Reported Systems Changes and Sustainability Perceptions of Three State Departments of Health Implementing Multi-Faceted Evidence-Based Fall Prevention Efforts

Integrated solutions for sustainable fall prevention in primary care: a pragmatic hybrid-type 2 mixed methods implementation and effectiveness study

The iSOLVE implementation project established and evaluated integrated processes and pathways, including a decision-making tool and educational interventions for general medical practitioners (GPs) and the upskilling of allied health professionals (AHPs). The study used a mixed-methods (parallel) design comprising surveys, qualitative methodologies, and an embedded cluster randomized controlled trial (RCT). Sampling was conducted within a Primary Health Network (PHN) geographic area in Sydney, Australia. AHP workshops (n = 367 attendees) covered six evidence-based interventions, resulting in increased confidence (p < 0.001) and numerous enhancements in fall prevention delivery. Among GPs, 75 were recruited from 27 practices. GPs in the experimental group were more likely to engage in fall prevention activities, including risk assessments, medication reviews, and providing advice, compared to the control group (p = 0.002). They were also more likely to refer patients to AHPs at 3 months (p = 0.002); however, this effect was not significant at 12 months (p = 0.13), as referral behaviors increased in the control group over time. Responses to free-text questions of practice change highlighted differences, with the experimental group reporting a more proactive and comprehensive approach to fall prevention. In a subset of GP patients (n = 560), no significant effect was observed in reducing the rate of falls (IRR = 0.96). The pragmatic nature of the project and potential contamination across multiple elements likely influenced this outcome. However, an area-wide survey of GPs (n = 562) revealed an increase in fall prevention referrals to AHPs over 5 years, from 70 to 82% (p = 0.028). Our findings highlight the importance of equipping GPs with tools and strategies to adopt a proactive approach to fall prevention among older patients. AHPs play a crucial role in this effort, and fostering relationships and connectivity across primary care networks is essential to maximizing the impact of fall prevention initiatives.

Clinical trial registration

Australian New Zealand Clinial Trials Registry, ACTRN12615000401550, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368286.

Physical Activity Engagement After Tai Ji Quan Intervention Among Older Adults With Mild Cognitive Impairment or Memory Concerns: A Secondary Analysis of a Randomized Clinical Trial

Importance

The effect of exercise interventions on increasing and sustaining moderate to vigorous physical activity (MVPA) among older adults with mild cognitive impairment (MCI), who are at heightened risk of dementia, remains unclear.

Objective

To examine whether participation in a 6-month, supervised, home-based tai ji quan intervention increases MVPA among US community-dwelling older adults at 1 year.

Design, Setting, and Participants

This study was a secondary analysis of a parallel-group, outcome assessor-blinded, randomized clinical trial conducted virtually at participants' homes. Eligible participants were aged 65 years or older, lived independently, and had a baseline Clinical Dementia Rating (CDR) global score of 0.5 or less. Participants were enrolled between October 1, 2019, and June 30, 2022. Final follow-up occurred in May 2023.

Interventions

Participants were randomly assigned (1:1:1) to standard tai ji quan, cognitively enhanced tai ji quan, or stretching, and they exercised (via real-time videoconferencing) 1 hour semiweekly for 6 months.

Main Outcomes and Measures

The primary outcome was self-reported time engaged in MVPA (in minutes per week), assessed with the International Physical Activity Questionnaire at baseline and at 4, 6, and 12 months following randomization. The Physical Activity Guidelines for Americans recommend that older adults achieve at least 150 min/wk of MVPA, and the number of participants meeting this recommendation was also assessed. Analyses followed the intention-to-treat principle.

Results

Among the 318 participants enrolled, 107 were randomized to standard tai ji quan, 105 to cognitively enhanced tai ji quan, and 106 to stretching. Their mean (SD) age was 76 (5) years, 212 (66.7%) were women, and 247 (77.7%) had a CDR global score of 0.5. A total of 304 participants (95.6%) completed the trial, and 299 (94.0%) had complete data on the primary outcome at the 12-month follow-up. At 12 months, both tai ji quan groups had increased MVPA levels compared with the stretching control group, with mean differences from baseline of 66 min/wk (95% CI, 25-108 min/wk; P = .002) with standard tai ji quan and 65 min/wk (95% CI, 24-108 min/wk; P = .002) with cognitively enhanced tai ji quan. Odds ratios for meeting the recommended amount of MVPA (≥150 min/wk) were 3.11 (95% CI, 1.75-5.53; P < .001) for the standard tai ji quan group and 3.67 (95% CI, 2.02-6.65; P < .001) for the cognitively enhanced tai ji quan group compared with the stretching group.

