Integration of hospital and community care for paediatric ophthalmology: A mixed-methods study.

BACKGROUND: To explore collaborative care models for paediatric eye care that integrate hospital and community-based care to address access blocks. METHODS: Sequential referrals to a tertiary paediatric ophthalmology clinic between April and October 2019 and subsequent encounters up until July 2020 at a major metropolitan public children's hospital in Sydney, Australia, were reviewed to identify those cases suitable for community care. Semi-structured phone interviews were conducted with eye health service providers, including ophthalmologists, orthoptists and optometrists, as well as service users to explore their perspectives on potential changes to service delivery. Qualitative data were analysed deductively using the Levesque model for access to healthcare and Consolidated Framework for Implementation Research (CFIR) to inform implementation strategies for future models of care. RESULTS: One-third of the 439 audited referrals (30.5%; 134/439) were identified as suitable for community management. Interviews revealed five themes relating to potential models of care, which would support and promote access: integrated health systems, standardised quality of care, interprofessional trust, multidisciplinary governance and patient-centred care. Key recommendations for future implementation included: (i) identifying and preparing clinical champions, (ii) conducting educational meetings, (iii) conducting local needs assessments and (iv) informing local opinion leaders. CONCLUSIONS: This audit highlights access blocks and poor targeting of referrals to tertiary paediatric ophthalmology services in a metropolitan hospital. Integration with community practitioners was identified as an acceptable way to streamline services, and strategies that may support successful implementation in this setting were identified.

Feasibility of providing collaborative glaucoma care from a community optometry perspective: a mixed-methods assessment.

CLINICAL RELEVANCE: Despite evidence showing that optometry-led collaborative glaucoma care can be delivered at reduced cost compared to ophthalmology-based care without compromising patient outcomes, such models of care are not widely practiced in Australia. Ensuring glaucoma patients have equitable access to effective and cost-effective care is a matter of public health importance. BACKGROUND: This study examined the feasibility and business case assessment for providing glaucoma care from a community optometry perspective. METHODS: Nine optometrists were interviewed in a semi-structured format, focusing on the economic feasibility, barriers, and benefits of collaborative glaucoma care. The Consolidated Framework for Intervention Research was used for thematic data analysis. Costs and revenues associated with providing glaucoma care were sourced from the literature and interviews. A business case model assessing the profitability of glaucoma care in optometric practice was developed. RESULTS: Thematic analysis revealed concerns over financial viability such that current Medicare Benefits Schedule fees are not sufficient to justify the cost of running a community optometry glaucoma clinic. All participants received a supplementary source of revenue. This finding was confirmed by the business case assessment. Inter-professional trust was perceived to be a key barrier to initiation of collaborative care however was able to be overcome quickly upon commencement of a collaborative care relationship. Optometrists perceived that collaborative care was beneficial to all involved, including patients, ophthalmologists, optometrists, and health payers. There was a perception of a growing divide between clinical and retail optometry, which was thought by most participants to be appropriate. CONCLUSION: This study is the first to explore the feasibility and business case for community-based optometrists to provide collaborative glaucoma care in Australia. Our findings show that current public funding is insufficient to justify the business case to private optometry practice, despite being perceived by optometrists as beneficial to all involved.

A Scoping Review of National Policies for Healthy Ageing in Mainland China from 2016 to 2020.

There remains limited literature to facilitate understanding of healthy ageing-related policies in China over the last five-year policy planning cycle. This study aims to characterise all relevant policies and identifies the policy gaps from a health system perspective. A scoping review framework was used. A thorough search for healthy ageing-related policies was performed on the websites of all government ministries affiliated with the Chinese State Council. Essential information was extracted and mapped to an integrated framework of the World Health Organization's Health System Building Blocks and the Chinese 13th Five-Year Plan for Healthy Ageing. A total of 12471 policy documents were identified, while 99 policy documents were included. There were 14 ministries involved in the generation of policies, but multisectoral collaboration between the ministries remained limited. National Health Commission and Ministry of Civil Affairs were the leading ministries. Promoting the integration of medical services and older people care was most frequently addressed within these policies. Applying the health system perspective, governance and financing were often addressed, but there were limited policies on other components of the health system. The findings of this study support four policy recommendations: (1) to enhance multisectoral collaboration in policy development; (2) to strengthen health system building blocks, including healthcare workforce, service delivery, health information, and medical products and technologies; (3) to establish a consolidated policy system centered on the national healthy ageing plan; (4) to formulate a national implementation work plan to promote an integrated health care model for older people.

Perspectives of people with late age-related macular degeneration on mental health and mental wellbeing programmes: a qualitative study.

