Contact investigations for antibiotic-resistant bacteria: a mixed-methods study of patients' comprehension of and compliance with self-sampling requests post-discharge.

BACKGROUND: Contact investigation is an important tool to identify unrecognized patients who are colonized with antibiotic-resistant bacteria. Many Dutch hospitals include already discharged contact patients by sending them a self-sampling request at home, incl. an information letter and sampling materials. Each hospital composes these information letters on their own initiative, however, whether discharged patients comprehend and comply with these requests remains unclear. Therefore, the aim was to provide insight into patients' comprehension of and self-reported compliance with self-sampling requests post-discharge. METHODS: This mixed-methods study was performed in eight Dutch hospitals. First, the Common European Framework of Reference (CEFR) language level of self-sampling request letters was established. Second, a questionnaire about patients' comprehension of the letter, self-reported compliance, and reasons for compliance or non-compliance were sent to patients that received such a request in 2018/2019. Finally, a random selection of questionnaire respondents was interviewed between January and March 2020 to gain additional insights. RESULTS: CEFR levels of 15 letters were established. Four letters were assigned level B1, four letters B1-B2, and seven letters B2. The majority of patients reported good comprehension of the letter they had received. Conversely, some respondents indicated that information about the bacterium (18.4%), the way in which results would be communicated (18.1%), and the self-sampling instructions (9.7%) were (partially) unclear. Furthermore, self-reported compliance was high (88.8%). Reasons to comply were personal health (84.3%), the health of others (71.9%), and general patient safety (96.1%). Compliant patients appeared to have a need for confirmation, wanted to protect family and/or friends, and felt they were providing the hospital the ability to control the transmission of antibiotic-resistant bacteria. Although a limited number of non-compliant patients responded to the questionnaire, it seemed that more patients did not comply with self-sampling requests when they received a letter in a higher CEFR-level (B2) compared to a lower CEFR-level (< B2) (9.8% vs. 2.5%, P = 0.049). CONCLUSIONS: This study showed an overall good comprehension of and high self-reported compliance with self-sampling requests post-discharge. Providing balanced information in self-sampling request letters has the potential to reduce patient's ambiguity and concerns, and can cause increased compliance with self-sampling requests.

Effects of a management team training intervention on the compliance with a surgical site infection bundle: a before-after study in operating theatres in the Netherlands.

OBJECTIVES: To assess the effects of a quality improvement (QI) team training intervention, by measuring the intervention fidelity and the compliance with a surgical site infection (SSI) bundle in the operating theatre (OT). DESIGN: Multicentre before-after study. SETTING: This study was performed in four Dutch hospitals. INTERVENTION: The QI team training intervention consisted of four sessions per hospital and stimulated participants to set culture norms and targets, identify barriers, and formulate management activities to improve compliance with four standard operating procedures (SOPs) of a SSI bundle in the OT. Participants were executive board members, top-level managers, leading clinicians and support staff. The four SOPs were: (1) reducing door movements; (2) preoperative antibiotic prophylaxis prescribing; (3) preoperative shaving; and (4) postoperative normothermia. Poisson and logistic regression analyses were performed to analyse the effect of the intervention on compliance with the individual SOPs (primary outcome measure) and on the influence of medical specialty, time of day the procedure took place and time in the OT (secondary outcome measures). RESULTS: Not all management layers were successfully involved during all sessions in the hospitals. Top-level managers were best represented in all hospitals, leading clinicians the least. The number of implemented improvement activities was low, ranging between 2 and 14. The team training intervention we developed was not associated with improvements in the compliance with the four SOP of the SSI bundle. Medical specialty, time of day, and time in OT were associated with median number of door movements, and preoperative antibiotic prophylaxis administration. CONCLUSION: This study showed that after the QI team training intervention the overall compliance with the four SOPs did not improve. Minimal involvement of leading clinicians and a low number of self-initiated activities after the team training were important barriers for compliance.

The Effect of Written and Video Discharge Instructions After Mild Traumatic Brain Injury on Healthcare Costs and Productivity Costs.

