The impact of lidocaine plaster prescribing reduction strategies: A comparison of two national health services in Europe.

AIMS: In 2017, two distinct interventions were implemented in Ireland and England to reduce prescribing of lidocaine medicated plasters. In Ireland, restrictions on reimbursement were introduced through implementation of an application system for reimbursement. In England, updated guidance on items which should not be routinely prescribed in primary care, including lidocaine plasters, was published. This study aims to compare how the interventions impacted prescribing of lidocaine plasters in these countries. METHODS: We conducted an interrupted time-series study using general practice data. For Ireland, monthly dispensing data (2015-2019) from the means-tested General Medical Services (GMS) scheme was used. For England, data covered all patients. Outcomes were the rate of dispensings, quantity and costs of lidocaine plasters, and we modelled level and trend changes from the first full month of the policy/guidance change. RESULTS: Ireland had higher rates of lidocaine dispensings compared to England throughout the study period; this was 15.22/1000 population immediately pre-intervention, and there was equivalent to a 97.2% immediate reduction following the intervention. In England, the immediate pre-intervention dispensing rate was 0.36/1000, with an immediate reduction of 0.0251/1000 (a 5.8% decrease), followed by a small but significant decrease in the monthly trend relative to the pre-intervention trend of 0.0057 per month. CONCLUSIONS: Among two different interventions aiming to decrease low-value lidocaine plaster prescribing, there was a substantially larger impact in Ireland of reimbursement restriction compared to issuing guidance in England. However, this is in the context of much higher baseline rates of use in Ireland compared to England.

Patient and hospital-level factors associated with time to surgery after hip fracture in Ireland: Analysis of national audit data 2016-2020.

INTRODUCTION: In hip fracture care, time to surgery (TTS) is a commonly used quality indicator associated with patient outcomes including mortality. This study aimed to identify patient and hospital-level characteristics associated with TTS in Ireland. METHODS: National data from the Irish Hip Fracture Database (IHFD) (2016-2020) were analysed along with hospital-level characteristics obtained from a 2020 organisational survey. Generalised linear model regression was used to explore the association of TTS with case-mix, surgical details, hospital-level staffing and specific protocols recommended to expedite surgery. RESULTS: A total of 14,951 patients with surgically treated hip fracture from 16 hospitals were included (Mean age= 80.6 years (SD=8.8), 70.4% female). Mean TTS was 40.9 h (SD=60.3 h). Case-mix factors associated with longer TTS were male sex and higher American Society of Anaesthesiologists (ASA) grade. Other factors found to be associated with longer TTS included low pre-morbid mobility, inter-hospital transfer, weekday presentation, pre-operative medical physician assessment, intracapsular fracture type, arthroplasty surgery, general anaesthesia, consultant grade of surgeon and lower hospital-level orthopaedic surgical capacity. The oldest age-group and pre-fracture nursing home residence were associated with shorter TTS when adjusted for other case-mix factors. None of four explored protocols for expediting surgery were associated with TTS. CONCLUSION: Patients with more comorbidity experience longer surgical delay after hip fracture in Ireland, in line with international research. Low availability of senior orthopaedic surgeons in Ireland may be delaying hip fracture surgery. Pathway of presentation, including via inter-hospital transfer or hospital bypass, is an important factor that requires further exploration. Further research is required to identify successful system-level protocols and interventions that may expedite hip fracture surgery within this setting.

Long-term outcome collection after hip fracture in Ireland: a systematic review of traditional and grey literature.