PURPOSE: People with age-related macular degeneration (AMD) experience high rates of depression, but rarely engage in or have access to tailored mental wellbeing programmes. This qualitative study investigated the perspectives of those primarily with late AMD on mental health and mental wellbeing programmes. METHODS: Twenty-eight people with late AMD in at least one eye, and one person with early AMD in both eyes, aged 56-87 years (mean age 78 years) attending a private eye clinic between December 2019 and January 2020 in Sydney, New South Wales, Australia, participated. Individual semi-structured interviews were conducted and analysed deductively using content analysis, following the individual level factors for health promotion interventions in the behaviour change wheel: Capability (Physical & Psychological), Opportunity (Physical & Social), and Motivation (Reflective & Automatic). RESULTS: Six major themes were identified: Capability: (1) Impact of vision loss on mobility and leisure pursuits; (2) Adjustment to living with vision loss; Opportunity: (3) Program considerations for those with AMD; (4) Stigma and self-perception of vision loss and mental health; Motivation: (5) Accumulation of vision-related issues as a barrier to participation; (6) Examples of others living with vision loss. General personal factors relevant to delivery of a programme in this age group were also identified: Comorbidities; Limitations using technology; Isolation; Financial concerns and Beliefs that undesired effects of aging are inevitable. CONCLUSIONS: Complex individual, environmental and social factors influence the perspectives of people with late AMD on mental health, and potential participation in mental wellbeing programmes. These factors should be considered when developing and implementing mental wellbeing programmes to improve the emotional and functional rehabilitation outcomes for people with AMD.

Falls prevention interventions for community-dwelling older people living in mainland China: a narrative systematic review.

BACKGROUND: Falls in community-dwelling older people have been recognised as a significant public health issue in China given the rapidly growing aged population. Although there are several reviews documenting falls prevention programs for community-dwelling older adults, no systematic reviews of the scope and quality of falls prevention interventions in Mainland China exist. Therefore, the aim of this study was to systematically review falls prevention interventions for community-dwelling older people living in Mainland China. METHODS: We systematically reviewed literature from Chinese and English databases. All types of randomised controlled trials (RCTs) and quasi-experimental studies published from 1st January 1990 to 30th September 2019 were included. Observational studies and studies in care facilities and hospitals were excluded. Narrative synthesis was performed to summarise the key features of all included studies. Quality assessment was conducted using the Cochrane Risk of Bias Tool and ROBINS-I tool for randomised and non-randomised studies respectively. RESULTS: A total of 1020 studies were found, and 101 studies were included in the analysis. Overall, very few high quality studies were identified, and there was insufficient rigor to generate reliable evidence on the effectiveness of interventions or their scalability. Most interventions were multiple component interventions, and most studies focused on outcomes such as self-reported falls incidence or awareness of falls prevention. CONCLUSION: There is an opportunity to undertake an evaluation of a rigorously-designed, large-scale falls prevention program for community-dwelling older people in Mainland China. To help mitigate the rising burden of falls in Mainland China, recommendations for future falls prevention interventions have been made. These include: (1) target disadvantaged populations; (2) incorporate personalised interventions; and (3) investigate the effectiveness of those under-explored interventions, such as psychological, social environment, management of urinary incontinence, fluid or nutrition therapy and surgery. The study results will also potentially provide a useful evidence base for other low-and-middle income countries in a similar situation.

Orientation and mobility outcome measures.

Despite orientation and mobility (O&M) being a significant factor determining quality of life of people with low vision or blindness, there are no gold standard measures or agreement on how to measure O&M performance. In the first part of this systematic review, an inventory of O&M outcome measures used by recent studies to assess the performance of orientation and/or mobility of adults with vision impairment (low vision and blindness) is presented. A wide variety of O&M outcome measures have been implemented in different fields of study, such as epidemiologic research and interventional studies evaluating training, assistive technology, vision rehabilitation and vision restoration. The most frequent aspect of outcome measures is efficiency such as time, distance, speed and percentage of preferred walking speed, followed by obstacle contacts and avoidance, and dis/orientation and veering. Other less commonly used aspects are target identification, safety and social interaction and self-reported outcome measures. Some studies employ sophisticated equipment to capture and analyse O&M performance in a laboratory setting, while others carry out their assessment in real-world indoor or outdoor environments. In the second part of this review, the appropriateness of implementing the identified outcome measures to assess O&M performance in clinical and functional O&M practice is evaluated. Nearly a half of these outcome measures meet all four criteria of face validity (either clinical or functional), responsiveness, reliability and feasibility and have the potential to be implemented in clinical or functional O&M practice. The findings of this review confirm the complicated and dynamic nature of O&M. Multiple measures are required in any evaluation of O&M performance to facilitate holistic assessment of O&M abilities and limitations of each individual.