OBJECTIVE: To compare healthcare and productivity costs between patients with mild traumatic brain injury (mTBI) who received verbal discharge instructions only and patients who received an additional flyer with or without video instructions. SETTING: Emergency departments (EDs) of 6 hospitals in the Netherlands. PARTICIPANTS: In total, 1155 adult patients with mTBI (384 with verbal instructions; 771 with additional flyer with or without video instructions) were included. DESIGN: Cost study with comparison between usual care and intervention. METHODS: Medical and productivity costs up to 3 months after presentation at the ED were compared between mTBI patients with usual care and mTBI patients who received the intervention. RESULTS: Mean medical costs per mTBI patient were slightly higher for the verbal instructions-only cohort (€337 vs €315), whereas mean productivity costs were significantly higher for the flyer/video cohort (€1625 vs €899). Higher productivity costs were associated with higher working age, injury severity, and postconcussion symptoms. CONCLUSION: This study showed that the implementation of flyer (and video) discharge instructions for patients with mTBI who present at the ED increased reports of postconcussion symptoms and reduced medical costs, whereas productivity costs were found to be higher for the working population in the first 3 months after the sustained head injury.

Health-related quality of life and return to work 1 year after major trauma from a network perspective.

INTRODUCTION: Major trauma often results in long-term disabilities. The aim of this study was to assess health-related quality of life, cognition, and return to work 1 year after major trauma from a trauma network perspective. METHODS: All major trauma patients in 2016 (Injury Severity Score > 15, n = 536) were selected from trauma region Southwest Netherlands. Eligible patients (n = 365) were sent questionnaires with the EQ-5D-5L and questions on cognition, level of education, comorbidities, and resumption of paid work 1 year after trauma. RESULTS: A 50% (n = 182) response rate was obtained. EQ-US and EQ-VAS scored a median (IQR) of 0.81 (0.62-0.89) and 70 (60-80), respectively. Limitations were prevalent in all health dimensions of the EQ-5D-5L; 90 (50%) responders reported problems with mobility, 36 (20%) responders reported problems with self-care, 108 (61%) responders reported problems during daily activities, 129 (73%) responders reported pain or discomfort, 70 (39%) responders reported problems with anxiety or depression, and 102 (61%) of the patients reported problems with cognition. Return to work rate was 68% (37% full, 31% partial). A median (IQR) EQ-US of 0.89 (0.82-1.00) and EQ-VAS of 80 (70-90) were scored for fully working responders; 0.77 (0.66-0.85, p < 0.001) and 70 (62-80, p = 0.001) for partial working respondents; and 0.49 (0.23-0.69, p < 0.001) and 55 (40-72, p < 0.001) for unemployed respondents. CONCLUSION: The majority experience problems in all health domains of the EQ-5D-5L and cognition. Return to work status was associated with all health domains of the EQ-5D-5L and cognition.

Effect of Video Discharge Instructions for Patients With Mild Traumatic Brain Injury in the Emergency Department: A Randomized Controlled Trial.

STUDY OBJECTIVE: We measure the effect of video discharge instructions on postconcussion symptoms in patients with mild traumatic brain injury in the emergency department. METHODS: A multicenter randomized controlled trial was conducted in which patients with mild traumatic brain injury were randomly assigned to either intervention (verbal, written, and video discharge information) or control (verbal and written discharge information only). All patients were interviewed 1 week and 3 months from randomization. Primary outcome measure was the Rivermead Post-Concussion Symptoms Questionnaire at 3 months. Secondary outcomes were correct recall, Hospital Anxiety and Depression Scale score, health-related quality of life (12-Item Short Form Health Survey), return visits, and patient satisfaction. RESULTS: A total of 2,883 patients were assessed for eligibility, of whom 381 were included in the control group and 390 in the video intervention group. Difference in mean total Rivermead Post-Concussion Symptoms Questionnaire score between the 2 groups was 0.2 at 1 week and 0.3 at 3 months after traumatic brain injury (estimated effect -0.7; 95% confidence interval -2.1 to 0.7). There was also no difference in Hospital Anxiety and Depression Scale score, recall, 12-Item Short Form Health Survey score, return visits, and patient satisfaction between the control and intervention group. CONCLUSION: Severity of postconcussion symptoms in patients with mild traumatic brain injury did not improve by adding video information to standard care. Also, there was no difference in recall, health-related quality of life, return visits, and patient satisfaction between the control and intervention groups.

