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BackgroundThe introduction of Web-based education and open universities has seen an increase in access to professional development within the health professional education marketplace. Economic efficiencies of Web-based education and traditional face-to-face educational approaches have not been compared under randomized controlled trial conditions. ObjectiveTo compare costs and effects of Web-based and face-to-face short courses in falls prevention education for health professionals. MethodsWe designed two short courses to improve the clinical performance of health professionals in exercise prescription for falls prevention. One was developed for delivery in face-to-face mode and the other for online learning. Data were collected on learning outcomes including participation, satisfaction, knowledge acquisition, and change in practice, and combined with costs, savings, and benefits, to enable a break-even analysis from the perspective of the provider, cost-effectiveness analysis from the perspective of the health service, and cost-benefit analysis from the perspective of the participant. ResultsFace-to-face and Web-based delivery modalities produced comparable outcomes for participation, satisfaction, knowledge acquisition, and change in practice. Break-even analysis identified the Web-based educational approach to be robustly superior to face-to-face education, requiring a lower number of enrollments for the program to reach its break-even point. Cost-effectiveness analyses from the perspective of the health service and cost-benefit analysis from the perspective of the participant favored face-to-face education, although the outcomes were contingent on the sensitivity analysis applied (eg, the fee structure used). ConclusionsThe Web-based educational approach was clearly more efficient from the perspective of the education provider. In the presence of relatively equivocal results for comparisons from other stakeholder perspectives, it is likely that providers would prefer to deliver education via a Web-based medium. Trial RegistrationAustralian New Zealand Clinical Trials Registry (ACTRN): 12610000135011; http://www.anzctr.org.au/trial_view.aspx?id=335135 (Archived by WebCite at http://www.webcitation.org/668POww4L)

BackgroundExercise is an effective intervention for the prevention of falls; however, some forms of exercises have been shown to be more effective than others. There is a need to identify effective and efficient methods for training health professionals in exercise prescription for falls prevention. ObjectiveThe objective of our study was to compare two approaches for training clinicians in prescribing exercise to prevent falls. MethodsThis study was a head-to-head randomized trial design. Participants were physiotherapists, occupational therapists, nurses, and exercise physiologists working in Victoria, Australia. Participants randomly assigned to one group received face-to-face traditional education using a 1-day seminar format with additional video and written support material. The other participants received Web-based delivery of the equivalent educational material over a 4-week period with remote tutor facilitation. Outcomes were measured across levels 1 to 3 of Kirkpatrick’s hierarchy of educational outcomes, including attendance, adherence, satisfaction, knowledge, and self-reported change in practice. ResultsOf the 166 participants initially recruited, there was gradual attrition from randomization to participation in the trial (n = 67 Web-based, n = 68 face-to-face), to completion of the educational content (n = 44 Web-based, n = 50 face-to-face), to completion of the posteducation examinations (n = 43 Web-based, n = 49 face-to-face). Participant satisfaction was not significantly different between the intervention groups: mean (SD) satisfaction with content and relevance of course material was 25.73 (5.14) in the Web-based and 26.11 (5.41) in the face-to-face group; linear regression P = .75; and mean (SD) satisfaction with course facilitation and support was 11.61 (2.00) in the Web-based and 12.08 (1.54) in the face-to-face group; linear regression P = .25. Knowledge test results were comparable between the Web-based and face-to-face groups: median (interquartile range [IQR]) for the Web-based group was 90.00 (70.89–90.67) and for the face-to-face group was 80.56 (70.67–90.00); rank sum P = .07. The median (IQR) scores for the exercise assignment were also comparable: Web-based, 78.6 (68.5–85.1), and face-to-face, 78.6 (70.8–86.9); rank sum P = .61. No significant difference was identified in Kirkpatrick’s hierarchy domain change in practice: mean (SD) Web-based, 21.75 (4.40), and face-to-face, 21.88 (3.24); linear regression P = .89. ConclusionWeb-based and face-to-face approaches to the delivery of education to clinicians on the subject of exercise prescription for falls prevention produced equivalent results in all of the outcome domains. Practical considerations should arguably drive choice of delivery method, which may favor Web-based provision for its ability to overcome access issues for health professionals in regional and remote settings. Trial RegistrationAustralian New Zealand Clinical Trials Registry number: ACTRN12610000135011; http://www.anzctr.org.au/ACTRN12610000135011.aspx (Archived by WebCite at http://www.webcitation.org/63MicDjPV)