This review aimed to describe the methods and results from recent Irish research about post-acute hip fracture outcomes. Meta-analyses estimate the 30-day and 1-year mortality rate at 5% and 24% respectively. There is a need for standardised recommendations about which data should be recorded to aid national and international comparisons. PURPOSE: Over 3700 older adults experience hip fracture in Ireland annually. The Irish Hip Fracture Database national audit records acute hospital data but lacks longer-term outcomes. This systematic review aimed to summarise and appraise recent Irish studies that collected long-term hip fracture outcomes and to generate pooled estimates where appropriate. METHODS: Electronic databases and grey literature were searched in April 2022 for articles, abstracts, and theses published from 2005 to 2022. Eligible studies were appraised by two authors and outcome collection details summarised. Meta-analyses of studies with common outcomes were conducted where the sample was generalisable to the broad hip fracture population. RESULTS: In total, 84 studies were identified from 20 clinical sites. Outcomes commonly recorded were mortality (n = 48 studies; 57%), function (n = 24; 29%), residence (n = 20; 24%), bone-related outcomes (n = 20; 24%), and mobility (n = 17; 20%). One year post-fracture was the most frequent time point, and patient telephone contact was the most common collection method used. Most studies did not report follow-up rates. Two meta-analyses were performed. The pooled estimate for one-year mortality was 24.2% (95% CI = 19.1-29.8%, I2 = 93.8%, n = 12 studies, n = 4220 patients), and for 30-day mortality was 4.7% (95% CI = 3.6-5.9%, I2 = 31.3%, n = 7 studies, n = 2092 patients). Reports of non-mortality outcomes were deemed inappropriate for meta-analysis. CONCLUSION: Hip fracture long-term outcomes collected in Irish research are broadly in line with international recommendations. Heterogeneity of measures and poor reporting of methods and findings limits collation of results. Recommendations for standard outcome definitions nationally are warranted. Further research should explore the feasibility of recording long-term outcomes during routine hip fracture care in Ireland to enhance national audit.

Geographical variation in orthopedic procedures in Norway: Cross-sectional population-based study.

BACKGROUND: Standardized surgery rates for common orthopedic procedures vary across geographical areas in Norway. We explored whether area-level factors related to demand and supply in publicly funded healthcare are associated with geographical variation in surgery rates for six common orthopedic procedures. METHODS: The present study is a cross-sectional population-based study of hospital referral areas in Norway. We included adult admissions for arthroscopy for degenerative knee disease, arthroplasty for osteoarthritis of the knee and hip, surgical treatment for hip fracture, and decompression with/without fusion for lumbar disk herniation and lumbar spinal stenosis in 2012-2016. Variation in age and sex standardized rates was estimated using extremal quotients, coefficients of variation, and systematic components of variation (SCV). Associations between surgery rates and the socioeconomic factors urbanity, unemployment, low-income, high level of education, mortality, and number of surgeons and hospitals were explored with linear regression analyses. RESULTS: Knee arthroscopy showed highest level of variation (SCV 10.3) and decreased in numbers. Variation was considerable for spine surgery (SCV 3.8-4.9), moderate to low for arthroplasty procedures (SCV 0.8-2.6), and small for hip fracture surgery (SCV 0.2). Higher rates of knee arthroscopy were associated with more orthopedic surgeons (adjusted coefficient 24.8, 95% confidence interval (CI): 2.7-47.0), and less urban population (adjusted coefficient -13.3, 95% CI: -25.4 to -1.2). Higher spine surgery rates were associated with more hospitals (adjusted coefficient 22.4, 95% CI: 4.6-40.2), more urban population (adjusted coefficient 2.1, 95% CI: 0.4-3.8), and lower mortality (adjusted coefficient -192.6, 95% CI: -384.2 to -1.1). Rates for arthroplasty and hip fracture surgery were not associated with supply/demand factors included. CONCLUSIONS: Arthroscopy for degenerative knee disease decreased in line with guidelines, but showed high variation of surgery rates. Socioeconomic factors included in this study did not explain geographical variation in orthopedic surgery.

Geographic variation in hip fracture surgery rate, care quality and outcomes: a comparison between national registries in Ireland and Denmark.

