How therapeutic relationships develop in group-based telehealth and their perceived impact on processes and outcomes of a complex intervention: a qualitative study

BACKGROUND

Therapeutic relationships are a key domain in healthcare delivery. While well-understood in in-person interventions, how therapeutic relationships develop in more complex contexts is unclear. This study aimed to understand (1) how therapeutic relationships are developed during the telehealth delivery of a group-based, complex intervention and (2) the perceived impact of these relationships on intervention processes, such as intervention delivery and engagement, and patient outcomes, such as patient safety and satisfaction.

METHODS

This qualitative study, nested within a randomised controlled trial, used an interpretivist approach to explore the perceptions of 25 participants (18 patients with shoulder pain and 7 clinicians) regarding developing therapeutic relationships in a group-based, complex intervention delivered via telehealth. Semi-structured interviews were conducted within 4 weeks of the telehealth intervention period and then analysed through in-depth, inductive thematic analysis.

RESULTS

We identified six themes: (1) 'Patients trust clinicians who demonstrate credibility, promoting the development of therapeutic relationships'; (2) 'Simple features and approaches shape the therapeutic relationship', including small talk, time spent together and social observation; (3) 'A sense of belonging and support fosters connections', facilitated by clinicians providing individualised attention within the group; (4) 'Developing therapeutic relationships can impact the delivery of core intervention components', reflecting challenges clinicians faced; (5) 'Therapeutic relationships can facilitate intervention engagement', through enhanced patient understanding and confidence and (6) 'Therapeutic relationships can contribute to patient safety and satisfaction', with patients feeling more comfortable reporting intervention-related issues.

CONCLUSIONS

Therapeutic relationships were developed during group-based telehealth sessions through a set of factors that may require additional skills and effort compared with in-person interactions. While these relationships have a perceived positive impact on intervention engagement and patient outcomes, clinicians need to find a balance between building relationships and delivering the telehealth intervention with fidelity.

TRIAL REGISTRATION NUMBER

ACTRN12621001650886.

Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: A systematic review and meta-analysis

BACKGROUND

There is a growing consensus to reduce the use of restrictive care practices in mental health settings to minimise the physical and psychological complications for patients. However, data regarding restrictive care practice use and factors contributing to variations in the proportion estimates has not previously been synthesised.

AIMS

This study aimed to synthesise evidence on (1) the pooled proportions of physical restraint, seclusion or chemical restraint in adult mental health inpatients and (2) sources of variability in these proportion estimates.

METHODS

Studies were identified from Scopus, MEDLINE, PsycINFO, Web of Science, Embase and CINAHL databases following the PRISMA 2020 guidelines. We conducted a meta-analysis of studies published in English language from 1 January 2010 to 15 August 2022. Binomial data were pooled using a random effect model, with 95% confidence intervals. Meta-regression was also computed to identify factors that may contribute to variations in the proportion estimates.

RESULTS

A total of 77 studies were included in this meta-analysis. The pooled prevalence of physical restraint, seclusion and chemical restraint was 14.4%, 15.8% and 25.7%, respectively. Data were heterogeneous across studies (I2  > 99%). Reporting practices and geographical locations contributed to the variability in the reported estimates of restrictive care practices, with studies from Asian countries reporting higher proportions.

CONCLUSION

There appear differences between geographical locations in the proportion of restrictive practices in mental health inpatients; however, this is complicated by how these prevalence data have been measured and defined. Consistency in the reporting of restrictive care practices in mental health is required to make valid comparisons between geographical regions, policy settings and practice innovations.

RELEVANCE TO CLINICAL PRACTICE

Efforts are needed to develop training programmes and policy changes to ensure consistency in defining and reporting of restrictive care practices in mental health facilities.

PATIENT/PUBLIC CONTRIBUTION

This is a systematic review that analysed data from previously published studies, and there was no patient/public contribution in this study.

PROTOCOL REGISTRATION

The protocol for this review has been registered to PROSPERO: CRD42022335167.

Comparison of Goal Achievement during an Early, Intensive Nutrition Intervention Delivered to People with Upper Gastrointestinal Cancer by Telephone Compared with Mobile Application

Objective

This study is aimed at exploring whether the mode of nutrition intervention delivery affected participant goal achievement in a three-arm randomised controlled trial of early and intensive nutrition intervention delivered to upper gastrointestinal cancer patients.

