The Enduring Effects of Parental Alcohol, Tobacco, and Drug Use on Child Well-being: A Multilevel Meta-Analysis

The effects of psychoactive substance abuse are not limited to the user, but extend to the entire family system, with children of substance abusers being particularly at risk. This meta-analysis attempted to quantify the longitudinal relationship between parental alcohol, tobacco, and drug use and child well-being, investigating variation across a range of substance and well-being indices and other potential moderators. We performed a literature search of peer-reviewed, English language, longitudinal observational studies that reported outcomes for children aged 0 to 18 years. In total, 56 studies, yielding 220 dependent effect sizes, met inclusion criteria. A multilevel random-effects model revealed a statistically significant, small detriment to child well-being for parental substance abuse over time (r = .15). Moderator analyses demonstrated that the effect was more pronounced for parental drug use (r = .25), compared with alcohol use (r = .13), tobacco use (r = .13), and alcohol use disorder (r = .14). Results highlight a need for future studies that better capture the effect of parental psychoactive substance abuse on the full breadth of childhood well-being outcomes and to integrate substance abuse into models that specify the precise conditions under which parental behavior determines child well-being

RESPOND – A patient-centred programme to prevent secondary falls in older people presenting to the emergency department with a fall: Protocol for a mixed methods programme evaluation.

Background Programme evaluations conducted alongside randomised controlled trials (RCTs) have potential to enhance understanding of trial outcomes. This paper describes a multi-level programme evaluation to be conducted alongside an RCT of a falls prevention programme (RESPOND). Objectives 1) To conduct a process evaluation in order to identify the degree of implementation fidelity and associated barriers and facilitators. 2) To evaluate the primary intended impact of the programme: participation in fall prevention strategies, and the factors influencing participation. 3) To identify the factors influencing RESPOND RCT outcomes: falls, fall injuries and ED re-presentations. Methods/ Design Five hundred and twenty eight community-dwelling adults aged 60–90 years presenting to two EDs with a fall will be recruited and randomly assigned to the intervention or standard care group. All RESPOND participants and RESPOND clinicians will be included in the evaluation. A mixed methods design will be used and a programme logic model will frame the evaluation. Data will be sourced from interviews, focus groups, questionnaires, clinician case notes, recruitment records, participant-completed calendars, hospital administrative datasets, and audio-recordings of intervention contacts. Quantitative data will be analysed via descriptive and inferential statistics and qualitative data will be interpreted using thematic analysis. Discussion The RESPOND programme evaluation will provide information about contextual and influencing factors related to the RCT outcomes. The results will assist researchers, clinicians, and policy makers to make decisions about future falls prevention interventions. Insights gained are likely to be transferable to preventive health programmes for a range of chronic conditions

RESPOND – A patient-centred program to prevent secondary falls in older people presenting to the emergency department with a fall: Protocol for a multi-centre randomised controlled trial

Introduction: Participation in falls prevention activities by older people following presentation to the Emergency Department (ED) with a fall is suboptimal. This randomised controlled trial (RCT) will test the RESPOND program which is designed to improve older persons’ participation in falls prevention activities through delivery of patient-centred education and behaviour change strategies. Design and setting: An RCT at two tertiary referral EDs in Melbourne and Perth, Australia. Participants: Five-hundred and twenty eight community-dwelling people aged 60-90 years presenting to the ED with a fall and discharged home will be recruited. People who: require an interpreter or hands-on assistance to walk; live in residential aged care or >50 kilometres from the trial hospital; have terminal illness, cognitive impairment, documented aggressive behaviour or history of psychosis; are receiving palliative care; or are unable to use a telephone will be excluded. Methods: Participants will be randomly allocated to the RESPOND intervention or standard care control group. RESPOND incorporates: (1) home-based risk factor assessment; (2) education, coaching, goal setting, and follow-up telephone support for management of one or more of four risk factors with evidence of effective intervention; and (3) healthcare provider communication and community linkage delivered over six months. Primary outcomes are falls and fall injuries per-person-year. Discussion: RESPOND builds on prior falls prevention learnings and aims to help individuals make guided decisions about how they will manage their falls risk. Patient-centred models have been successfully trialled in chronic and cardiovascular disease however evidence to support this approach in falls prevention is limited. Trial registration. The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684)

Multifactorial falls prevention programmes for older adults presenting to the Emergency Department with a fall: systematic review and meta-analysis.

Background: Falls are a leading cause of emergency department (ED) presentations in older adults. Objective: To determine whether multifactorial falls prevention interventions are effective in preventing falls, fall injuries, ED re-presentations and hospital admissions in older adults presenting to the ED with a fall. Design: Systematic review and meta-analyses of randomised control trials (RCTs). Methods: Four health-related electronic databases were searched (inception to June 2018) with two independent reviewers determining inclusion, assessing study quality and undertaking data extraction. Study selection: RCTs of multifactorial falls prevention interventions targeting community dwelling older adults (≥ 60 years) presenting to the ED with a fall and providing quantitative data on at least one of the review outcomes. Results: Twelve studies involving 3,986 participants, from six countries, were eligible for inclusion. Studies were of variable methodological quality. The multifactorial interventions were heterogeneous, though the majority included components such as education, referral to relevant healthcare services, home modifications, exercise, and medication changes. Meta-analyses demonstrated a non-significant reduction in falls (rate ratio=0.78; 95% CI 0.58, 1.05) with multi-factorial falls prevention programs. Multi-factorial interventions did not significantly affect the number of fallers (risk ratio=1.02; 95% CI 0.88, 1.18), rate of fractured neck of femur (risk ratio=0.82; 95% CI 0.53, 1.25), fall-related ED presentations (rate ratio=0.99; 95% CI 0.84, 1.16), or hospitalisations (rate ratio=1.14; 95% CI 0.69, 1.89). Conclusions: There is insufficient evidence to support the use of multifactorial falls interventions to prevent falls or hospital utilisation in older people presenting to ED following a fall. Further research targeting this population group is required

Evaluation of RESPOND, a patient-centred program to prevent falls in older people presenting to the Emergency Department with a fall: A randomised controlled trial.

Background: Falls are a leading reason for older people presenting to the emergency department (ED). Many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program—RESPOND—had an effect on falls and fall injuries in older people presenting to the ED after a fall. Methods and findings: Community dwelling people aged 60-90 years presenting to the ED with a fall and planned for discharge home within 72 hours, were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (MMSE>23). Recruitment occurred between 1st April 2014―29th June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised: (1 home-based risk assessment; (2) six months telephone-based education, coaching, goal setting and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis—217 randomised to RESPOND and 213 to control. Mean age of participants was 73 years, 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43 to 0.99]; p=0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51 to 1.29]; p=0.374). The rate of fractures was significantly lower in the RESPOND group compared to the control (0.05 vs. 0.12; IRR 0.37 [95% CI 0.15 to 0.91]; p=0.03) but there was no significant difference in other secondary outcomes between groups: ED presentations, hospitalisations or falls risk, falls efficacy and quality of life. There were two deaths in the RESPOND group and one in the control. No adverse events or unintended harm were reported. Limitations of this study were the high number of drop outs (n=93), over or under reporting of falls, fall injuries and hospitalisations across both groups and the relatively small number of fracture events. Conclusions: In this study, providing a telephone-based, patient-centred falls prevention program reduced falls and fractures, but not fall injuries, in older people presenting to the ED with a fall. Adopting patient-centred strategies into routine clinical practice for falls prevention could offer an opportunity to improve outcomes and reduce falls in patients attending ED

Innovations to reduce demand and crowding in emergency care; a review study

Emergency Department demand continues to rise in almost all high-income countries, including those with universal coverage and a strong primary care network. Many of these countries have been experimenting with innovative methods to stem demand for acute care, while at the same time providing much needed services that can prevent Emergency Department attendance and later hospital admissions. A large proportion of patients comprise of those with minor illnesses that could potentially be seen by a health care provider in a primary care setting. The increasing number of visits to Emergency Departments not only causes delay in urgent care provision but also increases the overall cost. In the UK, the National Health Service (NHS) has made a number of efforts to strengthen primary healthcare services to increase accessibility to healthcare as well as address patients¿ needs by introducing new urgent care services. In this review, we describe efforts that have been ongoing in the UK and France for over a decade as well as specific programs to target the rising needs of emergency care in both England and France. Like many such programs, there have been successes, failures and unintended consequences. Thus, the urgent care system of other high-income countries can learn from these experiments