Research capacity and culture: a survey of Australian Orthopaedic Association members.

BACKGROUND: Strong research capacity and culture (RCC) within professional groups predict engagement in high-quality research and the integration of evidence into practice. However, factors affecting RCC participation and development are currently unknown in Australian Orthopaedic Surgeons. STUDY DESIGN: Cross-sectional survey. METHODS: All Australian Orthopaedic Association members were invited to complete the individual domain of the validated Research Capacity and Culture tool. RESULTS: One hundred and sixty-three Australian Orthopaedic Association members (9%) provided survey answers. Survey findings indicated that AOA members scored moderate or high for most RCC domains (14 out of 15). Barriers to the completion of research included a lack of time, other work roles taking priority, and a lack of funds for research. CONCLUSION: The Australian Orthopaedic Association members surveyed in this study demonstrated adequate research skills and experience, although reported they could benefit from additional support securing funding and navigating specific research tasks. Increasing future collaboration with academic institutions and clinician-researcher roles may enhance the output of high-quality orthopaedic research in Australia.

Conducting Community-Based Research in An African Immigrant Population: Lessons Learned.

Background: Although small, the African immigrant population is one of the fastest growing immigrant populations in the United States. Emerging research indicates a high prevalence of noncommunicable preventable chronic conditions in this population. Like other African Americans, African immigrants are mistrustful of the health care system, hampering efforts for prevention and intervention research. Purpose: To describe our experiences conducting 2 studies in an African immigrant community, discuss the lessons learned, and provide advice to researchers interested in conducting research in similar populations. Design: The 2 published studies for which we derive lessons learned for this paper were a cross-sectional study and a qualitative study using focus group interviews. Participants included Zimbabwean immigrants in the Eastern United States recruited at religious festivals and community events. The 2 studies enrolled a total of 135 participants. Results: Of our recruitment goal of 120 in the first study, we enrolled only 98 despite numerous efforts. However, after strategically partnering with a community advisory board (CAB), in the second study, we met our recruitment goal within 4 months. With the CAB, we recruited a larger proportion of men (38% versus 24%). Without the CAB, 350 individuals agreed to participate, but only 98 (28%) returned the questionnaire, whereas with the CAB, 40 agreed to participate, and 37 (93%) successfully completed the study. Conclusion: Conducting health-related research in immigrants requires strategic partnerships with the community to build strong relationships between the research team and the target community. By nurturing these relationships, research teams can effectively access this hard-to-reach population and achieve high participation.

Excess burden of respiratory and abdominal conditions following COVID-19 infections during the ancestral and Delta variant periods in the United States: An EHR-based cohort study from the RECOVER program.

IMPORTANCE: The frequency and characteristics of post-acute sequelae of SARS-CoV-2 infection (PASC) may vary by SARS-CoV-2 variant. OBJECTIVE: To characterize PASC-related conditions among individuals likely infected by the ancestral strain in 2020 and individuals likely infected by the Delta variant in 2021. DESIGN: Retrospective cohort study of electronic medical record data for approximately 27 million patients from March 1, 2020-November 30, 2021. SETTING: Healthcare facilities in New York and Florida. PARTICIPANTS: Patients who were at least 20 years old and had diagnosis codes that included at least one SARS-CoV-2 viral test during the study period. EXPOSURE: Laboratory-confirmed COVID-19 infection, classified by the most common variant prevalent in those regions at the time. MAIN OUTCOME(S) AND MEASURE(S): Relative risk (estimated by adjusted hazard ratio [aHR]) and absolute risk difference (estimated by adjusted excess burden) of new conditions, defined as new documentation of symptoms or diagnoses, in persons between 31-180 days after a positive COVID-19 test compared to persons without a COVID-19 test or diagnosis during the 31-180 days after the last negative test. RESULTS: We analyzed data from 560,752 patients. The median age was 57 years; 60.3% were female, 20.0% non-Hispanic Black, and 19.6% Hispanic. During the study period, 57,616 patients had a positive SARS-CoV-2 test; 503,136 did not. For infections during the ancestral strain period, pulmonary fibrosis, edema (excess fluid), and inflammation had the largest aHR, comparing those with a positive test to those without a COVID-19 test or diagnosis (aHR 2.32 [95% CI 2.09 2.57]), and dyspnea (shortness of breath) carried the largest excess burden (47.6 more cases per 1,000 persons). For infections during the Delta period, pulmonary embolism had the largest aHR comparing those with a positive test to a negative test (aHR 2.18 [95% CI 1.57, 3.01]), and abdominal pain carried the largest excess burden (85.3 more cases per 1,000 persons). CONCLUSIONS AND RELEVANCE: We documented a substantial relative risk of pulmonary embolism and a large absolute risk difference of abdomen-related symptoms after SARS-CoV-2 infection during the Delta variant period. As new SARS-CoV-2 variants emerge, researchers and clinicians should monitor patients for changing symptoms and conditions that develop after infection.

