Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system

Effects of leisure-time physical activity interventions on frailty-related characteristics of frail older adults in long-term care: a systematic review

Background: The proportion of frailty in older adults is increasing in many countries. Demand for institutional long-term care followed by an increasing globally. Aims: The effects of leisure-time physical activity (LTPA) interventions on frail older adults in long-term care facilities (LTCFs) of randomized controlled trials. Design: A literature searches of the published articles indexed in CINAHL, MEDLINE, PsycINFO, ProQuest, and Google Scholar between 2000 and 2017 was conducted. Methods: The inclusion criteria were divided into four sections: (1) design: randomized controlled trials; (2) sample population: LTCF adults aged 60 years or over with frailty; (3) intervention: LTPA; and (4) body composition: physical, functional or neuropsychological tests as either the primary or the secondary outcomes. Results: Three main themes were identified (the particular monitor, intervention duration and outcome measurement dimensions). Impact statement and conclusions: LTPA interventions effectively improved the physical performance and body composition of frail older adults in LTCFs. Nevertheless, an optimal combination of intensity, duration and frequency is crucial.

Sharing knowledge of falls prevention for people with dementia: insights for community care practice

People living with dementia (PLWD) fall more frequently, with more adverse consequences, than general community-dwelling older people; however, falls prevention evidence for PLWD is limited. Increased success of falls prevention strategies for PLWD may rely on tailored interventions to address dementia-specific risk factors. The Australian person-centred care environment highlights the need to better understand sharing of falls prevention knowledge between clients, carers and health professionals. This study aims to examine knowledge of falls prevention for PLWD among community care health professionals (CCHPs) and explore effectiveness of an action-research approach to enhance falls prevention practice. Consecutive action-research sessions were conducted with four groups of Australian multidisciplinary CCHPs (n=18), including a knowledge survey of CCHPs, followed by implementation of action plans. Thematic analysis of the transcribed discussion was undertaken. Results showed limited knowledge and understanding of evidence-based falls prevention strategies, but small incremental changes made by CCHPs through action research offered insights into enhancing knowledge and awareness. Appropriate professional development for community care health professionals is needed to support falls prevention for PLWD, along with associated organisational changes, to ensure knowledge is adequate.

Integrated solutions for sustainable fall prevention in primary care, the iSOLVE project: a type 2 hybrid effectiveness-implementation design

Background

Despite strong evidence giving guidance for effective fall prevention interventions in community-residing older people, there is currently no clear model for engaging general medical practitioners in fall prevention and routine use of allied health professionals in fall prevention has been slow, limiting widespread dissemination. This protocol paper outlines an implementation-effectiveness study of the Integrated Solutions for Sustainable Fall Prevention (iSOLVE) intervention which has developed integrated processes and pathways to identify older people at risk of falls and engage a whole of primary care approach to fall prevention.

Methods/design

This protocol paper presents the iSOLVE implementation processes and change strategies and outlines the study design of a blended type 2 hybrid design. The study consists of a two-arm cluster randomized controlled trial in 28 general practices and recruiting 560 patients in Sydney, Australia, to evaluate effectiveness of the iSOLVE intervention in changing general practitioner fall management practices and reducing patient falls and the cost effectiveness from a healthcare funder perspective. Secondary outcomes include change in medications known to increase fall risk. We will simultaneously conduct a multi-methodology evaluation to investigate the workability and utility of the implementation intervention. The implementation evaluation includes in-depth interviews and surveys with general practitioners and allied health professionals to explore acceptability and uptake of the intervention, the coherence of the proposed changes for those in the work setting, and how to facilitate the collective action needed to implement changes in practice; social network mapping will explore professional relationships and influences on referral patterns; and, a survey of GPs in the geographical intervention zone will test diffusion of evidence-based fall prevention practices. The project works in partnership with a primary care health network, state fall prevention leaders, and a community of practice of fall prevention advocates.

Discussion

The design is aimed at providing clear direction for sustainability and informing decisions about generalization of the iSOLVE intervention processes and change strategies. While challenges exist in hybrid designs, there is a potential for significant outcomes as the iSOLVE pathways project brings together practice and research to collectively solve a major national problem with implications for policy service delivery.

Trial registration

Australian New Zealand Clinial Trials Registry ACTRN12615000401550

Evaluating a clinical practice intervention to promote delivery of salbutamol by metered-dose inhalers with holding chambers in a pediatric emergency department

OBJECTIVE

The primary objective of this study was to quantify the impact of a clinical practice intervention to promote the delivery of salbutamol by metered-dose inhaler (MDI) in a pediatric emergency department (PED). A secondary objective was to retrospectively document the components of the intervention.

METHODS

PED inventory data for salbutamol inhalation solution (nebules), MDIs, and holding chambers were obtained from the pharmacy department. Patient data were obtained from the hospital's decision support unit. Interrupted time series analysis was used to evaluate trends in salbutamol inventory data, patient triage acuity, and hospital admissions from January 1, 2003, to May 31, 2010. Interviews and administrative documents were used to identify components of the intervention, which began in 2006.