Methods

Newly diagnosed upper gastrointestinal cancer patients were recruited from four tertiary hospitals in Melbourne, Australia. Participants in the intervention groups received a regular nutrition intervention for 18 weeks from an experienced dietitian via telephone or mobile application (app) using behaviour change techniques to assist in goal achievement. Univariate and multiple regression models using STATA determined goal achievement, dose, and frequency of contact between groups. A p value <0.05 was considered statistically significant.

Results

The telephone group (n = 38) had 1.99 times greater frequency of contact with the research dietitian (95% CI: 1.67 to 2.36, p < 0.001) and 2.37 times higher frequency of goal achievement (95% CI: 1.1 to 5.11, p = 0.03) compared with the mobile app group (n = 36). The higher dose (RR 0.03) of intervention and more behaviour change techniques employed in the telephone group compared with the mobile app group increased participant goal achievement (95% CI: 0.01 to 0.04, p < 0.001). Discussion. Telephone nutrition intervention delivery led to a higher frequency of goal achievement compared to the mobile app intervention. There was also a higher number of behaviour change techniques employed which may have facilitated the greater goal achievement. Mobile app-based delivery may have poorer acceptance in this population with high levels of withdrawal. Practice Implications. We need to ensure that specifically designed technologies for our target populations are fit for purpose, efficacious, and acceptable to both patients and healthcare providers. This trial is registered with ACTRN12617000152325.

Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE): protocol for a helix-counterbalanced randomised controlled trial

INTRODUCTION

Clinical practice guidelines recommend against the routine use of psychotropic medications in residential aged care facilities (RACFs). Knowledge brokers are individuals or groups who facilitate the transfer of knowledge into practice. The objective of this trial is to evaluate the effectiveness and cost-effectiveness of using knowledge brokers to translate Australia's new Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia and in Residential Aged Care.

METHODS AND ANALYSIS

The Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial is a helix-counterbalanced randomised controlled trial. The 12-month trial will be conducted in up to 19 RACFs operated by four Australian aged care provider organisations in Victoria, New South Wales, Western Australia and Queensland. RACFs will be randomised to receive three levels of implementation strategies (knowledge broker service, pharmacist-led quality use of medications education activities and distribution of the Guidelines and supporting materials) across three medication contexts (antipsychotics, benzodiazepines and antidepressants). Implementation strategies will be delivered by an embedded on-site aged care pharmacist working at a system level across each participating RACF. All RACFs will receive all implementation strategies simultaneously but for different medication contexts. The primary outcome will be a composite dichotomous measure of 6-month RACF-level concordance with Guideline recommendations and good practice statements among people using antipsychotics, benzodiazepines and antidepressants for changed behaviours. Secondary outcomes will include proportion of residents with Guideline concordant use of antipsychotics, benzodiazepines and antidepressants measured at the RACF-level and proportion of residents with psychotropic medication use, hospitalisation, falls, falls with injury, polypharmacy, quality of life, activities of daily living, medication incidents and behavioural incidents measured at the RACF-level.

DISCUSSION

The EMBRACE trial investigates a novel guideline implementation strategy to improve the safe and effective use of psychotropic medications in RACFs. We anticipate that the findings will provide new information on the potential role of knowledge brokers for successful and cost-effective guideline implementation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623001141639. Registered 6 November 2023 - retrospectively registered, https://www.anzctr.org.au/TrialSearch.aspx .

Clinical innovation and scope of practice regulation: a case study of the Charlie Teo decision

The issue of regulation of scope of practice (SOP) has recently been highlighted through the high-profile case of New South Wales-based neurosurgeon, Mr Charles Teo and specifically the finding of 'unsatisfactory professional conduct' by the NSW Health Care Complaints Commission (HCCC) in Teo, Charles (2023) NSWMPSC 2 (12 July 2023). The HCCC decision went to two issues in Teo's practice: (1) his decision to perform a surgery not within the SOP of his profession [at 238]; and (2) his failure to gain patient informed consent for that surgery [at 245]. This paper explores the findings against Teo with respect to SOP and recommends a nuanced approach to the regulation of clinical innovation and SOP evolution.

Program Evaluation and Refinement of the "Safe Functional Home Exercise" Program for Improving Physical Activity in Older People with Dementia Who Receive Home Care

INTRODUCTION

People with dementia who receive home care have low levels of physical activity participation.

OBJECTIVES

To evaluate and refine a co-designed exercise program for home care clients with dementia, led by trained care support workers.

