski, M. L. (2000) Primary care outcomes in patients treated by nurse practitioners or physicians. Journal Of The American Medical Association 283:pp. 5968.

Pinkerton, J.-A. & Bush, H. A. (2000) Nurse practitioners and physicians: patients' perceived health and satisfaction with care. Journal Of The American Academy Of Nurse Practitioners 12:pp. 211-217.

Polit, D.F. and Beck, C.T. (2008) Nursing research: generating and assessing evidence for nursing practice. 8th ed. Philadelphia: Lippincott.

Polit, D.F. & Beck, C.T. (2010) Essentials of Nursing Research: Appraising Evidence for nursing Practice. 7th ed. Philadelphia: Lippincott Williams & Wilkins.

Scottish Dermatological Society (2010) Skin Disease and Dermatologists [online] Available at: http://www.sds.org.uk/links.php (Accessed 16 February, 2011)

Sidani, S. & Irvine, D. (1999) A conceptual framework for evaluating the nurse practitioner role in acute care settings. Journal of Advanced Nursing 30:pp. 58-66.

Schuttelaar, M., Vermeulen, K., Drukker, N. and Coenraads, P. (2010) A randomized controlled trial in children with eczema: nurse practitioner vs. dermatologist. British Journal of Dermatology 162: 162170.

VIII

Tharyan, P. and Jebaraj, P (2006) Systematic reviews of randomized controlled trials and evidence informed palliative care. Indian Journal of Palliative Care 12:pp.39-41

Tranfield, D., Denyer , D. and Smart, P. (2003) Towards a methodology for developing evidence-informed management knowledge by means of systematic review. British Journal of Management 14(3):pp. 207-222

Webb, C. & Roe, B. (2008) Reflections on the past, present and future of systematic reviews. Blackwell Publishing Ltd.

Welwyn Hatfield PCT( 2011) PCT-wide, primary-care-led dermatology service Working in Partnership Programme-NHS [online], Available at: http://www.wipp.nhs.uk/uploads/gpdb/pct_wide_dermatology_service.pdf (Accessed March 7, 2011)

IX

APPENDIX II Search Strategy: Embase <1980 to 2011 Week 21> 1 2 3 4 5 6 7 8 9 randomised controlled trials.mp. (9376) randomized controlled trials.mp. or Randomized Controlled Trial/ (301164) Controlled Clinical Trial/ (173464) randomised controlled trial*.mp. (17669) randomized controlled trial*.mp. (310633) randomized controlled trial.pt. (0) controlled clinical trial.pt. (0) 1 or 2 or 3 or 4 or 5 or 6 or 7 (347019) (nurse adj led adj clinic*).mp. [mp=title, abstract, subject headings, heading word,

drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword] (237) 10 (nurse adj2 clinic*).mp. [mp=title, abstract, subject headings, heading word, drug

trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword] (10078) 11 (nurse adj run adj clinic).mp. [mp=title, abstract, subject headings, heading word,

drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword] (14) 12 (nurse adj practitioner adj led adj3 clinic*).mp. [mp=title, abstract, subject

headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword] (6)

13

(nurse adj follow adj up adj clinic*).mp. [mp=title, abstract, subject headings,

heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword] (3) 14 15 16 17 18 9 or 10 or 11 or 12 or 13 (10082) Dermatology/ (19400) exp Skin Diseases/ (879957) 15 or 16 (890162) 8 and 14 and 17 (53)

Medline Database: Ovid MEDLINE(R) <1948 to July Week 4 2011> Search Strategy: 1 2 3 4 5 6 7 8 randomised controlled trials.mp. (7528) randomized controlled trials.mp. or Randomized Controlled Trial/ (393031) Controlled Clinical Trial/ (83249) randomised controlled trial*.mp. (14009) randomized controlled trial*.mp. (395490) randomized controlled trial.pt. (314972) controlled clinical trial.pt. (83249) 1 or 2 or 3 or 4 or 5 or 6 or 7 (476801)

XI

(nurse adj led adj clinic*).mp. [mp=protocol supplementary concept, rare disease

supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier] (159) 10 (nurse adj2 clinic*).mp. [mp=protocol supplementary concept, rare disease

supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier] (8888) 11 (nurse adj run adj clinic).mp. [mp=protocol supplementary concept, rare disease

supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier] (12) 12 (nurse adj practitioner adj led adj3 clinic*).mp. [mp=protocol supplementary concept,

rare disease supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier] (5) 13 (nurse adj follow adj up adj clinic*).mp. [mp=protocol supplementary concept, rare

disease supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier] (2) 14 15 16 17 18 9 or 10 or 11 or 12 or 13 (8892) Dermatology/ (11820) exp Skin Diseases/ (716404) 15 or 16 (724398) 8 and 14 and 17 (26) Web of science (looking through all databases) # 14 #5 # 13 #12 AND #11 AND #5 5 #12 AND #10 AND