Virtual communities of practice for novice occupational therapists: a vehicle for learning, support and professional identity strengthening?

INTRODUCTION: Healthcare practitioners delivering services in rural and underserved areas need timely access to appropriate knowledge to optimise the care they deliver. Novice generalist occupational therapists in South Africa experience this need as they respond to a high demand for hand therapy. Embedded within a study aimed at identifying their support and development needs, this article describes participants' experience of a virtual community of practice. METHODS: A qualitative case study design was employed. Nine occupational therapists participated in a virtual community of practice that met fortnightly for meetings and interacted on WhatsApp. Data were collected through photo elicitation, facilitated reflection, and case discussions. An online survey questionnaire was used to evaluate participants' experience of this virtual community. Thematic analysis was applied to the anonymous responses submitted by participants (n=7). A number of strategies were employed to ensure the trustworthiness of results including prolonged engagement, member checking, peer examination, reflexive reading and writing, triangulation, and a dense description of participants to enable readers to evaluate the transferability of results. RESULTS: Three themes were generated from analysis. The first theme, versatile support, describes participants' experience of being helped and supported, appreciating the immediacy of support, and being able to share resources. A vehicle for learning captures participants' experience of mutual learning, opportunity to reflect, to acquire knowledge and skills, and develop their clinical reasoning. Finally, the community of practice was grounding: learning opportunities were contextually relevant and participants were able to consolidate their professional values and identity. Participants raised the importance of using online platforms that were accessible, recommended a group size of 5-10 members, and proposed 60-90-minute meetings held weekly or fortnightly. CONCLUSION: A virtual community of practice provided both support and professional development opportunities for therapists delivering hand therapy. Careful planning and implementation to upscale this intervention are recommended for rehabilitation personnel delivering care to underserved communities in South Africa. The logistics of virtual communities need to mitigate for connectivity difficulties, and online platforms should enable real-time support. Participant satisfaction and the evaluation of implementation outcomes should be considered in the design of virtual communities of practice.

Long COVID incidence in adults and children between 2020 and 2023: a real-world data study from the RECOVER Initiative.

Estimates of post-acute sequelae of SARS-CoV-2 infection (PASC) incidence, also known as Long COVID, have varied across studies and changed over time. We estimated PASC incidence among adult and pediatric populations in three nationwide research networks of electronic health records (EHR) participating in the RECOVER Initiative using different classification algorithms (computable phenotypes). Overall, 7% of children and 8.5%-26.4% of adults developed PASC, depending on computable phenotype used. Excess incidence among SARS-CoV-2 patients was 4% in children and ranged from 4-7% among adults, representing a lower-bound incidence estimation based on two control groups - contemporary COVID-19 negative and historical patients (2019). Temporal patterns were consistent across networks, with peaks associated with introduction of new viral variants. Our findings indicate that preventing and mitigating Long COVID remains a public health priority. Examining temporal patterns and risk factors of PASC incidence informs our understanding of etiology and can improve prevention and management.

Mental health service utilization and help seeking behaviours of adult Cambodians living in Western countries: A systematic scoping review.