RESULTS

There was a 1,215% increase in the proportion of salbutamol delivered as MDIs compared to total inhaled salbutamol (MDI plus nebulization solution) following the intervention (95% CI 1,032% to 1,396%, p < 0.001). Increases in salbutamol MDI use were associated with the implementation of an institution-specific asthma care map. A relative decrease of 32% in the hospital admission rate (absolute -7.25%: 95% CI -8.31 to -6.19, p < 0.001) was associated with the change in salbutamol MDI use and the use of the asthma care map.

CONCLUSIONS

A multifaceted intervention, designed and implemented by local PED clinical leaders, resulted in a pronounced change in salbutamol inhalation practice, with an associated decrease in admission rates. This intervention demonstrated many of the criteria for successful health system change. Findings from this research may be contextualized to inform change elsewhere.

Sustainability of community-based fall prevention programs: a systematic review

BACKGROUND

Fall prevention programs may be implemented but not sustained. We conducted a systematic review to identify any theories, models, frameworks, influencing factors or interventions for sustaining fall prevention programs in the community.

METHODS

Peer-reviewed publications describing, investigating, or evaluating program sustainability were accessed. A narrative review was conducted to compare and synthesize study findings.

RESULTS

Nineteen publications were included. Three conceptual frameworks were identified describing how programs may be better sustained. While ongoing financial support and the participation of older people were commonly reported influences, other factors specific to the type of program and setting were also reported. Planning, training, and collaboration between program stakeholders may facilitate sustainable programs.

IMPACT ON INDUSTRY

Organizations can use these findings when planning for sustainable programs. However more robust empirical studies are needed to confirm the value of conceptual frameworks, the critical factors and most effective interventions for sustaining community-based fall prevention programs.

[Implementation of a diabetes disease management program in Switzerland: patients' and healthcare professionals' point of view]

BACKGROUND

A reorganization of healthcare systems is required to meet the challenge of the increasing prevalence of chronic diseases, e.g. diabetes. In North-America and Europe, several countries have thus developed national or regional chronic disease management programs. In Switzerland, such initiatives have only emerged recently. In 2010, the canton of Vaud set up the "Diabetes Cantonal Program", within the framework of which we conducted a study designed to ascertain the opinions of both diabetic patients and healthcare professionals on the elements that could be integrated into this program, the barriers and facilitators to its development, and the incentives that could motivate these actors to participate.

METHODS

We organized eight focus-groups: one with diabetic patients and one with healthcare professionals in the four sanitary areas of the canton of Vaud. The discussions were recorded, transcribed and submitted to a thematic content analysis.

RESULTS

Patients and healthcare professionals were rather in favour of the implementation of a cantonal program, although patients were more cautious concerning its necessity. All participants envisioned a set of elements that could be integrated to this program. They also considered that the program could be developed more easily if it were adapted to patients' and professionals' needs and if it used existing structures and professionals. The difficulty to motivate both patients and professionals to participate was mentioned as a barrier to the development of this program however. Quality or financial incentives could therefore be created to overcome this potential problem.

CONCLUSION

The identification of the elements to consider, barriers, facilitators and incentives to participate to a chronic disease management program, obtained by exploring the opinions of patients and healthcare professionals, should favour its further development and implementation.

Effects of a complex intervention on fall risk in the general practitioner setting: a cluster randomized controlled trial

PURPOSE

To study the feasibility of first, reaching functionally declined, but still independent older persons at risk of falls through their general practitioner (GP) and second, to reduce their physiological and psychological fall risk factors with a complex exercise intervention. We investigated the effects of a 16-week exercise intervention on physiological (function, strength, and balance) and psychological (fear of falling) outcomes in community-dwelling older persons in comparison with usual care. In addition, we obtained data on adherence of the participants to the exercise program.

METHODS

Tests on physical and psychological fall risk were conducted at study inclusion, and after the 16-week intervention period in the GP office setting. The 16-week intervention included progressive and challenging balance, gait, and strength exercise as well as changes to behavioral aspects. To account for the hierarchical structure in the chosen study design, with patients nested in GPs and measurements nested in patients, a three-level linear mixed effects model was determined for analysis.

RESULTS

In total, 33 GPs recruited 378 participants (75.4% females). The mean age of the participants was 78.1 years (standard deviation 5.9 years). Patients in the intervention group showed an improvement in the Timed-Up-and-Go-test (TUG) that was 1.5 seconds greater than that showed by the control group, equivalent to a small to moderate effect. For balance, a relative improvement of 0.8 seconds was accomplished, and anxiety about falls was reduced by 3.7 points in the Falls Efficacy Scale-International (FES-I), in the intervention group relative to control group. In total, 76.6% (N = 170) of the intervention group participated in more than 75% the supervised group sessions.

CONCLUSION

The strategy to address older persons at high risk of falling in the GP setting with a complex exercise intervention was successful. In functionally declined, community-dwelling, older persons a complex intervention for reducing fall risks was effective compared with usual care.