METHODS

An action research cycle whereby support workers, clients and carers (each n = 26) from the "Safe Functional Home Exercise" feasibility study were invited to complete an evaluation survey. Participants rated statements using Likert-style scales on (1) staff training, (2) staff confidence, (3) program support and (4) satisfaction. The participants could provide comments for situations that affected exercise performance, suggested improvements for staff training, program support and exercises. The co-design panel (original program designers) was reconvened to refine the exercise program.

RESULTS

Support workers (n = 19), clients (n = 15) and carers (n = 13) returned their surveys. Support workers (74-90%), carers (77-92%) and clients (100%) rated program support positively and were overall satisfied. Support workers (>80%) agreed that the training course was relevant and were confident in delivering the exercises to clients. Situations included "Covid isolation", the client's "poor medical condition" and "mood fluctuations" that made exercising difficult. Improvements included "making a client video" and "providing tips to motivate clients". The co-design panel modified the exercise program.

CONCLUSIONS

The "Safe Functional Home Exercise" program is the first exercise program co-designed for people with dementia. It is well accepted by support workers, people with dementia and carers. Utilising support workers to facilitate physical activity participation is potentially low-cost and scalable in home care. Future studies are needed to evaluate the refined program in home care.

Activin A level is associated with physical function in critically ill patients

BACKGROUND

Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels.

OBJECTIVES

The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital.

METHODS

Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU.

RESULTS

High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures.

CONCLUSIONS

Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness.

STUDY REGISTRATION

ACTRN12615000047594.

How can scope of practice be described and conceptualised in medical and health professions? A systematic review for scoping and content analysis

BACKGROUND

The term scope of practice (SOP) refers to the limits of a health professional's knowledge, skills and experience and reflects all tasks and activities they undertake within the context of their professional role. Inconsistency in definitions of SOP contributes to uncertainty and confusion regarding professional practice boundaries and potentially impacts societal access to safe, effective and efficient healthcare options. The aim of this paper is to understand the conceptual diversity that may exist in terminology used to describe medical, nursing/midwifery and allied health SOP within an Australian practice context exemplar.

METHODS

A systematic review for scoping and content analysis of SOP definitions and concepts, involving inductive thematic analysis and synthesis of published and grey literature.

RESULTS

The initial search strategy yielded 11,863 hits, of which 379 were suitable for inclusion. Data coding identified various SOP terms and definitions and the emergence of six, conceptual elements underpinning the theoretical construct. These were subsequently proposed as a preliminary conceptual model ('Solar') to explain how the six conceptual elements may be applied across various professions, clinical settings and jurisdictions to better understand and address current and evolving SOP issues.

CONCLUSION

The findings of this study highlight limited consistency in SOP definitions and terminology within a single jurisdiction, and the conceptual complexity of the underlying theoretical construct. Further research is required to build on the proposed 'Solar' conceptual model and create a universal SOP definition across jurisdictions, to enhance understanding of the importance of SOP to workforce policy, clinical governance, service models and patient outcomes.

Body composition changes and their relationship with obstructive sleep apnoea symptoms, severity: The Sleeping Well Trial

BACKGROUND & AIMS

Obstructive sleep apnoea (OSA) and obesity share a complex bi-directional relationship as location of body fat and changes in regional body composition may be more important for OSA improvement than changes in total body weight only. The aim of this study was to evaluate the impact of a 6-month weight loss intervention for adults newly diagnosed with moderate-severe OSA and obesity on regional body composition. The secondary aims evaluated the relationship between changes in OSA symptoms and severity and anthropometry and regional body composition during the first 12-months after commencing CPAP and explored differences in outcomes between males and females.

METHODS

Participants (n = 59) received CPAP overnight at home alongside a 6-month modified fasting intervention with 12-months follow up. Regional body composition was measured by Dual X-ray absorptiometry, (DXA) and anthropometry before and after the lifestyle intervention. OSA severity was measured using the apnoea hypopnea index via overnight polysomnography and OSA symptoms were measured using the Epworth Sleepiness scale.

RESULTS

Forty-seven adults (74% male) had complete measures available with a mean age of 50.0 y (SD 11.0) and BMI 34.1 kg/m2 (SD 5.0). Following the intervention average fat mass changed by -5.27 kg (5.36), p < 0.001) and visceral adipose tissue (-0.63 kg (0.67), p < 0.001) significantly decreased in males only with a maintenance of fat-free mass (mean -0.41 kg (1.80), p = 0.18). Females (n = 12) had significant decreases in waist circumference (mean -3.36 cm (3.18) p < 0.01), android lean (-0.12 kg (0.04), p < 0.05) and android total mass (-0.28 kg (0.39), p < 0.05) only. Regional body composition changes in males were positively associated with improvements in OSA severity (p < 0.01) but not OSA symptoms.