BACKGROUND: Health disparity and under-utilization of health services is prevalent among Asian refugees and migrants in Western countries and can profoundly impact health outcomes. Cambodians who survived extreme physical and emotional trauma during the genocides enacted by the Khmer Rouge regime in the 1970's are particularly vulnerable to poor mental health outcomes decades later. Understanding the experiences of help-seeking and service use by displaced Cambodians in Western countries may help to design more effective and culturally safe healthcare services. AIMS: To identify characteristics or factors associated with help seeking behaviours and service utilization of displaced Cambodians with mental health issues living in Western countries. METHODS: This review followed the Arksey & O'Malley methodological framework for scoping reviews. Articles for review were identified through searches of nine electronic databases and manual searches. Relevant articles were selected, and data was extracted and synthesized into key themes. RESULTS: This review included 15 articles. Most of the studies were conducted in the USA (n = 13) with one each conducted in Canada and New Zealand. Seven studies used qualitative interviews, five used a cross-sectional survey approach, two used a mixed-methods approach and one was a narrative review and case series. Key findings highlighted the impact of Cambodian cultural beliefs about mental health (guilt, shame and help-seeking stigma) on service utilization and the disconnect between Western models of service provision and preferred Cambodian ways of receiving support. CONCLUSION: Mental health services in Western countries are likely to be under-utilized by Cambodians due to a mismatch between health beliefs and Western models of care. Further investigation of the association between health beliefs and barriers to service utilization among adult Cambodian refugees is warranted.

Research capacity and culture among hand therapists in Australia: A cross-sectional survey.

BACKGROUND: Identifying the factors influencing engagement in research capacity and culture (RCC) in hand therapy practice is essential to inform strategies to support contributions to high-quality research and its implementation in clinical practice. However, the RCC of clinicians providing hand therapy services in Australia has not been investigated. PURPOSE: This study aimed to measure RCC among hand therapists in Australia to identify perceived barriers, motivators, and skills related to undertaking research. STUDY DESIGN: Cross-sectional survey. METHODS: All Australian Hand Therapy Association members were invited to complete the RCC tool, which includes three domains: i) individual, ii) professional group (team), and iii) organization. RESULTS: One hundred twenty-two therapists (13.6% response rate) completed the survey. Survey findings indicate that the RCC of hand therapists in Australia is relatively low across all RCC domains, with scores on these items being either moderate or low. The findings from this study suggest that the areas or skills that respondents felt most confident with were more closely aligned to the clinical skills required as evidence-based practitioners, compared to other skills more closely aligned with the clinician-researchers, such as data analysis or writing proposals. CONCLUSIONS: Hand therapists in Australia may not possess the research experience or skills required to confidently complete a range of research-related activities. Future support strategies should focus on improving hand therapist knowledge and confidence regarding common research tasks and provide funding and mentoring for additional hand therapist clinician-researcher roles.

"Surthriving" Hand Rehabilitation: Proposing Interventions to Support Novice Occupational Therapists Working in Underserved Contexts.

Hand rehabilitation delivered to underserved South African communities is often the responsibility of novice or generalist occupational therapists. Novice therapists typically work with restricted supervision, support, and resources. Little is known about how these therapists should be supported in order to strengthen the services that they deliver. This study is aimed at understanding how novice occupational therapists in their first year of practice describe their experience of delivering hand rehabilitation in order to identify their support and development needs and propose interventions to address these needs. A qualitative instrumental case study design was used. Data were collected from novice occupational therapists (n = 9) who participated in an online community of practice. Data collection techniques included photoelicitation, facilitated reflection activities, and case discussion. Reflexive thematic analysis was employed. Trustworthiness strategies included reflexive writing, prolonged engagement, data source triangulation, member checking, and peer audit. Analysis generated three themes: (1) "submerged: I had to drown a little" captured participants' experience of being saturated by contextual features including poverty and poor basic management of hand injuries. (2) "Starting somewhere" captured participants' journey of treating patients with hand injuries. They transitioned from an initial sense of having "no idea" to developing "some idea"; their clinical reasoning was challenged when working with no diagnosis, unfamiliar presentations, or when contextual features rendered traditional approaches to therapy inappropriate. Finally, (3) "dynamics of 'surthrival'" captured elements that contributed to participants either thriving or merely surviving their hand rehabilitation experience. The proposed strategies identified in this study to address the support and development needs of novice therapists include interventions focused on systems and health services; learning opportunities to support competency and physical resources; and emotional support. Beyond application to the South African context, these strategies may be considered for supporting generalist or novice therapists delivering hand rehabilitation in other low- to middle-income countries.

Health Consequences of Climate Change: Continuing Education Opportunities for Health Professionals in the United States.