Conclusion and Relevance

In this secondary analysis of a randomized clinical trial involving older adults with MCI or self-reported memory concerns, home-based tai ji quan training (delivered via videoconferencing) increased MVPA 6 months following cessation of the intervention compared with stretching. These findings suggest that tai ji quan may be promoted as an avenue to achieve physical activity guidelines for older adults with MCI or subjective memory concerns.

Trial Registration

ClinicalTrials.gov Identifier: NCT04070703.

"It's all about the money": an interpretive description of embedding physical therapy-led falls prevention group exercise in long-term care

BACKGROUND

Falls prevention interventions are effective for community dwelling older adults however, the same cannot be said for older adults living in long-term care (LTC). The Staying UpRight (SUp) randomized controlled trial was designed to test the effectiveness of a progressive strength and balance group exercise program delivered to LTC residents. This paper explores the factors impacting LTC providers' decisions to continue the program on completion of the funded trial period.

METHODS

A qualitative study using an Interpretive Description approach. Semi-structured interviews and focus groups were conducted with 15 LTC staff involved in the randomized controlled trial. Data were analysed using conventional content analysis.

RESULTS

Practice change occurred following participation in the trial with some facilities starting exercise groups, some increasing the number of exercise groups offered and physical therapists selecting elements of the program to adopt into their practice. Decisions about continuing with SUp as designed were constrained by organizational decisions regarding funding and resources. Three factors were identified which informed decision-making: business models and philosophies, requirements for evidence, and valuing physical therapy.

CONCLUSIONS

Managers and facilitators adapted SUp by selecting and delivering components of the program in response to the changes they had observed in participating residents. However, our findings highlight that while SUp was valued, the tight financial environment created by the current funding model in New Zealand did not support funding physical therapist delivered falls prevention exercise programs in LTC. This study may provide policy makers with important information on changes needed to support falls prevention service delivery in LTC.

TRIAL REGISTRATION

This study is a sub-study of a randomized controlled trial which was registered to the Australian New Zealand Clinical Trials Registry ACTRN12618001827224 on 09/11/2018. Universal trial number U1111-1217-7148.

A community-based single fall prevention exercise intervention for older adults (STEADY FEET): Study protocol for a randomised controlled trial

BACKGROUND

Falls and fall-related injuries in older adults are a leading cause of disability and death. Evidence has shown the benefits of exercises in improving functional outcomes and reducing fall rates among community-dwelling older adults. However, there is lack of effective community-based single exercise intervention for a broad population of older adults who are at high risk for falls. We aim to evaluate the effectiveness of Steady Feet (SF), a 6-month tailored community fall prevention exercise programme for improving functional outcomes. SF classes are facilitated by community fitness instructors and an exercise video. The main outcome is between-group changes in short physical performance battery (SPPB) scores. Secondary outcomes include balance confidence, fear of falling, quality of life, fall rates, and cost effectiveness.

METHODS

We present the design of a 6-month randomised controlled trial of 260 older adults (≥ 60 years old). Individuals will be randomised in a 1:1 allocation ratio to the SF group or usual care group. Participants will be assessed at baseline, 3-month, and 6-month. Data on socio-demographics, co-morbidities, balance confidence, fear of falling, quality of life, physical activity level, rate of perceived exertion, fall(s) history, healthcare utilisation and cost, and satisfaction levels will be collected. Participants will also undergo functional assessments such as SPPB. Moreover, providers' satisfaction and feedback will be obtained at 3-month.

DISCUSSION

An effective community fall prevention programme may lead to improved functional outcomes and reduced fall rates. Findings will also help inform the implementation and scaling of SF nation-wide.

TRIAL REGISTRATION

Clinicaltrials.gov registration: NCT04801316. Registered on 15th March 2021.

Estimating the Economic Burden Related to Older Adult Falls by State

OBJECTIVE

Unintentional falls in older adults (persons 65 years of age and older) impose a significant economic burden on the health care system. Methods for calculating state-specific health care costs are limited. This study describes 2 methods to estimate state-level direct medical spending due to older adult falls and explains their differences, advantages, and limitations.

