Classification system for primary care provider eConsults about medications for older adults with frailty

BACKGROUND

Providing primary care for people with frailty can be challenging due to an increased risk of adverse outcomes and use of potentially inappropriate medications which may exacerbate characteristics of frailty. eConsult is a service where primary care providers can receive timely specialist advice for their patients through a secure web-based application. We aimed to develop a classification system to characterize medication-focused eConsult questions for older adults with frailty and assess its usability.

METHODS

A classification system was developed and refined over three cycles of improvement through a cross-sectional study of 35 cases categorized as medication-focused from cases submitted in 2019 for patients aged 65 or older with frailty through the Champlain BASE eConsult service (Ontario, Canada). The final classification system was then applied to each case.

RESULTS

The classification system contains 5 sections: (1) case descriptives; (2) intent and type of question; (3) medication recommendations and additional information in the response; (4) medication classification; and (5) potentially inappropriate medications. Among the 35 medication-focused cases, the most common specialties consulted were endocrinology (9 cases, 26%) and cardiology (5 cases, 14%). Medication histories were available for 29 cases (83%). Many patients were prescribed potentially inappropriate medications based on explicit tools (AGS Beers Criteria®, STOPPFall, Anticholinergic Cognitive Burden Scale, ThinkCascades) yet few consults inquired about these medications.

CONCLUSION

A classification system to describe medication-related eConsult cases for patients experiencing frailty was developed and applied to 35 eConsult cases. It can be applied to more cases to identify professional development opportunities and enhancements for eConsult services.

What do primary care providers want to know when caring for patients living with frailty? An analysis of eConsult communications between primary care providers and specialists

BACKGROUND

Frailty is a complex condition that primary care providers (PCPs) are managing in increasing numbers, yet there is no clear guidance or training for frailty care.

OBJECTIVES

The present study examined eConsult questions PCPs asked specialists about patients with frailty, the specialists' responses, and the impact of eConsult on the care of these patients.

DESIGN

Cross-sectional observational study.

SETTING

ChamplainBASE™ eConsult located in Eastern Ontario, Canada.

PARTICIPANTS

Sixty one eConsult cases closed by PCPs in 2019 that use the terms "frail" or "frailty" to describe patients 65 years of age or older.

MEASUREMENTS

The Taxonomy of Generic Clinical Questions (TGCQ) was used to classify PCP questions and the International Classification for Primary Care 3 (ICPC-3) was used to classify the clinical content of each eConsult. The impact of eConsult on patient care was measured by PCP responses to a mandatory survey.

RESULTS

PCPs most frequently directed their questions to cardiology (n = 7; 11%), gastroenterology (n = 7; 11%), and endocrinology (n = 6; 10%). Specialist answers most often pertained to medications (n = 63, 46%), recommendations for clinical investigation (n = 24, 17%), and diagnoses (n = 22, 16%). Specialist responses resulted in PCPs avoiding referral in 57% (n = 35) of cases whereas referrals were still required in 15% (n = 9) of cases. Specialists responded to eConsults in a median 1.11 days (IQR = 0.3-4.7), and 95% (n = 58) of cases received a response within 7 days. Specialists recorded a median of 15 min to respond (IQR = 10-20), with a median cost of $50.00 CAD (IQR = 33.33 - 66.66) per eConsult.

CONCLUSIONS

Through the analysis of questions and responses submitted to eConsult, this study provides novel information on PCP knowledge gaps and approaches to care for patients living with frailty. Furthermore, these analyses provide evidence that eConsult is a feasible and valuable tool for improving care for patients with frailty in primary care settings.

Use of Artificial Intelligence in the Identification and Management of Frailty: A Scoping Review Protocol

INTRODUCTION

Rapid population ageing and associated health issues such as frailty are a growing public health concern. While early identification and management of frailty may limit adverse health outcomes, the complex presentations of frailty pose challenges for clinicians. Artificial intelligence (AI) has emerged as a potential solution to support the early identification and management of frailty. In order to provide a comprehensive overview of current evidence regarding the development and use of AI technologies including machine learning and deep learning for the identification and management of frailty, this protocol outlines a scoping review aiming to identify and present available information in this area. Specifically, this protocol describes a review that will focus on the clinical tools and frameworks used to assess frailty, the outcomes that have been evaluated and the involvement of knowledge users in the development, implementation and evaluation of AI methods and tools for frailty care in clinical settings.