Ireland and Denmark have similar hip fracture surgery rates but differences in care quality indicators and patterns of intracapsular fracture repair. Very high variation in total hip arthroplasty rate within both countries and higher observed early mortality in Denmark require further investigation. PURPOSE: To explore and compare geographic variation of hip fracture surgery rate, care quality and outcomes in Ireland and Denmark. METHODS: Patients aged ≥ 65 years with surgically treated hip fracture were included from the Irish Hip Fracture Database (years = 2017-2020, n = 12,904) and the Danish Multidisciplinary Hip Fracture Registry (years = 2016-2017, n = 12,924). The age and sex standardised rate of hip fracture surgery and the proportion of patients with seven process quality indicators, three surgery types and four outcomes were calculated. Systematic components of variation (SCV) were calculated based on hospital area (6 Irish hospital groups, 5 Danish regions). RESULTS: The age and sex standardised rate of hip fracture surgery per 1000 older population in 2017 was 4.7 (95% CI = 4.4-5.1) in Ireland and 5.3 (95% CI = 5.1-5.5) in Denmark. Ireland had lower rates of surgery within 36 h (59% versus 84%), nutritional assessment (27% versus 84%) and pre-discharge mobility recording (52% versus 92%). Patterns of intracapsular fracture repair also differed between countries (hemiarthroplasty: Ireland = 85%, Denmark = 52%). Both countries had very high variation for total hip arthroplasty (THA) provision (SCV Ireland = 10.6, Denmark = 97.9). Ireland had longer hospital stays (median 12 versus 7 days), but lower 7-day (1.0% versus 3.1%) and 14-day (2.0% versus 5.5%) mortality. CONCLUSION: Ireland and Denmark have similar hip fracture surgery rates, but differences in care quality, surgery patterns and outcomes. High variation in THA provision and observed differences in mortality require further exploration. In Ireland, there is scope for improvement regarding early surgery, mobility, nutrition assessment and improved post-discharge follow-up.

Hospital initiation of benzodiazepines and Z-drugs in older adults and discontinuation in primary care.

OBJECTIVE: To examine factors associated with continuation of hospital-initiated benzodiazepine receptor agonists (BZRAs) among adults aged ≥65 years, specifically instructions on hospital discharge summaries. METHODS: This retrospective cohort study involved anonymised electronic record data on prescribing and hospitalisations for 38,229 patients aged ≥65 from forty-four GP practices in Ireland 2011-2016. BZRA initiations were identified among patients with no BZRA prescription in the previous 12 months. Multivariate regression examined whether instructions on discharge messages for hospital-initiated BZRA prescriptions was associated with continuation after discharge in primary care and time to discontinuation. RESULTS: In total, 418 hospital-initiated BZRAs were identified, 48.8% being to males and mean patient age was 79.0 (SD 8.3) years. Almost 60% of these discharge summarieshad some BZRA instructions (e.g. duration). Approximately 40% (n = 166) were continued in primary care. Lower age, being prescribed a Z-drug or great number of medicines were associated with higher risk of continuation. Of those continued in primary care, in 98 cases (59.6%) the BZRA was discontinued during follow-up (after a mean 184 days). Presence of instructions was associated with higher likelihood of discontinuation (hazard ratio 1.71, 95%CI 1.11-2.62). CONCLUSIONS: Improved communication to GPs after hospital discharge may be important in avoiding long-term BZRA use.

Geographical variation of emergency hospital admissions for ambulatory care sensitive conditions in older adults in Ireland 2012-2016.

