Self-management Programs Within Rehabilitation Yield Positive Health Outcomes at a Small Increased Cost Compared With Usual Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine if self-management programs, supported by a health professional, in rehabilitation are cost effective. DATA SOURCES: Six databases were searched until December 2023. STUDY SELECTION: Randomized controlled trials with adults completing a supported self-management program while participating in rehabilitation or receiving health professional input in the hospital or community settings were included. Self-management programs were completed outside the structured, supervised therapy and health professional sessions. Included trials had a cost measure and an effectiveness outcome reported, such as health-related quality of life or function. Grading of Recommendations, Assessment, Development, and Evaluations was used to determine the certainty of evidence across trials included in each meta-analysis. Incremental cost-effectiveness ratios were calculated based on the mean difference from the meta-analyses of contributing health care costs and quality of life. DATA EXTRACTION: After application of the search strategy, two independent reviewers determined eligibility of identified literature, initially by reviewing the title and/or abstract before full-text review. Using a customized form, data were extracted by one reviewer and checked by a second reviewer. DATA SYNTHESIS: Forty-three trials were included, and 27 had data included in meta-analyses. Where self-management was a primary intervention, there was moderate certainty of a meaningful positive difference in quality-of-life utility index of 0.03 units (95% confidence interval, 0.01-0.06). The cost difference between self-management as the primary intervention and usual care (comprising usual intervention/therapy, minimal intervention [including education only], or no intervention) potentially favored the comparison group (mean difference=Australian dollar [AUD]90; 95% confidence interval, -AUD130 to AUD310). The cost per quality-adjusted life year (QALY) gained for self-management programs as a stand-alone intervention was AUD3000, which was below the acceptable willingness-to-pay threshold in Australia per QALY gained (AUD50,000/QALY gained). CONCLUSIONS: Self-management as an intervention is low cost and could improve health-related quality of life.

Safety-related outcomes for patients with a tracheostomy and the use of flexible endoscopic evaluation of swallowing (FEES) for assessment and management of swallowing: A systematic review.

PURPOSE: The purpose of this systematic review was to examine safety-related outcomes for patients with tracheostomy after flexible endoscopic evaluation of swallowing (FEES) to assess and manage their swallow, when compared to other non-instrumental swallow assessments such as clinical swallowing examination (CSE) and/or a modified Evans blue dye test (MEBDT). METHOD: Three databases were searched for articles referring to safety-related outcome data for adults with a tracheostomy, who underwent FEES and CSE and/or MEBDT. Articles were screened using predefined inclusion/exclusion criteria. RESULT: The search strategy identified 2097 articles; following abstract and full-text screening, seven were included for review. The summary of evidence found low to very low certainty that FEES was associated with improved outcomes across swallow safety, physiological outcomes, tracheostomy cannulation duration, functional outcomes, and detection of upper airway pathologies. CONCLUSION: This systematic review demonstrated low to very low certainty evidence from seven heterogeneous studies with low sample sizes that incorporating FEES may be associated with improved safety-related outcomes. There is less evidence supporting the accuracy of other swallow assessments conducted at the point of care (i.e. CSE and MEBDT). Future research requires studies with larger sample sizes and routine reporting of safety-related outcomes with use of FEES.

Reforming allied health service provision in residential aged care to improve the rehabilitation reach: a feasibility study.

Objective My Therapy is an allied health guided, co-designed rehabilitation self-management program for residents of aged care facilities. This study aimed to determine the feasibility of implementing My Therapy in a residential aged care setting. Methods This observational study was conducted on a 30-bed wing, within a 90-bed metropolitan residential aged care facility, attached to a public health service, in Victoria, Australia. Staff and resident data were collected prospectively over 6 weeks (staff focus groups, patient surveys, and audits) to evaluate the feasibility domains of acceptability , reach and demand , practicality , integration , limited efficacy testing and adaptations . Results Twenty-six residents and five allied health staff (physiotherapy and occupational therapy) participated. My Therapy was acceptable to residents (survey) and staff (focus groups). Via initial My Therapy discussions between the resident and the therapists, to determine goals and resident preferences, My Therapy reached 26 residents (n = 26/26, 100% program reach ), with 15 residents subsequently receiving a rehabilitation program (n = 15/26, 58% program demand ). The remaining 11 residents did not participate due to resident preference or safety issues (n = 11/26, 42%). Collecting physical function outcome measures for limited efficacy testing was practical , and the cost of My Therapy was AUD$6 per resident per day, suggesting financial integration may be possible. Several adaptations were required, due to limited allied health staff, complex resident goal setting and program co-design. Conclusion My Therapy has the potential to improve the rehabilitation reach of allied health services in residential aged care. While introducing this low-cost intervention is feasible, adaptations were required for successful implementation.

