Keep taking the tablets

People who keep taking their heart disease tablets as directed tend to do better than people who don't. Is this improved prognosis a result of the drugs or do people who diligently take tablets tend to be healthier in general than people who won't, or can't? To find out, researchers studied a large cohort of survivors of heart attack from Ontario who were discharged from hospital with prescriptions for a statin, a β blocker, or a calcium channel blocker.

After a median follow-up of nearly two and half years, the authors found a clear link between worsening adherence and increasing risk of death for statins and β blockers, drugs that improve survival after a heart attack. No such link was seen between death and adherence to calcium channel blockers, which don't improve survival. The authors infer that patients who take their tablets live longer because of the biological action of the drugs not the so called "health adherer effect."

To test their hypothesis further the researchers also looked for associations between poor adherence to the heart drugs and admissions for cancer—a link you might expect to find if poor adherence was associated with unhealthy lifestyles. They found no associations between adherence and cancers of the lung, breast, or prostate.

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Preventing falls in older people

Falls are common in older people living in institutions, and they often cause serious injuries such as hip fracture. The clinical and economic costs of such injuries are high, and numerous guidelines have been developed to reduce falls and related injuries. A systematic review by Oliver and colleagues, in the BMJ, evaluated interventions to prevent falls and fractures in people living in hospitals and care homes.

People in institutional settings have different risk profiles from those living in the community because their activity is limited and they often have cognitive impairment. Also, interventions in institutions are often dependent on the involvement of staff rather than the individual. The most recent Cochrane systematic review and clinical guidelines on preventing falls consider prevention programmes in general and do not provide specific guidance for institutional settings.

The review by Oliver and colleagues provides limited evidence of the effectiveness of multifaceted interventions in hospitals (13 studies, relative risk 0.82) and of hip protectors in care homes (11 studies, 0.67). Only these two of the eight categories of intervention in the two settings showed some evidence of effectiveness; the others were inconclusive.

Interpretation of the review is complicated by differences in the outcomes measured: the percentage of people who fall, the total number of falls, the number of falls per participant, and falls as a time dependent variable. The best outcome measure is the number of falls because interventions are probably better at preventing multiple falls in one person than reducing the overall number of people who fall. The meta-analyses in the review present data to support this.

Dementia (or cognitive impairment) increases the risk of falls and fractures. The prevalence of dementia in elderly people in institutional care is high, and evidence is lacking that programmes aimed at preventing falls are effective in this group. The review shows that the presence of dementia does not influence the effectiveness of strategies to prevent falls and fractures in institutional settings. In addition, the review found no evidence that effectiveness is increased by improved adherence.

It is not clear what effect these results should have on clinical practice. Although there is an emerging consensus that multifaceted interventions and exercise programmes prevent falls in community settings, we cannot be confident that the same applies to preventing falls and fractures in hospitals and care homes.

Clinicians will need to apply the available evidence in the context of the institutional setting, local policies and guidelines, and available resources. Key interventions are those that are cornerstones of appropriate care for elderly people. These include adequate supervision, encouragement of supervised mobility and exercise, individually prescribed aids, a safe institutional environment, avoidance of psychotropic drugs where possible, and recognition of changes in health status that predispose to falls, such as delirium. The combination of these can be considered a multifactorial intervention.

Researchers should use the available evidence to design focused studies that can answer the question of how to prevent falls in institutional care. Ideally a large multicentre study will examine a standardised multifactorial intervention (including the components outlined above) with falls and peripheral fractures as key outcomes. This should be a cluster randomised trial with hospital and residential care facility strata. Economic analyses will be required to guide implementation. Until further research is completed, uncertainty remains about the prevention of falls and fractures in hospitals and nursing care facilities.

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Feedback of Audit

Many people advocate audit and feedback as a strategy for improving professional practice. The main results of an update of a Cochrane review on the effects of audit and feedback are reported.  The Cochrane Effective Practice and Organisation of Care Group’s register up to January 2004 was searched. Randomised trials of audit and feedback that reported objectively measured professional practice in a healthcare setting or healthcare outcomes were included.

Data were independently extracted and the quality of studies were assessed by two reviewers. Quantitative, visual and qualitative analyses were undertaken. 118 trials are included in the review. In the primary analysis, 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback was a component to no intervention. For dichotomous outcomes, the median-adjusted risk difference of compliance with desired practice was 5% (interquartile range 3–11). For continuous outcomes, the median-adjusted percentage change relative to control was 16% (interquartile range 5–37). Low baseline compliance with recommended practice and higher intensity of audit and feedback appeared to predict the effectiveness of audit and feedback.

In conclusions audit and feedback can be effective in improving professional practice. The effects are generally small to moderate. The absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high.

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