OBJECTIVE: Ambulatory care sensitive (ACS) conditions are those for which intensified primary care management could potentially prevent emergency admissions. This study aimed to quantify geographical variation in emergency admissions with ACS conditions in older adults and explore factors influencing variation. DESIGN: Repeated cross-sectional study. SETTING: 34 public hospitals in the Ireland. PARTICIPANTS: Adults aged ≥65 years hospitalised for seven ACS conditions between 2012 and 2016 (chronic obstructive pulmonary disease, congestive heart failure (CHF), diabetes, angina, pyelonephritis/urinary tract infections (UTIs), dehydration and pneumonia). PRIMARY OUTCOME MEASURE: Age and sex standardised emergency admission rates (SARs) per 1000 older adults. ANALYSIS: Age and sex SARs were calculated for 21 geographical areas. Extremal quotients and systematic components of variance (SCV) quantified variation. Spatial regression analyses was conducted for SARs with unemployment, urban population proportion, hospital turnover, supply of general practitioners (GPs), and supply of hospital-based specialists as explanatory variables. RESULTS: Over time, an increase in UTI/pyelonephritis SARs was seen while SARs for angina and CHF decreased. Geographic variation was moderate overall and high for dehydration and angina (SCV=11.7-50.0). For all conditions combined, multivariable analysis showed lower urban population (adjusted coefficient: -2.2 (-3.4 to -0.9, p<0.01)), lower GP supply (adjusted coefficient: -5.5 (-8.2 to -2.9, p<0.01)) and higher geriatrician supply (adjusted coefficient: 3.7 (0.5 to 6.9, p=0.02)) were associated with higher SARs. CONCLUSIONS: Future research should evaluate methods of preventing admissions for ACS conditions among older adults, including how resources are allocated at a local level.

Persistence with oral bisphosphonates and denosumab among older adults in primary care in Ireland.

Gaps in pharmacological treatment for osteoporosis can reduce effectiveness. Among older adults, we found about half of new users of oral bisphosphonate and denosumab persisted with their treatment at 2 years, with few switching to alternative therapy. Persistence is suboptimal and warrants evaluation of interventions to improve this. PURPOSE: Gaps in pharmacological treatment for osteoporosis can reduce effectiveness. This study aimed to estimate persistence rates for oral bisphosphonates and denosumab in older primary care patients and identify factors associated with discontinuation. METHODS: Older patients newly prescribed oral bisphosphonates or denosumab during 2012-2017 were identified from 44 general practices (GP) in Ireland. Persistence without a coverage gap of >90 days was calculated for both medications from therapy initiation. Factors associated with time to discontinuation were explored using Cox regression analysis. Exposures included age group, osteoporosis diagnosis, fracture history, calcium/vitamin D prescription, number of other medications, health cover, dosing frequency (bisphosphonates) and previous bone-health medication (denosumab). RESULTS: Of 41,901 patients, n=1569 were newly initiated on oral bisphosphonates and n=1615 on denosumab. Two-year persistence was 49.4% for oral bisphosphonates and 53.8% for denosumab and <10% were switched to other medication. Having state-funded health cover was associated with a lower hazard of discontinuation for both oral bisphosphonates (HR=0.49, 95% CI=0.36-0.66, p<0.01) and denosumab (HR=0.71, 95% CI=0.57-0.89, p<0.01). Older age group, number of medications and calcium/vitamin D prescription were also associated with better bisphosphonate persistence, while having osteoporosis diagnosed was associated with better denosumab persistence. CONCLUSION: Persistence for osteoporosis medications is suboptimal. Of concern, few patients are switched to other bone-health treatments when denosumab is stopped which could increase fracture risk. Free access to GP services and medications may have resulted in better medication persistence in this cohort. Future research should explore prescribing choices in primary care osteoporosis management and evaluate cost-effectiveness of interventions for improving persistence.

Factors associated with initiation of bone-health medication among older adults in primary care in Ireland.