CONCLUSION

Improvements in regional body composition were seen in males only which were related to improvements in OSA severity but not OSA symptoms. Females may exhibit different OSA pathophysiology and may require different treatment approaches.

TRIAL REGISTRATION

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369975&isReview=trueAACTRN12616000203459 ACTRN12616000203459.

A Scalable Program for Improving Physical Activity in Older People with Dementia Including Culturally and Linguistically Diverse (CALD) Groups Who Receive Home Support: A Feasibility Study

Home care clients with dementia/cognitive impairment are typically functionally dependent and physically inactive. We pilot-tested a co-designed physical exercise program for its feasibility, safety, adherence and potential for benefits on physical activity, physical function, healthcare use and falls. Trained community care support workers delivered a 12-week home exercise program to clients with dementia/cognitive impairment, once weekly for 15 min during care shifts, supplemented by carers' supervision of exercises for 30 min, three times weekly. A physiotherapist provided fortnightly phone support to ensure safety and exercise progression. Baseline and Week 12 assessments using validated scales for physical activity, physical function, daily living independence, falls efficacy, quality of life, self-reported healthcare use, falls and sleep quality were undertaken. Differences were examined with regression analyses. Care support workers (n = 26) and client/carer dyads (n = 26 and 80.8% culturally and linguistically diverse) participated. Participants recorded adverse events/falls and exercises in dairies. Fifteen dyads completed the program. No falls/adverse events occurred with the exercises. The adherence rates against targets for exercise time completed and days in which exercise were undertaken for support workers were 137%/79.6%, and for client/carer dyads were 82%/104.8%, respectively. Physical activity participation, physical function and falls efficacy significantly improved at Week 12 compared to baseline. The feasibility, safety and adherence of the co-designed physical exercise program were demonstrated. Strategies to minimise dropouts in future effectiveness studies are required.

The Potential for Effect of a Six-Week Training Program for Gait Aid Use in Older People with Dementia with Unsteadiness of Gait: A Pilot Study

This study examined the potential for effect of a six-week gait aid training program for people with dementia on spatiotemporal gait outcomes, perception of use, and falls with gait aid use. The program utilised four 30-min physiotherapy home visits, scheduled at weeks 1/2/3/6, and was enhanced by carer-supervised practice. Falls and the physiotherapist's clinical judgement of participants achieving safe gait aid use during and after the program were described. Perception ratings at each visit were measured using Likert scales which, along with the spatiotemporal outcomes using the gait aid (Time-Up-and-Go-Test, 4-m-walk-test, Figure-of-8-Walk-Test with/without a cognitive task) at weeks 1 and 6, and at weeks 6 and 12 (6-week post-program), were examined with ordinal logistic regression analyses. Twenty-four community-dwelling older people with dementia and their carers participated. Twenty-one (87.5%) older people achieved safe gait aid use. Twenty falls occurred, and only one faller was using their gait aid when they fell. Walking speed, step length, and cadence significantly improved when walking with the gait aid at week 6 compared with week 1. No significant improvements in spatiotemporal outcomes were retained at week 12. Physiotherapists were more likely to agree that gait aid use had improved walking safety among older people with dementia with subsequent training visits. Larger studies of the gait aid training program are needed for this clinical group.

Roles and effectiveness of knowledge brokers for translating clinical practice guidelines in health-related settings: a systematic review

BACKGROUND

Poor translation of clinical practice guidelines (CPGs) into clinical practice is a barrier to the provision of consistent and high-quality evidence-based care. The objective was to systematically review the roles and effectiveness of knowledge brokers (KBs) for translating CPGs in health-related settings.

METHODS

MEDLINE, Embase, PsycINFO and CINAHL Plus were searched from 2014 to June 2022. Randomised controlled trials (RCTs), controlled and uncontrolled preintervention and postintervention studies involving KBs, either alone or as part of a multicomponent intervention, that reported quantitative postintervention changes in guideline implementation in a healthcare setting were included. A KB was defined as an intermediary who facilitated knowledge translation by acting in at least two of the following core roles: knowledge manager, linkage agent or capacity builder. Specific activities undertaken by KBs were deductively coded to the three core roles, then common activities were inductively grouped. Screening, data extraction, quality assessment and coding were performed independently by two authors.