[Homeless patients in Rotterdam with a need for medical care: data from the Rotterdam Street Doctors' office in the years 2006-2017]. / Rotterdamse daklozen met een zorgvraag.

OBJECTIVE: To describe the demographic and medical characteristics and changes of the patients who visit the Rotterdam Street Doctors' office hours. DESIGN: Retrospective study of registered patient contacts from 2006-2017. METHOD: Street doctors registered age, gender and ICPC diagnoses of patients in a GP information system. The characteristics of these patients have been analysed for three periods of four years: 2006-2009, 2010-2013, 2014-2017. For each of these periods, the number of individual patients visiting the Rotterdam Street Doctors' office hours at least once, have been documented. Data from the period 2014-2017, have been used to describe characteristics of homeless patients and have been compared with a regular GP practice. RESULTS: At the street doctors' office, patients with mental problems are most often documented, followed by patients with heart diseases and endocrine problems. Serious illnesses that require extra care are registered , such as drug and alcohol addiction, HIV, tuberculosis and hepatitis C. Patients with mental problems and trauma have a larger share at the street doctor's office than in a regular GP practice. The proportion of women has increased since 2006 as has the proportion of elderly patients. The proportion of patients with documented needs for cardiovascular diseases (in particular hypertension), endocrine disorders (in particular diabetes and thyroid diseases) and cancer has increased. CONCLUSION: A relatively large part of the patient contacts at the street doctor's office is devoted to mental problems and trauma. As the proportion of patients with chronic diseases and risk factors is rising, street doctor care seems to move towards regular care. But extra care for serious classical illnesses among the homeless is still necessary.

[Decrease in minor injury related visits to Emergency Departments coincides with higher numbers of primary care contacts]. / Stijging lichte letsels bij de huisarts valt samen met daling op de SEH.

OBJECTIVE: In the past 10 years, there has been a decrease in the number of patients who report to the Emergency Department (ED) every year for injuries from accidents or violence, especially in the subgroup of patients who did not require hospital admission. We investigated how the number of injury-related emergency department visits and GP contacts evolved over the period 2013-2017. DESIGN: Retrospective observational trend study. METHOD: To calculate the trend in emergency department visits in the Netherlands, we used data from the injury information system (LIS) for the period 2013-2017. To calculate the trend in GP contacts (GP practices as well as GP centres), we used data from the NivelZorgregistraties (Nivel medical records). In order to compare the trends, we distinguished between minor and major injuries. The numbers from the records were extrapolated to numbers for the whole of the Netherlands. RESULTS: In the period studied, the number of patients with minor injuries who visited the ED dropped by 38.5%, while the number of patients with major injuries (fractures and brain injuries) increased by 4.1%. In the same period, the number of GP contacts for minor injuries at GP practices increased by 25% and at GP centres by 43%; the number of primary care contacts for major injuries increased by 5.1% (GP practices) and 31% (GP centres) respectively. CONCLUSION: The role of general practitioners in the treatment of patients with minor injuries is increasing. The trend in major injuries is a better indicator for monitoring accidents and violence in the Netherlands. Conflict of interest and financial support: none declared.

Falls in older aged adults in 22 European countries: incidence, mortality and burden of disease from 1990 to 2017.