Feasibility of implementing an innovative manual handling risk assessment training program for staff working in long-term care.

BACKGROUND: The Risk Assessment for moving Individuals SafEly (RAISE) program is a hospital-based manual handling nursing training program. RAISE involves upskilling on continual risk assessment during patient-assisted movements. RAISE aims to optimise staff and patient safety while providing the patient with movement and rehabilitation opportunities. Implementation of RAISE in the hospital setting has been established. The aim of this study was to explore the feasibility of implementing RAISE in the long-term care setting. METHODS: We examined three feasibility domains: acceptability, practicality, and limited efficacy (observed nursing behaviour change which has the potential to reduce nursing injuries), using a prospective pilot pre-post design in the long-term care setting. Staff completed a 4-hour training session on RAISE delivered by two physiotherapists, followed by 8 h of supported behaviour change in the workplace. Staff acceptability and practicality of incorporating risk assessment strategies into manual handling approaches were explored through pre- and post-training staff surveys and a semi-structured interview. Resident acceptability of manual handling practices was explored via survey data collected after the RAISE training. Pre to post-training changes in staff knowledge and behaviour were examined through the pre- and post-training staff survey, and observation of staff assisting resident movement. RESULTS: Two enrolled nurses and five residents participated. Staff reported the RAISE program was acceptable and practical to implement in the long-term care setting. There were no adverse events or safety concerns. Staff reported the RAISE program provided guidance and enhanced staff empowerment to make decisions during assisted resident movement. There were 26 observed resident-staff manual handling interactions recorded, with 13 pre-training and 13 post-training. Post-training, RAISE skills had improved and were completed 100% of the time, except for completing a physical risk assessment which improved from 46 to 85%, demonstrating limited efficacy. Residents reported it's important for staff to be trained on how to assist them to mobilise and they found the concept of the RAISE program acceptable. CONCLUSIONS: This pilot study supports the feasibility of long-term care facilities participating in future studies testing the effectiveness and cost-effectiveness of the Risk Assessment for moving Individuals SafEly (RAISE) patient and resident manual handling program.

Nurses sustain manual handling risk assessment behaviours six-months after a training program to move patients safely: a pre-post study.

PURPOSE: To determine if a patient manual handling training program focused on dynamic manual handling risk assessment for staff and patient safety, together with the patient's need for physical rehabilitation, can be transferred and sustained in clinical practice. MATERIALS AND METHODS: Using a pre-post design, nurses (n = 72) from acute and rehabilitation wards participated in a 4-hour training session teaching dynamic manual handling risk assessment to safely move patients. Clinical observations audits of patient transfers were conducted prior to, and at 1-month and 6-months post training. Surveys determined experiences of training. Nurse musculoskeletal injuries and patient falls were measured 6-months after training. RESULTS: Program patient handling skills were competently implemented 89% of the time 1-month following training and were sustained 6-months following training. There was no change in falls rates and staff injury rates were very low pre- and post-training. Training was well received and all nurses passed the competency assessment. CONCLUSION: The patient handling training program taught nurses to better identify factors associated with risk to themselves and their patients and gave them improved skills to help patients move. Skills were incorporated safely into clinical practice and sustained at 6-months. It is uncertain whether training impacted musculoskeletal injuries.Implications for rehabilitationA dynamic manual handling risk assessment program for safely transferring and moving patients balances staff safety with the patient's need for physical rehabilitation.Nurses can be taught risk assessment skills to better identify factors associated with risk to themselves and their patients that can be translated to clinical practice.Thorough risk assessment at the point of the nurse-patient interaction can enable a patient to move at their highest level of function thus providing patients with opportunities to progress their rehabilitation at every interaction.

Progressive resistance training in young people with Prader-Willi syndrome: protocol for a randomised trial (PRESTO).

