Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

BACKGROUND

Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services.

METHODS AND FINDINGS

This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control β -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination.

CONCLUSIONS

Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Tailored Education Increased Capability and Motivation for Fall Prevention in Older People After Hospitalization

Recently hospitalized older people are at risk of falls and face barriers to undertaking fall prevention strategies after they return home from hospital. The authors examined the effects of tailored education delivered by physiotherapists on the knowledge (capability) and the motivation of older people to engage in fall prevention after hospital discharge. Utilizing data gathered from a recent trial, data was analyzed from 390 people who were 60 years and over without impaired cognition (>7/10 abbreviated mental test score) and discharged from three Australian hospitals. Motivation and capability were measured at baseline in the hospital and at 6-months after hospital discharge by blinded assistants using structured surveys. Bivariate analysis using generalized linear modeling explored the impact of education on the capability and motivation. Engagement in fall prevention strategies was entered as an independent variable during analysis to determine associations with capability and motivation. The education significantly improved capability [-0.4, 95% CI (-0.7, -0.2), p < 0.01] and motivation [-0.8, 95% CI (-1.1, -0.5), p < 0.01] compared with social-control at the time of hospital discharge. In contrast, social-control participants gained capability and motivation over the 6-months, and no significant differences were found between groups in capability [0.001, 95% CI (-0.2, 0.2), p = 0.9] and motivation [-0.01, 95% CI (-0.3, 0.3), p = 0.9] at follow-up. Tailored fall prevention education is recommended around hospital discharge. Participants still needed to overcome barriers to falls prevention engagement post hospitalization. Thus, tailored education along with direct clinical services such as physiotherapy and social supports is warranted for older people to avoid falls and regain function following hospitalization.

Group-based pelvic floor muscle training for all women during pregnancy is more cost-effective than postnatal training for women with urinary incontinence: cost-effectiveness analysis of a systematic review

QUESTION

What is the most cost-effective way of providing pelvic floor muscle training (PFMT) to prevent or treat postpartum incontinence?

DESIGN

Meta-analysis and cost-effectiveness analysis of models of care included in a recent Cochrane systematic review.

PARTICIPANTS

Pregnant and postnatal women.

INTERVENTION

Supervised PFMT for preventing or treating urinary and/or faecal incontinence.

OUTCOME MEASURES

Postpartum urinary or faecal incontinence.

ANALYSIS

We examined the comparative incremental cost effectiveness of different approaches to successfully prevent or cure one case of incontinence. Costs were valued in Australian dollars using publicly available market rates and enterprise agreements as of 2019. Comparisons involving group-based treatment approaches were subject to sensitivity analyses where the numbers of patients attending each group were varied to identify thresholds where recommendations change.

RESULTS

Seventeen trials were included for meta-analysis. Three models of care were clinically effective: individually supervised PFMT during pregnancy to prevent urinary incontinence (Model 1), group-based PFMT during pregnancy to prevent or treat urinary incontinence (Model 2) and individually supervised postnatal PFMT to treat urinary incontinence and prevent or treat faecal incontinence (Model 3). The health service costs per urinary incontinence case prevented or cured were $768 for Model 1, and $1,970 for Model 3. However, Model 2 generated a cost saving of $14 if there were eight participants per session, with greater savings if more participants attend. The health service cost per faecal incontinence case prevented or cured was $2,784 (Model 3).

CONCLUSION

Providing group-based PFMT for all women during pregnancy is likely more efficient than individual PFMT for incontinent women postnatally; however, providing PFMT for postnatal women with urinary incontinence should not be discounted because of the added known benefit for preventing and treating faecal incontinence.

Definitions and use of the teach-back method in healthcare consultations with patients: A systematic review and thematic synthesis

OBJECTIVE

To review and synthesise definitions of the teach-back method in the literature. The second aim is to synthesise the barriers, facilitators and perceptions of teach-back use in healthcare consultations with patients.

METHODS

A systematic review and thematic synthesis following Braun and Clarke's method.

RESULTS

The primary search found 1429 citations and the secondary search added 221 citations. Screening identified 66 citations eligible for data extraction. We contrasted and synthesised operational definitions of the teach-back method. The synthesis generated seven themes related to healthcare provider (HCP) and patient perceptions of teach-back (effectiveness, stigma and time-related perceptions), the universal application of teach-back, patient health outcomes and healthcare provider training.