INTRODUCTION: Falls in older aged adults are an important public health problem. Insight into differences in fall-related injury rates between countries can serve as important input for identifying and evaluating prevention strategies. The objectives of this study were to compare Global Burden of Disease (GBD) 2017 estimates on incidence, mortality and disability-adjusted life years (DALYs) due to fall-related injury in older adults across 22 countries in the Western European region and to examine changes over a 28-year period. METHODS: We performed a secondary database descriptive study using the GBD 2017 results on age-standardised fall-related injury in older adults aged 70 years and older in 22 countries from 1990 to 2017. RESULTS: In 2017, in the Western European region, 13 840 per 100 000 (uncertainty interval (UI) 11 837-16 113) older adults sought medical treatment for fall-related injury, ranging from 7594 per 100 000 (UI 6326-9032) in Greece to 19 796 per 100 000 (UI 15 536-24 233) in Norway. Since 1990, fall-related injury DALY rates showed little change for the whole region, but patterns varied widely between countries. Some countries (eg, Belgium and Netherlands) have lost their favourable positions due to an increasing fall-related injury burden of disease since 1990. CONCLUSIONS: From 1990 to 2017, there was considerable variation in fall-related injury incidence, mortality, DALY rates and its composites in the 22 countries in the Western European region. It may be useful to assess which fall prevention measures have been taken in countries that showed continuous low or decreasing incidence, death and DALY rates despite ageing of the population.

Patient Discharge Instructions in the Emergency Department and Their Effects on Comprehension and Recall of Discharge Instructions: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: We conduct a systematic review with meta-analysis to provide an overview of the different manners of providing discharge instructions in the emergency department (ED) and to assess their effects on comprehension and recall of the 4 domains of discharge instructions: diagnosis, treatment, follow-up, and return instructions. METHODS: We performed a systematic search in the PubMed, EMBASE, Web of Science Google Scholar, and Cochrane databases for studies published before March 15, 2018. A quality assessment of included articles was performed. Pooled proportions of correct recall by manner of providing discharge instructions were calculated. RESULTS: A total of 1,842 articles were screened, and after selection, 51 articles were included. Of the 51 included studies, 12 used verbal discharge instructions only, 30 used written discharge instructions, and 7 used video. Correct recall of verbal, written, and video discharge instructions ranged from 8% to 94%, 23% to 92%, and 54% to 89%, respectively. Meta-analysis was performed on data of 1,460 patients who received verbal information only, 3,395 patients who received written information, and 459 patients who received video information. Pooled data showed differences in correct recall, with, on average, 47% for patients who received verbal information (95% confidence interval 32.2% to 61.7%), 58% for patients who received written information (95% confidence interval 44.2% to 71.2%), and 67% for patients who received video information (95% confidence interval 57.9% to 75.7%). CONCLUSION: Communicating discharge instructions verbally to patients in the ED may not be sufficient. Although overall correct recall was not significantly higher, adding video or written information to discharge instructions showed promising results for ED patients.

A multimodal intervention to improve hand hygiene compliance via social cognitive influences among kindergarten teachers in China.

Children attending kindergarten are at high risk for contracting infections, for which hand hygiene (HH) has been recognized as the most cost-effective prevention measure globally. Kindergarten teachers' HH behavior plays a vital role in encouraging favorable hygiene techniques and environment. This study aims to evaluate the effectiveness of a multimodal intervention at changing kindergarten teachers' HH behavior and social cognitive factors that influences HH behavior in China. The intervention named "Clean Hands, Happy Life" includes HH products with refills, reminders and cues for action, a kick-off event with awards, and training programs. We evaluated the intervention using a self-administrative questionnaire with a stratified random sample of 12 kindergartens. Two surveys was completed by 176 teachers at baseline and 185 after the 6-month intervention. Compared with the baseline scores, there was a significant improvement in the overall self-reported HH compliance of teachers (9.38 vs. 9.68 out of 10, p = 0.006), as well as teachers' perceived disease susceptibility, disease severity and behavioral control after the intervention (p<0.05). We found that teachers' HH compliance was likely to be higher among those who have better HH guideline awareness (ß = 0.48, p<0.01) and perceived behavioral control (ß = 0.26, p = 0.01), which explained 24.2% of the variance of self-reported compliance of teachers at baseline. The assessed intervention may provide Chinese kindergarten teachers with behavioral skills and cognitions that associated with the compliance of HH behavior. We thus recommend future intervention studies consider our HH behavior change techniques, address multiple social cognitive determinants of HH behavior and include the change of targeted influences in the impact evaluation.

Fall-related healthcare use and mortality among older adults in the Netherlands, 1997-2016.