INTRODUCTION: Preliminary evidence suggests that progressive resistance training may be beneficial for people with Prader-Willi Syndrome (PWS), a rare genetic condition that results in muscle weakness and low muscle tone.To establish whether community-based progressive resistance training is effective in improving the muscle strength of people with PWS; to determine cost-effectiveness; and, to complete a process evaluation assessing intervention fidelity, exploring mechanisms of impact, understanding participant experiences and identifying contextual factors affecting implementation. METHODS AND ANALYSIS: A multisite, randomised controlled trial will be completed. Sixty participants with PWS will be randomised to receive either progressive resistance training (experimental) or non-progressive exercise (placebo control). Participants will be aged 13 to 60 years, be able to follow simple instructions in English and have no contraindications to performing progressive resistance training. The experimental group will complete progressive resistance training two times weekly for 24 weeks supervised by an exercise professional at a community gym. The control group will receive all aspects of the intervention except progressive overload. Outcomes will be assessed at week 25 (primary endpoint) and week 52 by a blinded assessor. The primary outcome is muscle strength assessed using one repetition maximum for upper limb and lower limb. Secondary outcomes are muscle mass, functional strength, physical activity, community participation, health-related quality of life and behaviour. Health economic analysis will evaluate cost-effectiveness. Process evaluation will assess safety and intervention fidelity, investigate mechanism of impact, explore participant experiences and identify contextual factors affecting implementation. Data collection commenced in February 2020 and will conclude in September 2023. ETHICS AND DISSEMINATION: Ethical approval was obtained from The Royal Children's Hospital Human Research Ethics Committee (HREC/50874/RCHM-2019) under the National Mutual Acceptance initiative. Research governance approvals were obtained from five clinical sites. Results will be disseminated through published manuscripts, conference presentations, public seminars and practical resources for stakeholder groups. TRIAL REGISTRATION NUMBER: ACTRN12620000416998; Australian and New Zealand Clinical Trial Registry.

The impact of outsourcing bed-based aged care services on quality of care: A multisite observational study.

BACKGROUND: Outsourcing health-care services has become popular globally, provided by both profit and non-for-profit organizations with varying degrees of quality. To date, few published studies have evaluated the quality of care in health services using outsourcing. OBJECTIVE: The purpose of this study was to determine if there were differences in quality of care (effectiveness, safety and patient experience) for a Transition Care Program designed to improve older people's independence and confidence after a hospital stay, when provided within a public health network compared to being outsourced to private facilities. METHODS: For clients discharged to a residential Transition Care Program operating across three sites from a large health service network (n = 1546), an audit of medical records was completed. Site 1 remained within the public health service (internally managed), whereas Sites 2 and 3 involved outsourcing to residential aged care facilities. The main outcome measures were discharge destination, length of stay and number of falls. Client demographics were analysed descriptively, and inferential statistics for continuous data and negative binomial regression for event data were used to examine differences between the sites. RESULTS: There were differences in quality of care between the internally and outsourced managed sites. One outsourced site discharged a smaller proportion to rehabilitation (P = 0.003) compared to the other two sites. There were differences in length of stay between the three sites. The length of stay was a mean of 4.8 days less at Site 1 (internally managed) (95% Confidence Interval (CI) 0.5 to 9.1) than Site 2 and 4.6 days less (95% CI 1.2 to 8.1) than Site 3. For those discharged to permanent residential care, the length of stay was 9.4 days less at the internal site than Site 2 (95% CI 3.5 to 15.2) and 7.0 days less than Site 3 (95% CI 1.9 to 12). Additionally, a lower rate of falls was recorded at Site 1 (internally managed) compared to Site 2 (outsourced) (incidence rate ratio = 0.44 (95% CI 0.32 to 0.60), P < 0.001). CONCLUSION: An internally managed Transition Care Program in a public health network was associated with better quality of care outcomes compared to outsourced services.

Service redesign interventions to reduce waiting time for paediatric rehabilitation and therapy services: A systematic review of the literature.