DISCUSSION

Operational definitions of the teach-back method varied in the literature and contained implied steps. HCPs and patient perceptions of teach-back operated as both enablers and barriers to its use. HCPs training programs for the teach-back method were identified as beneficial for altering HCPs perceptions about the method and increased its use with patients.

PRACTICE IMPLICATIONS

Standardising operational definitions of the teach-back method can support replicability of research and enhance HCPs communication skills training programs. HCPs training on teach-back use can support the increased use of the technique with broader patient populations.

Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis

BACKGROUND

Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths.

OBJECTIVE

To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates.

METHODS

Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations.

RESULTS

Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available.

CONCLUSION

Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use.

Non-pharmacological interventions to prevent hospital or nursing home admissions among community-dwelling older people with dementia: A systematic review and meta-analysis

Older people with dementia more frequently experience episodes of hospital care, transferal to nursing home and adverse events when they are in these environments. This study synthesised the available evidence examining non-pharmacological interventions to prevent hospital or nursing home admissions for community-dwelling older people with dementia. Seven health science databases of all dates were searched up to 2 December 2019. Randomised controlled trials and comparative studies investigating non-pharmacological interventions for older people with dementia who lived in the community were included. Meta-analyses using a random-effect model of randomised controlled trials were used to assess the effectiveness of interventions using measures taken as close to 12 months into follow-up as reported. Outcomes were risk and rate of hospital and nursing home admissions. Risk ratio (RR) or rate ratios (RaR) with 95% confidence interval were used to pool results for hospital and nursing home admission outcomes. Sensitivity analyses were conducted to include pooling of results from non-randomised trails. Twenty studies were included in the review. Community care coordination reduced rate of nursing home admissions [(2 studies, n = 303 people with dementia and 86 patient-caregiver dyads), pooled RaR = 0.66, 95% CI (0.45, 0.97), I²  = 0%, p = .45]. Single interventions of psychoeducation and multifactorial interventions comprising of treatment and assessment clinics indicated no effect on hospital or nursing home admissions. The preliminary evidence of community care coordination on reducing the rate of nursing home admissions may be considered with caution when planning for community services or care for older people living with dementia.

Perspectives of older adults regarding barriers and enablers to engaging in fall prevention activities after hospital discharge

Older adults recently discharged from hospital are at high risk of functional decline and falls. A tailored fall prevention education provided at hospital discharge aimed to improve the capacity of older adults to engage in falls prevention activities. What remains unknown are the factors affecting behaviour change after hospital discharge. This study identified the perceived barriers and enablers of older adults to engagement in fall prevention activities during the 6-month period post-discharge. An exploratory approach using interpretative phenomenological analysis focused on the lived experience of a purposive sample (n = 30) of participants. All were recruited as a part of an RCT (n = 390) that delivered a tailored fall prevention education program at three hospital rehabilitation wards in Perth, Australia. Data were collected at 6-month post-discharge using semi-structured telephone surveys. Personal stories confirmed that some older adults have difficulty recovering functional ability after hospital discharge. Reduced physical capability, such as experiences of fatigue, chronic pain and feeling unsteady when walking were barriers for participants to safely return to their normal daily activities. Participants who received the tailored fall education program reported positive effects on knowledge and motivation to engage in fall prevention. Participants who had opportunities to access therapy or social supports described more positive experiences of recovery compared to individuals who persevered without assistance. A lack of physical and social support was associated with apprehension and fear toward adverse events such as falls, injuries, and hospital readmission. The lived experience of participants following hospital discharge strongly suggested that they required more supports from both healthcare professionals and caregivers to ensure that their needs were met. Further research that evaluates how to assist this population to engage in programs that will mitigate the high risk of falls and hospital readmissions is required.

Developing a Taxonomy of Communication Techniques and Aids Used By Healthcare Providers During Patient Consultations: Protocol for a Systematic Review

Background

Currently, there is no available standardized taxonomy of defined communication techniques and aids used by healthcare providers during patient consultations. It is challenging to identify communication techniques that contribute to effective healthcare provider and patient consultations and to replicate communication interventions in research.