RESULTS

16 studies comprising 6 RCTs, 8 uncontrolled precomparisons-postcomparisons, 1 controlled precomparison-postcomparison and 1 interrupted time series were included. 14 studies (88%) were conducted in hospital settings. Knowledge manager roles included creating and distributing guideline material. Linkage agent roles involved engaging with internal and external stakeholders. Capacity builder roles involved audit and feedback and educating staff. KBs improved guideline adherence in 10 studies (63%), had mixed impact in 2 studies (13%) and no impact in 4 studies (25%). Half of the RCTs showed KBs had no impact on guideline adherence. KBs acted as knowledge managers in 15 (94%) studies, linkage agents in 11 (69%) studies and capacity builders in all studies.

CONCLUSION

Knowledge manager and capacity builder roles were more frequently studied than linkage agent roles. KBs had mixed impact on translating CPGs into practice. Further RCTs, including those in non-hospital settings, are required.

PROSPERO REGISTRATION NUMBER

CRD42022340365.

Effectiveness of tailored COVID-19 messages for vulnerable Australians: A study protocol

Multiple approaches can be used to communicate public health messages through mass media. It is unclear which approaches are superior for meeting the needs of the general community along with vulnerable population subgroups. To compare different public health strategy communication approaches for influencing the COVID-safe behavioural intentions of both community and vulnerable population subgroups. This study will conduct three concurrent 'helix' randomised controlled trials with Latin square sequencing and factorial intervention allocation to assess the effectiveness of different communication strategies amongst the Australian general community and six subgroups that are considered vulnerable to contracting, transmitting or experiencing severe consequences of COVID-19 infection. Communication approaches being compared include: the format of communication (written versus video), who is providing information (general practitioner, politician, community-representative), what is said and how it is delivered (direct information provision versus conversational approach) and the visual content of video messaging (animation versus 'talking head'). Recruited participants will be randomly allocated to receive a specific combination of health messaging strategies using six different COVID-19 context areas. Outcomes will be assessed in a survey using behaviour intention questions, and questions surrounding level of agreement with feeling represented in the health messaging strategy. These trials will use a unique research approach to provide an experimental evidence base to help guide development of impactful and inclusive COVID-19 and related public health messaging. All three trials are registered with the Australian New Zealand Clinical Trials Registry (ANZCTR). Trial 1: Update and impact of Government recommendations about COVID-19 (coronavirus)-Stage 3, Trial 1, vulnerable subgroup populations (ACTRN12622000606785). Trial 2: Update and impact of Government recommendations about COVID-19 (coronavirus)-Stage 3, Trial 2, community group (ACTRN12622000605796). Trial 3: Update and impact of Government recommendations about COVID-19 (coronavirus)-Stage 3, Trial 3, What communication strategy is most effective for both vulnerable and community group populations? (ACTRN12622000617763).

A 12-month weight loss intervention in adults with obstructive sleep apnoea: is timing important? A step wedge randomised trial

BACKGROUND/OBJECTIVES

Continuous positive airway pressure (CPAP) concomitant with weight loss is a recommended treatment approach for adults with moderate-severe obstructive sleep apnoea (OSA) and obesity. This requires multiple synchronous behaviour changes. The aim of this study was to examine the effectiveness of a 6-month lifestyle intervention and to determine whether the timing of starting a weight loss attempt affects weight change and trajectory after 12 months in adults newly diagnosed with moderate-severe OSA and treated at home with overnight CPAP.

METHODS

Using a stepped-wedge design, participants were randomised to commence a six-month lifestyle intervention between one and six-months post-enrolment, with a 12-month overall follow-up. Adults (n = 60, 75% males, mean age 49.4 SD 10.74 years) newly diagnosed with moderate-severe OSA and above a healthy weight (mean BMI 34.1 SD 4.8) were recruited.

RESULTS

After 12 months, exposure to the intervention (CPAP and lifestyle) resulted in a 3.7 (95% CI: 2.6 to 4.8, p < 0.001) kg loss of weight compared to the control condition (CPAP alone). Timing of the weight loss attempt made no difference to outcomes at 12 months. When exposed to CPAP only (control period) there was no change in body weight (Coef, [95% CI] 0.03, [-0.3 to 0.36], p = 0.86).

CONCLUSIONS

The lifestyle intervention resulted in a modest reduction in body weight, while timing of commencement did not impact the degree of weight loss at 12 months. These findings support the recommendation of adjunctive weight-loss interventions within six-months of starting CPAP.

