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Amstutz A, Schönenberger CM, Speich B, Griessbach A, Schwenke JM, Glasstetter J, James S, Verkooijen HM, Nickolls B, Relton C, Hemkens LG, Chammartin F, Gerber F, Labhardt ND, Schandelmaier S, Briel M. Characteristics, consent patterns, and challenges of randomized trials using the Trials within Cohorts (TwiCs) design - A scoping review. J Clin Epidemiol 2024; 174:111469. [PMID: 39032590 DOI: 10.1016/j.jclinepi.2024.111469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 06/07/2024] [Accepted: 07/15/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES Trials within Cohorts (TwiCs) is a pragmatic design approach that may overcome frequent challenges of traditional randomized trials such as slow recruitment, burdensome consent procedures, or limited external validity. This scoping review aims to identify all randomized controlled trials using the TwiCs design and to summarize their design characteristics, ways to obtain informed consent, output, reported challenges and mitigation strategies. STUDY DESIGN AND SETTING Systematic search of Medline, Embase, Cochrane, trial registries and citation tracking up to December 2022. TwiCs were defined as randomized trials embedded in a cohort with postrandomization consent for the intervention group and no specific postrandomization consent for the usual care control group. Information from identified TwiCs was extracted in duplicate from protocols, publications, and registry entries. We analyzed the information descriptively and qualitatively to highlight methodological challenges and solutions related to nonuptake of interventions and informed consent procedure. RESULTS We identified a total of 46 TwiCs conducted between 2005 and 2022 in 14 different countries by a handful of research groups. The most common medical fields were oncology (11/46; 24%), infectious diseases (8/46; 17%), and mental health (7/46; 15%). A typical TwiCs was investigator-initiated (46/46; 100%), publicly funded (36/46; 78%), and recruited outpatients (27/46; 59%). Excluding eight pilot trials, only 16/38 (42%) TwiCs adjusted their calculated sample size for nonuptake of the intervention, anticipating a median nonuptake of 25% (interquartile range 10%-32%) in the experimental arm. Seventeen TwiCs (45%) planned analyses to adjust effect estimates for nonuptake. Regarding informed consent, we observed three patterns: 1) three separate consents for cohort participation, randomization, and intervention (17/46; 37%); 2) combined consent for cohort participation and randomization and a separate intervention consent (10/46; 22%); and 3) consent only for cohort participation and intervention (randomization consent not mentioned; 19/46; 41%). CONCLUSION Existing TwiCs are globally scattered across a few research groups covering a wide range of medical fields and interventions. Despite the potential advantages, the number of TwiCs remains small. The variability in consent procedures and the possibility of substantial nonuptake of the intervention warrants further research to guide the planning, implementation, and analysis of TwiCs.
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Affiliation(s)
- Alain Amstutz
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Oslo Center for Biostatistics and Epidemiology, Oslo University Hospital, University of Oslo, Oslo, Norway; Bristol Medical School, University of Bristol, Bristol, UK
| | - Christof M Schönenberger
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Benjamin Speich
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandra Griessbach
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes M Schwenke
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jan Glasstetter
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sophie James
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Beverley Nickolls
- Wolfson Institute of Population Health, Queen Mary University, London, UK
| | - Clare Relton
- Wolfson Institute of Population Health, Queen Mary University, London, UK
| | - Lars G Hemkens
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Frédérique Chammartin
- International Clinical Health Services Research Unit, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Felix Gerber
- International Clinical Health Services Research Unit, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Niklaus D Labhardt
- International Clinical Health Services Research Unit, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Schandelmaier
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; School of Public Health, University College Cork, Cork, Ireland; MTA-PET Lendület "Momentum" Evidence Group, Medical School, University of Pécs, Pécs, Hungary
| | - Matthias Briel
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Canada
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Mohr S, Müller C, Hildebrand F, Laubach M. [Fall prevention in old people through occupational therapy home assessment, consultation and modification: a process outline]. Z Gerontol Geriatr 2023; 56:408-414. [PMID: 36070010 PMCID: PMC10406676 DOI: 10.1007/s00391-022-02103-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
Falls occur frequently in old people and are associated with relevant short-term and long-term trauma sequelae. Particularly in the light of demographic change, preventive measures such as falls prevention are increasingly gaining in importance. Occupational therapy home assessments enable the evaluation of external and behavioral risk factors for falls in the context of environmental prevention. Environmental prevention is an effective measure in preventing morbidity and mortality related to falls in old people and the increase in healthcare costs associated with falls. Occupational therapy home assessments effectively reduce fall risk and fall rate among older people at risk of falling and can be implemented in the context of existing regulatory frameworks. The aim of this overview is to illustrate the optimal process of home assessment and adaptation for patients at risk of falling by general practitioners, orthopedic surgeons and occupational therapists.
