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 hospitalisations 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 3 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 centred medication review in older patients in hospital. It is expected that patient centred 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 2024
Pilot study completed, findings published and presented (3 oral, 2 poster) at national/international conferences.1,2
The step wedge randomised controlled trial concluded in all study hospitals on 3 July 2023. The study outcomes include outcomes of the index admission and one year follow-up (to 3 July 2024).
The patient reported outcomes (on discharge from index admission and after 3 months) collected.
Recruitment and data collection for the mixed methods analysis from patients/carers and multidisciplinary clinicians complete.
Data extraction from the hospital electronic medical records for the study period is in progress. Data extraction and transfer from electronic health records from the index admission in the randomised controlled trial has been complex due to the delays in routine coding, large file sizes and sensitivity of the multisite health data.
Measurement of the frailty of patients for pre-planned subgroup analysis using an electronic frailty index for acute hospital (eFI-AH) has been developed and validated.3
Protocol and ethics application for obtaining linked data for 28 day and one year outcomes of the study in progress.
A review of literature relevant to the context of the research project has been published.4
Publications and other resources
1 Fujita K, Hooper P, Masnoon N, Lo S, Gnjidic D, Etherton-Beer C, Reeve E, Magin P, Bell JS, Rockwood K, O'Donnell LK, Sawan M, Baysari M, Hilmer SN. Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study. Drugs Aging. 2023 Jul;40(7):633-642. doi: 10.1007/s40266-023-01032-6. Epub 2023 May 9. PMID: 37160561; PMCID: PMC10299923.
2 Masnoon N, Lo S, Hilmer S. A stewardship program to facilitate anticholinergic and sedative medication deprescribing using the drug burden index in electronic medical records. Br J Clin Pharmacol. 2023 Feb;89(2):687-698. doi: 10.1111/bcp.15517. Epub 2022 Sep 15. PMID: 36038522; PMCID: PMC10953400.
3 Fujita K, Lo SY, Hubbard RE, Gnjidic D, Hilmer SN. Comparison of a multidomain frailty index from routine health data with the hospital frailty risk score in older patients in an Australian hospital. Australas J Ageing. 2023 Sep;42(3):480-490. doi: 10.1111/ajag.13162. Epub 2022 Dec 13. PMID: 36511440; PMCID: PMC10946514.
4 Fujita K, Masnoon N, Mach J, O'Donnell LK, Hilmer SN. Polypharmacy and precision medicine. Camb Prism Precis Med. 2023 Mar 10;1:e22. doi: 10.1017/pcm.2023.10. eCollection 2023. PMID: 38550925; PMCID: PMC10953761.
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 have received 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 were followed up 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 is designed to 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 2024
The outcome assessments for this project concluded in December 2023. Analysis and collation of results is now in progress. Quality of Life data has been analysed and did not show significant differences between groups. Further Health Economic analysis is being considered and work will start on the analysis of primary outcomes in the next 3 months.
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.
Conferences
Heather Block, 'The Profile of frail older people admitted to hospital and the FORTRESS Trial' [eposter], The Australian and New Zealand Society for Sarcopenia and Frailty Research Conference (ANZFSSR), 17 March 2022, Brisbane QLD.
Kisani Manuel, 'Healthcare professional attitudes to implementation of frailty interventions' [eposter], ANZFSSR, 17 March 2022, Brisbane QLD.
Heather Block, 'The Profile of frail older people admitted to hospital and the FORTRESS Trial' [eposter], Annual conference for the Australian Association of Gerontology, 23 November 2022, Adelaide SA.
Kisani Manuel, 'What do we think about Frailty? Perceptions of frailty amongst inpatient geriatric and rehabilitation staff' [eposter], Annual conference for the Australian Association of Gerontology, 23 November 2022, Adelaide SA.
Rosanna Tran, 'Detection of frailty in older people admitted to Hornsby Ku-ring-gai Hospital' [eposter], Aged Care Collaborative Forum, 1 December 2022, Virtual NSW.
Rosanna Tran, 'The identification of frailty and frailty exercise interventions in older people admitted to hospital and recruited into the FORTRESS Study' [poster], International Association of Gerontology & Geriatric (IAGG), 12-14 June 2023, Yokohama Japan.
Annie Yu, 'Medication Challenges in Geriatric Frailty: Assessing Polypharmacy and Inappropriate Prescribing Patterns' [poster], ANZFSSR, 21-23 June 2024, Melbourne Vic.
Papers
Heather Block, 'Frailty in older people: Rehabilitation Treatment Research Examining Separate Settings (FORTRESS): protocol for a hybrid type II stepped wedge, cluster, randomised trial', BMC Geriatrics, 27 June 2022
Kisani Manuel, 'Implementation of frailty intervention in transition from hospital to home: a realist process evaluation protocol for the FORTRESS trial', BMJ Open, pending.
Heather Block, 'Frailty evidence-practice gaps in acute care hospitals', Aust J on Ageing, accepted 23 April 2024.
Other
Rosanna Tran, 'IAGG Conference: The identification of frailty and frailty interventions in older people admitted to hospital and recruited into the FORTRESS Study' [Letter to Editor], IAGG Journal, 4 July 2023.
Kerri Lockwood, 'Synopsis: FORTRESS (Frailty in Older people: Rehabilitation, Treatment, Research, Examining Separate Settings)' [Primary Health Network Newsletter], October 2023.
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 16 clinics in 6 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 2024
Recruitment for the study is completed with a total number of 240 participants enrolled in the trial. The last patient’s final visit is expected in June 2024. Six month and 12 month follow-up assessments are ongoing.
The Baseline data cleaning has been completed in e-case report forms in REDcap and baseline case report forms have been locked in preparation for analysis.
The Australasian Kidney Trials Network (AKTN) clinical trial team are working with hospital Health Information Services teams for discharge codes and hospital admission data. These data will enable the study to meet the secondary and exploratory objectives of the study related to time and cost for hospitalisations.
An article about training healthcare professionals to deliver goal attainment scaling has been published in the Journal of Patient Reported Outcomes. We are in the process of working on the GOAL Trial Baseline characteristics Paper. The Process Evaluation paper has been submitted for publication and this is under review. Publication steering committee was established, and the team will be inviting colleagues for authorship and collaboration.
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.
Logan, B., Viecelli, A., Johnson, D. et al. Study protocol for 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. Trials 24, 365 (2023). https://doi.org/10.1186/s13063-023-07363-4.
Logan, B., Viecelli, A., Pascoe, E. et al. Training healthcare professionals to administer Goal Attainment Scaling as an outcome measure. J Patient Rep Outcomes 8, 22 (2024). https://doi.org/10.1186/s41687-024-00704-0.