Telemedicine-Based Risk Program to Prevent Falls Among Older Adults: Protocol for a Randomized Quality Improvement Trial

BACKGROUND

The Center for Disease Control and Prevention's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative offers health care providers tools and resources to assist with fall risk screening and multifactorial fall risk assessment and interventions. Its effectiveness has never been evaluated in a randomized trial.

OBJECTIVE

This study aims to describe the protocol for the STEADI Options Randomized Quality Improvement Trial (RQIT), which was designed to evaluate the impact on falls and all-cause health expenditures of a telemedicine-based form of STEADI implemented among older adults aged 65 years and older, within a primary care setting.

METHODS

STEADI Options was a pragmatic RQIT implemented within a health system comparing a telemedicine version of the STEADI fall risk assessment to the standard of care (SOC). Before screening, we randomized all eligible patients in participating clinics into the STEADI arm or SOC arm based on their scheduled provider. All received the Stay Independent screener (SIS) to determine fall risk. Patients were considered at risk for falls if they scored 4 or more on the SIS or answered affirmatively to any 1 of the 3 key questions within the SIS. Patients screened at risk for falls and randomized to the STEADI arm were offered a registered nurse (RN)-led STEADI assessment through telemedicine; the RN provided assessment results and recommendations to the providers, who were advised to discuss fall-prevention strategies with their patients. Patients screened at risk for falls and randomized to the SOC arm were asked to participate in study data collection only. Data on recruitment, STEADI assessments, use of recommended prevention services, medications, and fall occurrences were collected using electronic health records and patient surveys. Using staff time diaries and administrative records, the study prospectively collected data on STEADI implementation costs and all-cause outpatient and inpatient charges incurred over the year following enrollment.

RESULTS

The study enrolled 720 patients (n=307, 42.6% STEADI arm; n=353, 49% SOC arm; and n=60, 8.3% discontinued arm) from September 2020 to December 2021. Follow-up data collection was completed in January 2023. As of February 2024, data analysis is complete, and results are expected to be published by the end of 2025.

CONCLUSIONS

The STEADI RQIT evaluates the impact of a telemedicine-based, STEADI-based fall risk assessment on falls and all-cause health expenditures and can provide information on the intervention's effectiveness and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05390736, http://clinicaltrials.gov/ct2/show/NCT05390736.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/54395.

An Effectiveness Trial of STEADI in an Outpatient, Primary Care Practice

The STEADI Options trial uses a randomized, controlled-trial design to assess the effectiveness and cost-effectiveness of the STEADI Initiative . Beginning March, 2020, we will randomize 3,000 adults ≥ 65 years of age at risk for falls seen in an Emory Clinic primary care practice to: (1) full STEADI; (2) a STEADI-derived gait, balance, and strength assessment with physical therapy referrals; (3) a STEADI-derived medication review and management; or (4) usual care. This presentation will discuss decisions made by the study team to facilitate implementation of STEADI including electronically conducting screening prior to the date of encounter, the use of dedicated nursing staff to conduct assessments, implementation of strength, balance, orthostatic hypotension, and vision testing, methods to facilitate medication review, and communication of assessment information to providers. The results from this study will be used to estimate the impact of STEADI on falls, service utilization, and costs over one year.

Swiss S1 guideline for the treatment of rosacea

Rosacea (in German sometimes called 'Kupferfinne', in French 'Couperose' and in Italian 'Copparosa') is a chronic and frequently relapsing inflammatory skin disease primarily affecting the central areas of the face. Its geographic prevalence varies from 1% to 22%. The differential diagnosis is wide, and the treatment is sometimes difficult and varies by stage of rosacea. For erythematous lesions and telangiectasia, intense pulsed light (IPL) therapy and lasers are popular treatment option. In addition, a vasoconstrictor agent, brimonidine, has recently been developed. For papulopustular rosacea, topical antibiotics, topical and systemic retinoids, as well as systemic antibiotics are used. A topical acaricidal agent, ivermectin, has undergone clinical development and is now on the market. In the later stages, hyperplasia of the sebaceous glands develops, resulting in phymatous growths such as the frequently observed bulbous nose or rhinophyma. Ablative laser treatments have largely replaced classical abrasive tools. Here, we reviewed the current evidence on the treatment of rosacea, provide a guideline (S1 level) and discuss the differential diagnosis of rosacea.

Continuity and innovation in the data collection protocols of the second Wave of the National Social Life, Health, and Aging Project

BACKGROUND

The second Wave (W2) of the National Social Life, Health, and Aging Project (NSHAP), a nationally representative, longitudinal survey of older adults now between the ages of 62 and 90, conducted approximately 3,400 interviews. Selected coresidential romantic partners as well as W1 panel nonrespondents were selected for W2. Data collection included in-person questionnaires, up to 15 biomeasures, and a post-interview questionnaire.

METHODS

A proxy questionnaire also collected data on respondents that were deceased or in too poor health to participate in W2. Biomeasure collection included height, weight, hip and waist circumference, blood pressure, heart rate, and preventricular contraction, timed walk and chair stands, smell, saliva collection using a Salivette (cortisol), saliva passive drool in a tube (dehydroepiandrosterone, estradiol, progesterone, testosterone), dried blood spots (Epstein-Barr virus antibody titers, C-reactive protein, glycosylated hemoglobin, hemoglobin, cholesterol, high-density lipoprotein), whole blood in a microtainer (cytokines), urine (creatinine, vasopressin, oxytocin), Oragene (genotype), respondent-administered vaginal swabs (bacterial vaginosis,yeast, and vaginal cell cytology), and Actiwatch (sleep patterns and activity).