Despite well-documented benefits of rehabilitation and therapy services for children with disabilities, long waiting lists to access these services are common. There is a growing body of evidence, primarily from mixed or adult services, demonstrating that waiting times can be reduced through strategies that target wasteful processes and support services to keep up with demand. However, providers of rehabilitation and therapy services for children face additional complexities related to the long-term nature of many developmental conditions and the need to consider timing of interventions with developmental milestones and education transition points. This review aimed to synthesise available evidence on service redesign strategies in reducing waiting time for paediatric therapy services. We conducted a systematic review of studies conducted in outpatient paediatric rehabilitation or therapy settings, including physical and mental health services, evaluating a service redesign intervention and presenting comparative data on time to access care. Two reviewers independently applied inclusion criteria, assessed risk of bias and extracted data. Findings were analysed descriptively and the certainty of evidence was synthesised according to criteria for health service research. From 1934 studies identified, 33 met the criteria for inclusion. Interventions were categorised as rapid response strategies, process efficiency interventions or substitution strategies (using alternative providers in place of medical specialists). Reductions in waiting time were reported in 30 studies. Evidence is limited by study designs with high risk of bias, but this is mitigated by consistency of findings and large effect sizes. There is moderate-certainty evidence that service redesign strategies similar to those used in adult populations can be applied in paediatric rehabilitation and therapy settings to reduce waiting time.

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 ß 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control ß 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker ß -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control ß 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control ß -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker ß -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 ß 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control ß -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker ß -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.

Self-managed occupational therapy and physiotherapy for adults receiving inpatient rehabilitation ('My Therapy'): protocol for a mixed-methods process evaluation.

BACKGROUND: Process evaluations have been recommended alongside clinical and economic evaluations to enable an in-depth understanding of factors impacting results. My Therapy is a self-management program designed to augment usual care inpatient rehabilitation through the provision of additional occupational therapy and physiotherapy exercises and activities, for the patient to complete outside of supervised therapy. The aims of the process evaluation are to assess the implementation process by investigating fidelity, quality of implementation, acceptability, adoption, appropriateness, feasibility and adaptation of the My Therapy intervention; and identify contextual factors associated with variations in outcomes, including the perspectives and experiences of patients and therapists. METHODS: The process evaluation will be conducted alongside the clinical and economic evaluation of My Therapy, within eight rehabilitation wards across two public and two private Australian health networks. All participants of the stepped wedge cluster randomised trial (2,160 rehabilitation patients) will be included in the process evaluation (e.g., ward audit); with a subset of 120 participants undergoing more intensive evaluation (e.g., surveys and activity logs). In addition, 24 staff (occupational therapists and physiotherapists) from participating wards will participate in the process evaluation. The mixed-methods study design will adopt a range of quantitative and qualitative research approaches. Data will be collected via a service profile survey and audits of clinical practice across the participating wards (considering areas such as staffing profiles and prescription of self-management programs). The intensive patient participant data collection will involve structured therapy participation and self-management program audits, Exercise Self Efficacy Scale, patient activity logs, patient surveys, and patient-worn activity monitors. Staff data collection will include surveys and focus groups. DISCUSSION: The process evaluation will provide context to the clinical and economic outcomes associated with the My Therapy clinical trial. It considers how clinical and economic outcomes were achieved, and how to sustain the outcomes within the participating health networks. It will also provide context to inform future scaling of My Therapy to other health networks, and influence future models of rehabilitation and related policy. TRIAL REGISTRATION: This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true ).

Self-managed occupational therapy and physiotherapy for adults receiving inpatient rehabilitation ('My Therapy'): protocol for a stepped-wedge cluster randomised trial.

BACKGROUND: Ensuring patients receive an effective dose of therapeutic exercises and activities is a significant challenge for inpatient rehabilitation. My Therapy is a self-management program which encourages independent practice of occupational therapy and physiotherapy exercises and activities, outside of supervised therapy sessions. METHODS: This implementation trial aims to determine both the clinical effectiveness of My Therapy on the outcomes of function and health-related quality of life, and cost-effectiveness per minimal clinically important difference (MCID) in functional independence achieved and per quality adjusted life year (QALY) gained, compared to usual care. Using a stepped-wedge cluster randomised design, My Therapy will be implemented across eight rehabilitation wards (inpatient and home-based) within two public and two private Australian health networks, over 54-weeks. We will include 2,160 patients aged 18 + years receiving rehabilitation for any diagnosis. Each ward will transition from the usual care condition (control group receiving usual care) to the experimental condition (intervention group receiving My Therapy in addition to usual care) sequentially at six-week intervals. The primary clinical outcome is achievement of a MCID in the Functional Independence Measure (FIM™) at discharge. Secondary outcomes include improvement in quality of life (EQ-5D-5L) at discharge, length of stay, 30-day re-admissions, discharge accommodation, follow-up rehabilitation services and adverse events (falls). The economic outcomes are the cost-effectiveness per MCID in functional independence (FIM™) achieved and per QALY gained, for My Therapy compared to usual care, from a health-care sector perspective. Cost of implementation will also be reported. Clinical outcomes will be analysed via mixed-effects linear or logistic regression models, and economic outcomes will be analysed via incremental cost-effectiveness ratios. DISCUSSION: The My Therapy implementation trial will determine the effect of adding self-management within inpatient rehabilitation care. The results may influence health service models of rehabilitation including recommendations for systemic change to the inpatient rehabilitation model of care to include self-management. Findings have the potential to improve patient function and quality of life, and the ability to participate in self-management. Potential health service benefits include reduced hospital length of stay, improved access to rehabilitation and reduced health service costs. TRIAL REGISTRATION: This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true ).