A systematic review and meta-analysis of exercise-based falls prevention strategies in adults aged 50+ years with visual impairment.

PURPOSE: To determine the impact of exercise or physical training on falls or physical function in people aged 50+ years with visual impairment, compared with control (no intervention or usual care). METHODS: An updated systematic review of randomised controlled trials, investigating the effect of exercise or physical activity on falls prevention or physical function in adults aged 50+ with visual impairment. Searches of CINAHL, the Cochrane Register of Controlled Trials (CENTRAL), Embase, and Medline were undertaken. Three trials were identified for the period February 2013 to July 2017 and added to the four in the original review. RESULTS: New trials evaluated yoga, the Otago Exercise Programme in combination with a home safety programme and the Alexander Technique. Meta-analysis of data from two trials (n = 163) indicated a non-statistically significant positive impact of exercise on the Chair Stand Test (WMD -1.85 s, 95% CI -4.65 to 0.96, p = 0.20, I2 22%). In this update, two new trials measured falls so meta-analysis was possible for three trials (n = 539) and revealed no impact on falls (RR 1.05, 95% CI 0.73 to 1.50, p = 0.81, I2 30%). DISCUSSION: Although exercise or physical training can improve physical function in older adults with visual impairment, and diverse strategies are being evaluated, there are no proven falls prevention strategies. In the few studies available, falls are not consistently reported and more work is required to investigate falls prevention in older adults with visual impairment.

Impact of the Alexander technique on well-being: a randomised controlled trial involving older adults with visual impairment.

BACKGROUND: Older adults with visual loss have high rates of depression, restricted participation and reduced quality of life. We sought to measure the impact of lessons in the Alexander technique on vision-related emotional and social well-being, as secondary outcomes to a study on improving physical functioning in this population. METHODS: This is a single-blind randomised controlled trial. One hundred and twenty community-dwelling adults aged 50 to 90 years with visual impairments were randomised to either 12 Alexander lessons over 12 weeks and usual care or usual care. The Perceived Visual Ability Scale, the Keele Assessment of Participation, the emotional subscale of the Impact of Vision Impairment Profile, the Positive and Negative Affect Scale and the five-item Geriatric Depression Scale were administered at baseline and three and 12 months. Participants were receiving services from Guide Dogs NSW/ACT. RESULTS: None of the validated questionnaires found statistically significant improvements after adjustment for baseline at three or 12 months, although the emotional subscale of the Impact of Vision Impairment approached significance in favour of the intervention group (4.54 points, 95 per cent CI: -0.14 to 9.21, p = 0.06). Depressive symptoms were prevalent and associated with greater impact of visual impairment on emotional well-being (odds ratio: 1.12, 95 per cent CI: 1.07 to 1.17, p < 0.0001). Faster gait, an indicator of general mobility, was associated with less depressive symptoms (odds ratio: 1.27, 95 per cent CI: 1.06 to 1.54, p = 0.01). CONCLUSION: On average, there was no significant impact of weekly lessons in the Alexander technique on social and emotional well-being, although the emotional impact of visual impairment showed a trend toward less distress in the intervention group. Our data found that emotional distress associated with visual impairment influences depressive symptoms but contrary to expectations, the level of social support received was not significant. Additionally, gait speed is a significant predictor of depressive symptoms, suggesting that general mobility is of importance to the well-being of older adults with visual impairments.

Can the Alexander Technique improve balance and mobility in older adults with visual impairments? A randomized controlled trial.

OBJECTIVE: To investigate the impact of Alexander Technique lessons on balance and mobility in older adults with visual impairments. DESIGN: Randomized assessor blinded controlled trial with intervention and usual care control groups. SETTING: Participants' homes. SUBJECTS: A total of 120 community-dwellers aged 50+ with visual impairments. INTERVENTION: Twelve weeks of Alexander lessons and usual care. MAIN OUTCOME MEASURES: Short Physical Performance Battery items were primary outcomes at 3 months and secondary outcomes at 12 months. Additional secondary outcomes were postural sway, maximal balance range and falls over 12 months. RESULTS: Between-group differences in primary outcomes were not significant. The intervention group reduced postural sway on a firm surface with eyes open at 3 months after adjusting for baseline values (-29.59 mm, 95%CI -49.52 to -9.67, P < 0.01). Planned sub-group analyses indicated a greater intervention effect among past multiple-fallers (2+) than non-multiple fallers for gait speed (P = 0.02) and step length (P < 0.01) at 3 months and chair stand at 12 months (P < 0.01). There was a non-significant reduction in falls rate (IRR = 0.64, 95%CI 0.34 to 1.15, P = 0.13) and injurious falls (IRR = 0.61, 95% CI 0.28 to 1.30, P = 0.20) in the intervention group compared to the control group. CONCLUSION: The intervention did not have a significant impact on the primary outcomes but benefits for the intervention group in postural sway, trends towards fewer falls and injurious falls and improved mobility among past multiple-fallers suggest further investigation of the Alexander Technique is warranted.