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Affiliation(s)
- Sara Mohr
- Amsterdam University of Applied Sciences, Amsterdam, Niederlande
- Ergo Unterwegs GbR, Bruchsal, Deutschland
| | - Christian Müller
- SHG-Bildung, Fachschule für Ergotherapie, Saarbrücken, Deutschland
| | - Frank Hildebrand
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Markus Laubach
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland.
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Lektip C, Chaovalit S, Wattanapisit A, Lapmanee S, Nawarat J, Yaemrattanakul W. Home hazard modification programs for reducing falls in older adults: a systematic review and meta-analysis. PeerJ 2023; 11:e15699. [PMID: 37489124 PMCID: PMC10363339 DOI: 10.7717/peerj.15699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/14/2023] [Indexed: 07/26/2023] Open
Abstract
Objective This study aims to assess the effect of home modification in preventing falls in older adults. Methods A systematic review and meta-analysis of randomized studies were performed. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered prospectively. Five electronic databases were systematically searched for related articles. The titles and abstracts of the articles found using the key search phrases-home modification and falling-were screened using inclusion and exclusion criteria. The Cochrane risk of bias tool was used to evaluate the studies' methodology. Results A total of 12 trials were included. A meta-analysis was conducted using 10 studies with n = 1, 960 participants showing a clinically meaningful 7% reduction in falls (risk ratio = 0.93; 0.87-1). Conclusions Falls can be significantly reduced with the use of home modification interventions that are thorough, well-focused, have an environmental-fit perspective, and have adequate follow-up.
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Affiliation(s)
- Charupa Lektip
- Movement Sciences and Exercise Research Center, Walailak University, Nakhon Si Thammarat, Thailand
- Department of Physical Therapy, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat, Thailand
| | - Sirawee Chaovalit
- Department of Physical Therapy, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Apichai Wattanapisit
- School of Medicine, Walailak University, Nakhon Si Thammarat, Thailand
- Walailak University Hospital, Nakhon Si Thammarat, Thailand
| | - Sarawut Lapmanee
- Department of Basic Medical Sciences, Faculty of Medicine, Siam University, Bangkok, Thailand
| | - Jiraphat Nawarat
- Movement Sciences and Exercise Research Center, Walailak University, Nakhon Si Thammarat, Thailand
- Department of Physical Therapy, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat, Thailand
| | - Weeranan Yaemrattanakul
- Department of Physical Therapy, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Clemson L, Stark S, Pighills AC, Fairhall NJ, Lamb SE, Ali J, Sherrington C. Environmental interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2023; 3:CD013258. [PMID: 36893804 PMCID: PMC9998238 DOI: 10.1002/14651858.cd013258.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND Falls and fall-related injuries are common. A third of community-dwelling people aged over 65 years fall each year. Falls can have serious consequences including restricting activity or institutionalisation. This review updates the previous evidence for environmental interventions in fall prevention. OBJECTIVES To assess the effects (benefits and harms) of environmental interventions (such as fall-hazard reduction, assistive technology, home modifications, and education) for preventing falls in older people living in the community. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, other databases, trial registers, and reference lists of systematic reviews to January 2021. We contacted researchers in the field to identify additional studies. SELECTION CRITERIA We included randomised controlled trials evaluating the effects of environmental interventions (such as reduction of fall hazards in the home, assistive devices) on falls in community-residing people aged 60 years and over. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. MAIN RESULTS We included 22 studies from 10 countries involving 8463 community-residing older people. Participants were on average 78 years old, and 65% were women. For fall outcomes, five studies had high risk of bias and most studies had unclear risk of bias for one or more risk of bias domains. For other outcomes (e.g. fractures), most studies were at high risk of detection bias. We downgraded the certainty of the evidence for high risk of bias, imprecision, and/or inconsistency. Home fall-hazard reduction (14 studies, 5830 participants) These interventions aim to reduce falls by assessing fall hazards and making environmental safety adaptations (e.g. non-slip strips on steps) or behavioural strategies (e.g. avoiding clutter). Home fall-hazard interventions probably reduce the overall rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.61 to 0.91; 12 studies, 5293 participants; moderate-certainty evidence); based on a control group risk of 1319 falls per 1000 people a year, this is 343 (95% CI 118 to 514) fewer falls. However, these interventions were more effective in people who are selected for higher risk of falling, with a reduction of 38% (RaR 0.62, 95% CI 0.56 to 0.70; 9 studies, 1513 participants; 702 (95% CI 554 to 812) fewer falls based on a control risk of 1847 falls per 1000 people; high-certainty evidence). We found no evidence of a reduction in rate of falls when people were not selected for fall risk (RaR 1.05, 95% CI 0.96 to 1.16; 6 studies, 3780 participants; high-certainty evidence). Findings were similar for the number of people experiencing one or more falls. These interventions probably reduce the overall risk by 11% (risk ratio (RR) 0.89, 95% CI 0.82 to 0.97; 12 studies, 5253 participants; moderate-certainty evidence); based on a