Do home adaptation interventions help to reduce emergency fall admissions? A national longitudinal data-linkage study of 657,536 older adults living in Wales (UK) between 2010 and 2017.

BACKGROUND: falls are common in older people, but evidence for the effectiveness of preventative home adaptations is limited. AIM: determine whether a national home adaptation service, Care&Repair Cymru (C&RC), identified individuals at risk of falls occurring at home and reduced the likelihood of falls. STUDY DESIGN: retrospective longitudinal controlled non-randomised intervention cohort study. SETTING: our cohort consisted of 657,536 individuals aged 60+ living in Wales (UK) between 1 January 2010 and 31 December 2017. About 123,729 individuals received a home adaptation service. METHODS: we created a dataset with up to 41 quarterly observations per person. For each quarter, we observed if a fall occurred at home that resulted in either an emergency department or an emergency hospital admission. We analysed the data using multilevel logistic regression. RESULTS: compared to the control group, C&RC clients had higher odds of falling, with an odds ratio (OR [95% confidence interval]) of 1.93 [1.87, 2.00]. Falls odds was higher for females (1.44 [1.42, 1.46]), older age (1.07 [1.07, 1.07]), increased frailty (mild 1.57 [1.55, 1.60], moderate 2.31 [2.26, 2.35], severe 3.05 [2.96, 3.13]), and deprivation (most deprived compared to least: 1.16 [1.13, 1.19]). Client fall odds decreased post-intervention; OR 0.97 [0.96, 0.97] per quarter. Regional variation existed for falls (5.8%), with most variation at the individual level (31.3%). CONCLUSIONS: C&RC identified people more likely to have an emergency fall admission occurring at home, and their service reduced the odds of falling post-intervention. Service provisioning should meet the needs of an individual and need varies by personal and regional circumstance.

Do home modifications reduce care home admissions for older people? A matched control evaluation of the Care & Repair Cymru service in Wales.

BACKGROUND: home advice and modification interventions aim to promote independent living for those living in the community, but quantitative evidence of their effectiveness is limited. AIM: assess the risk of care home admissions for people with different frailty levels receiving home advice and modification interventions against a control group who do not. STUDY DESIGN AND SETTING: matched control evaluation using linked longitudinal data from the Secure Anonymised Information Linkage (SAIL) Databank, comprising people aged 60-95, registered with a SAIL contributing general practice. The intervention group received the Care & Repair Cymru (C & RC) service, a home advice and modification service available to residents in Wales. METHODS: frailty, age and gender were used in propensity score matching to assess the Hazard Ratio (HR) of care home admissions within a 1-, 3- and 5-year period for the intervention group (N = 93,863) compared to a matched control group (N = 93,863). Kaplan-Meier curves were used to investigate time to a care home admission. RESULTS: the intervention group had an increased risk of a care home admission at 1-, 3- and 5-years [HR (95%CI)] for those classified as fit [1-year: 2.02 (1.73, 2.36), 3-years: 1.87 (1.72, 2.04), 5-years: 1.99 (1.86, 2.13)] and mildly frail [1-year: 1.25 (1.09, 1.42), 3-years: 1.25 (1.17, 1.34), 5-years: 1.30 (1.23, 1.38)], but a reduced risk of care home admission for moderately [1-year: 0.66 (0.58, 0.75), 3-years: 0.75 (0.70, 0.80), 5-years: 0.83 (0.78, 0.88)] and severely frail individuals [1-year: 0.44 (0.37, 0.54), 3-years: 0.54 (0.49, 0.60), 5-years: 0.60(0.55, 0.66)]. CONCLUSIONS: HRs indicated that the C & RC service helped to prevent care home admissions for moderately and severely frail individuals. The HRs generally increased with follow-up duration.

The Value of Routinely Collected Data in Evaluating Home Assessment and Modification Interventions to Prevent Falls in Older People: Systematic Literature Review.