Exercise and physical training improve physical function in older adults with visual impairments but their effect on falls is unclear: a systematic review.

QUESTION: Can exercise or physical training improve physical function and prevent falls in older adults with visual impairments? DESIGN: Systematic review of randomised controlled trials with meta-analysis. PARTICIPANTS: Older adults (≥ 60 years) with visual impairments. INTERVENTION: Individual or group exercise or physical training classes in any settings. OUTCOME MEASURES: Mobility, balance, strength and proprioception measured with performance tests or questionnaires and/or falls with calendars or incident reports. RESULTS: Four eligible trials with a total of 522 participants were identified. Multimodal group exercise (n = 50 and 41) and Tai Chi (n=40) improved physical function among residents of care settings. Meta-analysis of data from two trials indicated a significant positive impact of multimodal exercise on the Berg Balance Score (weighted mean difference 3.9 points, 95% CI 1.8 to 6.0), but not on the Timed Up and Go test (weighted mean difference 1.5seconds, 95% CI -1.7 to 4.6). One trial (n=41) found that multimodal exercise reduced the time to first fall (p=0.049). A factorial trial (n=391) among community dwellers did not find a significant effect on falls from a home-based exercise intervention, although clinically relevant effects in either direction were not excluded by the study (incidence rate ratio=1.15, 95% CI 0.82 to 1.61). CONCLUSION: Exercise interventions in residential care settings improve performance on some tests of physical function that are risk factors for falls but the impact on falls is not yet clear. The impact of exercise and training on physical function and falls in community-dwelling older adults with visual impairments also warrants further investigation.

A qualitative study on the perceptions of preventing falls as a health priority among older people in Northern India.

BACKGROUND: In India, fall-related injury morbidity and mortality is an emerging public health problem in older people. Despite awareness of a growing burden, there is a scarcity of literature on effective and acceptable interventions. This study was undertaken to explore the perceptions of older people regarding the risk of falls and understanding of fall prevention programmes. METHODS: We conducted six focus group discussions (FGDs), comprising single gender for three socio-demographic groups in a north Indian city, Chandigarh, in 2011. FGDs were conducted in local language (Punjabi), recorded, transcribed and translated in English. Two researchers independently conducted thematic analysis. RESULTS: Focus group participants were aware of the devastating consequences of fall-related injuries. The predominant reasons for explaining an increased risk of falling was age, uneven surfaces, physical weakness and mental health. There were several other competing health priorities in this population. Preventive measures ranging from individual to government level initiatives were suggested. The experience, knowledge, perceptions and health priorities were diverse among the three socio-demographic groups. However, the feasibility, acceptability and effectiveness for improving balance and strength using yoga in this population needs to be evaluated. CONCLUSIONS: Careful consideration of health priorities is required for development of falls prevention, particularly among the urban poor. Further, initiatives that foster community engagement, such as participatory action may increase acceptability of initiatives to prevent fall-related injury among older people in India.

Improving balance and mobility in people over 50 years of age with vision impairments: can the Alexander Technique help? A study protocol for the VISIBILITY randomised controlled trial.

BACKGROUND: Falls are an increasingly important and costly public health problem. Vision is key to postural stability as we age and this puts adults with visual impairments at greater risk of falls. Physical interventions improve balance in the general population and in older adults with visual impairments in residential care. They also prevent falls in the general community but to date have not been shown effective in community-dwelling adults with visual impairments. OBJECTIVE: To investigate, with a randomised controlled trial, whether the Alexander Technique (AT) can improve balance and mobility in the community-dwelling population with visual impairments and thus reduce the risk of falls. The AT is a form of physical re-education that has recently received attention for its possible value in rehabilitation. METHOD AND DESIGN: One hundred and twenty people with visual impairments over 50 years of age will be recruited from Guide Dogs New South Wales/Australian Capital Territory (NSW/ACT). Participants will be independently mobile and cognitively able to take part in the programme. After baseline assessment participants will be randomly assigned to two groups. The control group will receive usual care from Guide Dogs NSW/ACT, and the intervention group will receive 12 weekly home-based lessons in the AT in addition to usual care. The primary outcome measures will be physical measures from the short physical performance battery at 3 months. Secondary outcome measures will be balance, mobility, social participation and emotional well-being at 3 and 12 months. TRIAL REGISTRATION NUMBER: The protocol is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12610000634077).