METHODS AND ANALYSIS

This scoping review protocol details a systematic search of eight major academic databases, including Medline, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ageline, Web of Science, Scopus and Institute of Electrical and Electronics Engineers (IEEE) Xplore using the framework developed by Arksey and O'Malley and enhanced by Levac et al and the Joanna Briggs Institute. The search strategy has been designed in consultation with a librarian. Two independent reviewers will screen titles and abstracts, followed by full texts, for eligibility and then chart the data using a piloted data charting form. Results will be collated and presented through a narrative summary, tables and figures.

ETHICS AND DISSEMINATION

Since this study is based on publicly available information, ethics approval is not required. Findings will be communicated with healthcare providers, caregivers, patients and research and health programme funders through peer-reviewed publications, presentations and an infographic.

REGISTRATION DETAILS

OSF Registries (https://doi.org/10.17605/OSF.IO/T54G8).

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Electronic consultation use by advanced practice nurses in older adult care-A descriptive study of service utilization data

AIMS AND OBJECTIVES

To describe characteristics of service utilization by advanced practice nurses (APNs) employing an electronic consultation (eConsult) service in their care for older adults.

BACKGROUND

Canada's aging population is projected to place unprecedented demands on the healthcare system. APNs, which include clinical nurse specialists (CNSs) and nurse practitioners (NPs), are nurses with advanced knowledge who can independently provide age-appropriate care. eConsult is a secure web-based platform enabling asynchronous, provider-to-provider communication. APNs can send and receive eConsults to address patient-specific concerns.

METHODS

This is a retrospective analysis of eConsult utilization and user survey data for cases completed in 2019, reported in line with the STROBE guidelines. Eligible eConsults included those that had APN involvement (as a referrer or responder) and were concerning an older patient (≥65 years). Descriptive statistics were used to analyse service utilization and survey response data.

RESULTS

Of 430 eligible eConsults, 421 (97.9%) were initiated by NPs and the rest by physicians. 23 (5.3%) were received by a CNS, of which 14 (3.3%) involved an NP-to-CNS exchange. Median specialist response interval was 0.9 days. 53% of eConsults was for dermatology, haematology, cardiology, gastroenterology and endocrinology. 73% of eConsults avoided a face-to-face referral after the consultation. In 90% of eConsults, APNs rated the service as helpful and/or educational.

CONCLUSIONS

Through eConsult, APNs can collaborate with each other and physicians to access and provide a breadth of advice facilitating timely specialist-informed care for older patients, thus helping to alleviate some of the demands placed on the healthcare system.

RELEVANCE TO CLINICAL PRACTICE

There is an opportunity for APNs to further adopt eConsult into their clinical practice, and this can, in turn, support the integration of the APN role in the health workforce.

PATIENT OR PUBLIC CONTRIBUTION

Current APN eConsult users were involved in the study design and interpretation of results.

Using electronic consultation (eConsult) to identify frailty in provider-to-provider communication: a feasibility and validation study

BACKGROUND

Frailty is a complex age-related clinical condition that increases vulnerability to stressors. Early recognition of frailty is challenging. While primary care providers (PCPs) serve as the first point of contact for most older adults, convenient tools for identifying frailty in primary care are lacking. Electronic consultation (eConsult), a platform connecting PCPs to specialists, is a rich source of provider-to-provider communication data. Text-based patient descriptions on eConsult may provide opportunities for earlier identification of frailty. We sought to explore the feasibility and validity of identifying frailty status using eConsult data.

METHODS

eConsult cases closed in 2019 and submitted on behalf of long-term care (LTC) residents or community-dwelling older adults were sampled. A list of frailty-related terms was compiled through a review of the literature and consultation with experts. To identify frailty, eConsult text was parsed to measure the frequency of frailty-related terms. Feasibility of this approach was assessed by examining the availability of frailty-related terms in eConsult communication logs, and by asking clinicians to indicate whether they can assess likelihood of frailty by reviewing the cases. Construct validity was assessed by comparing the number of frailty-related terms in cases about LTC residents with those about community-dwelling older adults. Criterion validity was assessed by comparing clinicians' ratings of frailty to the frequency of frailty-related terms.