Developing a practice-based research network by integrating quality improvement: challenges and ingredients for success

Improving patient outcomes in community-based settings is the goal of both the Clinical Translational Science Award program and practice-based quality improvement (QI) programs. Given this common goal, integrating QI and outcomes research is a promising strategy for developing, implementing, and evaluating clinical interventions. This article describes the challenges and strengths illuminated by the conduct of a combined research/QI study in a nascent practice-based research network. Challenges include research's exclusion of clinic patients who might benefit from the intervention; QI programs' less uniform approach to intervention implementation; and the need for both academic and clinically relevant products and publications. A major strength is the increased likelihood of both engaging clinical practices in research and developing successful clinical interventions. Required elements for success include identification of enthusiastic clinical research "champions," involvement of researchers with clinical experience, and adequate funding to support both research and clinical resources and dissemination. Combined Ql/research projects in the practice-based research environment have the potential to improve and shorten the cycle from good idea to improved clinical outcomes in real-world settings.

Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: translating aging research into clinical geriatrics

Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the program's influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.

Knowledge translation for falls prevention: the view from Canada

Researchers have now conclusively demonstrated that many falls in older adults can be prevented, and that the interventions can produce cost-savings. Because most falls are multifactorial, falls prevention interventions can involve several approaches delivered by numerous health care professions in multiple settings. These complexities may make knowledge translation (KT) more challenging than with simpler interventions for specific diseases. After describing these complexities and reviewing the evidence base for falls prevention, this paper examines the few published demonstrations of KT in falls prevention. It continues with a description of the visibility and accessibility of falls prevention Clinical Practice Guidelines (CPGs) on the websites of four key Canadian health professional associations: nurses, occupational therapists, physical therapists, and physicians. The paper concludes with a review of published studies of KT in falls prevention in Canadian health care settings, including research on care or treatment gaps in falls prevention and the uptake of CPGs.

IMPACT ON INDUSTRY

Those in the long term care and hospital industries may use the findings when considering fall prevention programs. This paper does not cover occupational falls, and participants in the referenced studies will be past conventional retirement age.

Formative evaluation of the telecare fall prevention project for older veterans

Background

Fall prevention interventions for community-dwelling older adults have been found to reduce falls in some research studies. However, wider implementation of fall prevention activities in routine care has yielded mixed results. We implemented a theory-driven program to improve care for falls at our Veterans Affairs healthcare facility. The first project arising from this program used a nurse advice telephone line to identify patients' risk factors for falls and to triage patients to appropriate services. Here we report the formative evaluation of this project.

Methods

To evaluate the intervention we: 1) interviewed patient and employee stakeholders, 2) reviewed participating patients' electronic health record data and 3) abstracted information from meeting minutes. We describe the implementation process, including whether the project was implemented according to plan; identify barriers and facilitators to implementation; and assess the incremental benefit to the quality of health care for fall prevention received by patients in the project. We also estimate the cost of developing the pilot project.

Results

The project underwent multiple changes over its life span, including the addition of an option to mail patients educational materials about falls. During the project's lifespan, 113 patients were considered for inclusion and 35 participated. Patient and employee interviews suggested support for the project, but revealed that transportation to medical care was a major barrier in following up on fall risks identified by nurse telephone triage. Medical record review showed that the project enhanced usual medical care with respect to home safety counseling. We discontinued the program after 18 months due to staffing limitations and competing priorities. We estimated a cost of $9194 for meeting time to develop the project.

Conclusions

The project appeared feasible at its outset but could not be sustained past the first cycle of evaluation due to insufficient resources and a waning of local leadership support due to competing national priorities. Future projects will need both front-level staff commitment and prolonged high-level leadership involvement to thrive.

Secondary prevention after coronary artery bypass graft surgery: findings of a national randomized controlled trial and sustained society-led incorporation into practice

BACKGROUND

Despite evidence supporting the use of aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering therapies in eligible patients, adoption of these secondary prevention measures after coronary artery bypass grafting has been inconsistent. We sought to rigorously test on a national scale whether low-intensity continuous quality improvement interventions can be used to speed secondary prevention adherence after coronary artery bypass grafting.

METHODS AND RESULTS

A total of 458 hospitals participating in the Society of Thoracic Surgeons National Cardiac Database and treating 361 328 patients undergoing isolated coronary artery bypass grafting were randomized to either a control or an intervention group. The intervention group received continuous quality improvement materials designed to influence the prescription of the secondary prevention medications at discharge. The primary outcome measure was discharge prescription rates of the targeted secondary prevention medications at intervention versus control sites, assessed by measuring preintervention and postintervention site differences. Prerandomization treatment patterns and baseline data were similar in the control (n=234) and treatment (n=224) groups. Individual medication use and composite adherence increased over 24 months in both groups, with a markedly more rapid rate of adherence uptake among the intervention hospitals and a statistically significant therapy hazard ratio in the intervention versus control group for all 4 secondary prevention medications.

CONCLUSIONS

Provider-led, low-intensity continuous quality improvement efforts can improve the adoption of care processes into national practice within the context of a medical specialty society infrastructure. The findings of the present trial have led to the incorporation of study outcome metrics into a medical society rating system for ongoing quality improvement.