Return on investment of a model of access combining triage with initial management: an economic analysis.

OBJECTIVES: Timely access to outpatient services is a major issue for public health systems. To address this issue, we aimed to establish the return on investment to the health system of the implementation of an alternative model for access and triage (Specific Timely Appointments for Triage: STAT) compared with a traditional waitlist model. DESIGN: Using a prospective pre-post design, an economic analysis was completed comparing the health system costs for participants who were referred for community outpatient services post-implementation of STAT with a traditional waitlist comparison group. SETTING: Eight community outpatient services of a health network in Melbourne, Australia. PARTICIPANTS: Adults and children referred to community outpatient services. INTERVENTIONS: STAT combined targeted activities to reduce the existing waiting list and direct booking of patients into protected assessment appointments. STAT was compared with usual care, in which new patients were placed on a waiting list and offered appointments as space became available. OUTCOMES: Health system costs included STAT implementation costs, outpatient health service use, emergency department presentations and hospital admissions 3 months before and after initial outpatient appointment. Waiting time was the primary outcome. Incremental cost-effectiveness ratios (ICERs) were estimated from the health system perspective. RESULTS: Data from 557 participants showed a 16.9 days or 29% (p<0.001) reduction in waiting time for first appointment with STAT compared with traditional waitlist. The ICER showed a cost of $A10 (95% CI -19 to 39) per day reduction in waiting time with STAT compared with traditional waitlist. Modelling showed the cost reduced to $A4 (95% CI -25 to 32) per day of reduction in waiting, if reduction in waiting times is sustained for 12 months. CONCLUSIONS: There was a significant reduction in waiting time with the introduction of STAT at minimal cost to the health system. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12615001016527).

Motivational interviewing with community-dwelling older adults after hip fracture (MIHip): protocol for a randomised controlled trial.

INTRODUCTION: Community-dwelling people recovering from hip fracture have the physical capacity to walk in their community but lack the confidence to do so. The primary aim of this trial is to determine whether motivational interviewing increases time spent walking at 12 months in community-dwelling people after hip fracture compared with an attention placebo control group. Secondary aims are to evaluate cost effectiveness, patient and health service outcomes and to complete a process evaluation. METHODS AND ANALYSIS: An assessor-blinded parallel group randomised controlled design with embedded health economic evaluation and process evaluation will compare the effects of n=270 participants randomly allocated to an experimental group (motivational interviewing) or a control group (dietary advice). For inclusion, participants are aged ≥65 years, living at home independently within 6 months of discharge from hospital after hip fracture and able to walk independently and communicate with conversational English. Key exclusion criteria are severe depression or anxiety, impaired intellectual functioning and being medically unstable to walk. Participants allocated to the experimental group will receive 10 (8 weekly and 2 booster) telephone-based sessions of motivational interviewing to increase walking over 16 weeks. Participants allocated to the control group will receive an equivalent dose of telephone-based dietary advice. The primary outcome is daily time spent walking over 7 days assessed at weeks 0, 9, 26 and 52. Secondary outcomes include measures of psychological-related function, mobility-related function, community participation, health-related quality of life and falls. Health service utilisation and associated costs will be assessed. Process evaluation will assess the fidelity of the motivational interviewing intervention and explore contextual factors through semistructured interviews. ETHICS AND DISSEMINATION: Ethical approval obtained from Eastern Health (E19-002), Peninsula Health (50261/EH-2019), Alfred Health (617/20) and La Trobe University (E19/002/50261). The findings will be disseminated in peer-reviewed journals, conference presentations and public seminars. TRIAL REGISTRATION NUMBER: ACTRN12619000936123.