RESULTS

One hundred thirteen LTC and 112 community cases were included. Frailty-related terms identified per case averaged 4.55 ± 3.95 in LTC and 1.96 ± 2.68 in the community (p < .001). Clinicians consistently rated cases with ≥ 5 frailty-related terms as highly likely of living with frailty.

CONCLUSIONS

The availability of frailty-related terms establishes the feasibility of using provider-to-provider communication on eConsult to identify patients with high likelihood of living with this condition. The higher average of frailty-related terms in LTC (versus community) cases, and agreement between clinician-provided frailty ratings and the frequency of frailty-related terms, support the validity of an eConsult-based approach to identifying frailty. There is potential for eConsult to be used as a case-finding tool in primary care for early recognition and proactive initiation of care processes for older patients living with frailty.

What is the level of information technology maturity in Ontario's long-term care homes? A cross-sectional survey study protocol

INTRODUCTION

The number of Canadians 75 years and older is expected to double over the next 20 years, putting continuing care systems such as long-term care (LTC) homes under increasing pressure. Health information technology (IT) has been found to improve the quality, safety and efficiency of care in numerous clinical settings and could help optimise LTC for residents. However, the level of health IT adoption in Ontario's LTC homes is unknown and, as a result, requires an accurate assessment to provide a baseline understanding for future planning.

METHODS AND ANALYSIS

We will use a cross-sectional design to investigate the level of IT maturity in Ontario's LTC homes. IT maturity will be assessed with the LTC IT Maturity Instrument, a validated survey examining IT capabilities, the extent of IT use and degree of internal/external IT integration across the domains of resident care, clinical support and administrative activities. All LTC homes in Ontario will be invited to participate. The Director of Care for each home will be directly contacted for recruitment. The survey will be distributed online (or by paper, if preferred) to LTC homes and completed by a staff member designated by the LTC to be knowledgeable about its IT systems. Analyses will consist of descriptive statistics characterising IT maturity across LTC homes and inferential statistics to examine the association between key facility-level characteristics (size, ownership, rurality) and IT maturity.

ETHICS AND DISSEMINATION

This study was reviewed by the Ottawa Health Science Network Research Ethics Board and was exempt from full ethics review. Findings will be disseminated through peer-reviewed publication and presentations to the scientific community and stakeholders. Dissemination of our findings will not only inform provincial planning for harnessing the potential of technology in LTC but may also enable quality improvement initiatives in individual LTC homes.

Changing patterns in reporting and sharing of review data in systematic reviews with meta-analysis of the effects of interventions: cross sectional meta-research study

OBJECTIVES

To examine changes in completeness of reporting and frequency of sharing data, analytical code, and other review materials in systematic reviews over time; and factors associated with these changes.

DESIGN

Cross sectional meta-research study.

POPULATION

Random sample of 300 systematic reviews with meta-analysis of aggregate data on the effects of a health, social, behavioural, or educational intervention. Reviews were indexed in PubMed, Science Citation Index, Social Sciences Citation Index, Scopus, and Education Collection in November 2020.

MAIN OUTCOME MEASURES

The extent of complete reporting and the frequency of sharing review materials in the systematic reviews indexed in 2020 were compared with 110 systematic reviews indexed in February 2014. Associations between completeness of reporting and various factors (eg, self-reported use of reporting guidelines, journal policies on data sharing) were examined by calculating risk ratios and 95% confidence intervals.

RESULTS

Several items were reported suboptimally among 300 systematic reviews from 2020, such as a registration record for the review (n=113; 38%), a full search strategy for at least one database (n=214; 71%), methods used to assess risk of bias (n=185; 62%), methods used to prepare data for meta-analysis (n=101; 34%), and source of funding for the review (n=215; 72%). Only a few items not already reported at a high frequency in 2014 were reported more frequently in 2020. No evidence indicated that reviews using a reporting guideline were more completely reported than reviews not using a guideline. Reviews published in 2020 in journals that mandated either data sharing or inclusion of data availability statements were more likely to share their review materials (eg, data, code files) than reviews in journals without such mandates (16/87 (18%) v 4/213 (2%)).

CONCLUSION

Incomplete reporting of several recommended items for systematic reviews persists, even in reviews that claim to have followed a reporting guideline. Journal policies on data sharing might encourage sharing of review materials.