DESIGN

The first method, partial attributable fraction, applied a national attributable fraction to the total state health expenditure accounts in 2014 by payer type (Medicare, Medicaid, and private insurance). The second method, count applied to cost, obtained 2014 state counts of older adults treated and released from an emergency department and hospitalized because of a fall injury. The counts in each state were multiplied by the national average lifetime medical costs for a fall-related injury from the Web-based Injury Statistics Query and Reporting System. Costs are reported in 2014 US dollars.

SETTING

United States.

PARTICIPANTS

Older adults.

MAIN OUTCOME MEASURE

Health expenditure on older adult falls by state.

RESULTS

The estimate from the partial attributable fraction method was higher than the estimate from the count applied to cost method for all states compared, except Utah. Based on the partial attributable fraction method, in 2014, total personal health care spending for older adult falls ranged from $48 million in Alaska to $4.4 billion in California. Medicare spending attributable to older adult falls ranged from $22 million in Alaska to $3.0 billion in Florida. For the count applied to cost method, available for 17 states, the lifetime medical costs of 2014 fall-related injuries ranged from $68 million in Vermont to $2.8 billion in Florida.

CONCLUSIONS

The 2 methods offer states options for estimating the economic burden attributable to older adult fall injuries. These estimates can help states make informed decisions about how to allocate funding to reduce falls and promote healthy aging.

Impact of a Behavioral Intervention on Diet, Eating Patterns, Self-Efficacy, and Social Support

OBJECTIVE

To examine the effectiveness of a structured multimodal behavioral intervention to change dietary behaviors, as well as self-efficacy and social support for engaging in healthier diets.

METHODS

A quasi-experimental design was used to assign sites into intervention and comparison groups. Data were collected at baseline, 3 months, and 6 months. The intervention group participated in Texercise Select, a 12-week lifestyle enhancement program. Multiple mixed-effects models were used to examine nutrition-related changes over time.

RESULTS

For the intervention group, significant improvements were observed for fast food consumption (P = .011), fruit/vegetable consumption (P = .008), water consumption (P = .009), and social support (P < .001) from baseline to 3 months. The magnitude of these improvements was significantly greater than changes in the comparison group.

CONCLUSIONS AND IMPLICATIONS

Findings suggest the intervention's ability to improve diet-related outcomes among older adults; however, additional efforts are needed to maintain changes over longer periods.

State-Identified Implementation Strategies to Increase Uptake of Immediate Postpartum Long-Acting Reversible Contraception Policies

BACKGROUND

In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation.

MATERIALS AND METHODS

Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified.

RESULTS

The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities.

CONCLUSIONS

Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.

Examination of sustainability indicators for fall prevention strategies in three states

With 1-in-4 older adults suffering a fall each year, fall prevention efforts have emerged as a public health priority. Multi-level, evidence-based fall prevention programs have been promoted by the CDC and other government agencies. To ensure participants and communities receive programs' intended benefits, organizations must repeatedly deliver the programs over time and plan for program sustainability as part of 'scaling up' the initiative. The State Falls Prevention Project (SFPP) began in 2011 when the CDC provided 5 years of funding to State Departments of Health in Colorado, New York, and Oregon to simultaneously implement four fall prevention strategies: 1) Tai Chi: Moving for Better Balance; 2) Stepping On; 3) Otago Exercise Program; and 4) STEADI (STopping Elderly Accidents, Deaths, and Injuries) toolkit. Surveys were performed to examine systems change and perceptions about sustainability across states. The purposes of this study were to: 1) examine how funding influenced the capacity for program implementation and sustainability within the SFPP; and 2) assess reported Program Sustainability Assessment Tool (PSAT) scores to learn about how best to sustain fall preventing efforts after funding ends. Data showed that more organizations offered evidence-based fall prevention programs in participants' service areas with funding, and the importance of programming implementation, evaluation, and reporting efforts were likely to diminish once funding concluded. Participants' reported PSAT scores about perceived sustainability capacity did not directly align with previously reported perceptions about PSAT domain importance or modifiability. Findings suggest the importance of grantees to identify potential barriers and enablers influencing program sustainability during the planning phase of the programs.