Objective

The aim of this paper is to describe a protocol for the development and pilot of a taxonomy of communication techniques and aids used by healthcare providers during patient consultations.

Methods

A systematic review will be completed to identify eligible studies. Extracted techniques and aids will be organized into a preliminary taxonomy by a multidisciplinary team. The preliminary taxonomy will be piloted by two groups: research assistants trained in taxonomy application and healthcare providers and healthcare professional students not trained in taxonomy use. The pilot will use custom developed video footage of health provider and patient interactions. Interrater validity and interview feedback will be used to inform a Delphi panel of multidisciplinary healthcare providers and patient experts when they convene to finalize the preliminary taxonomy.

Results

This study was funded in November 2017 by the Monash University Interdisciplinary Research Seed Funding Scheme. Data collection commenced in March 2018, and data analysis is in progress. We expect the results to be published in 2021.

Conclusions

This is the first known attempt to develop a defined and standardized taxonomy of communication techniques and aids used by healthcare providers in patient consultations. The findings will be used to inform future research by providing a detailed taxonomy of healthcare providers’ communication techniques and standardized definitions.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16801

Efficacy of different load intensity and time-under-tension calf loading protocols for Achilles tendinopathy (the LOADIT trial): protocol for a randomised pilot study

Background

Modifying variables in exercise prescription can produce specific effects on Achilles tendinopathy outcomes. This study aims to determine the feasibility of conducting an adequately powered randomised trial in the future to assess the efficacy of different load intensity and time-under-tension exercise parameters for improving pain and function in individuals with persistent midportion Achilles tendinopathy.

Methods

The trial is designed as prospective, four-armed feasibility and randomised pilot trial with 3 months follow-up. Interventions will be provided in a gym setting. The investigator, who will be blind to the allocation of participants, will conduct all pre- and post-intervention assessments. Forty-eight male participants with Achilles tendinopathy will be recruited from the community. We will use a 2 × 2 factorial design with factors of load intensity (six or eighteen repetitions maximum) and time-under-tension (two or six second repetitions). Participants will be randomised into one of the testing groups: six RM with two second repetitions, six RM with six second repetitions, eighteen RM with two second repetitions or eighteen RM with six second repetitions. Trial feasibility will be indicated by the rate of conversion, recruitment and retention, adherence to the interventions by participants, the utility of videoconferencing mode for weekly exercise supervision, incidence of adverse events, and feasibility of future economic evaluation. The secondary clinical outcomes will assess pain and disability, participant impression of change, satisfaction, health-related quality of life, physical activity, work absenteeism, psychological measures at baseline, 6 and 12 weeks, and plantarflexor contractile dysfunction (torque, rate of force development and muscle force steadiness) at baseline and 12 weeks. These clinical outcomes are primarily measured to provide information regarding potential treatment effects and trends.

Discussion

The proposed study and follow-up powered randomised trial will be a first step towards determining exercise dose parameters that may optimise outcomes for Achilles tendinopathy. We have chosen to focus on load intensity and time-under-tension, as these parameters are important for tendon adaptation. This work has the potential to lead to more effective exercise loading interventions for Achilles tendinopathy.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618001315202. Registered retrospectively on August 6th, 2018.

Impact of the Method of Delivering Electronic Health Behavior Change Interventions in Survivors of Cancer on Engagement, Health Behaviors, and Health Outcomes: Systematic Review and Meta-Analysis

Background

Increased accessibility to the internet and mobile devices has seen a rapid expansion in electronic health (eHealth) behavior change interventions delivered to patients with cancer and survivors using synchronous, asynchronous, and combined delivery methods. Characterizing effective delivery methods of eHealth interventions is required to enable improved design and implementation of evidence-based health behavior change interventions.

Objective

This study aims to systematically review the literature and synthesize evidence on the success of eHealth behavior change interventions in patients with cancer and survivors delivered by synchronous, asynchronous, or combined methods compared with a control group. Engagement with the intervention, behavior change, and health outcomes, including quality of life, fatigue, depression, and anxiety, were examined.

Methods

A search of Scopus, Ovid MEDLINE, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature Plus, PsycINFO, Cochrane CENTRAL, and PubMed was conducted for studies published between March 2007 and March 2019. We looked for randomized controlled trials (RCTs) examining interventions delivered to adult cancer survivors via eHealth methods with a measure of health behavior change. Random-effects meta-analysis was performed to examine whether the method of eHealth delivery impacted the level of engagement, behavior change, and health outcomes.