Implementing a Telehealth Support Tool for Community-Dwelling Older Adults During the COVID-19 Pandemic: A Qualitative Investigation of Provider Experiences

During the COVID-19 pandemic, policymakers had to quickly offer telehealth services to address older adults' needs. This study aimed to understand the experiences of providers who implemented a telephone-based telehealth tool named Socio-Geriatric Evaluation (ESOGER), which assessed health and social isolation risks in community-dwelling older adults in Quebec (Canada). This qualitative study used 20 semi-structured online/phone interviews with health and social service providers coming from publicly-funded healthcare facilities and community organizations. We included adopters and non-adopters of the telehealth tool. Interviews were audio-recorded and transcribed verbatim. We used reflexive thematic analysis to interpret the data. Three dimensions of providers' practice influenced the tool's implementation: service organization, working conditions, and interactions with older adults. Participants reported that the tool fostered continuity of care, provided guidance for their pandemic-related new tasks, and helped identify and support socially isolated older adults. Challenges to implementation included limited appropriateness of the telehealth tool for diverse services, feasibility barriers to adopting a new tool amid the health crisis, and acceptability challenges with some older adults. Despite relevance of the telehealth tool for providers, organizational, professional, and interactional barriers could hinder implementation success. Participatory approaches to telehealth may be promising avenues for future policies in this field.

Electronic consultation in correctional facilities worldwide: a scoping review

OBJECTIVE

To provide an overview of the use of and evidence for eConsult in correctional facilities worldwide.

DESIGN

Scoping review.

DATA SOURCES

Three academic databases (MEDLINE, Embase and CINAHL) were searched to identify papers published between 1990 and 2020 that presented data on eConsult use in correctional facilities. The grey literature was also searched for any resources that discussed eConsult use in correctional facilities. Articles and resources were excluded if they discussed synchronous, patient-to-provider or unsecure communication. The reference lists of included articles were also hand searched.

RESULTS

Of the 226 records retrieved from the academic literature search and 595 from the grey literature search, 22 were included in the review. Most study populations included adult male offenders in a variety of correctional environments. These resources identified 13 unique eConsult services in six countries. Six of these services involved multiple medical specialties, while the remaining services were single specialty. The available evidence was organised into five identified themes: feasibility, cost-effectiveness, access to care, provider satisfaction and clinical impact.

CONCLUSIONS

This study identified evidence that the use of eConsult in correctional facilities is beneficial and avoids unnecessary transportation of offenders outside of the facilities. It is feasible, cost-effective, increases access to care, has an impact on clinical care and has high provider satisfaction. Some gaps in the literature remain, and we suggest further research on patient satisfaction, enablers and barriers to implementation, and women, youth and transgender populations in this setting to inform service providers and stakeholders. Despite some gaps, eConsult is evidently an important tool to provide timely, high-quality care to offenders.

Natural Language Processing to Identify Digital Learning Tools in Postgraduate Family Medicine: Protocol for a Scoping Review

Background

The COVID-19 pandemic has highlighted the growing need for digital learning tools in postgraduate family medicine training. Family medicine departments must understand and recognize the use and effectiveness of digital tools in order to integrate them into curricula and develop effective learning tools that fill gaps and meet the learning needs of trainees.

Objective

This scoping review will aim to explore and organize the breadth of knowledge regarding digital learning tools in family medicine training.

Methods

This scoping review follows the 6 stages of the methodological framework outlined first by Arksey and O’Malley, then refined by Levac et al, including a search of published academic literature in 6 databases (MEDLINE, ERIC, Education Source, Embase, Scopus, and Web of Science) and gray literature. Following title and abstract and full text screening, characteristics and main findings of the included studies and resources will be tabulated and summarized. Thematic analysis and natural language processing (NLP) will be conducted in parallel using a 9-step approach to identify common themes and synthesize the literature. Additionally, NLP will be employed for bibliometric and scientometric analysis of the identified literature.

Results

The search strategy has been developed and launched. As of October 2021, we have completed stages 1, 2, and 3 of the scoping review. We identified 132 studies for inclusion through the academic literature search and 127 relevant studies in the gray literature search. Further refinement of the eligibility criteria and data extraction has been ongoing since September 2021.