The Impact of Enhanced Recovery After Surgery on Total Joint Arthroplasty: Protocol for a Systematic Review and Meta-analysis.

BACKGROUND: The number of total joint arthroplasties (TJAs) being performed is increasing worldwide. To match this increasing demand, there has been focus on hastening patients' recovery of function. This effort has culminated in the formulation of enhanced recovery after surgery (ERAS) strategies. However, with evolving ERAS programs and new recommendations, a review of current evidence is required to provide clinicians with up-to-date information about its effect on outcomes for TJA. OBJECTIVE: The objective of this study is to assess the utility of ERAS programs on patient, health service, and economic outcomes for primary, elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A systematic search will be conducted in Medline (Ovid), EMCARE (Ovid), EMBASE (Ovid), Web of Science, CINAHL, National Health Service Economic Evaluations Database, and the Cochrane Library. Analytical, observational, and experimental designs will be included in this systematic review. Only studies including patients undergoing primary TKA and THA comparing ERAS programs with conventional surgery and postoperative care will be included. Data related to patient outcomes, health service outcomes, safety, and economic evaluation will be extracted. RESULTS: The search terms and primary database searches have been finalized. Findings will be reported in narrative and tabular form. Where appropriate, random effects meta-analyses will be conducted for each outcome, and heterogeneity quantified with Cochran Q test and I2 statistic. Measures of effect or mean differences will be reported with 95% confidence intervals. The results of this systematic review will be disseminated in a peer-reviewed journal. CONCLUSIONS: This protocol will guide a systematic review assessing outcomes associated with ERAS surgery in primary THA and TKA. TRIAL REGISTRATION: Open Science Framework osf.io/y4bhs; https://osf.io/y4bhs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25581.

Physical activity coaching for adults with mobility limitations: protocol for the ComeBACK pragmatic hybrid effectiveness-implementation type 1 randomised controlled trial.

INTRODUCTION: Mobility limitation is common and often results from neurological and musculoskeletal health conditions, ageing and/or physical inactivity. In consultation with consumers, clinicians and policymakers, we have developed two affordable and scalable intervention packages designed to enhance physical activity for adults with self-reported mobility limitations. Both are based on behaviour change theories and involve tailored advice from physiotherapists. METHODS AND ANALYSIS: This pragmatic hybrid effectiveness-implementation type 1 randomised control trial (n=600) will be undertaken among adults with self-reported mobility limitations. It aims to estimate the effects on physical activity of: (1) an enhanced 6-month intervention package (one face-to-face physiotherapy assessment, tailored physical activity plan, physical activity phone coaching from a physiotherapist, informational/motivational resources and activity monitors) compared with a less intensive 6-month intervention package (single session of tailored phone advice from a physiotherapist, tailored physical activity plan, unidirectional text messages, informational/motivational resources); (2) the enhanced intervention package compared with no intervention (6-month waiting list control group); and (3) the less intensive intervention package compared with no intervention (waiting list control group). The primary outcome will be average steps per day, measured with the StepWatch Activity Monitor over a 1-week period, 6 months after randomisation. Secondary outcomes include other physical activity measures, measures of health and functioning, individualised mobility goal attainment, mental well-being, quality of life, rate of falls, health utilisation and intervention evaluation. The hybrid effectiveness-implementation design (type 1) will be used to enable the collection of secondary implementation outcomes at the same time as the primary effectiveness outcome. An economic analysis will estimate the cost-effectiveness and cost-utility of the interventions compared with no intervention and to each other. ETHICS AND DISSEMINATION: Ethical approval has been obtained by Sydney Local Health District, Royal Prince Alfred Zone. Dissemination will be via publications, conferences, newsletters, talks and meetings with health managers. TRIAL REGISTRATION NUMBER: ACTRN12618001983291.

Sustainable waiting time reductions after introducing the STAT model for access and triage: 12-month follow up of a stepped wedge cluster randomised controlled trial.

