Discharge planning from hospital.

BACKGROUND: Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review. OBJECTIVES: To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS: We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov). SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS: Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text. MAIN RESULTS: We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). AUTHORS' CONCLUSIONS: A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.

Discharge planning from hospital to home.

BACKGROUND: Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital. OBJECTIVES: To determine the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS: We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2012). SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS: Two authors independently undertook data analysis and quality assessment using a pre designed data extraction sheet. Studies are grouped according to patient group (elderly medical patients, patients recovering from surgery and those with a mix of conditions) and by outcome. Our statistical analysis was done on an intention to treat basis, we calculated risk ratios for dichotomous outcomes and mean differences for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible, because of differences in the reporting of outcomes, we have presented the data in narrative summary tables. MAIN RESULTS: We included twenty-four RCTs (8098 patients); three RCTS were identified in this update. Sixteen studies recruited older patients with a medical condition, four recruited patients with a mix of medical and surgical conditions, one recruited patients from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials patients admitted to hospital following a fall (110 patients). Hospital length of stay and readmissions to hospital were statistically significantly reduced for patients admitted to hospital with a medical diagnosis and who were allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.82, 95% CI 0.73 to 0.92, 12 trials). For elderly patients with a medical condition there was no statistically significant difference between groups for mortality (RR 0.99, 95% CI 0.78 to 1.25, five trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials, patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs. AUTHORS' CONCLUSIONS: The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.

Interventions for preventing falls in older people living in the community.

BACKGROUND: Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009. OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers. SELECTION CRITERIA: Randomised trials of interventions to reduce falls in community-dwelling older people. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate. MAIN RESULTS: We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty-two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; seven trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; six trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; five trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; six trials; 1625 participants).Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; seven trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.Home safety assessment and modification interventions were effective in reducing rate of falls (RR 0.81, 95% CI 0.68 to 0.97; six trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; seven trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity.Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; three trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; one trial; 306 participants), but second eye cataract surgery did not.Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; one trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; one trial; 659 participants).An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; one trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling.There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; one trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; two trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials; 2555 participants).No conclusions can be drawn from the 47 trials reporting fall-related fractures.Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home-based exercise in over 80-year-olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors. AUTHORS' CONCLUSIONS: Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

Perspectives of Australian GPs on tailoring fall risk management: a qualitative study.

Falls among older people are highly prevalent, serious and costly, and translation of evidence about falls prevention needs to occur urgently. GPs can identify older people at risk of falling and put preventative measures in place before a fall. Because GPs are key to identifying older people at risk of falls and managing falls risk, this study explored how GPs adapted to the iSOLVE (Integrated SOLutions for sustainable falls preVEntion) process to embed evidence-based falls prevention strategies within primary care, and whether and how they changed their practice. A theoretically informed qualitative study using normalisation process theory was conducted in parallel to the iSOLVE trial to elicit GPs' views about the iSOLVE process. Data were coded and a thematic analysis of interview transcripts was conducted using constant comparison between the data and themes as they developed. In all, 24 of 32 eligible GPs (75%) from general practices located in the North Sydney Primary Health Network, Australia, were interviewed. Six themes were identified: (1) making it easy to ask the iSOLVE questions; (2) internalising the process; (3) integrating the iSOLVE into routine practice; (4) addressing assumptions about patients and fall prevention; (5) the degree of change in practice; and (6) contextual issues influencing uptake. The iSOLVE project focused on practice change, and the present study indicates that practice change is possible. How GPs addressed falls prevention in their practice determined the translation of evidence into everyday practice. Support tools for falls prevention must meet the needs of GPs and help with decision making and referral. Fall prevention can be integrated into routine GP practice through the iSOLVE process to tailor fall risk management.

Implementation of the StandingTall programme to prevent falls in older people: a process evaluation protocol.

INTRODUCTION: One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. METHODS AND ANALYSIS: This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. TRIAL REGISTRATION NUMBER: ACTRN12619001329156.

Discharge planning from hospital to home.

BACKGROUND: Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital. OBJECTIVES: To determine the effectiveness of planning the discharge of patients moving from hospital. SEARCH STRATEGY: We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2009). SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS: Two authors independently undertook data analysis and quality assessment using a predesigned data extraction sheet. Studies are grouped according to patient group (elderly medical patients, surgical patients and those with a mix of conditions) and by outcome. MAIN RESULTS: Twenty-one RCTs (7234 patients) are included; ten of these were identified in this update. Fourteen trials recruited patients with a medical condition (4509 patients), four recruited patients with a mix of medical and surgical conditions (2225 patients), one recruited patients from a psychiatric hospital (343 patients), one from both a psychiatric hospital and from a general hospital (97 patients), and the final trial recruited patients admitted to hospital following a fall (60 patients). Hospital length of stay and readmissions to hospital were significantly reduced for patients allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.85, 95% CI 0.74 to 0.97, 11 trials). For elderly patients with a medical condition (usually heart failure) there was insufficient evidence for a difference in mortality (RR 1.04, 95% CI 0.74 to 1.46, four trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs. AUTHORS' CONCLUSIONS: The evidence suggests that a structured discharge plan tailored to the individual patient probably brings about small reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.

Predicting fitness to drive in people with cognitive impairments by using DriveSafe and DriveAware.