Conclusions

In this scoping review, we will identify and consolidate information and evidence related to the use and effectiveness of existing digital learning tools in postgraduate family medicine training. Our findings will improve the understanding of the current landscape of digital learning tools, which will be of great value to educators and trainees interested in using existing tools, innovators looking to design digital learning tools that meet current needs, and researchers involved in the study of digital tools.

Trial Registration

OSF Registries osf.io/wju4k; https://osf.io/wju4k

International Registered Report Identifier (IRRID)

DERR1-10.2196/34575

Electronic Consultation by Advanced Practice Nurses to Improve Access to Specialist Care for Older Adults

Older adults face several challenges when accessing specialist care. Advanced practice nurses (APNs) can perform an important role in primary care for older adults, particularly when bolstered with digital tools. In the current study, we conducted a multiple case study of electronic consultations (eConsults) involving APNs to assess how these practitioners use the service to improve access to care. All eConsults submitted by or to an APN in 2019 on behalf of patients aged ≥65 years were reviewed to identify examples from six settings representative of the range of advanced nursing practices. For each setting, a final case was chosen using an iterative process and stratified by specialty and type of advice. Included cases were assessed using a conceptual framework for health care access. Selected cases illustrate how APNs can be effective users of eConsults in a diversity of health care settings. The framework allowed for an in-depth study of access over the range of interactions that take place among patients, caregivers, providers, and the health care system. [Journal of Gerontological Nursing, 48(4), 33-40.].

Physical Function and Survival in Older Adults: A longitudinal study accounting for time-varying effects

PURPOSE OF THE STUDY

Variation in physical function in older adults over time raises several methodological challenges in the study of its association with survival, many of which have largely been overlooked in previous studies. The objective of this study is to examine the relationship between time-varying measures of physical function and survival in men and women aged 70 years and over, while accounting for the time-varying effects of health and lifestyle characteristics.

METHODS

1,846 women and 1,245 men in the Cardiovascular Health Study followed annually for up to 10 years beginning at age 70-74 years were included. We estimated the effect of gait speed and grip strength on survival over the subsequent year, using age as the timescale.

RESULTS

A 0.1m/s higher gait speed was associated with a 12% decrease in the likelihood of death in the subsequent year among women (HR 0.88, 95% CI 0.82-0.94). There was no statistically significant effect of gait speed on survival among men (HR 0.97, 95% CI 0.91 to 1.03), or of grip strength on survival among women (HR 0.97, 95% CI 0.95-1.00) or men (HR 0.99, 95% CI 0.97-1.01), over one year.

CONCLUSIONS

Upon using time-varying measures of physical function while accounting for time-varying effects of health and lifestyle characteristics, higher gait speed was associated with increased survival among the women in our study. We found no evidence of an association between gait speed and one-year survival in men, or between grip strength and one-year survival in women or men.

The REPRISE project: protocol for an evaluation of REProducibility and Replicability In Syntheses of Evidence

BACKGROUND

Investigations of transparency, reproducibility and replicability in science have been directed largely at individual studies. It is just as critical to explore these issues in syntheses of studies, such as systematic reviews, given their influence on decision-making and future research. We aim to explore various aspects relating to the transparency, reproducibility and replicability of several components of systematic reviews with meta-analysis of the effects of health, social, behavioural and educational interventions.

METHODS

The REPRISE (REProducibility and Replicability In Syntheses of Evidence) project consists of four studies. We will evaluate the completeness of reporting and sharing of review data, analytic code and other materials in a random sample of 300 systematic reviews of interventions published in 2020 (Study 1). We will survey authors of systematic reviews to explore their views on sharing review data, analytic code and other materials and their understanding of and opinions about replication of systematic reviews (Study 2). We will then evaluate the extent of variation in results when we (a) independently reproduce meta-analyses using the same computational steps and analytic code (if available) as used in the original review (Study 3), and (b) crowdsource teams of systematic reviewers to independently replicate a subset of methods (searches for studies, selection of studies for inclusion, collection of outcome data, and synthesis of results) in a sample of the original reviews; 30 reviews will be replicated by 1 team each and 2 reviews will be replicated by 15 teams (Study 4).

DISCUSSION

The REPRISE project takes a systematic approach to determine how reliable systematic reviews of interventions are. We anticipate that results of the REPRISE project will inform strategies to improve the conduct and reporting of future systematic reviews.