BACKGROUND: Adults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however, under-treatment is common. OBJECTIVE: This study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care. DESIGN: This was a retrospective cohort study. SETTING: The study used data from forty-four general practices in Ireland from 2011-2017. SUBJECTS: The study included adults aged ≥ 65 years who were naïve to bone-health medication for 12 months. METHODS: Overall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with the Poisson distribution. RESULTS: Of 36,799 patients (51% female, mean age 75.4 (SD = 8.4)) included, 8% (n = 2,992) were observed to initiate bone-health medication during the study. One-fifth of all patients (n = 8,193) had osteoporosis or had high fracture-risk but only 21% of them (n = 1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR = 1.33 (95% CI = 1.17-1.50), P < 0.01) and all fractures (IRR = 1.30 (95% CI = 1.17-1.44), P < 0.01) were associated with medication initiation. Previous fracture, rheumatoid arthritis and corticosteroid use were associated with initiation, while liver, kidney, cardiovascular disease, diabetes and oestrogen-only hormone replacement therapy showed an inverse association. CONCLUSIONS: Bone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.

Novel approach to meta-analysis of tests and clinical prediction rules with three or more risk categories.

OBJECTIVE: Multichotomous tests have three or more outcome or risk categories, and can provide richer information and a better fit with clinical decision-making than dichotomous tests. Our objective is to present a fully developed approach to the meta-analysis of multichotomous clinical prediction rules (CPRs) and tests, including meta-analysis of stratum specific likelihood ratios. STUDY DESIGN: We have developed a novel approach to the meta-analysis of likelihood ratios for multichotomous tests that avoids the need to dichotomise outcome categories, and demonstrate its application to a sample CPR. We also review previously reported approaches to the meta-analysis of the area under the receiver operating characteristic curve (AUROCC) and meta-analysis of a measure of calibration (observed:expected) for multichotomous tests or CPRs. RESULTS: Using data from 10 studies of the Cancer of the Prostate Risk Assessment (CAPRA) risk score for prostate cancer recurrence, we calculated summary estimates of the likelihood ratios for low, moderate and high risk groups of 0.40 (95% CI 0.32 to 0.49), 1.24 (95% CI 0.99 to 1.55) and 4.47 (95% CI 3.21 to 6.23), respectively. Applying the summary estimates of the likelihood ratios for each risk group to the overall prevalence of cancer recurrence in a population allows one to estimate the likelihood of recurrence for each risk group in that population. CONCLUSION: An approach to meta-analysis of multichotomous tests or CPRs is presented. A spreadsheet for data preparation and code for R and Stata are provided for other researchers to download and use. Combined with summary estimates of the AUROCC and calibration, this is a comprehensive strategy for meta-analysis of multichotomous tests and CPRs.

Existing validated clinical prediction rules for predicting response to physiotherapy interventions for musculoskeletal conditions have limited clinical value: A systematic review.

OBJECTIVE: To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions. STUDY DESIGN AND SETTING: PubMed, EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies). RESULTS: Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall. CONCLUSION: Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studies.

Geographical variation in musculoskeletal surgical care in public hospitals in Ireland: a repeated cross-sectional study.

OBJECTIVE: To examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland. DESIGN: Repeated cross-sectional study. SETTING: 36 public hospitals in Ireland. PARTICIPANTS: Adult admissions for hip fracture, hip and knee replacement, knee arthroscopy and lumbar spine interventions over 5 years (2012-2016). PRIMARY OUTCOME MEASURE: Standardised discharge rate (SDR). ANALYSIS: Age and sex SDRs were calculated for 21 geographical areas. Extremal quotients, coefficients of variation and systematic components of variance were calculated. Linear regression analyses were conducted exploring the relationship between SDRs and year, unemployment, % urban population, number of referral hospitals, % on waiting lists>6 months and % with private health insurance for each procedure. RESULTS: Across 36 public hospitals, n=102 756 admissions were included. Hip fracture repair showed very low variation. Elective hip and knee procedures showed high variation in particular years, while variation for lumbar interventions was very high. Knee arthroscopy rates decreased over time. Higher unemployment was associated with knee and hip replacement rates and urban areas had lower hip replacement rates. Spinal procedure rates were associated with a lower number of referral hospitals in a region and spinal injection rates were associated with shorter waiting lists. A higher proportion of patients having private health insurance was associated with higher rates of hip and knee replacement and lumbar spinal procedures. CONCLUSIONS: Variation and factors associated with SDRs for publicly funded hip and knee procedures are consistent with similar international research in this field. Further research should explore reasons for high rates of spinal injections and the impact of private practice on musculoskeletal procedure variation.

Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score.

BACKGROUND: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. OBJECTIVE: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. DESIGN: Meta-analysis of accuracy, discrimination, and calibration. METHODS: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. KEY RESULTS: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71-0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91-1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70-0.81) and 0.88 (0.69-1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. CONCLUSIONS: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.

Modification of Potentially Inappropriate Prescribing Following Fall-Related Hospitalizations in Older Adults.

BACKGROUND: There is strong evidence that potentially inappropriate prescribing is associated with falls in older adults. Fall-related hospitalizations should trigger medication review. OBJECTIVES: The aim of this before-and-after cohort study was to explore patterns of relevant potentially inappropriate prescribing in older people with fall-related hospitalizations. METHODS: Data on older adults with hospitalizations for falls, fractures and syncope between 2012 and 2016 were collected from 44 general practices in Ireland. Fall-related prescribing was defined from the Screening Tool for Older Persons' Prescriptions (sedatives and vasodilators) and the Screening Tool to Alert doctors to Right Treatment (vitamin D). Prevalence of prescriptions were estimated from general practice and hospital discharge records. Mixed-effects logistic regression was conducted to compare the 12-month pre- and post-hospitalization periods. RESULTS: Overall, 927 individuals (68% female, average age 81.2 years; standard deviation 8.6) were included, 45% of whom had a diagnosis of fracture, 28% had syncope, and 27% had a fall without fracture/syncope. After adjustment for covariates and practice clustering effects, both vitamin D and sedatives had higher odds of prescription post-hospitalization (adjusted odds ratio [aOR] 4.47, 95% confidence interval [CI] 2.09-9.54, and aOR 1.75, 95% CI 1.29-2.39, respectively). With adjustments for age and sex, having a fracture was associated with new initiation of vitamin D (aOR 2.81, 95% CI 1.76-4.46) and having syncope was associated with continuing on vasodilators (aOR 1.99, 95% CI 1.06-3.74). No factors were associated with new sedative initiation. CONCLUSION: Fall-related potentially inappropriate prescribing is prevalent in older adults who have a history of falls, and continues after discharge from hospital. Future studies should investigate why such prescribing is initiated after a fall-related hospitalization, and explore interventions that could reduce such hazardous prescribing.

Addressing cognitive impairment following stroke: systematic review and meta-analysis of non-randomised controlled studies of psychological interventions.

OBJECTIVE: Cognitive impairment is a pervasive outcome of stroke, reported in over half of patients 6 months post-stroke and is associated with increased disability and a poorer quality of life. Despite the prevalence of post-stroke cognitive impairment, the efficacy of existing psychological interventions for the rehabilitation of cognitive impairment following stroke has yet to be established. The aim of this study is to identify psychological interventions from non-randomised studies that intended to improve post-stroke cognitive function and establish their efficacy. DESIGN: Systematic review and meta-analysis of non-randomised studies of psychological interventions addressing post-stroke cognitive impairment. DATA SOURCES: Electronic searches were performed in the Pubmed, EMBASE and PsycINFO databases, the search dating from inception to February 2017. ELIGIBILITY CRITERIA: All non-randomised controlled studies and quasi-randomised controlled trials examining psychological interventions to improve cognitive function following stroke were included, such as feasibility studies, pilot studies, experimental studies, and quasi-experimental studies. The primary outcome was cognitive function. The prespecified secondary outcomes were functional abilities in daily life and quality of life. METHODS: The current meta-analyses combined the findings of seven controlled studies, examining the efficacy of psychological interventions compared with treatment-as-usual controls or active controls, and 13 one-group pre-post studies. RESULTS: Results indicated an overall small effect on cognition across the controlled studies (Hedges' g=0.38, 95% CI=0.06 to 0.7) and a moderate effect on cognition across the one-group pre-post studies (Hedges' g=0.51, 95% CI=0.3 to 0.73). Specific cognitive domains, such as memory and attention also demonstrated a benefit of psychological interventions. CONCLUSIONS: This review provides support for the potential of psychological interventions to improve overall cognitive function post-stroke. Limitations of the study, in terms of risk of bias and quality of included studies, and future research directions are explored. PROSPERO REGISTRATION NUMBER: CRD42017069714.