risk of 519 per 1000 people per year, this is 57 (95% CI 15 to 93) fewer fallers. However, for people at higher risk of falling, we found a 26% decrease in risk (RR 0.74, 95% CI 0.65 to 0.85; 9 studies, 1473 participants), but no decrease for unselected populations (RR 0.99, 95% CI 0.92 to 1.07; 6 studies, 3780 participants) (high-certainty evidence). These interventions probably make little or no important difference to health-related quality of life (HRQoL) (standardised mean difference 0.09, 95% CI -0.10 to 0.27; 5 studies, 1848 participants; moderate-certainty evidence). They may make little or no difference to the risk of fall-related fractures (RR 1.00, 95% 0.98 to 1.02; 2 studies, 1668 participants), fall-related hospitalisations (RR 0.96, 95% CI 0.87 to 1.06; 3 studies, 325 participants), or in the rate of falls requiring medical attention (RaR 0.91, 95% CI 0.58 to 1.43; 3 studies, 946 participants) (low-certainty evidence). The evidence for number of fallers requiring medical attention was unclear (2 studies, 216 participants; very low-certainty evidence). Two studies reported no adverse events. Assistive technology Vision improvement interventions may make little or no difference to the rate of falls (RaR 1.12, 95% CI 0.84 to 1.50; 3 studies, 1489 participants) or people experiencing one or more falls (RR 1.09, 95% CI 0.79 to 1.50) (low-certainty evidence). We are unsure of the evidence for fall-related fractures (2 studies, 976 participants) and falls requiring medical attention (1 study, 276 participants) because the certainty of the evidence is very low. There may be little or no difference in HRQoL (mean difference 0.40, 95% CI -1.12 to 1.92) or adverse events (falls while switching glasses; RR 1.00, 95% CI 0.98 to 1.02) (1 study, 597 participants; low-certainty evidence). Results for other assistive technology - footwear and foot devices, and self-care and assistive devices (5 studies, 651 participants) - were not pooled due to the diversity of interventions and contexts. Education We are uncertain whether an education intervention to reduce home fall hazards reduces the rate of falls or the number of people experiencing one or more falls (1 study; very low-certainty evidence). These interventions may make little or no difference to the risk of fall-related fractures (RR 1.02, 95% CI 0.96 to 1.08; 1 study, 110 participants; low-certainty evidence). Home modifications We found no trials of home modifications that measured falls as an outcome for task enablement and functional independence. AUTHORS' CONCLUSIONS We found high-certainty evidence that home fall-hazard interventions are effective in reducing the rate of falls and the number of fallers when targeted to people at higher risk of falling, such as having had a fall in the past year and recently hospitalised or needing support with daily activities. There was evidence of no effect when interventions were targeted to people not selected for risk of falling. Further research is needed to examine the impact of intervention components, the effect of awareness raising, and participant-interventionist engagement on decision-making and adherence. Vision improvement interventions may or may not impact the rate of falls. Further research is needed to answer clinical questions such as whether people should be given advice or take additional precautions when changing eye prescriptions, or whether the intervention is more effective when targeting people at higher risk of falls. There was insufficient evidence to determine whether education interventions impact falls.
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Affiliation(s)
- Lindy Clemson
- Sydney School of Health Sciences, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia
| | - Susan Stark
- Participation, Environment and Performance Laboratory, Program in Occupational Therapy, Washington University, St Louis, MO, USA
| | - Alison C Pighills
- Mackay Institute of Research and Innovation, Mackay Hospital and Health Service, Mackay, Australia
- College of Healthcare Sciences, James Cook University, Townsville, Australia
| | - Nicola J Fairhall
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah E Lamb
- College of Medicine and Health , University of Exeter, Exeter, UK
| | - Jinnat Ali
- Faculty of Health Science, The University of Sydney, Sydney, Australia
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Sheth S, Cogle CR. Home Modifications for Older Adults: A Systematic Review. J Appl Gerontol 2023; 42:1151-1164. [PMID: 36655622 DOI: 10.1177/07334648231151669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
While ≧10,000 Americans turn 65 years old every day, only 10% of American homes are "aging ready." Unsafe homes can exacerbate disability, lead to falls, and increase the likelihood of hospitalization. With increased investments in home and community-based services, public health stakeholders are considering home modifications to promote successful aging. While several home modification models exist, there is significant heterogeneity between models and no consensus on critical features. PubMed, EMBASE, and Web of Science were reviewed and twelve randomized controlled trials of home modifications for older adults were identified and evaluated for model structure, reported outcomes, and risk of bias. Overall, occupational therapist-driven home modifications supplemented with clinical, physical activity, and/or behavioral components saw the greatest success. This systematic review discusses the components of these models, highlights particularly effective and frequently used features, and the practice and research needed to create effective next-generation home modification models which promote healthy longevity.
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Affiliation(s)
- Sohum Sheth
- College of Medicine, 12233University of Florida, Gainesville, FL, USA
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