Changing research culture toward more use of replication research: a narrative review of barriers and strategies

OBJECTIVE

The aim of this paper is to review the literature on barriers to conducting replication research and strategies to increase its use and promotion by researchers, editors, and funders.

STUDY DESIGN AND SETTING

This review was part of a larger meta-narrative review aimed at conducting a concept analysis of replication and developing a replication research framework. A combination of systematic and snowball search strategies was used to identify relevant literature in multiple research fields. Data were coded and analyzed using the Theoretical Domains Framework for barriers to replication and the behavior change wheel for solutions.

RESULTS

In total, 153 papers were included in this narrative review. Multiple barriers limit the use of replication research by researchers, editors, and funders. Many of the barriers were related to knowledge and skills of all these actors. Social influences and the research environmental context were also described as not supportive. Multiple strategies were proposed to create positive outcomes expectations, reinforcement, and structural changes in the physical and social context of research.

CONCLUSION

A social change involving advisory groups, research organizations, and institutions is required to establish new norms that will value, promote, support, and reward replication research.

"One more time": why replicating some syntheses of evidence relevant to COVID-19 makes sense

•Given the urgent need for credible answers to high-priority questions about the health and social impacts of COVID-19, many systematic reviewers seek to contribute their skills and expertise. •Rather than embarking on unnecessary, duplicate reviews, we encourage the evidence synthesis community to prioritise purposeful replication of systematic reviews of evidence relevant to COVID-19. •We explain why replication of systematic reviews is important, how to carry out a replication, and when to consider replication of reviews.

PROTOCOL: When and how to replicate systematic reviews

This is a protocol for a co-registered Cochrane and Campbell Review (Methodology). The objectives are as follows: To identify, describe and assess methods for: when to replicate a systematic review; how to replicate a systematic review.

Implementing frailty into clinical practice: a cautionary tale

BACKGROUND

Little is known about the contribution of frailty in improving patient-level prediction beyond readily available clinical information. The objective of this study is to compare the predictive ability of 129 combinations of seven frailty markers (cognition, energy, mobility, mood, nutrition, physical activity, and strength) and quantify their contribution to predictive accuracy beyond age, sex, and number of chronic diseases.

METHODS

Two cohorts from the Established Populations for Epidemiologic Studies of the Elderly were used. The model with the best predictive fit in predicting 6-year incidence of disability was determined using the Akaike Information Criterion. Predictive accuracy was measured by the C statistic.

RESULTS

Incident disability was 23% in one cohort and 20% in the other cohort. The "best model" in each cohort was found to be a model including between five and seven frailty markers including cognition, mobility, nutrition, physical activity, and strength. Predictive accuracy of the 129 models ranged from 0.73 to 0.77 across both cohorts. Adding frailty markers to age, sex, and chronic disease increased predictive accuracy by up to 3% in both cohorts (p < .001). The contribution of frailty increased up to 9% in the oldest age group.

CONCLUSIONS

Adding frailty markers provided a modest increase in patient-level prediction of disability. Such a modest increase may still be worthwhile because while age, sex, and the number of chronic diseases are not modifiable, frailty may be. Further studies examining the contribution of frailty in improving prediction are needed before adopting frailty as a prognostic tool.

Understanding and meeting the needs of the older population: a global challenge

BACKGROUND

In the past century, there has been a significant rise in life expectancy in almost all regions of the world, contributing to an increasingly older population. The aging of the population, in conjunction with urbanization and industrialization, has resulted in an important epidemiological transition marked by a widespread increase in the prevalence of chronic diseases and their sequelae. Current trends suggest that the transition will have a greater impact on developing countries compared to developed countries. An adequate response to the transition requires a strong emphasis on primary prevention and adequate resource allocation.

Contribution of frailty markers in explaining differences among individuals in five samples of older persons

BACKGROUND

There has been little research on the relative importance of frailty markers. The objective was to investigate the association among seven frailty domains (nutrition, physical activity, mobility, strength, energy, cognition, and mood) and their relative contribution in explaining differences among individuals in five samples of older persons.

METHODS

Data from five studies of aging were analyzed using multiple correspondence analysis. Aggregation of frailty markers was evaluated using graphical output. Decomposition of variability was used to assess the relative contribution of each marker in each sample. Results were combined across the samples to assess the average contribution.

