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Competing Interests: Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: SG and GF are chief investigator and co-investigator for the Prehospital Early Warning scores for Sepsis (PHEWS) study, funded by the National Institute for Health Research (NIHR 17/136/10).

Objectives: To determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes., Design: Multicentre, parallel, cluster randomised controlled trial., Setting: Long term care homes in the UK, registered to care for older people or those with dementia., Participants: 1657 consenting residents and 84 care homes. 39 were randomised to the intervention group and 45 were randomised to usual care., Interventions: Guide to Action for Care Homes (GtACH): a multifactorial fall prevention programme or usual care., Main Outcome Measures: Primary outcome measure was fall rate at 91-180 days after randomisation. The economic evaluation measured health related quality of life using quality adjusted life years (QALYs) derived from the five domain five level version of the EuroQoL index (EQ-5D-5L) or proxy version (EQ-5D-5L-P) and the Dementia Quality of Life utility measure (DEMQOL-U), which were self-completed by competent residents and by a care home staff member proxy (DEMQOL-P-U) for all residents (in case the ability to complete changed during the study) until 12 months after randomisation. Secondary outcome measures were falls at 1-90, 181-270, and 271-360 days after randomisation, Barthel index score, and the Physical Activity Measure-Residential Care Homes (PAM-RC) score at 91, 180, 270, and 360 days after randomisation., Results: Mean age of residents was 85 years. 32% were men. GtACH training was delivered to 1051/1480 staff (71%). Primary outcome data were available for 630 participants in the GtACH group and 712 in the usual care group. The unadjusted incidence rate ratio for falls between 91 and 180 days was 0.57 (95% confidence interval 0.45 to 0.71, P<0.001) in favour of the GtACH programme (GtACH: six falls/1000 residents v usual care: 10 falls/1000). Barthel activities of daily living indices and PAM-RC scores were similar between groups at all time points. The incremental cost was £108 (95% confidence interval -£271.06 to 487.58), incremental QALYs gained for EQ-5D-5L-P was 0.024 (95% confidence interval 0.004 to 0.044) and for DEMQOL-P-U was 0.005 (-0.019 to 0.03). The incremental costs per EQ-5D-5L-P and DEMQOL-P-U based QALY were £4544 and £20 889, respectively., Conclusions: The GtACH programme was associated with a reduction in fall rate and cost effectiveness, without a decrease in activity or increase in dependency., Trial Registration: ISRCTN34353836., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: funding from the National Institute for Health Research; no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the effect of specialist geriatric medical management on the outcomes of at risk older people discharged from acute medical assessment units., Design: Individual patient randomised controlled trial comparing intervention with usual care., Setting: Two hospitals in Nottingham and Leicester, UK., Participants: 433 patients aged 70 or over who were discharged within 72 hours of attending an acute medical assessment unit and at risk of decline as indicated by a score of at least 2 on the Identification of Seniors At Risk tool., Intervention: Assessment made on the acute medical assessment unit and further outpatient management by specialist physicians in geriatric medicine, including advice and support to primary care services., Main Outcome Measures: The primary outcome was the number of days spent at home (for those admitted from home) or days spent in the same care home (if admitted from a care home) in the 90 days after randomisation. Secondary outcomes were determined at 90 days and included mortality, institutionalisation, dependency, mental wellbeing, quality of life, and health and social care resource use., Results: The two groups were well matched for baseline characteristics, and withdrawal rates were similar in both groups (5%). Mean days at home over 90 days' follow-up were 80.2 days in the control group and 79.7 in the intervention group. The 95% confidence interval for the difference in means was -4.6 to 3.6 days (P=0.31). No significant differences were found for any of the secondary outcomes., Conclusions: This specialist geriatric medical intervention applied to an at risk population of older people attending and being discharged from acute medical units had no effect on patients' outcomes or subsequent use of secondary care or long term care.

Objective: To determine the extent of use of unlicensed and off label drugs in children in hospital in five European countries., Design: Prospective study of drugs administered to children in general paediatric medical wards over four weeks., Setting: Children's wards in five hospitals (one each in the United Kingdom, Sweden, Germany, Italy, and the Netherlands)., Subjects: Children aged 4 days to 16 years admitted to general paediatric medical wards., Main Outcome Measure: Proportion of drugs that were used in an unlicensed or off label manner., Results: 2262 drug prescriptions were administered to 624 children in the five hospitals. Almost half of all drug prescriptions (1036; 46%) were either unlicensed or off label. Of these 1036, 872 were off label and 164 were unlicensed. Over half of the patients (421; 67%) received an unlicensed or off label drug prescription., Conclusions: Use of off label or unlicensed drugs to treat children is widespread. This problem is likely to affect children throughout Europe and requires European action.