English language proficiency and hospital admissions via the emergency department by aged care residents in Australia: A mixed-methods investigation

Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p = 0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p = 0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.

Australian public health COVID-19 messaging is missing its mark in some vulnerable communities and people who reject COVID-19 safety advice

Background

There are groups in our community who may be more vulnerable to contracting, transmitting, or experiencing negative health impacts of COVID-19 than the general community. They may also have greater difficulty accessing, accepting, and acting upon COVID-19 public health information. Our aim was to understand if vulnerable communities and those who express "COVID-risk" behavioural intentions seek and respond differently to COVID-19 public health information.

Methods

This observational, cross-sectional study recruited adults aged over 18 years from the Australian general community and six community groups (people with disabilities and their caregivers, Aboriginal and Torres Strait Islanders, aged care workers, street-based sex workers, refugees and asylum seekers, and the deaf and hard of hearing). We investigated attitudes and beliefs about COVID-19 public health messages. We identified factors associated with the respondent's perception of the ease of finding information and understanding it, and its relevance to them. We also examined latent classes that were developed based on attitudes to public health measures and vulnerable group categories, along with demographic variables.

Results

We received 1444 responses (n = 1121 general community; n ≥50 for each vulnerable group). The vulnerable groups examined found COVID-19 public health messages as easy, if not easier, to find and understand than the general community. Four latent classes were identified: COVID-safe mask wearers (10% of sample), COVID-safe test takers (56%), COVID-risk isolators (19%) and COVID-risk visitors (15%). The COVID-risk classes (34% of sample) were less likely to consider COVID-19 information easy to find, understandable, and relevant.

Conclusions

Additional public health messaging strategies may be needed for targeting people with "COVID-risk" beliefs and attitudes who appear across the community (general and vulnerable groups) rather than just targeting specific cultural or other groupings that we think may be vulnerable. COVID-risk classes identified through this study were not defined by demographic characteristics or cultural groupings, but were spread across vulnerable communities and the general community. Different approaches for tailoring and delivery of specific public health information for these groups are needed.

Effect of Early and Intensive Telephone or Electronic Nutrition Counselling Delivered to People with Upper Gastrointestinal Cancer on Quality of Life: A Three-Arm Randomised Controlled Trial

BACKGROUND

Delay in dietetic service provision for upper gastrointestinal cancer exacerbates disease-related malnutrition and consequently increases morbidity and mortality. Dietetic services are usually referral-based and provided face-to-face in inpatient or outpatient settings, which can delay the commencement of nutrition care. The aim of this study was to provide intensive dietetic intervention close to the time of diagnosis for upper gastrointestinal cancer and assess the effect on quality-adjusted life years.

METHODS

A three-arm randomised controlled trial of adults newly diagnosed with upper gastrointestinal cancer was performed. A behavioural-based, individually tailored, symptom-directed nutrition intervention was provided in addition to usual care, delivered by a dietitian using a telephone (synchronously) or a mobile application (asynchronously) for 18 weeks, compared with a usual care control group. Data were collected at baseline, three, six, and twelve months post-randomisation. The primary outcome was quality-adjusted life years (EQ-5D-5L quality of life assessment tool). Data were analysed using linear mixed models.

RESULTS

One hundred and eleven participants were randomised. Quality-adjusted life years were not different in the intervention groups compared with control (telephone: mean (95% CI) 0.04 (0.43, 2.3), p = 0.998; App: -0.08 (-0.18, 0.02), p = 0.135) after adjustment for baseline, nutrition risk status, age, and gender. Survival was similar between groups over 12 months. The asynchronous mobile app group had a greater number of withdrawals compared with the telephone group.

CONCLUSION

Early and intensive nutrition counselling, delivered at home, during anticancer treatment did not change quality-adjusted life years or survival over 12 months compared with usual care. Behavioural counselling alone was unable to achieve nutritional adequacy. Dietetic services delivered asynchronously using a mobile app had low acceptance for patients undergoing anticancer treatment.

TRIAL REGISTRATION

27 January 2017 Australian and New Zealand Clinical Trial Registry, ACTRN12617000152325.

Factors Affecting Engagement of Older Adults in Exercise Following Hospitalization

BACKGROUND AND PURPOSE

Exercise interventions can improve physical recovery and reduce falls in older adults following hospitalization. The aim of the study was to identify factors associated with exercise engagement after hospital discharge.