RESULTS

Frailty markers were found to consistently aggregate in each sample, suggesting a possible underlying construct. Physical strength had the highest contribution on average in explaining differences among individuals. Mobility and energy also had large contributions. Nutrition and cognition had the smallest contributions.

CONCLUSIONS

Our results provide further evidence supporting the notion that frailty domains may belong to a common construct. Physical strength may be the most important discriminating characteristic.

I May Be Frail But I Ain't No Failure

The terms "successful aging" and "the frail elderly" are now commonly used in aging research, but biomedical researchers may be unaware of the possible unintended negative consequences of their use. A commonly used operational definition of successful aging (high cognitive and physical function, low probability of disease, and active engagement with life) reflects values not necessarily shared by other cultures or even by older persons in our own culture. Other definitions for "a good old age" have been proposed. The adjective "successful" implies that those who do not meet its definition are unsuccessful or a failure. Labels such as "frail" predispose the person described to the phenomenon of identity spread, whereby the label becomes the master identity. Labels encourage us to regard someone as "other". Yet only 10-15% of us will die without a significant period of disability. Research has demonstrated that older persons internalize stereotypes of aging, which can have important short- and long-term effects. The language and theories of social scientists can be poorly understood by those outside of their field, yet biomedical clinicians and researchers should be aware of this literature so that unnecessary suffering is not unintentionally inflicted on our patients and our future selves.

Frailty and its association with disability and comorbidity in a community-dwelling sample of seniors in Montreal: a cross-sectional study

BACKGROUND AND AIMS

The term frailty is used to describe older persons at high risk for adverse health outcomes. In 2001, Fried et al. proposed a now widely cited definition which suggests that frailty is a clinical entity related to, but distinct from, ADL disability and comorbidity. Frailty status was assessed based on the presence of any three of the following five characteristics: shrinking, weakness, poor endurance, slowness, and low activity. The objectives of the current study are to estimate the prevalence of frailty in a sample of community-dwelling older persons, to identify sociodemographic and health variables associated with frailty, and to examine the complex relationships between frailty and comorbidity, ADL disability and IADL disability.

METHODS

This study is based on cross-sectional analysis of 740 community-dwelling seniors from the Montreal Unmet Needs Study (MUNS). The five characteristics of frailty were operationalised using measures available in MUNS. The Cochran-Mantel-Haenszel test was used to identify variables associated with frailty. Overlaps between frailty, comorbidity and disability were assessed using proportions.

RESULTS

Overall, 7.4% were classified as frail, 49.7% prefrail and 42.8% non-frail. Frailty was associated with age, sex, income, education, number of chronic diseases, ADL disability, and IADL disability. Among those classified as frail, 29.1% had disabilities in ADLs, 92.7% in IADLs and 81.8% had comorbidity.

CONCLUSION

Findings on the relationship between frailty and sociodemographic variables, morbidity and disability, support previous studies, providing further evidence that although frailty seems to be a distinct geriatric concept, it also overlaps with other concepts.

A multidisciplinary systematic literature review on frailty: overview of the methodology used by the Canadian Initiative on Frailty and Aging

Background

Over the past two decades, there has been a substantial growth in the body of literature on frailty in older persons. However, there is no consensus on its definition or the criteria used to identify frailty. In response to this lack of consensus, the Canadian Initiative on Frailty and Aging carried out a set of systematic reviews of the literature in ten areas of frailty research: biological basis; social basis; prevalence; risk factors; impact; identification; prevention and management; environment and technology; health services; health and social policy. This paper describes the methodology that was developed for the systematic reviews.

Methods

A Central Coordination Group (CCG) was responsible for developing the methodology. This involved the development of search strategies and keywords, article selection processes, quality assessment tools, and guidelines for the synthesis of results. Each review was conducted by two experts in the content area, with the assistance of methodologists and statisticians from the CCG.

Results

Conducting a series of systematic literature reviews involving a range of disciplines on a concept that does not have a universally accepted definition posed several conceptual and methodological challenges. The most important conceptual challenge was determining what would qualify as literature on frailty. The methodological challenges arose from our goal of structuring a consistent methodology for reviewing literature from diverse fields of research. At the outset, certain methodological guidelines were deemed essential to ensure the validity of all the reviews. Nevertheless, it was equally important to permit flexibility in the application of the proposed methodology to capture the essence of frailty research within the given fields.