OBJECTIVES: Fall-related injuries are a leading cause of morbidity among older adults, leading to a high healthcare consumption and mortality. We aim to describe and quantify time trends of fall-related healthcare use and mortality among adults aged ≥65 years in the Netherlands, 1997-2016. DESIGN: Data were extracted from the Dutch Injury Surveillance System, Dutch Hospital Discharge Registry, and Cause-of-Death Statistics Netherlands, by age, sex, diagnosis, injury location, and year. MEASUREMENTS: Absolute numbers and age-standardized rates of fall-related Emergency Department (ED) visits, hospital admissions, and fatalities, as well as average length of hospital stay (LOS) were calculated. RESULTS: Between 1997 and 2016, absolute numbers of fall-related ED visits increased by 48%, hospital admissions increased by 59%, and mortality showed an almost threefold increase. These absolute numbers doubled among adults aged ≥85 years. A shift in fall-related injury diagnosis was observed over the years with a growing share of skull/brain injuries. In contrast to the increase in absolute numbers, standardized incidence rates of ED visits decreased by 30% (p = 0.00), whereas incidence rates of hospital admissions and mortality did not significantly change over time. Furthermore, the absolute number of hospital admission days almost halved, due to a reduced average LOS from 18.5 (95% confidence interval (CI): 18.2-18.8) days (1997) to 6.1 (95% CI, 6.1-6.2) days (2016). CONCLUSION: Even though the standardized incidence rates of ED visits decreased in the past twenty years, the absolute number of fall-related ED visits increased. The number of hospital admissions has also increased, but the total number of admission days has almost halved during the same period. If the observed trends would continue, this may have implications for healthcare resource allocation, as the burden of care in EDs increases, and the admission duration reduces.

A hand hygiene intervention to decrease hand, foot and mouth disease and absence due to sickness among kindergarteners in China: A cluster-randomized controlled trial.

OBJECTIVES: To evaluate the effect of the "Clean Hands, Happy Life" intervention on the incidence of hand, food and mouth disease (HFMD) and on school absences due to sickness in kindergarten students. METHODS: The intervention consisted of four hand hygiene (HH) promotion components and was evaluated in a cluster-randomized controlled trial among 8275 children and 18 kindergartens from May to October, 2015 in Shenzhen, China. We compared two intervention arms - received the intervention in kindergartens only and in both kindergartens and families, respectively - to the control arm in multilevel analyses. RESULTS: During the follow-up, the incidence of HFMD in both intervention arms was significantly lower than in the control arm (IRR1: 0.39, 95%CI: 0.26-0.59; IRR2: 0.30, 95%CI: 0.19-0.49); the duration of absence due to sickness (in days) in both intervention arms was significantly shorter than in the control arm (ß1 = 0.58, 95%CI: 0.41-0.74; ß2 = 0.34, 95%CI: 0.17-0.50), controlling for the area type of kindergarten and grade level of children. Furthermore, during the follow-up we found that there were fewer episodes of absence due to respiratory, skin and eye infections (P < 0.05). CONCLUSIONS: Our intervention is effective at reducing HFMD infections and absence due to sickness in children attending kindergartens in China.

Economic Evaluations of Falls Prevention Programs for Older Adults: A Systematic Review.

OBJECTIVES: To provide a comprehensive overview of economic evaluations of falls prevention programs and to evaluate the methodology and quality of these studies. DESIGN: Systematic review of economic evaluations on falls prevention programs. SETTING: Studies (N=31) of community-dwelling older adults (n=25), of older adults living in residential care facilities (n=3), and of both populations (n=3) published before May 2017. PARTICIPANTS: Adults aged 60 and older. MEASUREMENTS: Information on study characteristics and health economics was collected. Study quality was appraised using the 20-item Consensus on Health Economic Criteria. RESULTS: Economic evaluations of falls prevention through exercise (n = 9), home assessment (n = 6), medication adjustment (n = 4), multifactorial programs (n = 11), and various other programs (n = 13) were identified. Approximately two-thirds of all reported incremental cost-effectiveness ratios (ICERs) with quality-adjusted life-years (QALYs) as outcome were below the willingness-to-pay threshold of $50,000 per QALY. All studies on home assessment and medication adjustment programs reported favorable ICERs, whereas the results of studies on exercise and multifactorial programs were inconsistent. The overall methodological quality of the studies was good, although there was variation between studies. CONCLUSION: The majority of the reported ICERs indicated that falls prevention programs were cost-effective, but methodological differences between studies hampered direct comparison of the cost-effectiveness of program types. The results imply that investing in falls prevention programs for adults aged 60 and older is cost-effective. Home assessment programs (ICERs < $40,000/QALY) were the most cost-effective type of program for community-dwelling older adults, and medication adjustment programs (ICERs < $13,000/QALY) were the most cost-effective type of program for older adults living in a residential care facility. J Am Geriatr Soc 66:2197-2204, 2018.