OBJECTIVES: To examine the psychometric properties of DriveSafe and DriveAware and their predictive validity. DESIGN: Prospective study compared screening tests with criterion standard. SETTING: Two driving rehabilitation centers affiliated with a university and a geriatric rehabilitation facility. PARTICIPANTS: Consecutive sample of drivers with functional impairments (n=115) and subgroup of drivers with cognitive impairments (n=96) referred for a driving assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Driving performance was measured by a standardized assessment in real traffic. RESULTS: Rasch analysis provided evidence for construct validity and internal reliability of both tests. Tests trichotomized drivers into unsafe, safe, and further testing categories. The optimal lower cutoff identified unsafe drivers with a specificity of 97% (95% confidence interval [CI], 83-100) in the test sample and 96% (95% CI, 80-100) in the validation sample. The optimal upper cutoff identified safe drivers with a sensitivity of 93% (95% CI, 77-99) and 95% (95% CI, 76-100), respectively. CONCLUSIONS: By using DriveSafe and DriveAware, drivers with cognitive impairments referred for a driving assessment can be categorized as unsafe, safe, or requiring further testing, with only 50% needing an on-road assessment. Before clinical practice is changed, these findings should be replicated.

Masculinity and preventing falls: insights from the fall experiences of men aged 70 years and over.

PURPOSE: To explore men's fall experiences through the lens of masculine identities so as to assist health professionals better engage men in fall prevention programs. METHODS: Twenty-five men, aged 70-93 years who had experienced a recent fall, participated in a qualitative semi-structured interview. Men's willingness to engage in fall prevention programs taking account of individual contexts and expressions of masculinity, were conceptualised using constant comparative methods. RESULTS: Men's willingness to engage in fall prevention programs was related to their perceptions of the preventability of falls; personal relevance of falls; and age, health, and capability as well as problem-solving styles to prevent falls. Fall prevention advice was rarely given when men accessed the health system at the time of a fall. CONCLUSIONS: Contrary to dominant expectations about masculine identity, many men acknowledged fall vulnerability indicating they would attend or consider attending, a fall prevention program. Health professionals can better engage men by providing consistent messages that falls can be prevented; tailoring advice, understanding men are at different stages in their awareness of fall risk and preferences for action; and by being aware of their own assumptions that can act as barriers to speaking with men about fall prevention. Implications for rehabilitation Men accessing the health system at the time of the fall, and during rehabilitation following a fall represent prime opportunities for health professionals to speak with men about preventing falls and make appropriate referrals to community programs. Tailored advice will take account of individual men's perceptions of preventability; personal relevance; perceptions of age, health and capability; and problem-solving styles.

Predicting fitness to drive using the visual recognition slide test (USyd).

OBJECTIVE: The authors examined the construct and predictive validity and internal reliability of the Visual Recognition Slide Test developed at the University of Sydney (VRST-USyd). METHOD: A historical cohort study using retrospective descriptive analysis of VRST-USyd scores and on-road driving performance for 838 drivers with impairments was conducted. RESULTS: Rasch analysis provided evidence for the construct validity and internal reliability of the VRST-USyd. Goodness-of-fit statistics for all items were acceptable. The test had high participant and item reliability indexes and separated the participants into four groups with varying levels of skill. Using a cutoff score of 95/164, the sensitivity of the test was 81%, and the specificity was 90%. However, when coupled with clinicians' judgment of participants' awareness of their driving performance during the on-road assessment, this score improved. CONCLUSION: There is evidence for reliability and construct and predictive validity of the VRST-USyd. The measurement of awareness requires further research.

Men's perspectives on fall risk and fall prevention following participation in a group-based programme conducted at Men's Sheds, Australia.

Research on older men's views regarding fall prevention is limited. The purpose of this qualitative study was to explore the experiences and perspectives of older men regarding fall risk and prevention so that fall prevention programmes can better engage older men. Eleven men who had taken part in a group-based fall prevention programme called Stepping On conducted at Men's Sheds in Sydney, Australia, participated in semi-structured interviews during June and July 2015 which were audio-recorded and transcribed. Data were coded and analysed using constant comparative methods. Over-arching theoretical categories were developed into a conceptual framework linking programme context and content with effects of programme participation on men. Men's Sheds facilitated participation in the programme by being inclusive, male-friendly places, where Stepping On was programmed into regular activities and was conducted in an enjoyable, supportive atmosphere. Programme content challenged participants to think differently about themselves and their personal fall risk, and provided practical options to address fall risk. Two major themes were identified: adjusting the mindset where men adopted a more cautious mindset paying greater attention to potential fall risks, being careful, concentrating and slowing down; and changing the ways where men acted purposefully on environmental hazards at home and incorporated fall prevention exercises into their routine schedules. Practitioners can engage and support older men to address falls by better understanding men's perspectives on personal fall risk and motivations for action.

Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial.

RATIONALE: Excess mortality and residual disability are common after hip fracture. HYPOTHESIS: Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture. DESIGN: Randomized, controlled, parallel-group superiority study. SETTING: Outpatient clinic PARTICIPANTS: Patients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007. INTERVENTION: Twelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support. OUTCOMES: Functional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization. RESULTS: Risk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04-0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04-0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001-.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001-.05). CONCLUSION: The HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care.