RESULTS

Measures, such as response and cooperation rates, are also provided to evaluate design and implementation.

DISCUSSION

This article describes both innovation in the development and implementation of W2 as well as fidelity to W1 study design and data collection procedures.

Suicide assisted by two Swiss right-to-die organisations

BACKGROUND

In Switzerland, non-medical right-to-die organisations such as Exit Deutsche Schweiz and Dignitas offer suicide assistance to members suffering from incurable diseases.

OBJECTIVES

First, to determine whether differences exist between the members who received assistance in suicide from Exit Deutsche Schweiz and Dignitas. Second, to investigate whether the practices of Exit Deutsche Schweiz have changed since the 1990s.

METHODS

This study analysed all cases of assisted suicide facilitated by Exit Deutsche Schweiz (E) and Dignitas (D) between 2001 and 2004 and investigated by the University of Zurich's Institute of Legal Medicine (E: n = 147; D: n = 274, total: 421). Furthermore, data from the Exit Deutsche Schweiz study which investigated all cases of assisted suicide during the period 1990-2000 (n = 149) were compared with the data of the present study.

RESULTS

More women than men were assisted in both organisations (D: 64%; E: 65%). Dignitas provided more assistance to non-residents (D: 91%; E: 3%; p = 0.000), younger persons (mean age in years (SD): D: 64.5 (14.1); E: 76.6 (13.3); p = 0.001), and people suffering from fatal diseases such as multiple sclerosis and amyotrophic lateral sclerosis (D: 79%; E: 67%; p = 0.013). Lethal medications were more often taken orally in cases assisted by Dignitas (D: 91%; E: 76%; p = 0.000). The number of women and the proportion of older people suffering from non-fatal diseases among suicides assisted by Exit Deutsche Schweiz has increased since the 1990s (women: 52% to 65%, p = 0.031; mean age in years (SD): 69.3 (17.0) to 76.9 (13.3), p = 0.000), non-fatal diseases: 22% to 34%, p = 0.026).

CONCLUSIONS

Weariness of life rather than a fatal or hopeless medical condition may be a more common reason for older members of Exit Deutsche Schweiz to commit suicide. The strong over-representation of women in both Exit Deutsche Schweiz and Dignitas suicides is an important phenomenon so far largely overlooked and in need of further study.

[Managing urinary incontinence in stroke rehabilitation--a review]

BACKGROUND

Urinary incontinence following stroke is an extensive problem for the patients and their relatives that influences the well-being and care in the future. There are a lot of therapeutic interventions available, their effectiveness, however, is not known in detail. For rehabilitation practice the ongoing question is how Urinary Incontinence (UI) can best be treated in a way that the patients daily life is not compromised.

METHOD

The search for clinical trials was carried out in PubMed, CINAHL, and Cochrane Library, restricted to German and English papers published between 1989 and April 2005. Medical, nursing and physiotherapeutic interventions for treating UI after stroke were described and analysed.

RESULTS

The clinical trials were divided into process-oriented trials and those looking at individual interventions. The process trials could be divided into three different groups with an overall success of 82-95 %, 50-56 % and 23-36 % respectively. Behavioral methods (caregiver-induced, patient-active and other interventions) and medical interventions are available. The studies of the most successful group include staff education and application of interventions based on an assessment procedure and a guideline. No clinical trial on individual interventions reached a result like the process-oriented studies.

CONCLUSION

For treating urinary incontinence a multimodal approach is necessary: special education of the nurses, applying and acting in a problem-solving process, for example in the Rehabilitation Cycle and delivering care based on an assessment procedure and guidelines. Development of a guideline for treating urinary incontinence after stroke can be recommended. Further research in the efficacy of individual interventions is needed.

The butterbur extract petasin has no effect on skin test reactivity induced by different stimuli: a randomized, double-blind crossover study using histamine, codeine, methacholine, and aeroallergen solutions

BACKGROUND

Petasin (Ze 339) was recently introduced on the market as a potent herbal antiallergic drug for treatment of respiratory allergies such as hay fever. Few clinical studies have been performed so far addressing the clinical effectiveness of Ze 339.

OBJECTIVE

To evaluate the antiallergic properties of Ze 339 using skin prick tests with different stimuli, such as codeine, histamine, methacholine, and a relevant inhalant allergen.

METHODS

A randomized, double-blind, placebo-controlled study was performed in which Ze 339 was compared to acrivastine, a short-acting antihistamine, in 8 patients with respiratory allergy and in 10 nonatopic, healthy volunteers. Antiallergic activity of Ze 339 was determined by analyzing inhibitory potency in skin prick tests with codeine, histamine, methacholine, and an inhalant allergen. Wheal-and-flare reactions were assessed 90 minutes after a double dose of Ze 339, acrivastine, or placebo. An interval of at least 3 days was left between the skin tests.

RESULTS

Acrivastine was identified as the only substance that significantly inhibited skin test reactivity to all solutions analyzed in all study subjects. In contrast, no significant inhibition could be demonstrated for Ze 339 with any test solution. Moreover, the results of Ze 339 did not differ significantly from placebo.

CONCLUSIONS

In this study we found no antiallergic, particularly antihistaminic, effect of Ze 339 in skin tests using a variety of stimuli often used to evaluate immediate skin test reactivity. The mechanism by which Ze 339 is effective in the treatment of seasonal allergic rhinitis still needs to be elucidated.

A graphical method for finding maximin efficiency designs

We consider the problem of designing an experiment when there are two competing optimality criteria. Designs that maximize the minimum efficiencies under the two criteria are proposed along with a graphical method for finding these maximin designs.