Climate change is a looming public health challenge. The health consequences of climate change are increasingly recognized as contributing to negative health outcomes for individuals, families, communities, and populations. The education of health professionals in academic programs and continuing education in clinical practice settings is critical in today's world. The Association of American Medical Colleges and the National League for Nursing, among other organizations, have urged academic programs to include the impact of climate change on health in health professions education and have started to integrate it into curricula. However, health professionals educated over the past several decades have received little content related to the deleterious impact of climate change on health. Therefore, continuing education programs addressing the health consequences of climate change are being developed to fill the gap in health professions education globally. This review study explicated the available continuing education opportunities for public health professionals and health care providers related to the health consequences of climate change. [J Contin Educ Nurs. 2023;54(12):561-566.].

Leadership in Nursing Education for Advancing a School of Nursing-Led Center for Climate Change, Climate Justice, and Health.

BACKGROUND: This article examines innovations in the development and advancement of a school of nursing-led climate change center and innovative leadership related to climate change and health in nursing education. METHOD: The integration of health consequences of climate change in curricula and continuing education is essential to prepare nursing students and nurses for clinical practice. RESULTS: Transformational leadership is a key concept for effective leadership in nursing education to address climate change as the looming public health challenge of the 21st century. Transformational leadership strengthened one nursing program's curricula, dissemination of relevant scholarship, and achievements with public health outreach related to climate change, climate justice, and health. CONCLUSION: Nursing education leaders can influence nursing practice and improve societal health outcomes related to the health consequences of climate change across all levels of education and continuing education for professional nurses. [J Nurs Educ. 2023;62(9):528-531.].

Therapeutic trials for long COVID-19: A call to action from the interventions taskforce of the RECOVER initiative.

Although most individuals recover from acute SARS-CoV-2 infection, a significant number continue to suffer from Post-Acute Sequelae of SARS-CoV-2 (PASC), including the unexplained symptoms that are frequently referred to as long COVID, which could last for weeks, months, or even years after the acute phase of illness. The National Institutes of Health is currently funding large multi-center research programs as part of its Researching COVID to Enhance Recover (RECOVER) initiative to understand why some individuals do not recover fully from COVID-19. Several ongoing pathobiology studies have provided clues to potential mechanisms contributing to this condition. These include persistence of SARS-CoV-2 antigen and/or genetic material, immune dysregulation, reactivation of other latent viral infections, microvascular dysfunction, and gut dysbiosis, among others. Although our understanding of the causes of long COVID remains incomplete, these early pathophysiologic studies suggest biological pathways that could be targeted in therapeutic trials that aim to ameliorate symptoms. Repurposed medicines and novel therapeutics deserve formal testing in clinical trial settings prior to adoption. While we endorse clinical trials, especially those that prioritize inclusion of the diverse populations most affected by COVID-19 and long COVID, we discourage off-label experimentation in uncontrolled and/or unsupervised settings. Here, we review ongoing, planned, and potential future therapeutic interventions for long COVID based on the current understanding of the pathobiological processes underlying this condition. We focus on clinical, pharmacological, and feasibility data, with the goal of informing future interventional research studies.

Excess burden of respiratory and abdominal conditions following COVID-19 infections during the ancestral and Delta variant periods in the United States: An EHR-based cohort study from the RECOVER Program.

Importance: The frequency and characteristics of post-acute sequelae of SARS-CoV-2 infection (PASC) may vary by SARS-CoV-2 variant. Objective: To characterize PASC-related conditions among individuals likely infected by the ancestral strain in 2020 and individuals likely infected by the Delta variant in 2021. Design: Retrospective cohort study of electronic medical record data for approximately 27 million patients from March 1, 2020-November 30, 2021. Setting: Healthcare facilities in New York and Florida. Participants: Patients who were at least 20 years old and had diagnosis codes that included at least one SARS-CoV-2 viral test during the study period. Exposure: Laboratory-confirmed COVID-19 infection, classified by the most common variant prevalent in those regions at the time. Main Outcomes and Measures: Relative risk (estimated by adjusted hazard ratio [aHR]) and absolute risk difference (estimated by adjusted excess burden) of new conditions, defined as new documentation of symptoms or diagnoses, in persons between 31-180 days after a positive COVID-19 test compared to persons with only negative tests during the 31-180 days after the last negative test. Results: We analyzed data from 560,752 patients. The median age was 57 years; 60.3% were female, 20.0% non-Hispanic Black, and 19.6% Hispanic. During the study period, 57,616 patients had a positive SARS-CoV-2 test; 503,136 did not. For infections during the ancestral strain period, pulmonary fibrosis, edema (excess fluid), and inflammation had the largest aHR, comparing those with a positive test to those with a negative test, (aHR 2.32 [95% CI 2.09 2.57]), and dyspnea (shortness of breath) carried the largest excess burden (47.6 more cases per 1,000 persons). For infections during the Delta period, pulmonary embolism had the largest aHR comparing those with a positive test to a negative test (aHR 2.18 [95% CI 1.57, 3.01]), and abdominal pain carried the largest excess burden (85.3 more cases per 1,000 persons). Conclusions and Relevance: We documented a substantial relative risk of pulmonary embolism and large absolute risk difference of abdomen-related symptoms after SARS-CoV-2 infection during the Delta variant period. As new SARS-CoV-2 variants emerge, researchers and clinicians should monitor patients for changing symptoms and conditions that develop after infection.