BACKGROUND: Timely access is a challenge for providers of outpatient and community-based health services, as seen by the often lengthy waiting lists to manage demand. The Specific Timely Appointments for Triage (STAT) model, an alternative approach for managing access and triage, reduced waiting time by 34% in a stepped wedge cluster randomised controlled trial involving 8 services and more than 3000 participants. Follow up periods ranged from 3 to 10 months across the participating services in accordance with the stepped wedge design. This study aimed to determine whether outcomes were sustained for a full 12 months after implementation of the STAT model at each site. METHODS: Routinely collected service data were obtained for a total of 12 months following implementation of the STAT model at each of the 8 services that participated in a stepped wedge cluster randomised controlled trial. The primary outcome was time to first appointment. Secondary outcomes included non-attendance rates, time to second appointment and service use over 12 weeks. Outcomes were compared to pre-intervention data from the original trial, modelled using generalised linear mixed effects models accounting for clustering of sites. RESULTS: A 29% reduction in waiting time could be attributed to STAT over 12 months, compared to 34% in the original trial. A reduction in variability in waiting time was sustained. There were no significant changes in time to second appointment or in the number of missed appointments in the extended follow up period. CONCLUSIONS: STAT is an effective strategy for reducing waiting time in community-based outpatient services. At 12 months, small reductions in the overall effect are apparent, but reductions in variability are sustained, suggesting that people who previously waited the longest benefit most from the STAT model. TRIAL REGISTRATION: This is a 12-month follow up of a stepped wedge cluster randomised controlled trial that was registered with the Australia and New Zealand Clinical Trials Registry ( ACTRN12615001016527 ).

Establishing measurement properties in the assessment of inter-recti distance of the abdominal muscles in a postnatal women.

BACKGROUND: Diastasis of the rectus abdominis muscle is often evaluated in clinical practice but it is unknown which clinical method has the best measurement properties. OBJECTIVE: The aim of this study was to determine: (i) the criterion validity of the callipers, tape measure and finger-width to evaluate the inter-recti distance of the abdominal muscles compared to ultrasound; and (ii) inter-rater and retest reliability of these methods. DESIGN: Measurement study. METHODS: Two physiotherapists assessed the inter-recti distance of rectus abdominis on 50 women postnatally using the three clinical methods. These measurements were compared to ultrasound and assessed for inter-rater and retest reliability. RESULTS: Callipers had very good positive correlations with ultrasound (r = 0.85 to 0.99) and narrow limits of agreement (LOA) (<6 mm). Finger-width and tape measure had moderate to very good correlation with ultrasound (tape measure r = 0.82 to 0.98; finger-width r = 0.75 to 0.98) with wider limits of agreement (tape measure LOA <8 mm; finger-width LOA <18 mm). Callipers demonstrated excellent inter-rater (ICC = 0.80 to 0.99) and retest (ICC = 1.00) reliability. Inter-rater reliability testing was very good for tape measure (ICC = 0.80 to 0.97) and moderate to very good (ICC = 0.44 to 0.85) for finger-width. Retest reliability demonstrated very good reliability (ICC = 0.99 to 1.00) for both finger-width and tape measure. The largest inter-recti distances, strongest correlations and reliability were found at the level of the lower umbilicus. CONCLUSION: Callipers, tape measure and finger-width are valid and reliable methods of measuring inter-recti distance in postnatal women. Validity, and relative and absolute reliability were found to be the strongest using the callipers.

FitSkills: protocol for a stepped wedge cluster randomised trial of a community-based exercise programme to increase participation among young people with disability.

INTRODUCTION: There is a need to develop relevant, acceptable initiatives that facilitate physical activity participation in young people with disability. FitSkills was developed to support young people with disability to exercise. The primary aims are to investigate if FitSkills can be scaled up from a small, university-led programme to run as a larger community-university partnership programme, and to determine its effectiveness in improving physical activity participation and health-related quality of life for young people with disability. The secondary aims are to evaluate cost-effectiveness, changes in attitudes towards disability and other health-related outcomes for young people with disability. METHODS AND ANALYSIS: A stepped wedge cluster randomised trial using a cohort design and embedded health economic evaluation will compare the effect of FitSkills with a control phase. FitSkills matches a young person with disability with a student mentor and the pair exercise together at their local gymnasium for 1 hour, two times per week for 12 weeks (24 sessions in total). One hundred and sixty young people with disability aged 13 to 30 years will be recruited. Eight community gymnasia will be recruited and randomised into four cluster units to have FitSkills introduced at 3-month intervals. Primary (feasibility, participation and health-related quality of life) and secondary outcomes will be collected longitudinally every 3 months from trial commencement, with eight data collection time points in total. The Practical Robust Implementation and Sustainability Model will be used to support knowledge translation and implementation of project findings into policy and practice. ETHICS AND DISSEMINATION: Ethical approval was obtained from the La Trobe University Human Ethics Committee (HEC17-012), Australian Catholic University (2017-63R), Deakin University (2017-206) and the Victorian Department of Education and Training (2018_003616). Results will be disseminated through published manuscripts, conference presentations, public seminars and practical resources for stakeholder groups. TRIAL REGISTRATION NUMBER: ACTRN12617000766314. TRIAL SPONSOR: La Trobe University.