METHODS

This study was a secondary analysis of data collected as part of a randomized controlled trial. Participants were 60 years and older, discharged from 3 rehabilitation hospitals in Australia, and followed for 6 months after discharge. The primary outcome was level of engagement in exercise after discharge, measured using setting, type, frequency, and time. A secondary outcome was self-efficacy for exercise at 6-month follow-up. Data were gathered at baseline in hospital and at 6 months after discharge by telephone using structured surveys. Associations between exercise and participant characteristics were evaluated using logistic regression models.

RESULTS AND DISCUSSION

Participants' (n = 292) mean age was 78 (SD 8) years and 63% were female. There were 146 (50%) who exercised after hospitalization for a median (interquartile range) time of 60 (60-75) minutes per week. Characteristics that were significantly associated with post-discharge engagement in exercise were having higher levels of functional ability at discharge (adjusted odds ratio [AOR] 1.2, 95% CI 1.0, 1.4), living with a partner (AOR 2.9, 95% CI 1.7, 4.9), and engagement in exercise prior to hospital admission (AOR 1.7, 95% CI 1.0, 2.8). The mean self-efficacy for exercise score at 6 months post-discharge was 58.5/90 (SD 24.5). Characteristics that were significantly predictive of a higher mean self-efficacy score at 6 months after hospitalization were having a college or university education (adjusted β-coefficient [Adj β] 11.5, 95% CI 3.8, 19.0), exercise prior to hospital admission (Adj β 12.3, 95% CI 5.1, 19.5), living with a partner at discharge (Adj β 14.5, 95% CI 7.1, 21.9), and higher functional ability at discharge (Adj β 4.0, 95% CI 1.9, 6.1).

CONCLUSION

Older adults have low levels of engagement in exercise that might impact their recovery after hospitalization. During exercise prescription, clinicians should prioritize older adults who live alone, who have lower functional ability, and no previous habit of exercising.

Improving Policy for the Prevention of Falls Among Community-Dwelling Older People—A Scoping Review and Quality Assessment of International National and State Level Public Policies

Objectives: Effective public policy to prevent falls among independent community-dwelling older adults is needed to address this global public health issue. This paper aimed to identify gaps and opportunities for improvement of future policies to increase their likelihood of success.

Methods: A systematic scoping review was conducted to identify policies published between 2005–2020. Policy quality was assessed using a novel framework and content criteria adapted from the World Health Organization’s guideline for Developing policies to prevent injuries and violence and the New Zealand Government’s Policy Quality Framework.

Results: A total of 107 articles were identified from 14 countries. Content evaluation of 25 policies revealed that only 54% of policies met the WHO criteria, and only 59% of policies met the NZ criteria. Areas for improvement included quantified objectives, prioritised interventions, budget, ministerial approval, and monitoring and evaluation.

Conclusion: The findings suggest deficiencies in a substantial number of policies may contribute to a disconnect between policy intent and implementation. A clear and evidence-based model falls prevention policy is warranted to enhance future government efforts to reduce the global burden of falls.

The impact of additional allied health staffing on rehabilitation outcomes at discharge from a sub-acute geriatric evaluation and management unit: A quasi-experimental, pre-post intervention study

OBJECTIVE

The purpose of this study was to examine the impact of increasing allied health staffing levels on patient and health service outcomes across 1) all Geriatric Evaluation and Management patients, and 2) Geriatric Evaluation and Management patients discharged to home in the community.

DESIGN

Quasi-experimental, pre-post intervention study.

SETTING

Two sub-acute hospital units in an Australian, tertiary health service.

SUBJECTS

Data related to patients admitted to the study units, who were classified as Geriatric Evaluation and Management patients.

INTERVENTIONS

Comparison of therapy time across two units with a differential in staffing allocation over a six-month trial period.

MAIN MEASURES

Primary outcomes: length of stay, readmission rate, and improvement on the Functional Independence Measure. Secondary outcomes: total cost of admission per patient and number of allied health sessions.

RESULTS

Data were analysed for 214 patients (mean age = 79.9, standard deviation (SD) = 9.4 years, mean Functional Independence Measure (FIM = 64.9, SD = 21.2) admitted to the intervention unit, and 199 patients (mean age = 81.3, SD = 8.5, mean FIM = 64.2, SD = 24.0) admitted to the control unit. The overall difference in staffing allocation between the control and intervention units for the trial period was 21%. There was no statistically significant difference between units in subacute length of stay (Adj Coef = -0.10 days, 95%CI = -0.39 to 0.19), rate of readmission (OR = 1.0, 95%CI = 0.5 to 2.0) or change in function (Coef = 1.42 FIM change score, 95%CI = -2.4 to 5.3).