Results

A total of 24 RCTs were included predominantly examining dietary and physical activity behavior change interventions. There were 11 studies that used a synchronous approach and 11 studies that used an asynchronous approach, whereas 2 studies used a combined delivery method. Use of eHealth interventions improved exercise behavior (standardized mean difference [SMD] 0.34, 95% CI 0.21-0.48), diet behavior (SMD 0.44, 95% CI 0.18-0.70), fatigue (SMD 0.21, 95% CI −0.08 to 0.50; SMD change 0.22, 95% CI 0.09-0.35), anxiety (SMD 1.21, 95% CI: 0.36-2.07; SMD change 0.15, 95% CI −0.09 to 0.40), depression (SMD 0.15, 95% CI 0.00-0.30), and quality of life (SMD 0.12, 95% CI −0.10 to 0.34; SMD change 0.14, 95% CI 0.04-0.24). The mode of delivery did not influence the amount of dietary and physical activity behavior change observed.

Conclusions

Physical activity and dietary behavior change eHealth interventions delivered to patients with cancer or survivors have a small to moderate impact on behavior change and a small to very small benefit to quality of life, fatigue, depression, and anxiety. There is insufficient evidence to determine whether asynchronous or synchronous delivery modes yield superior results. Three-arm RCTs comparing delivery modes with a control with robust engagement reporting are required to determine the most successful delivery method for promoting behavior change and ultimately favorable health outcomes.

A new model of care and in-house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial

OBJECTIVES

To evaluate whether an alternative model of care in aged care facilities, including in-house general practitioners, influenced health outcomes for residents.

DESIGN

Stepped wedge, cluster randomised controlled trial over 90 weeks (31 December 2012 - 21 September 2014), with a 54-week pre-trial retrospective data period (start: 19 December 2011) and a 54-week post-trial prospective data collection period (to 4 October 2015).

PARTICIPANTS, SETTING

Fifteen residential aged care facilities operated by Bupa Aged Care in metropolitan and regional cities in four Australian states.

INTERVENTION

Residential aged care facilities sought to recruit general practitioners as staff members; care staff roles were redefined to allow registered nurses greater involvement in care plan development.

MAIN (PRIMARY) OUTCOME MEASURES

Numbers of falls; numbers of unplanned transfers to hospital; polypharmacy.

RESULTS

The new model of care could be implemented in all facilities, but four could not recruit in-house GPs at any time during the trial period. Intention-to-treat analyses found no statistically significant effect of the intervention on the primary outcome measures. Contamination-adjusted intention-to-treat analyses identified that the presence of an in-house GP was associated with reductions in the numbers of unplanned hospital transfers (incidence rate ratio [IRR], 0.53; 95% CI, 0.43-0.66) and admissions (IRR, 0.52; 95% CI, 0.41-0.64) and of out-of-hours GP call-outs (IRR, 0.54; 95% CI, 0.36-0.80), but also with an increase in the number of reported falls (IRR, 1.37; 95% CI, 1.20-1.58).

CONCLUSIONS

Recruiting GPs to work directly in residential aged care facilities is difficult, but may reduce the burden of unplanned presentations to hospitals and increase the reporting of adverse events.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry, ACTRN12613000218796 (25 February 2013).

Risk factors for social isolation in post-hospitalized older adults

INTRODUCTION

Social isolation in older adults is associated with high rates of adverse health outcomes. Older adults who have had a recent significant health event are likely to be at risk of social isolation following hospitalization. This study aims to identify risk factors amongst older adults at hospital discharge that are associated with social isolation at three months post-hospitalization.

METHODS

Older adults were surveyed at hospital discharge and three months post-hospitalization. Baseline data including demographics, self-reported quality of life, physical activity and capacity levels, lifestyle factors, symptoms of depression and anxiety were collected at discharge. Social isolation was measured using the Friendship Scale at the three-month follow-up. Regression analyses were used to examine the relationship between baseline characteristics and social isolation at three months post-hospitalization.