"Burnout felt inevitable": Experiences of university staff in educating the nursing and allied health workforce during the first COVID-19 waves.

Introduction: Maintaining progress in the face of looming burnout during the first 2 years of the COVID-19 pandemic was crucial for the health workforce, including those educating the next generation of health professionals. The experiences of students and healthcare practitioners have been explored to a greater degree than the experiences of university-based health professional educators. Methods: This qualitative study examined the experiences of nursing and allied health academics at an Australian University during COVID-19 disruptions in 2020 and 2021 and describes the strategies that academics and/or teams implemented to ensure course continuity. Academic staff from nursing, occupational therapy, physiotherapy, and dietetics courses at Swinburne University of Technology, Australia provided narratives regarding the key challenges and opportunities they faced. Results: The narratives highlighted the strategies generated and tested by participants amidst rapidly changing health orders and five common themes were identified: disruption; stress; stepping up, strategy and unexpected positives, lessons, and legacy impacts. Participants noted challenges related to student engagement in online learning and ensuring the acquisition of discipline-specific practical skills during periods of lock-down. Staff across all disciplines reported increased workload associated with converting teaching to on-line delivery, sourcing alternative fieldwork arrangements, and dealing with high levels of student distress. Many reflected on their own expertise in using digital tools in teaching and their beliefs about the effectiveness of distance teaching for health professional training. Ensuring students were able to complete required fieldwork hours was particularly challenging due to constantly changing public health orders and conditions and staffing shortages at health services. This was in addition to illness and isolation requirements further impacting the availability of teaching associates for specialist skills classes. Discussion: Solutions such as remote and blended learning telehealth, and simulated placements were rapidly implemented in some courses especially where fieldwork could not be rescheduled or amended at the health settings. The implications and recommendations for educating and ensuring competence development in the health workforce during times when usual teaching methods are disrupted are discussed.

Comparison of two relative motion extension approaches (RME with versus without an additional overnight orthosis) following zones V-VI extensor tendon repairs: A randomized equivalence trial.

STUDY DESIGN: Multi--center randomized controlled trial with two intervention parallel groups. An equivalence trial. INTRODUCTION: Relative motion extension (RME) orthoses are widely used in the postoperative management of finger extensor tendon repairs in zones V-VI. Variability in orthotic additions to the RME only (without a wrist orthosis) approach has not been verified in clinical studies. PURPOSE OF THE STUDY: To examine if two RME only approaches (with or without an additional overnight wrist-hand-finger orthosis) yields clinically similar outcomes. METHODS: Thirty-two adult (>18 years) participants (25 males, 7 females) were randomized to one of two intervention groups receiving either 1) a relative motion extension orthosis for day wear and an overnight wrist-hand-finger orthosis ('RME Day' group), or 2) a relative motion extension orthosis to be worn continuously ('RME 24-Hr' group); both groups for a period of four postoperative weeks. RESULTS: Using a series of linear mixed models we found no differences between the intervention groups for the primary (ROM including TAM, TAM as a percentage of the contralateral side [%TAM], and Millers Criteria) and secondary outcome measures of grip strength, QuickDASH and PRWHE scores. The models did identify several covariates that are correlated with outcome measures. The covariate 'Age' influenced TAM (P = .006) and %TAM (P = .007), with increasing age correlating with less TAM and recovery of TAM compared to the contralateral digit. 'Sex' and 'Contralateral TAM' are also significant covariates for some outcomes. DISCUSSION: With similar outcomes between both intervention groups, the decision to include an additional night orthosis should be individually tailored for patients rather than protocol-based. As the covariates of 'Age' and 'Sex' influenced outcomes, these should be considered in clinical practice. CONCLUSIONS: A relative motion extension only approach with or without an additional overnight wrist-hand-finger orthosis yielded clinically similar results whilst allowing early functional hand use, without tendon rupture.

