Magnolia Cardona

To identify the determinants, prevalence, and proposed solutions for potentially avoidable hospital transfers (PAHT) of residential aged care facility (RACF) residents in Australia, a scoping review was conducted using PubMed, CINAHL, Cochrane Library and Google Scholar, covering the period from 2015 to 2025. The database search identified 1350 articles, of which 43 studies met inclusion criteria. Prevalence of PAHT ranged from of 8.5% to 95.2% when defined as specific conditions manageable by an outreach service; from 2.2% to 55.6% when defined as potentially manageable with primary care; and from 11.6% to 53% when defined as an Emergency Department (ED) presentation not requiring a hospital admission. The most frequently reported determinant of PAHT pertained to the overarching theme of RACF clinical decision-making and systemic RACF practice-based factors. Establishment of, and access to, outreach services was the main proposed solution, alongside onsite General Practitioners (GP), Advance Care Planning (ACP), and capacity building for RACF nurses. Despite Australia’s diversity, our findings demonstrate patterns and similarities in prevalence, determinants and solutions. Consensus or standardisation of denominators would enhance comparability of outcomes across studies. These findings offer opportunities to reconsider solutions in response to the chronic challenge of avoidable nursing home patient transfers.

Background: Patients with dementia (PwD) nearing end of life (nEOL) do not always receive optimal end-of-life care, including timely specialist palliative care input. In hospitalized PwD likely to be nEOL, we aimed to determine the prevalence of goals of care discussions; the incidence and timing of referral to palliative care; factors associated with palliative care referral and timely (within 2 days) palliative care referral; and the prevalence of polypharmacy (>5 medications) and in-hospital deprescribing (cessation). Methods: A retrospective chart review of a cohort of PwD admitted under geriatric medicine 1 July 2021–30 June 2022 was conducted, screening to identify nEOL status. Results: A total of 298 patients (mean age of 83.5 [SD 7.4] and 51.3% females) were included in the final analysis. Eleven percent of eligible patients (33/298) died during admission. Overall, 80.9% had discussed an advance care plan (ACP). The mean time from admission to the discussion of an ACP was 1 day (SD = 5.02). One in twenty (5.4%) had their goals of care revised during admission, with 15 transitioning to palliation. Only 7.1% were referred to palliative care during admission. The mean time to referral was 9.8 days (SD 7.3; range 0–26). One in fourteen (7.4%) were discharged from hospital on an end-of-life pathway. In multivariable analysis, both the clinical frailty score (CFS) (aOR per unit increase 3.66; 95%CI 1.65–8.09, p = 0.001) and meeting ≥ 2 deterioration criteria (per CriSTAL tool) (OR 3.68; 95% CI 1.07–12.70, p = 0.039) were independently associated with referral to palliative care. Polypharmacy was common at admission (76.2%), with a mean number of medications of 8.4 (SD = 4). The median number of medications ceased during admission was two (IQR 0–4). Conclusions: Contrary to our hypothesis, we found a high quality of care of PwD likely nEOL, reflected by frequent ACPs in hospital, but it fell short of palliative care specialist input. Polypharmacy on admission and discharge may be further improved by aligning medication use with goals of care among PwD approaching the end of life, and considering the hospital nurse-driven identification of practice gaps is encouraged.

Background: There is an increasing demand for the provision of speech language pathology (SLP) services via telehealth. Therefore, we systematically reviewed randomized controlled trials comparing telehealth to face-to-face provision of SLP services. Methods: We searched Medline, Embase and Cochrane, clinical trial registries, and conducted a citation analysis to identify trials. We included randomized trials comparing similar care delivered live via telehealth (phone or video), to face-to-face. Primary outcomes included: % syllables stuttered (%SS) (for individuals who stutter); change in sound pressure levels monologue (for individuals with Parkinson's disease); and key function scores (for other areas). Where data were sufficient, mean differences were calculated. Results: Nine randomized controlled trials were included; eight evaluated video and one evaluated phone telehealth. Risk of bias was generally low or unclear, excepting blinding. There were no significant differences at any time-point up to 18 months for %SS (mean difference, MD 0.1, 95% CI −0.4 to 0.6, p = 0.70). For people with Parkinson's disease, there was no difference between groups in change in sound pressure levels (monologue) (MD 0.6, 95% CI −1.2 to 2.5, p = 0.49). Four trials investigated interventions for speech sound disorder, voice disorder and post-stroke dysphagia and aphasia; they found no differences between telehealth service delivery and face-to-face delivery. Conclusions: Evidence suggests that the telehealth provision of SLP services may be a viable alternative to their provision face-to-face, particularly to people who stutter and people with Parkinson's disease. The key limitation is the small number of randomized controlled trials, as well as evidence on the quality of life, well-being and satisfaction, and economic outcomes.

This commentary refers to ‘Cardiovascular disease risk communication and prevention: a meta-analysis’, by M. Bakhit et al., https://doi.org/10.1093/eurheartj/ehae002 and the discussion piece ‘Cardiovascular disease risk communication alone is not enough: why a recent review may be misleading’, by S. Griffiths et al., https://doi.org/10.1093/eurheartj/ehae529.