RESULTS

Older adults (n = 311) participated in the baseline survey, of whom 241 (78 %) completed the three-month survey. Higher depressive and anxiety symptoms at hospital discharge, comorbidity of cancer, history of cigarette smoking, prior access to community and respite service, and arrangement for shopping assistance post-discharge were factors independently associated with an increased risk of social isolation at three months post-hospitalization.

DISCUSSION

This study identified risk factors for social isolation that are unique to older post-hospitalized adults. These findings can help clinicians identify individuals at risk of social isolation and to target interventions that address these risk factors for the prevention of social isolation in older adults after hospitalization.

Guardianship in hospitals: a collaborative pilot project

Objectives This paper describes the development, implementation and preliminary results of a collaborative pilot project aimed at reducing the time hospital-based patients with cognitive impairments spend waiting for the allocation of legally appointed Advocate Guardian decision makers from the Office of the Public Advocate (OPA). The aim of the study was to investigate the effect of increased availability of public advocate guardians on guardian allocation waits, patient discharge outcomes and healthcare system demand. Methods A multi-institutional pilot program created a dedicated hospital guardian team within OPA, funded by the health networks, to reduce the time to guardian allocation for patients within each network. A multisite, quasi-experimental historical control group design was used, with initial data collection over 12 months, followed by study of 12-month post-implementation cohorts. Results Under the pilot program, the time from guardianship order lodgement to guardian allocation decreased significantly from 46.5 to 22.9 days, halving the average time hospital-based patients spend waiting for a guardian (difference -23.55 days, two-sample t(154) = -6.575, P < 0.0001, 95% confidence interval [-30.65, -16.48].). Mean total length of stay decreased from 163.2 to 148.5 days. The estimated value of the reduction in allocation wait time was A$15473 per patient, or A$5 of resources released per A$1 spent on increased staffing. Conclusions Direction of a small amount of resources from health services to staff within OPA appears to have created much greater savings for the health services involved. The pilot program has reduced the period of time vulnerable patients spend waiting in hospital for a guardian. What is known about the topic? Guardianship resources are under increasing stress, with demand outstripping funding and hospital-based applicants deprioritised due to assumptions of lower risk, leading to extensive wait times for guardian allocation. What does this paper add? The paper quantifies the impact of greater guardianship resourcing on access to both guardianship and healthcare resources, highlighting benefits for vulnerable patient groups, healthcare system sustainability and access to both guardianship and healthcare resources for the broader community. What are the implications for clinicians? Improving patient flow through healthcare systems may involve allocating resources to services that are managed outside the healthcare system where 'bottlenecks', such as wait times for guardian allocation, have been identified.

The Balance Intensity Scales for Therapists and Exercisers Measure Balance Exercise Intensity in Older Adults: Initial Validation Using Rasch Analysis

BACKGROUND

The Balance Intensity Scales (BIS) have been developed to measure the intensity of balance exercise in older adults.

OBJECTIVE

The objective was to determine whether the BIS for therapists (BIS-T) and for exercisers (BIS-E) are unidimensional measures of balance exercise intensity, able to be refined using the Rasch model into a hierarchical item order, and appropriately targeted for the older adult population with a variety of diagnoses in a range of exercise testing settings.

DESIGN

This was a scale development study using a pragmatic mixed-methods approach.

METHODS

Older adult exercisers (n = 108) and their therapists (n = 33) were recruited from a large metropolitan health service and rated balance exercise tasks on the BIS-T and BIS-E in a single session.

RESULTS

Scores on both the BIS items and global effort ratings for therapists and exercisers had good correlation and demonstrated unidimensionality. The BIS-T and BIS-E demonstrated a hierarchical distribution of items that fit the Rasch model. The Person Separation Index was moderate (0.62) for the BIS-T but poor (0.33) for the BIS-E.

LIMITATIONS

The limitations were that therapists in this study underprescribed high-intensity balance tasks.

CONCLUSIONS

Initial validation of the BIS-T and the BIS-E demonstrated that these scales can be used for the measurement of balance exercise intensity in older adult populations. The BIS-T items and global effort ratings are recommended for use by therapists, and the global effort ratings are recommended for use by exercisers. Ongoing validation of both scales using high-intensity balance task ratings and different populations of older adults is recommended.