Interventions for social and community participation for adults with intellectual disability, psychosocial disability or on the autism spectrum: An umbrella systematic review.

Objective: This umbrella systematic review examined the effectiveness, facilitators, and barriers of interventions for social, community and civic participation for adults on the autism spectrum, or with intellectual or psychosocial disability. Data Sources: Eight databases were searched to identify eligible reviews defined by the: Sample (≥50% adults on the autism spectrum or with intellectual or psychosocial disability), Phenomena of Interest (interventions in community settings that aimed to improve social, community or civic participation, or capacity to participate), Design (any), Evaluation (any method that evaluated impacts on participation or capacity to participate), and Research type (reviews as journal articles, dissertations or in grey literature, in English, published 2010-2020). Review Methods: Rapid review methods were used. One researcher screened 27,890 records and 788 potentially eligible full texts. A second reviewer independently screened 20% of records, and ambiguous full text publications. Study quality was extracted, and review quality was assessed with the Assessing Methodological Quality of Systematic Reviews (AMSTAR) checklist. Data from 522 studies in 57 eligible systematic reviews were extracted for narrative synthesis. The Corrected Covered Area (CCA) was calculated to indicate overlap between reviews. Results: There was a pooled sample of 28,154 study participants, predominantly from studies in North America, the UK and Europe. There was very low overlap between reviews (CCA = 0.3%). Reviews were predominantly low quality: 77.2% of reviews met <50% of AMSTAR criteria. Most studies were low (45.4%) or moderate (38.3%) quality. Three broad intervention categories improved participation, inclusion and belonging outcomes: (1) interventions to help people identify and connect with participation opportunities (e.g., person centred planning); (2) participation opportunities or activities (e.g., joining a community group, sports or outdoor activities, or arts-based activities); and (3) supports to build skills and capacity to participate socially and in the community. Conclusions: The evidence highlighted that improved social and community participation requires purposeful strategies that identify meaningful participation preferences (e.g., where, when, how, and with whom) and provide support to build capacity or enable ongoing participation. Community capacity building, peer support and advocacy may also be needed to make the community more accessible, and to enable people to exercise genuine choice.

Hand therapy role in return to work for patients with hand and upper limb conditions.

STUDY DESIGN: Electronic Web-based survey INTRODUCTION: Evidence supports the use of health-focused interventions combined with service coordination and work modification components to reduce the individual, community, and societal burden associated with acute and chronic musculoskeletal conditions. The levels of engagement, skill, and confidence of Australian hand therapists in assisting their patients to return to work (RTW) are currently unknown. PURPOSE OF THE STUDY: To identify current practices, skill, and the need for additional training in management of the RTW process from a sample of Australian hand therapists. METHODS: An electronic survey was sent to current members of the Australian Hand Therapy Association. Data collected included training and/or professional experience, caseload and/or workplace, scope of and barriers to vocational practice, and satisfaction with own contribution to the RTW process for patients. RESULTS: A total of 99 individual responses (12.4% of total membership) were included, with most indicating a limited role in the RTW process. Only 52.7% said they regularly monitored and adjusted their patients' RTW program. Most plans were informed by formal tests of underlying body structure and function components rather than the patient's ability to perform of a specific work role or task. Median satisfaction with the quality of RTW service they provided was 6 of 10, with 42% scoring ≤ 5 of 10, indicating considerable scope for improvement. CONCLUSIONS: Practice patterns are described for planning and monitoring RTW, and these did not always align with the evidence-base. Further exploration of clinician barriers to implementing RTW interventions is warranted, as is upskilling for those indicating a lack of confidence in this field.

