Annual Progress reports
Optimising quality use of medicines in hospital to improve outcomes in frail older people (1174447)
- Professor Sarah Hilmer (Chief Investigator A)
- University of Sydney
- Budget: $1,200,390.00
- Funding period: 2020 to 2025
Project Synopsis
Adverse drug reactions are one of the most reversible contributors to frailty and to hospitalizations in older people. It has been shown that polypharmacy (multiple medicine use) and overall exposure to certain medicines is highly prevalent in frail older people. The Asia-Pacific frailty guidelines list medication review as one of three evidence-based recommendations for the management of frailty. Under the National Safety and Quality Health Service Standard, comprehensive medication review for patients at high risk of medication-related harm is required, however there are no standard validated risk-assessment tools for identifying these patients. We aim to test a set of tools that we have developed to guide patient centered medication review in older patients in hospital. It is expected that patient centered medication review is likely to result in deprescribing since most older inpatients take at least one inappropriate medication. This should result in reduced frailty due to side effects of unnecessary medications and improve important outcomes for frail older people during and after hospital admission.
Progress report as of 30 April 2023
This project aims to improve comprehensive medication review in frail older people in hospital. The first aim, to measure frailty using routine data from the electronic hospital record, is now complete. The electronic frailty index for people in acute hospitals (eFI-AH) was validated from data manually extracted from the electronic medical record. This was done using an automated extract. The eFI-AH was further developed to align with the new comprehensive care assessment for NSW Hospital patients. The second aim, conducting a pilot of a comprehensive intervention of medication review in hospital, was completed in 2021. Despite the challenges of working during the pandemic, the project has demonstrated a significant increase in deprescribing of unnecessary high-risk medications and have published on the intervention and outcomes.
The intervention period in our multi-site clinical trial of the intervention has been completed. One year of follow up data is needed for final analysis.
The FORTRESS Study (Frailty Older People Rehabilitation Treatment Research Examining Separate Settings) (1177847)
- Professor Susan Kurrle (Chief Investigator A)
- University of Sydney
- Budget: $1,470,000.00
- Funding period: 2020 to 2024
Project Synopsis
Frailty is emerging as a challenge for older people and the health service they use. This study aims to assist frail older people living in the community to be as active and independent as possible. It takes a validated frailty screening tool (FRAIL Scale) and an evidence-based intervention using the 2017 Asia Pacific Clinical Practice Guidelines for Management of Frailty, and operationalises them together in the acute hospital setting. Patients assessed as frail will receive interventions targeting those factors contributing to their frailty; for example weight loss, self-reported exhaustion, slow walking speed, and multiple medications. On discharge the frail patients will be followed through their general practice to commence or continue interventions.
We will measure the effectiveness of the frailty intervention on hospital readmissions, frailty status, and quality of life. The uptake of the prescribed interventions and cost effectiveness of the intervention will also be measured.
This study will provide evidence that screening for frailty in acute care and intervening to address the identified factors contributing to frailty may provide significant impact through reducing hospital admissions and improving facility status and quality of life for frail older people.
Progress report as of 30 April 2023
This project had shown that frailty screening can be successfully implemented in an acute hospital setting. Interventions for participants by allied health staff have included physiotherapy to improve mobility and strength, pharmacist review concerning appropriateness of medications, and dietitian review to ensure adequate protein and calorie intake. On discharge, the patient's general practitioner has been informed on the interventions and referral to community allied health staff has occurred. Follow up of patients continues until early 2024, when analysis of outcome data will occur.
Publications and other resources
Block H, Annesley A, Lockwood K, Xu L, Cameron ID, Laver K, Crotty M, Sherrington C, Kifley A, Howard K, Pond D, Nguyen TA, Kurrle SE. Frailty in older people: Rehabilitation Treatment Research Examining Separate Settings (FORTRESS): protocol for a hybrid type II stepped wedge, cluster, randomised trial. BMC Geriatr. 2022 Jun 27;22(1):527. doi: 10.1186/s12877-022-03178-1. PMID: 35761212; PMCID: PMC9235164.
The GOAL Trial: Comprehensive Geriatric Assessment for Frail Older People with Chronic Kidney Disease to Increase Attainment of Patient Identified Goals: A Cluster Randomised Controlled Trial (1178519)
- Professor Ruth Hubbard (Chief Investigator A)
- University of Queensland
- Budget: $1,508,908.00
- Funding period: 2020 to 2024
Project Synopsis
Frailty is highly prevalent among older people with chronic kidney disease (CKD) and is associated with multiple adverse outcomes, including increasing disability, nursing home placement and death. Comprehensive Geriatric Assessment (CGA) to identify and manage medical, psychosocial and functional needs is recommended for all older people who are frail. However, links between geriatric medicine and nephrology are currently weak and evidence on the effectiveness of CGA for patients with CKD remains limited. Building on prior research to identify patient-important outcomes and validate a frailty index (FI) in older people with CKD, we propose a multi-site cluster randomised controlled trial of sixteen clinics in six states to examine the effect of CGA as opposed to usual care on frail patients (FI>0.25) with Stages 3 to 5 CKD. All patients will be followed up at 3, 6 and 12 months. The primary outcome will be Goal Attainment Scaling, based on achievement of patients’ expressed health outcome goals. Secondary outcomes will be quality of life (EQ-5D) and FI as well as days in hospital, transfer to an aged care facility and mortality. A cost-utility analysis and process evaluation will be undertaken. Dissemination and implementation strategies include the development of prototype educational materials to support independent patient goal setting and the generation of a Position Statement on Management of Frail Older People with CKD. The patient-important outcomes will also be incorporated into a new sub-stream of the Standardised Outcomes in Nephrology Initiative (SONG-Frailty) to ensure rapid translation into research, policy and practice.
Progress report as of 30 April 2023
The manuscript for the scoping review of Goal Attainment Scaling (GAS) has been published in BMJ Open. The primary outcome is attainment of self-identified goals assessed by the standardized Goal Attainment Scaling (GAS) at 3 months. Collection of primary outcome data and measurement of secondary outcomes including GAS at 6 and 12 months, quality of life (EQ-5D-5L) and frailty (Frailty Index-Short Form) were completed in one of the sites. The activity in is progress for the other sites.
Publications and other resources
Logan B, Jegatheesan D, Viecelli A, Pascoe E, Hubbard R. Goal attainment scaling as an outcome measure for randomised controlled trials: a scoping review. BMJ Open. 2022 Jul 22;12(7):e063061. doi: 10.1136/bmjopen-2022-063061. PMID: 35868829; PMCID: PMC9316030.