Falls After Hospital Discharge: A Randomized Clinical Trial of Individualized Multimodal Falls Prevention Education

BACKGROUND

Older people are at high risk of falls after hospital discharge. The study aimed to evaluate the effect of providing individualized falls prevention education in addition to usual care on falls rates in older people after hospital discharge compared to providing a social intervention in addition to usual care.

METHODS

A randomized clinical trial at three hospitals in Western Australia: participants followed for 6 months after discharge. Baseline and outcomes measured by assessors masked to group allocation. Participants: aged 60 years and over, admitted for rehabilitation. Eligibility included: cognitively able to undertake education (Abbreviated mental test score >7/10). Intervention: tailored education comprising patient video and workbook, structured discussion and goal setting led by trained therapist. Main outcomes: falls in the 6 months after discharge; proportion of participants sustaining one or more falls.

RESULTS

There were 382 (194 intervention; 188 control) participants (mean age 77.7 [SD 8.7] years). There were 378 falls (fall rate per 1,000 patient-days, 5.9 intervention; 5.9 control) reported by 164 (42.9%) participants in the 6 months following hospital discharge; 188 (49.7%) of these falls were injurious. There were no significant differences in falls rates between intervention and control groups: (adjusted IRR, 1.09; 95% CI [0.78 to 1.52]) or the proportion of participants who fell once or more (adjusted OR, 1.37; 95% CI [0.90 to 2.07]).

CONCLUSIONS

Providing individualized falls prevention education prior to discharge did not reduce falls at home after discharge. Further research is warranted to investigate how to reduce falls during this high-risk transition period.

Exploring purpose-designed audio-visual falls prevention messages on older people's capability and motivation to prevent falls

The number of falls and fall-associated injury rates among older people continues to rise worldwide. Increased efforts to influence older people's falls prevention behaviour are needed. A two-phase exploratory community-based participatory study was conducted in Western Australia. First, three prototype audio-visual (AV) falls prevention messages were designed collaboratively with six older people. Second, the messages' effect on community-dwelling older people's knowledge, awareness and motivation to take action regarding falls prevention was explored using focus groups. Data were analysed using thematic analysis to explore participants' responses to the messages. The participants' (n = 54) perspectives on the AV messages varied widely and stereotypes of ageing appeared to influence these. The presented falls facts (including falls epidemiology statistics) increased some participants' falls risk awareness and falls prevention knowledge. Other participants felt ready-to-use falls prevention information was lacking. Some expressed positive emotions or a personal connection to the messages and suggested the messages helped reduce ageing-related stigma. Strongly opposing viewpoints suggested that other participants identified implicit negative messages about ageing, which reduced their motivation with the messages. Suggestions to improve the message persuasiveness included adding more drama and tailoring messages to appeal to multiple age groups. Overall, the AV falls prevention messages designed in collaboration with older people elicited a divergent range of positive and negative perspectives from their peers, which was conceptualised by the overarching theme 'we all look at things different ways'. Opinions differed regarding whether the messages would appeal to older people. Public campaigns targeting falls prevention should be designed and tailored towards older peoples' differing perspectives about ageing.

Assessing the impact of diet, exercise and the combination of the two as a treatment for OSA: A systematic review and meta-analysis

This study aimed to provide an updated systematic review and meta-analysis of randomized controlled trials (RCT) investigating the effectiveness of lifestyle interventions on weight loss and the impact on the severity of obstructive sleep apnoea (OSA). A systematic search of five databases between 1980 and May 2018 was used to identify all RCT which employed a lifestyle intervention (i.e. diet-only, exercise-only or combination of the two) aiming to reduce the severity of OSA (assessed using the apnoea-hypopnoea index (AHI)). Random-effects meta-analyses followed by meta-regression were conducted. Ten RCT involving 702 participants (Intervention group: n = 354; Control group: n = 348) were assessed in two meta-analyses. The weighted mean difference in AHI (-8.09 events/h, 95% CI: -11.94 to -4.25) and body mass index (BMI, -2.41 kg/m² , 95% CI: -4.09 to -0.73) both significantly favoured lifestyle interventions over control arms. Subgroup analyses demonstrated that all interventions were associated with reductions in the AHI, but only the diet-only interventions were associated with a significant reduction in BMI. No association was found between the reduction in AHI or BMI and the length of the intervention, or with baseline AHI and BMI levels. All lifestyle interventions investigated appear effective for improving OSA severity and should be an essential component of treatment for OSA. Future research should be directed towards identifying subgroups likely to reap greater treatment benefits as well as other therapeutic benefits provided by these interventions.