The experience of recurrent fallers in the first year after stroke.

PURPOSE: Understanding the experiences of fallers after stroke could inform falls-prevention interventions, which have not yet shown effectiveness in this population. The aim of this study was to explore the experience of recurrent fallers post-stroke in relation to recovery and living with falls. METHODS: Participants who had more than one fall in the first year after stroke were identified from a prospective cohort study. The methods of grounded theory informed data collection and analysis. Semi-structured interviews were conducted, audio-recorded and transcribed. Coding was conducted and categories were developed inductively. RESULTS: Nine stroke survivors aged 53-85 were interviewed 18-22 months post-discharge. Participants had experienced between 2 and 9 falls and one participant suffered a fracture. Three inter-linked categories were identified: (i) Judging the importance of falls by exploring cause and consequence, (ii) getting back up, and (iii) being careful. CONCLUSIONS: Stroke survivors' assessment of their own falls-risk and their individual priorities contribute to their decisions around activity participation. "Being careful" could be described as a form of self-managing falls-risk. The inclusion of self-management principles, peer-educators, and education to rise from the floor in falls-management programmes warrants investigation. Not all falls were considered equally important by participants. This could be considered when defining falls-related outcomes. Implications for Rehabilitation Healthcare professionals may be able to offer an increased sense of control to stroke survivors through education about how to avoid particular causes and consequences of falls. Falls-related advice should be specific, relevant to the individual, and respectful of their sense of identity. Being able to rise from the floor appears to be important for coping with falls and falls-risk. Professionals should be cognisant of the potential differences of opinion between stroke survivors and their families around management of falls-risk.

Managing cognitive impairment following stroke: protocol for a systematic review of non-randomised controlled studies of psychological interventions.

INTRODUCTION: Stroke is one of the primary causes of death and disability worldwide, leaving a considerable proportion of survivors with persistent cognitive and functional deficits. Despite the prevalence of poststroke cognitive impairment, there is no established treatment aimed at improving cognitive function following a stroke. Therefore, the aims of this systematic review are to identify psychological interventions intended to improve poststroke cognitive function and establish their efficacy. METHODS AND ANALYSIS: A systematic review of non-randomised controlled studies that investigated the efficacy of psychological interventions aimed at improving cognitive function in stroke survivors will be conducted. Electronic searches will be performed in the PubMed, Embase and PsycINFO databases, the search dating from the beginning of the index to February 2017. Reference lists of all identified relevant articles will be reviewed to identify additional studies not previously identified by the electronic search. Potential grey literature will be reviewed using Google Scholar. Titles and abstracts will be assessed for eligibility by one reviewer, with a random sample of 50% independently double-screened by second reviewers. Any discrepancies will be resolved through discussion, with referral to a third reviewer where necessary. Risk of bias will be assessed with the Risk of Bias in Non-randomized Studies of Interventions tool. Meta-analyses will be performed if studies are sufficiently homogeneous. This review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of the evidence regarding cognitive function will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation. ETHICS AND DISSEMINATION: This systematic review will collect secondary data only and as such ethical approval is not required. Findings will be disseminated through presentations and peer-reviewed publication. This review will provide information on the effectiveness of psychological interventions for poststroke cognitive impairment, identifying which psychological interventions are effective for improving poststroke cognitive function. PROSPERO REGISTRATION NUMBER: CRD42017069714.