Increased care demand and medical costs after falls in nursing homes: A Delphi study.

AIMS AND OBJECTIVE: To estimate the increased care demand and medical costs caused by falls in nursing homes. BACKGROUND: There is compelling evidence that falls in nursing homes are preventable. However, proper implementation of evidence-based guidelines to prevent falls is often hindered by insufficient management support, staff time and funding. DESIGN: A three-round Delphi study. METHODS: A panel of 41 experts, all working in nursing homes in the Netherlands, received three online questionnaires to estimate the extra hours of care needed during the first year after the fall. This was estimated for ten falls categories with different levels of injury severity, in three scenarios, that is a best-case, a typical-case and a worst-case scenario. We calculated the costs of falls by multiplying the mean amount of extra hours that the participants spent on the care for a resident after a fall with their hourly wages. RESULTS: In case of a noninjurious fall, the extra time spent on the faller is on average almost 5 hr, expressed in euros that add to € 193. The extra staff time and costs of falls increased with increasing severity of injury. In the case of a fracture of the lower limb, the extra staff time increased to 132 hr, expressed in euros that is € 4,604. In the worst-case scenario of a fracture of the lower limb, the extra staff time increased to 284 hr, expressed in euros that is € 10,170. CONCLUSIONS: Falls in nursing homes result in a great deal of extra staff time spent on care, with extra costs varying between € 193 for a noninjurious fall and € 10,170 for serious falls. RELEVANCE TO CLINICAL PRACTICE: This study could aid decision-making on investing in appropriate implementation of falls prevention interventions in nursing homes.

Unnatural death: a major but largely preventable cause-of-death among homeless people?

Background: We aimed to assess the contribution of specific causes-of-death to excess mortality of homeless persons and to identify differences in cause-specific mortality rates after vs. before implementing social policy measures. Methods: We conducted a register based 10-year follow-up study of homeless adults in Rotterdam and calculated the proportion of deaths by cause-of-death in this cohort in the period 2001-2010. We estimated cause-specific mortality among the homeless compared to the general population with Standardized Mortality Ratios. We calculated Hazard Ratios adjusted for age and sex to compare mortality rates by cause-of-death among the homeless in the period after (2006-2010) vs. before (2001-2005) implementing social policy measures. Results: Our cohort consisted of 2130 homeless persons with a mean age of 40, 3 years. Unnatural death, cardiovascular disease and cancer were the main causes of death. Compared to the general population of Rotterdam, the homeless had an excess risk of death for all causes. The largest mortality differences with Rotterdam citizens were observed for unnatural death (SMR 14.8, CI 11.5-18.7), infectious diseases (SMR 10.0, CI 5.2-17.5) and psychiatric disorders (SMR 7.7, CI 4.0-13.5). Mortality due to intentional injuries (suicide and homicide) differed significantly between the two study periods (HR 0.45, CI 0.20-0.97). Conclusions: Reducing unnatural death should be a target in social policies aimed at improving the health of the homeless. We generated the hypothesis that social policies aimed at housing, work and improved contact with health care could be accompanied by less suicides and homicides within this vulnerable group.

Falls prevention activities among community-dwelling elderly in the Netherlands: A Delphi study.

