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.

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 .

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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 ß-coefficient [Adj ß] 11.5, 95% CI 3.8, 19.0), exercise prior to hospital admission (Adj ß 12.3, 95% CI 5.1, 19.5), living with a partner at discharge (Adj ß 14.5, 95% CI 7.1, 21.9), and higher functional ability at discharge (Adj ß 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.

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.