Objectives: To investigate if a prospective feedback loop that flags older patients at risk of death can reduce non-beneficial treatment at end of life. Design: Prospective stepped-wedge cluster randomised trial with usual care and intervention phases. Setting: Three large tertiary public hospitals in south-east Queensland, Australia. Participants: 14 clinical teams were recruited across the three hospitals. Teams were recruited based on a consistent history of admitting patients aged 75+ years, and needed a nominated lead specialist consultant. Under the care of these teams, there were 4,268 patients (median age 84 years) who were potentially near the end of life and flagged at risk of non-beneficial treatment. Intervention: The intervention notified clinicians of patients under their care determined as at-risk of non-beneficial treatment. There were two notification flags: a real-time notification and an email sent to clinicians about the at-risk patients at the end of each screening day. The nudge intervention ran for 16–35 weeks across the three hospitals. Main outcome measures: The primary outcome was the proportion of patients with one or more intensive care unit (ICU) admissions. The secondary outcomes examined times from patients being flagged at-risk. Results: There was no improvement in the primary outcome of reduced ICU admissions (mean probability difference [intervention minus usual care] = −0.01, 95% confidence interval −0.08 to 0.01). There were no differences for the times to death, discharge, or medical emergency call. There was a reduction in the probability of re-admission to hospital during the intervention phase (mean probability difference −0.08, 95% confidence interval −0.13 to −0.03). Conclusions: This nudge intervention was not sufficient to reduce the trial’s non-beneficial treatment outcomes in older hospital patients. Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).

Background There is an increasing demand for the provision of speech language pathology (SLP) services via telehealth. Therefore, we systematically reviewed randomized controlled trials comparing telehealth to face-to-face provision of SLP services. Methods We searched Medline, Embase, and Cochrane, clinical trial registries, and conducted a citation analysis to identify trials. We included randomized trials comparing similar care delivered live via telehealth (phone or video), to face-to-face. Primary outcomes included: % syllables stuttered (%SS) (for individuals who stutter); change in sound pressure levels monologue (for individuals with Parkinson’s disease); and key function scores (for other areas). Where data were sufficient, mean differences were calculated. Results Nine randomized controlled trials were included; 8 evaluated video and 1 evaluated phone telehealth. Risk of bias was generally low or unclear, excepting blinding. There were no significant differences at any time-point up to 18 months for %SS (mean difference, MD 0.1, 95% CI –0.4 to 0.6, p=0.70). For people with Parkinson’s disease, there was no difference between groups in change in sound pressure levels (monologue) (MD 0.6, 95% CI –1.2 to 2.5, p=0.49). Four trials investigated interventions for speech sound disorder, voice disorder, and post-stroke dysphagia and aphasia; they found no differences between telehealth service delivery and face-to-face delivery. Conclusions Evidence suggests that the telehealth provision of SLP services may be a viable alternative to their provision face-to-face, particularly to people who stutter and people with Parkinson’s disease. The key limitation is the small number of randomized controlled trials, as well as evidence on the quality of life, well-being and satisfaction, and economic outcomes.

Introduction: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study.Methods: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August–September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors.Results: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2–4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include.Conclusions: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Background and Aims: Knowledge of quantifiable cardiovascular disease (CVD) risk may improve health outcomes and trigger behavioural change in patients or clinicians. This review aimed to investigate the impact of CVD risk communication on patient-perceived CVD risk and changes in CVD risk factors. Methods: PubMed, Embase, and PsycINFO databases were searched from inception to 6 June 2023, supplemented by citation analysis. Randomized trials that compared any CVD risk communication strategy versus usual care were included. Paired reviewers independently screened the identified records and extracted the data; disagreements were resolved by a third author. The primary outcome was the accuracy of risk perception. Secondary outcomes were clinician-reported changes in CVD risk, psychological responses, intention to modify lifestyle, and self-reported changes in risk factors and clinician prescribing of preventive medicines. Results: Sixty-two trials were included. Accuracy of risk perception was higher among intervention participants (odds ratio = 2.31, 95% confidence interval = 1.63 to 3.27). A statistically significant improvement in overall CVD risk scores was found at 6–12 months (mean difference = −0.27, 95% confidence interval = −0.45 to −0.09). For primary prevention, risk communication significantly increased self-reported dietary modification (odds ratio = 1.50, 95% confidence interval = 1.21 to 1.86) with no increase in intention or actual changes in smoking cessation or physical activity. A significant impact on patients’ intention to start preventive medication was found for primary and secondary prevention, with changes at follow-up for the primary prevention group. Conclusions: In this systematic review and meta-analysis, communicating CVD risk information, regardless of the method, reduced the overall risk factors and enhanced patients’ self-perceived risk. Communication of CVD risk to patients should be considered in routine consultations.

Objectives Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. Design A mixed-methods scoping review was conducted using the Arksey and O’Malley framework. Data sources Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. Eligibility criteria Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. Data extraction and synthesis Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. Results The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. Conclusion High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.