INTRODUCTION: This study aimed to provide an overview of the current falls prevention activities in community-dwelling elderly with an increased risk of falling in the Netherlands. Therefore, we determined: a) how health professionals detect community-dwelling elderly with an increased risk of falling; b) which falls prevention activities are used by health professionals and why; c) how elderly can be stimulated to participate in falls prevention programs; and d) how to finance falls prevention. METHODS: A two-round online Delphi study among health experts was conducted. The panel of experts (n=125) consisted of community physiotherapists, community nurses, general practitioners, occupational therapists and geriatricians, from all over the Netherlands. The median and Inter Quartile Deviation (IQD) were reported for the questions with 5-point Likert scales, ranging from 'least' (1) to 'most' (5). RESULTS: Respectively 68% (n=85/125) and 58% (n=72/125) of the panel completely filled in the first and second round questionnaires. According to the panel, regular detection of fall risk of community-dwelling elderly with an increased risk of falling hardly takes place (median=2 [hardly]; IQD=1). Furthermore, these elderly are reluctant to participate in annual detection of fall risk (median=3 [reluctant]; IQD=1). According to 73% (n=37/51) of the panel, 0-40% of the elderly with an increased risk of falling are referred to exercise programs. In general, the panel indicated that structural follow-up is often lacking. Namely, after one month (n=21/43; 49%), three months (n=24/42; 57%), and six months (n=27/45; 60%) follow-up is never or hardly ever offered. Participation of elderly in falls prevention programs could be stimulated by a combination of measures. Should a combination of national health education, healthcare counseling, and removal of financial barriers be applied, 41-80% of the elderly is assumed to participate in falls prevention programs (n=47/64; 73%). None of the panel members indicated full financing of falls prevention by the elderly. A number of individuals are considered key in falls prevention activities, such as the general practitioner, physiotherapist, and informal caregiver. CONCLUSION: This Delphi study showed clear directions for improving falls prevention activities and how to increase participation rates.

Assessment of pre-injury health-related quality of life: a systematic review.

BACKGROUND: Insight into the change from pre- to post-injury health-related quality of life (HRQL) of trauma patients is important to derive estimates of the impact of injury on HRQL. Prospectively collected pre-injury HRQL data are, however, often not available due to the difficulty to collect these data before the injury. We performed a systematic review on the current methods used to assess pre-injury health status and to estimate the change from pre- to post-injury HRQL due to an injury. METHODS: A systematic literature search was conducted in EMBASE, MEDLINE, and other databases. We identified studies that reported on the pre-injury HRQL of trauma patients. Articles were collated by type of injury and HRQL instrument used. Reported pre-injury HRQL scores were compared with general age- and gender-adjusted norms for the EQ-5D, SF-36, and SF-12. RESULTS: We retrieved results from 31 eligible studies, described in 41 publications. All but two studies used retrospective assessment and asked patients to recall their pre-injury HRQL, showing widely varying timings of assessments (soon after injury up to years after injury). These studies commonly applied the SF-36 (n = 13), EQ-5D (n = 9), or SF-12 (n = 3) using questionnaires (n = 14) or face-to-face interviews (n = 11). Two studies reported prospective pre-injury assessment, based on prospective longitudinal cohort studies from a sample of initially non-injured patients, and applied questionnaires using the SF-36 or SF-12. The recalled pre-injury HRQL scores of injury patients consistently exceeded age- and sex-adjusted population norms, except in a limited number of studies on injury types of higher severity (e.g., traumatic brain injury and hip fractures). All studies reported reduced post-injury HRQL compared to pre-injury HRQL. Both prospective studies reported that patients had recovered to their pre-injury levels of physical and mental health, while in all but one retrospective study patients did not regain the reported pre-injury levels of HRQL, even years after injury. CONCLUSIONS: So far, primarily retrospective research has been conducted to assess pre-injury HRQL. This research shows consistently higher pre-injury HRQL scores than population norms and a recovery that lags behind that of prospective assessments, implying a systematic overestimation of the change in HRQL from pre- to post-injury due to an injury. More prospective research is necessary to examine the effect of recall bias and response shift. Researchers should be aware of the bias that may arise when pre-injury HRQL is assessed retrospectively or when population norms are applied, and should use prospectively derived HRQL scores wherever possible to estimate the impact of injury on HRQL.