Background Disinvestment (removal, reduction, or reallocation) of routinely provided health services can be difficult when there is little published evidence examining whether the services are effective or not. Evidence is required to understand if removing these services produces outcomes that are inferior to keeping such services in place. However, organisational imperatives, such as budget cuts, may force healthcare providers to disinvest from these services before the required evidence becomes available. There are presently no experimental studies examining the effectiveness of allied health services (e.g., physical therapy, occupational therapy, and social work) provided on weekends across acute medical and surgical hospital wards, despite these services being routinely provided internationally. The aim of this study was to understand the impact of removing weekend allied health services from acute medical and surgical wards using a disinvestment-specific non-inferiority research design. Methods and findings We conducted 2 stepped-wedge cluster randomised controlled trials between 1 February 2014 and 30 April 2015 among patients on 12 acute medical or surgical hospital wards spread across 2 hospitals. The hospitals involved were 2 metropolitan teaching hospitals in Melbourne, Australia. Data from n = 14,834 patients were collected for inclusion in Trial 1, and n = 12,674 in Trial 2. Trial 1 was a disinvestment-specific non-inferiority stepped-wedge trial where the 'current' weekend allied health service was incrementally removed from participating wards each calendar month, in a random order, while Trial 2 used a conventional non-inferiority stepped-wedge design, where a 'newly developed' service was incrementally reinstated on the same wards as in Trial 1. Primary outcome measures were patient length of stay (proportion staying longer than expected and mean length of stay), the proportion of patients experiencing any adverse event, and the proportion with an unplanned readmission within 28 days of discharge. The 'no weekend allied health service' condition was considered to be not inferior if the 95% CIs of the differences between this condition and the condition with weekend allied health service delivery were below a 2% increase in the proportion of patients who stayed in hospital longer than expected, a 2% increase in the proportion who had an unplanned readmission within 28 days, a 2% increase in the proportion who had any adverse event, and a 1-day increase in the mean length of stay. The current weekend allied health service included physical therapy, occupational therapy, speech therapy, dietetics, social work, and allied health assistant services in line with usual care at the participating sites. The newly developed weekend allied health service allowed managers at each site to reprioritise tasks being performed and the balance of hours provided by each professional group and on which days they were provided. Analyses conducted on an intention-to-treat basis demonstrated that there was no estimated effect size difference between groups in the proportion of patients staying longer than expected (weekend versus no weekend; estimated effect size difference [95% CI], p-value) in Trial 1 (0.40 versus 0.38; estimated effect size difference 0.01 [-0.01 to 0.04], p = 0.31, CI was both above and below non-inferiority margin), but the proportion staying longer than expected was greater with the newly developed service compared to its no weekend service control condition (0.39 versus 0.40; estimated effect size difference 0.02 [0.01 to 0.04], p = 0.04, CI was completely below non-inferiority margin) in Trial 2. Trial 1 and 2 findings were discordant for the mean length of stay outcome (Trial 1: 5.5 versus 6.3 days; estimated effect size difference 1.3 days [0.9 to 1.8], p < 0.001, CI was both above and below non-inferiority margin; Trial 2: 5.9 versus 5.0 days; estimated effect size difference -1.6 days [-2.0 to -1.1], p < 0.001, CI was completely below non-inferiority margin). There was no difference between conditions for the proportion who had an unplanned readmission within 28 days in either trial (Trial 1: 0.01 [-0.01 to 0.03], p = 0.18, CI was both above and below non-inferiority margin; Trial 2: -0.01 [-0.02 to 0.01], p = 0.62, CI completely below non-inferiority margin). There was no difference between conditions in the proportion of patients who experienced any adverse event in Trial 1 (0.01 [-0.01 to 0.03], p = 0.33, CI was both above and below non-inferiority margin), but a lower proportion of patients had an adverse event in Trial 2 when exposed to the no weekend allied health condition (-0.03 [-0.05 to -0.004], p = 0.02, CI completely below non-inferiority margin). Limitations of this research were that 1 of the trial wards was closed by the healthcare provider after Trial 1 and could not be included in Trial 2, and that both withdrawing the current weekend allied health service model and installing a new one may have led to an accommodation period for staff to adapt to the new service settings. Stepped-wedge trials are potentially susceptible to bias from naturally occurring change over time at the service level; however, this was adjusted for in our analyses. Conclusions In Trial 1, criteria to say that the no weekend allied health condition was non-inferior to current weekend allied health condition were not met, while neither the no weekend nor current weekend allied health condition demonstrated superiority. In Trial 2, the no weekend allied health condition was non-inferior to the newly developed weekend allied health condition across all primary outcomes, and superior for the outcomes proportion of patients staying longer than expected, proportion experiencing any adverse event, and mean length of stay. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12613001231730 and ACTRN12613001361796, Author(s): Terry P. Haines 1,2,*, Kelly-Ann Bowles 3, Deb Mitchell 1,2, Lisa O'Brien 2,4, Donna Markham 5, Samantha Plumb 6, Kerry May 5, Kathleen Philip 7, Romi Haas 1,2, Mitchell [...]

Weekend physical therapy services in the acute and/or sub-acute setting may optimize postoperative recovery following hip and knee arthroplasty, though evidence supporting these services is limited. To explore the change in patient and service outcomes of transferring a weekend physical therapy service from the acute to the sub-acute setting following hip and knee arthroplasty. This was a quasi-experimental research design nested within two stepped-wedge cluster randomized controlled trials. Acute weekend physical therapy services were sequentially discontinued and reallocated to the sub-acute setting in a random order from one ward at a time within the broader trial. Patient and service outcomes for participants 6 weeks following hip and knee arthroplasty (N = 247) were compared during 6 months of acute weekend physical therapy services (Phase 1, n = 117) followed by 6 months of sub-acute services (Phase 2, n = 130). Intention-to-treat statistical analyses were conducted. The intervention had a negligible effect on medium-term outcomes. The only statistically significant difference observed was slightly higher ratings of "worst pain experienced over the past week" [coefficient 0.865 (0.123 to 1.606), p =.022] during Phase 2. No interaction effects were observed despite a 2.4-day reduction in length of stay amongst complex patients during Phase 2 (18.28 and 15.86 days in Phase 1 and 2, respectively). No comparative advantage or disadvantage was observed by reallocating a weekend physical therapy budget from the acute to sub-acute setting following hip and knee arthroplasty. Further research investigating the cost-effectiveness of these services in the sub-acute setting may be warranted for complex patients. [ABSTRACT FROM AUTHOR]

Purpose: To describe health professionals' perceptions of the role of allied health during the acute phase following elective lower limb joint replacement surgery to inform the development of efficient allied health service models. Methods: This was a qualitative descriptive study conducted using semi-structured focus groups and thematic analysis. Participants were 25 medical, nursing, and allied health professionals working on two orthopaedic wards in a tertiary hospital in Victoria, Australia. Focus groups elicited staff perceptions regarding the aims and roles of acute allied health intervention following hip and knee replacement, how these services are currently provided, and how these services can best be provided. This study was undertaken alongside two stepped wedge cluster randomised controlled trials during which existing weekend allied health services were to be temporarily removed with opportunity to contribute to a stakeholder-driven model of these services. Results: The main theme that emerged was a sense of unrealised potential amongst health professionals in terms of patient outcomes following hip and knee joint replacement surgery arising from tension between perceptions of actual versus ideal allied health practice. Assessing function and planning for discharge accordingly was perceived to be a higher priority than intervening to improve functional independence. Conclusion: Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in patients following lower limb replacement surgery than current practice in this setting that prioritises discharge. Allied health service delivery in the acute phase following hip and knee joint replacement needs to balance the needs of the health service with those of the patients. Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in this population than current practice, which is to prioritise discharge. There may be more scope for nurses to be involved in promoting early postoperative mobilisation following joint replacement surgery, especially in uncomplicated cases. [ABSTRACT FROM AUTHOR]

Objective: The objective of this systematic review was to examine the effects of different balance exercise interventions compared with non-balance exercise controls on balance task performance in older adults.Design: Systematic review.Data Sources: Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus and Cochrane Database of Systematic Reviews were searched until July 2017.Eligibility Criteria For Selecting Studies: Systematic reviews and meta-analyses of randomised trials of balance exercise interventions for older adults were identified for extraction of eligible randomised trials. Eligibility criteria for inclusion of randomised trials in meta-analyses were comparison of a balance exercise intervention with a control group that did not perform balance exercises, report of at least one end-intervention balance outcome measurement that was consistent with the five subgroups of balance exercise identified, and full-text article available in English.Results: Ninety-five trials were included in meta-analyses and 80 in meta-regressions. For four balance exercise types (control centre of mass, multidimensional, mobility and reaching), significant effects for balance exercise interventions were found in meta-analyses (standardised mean difference (SMD) 0.31-0.50), however with considerable heterogeneity in observed effects (I2: 50.4%-80.6%). Risk of bias assessments (Physiotherapy Evidence Database score and funnel plots) did not explain heterogeneity. One significant relationship identified in the meta-regressions of SMD and balance exercise frequency, time and duration explained 2.1% of variance for the control centre of mass subgroup.Conclusion: Limitations to this study included the variability in design of balance interventions, incomplete reporting of data and statistical heterogeneity. The design of balance exercise programmes provides inadequate explanation of the observed benefits of these interventions. [ABSTRACT FROM AUTHOR]

Objectives To describe the experiences (including symptoms and perceived impacts on daily living) of people with a shoulder disorder. Methods Systematic review of qualitative studies. We searched for eligible qualitative studies indexed in Ovid MEDLINE, Ovid Embase, CINAHL (EBSCO), SportDiscus (EBSCO) and Ovid PsycINFO up until November 2017. Two authors independently screened studies for inclusion, appraised their methodological quality using the Critical Appraisal Skills Programme checklist, used thematic synthesis methods to generate themes describing the experiences reported by participants and assessed the confidence in the findings using the Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Results The inclusion criteria were met by eight studies, which included 133 participants (49 females and 84 males) with either rotator cuff disease, adhesive capsulitis, proximal humeral fracture, shoulder instability or unspecified shoulder pain. We generated seven themes to describe what people in the included studies reported experiencing: pain; physical function/activity limitations; participation restriction; sleep disruption; cognitive dysfunction; emotional distress; and other pathophysiological manifestations (other than pain). There were interactions between the themes, with particular experiences impacting on others (e.g. pain leading to reduced activities and sleep disruption). Following grading of the evidence, we considered it likely that most of the review findings were a reasonable representation of the experiences of people with shoulder disorders. Conclusion Patients with shoulder disorders contend with considerable disruption to their life. The experiences described should be considered by researchers seeking to select the most appropriate outcomes to measure in clinical trials and other research studies in people with shoulder disorders. [ABSTRACT FROM AUTHOR]