Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial.

BACKGROUND: Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services. METHODS AND FINDINGS: This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control ß 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control ß 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker ß -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control ß 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control ß -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker ß -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control ß 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control ß -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker ß -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination. CONCLUSIONS: Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Definition and Measurement of Physical and Chemical Restraint in Long-Term Care: A Systematic Review.

This systematic review aimed to identify thematic elements within definitions of physical and chemical restraint, compare explicit and implicit definitions, and synthesize reliability and validity of studies examining physical and/or chemical restraint use in long-term care. Studies were included that measured prevalence of physical and/or chemical restraint use, or evaluated an intervention to reduce restraint use in long-term care. 86 papers were included in this review, all discussed physical restraint use and 20 also discussed chemical restraint use. Seven themes were generated from definitions including: restraint method, setting resident is restrained in, stated intent, resident capacity to remove/control, caveats and exclusions, duration, frequency or number, and consent and resistance. None of the studies reported validity of measurement approaches. Inter-rater reliability was reported in 27 studies examining physical restraint use, and only one study of chemical restraint. Results were compared to an existing consensus definition of physical restraint, which was found to encompass many of the thematic domains found within explicit definitions. However, studies rarely applied measurement approaches that reflected all of the identified themes of definitions. It is necessary for a consensus definition of chemical restraint to be established and for measurement approaches to reflect the elements of definitions.

Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis.

BACKGROUND: Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths. OBJECTIVE: To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates. METHODS: Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations. RESULTS: Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available. CONCLUSION: Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use.

Risk factors for social isolation in post-hospitalized older adults.

INTRODUCTION: Social isolation in older adults is associated with high rates of adverse health outcomes. Older adults who have had a recent significant health event are likely to be at risk of social isolation following hospitalization. This study aims to identify risk factors amongst older adults at hospital discharge that are associated with social isolation at three months post-hospitalization. METHODS: Older adults were surveyed at hospital discharge and three months post-hospitalization. Baseline data including demographics, self-reported quality of life, physical activity and capacity levels, lifestyle factors, symptoms of depression and anxiety were collected at discharge. Social isolation was measured using the Friendship Scale at the three-month follow-up. Regression analyses were used to examine the relationship between baseline characteristics and social isolation at three months post-hospitalization. RESULTS: Older adults (n = 311) participated in the baseline survey, of whom 241 (78 %) completed the three-month survey. Higher depressive and anxiety symptoms at hospital discharge, comorbidity of cancer, history of cigarette smoking, prior access to community and respite service, and arrangement for shopping assistance post-discharge were factors independently associated with an increased risk of social isolation at three months post-hospitalization. DISCUSSION: This study identified risk factors for social isolation that are unique to older post-hospitalized adults. These findings can help clinicians identify individuals at risk of social isolation and to target interventions that address these risk factors for the prevention of social isolation in older adults after hospitalization.

The association between physical activity and social isolation in community-dwelling older adults.

OBJECTIVES: Social isolation is an increasing concern in older community-dwelling adults. There is growing need to determine effective interventions addressing social isolation. This study aimed to determine whether a relationship exists between physical activity (recreational and/or household-based) and social isolation. An examination was conducted for whether group- or home-based falls prevention exercise was associated with social isolation. METHODS: Cross-sectional analysis of telephone survey data was used to investigate relationships between physical activity, health, age, gender, living arrangements, ethnicity and participation in group- or home-based falls prevention exercise on social isolation. Univariable and multivariable ordered logistic regression analyses were conducted. RESULTS: Factors found to be significantly associated with reduced social isolation in multivariable analysis included living with a partner/spouse, reporting better general health, higher levels of household-based physical activity (OR = 1.03, CI = 1.01-1.05) and feeling less downhearted/depressed. Being more socially isolated was associated with symptoms of depression and a diagnosis of congestive heart failure (pseudo R2 = 0.104). DISCUSSION: Findings suggest that household-based physical activity is related to social isolation in community-dwelling older adults. Further research is required to determine the nature of this relationship and to investigate the impact of group physical activity interventions on social isolation.

Social Isolation, Physical Capacity, and Physical Activity in Older Community-Dwelling Adults Post-Hospitalization.

This paper investigated the potential relationships between physical capacity and physical activity (recreational and household) with social isolation amongst older adults. Data for hospitalized Victorians (n = 311) were analyzed in univariable, multivariable and latent growth curve analyses over six months. Measures included items from the Friendship Scale, Lubben Social Network Scale (LSNS-6), Australian Survey of Disability, Ageing and Carers Household (SDAC), and Phone-FITT. Over six months, improvements in physical capacity were related to reduced social isolation (-0.65, CI = -1.21, -0.09). Increased total (0.02, CI = 0.004, 0.04) and household-based physical activity (0.03, CI = 0.001, 0.06) were related to contact with more relatives. Higher baseline household-based physical activity was related to contact with fewer relatives (-0.01, CI = -0.02, -0.001). Along with physical capacity and activity, household-based physical activity appears to be strongly related to social isolation. Further research is required to determine the direction of relationships, to provide evidence for effective interventions.

Older Adult Perceptions of Participation in Group- and Home-Based Falls Prevention Exercise.

This paper describes why older adults begin, continue, and discontinue group- and home-based falls prevention exercise and benefits and barriers to participation. Telephone surveys were used to collect data for 394 respondents. Most respondents reported not participating in group- (66%) or home-based (78%) falls prevention exercise recently. Reasons for starting group-based falls prevention exercise include health benefits (23-39%), health professional recommendation (13-19%), and social interaction (4-16%). They discontinued because the program finished (44%) or due to poor health (20%). Commonly reported benefits were social interaction (41-67%) and health (15-31%). Disliking groups was the main barrier (2-14%). Home-based falls prevention exercise was started for rehabilitation (46-63%) or upon health professional recommendation (22-48%) and stopped due to recovery (30%). Improvement in health (18-46%) was the main benefit. These findings could assist health professionals in prescribing group-based falls prevention exercise by considering characteristics of older adults who perceive social interaction to be beneficial.