Development and internal validation of a dynamic fall risk prediction and monitoring tool in aged care using routinely collected electronic health data: a landmarking approach.

OBJECTIVES: Falls pose a significant challenge in residential aged care facilities (RACFs). Existing falls prediction tools perform poorly and fail to capture evolving risk factors. We aimed to develop and internally validate dynamic fall risk prediction models and create point-based scoring systems for residents with and without dementia. MATERIALS AND METHODS: A longitudinal cohort study using electronic data from 27 RACFs in Sydney, Australia. The study included 5492 permanent residents, with a 70%-30% split for training and validation. The outcome measure was the incidence of falls. We tracked residents for 60 months, using monthly landmarks with 1-month prediction windows. We employed landmarking dynamic prediction for model development, a time-dependent area under receiver operating characteristics curve (AUROCC) for model evaluations, and a regression coefficient approach to create point-based scoring systems. RESULTS: The model identified 15 independent predictors of falls in dementia and 12 in nondementia cohorts. Falls history was the key predictor of subsequent falls in both dementia (HR 4.75, 95% CI, 4.45-5.06) and nondementia cohorts (HR 4.20, 95% CI, 3.87-4.57). The AUROCC across landmarks ranged from 0.67 to 0.87 for dementia and from 0.66 to 0.86 for nondementia cohorts but generally remained between 0.75 and 0.85 in both cohorts. The total point risk score ranged from -2 to 57 for dementia and 0 to 52 for nondementia cohorts. DISCUSSION: Our novel risk prediction models and scoring systems provide timely person-centered information for continuous monitoring of fall risk in RACFs. CONCLUSION: Embedding these tools within electronic health records could facilitate the implementation of targeted proactive interventions to prevent falls.

Allied health service delivery in residential aged care and the impact of the coronavirus (COVID-19) pandemic: a survey of the allied health workforce.

Objectives Industry reports suggest that routine and essential care in Australian residential aged care (RAC), including allied health (AH) services, were disrupted during the coronavirus diseas 2019 (COVID-19) pandemic. This study aimed to explore whether AH services in RAC were paused during the pandemic, factors associated with a pause in care delivery, and qualitative details on how COVID-19 impacted AH service delivery. Methods A 26-question survey was distributed via social media, health service providers, and AH networks between February and April 2022. Participation was restricted to AH professionals and assistants with experience in RAC during the pandemic. A mix of closed and open-ended response questions was used to collect demographic data and experiences of delivering care during the pandemic. Quantitative responses were analysed with descriptive statistics and a probit model. Content analysis was performed on open-ended questions. Results One hundred and four AH professionals and assistants responded to the survey. Fifty-five percent of participants (n = 51) were contractually or casually employed. AH services were negatively impacted by the pandemic with 52% of respondents experiencing a pause in service delivery and 78% reporting poorer AH care quality. In a probit model, contracted/casually employed respondents were more likely to experience a pause in care delivery (1.03, P < 0.05) compared to permanently employed AH professionals. Conclusion Insecure work arrangements may have exacerbated inconsistent care during the pandemic (impacting residents) and may have negative implications on the RAC AH workforce. In the future, an AH inclusive workforce policy including data collection and research is required to monitor and plan the RAC workforce.

The use and predictive performance of the Peninsula Health Falls Risk Assessment Tool (PH-FRAT) in 25 residential aged care facilities: a retrospective cohort study using routinely collected data.

BACKGROUND: The Peninsula Health Falls Risk Assessment Tool (PH-FRAT) is a validated and widely applied tool in residential aged care facilities (RACFs) in Australia. However, research regarding its use and predictive performance is limited. This study aimed to determine the use and performance of PH-FRAT in predicting falls in RACF residents. METHODS: A retrospective cohort study using routinely-collected data from 25 RACFs in metropolitan Sydney, Australia from Jul 2014-Dec 2019. A total of 5888 residents aged ≥65 years who were assessed at least once using the PH-FRAT were included in the study. The PH-FRAT risk score ranges from 5 to 20 with a score > 14 indicating fallers and ≤ 14 non-fallers. The predictive performance of PH-FRAT was determined using metrics including area under receiver operating characteristics curve (AUROC), sensitivity, specificity, sensitivityEvent Rate(ER) and specificityER. RESULTS: A total of 27,696 falls were reported over 3,689,561 resident days (a crude incident rate of 7.5 falls /1000 resident days). A total of 38,931 PH-FRAT assessments were conducted with a median of 4 assessments per resident, a median of 43.8 days between assessments, and an overall median fall risk score of 14. Residents with multiple assessments had increased risk scores over time. The baseline PH-FRAT demonstrated a low AUROC of 0.57, sensitivity of 26.0% (sensitivityER 33.6%) and specificity of 88.8% (specificityER 82.0%). The follow-up PH-FRAT assessments increased sensitivityER values although the specificityER decreased. The performance of PH-FRAT improved using a lower risk score cut-off of 10 with AUROC of 0.61, sensitivity of 67.5% (sensitivityER 74.4%) and specificity of 55.2% (specificityER 45.6%). CONCLUSIONS: Although PH-FRAT is frequently used in RACFs, it demonstrated poor predictive performance raising concerns about its value. Introducing a lower PH-FRAT cut-off score of 10 marginally enhanced its predictive performance. Future research should focus on understanding the feasibility and accuracy of dynamic fall risk predictive tools, which may serve to better identify residents at risk of falls.

Diagnostic Informatics-The Role of Digital Health in Diagnostic Stewardship and the Achievement of Excellence, Safety, and Value.

Diagnostic investigations (pathology laboratory and medical imaging) aim to: increase certainty of the presence or absence of disease by supporting the process of differential diagnosis; support clinical management; and monitor a patient's trajectory (e. g., disease progression or response to treatment). Digital health can be defined as the collection, storage, retrieval, transmission, and utilization of data, information, and knowledge to support healthcare. Digital health has become an essential component of the diagnostic process, helping to facilitate the accuracy and timeliness of information transfer and enhance the effectiveness of decision-making processes. Digital health is also important to diagnostic stewardship, which involves coordinated guidance and interventions to ensure the appropriate utilization of diagnostic tests for therapeutic decision-making. Diagnostic stewardship and informatics are thus important in efforts to establish shared decision-making. This is because they contribute to the establishment of shared information platforms (enabling patients to read, comment on, and share in decisions about their care) based on timely and meaningful communication. This paper will outline key diagnostic informatics and stewardship initiatives across three interrelated fields: (1) diagnostic error and the establishment of outcomes-based diagnostic research; (2) the safety and effectiveness of test result management and follow-up; and (3) digitally enhanced decision support systems.

Delivering safe and effective test-result communication, management and follow-up: a mixed-methods study protocol.

INTRODUCTION: The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems. METHODS AND ANALYSIS: This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia.Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions.Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes.Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings. ETHICS AND DISSEMINATION: Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences.