Effectiveness of aquatic exercise for musculoskeletal conditions: a meta-analysis

Objective To investigate the effectiveness of aquatic exercise in the management of musculoskeletal conditions. Data Sources A systematic review was conducted using Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and The Cochrane Central Register of Controlled Trials from earliest record to May 2013. Study Selection We searched for randomized controlled trials (RCTs) and quasi-RCTs evaluating aquatic exercise for adults with musculoskeletal conditions compared with no exercise or land-based exercise. Outcomes of interest were pain, physical function, and quality of life. The electronic search identified 1199 potential studies. Of these, 1136 studies were excluded based on title and abstract. A further 36 studies were excluded after full text review, and the remaining 26 studies were included in this review. Data Extraction Two reviewers independently extracted demographic data and intervention characteristics from included trials. Outcome data, including mean scores and SDs, were also extracted. Data Synthesis The Physiotherapy Evidence Database (PEDro) Scale identified 20 studies with high methodologic quality (PEDro score ≥6). Compared with no exercise, aquatic exercise achieved moderate improvements in pain (standardized mean difference [SMD]=-.37; 95% confidence interval [CI], -.56 to -.18), physical function (SMD=.32; 95% CI,.13-.51), and quality of life (SMD=.39; 95% CI,.06-.73). No significant differences were observed between the effects of aquatic and land-based exercise on pain (SMD=-.11; 95% CI, -.27 to.04), physical function (SMD=-.03; 95% CI, -.19 to.12), or quality of life (SMD=-.10; 95% CI, -.29 to.09). Conclusions The evidence suggests that aquatic exercise has moderate beneficial effects on pain, physical function, and quality of life in adults with musculoskeletal conditions. These benefits appear comparable across conditions and with those achieved with land-based exercise. Further research is needed to understand the characteristics of aquatic exercise programs that provide the most benefit

Undertaking and using health service evaluations in the field

There is a great need for decision makers in healthcare to use robust and reliable evidence to support clinical and health policy choices that aim to improve the quality of healthcare and support the efficient use of scarce resources. This evidence is, however, often lacking in quality, quantity and reliability. While many health interventions hold good face validity, their implementation and use in practice may not always produce the desired improvements in patient care. This gap suggests that challenges exist in the production of such evidence. This thesis sought to respond to this challenge through the undertaking of two health service evaluations. Each evaluation representing an independent, discrete piece of work addressing the primary objective of this thesis—to evaluate the impact of specific complex health interventions —providing evidence for, or against, its ongoing use. These evaluation case studies then provided a platform for reflecting on the contextual issues of the evaluation, lessons learnt and challenges confronted, addressing the second objective of this thesis—to describe the methodological and practical challenges experienced when undertaking such health service evaluations. Case study 1 was a retrospective evaluation of a Telephone Support Program for elderly people with Chronic or Complex care needs. The intervention was developed and implemented by a private healthcare provider and commissioned by a private health insurer, aimed at reducing avoidable hospital admissions for elderly members living in the community. A non-randomised controlled study design was employed using propensity score matching. Compared to matched controls, the intervention was not observed to reduce hospital use of healthcare utilisation costs. However it was unclear if the finding of no effect was due to poor implementation fidelity, issues with data quality and integrity, methodological limitations of the evaluation or an ineffective intervention. Case study 2 was a comprehensive evaluation of the 6-PACK program, a falls prevention intervention specifically developed for acute hospital wards. It was undertaken as part of a rigorously designed cluster randomised control trial (RCT) involving six hospitals (24 acute wards) across Australia and included an economic evaluation, a cost of fall study and an examination of implementation fidelity. The program was found to be ineffective at reducing fall (IRR = 1.04, 95% CI, 0.78 to 1.37; P=0.796) or fall injuries (IRR, 0.96, 95% CI, 0.72 to 1.27; P=0.766), above that of usual care, as such an economic evaluation was not undertaken. The cost of fall study found that patients who experienced an in-hospital fall were observed to have a 7 day longer hospital stay (p<0.000) and an additional AUD$5,395 in hospitalisation costs (p<0.000), compared to those without a recorded fall. While patients who experienced a fall-related injury had an 11 day longer hospital stay (p<0.000) and an additional AUD$9,917 in hospitalisation costs (p=0.003), compared to those without a recorded fall. The examination of implementation fidelity found reasonable levels of implementation fidelity during the cluster RCT. Therefore implementation failure did not appear to have been a key factor for the observed no effect in the 6-PACK trial. These case studies highlighted some common challenges faced by evaluators when examining the impacts of an intervention in the ‘real-world’ setting. Three key themes emerged from the two case studies: 1) the challenges with designing and undertaking rigorous evaluations in the ‘real-world’ setting; 2) the use of secondary data sources, particularly with the measurement of outcome and confounding variables and the use of data across organisations and jurisdictions; and 3) the ability to define and examine implementation fidelity of complex health interventions. When examining complex health interventions determining the level of implementation fidelity is essential to the interpretation of study findings, particularly when conducted in the dynamic and complicated environment, that is, healthcare. In addition, to ensure a more rigorous approach to health service evaluation in the ‘real-world’ is taken, resources need to be dedicated to enhance existing data sources and systems that are more conducive to evaluation, improving the strength of measures and the ability for data linkage to occur easily across sites and jurisdictions

Geographical variation in incidence of knee arthroscopy for patients with osteoarthritis: A population-based analysis of Victorian hospital separations data

Background/Aim To evaluate the frequency and geographical variation in knee arthroscopy for adults (>25 years) with a concomitant diagnosis of osteoarthritis. Methods This was a retrospective cohort study of hospital separations involving an elective knee arthroscopy in public and private hospitals in Victoria, Australia. Participants included patients receiving knee arthroscopies with a diagnosis code indicating osteoarthritis (OA) from 1 July 2008 to 30 June 2009. Records were excluded if the patient was under 25 years or their arthroscopy involved a ligament reconstruction. Crude rates per 100 000 population and negative binomial regression offset by total knee arthroscopy volume were used to analyse differences by region. Results There were 9620 arthroscopic procedures meeting the inclusion criteria. There were 5500 (57.2%) admissions where the principal diagnosis was knee OA (gonarthrosis) and 3510 (36.5%) where the principal diagnosis indicated a mechanical derangement and there was a primary or associated diagnosis of OA. When we examined the incidence rate ratios (IRR) by region, after adjustment for relevant factors and accounting for the total knee arthroscopy volume within each region, we identified significant variation in knee arthroscopy rates for patients with OA. The region with the highest adjusted IRR was Barwon South Western (IRR: 1.26, 95% confidence interval (CI): 1.16–1.36) and the region with lowest adjusted incidence rate ratio was the Gippsland region (IRR: 0.89, 95% CI: 0.80–0.98). Conclusions We identified considerable geographical variation in arthroscopies for people with OA across Victoria. Further investigation is needed to understand whether this variation is a reflection of differences in OA prevalence, clinical decision‐making or access

In-hospital falls and fall-related injuries: a protocol for a cost of fall study.

BACKGROUND: In-hospital falls are common and pose significant economic burden on the healthcare system. To date, few studies have quantified the additional cost of hospitalisation associated with an in-hospital fall or fall-related injury. The aim of this study is to determine the additional length of stay and hospitalisation costs associated with in-hospital falls and fall-related injuries, from the acute hospital perspective.METHODS AND DESIGN: A multisite prospective study will be conducted as part of a larger falls-prevention clinical trial—the 6-PACK project. This study will involve 12 acute medical and surgical wards from six hospitals across Australia. Patient and admission characteristics, outcome and hospitalisation cost data will be prospectively collected on approximately 15 000 patients during the 15-month study period. A review of all in-hospital fall events will be conducted using a multimodal method (medical record review and daily verbal report from the nurse unit manager, triangulated with falls recorded in the hospital incident reporting and administrative database), to ensure complete case ascertainment. Hospital clinical costing data will be used to calculate patient-level hospitalisation costs incurred by a patient during their inpatient stay. Additional hospital and hospital resource utilisation costs attributable to in-hospital falls and fall-related injuries will be calculated using linear regression modelling, adjusting for a priori-defined potential confounding factors.DISCUSSION: This protocol provides the detailed statement of the planned analysis. The results from this study will be used to support healthcare planning, policy making and allocation of funding relating to falls prevention within acute hospitals

What matters most to patients following percutaneous coronary interventions?:A new patient-reported outcome measure developed using Rasch analysis

© 2019 Soh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Measuring patient reported outcomes can improve the quality and effectiveness of healthcare interventions. The aim of this study was to identify the final set of items that can be included in a patient-reported outcome measure to assess recovery of patients following percutaneous coronary interventions. Methods A consecutive sample of 200 patients registered in the Victorian Cardiac Outcomes Registry participated in a telephone survey 30 days following their percutaneous cardiac procedure. Rasch analysis was used to select the best set of items to form a concise and psychometrically sound patient-reported outcome measure. Key measurement properties assessed included overall fit to the Rasch measurement model, unidimensionality, response formats (thresholds), targeting, internal consistency and measurement invariance. Results Five items were identified as being reliable and valid measures of patient-reported outcomes: pain or discomfort, shortness of breath, confidence in performing usual activities, feeling unhappy and having trouble sleeping. Data showed overall fit to a Rasch model of expected item functioning (χ2 16.99; p = 0.07) and all items demonstrated unidimensionality (t-test less than 0.05 threshold value). Internal consistency was acceptable (equivalent Cronbach’s α 0.65) given there are only five items, but there was a ceiling effect (mean logit score -1.24) with compromised score precision for patients with better recovery. Conclusions We identified a succinct set of items that can be used in a patient-reported outcome measure following percutaneous coronary interventions. This patient-report outcome measure has good structural validity and acceptable internal consistency. While further psychometric evaluations are recommended, the items identified capture the patient’s perspective of their recovery following a percutaneous coronary intervention

Prosafe: a european endeavor to improve quality of critical care medicine in seven countries

BACKGROUND: long-lasting shared research databases are an important source of epidemiological information and can promote comparison between different healthcare services. Here we present ProsaFe, an advanced international research network in intensive care medicine, with the focus on assessing and improving the quality of care. the project involved 343 icUs in seven countries. all patients admitted to the icU were eligible for data collection. MetHoDs: the ProsaFe network collected data using the same electronic case report form translated into the corresponding languages. a complex, multidimensional validation system was implemented to ensure maximum data quality. individual and aggregate reports by country, region, and icU type were prepared annually. a web-based data-sharing system allowed participants to autonomously perform different analyses on both own data and the entire database. RESULTS: The final analysis was restricted to 262 general ICUs and 432,223 adult patients, mostly admitted to Italian units, where a research network had been active since 1991. organization of critical care medicine in the seven countries was relatively similar, in terms of staffing, case mix and procedures, suggesting a common understanding of the role of critical care medicine. conversely, icU equipment differed, and patient outcomes showed wide variations among countries. coNclUsioNs: ProsaFe is a permanent, stable, open access, multilingual database for clinical benchmarking, icU self-evaluation and research within and across countries, which offers a unique opportunity to improve the quality of critical care. its entry into routine clinical practice on a voluntary basis is testimony to the success and viability of the endeavor