CONCLUSIONS

Increasing allied health staffing allocation to a unit over six-months did not impact change in function or length of stay for patients admitted for Geriatric Evaluation and Management.

Cost analysis of employing general practitioners within residential aged care facilities based on a prospective, stepped-wedge, cluster randomised trial

OBJECTIVE

To assess the impacts of changing a model of care and employing general practitioners (GPs) within residential aged care facilities (RACFs) on costs to the aged care provider (ACP) and state and federal governments of Australia.

METHODS

This study was a cost analysis of a prospective, stepped-wedge, cluster randomised trial. All financial data from the ACP for every RACF involved, before and after implementation of the new model were obtained. Costs of hospital transfers, admissions, ambulance usage and GP consultations were calculated. Costs of new infrastructure, recruiting and training new staff were accounted for. Costs were standardised to 2019 Australian Dollars per occupied bed day (OBD).

RESULTS

Implementation of the new model of care resulted in overall cost savings of $9.7 per OBD to the ACP, with increased salary costs offset by increased federal government subsidies and Medicare claims income. Costs to the federal government increased by $19.6 per OBD, driven by increases in subsides. Costs savings of $3.0 per OBD to state governments were seen, driven by decreased costs of hospital transfers.

CONCLUSIONS

Implementation of a model of care including GPs employed at RACFs had a mixed impact on costs depending on perspective, with overall savings to the ACP and state government perspective.

Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Does Free-Text Information in Falls Incident Reports Assist to Explain How and Why the Falls Occurred in a Hospital Setting?

OBJECTIVE

The aim of this study was to explore whether information captured in falls reports in incident management systems could be used to explain how and why the falls occurred, with a view to identifying whether such reports can be a source of subsequent learnings that inform practice change.

METHODS

An analysis of prospectively collected falls incident reports found in the incident management systems from eight Western Australian hospitals during a stepped-wedge cluster-randomized controlled trial. The falls reported occurred in a cohort of older hospital patients (mean age = 82 y) on rehabilitation wards. Data coded from free-text comments in the incident reports were analyzed using deductive content analysis.

RESULTS

In the 493 analyzed falls incident reports, qualitative information describing aspects of the fall that clarified the patient, staff, and environment-related contributory factors was consistently low. Reports infrequently contained information about patients' and staff's call bell use behaviors (13%-19% of reports), fidelity of implementation of the care plan (8%) or environment-related factors such as bed settings (20%), and presence of clutter at the fall location (1%). The patients' account of the fall was present in less than 50% of reports, with an absence of concurrent text, which explained whether patient cognitive impairment was the reason for not obtaining this first-person account of the incident.

CONCLUSIONS

Falls reports in hospital incident management systems may not capture adequate information to explain how and why falls occur. This could limit creation of effective feedback loops to drive quality improvement efforts and targeted practice change.

Efficacy of high-volume injections with and without corticosteroid compared with sham for Achilles tendinopathy: a protocol for a randomised controlled trial

Introduction

Achilles tendinopathy (AT) is a common and disabling musculoskeletal condition. First-line management involving Achilles tendon loading exercise with, or without, other modalities may not resolve the problem in up to 44% of cases. Many people receive injections. Yet there are no injection treatments with demonstrated long-term efficacy. The aim of the trial is to examine the 12-month efficacy of high-volume injection (HVI) with corticosteroid and HVI without corticosteroid versus sham injection among individuals with AT.

Methods and analysis

The trial is a three-arm, parallel group, double-blind, superiority randomised controlled trial that will assess the efficacy of HVI with and without corticosteroid versus sham up to 12 months. We will block-randomise 192 participants to one of the three groups with a 1:1:1 ratio, and both participants and outcome assessors will be blinded to treatment allocation. All participants will receive an identical evidence-based education and exercise intervention. The primary outcome measure will be the Victorian Institute of Sport Assessment - Achilles (VISA-A) at 12 months post-randomisation, a validated, reliable and disease-specific measure of pain and function. Choice of secondary outcomes was informed by core outcome domains for tendinopathy. Data will be analysed using the intention-to-treat principle.

Ethics and dissemination

Ethics approval was obtained via the Monash University Human Ethics Committee (no: 13138). The study is expected to be completed in 2024 and disseminated via peer review publication and conference presentations.

Trial registration number

Australia and New Zealand Clinical trials registry (ACTRN12619001455156).

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.