How do health professionals prioritize clinical areas for implementation of evidence into practice? A cross-sectional qualitative study.

AIM: The current study aimed to identify and understand the reasons why allied health professionals think certain areas of healthcare service provision are a high priority for implementation of evidence into practice. METHODS: A cross-sectional online survey using open-ended questions was conducted between April and May 2018 to identify potential areas for practice change and characterize how participants justified identified areas of priority. Eligible participants were invited by email and included allied health professionals from public or private health services, governance agencies and universities across Australia. Responses were analysed using qualitative content analysis. RESULTS: There were 149 surveys commenced with 146 respondents completing the survey. Of the 146 respondents, 128 were female, 17 male and one unknown. Most of the respondents were between 40 and 49 years old and had a master's degree. In total respondents from more than 13 different professions completed the survey with 110 respondents having more than 10 years of experience in allied health. Ten themes emerged outlining the main reasons respondents felt that their nominated areas of practice change were a high priority for action. These included closing gaps between practice and policy/recommendation/guideline; closing research evidence to practice gaps; improving access to services; perceived cost-effectiveness of service delivery; improving effectiveness of allied health services; current imbalance between service supply and demand; amount of resources involved in service delivery; extent of the health problem; areas of allied health care futility; and equality of workload across allied health professionals. CONCLUSION: The current research provides insights into the decision-making processes of allied health professionals when prioritizing areas of clinical practice for implementation of evidence into practice. Despite an appetite for evidence-based practice, behaviour change was not always implemented in a consistent and systematic manner. There was variability in the type and application of evidence used by allied health professionals to support clinical practice. Whether a more systematic approach to research translation fosters evidence uptake awaits confirmation. Also awaiting investigation are the economic and societal impacts of consistently implementing research-informed clinical decision-making.

Home visits by occupational therapists improve adherence to recommendations: Process evaluation of a randomised controlled trial.

INTRODUCTION: As part of hospital discharge planning, occupational therapists often provide recommendations to improve the interaction between a person and their home environment. The aim of this study was to investigate the number and type of recommendations made by occupational therapists during a home assessment visit compared to hospital-based assessment for patients recovering from hip fracture. A secondary aim was to explore adherence rates to the different types of recommendations. METHODS: Process evaluation of a randomised controlled trial of 65 participants recovering from hip fracture, returning to community living after hospital discharge. All participants received inpatient multidisciplinary rehabilitation and hospital-based assessment by an occupational therapist (usual care). In addition, the intervention group participated in a single home visit with an occupational therapist prior to hospital discharge. Analysis included the number and type of occupational therapy recommendations, adherence to recommendations at 30 days after discharge, and mediation analysis. RESULTS: Participants in the home visit group received more recommendations than the usual care group (mean difference [MD] 2.8, 95% CI 1.6 to 3.9) and adhered to a greater proportion of recommendations for assistive technologies (MD 11.4%, 95% CI 2.6 to 20.2) and task modifications (MD 10.0%, 95% CI 0.7 to 19.3). Participants in both groups had lower rates of adherence to recommendations for home modifications compared with other types of recommendations. Adherence to recommendations was a mediator in the relationship between participants' involvement in a pre-discharge home visit and reduced hospital readmissions. CONCLUSION: There was greater adherence to occupational therapy recommendations when patients recovering from hip fracture participated in a home visit compared to hospital-based assessment, contributing to reduced readmissions to hospital in the first 30 days. Home visits offer additional benefits to hospital-based assessment through the use of a collaborative approach to decision making in the home environment.