Conclusion

The results of these reviews allowed us to establish the status of current knowledge on frailty and promote collaboration between disciplines. Conducting systematic literature reviews in health science that involve multiple disciplines is a mechanism to facilitate interdisciplinary collaboration and a more integrated understanding of health. This initiative highlighted the need for further methodological development in the performance of multidisciplinary systematic reviews.

Role of frailty in patients with cardiovascular disease

Frailty is a geriatric syndrome of increased vulnerability to stressors that has been implicated as a causative and prognostic factor in patients with cardiovascular disease (CVD). The American Heart Association and the Society of Geriatric Cardiology have called for a better understanding of frailty as it pertains to cardiac care in the elderly. The aim of this study was to systematically review studies of frailty in patients with CVD. A search was conducted of Ovid MEDLINE, EMBASE, the Cochrane Database, and unpublished sources. Inclusion criteria were an assessment of frailty using systematically defined criteria and a study population with prevalent or incident CVD. Nine studies were included, encompassing 54,250 elderly patients with a mean weighted follow-up of 6.2 years. In community-dwelling elders, CVD was associated with an odds ratio (OR) of 2.7 to 4.1 for prevalent frailty and an OR of 1.5 for incident frailty in those who were not frail at baseline. Gait velocity (a measure of frailty) was associated with an OR of 1.6 for incident CVD. In elderly patients with documented severe coronary artery disease or heart failure, the prevalence of frailty was 50% to 54%, and this was associated with an OR of 1.6 to 4.0 for all-cause mortality after adjusting for potential confounders. In conclusion, there exists a relation between frailty and CVD; frailty may lead to CVD, just as CVD may lead to frailty. The presence of frailty confers an incremental increase in mortality. The role of frailty assessment in clinical practice may be to refine estimates of cardiovascular risk, which tend to be less accurate in the heterogenous elderly patient population.

The effect of later-life health promotion on functional performance and body composition

BACKGROUND AND AIMS

Functional decline in older adults is related physiologically to both aging and lifestyle-related risk factors. The role of health promotion and lifestyle modifications in preventing functional performance decline in community-dwelling older adults has not been well established. We evaluated the effects of an education-based health promotion program on functional performance and body composition in midlife and older adults.

METHODS

A prospective study of a 4-week health promotion program for community- dwelling older adults. Outcome measures of gait speed, chair rise time, grip strength, weight, body mass index (BMI) and bioelectric impedance analysis (BIA) for body fat were assessed at baseline, 6 and 12 months.

RESULTS

Participants (n=117) with a mean age 62.9+/-8 years; 63.2% were women. Gait speed improved by 0.20 ms-1 (95% CI 0.14, 0.29; p<0.001) and chair rise time decreased by 0.36 s (95% CI -0.13, -0.56; p=0.001) at 12 months. There was no change in grip strength (p=0.433). There was a modest decrease in weight 0.55 kg (95% CI -0.08, -1.01; p=0.019), BMI 0.35 kgm-2 (95% CI -0.02, -0.64; p=0.033) and fat impedance 0.75% (95% CI -0.09, -1.26; p=0.021) at 12 months. Imputation to account for missing outcomes did not alter overall conclusions.

CONCLUSION

A 4-week education-based health promotion in later-life is feasible and may help to improve and maintain functional performance and body composition in midlife and older adults.

Frailty: an emerging research and clinical paradigm--issues and controversies

Clinicians and researchers have shown increasing interest in frailty. Yet, there is still considerable uncertainty regarding the concept and its definition. In this article, we present perspectives on key issues and controversies discussed by scientists from 13 different countries, representing a diverse range of disciplines, at the 2006 Second International Working Meeting on Frailty and Aging. The following fundamental questions are discussed: What is the distinction, if any, between frailty and aging? What is its relationship with chronic disease? Is frailty a syndrome or a series of age-related impairments that predict adverse outcomes? What are the critical domains in its operational definition? Is frailty a useful concept? The implications of different models and approaches are examined. Although consensus has yet to be attained, work accomplished to date has opened exciting new horizons. The article concludes with suggested directions for future research.