XII

6 # 12 # 11 >100,000 991 Topic=(dermatology) OR Topic=(skin clinic)

Topic=(nurse led clinic) OR Topic=(nurse run clinic) OR Topic=(nurse manage Topic=(nurse practitioner led clinic)

# 10 #9

706 491

Topic=(nurse follow-up clinic) OR Topic=(nurse follow up clinic)

Topic=(nurse managed clinic) OR Topic=(nurse run clinic) OR Topic=(nurse le Topic=(nurse practitioner led clinic)

#8 #7 #6 #5 #4 #3 #2 #1

309 135 605 >100,000 >100,000 73,618 >100,000 >100,000

Topic=(nurse managed clinic) Topic=(nurse run clinic) Topic=(nurse led clinic) #4 OR #3 OR #2 OR #1 Topic=(randomized controlled trials/) Topic=(random allocation/) Topic=(controlled clinical trial) Topic=(randomi?ed controlled trial)

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Appendix III Table 2: Characteristics of excluded studies

List of excluded studies Cork, Britton, Butler, Young et.al, 2003 Courtenay and Carey, 2007

Reason for exclusion Cohort study

Literature review

Shaw, Morrel and Goldsmith, 2008

Intervention given by a medical student not a nurse

van Os-Medendorp H, Ros WJ, Eland-de Kok PC, et al.,2007

After close reading discovered that none of the interested outcomes was an outcome in the trial

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Appendix IV JBI MAStARI Critical Appraisal Tool for Experimental Studies Study: Reviewer: Date: Record Number:

1. Was the assignment to treatment groups truly random? Yes No Unclear

2. Were participants blinded to treatment allocation? Yes No Unclear

3. Was allocation to treatment groups concealed from the allocator? Yes No Unclear

4. Were the outcomes of people who withdrew described and included in the analysis? Yes No Unclear

5. Were those assessing outcomes blind to the treatment allocation? Yes No Unclear

6. Were the control and treatment groups comparable at entry? Yes No Unclear

7. Were groups treated identically other than for the named interventions? Yes No Unclear

8. Were outcomes measured in the same way for all groups? Yes No Unclear

9. Were outcomes measured in a reliable way? Yes No Unclear

10. Was appropriate statistical analysis used? Yes No Unclear

Overall Appraisal: Rationale:

Include

Exclude

Seek further information

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Appendix V Cochrane Skin Group data extraction template (modified) DESCRIPTION OF INTERVENTIONS Intervention DERMATOLOGIST/GENERAL PRACTITIONER Period for consultation Education during consultation Were adequate instructions given to patients regarding using medications Y/N/Unsure Y/N/Unsure Intervention NURSE PRACTITIONER

PARTICIPANTS Inclusion criteria a) diagnosis b) Referred by c) severity of eczema d) duration

Exclusion criteria Setting (eg primary or secondary care, country, number of centres)

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Baseline demographic data

Intervention DERMATOLOGIST

Intervention NURSE PRACTITIONER

Total

Note s

Age Duration of condition Severity of condition Severe Moderate Mild Male Female Number of participants randomised Losses to follow up reasons stressful none Number lost to follow up % lost to follow up Final number of participants evaluable Intention to treat analysis yes / not stated / no distance

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Primary outcome measures 1. Quality of life Methods of assessing primary outcome measures 1. Infants Dermatitis Quality of Life Index (IDQOL) 2. Childrens Dermatology Life Quality Index (CDLQI)

3. Dermatitis Family Impact Questionnaire, (DFI)

Secondary outcome measures 1. adherence to treatment 2. Patient satisfaction 3. Severity of condition 4. Cost involved

Methods of assessing secondary outcome measures 1. Electronic monitoring 2. Client satisfaction questionnaires 3. Objective SCORAD 4. Cost analysis

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OUTCOME MEASURES RESULTS Intervention DERMATOLOGIST Quality of life (IDQOL). mean (SD) N= Total number @ Time point:0-4/0-12 weeks Quality of life (CDQOL). mean (SD) N= Total number @ Time point:0-4/0-12 weeks Family impact of childhood atopic dermatitis. mean (SD) N= Total number @ Time point: 0-4/0-12 weeks Intervention NURSE PRACTITIONER Notes

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METHODS Design: parallel group / cross over / other (describe) Duration of trial: Interval of assessment:

METHODOLOGICAL QUALITY OF STUDY Major Criteria 1. Generation of randomisation sequence Any information given? 2. Allocation concealment A Adequate - e.g. third party or opaque sealed Y/ N / unsure Method

envelopes B C D 3. Blinding Participant Clinician Y/ N / unsure Y/ N / unsure Y/ N / unsure Unclear - insufficient details provided Inadequate - e.g. open list or day of week Not used

Outcome assessor 4. Loss to follow-up

Were all randomised participants included in the analysis in the groups to which they were randomised? Y/ N / unsure

Funding body
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Declared:

Y/ N / unsure

Name:

Comments

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