The Effectiveness of Multicomponent Functional Maintenance Initiatives for Acutely Hospitalized Older Adults: A Systematic Review and Meta-analysis.

BACKGROUND AND PURPOSE: To evaluate the effectiveness of multicomponent functional maintenance initiatives (MFMIs) on functional outcomes and adverse events associated with functional decline among acutely hospitalized older adults. DATA SOURCES: Studies were sourced from OVID Medline, PubMed, Embase, CINAHL, the Cochrane Library, and PEDro databases from inception to April 15, 2020, and their bibliographies. STUDY SELECTION: Randomized controlled trials were included if they investigated multicomponent interventions comprising more than one nonpharmacological intervention targeting physical functional decline and another shared risk factor for geriatric syndromes in acutely hospitalized medical or nonelective surgical patients 65 years and older. DATA EXTRACTION: Two reviewers independently assessed for eligibility, extracted data, and conducted risk of bias assessments. DATA SYNTHESIS: Eight studies involving 5534 patients were included. Multicomponent functional maintenance initiatives did not appear to confer significant effects on functional status, length of stay, or 30-day hospital readmissions; however, clinical heterogeneity limited meta-analysis for some specific functional outcomes. Patients who did not receive MFMIs were more likely to be discharged to a nursing staff facility (odds ratio = 1.53; 95% confidence interval, 1.23 to 1.90). No effect of MFMI on all-cause mortality was observed, and adverse events were rare and unlikely attributed to nonpharmacological interventions. CONCLUSIONS: Data from a small number of studies suggest MFMIs reduce the likelihood of discharge to a nursing staff facility in acutely hospitalized older adults; however, this effect may not be driven via improvements in physical function. Standardized evaluation methods to determine MFMI effectiveness appear indicated to assist decision-making regarding their implementation in clinical practice.

The effect of transferring weekend physical therapy services from the acute to sub-acute setting in patients following hip and knee arthroplasty: a quasi-experimental study.

BACKGROUND: Weekend physical therapy services in the acute and/or sub-acute setting may optimize postoperative recovery following hip and knee arthroplasty, though evidence supporting these services is limited. PURPOSE: To explore the change in patient and service outcomes of transferring a weekend physical therapy service from the acute to the sub-acute setting following hip and knee arthroplasty. METHODS: This was a quasi-experimental research design nested within two stepped-wedge cluster randomized controlled trials. Acute weekend physical therapy services were sequentially discontinued and reallocated to the sub-acute setting in a random order from one ward at a time within the broader trial. Patient and service outcomes for participants 6 weeks following hip and knee arthroplasty (N = 247) were compared during 6 months of acute weekend physical therapy services (Phase 1, n = 117) followed by 6 months of sub-acute services (Phase 2, n = 130). Intention-to-treat statistical analyses were conducted. RESULTS: The intervention had a negligible effect on medium-term outcomes. The only statistically significant difference observed was slightly higher ratings of "worst pain experienced over the past week" [coefficient 0.865 (0.123 to 1.606), p = .022] during Phase 2. No interaction effects were observed despite a 2.4-day reduction in length of stay amongst complex patients during Phase 2 (18.28 and 15.86 days in Phase 1 and 2, respectively). CONCLUSIONS: No comparative advantage or disadvantage was observed by reallocating a weekend physical therapy budget from the acute to sub-acute setting following hip and knee arthroplasty. Further research investigating the cost-effectiveness of these services in the sub-acute setting may be warranted for complex patients.

Moving Past the Loss: A Longitudinal Qualitative Study of Health Care Staff Experiences of Disinvestment.

This longitudinal qualitative study examines staff experience of disinvestment from a service they are accustomed to providing to their patients. It took place alongside a disinvestment trial that measured the impact of the removal of weekend allied health services from acute wards at two hospitals. Data were gathered from repeated interviews and focus groups with 450 health care staff. We developed a grounded theory, which explains changes in staff perceptions over time and the key modifying factors. Staff appeared to experience disinvestment as loss; a key difference to other operational changes. Early staff experiences of disinvestment were primarily negative, but evolved with time and change-management strategies such as the provision of data, clear and persistent communication approaches, and forums where the big picture context of the disinvestment was robustly discussed. These allowed the disinvestment trial to be successfully implemented at two health services, with high compliance with the research protocol.

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.