BACKGROUND: Falls in older people commonly occur at home. Home assessment and modification (HAM) interventions can be effective in reducing falls; however, there are some concerns over the validity of evaluation findings. Routinely collected data could improve the quality of HAM evaluations and strengthen their evidence base. OBJECTIVE: The aim of this study is to conduct a systematic review of the evidence of the use of routinely collected data in the evaluations of HAM interventions. METHODS: We searched the following databases from inception until January 31, 2020: PubMed, Ovid, CINAHL, OpenGrey, CENTRAL, LILACS, and Web of Knowledge. Eligible studies were those evaluating HAMs designed to reduce falls involving participants aged 60 years or more. We included study protocols and full reports. Bias was assessed using the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. RESULTS: A total of 7 eligible studies were identified in 8 papers. Government organizations provided the majority of data across studies, with health care providers and third-sector organizations also providing data. Studies used a range of demographic, clinical and health, and administrative data. The purpose of using routinely collected data spanned recruiting and creating a sample, stratification, generating independent variables or covariates, and measuring key study-related outcomes. Nonhome-based modification interventions (eg, in nursing homes) using routinely collected data were not included in this study. We included two protocols, which meant that the results of those studies were not available. MeSH headings were excluded from the PubMed search because of a reduction in specificity. This means that some studies that met the inclusion criteria may not have been identified. CONCLUSIONS: Routine data can be used successfully in many aspects of HAM evaluations and can reduce biases and improve other important design considerations. However, the use of these data in these studies is currently not widespread. There are a number of governance barriers to be overcome to allow these types of linkage and to ensure that the use of routinely collected data in evaluations of HAM interventions is exploited to its full potential.

Exploring intergenerational relations in a multi-cultural context: the example of filial responsibility in Mauritius.

The purpose of this study is to explore attitudes towards filial responsibility amongst dyads of parents and young adult children using qualitative data from Mauritius, and to draw on the intergenerational solidarity-conflict and ambivalence frameworks to see whether they provide relevant interpretive tools for understanding these attitudes in a multi-cultural society. The study shows that although both generations agree that younger kin should support parents in later life, their motives vary: parents' attitudes reflect norms of obligation, children those of reciprocity; parents want autonomy and independence, but are ambivalent about expectations of future support. Both generations think providing support will be mediated by past parent-child relationships, socialization experiences, gender expectations and cultural tradition. The study suggests that attitudes towards filial responsibility are influenced by a broad set of mechanisms, which can be equated with concepts of structure, function, association, consensus and norm, as well as conflict and ambivalence.

Study protocol for investigating the impact of community home modification services on hospital utilisation for fall injuries: a controlled longitudinal study using data linkage.

INTRODUCTION: This study will evaluate the effectiveness of home adaptations, both in preventing hospital admissions due to falls for older people, and improving timely discharge. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and fall prevention. METHODS AND ANALYSIS: All individuals living in Wales, UK, aged 60 years and over, will be included in the study using anonymised linked data from the Secure Anonymised Information Linkage Databank. We will use a national database of home modifications implemented by the charity organisation Care & Repair Cymru (C&R) from 2009 to 2017 to define an intervention cohort. We will use the electronic Frailty Index to assign individual levels of frailty (fit, mild, moderate or severe) and use these to create a comparator group (non-C&R) of people who have not received a C&R intervention. Coprimary outcomes will be quarterly numbers of emergency hospital admissions attributed to falls at home, and the associated length of stay. Secondary outcomes include the time in moving to a care home following a fall, and the indicative financial costs of care for individuals who had a fall. We will use appropriate multilevel generalised linear models to analyse the number of hospital admissions related to falls. We will use Cox proportional hazard models to compare the length of stay for fall-related hospital admissions and the time in moving to a care home between the C&R and non-C&R cohorts. We will assess the impact per frailty group, correct for population migration and adjust for confounding variables. Indicative costs will be calculated using financial codes for individual-level hospital stays. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and prevention. ETHICS AND DISSEMINATION: Information governance requirements for the use of record-linked data have been approved and only anonymised data will be used in our analysis. Our results will be submitted for publication in peer-reviewed journals. We will also work with lay members and the knowledge transfer team at Swansea University to create communication and dissemination materials on key findings.

The meaning of "independence" for older people in different residential settings.

OBJECTIVES: Drawing on older people's understandings of "independence" and Collopy's work on autonomy, the article elaborates an interpretive framework of the concept in relation to 3 residential settings-the private dwelling-home, the extra-care, and the residential-care settings. METHOD: Data include 91 qualitative interviews with frail, older people living in each setting, collected as part of a larger Welsh study. Thematic analysis techniques were employed to identify patterns in meanings of independence across settings and then interpreted using Collopy's conceptualizations of autonomy, as well as notions of space and interdependencies. RESULTS: Independence has multiple meanings for older people, but certain meanings are common to all settings: Accepting help at hand; doing things alone; having family, friends, and money as resources; and preserving physical and mental capacities. Concepts of delegated, executional, authentic, decisional, and consumer autonomy, as well as social interdependencies and spatial and social independence, do provide appropriate higher order interpretive constructs of these meanings across settings. DISCUSSION: A broader interpretive framework of "independence" should encompass concepts of relative independence, autonomy(ies), as well as spatial and social independence, and can provide more nuanced interpretations of structured dependency and institutionalization theories when applied to different residential settings.