First year post-stroke healthcare costs and fall-status among those discharged to the community.

INTRODUCTION: Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. PATIENTS AND METHODS: Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. RESULTS: A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p < 0.01, respectively). DISCUSSION: The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. CONCLUSION: This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.

Falls-Related EvEnts in the first year after StrokE in Ireland: Results of the multi-centre prospective FREESE cohort study.

INTRODUCTION: Falls are common post-stroke adverse events. This study aimed to describe the first-year falls incidence, circumstances and consequences among persons discharged home after stroke in Ireland, and to examine the association between potential risk factors and recurrent falls. PATIENTS AND METHODS: Patients with acute stroke and planned home-discharge were recruited consecutively from five hospitals. Variables recorded pre-discharge included: age, stroke severity, co-morbidities, fall history, prescribed medications, hemi-neglect, cognition and functional independence (Barthel index). Falls were recorded with monthly diaries, and 6 and 12-month interviews. The association of pre-discharge factors with recurrent falls (>1 fall) was examined using univariable logistic regression. RESULTS: A total of 128 participants (mean age = 68.6, SD = 13.3) were recruited; 110 completed the 12-month follow-up. The first-year falls incidence was 44.5% (95% CI = 35.1-53.6) with 25.6% falling repeatedly (95% CI = 18.5-34.4). Fallers experienced 1-18 falls (median = 2) and five reported fractures; 47% of fallers experienced at least one fall outdoors. Only 10% of recurrent fallers had bone health medication prescribed at discharge. Lower Barthel index scores (<75/100, RR = 4.38, 1.64-11.72) and psychotropic medication prescription (RR = 2.10, 1.13-3.91) were associated with recurrent falls. DISCUSSION: This study presents prospectively collected information about falls circumstances. It was not powered for multivariable analysis of risk factors. CONCLUSION: One-quarter of stroke survivors discharged to the community fall repeatedly and mostly indoors in the first year. Specific attention may be required for individuals with poor functional independence or those on psychotropic medication. Future falls-management research in this population should explore falls in younger individuals, outdoor as well as indoor falls and post-stroke bone health status.

Validation of two risk-prediction models for recurrent falls in the first year after stroke: a prospective cohort study.

Background: several multivariable models have been derived to predict post-stroke falls. These require validation before integration into clinical practice. The aim of this study was to externally validate two prediction models for recurrent falls in the first year post-stroke using an Irish prospective cohort study. Methodology: stroke patients with planned home-discharges from five hospitals were recruited. Falls were recorded with monthly diaries and interviews 6 and 12 months post-discharge. Predictors for falls included in two risk-prediction models were assessed at discharge. Participants were classified into risk groups using these models. Model 1, incorporating inpatient falls history and balance, had a 6-month outcome. Model 2, incorporating inpatient near-falls history and upper limb function, had a 12-month outcome. Measures of calibration, discrimination (area under the curve (AUC)) and clinical utility (sensitivity/specificity) were calculated. Results: 128 participants (mean age = 68.6 years, SD = 13.3) were recruited. The fall status of 117 and 110 participants was available at 6 and 12 months, respectively. Seventeen and 28 participants experienced recurrent falls by these respective time points. Model 1 achieved an AUC = 0.56 (95% CI 0.46-0.67), sensitivity = 18.8% and specificity = 93.6%. Model 2 achieved AUC = 0.55 (95% CI 0.44-0.66), sensitivity = 51.9% and specificity = 58.7%. Model 1 showed no significant difference between predicted and observed events (risk ratio (RR) = 0.87, 95% CI 0.16-4.62). In contrast, model 2 significantly over-predicted fall events in the validation cohort (RR = 1.61, 95% CI 1.04-2.48). Conclusions: both models showed poor discrimination for predicting recurrent falls. A further large prospective cohort study would be required to derive a clinically useful falls-risk prediction model for a similar population.