A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls.

OBJECTIVE: to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme, for community-dwelling older people at high risk of future falls identified through a screening process. DESIGN: multicentre randomised controlled trial. SETTING: eight general practices and three day hospitals based in the East Midlands, UK. PARTICIPANTS: three hundred and sixty-four participants, mean age 79 years, with a median of three falls risk factors per person at baseline. INTERVENTIONS: a day hospital-delivered multifactorial falls prevention programme, consisting of strength and balance training, a medical review and a home hazards assessment. MAIN OUTCOME MEASURE: rate of falls over 12 months of follow-up, recorded using self-completed monthly diaries. RESULTS: one hundred and seventy-two participants in each arm contributed to the primary outcome analysis. The overall falls rate during follow-up was 1.7 falls per person-year in the intervention arm compared with 2.0 falls per person-year in the control arm. The stratum-adjusted incidence rate ratio was 0.86 (95% CI 0.73-1.01), P = 0.08, and 0.73 (95% CI 0.51-1.03), P = 0.07 when adjusted for baseline characteristics. There were no significant differences between the intervention and control arms in any secondary outcomes. CONCLUSION: this trial did not conclusively demonstrate the benefit of a day hospital-delivered multifactorial falls prevention programme, in a population of older people identified as being at high risk of a future fall.

National clinical audit for hospitalised exacerbations of COPD.

INTRODUCTION: Exacerbations of COPD requiring hospital admission are burdensome to patients and health services. Audit enables benchmarking performance between units and against national standards, and supports quality improvement. We summarise 23 years of UK audit for hospitalised COPD exacerbations to better understand which features of audit design have had most impact. METHOD: Pilot audits were performed in 1997 and 2001, with national cross-sectional audits in 2003, 2008 and 2014. Continuous audit commenced in 2017. Overall, 96% of eligible units took part in cross-sectional audit, 86% in the most recent round of continuous audit. We synthesised data from eight rounds of national COPD audit. RESULTS: Clinical outcomes were observed to change at the same time as changes in delivery of care: length of stay halved from 8 to 4 days between 1997 and 2014, alongside wider availability of integrated care. Process indicators did not generally improve with sequential cross-sectional audit. Under continuous audit with quality improvement support, process indicators linked to financial incentives (early specialist review (55-66%) and provision of a discharge bundle (53-74%)) improved more rapidly than those not linked (availability of spirometry (40-46%) and timely noninvasive ventilation (21-24%)). CONCLUSION: Careful piloting and engagement can result in successful roll-out of cross-sectional national audit in a high-burden disease. Audit outcome measures and process indicators may be affected by changes in care pathways. Sequential cross-sectional national audit alone was not generally accompanied by improvements in care. However, improvements in process indicators were seen when continuous audit was combined with quality improvement support and, in particular, financial incentives.

The national clinical audit of falls and bone health: the clinical management of hip fracture patients.

BACKGROUND: The standards of care for older people who present with a fractured neck of femur (#NOF) have been defined by previously published national guidelines. To assess compliance with these standards the Healthcare Commission commissioned the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians to deliver 'The National Clinical Audit of Falls and Bone Health for Older People'. METHODS: The audit was developed by a multi-disciplinary team using available best evidence to set audit standards. All acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England were recruited. Patients >65 years old presenting with a proven #NOF were included in the audit with a target of 20 cases per participating site. RESULTS: Data was entered for 3184 #NOF patients. 80% (2555/3184) were female with a median age of 83 years admitted from their own home (68% 2152/3184). Over 97% (3172/3184) presented to the A&E department on the same day as the fall (88% 2813/3184). The time in the A&E department was less than 2h in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240min. 35% (1080/3088) of #NOF patients were operated on within 24h of admission. Causes of delay to theatre included awaiting medical review (59% 566/956) or organisational reasons (29% 278/956). 48% (1480/2998) of patients were sat out of bed within 24h. Only 35% (1115/3184) of patients were cared for in an orthogeriatric setting. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10-27 days. CONCLUSIONS: There are currently unacceptable wide variations in the delivery of clinical care to older people presenting with a #NOF. Of concern were the long lengths of time in A&E for many patients and the low level of routine access to pre-operative medical assessment. It is hoped that the launch of joint initiatives between the British Orthopaedic Association and the British Geriatric Society aimed at delivering service improvements in this area should lead to improved outcomes.

Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556].

Falls in older people are a major public health concern in terms of morbidity, mortality and cost. Previous studies suggest that multifactorial interventions can reduce falls, and many geriatric day hospitals are now offering falls intervention programmes. However, no studies have investigated whether these programmes, based in the day hospital are effective, nor whether they can be successfully applied to high-risk older people screened in primary care. The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling. This will be tested by a pragmatic parallel-group randomised controlled trial in which the participants, identified as at high risk of falling, will be randomised into either the intervention Day hospital arm or to a control (current practice) arm. Those participants preferring not to enter the full randomised study will be offered the opportunity to complete brief diaries only at monthly intervals. This data will be used to validate the screening questionnaire. Three day hospitals (2 Nottingham, 1 Derby) will provide the interventions, and the University of Nottingham's Departments of Primary Care, the Division of Rehabilitation and Ageing Unit, and the Trent Institute for Health Service Research will provide the methodological and statistical expertise. Four hundred subjects will be randomised into the two arms. The primary outcome measure will be the rate of falls over one year. Secondary outcome measures will include the proportion of people experiencing at least one fall, the proportion of people experiencing recurrent falls (>1), injuries, fear of falling, quality of life, institutionalisation rates, and use of health services. Cost-effectiveness analyses will be performed to inform health commissioners about resource allocation issues. The importance of this trial is that the results may be applicable to any UK day hospital setting. SITES: General practices across Nottinghamshire and Derbyshire. Day hospitals:Derbyshire Royal Infirmary (Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service (Nottingham City Hospital Trust)Leengate Day Hospital (Queen's Medical Centre Nottingham University Hospital NHS Trust).

Reproducibility of circulatory changes to head-up tilt in healthy elderly subjects.

OBJECTIVE: to assess the reproducibility of the cardiovascular responses to head-up tilt including cardiac output, stroke volume and peripheral resistance, in healthy older subjects using non-invasive methods. PARTICIPANTS: twenty-five healthy community-dwelling volunteers with a mean age of 69+/-3 years. METHODS: the subjects underwent head-up tilt table testing on two occasions at an interval of 6 weeks. Pulse interval and blood pressure data were collected, on a beat-to-beat basis using a non-invasive monitor (Finapres, Ohmeda), during 70 degrees head-up tilt table testing and stored for analysis. ANALYSIS: the pulse interval and blood pressure data for the group were pooled and the relative changes in cardiac output, stroke volume and peripheral resistance were calculated using pulse contour analysis. RESULTS: the systolic blood pressure, pulse interval, cardiac output and stroke volume fell immediately after tilt with a rise in peripheral resistance. These responses were similar, though the baseline systolic blood pressure levels were lower at the second visit (P=0.06). CONCLUSION: these non-invasively assessed cardiovascular responses to head-up tilt in healthy older subjects show little variation between visits. The reproducibility of the responses in subjects with syncope and autonomic failure warrants further investigation.