A novel counterbalanced implementation study design: methodological description and application to implementation research

Background

Implementation research is increasingly being recognised for optimising the outcomes of clinical practice. Frequently, the benefits of new evidence are not implemented due to the difficulties applying traditional research methodologies to implementation settings. Randomised controlled trials are not always practical for the implementation phase of knowledge transfer, as differences between individual and organisational readiness for change combined with small sample sizes can lead to imbalances in factors that impede or facilitate change between intervention and control groups. Within-cluster repeated measure designs could control for variance between intervention and control groups by allowing the same clusters to receive a sequence of conditions. Although in implementation settings, they can contaminate the intervention and control groups after the initial exposure to interventions. We propose the novel application of counterbalanced design to implementation research where repeated measures are employed through crossover, but contamination is averted by counterbalancing different health contexts in which to test the implementation strategy.

Methods

In a counterbalanced implementation study, the implementation strategy (independent variable) has two or more levels evaluated across an equivalent number of health contexts (e.g. community-acquired pneumonia and nutrition for critically ill patients) using the same outcome (dependent variable). This design limits each cluster to one distinct strategy related to one specific context, and therefore does not overburden any cluster to more than one focussed implementation strategy for a particular outcome, and provides a ready-made control comparison, holding fixed. The different levels of the independent variable can be delivered concurrently because each level uses a different health context within each cluster to avoid the effect of treatment contamination from exposure to the intervention or control condition.

Results

An example application of the counterbalanced implementation design is presented in a hypothetical study to demonstrate the comparison of ‘video-based’ and ‘written-based’ evidence summary research implementation strategies for changing clinical practice in community-acquired pneumonia and nutrition in critically ill patient health contexts.

Conclusion

A counterbalanced implementation study design provides a promising model for concurrently investigating the success of research implementation strategies across multiple health context areas such as community-acquired pneumonia and nutrition for critically ill patients.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0896-0) contains supplementary material, which is available to authorized users.

The FOOTPATH study: protocol for a multicentre, participant- and assessor-blind, parallel group randomised clinical trial of foot orthoses for patellofemoral osteoarthritis

INTRODUCTION

Patellofemoral (PF) osteoarthritis (OA) is a common and burdensome subgroup of knee OA, with very little evidence for effective treatments. Prefabricated foot orthoses are an affordable and accessible intervention that have been shown to reduce PF pain in younger adults. Similarities between PF pain and PFOA, as well as our pilot work, suggest that foot orthoses may also be an effective intervention for PFOA. The primary objective of this study is to compare the 3 month efficacy of prefabricated foot orthoses and flat shoe inserts in people with PFOA, on knee pain severity.

METHODS AND ANALYSIS

The FOOTPATH Study (FOot OrThoses for PAtellofemoral osteoarTHritis) is a multicentre, randomised, participant- and assessor-blinded superiority trial with two parallel groups, a 3 month observation period (pre-randomisation) and 12 month follow-up. 160 participants with a clinical diagnosis of PFOA will be recruited from three sites in Australia, and randomised to one of two groups (prefabricated foot orthoses or flat shoe inserts). The primary outcome is worst knee pain severity during a self-nominated aggravating activity in the previous week (100 mm visual analogue scale) at 3 months, with a secondary endpoint at 12 months. Secondary outcomes include global rating of change, symptoms, function, health-related quality of life, kinesiophobia, self-efficacy and use of co-interventions for knee pain. Blinded, intention-to-treat analyses of primary and secondary patient-reported outcomes will be performed, as well as economic analyses.

ETHICS AND DISSEMINATION

Ethical approval has been granted by La Trobe University's Human Ethics Committee and The University of Queensland's Medical Research Ethics Committee. Study outcomes will be disseminated via peer-reviewed journals, conference presentations targeting a range of healthcare disciplines and an open access website with clinician resources.

TRIAL REGISTRATION NUMBER

ANZCTRN12617000385347; Pre-results.