Liaison Service Research Articles

A Systemic Review & Meta-Analysis of the Impact of Vascular-Geriatric Service Models on Short-Term Outcomes in Vascular Surgery Inpatients

Abstract Background Vascular surgeons are treating progressively older, frailer and more medically complex patients. Care models including both surgeons and geriatricians have improved peri-operative outcomes in orthopaedics and surgical oncology. This meta-analysis investigates the impact of “vascular-geriatric” services on short-term inpatient outcomes. Methods Search strategy included PubMed, Scopus and Embase databases, conference abstracts and clinical trial registries. All study methodologies comparing outcomes before and after the introduction of a dedicated vascular-geriatrics service were eligible. Meta-analyses compared the relative risk (RR) of mortality, complications and 30-day readmission using a random-effects model. Risk of bias was assessed with the MINORS tool. Results Eight studies were identified, including one randomised trial and seven ‘before & after’ observational studies. 2074 patients were included, 1065 in the “Vascular-Geriatrics” cohort and 1009 in standard care. Care models included comprehensive geriatric assessment as part of the pre-operative review process before elective aortic surgery, inpatient geriatric liaison services and formal vascular-geriatric co-management arrangements. Source studies were of moderate to high risk of bias. A meta-analysis of five studies demonstrated vascular-geriatrics models were significantly associated with lower mortality rates than standard care (pooled 2.4% vs 4.9%) (RR 0.51, 95% CI 0.28-0.94, p=.03) (I2=0%). Vascular-Geriatrics models were also significantly associated with lower risk of infective complications (RR 0.49, 95% CI 0.36–0.66, p<.001) (I2=0%) and delirium (RR 0.58, 95% CI 0.35–0.97, p=.04) (I2=48%). There was no difference in mean length of stay (SMD -2.20, 95% CI -4.6-0.19, p=.07) (I2=86%). or 30-day readmission rates between Vascular-Geriatrics models and standard care (RR 1.10, 95% CI 0.81-1.51, p=.54) (I2=38%). Conclusion While the source data is heterogenous and of limited quality, this meta-analysis suggests that dedicated geriatric intervention may reduce adverse peri-operative outcomes in vascular patients compared to traditional care models. Further studies are needed to investigate the most effective design of geriatrician-surgeon partnership.

Gerontological Simulation Lab: Process Mapping a New Virtual Ward for the Nursing Home Liaison Service

Abstract Background Simulation-based training is an increasingly accepted way for multidisciplinary teams to learn together. Its use in geriatric departments around Ireland is increasingly visible. The application of simulation to pathway and process development however is less common. We decided therefore to deploy a simulation lab to test a new virtual ward platform for local nursing homes. Methods We developed, in partnership with a digital provider, a piece of software that could enable the efficient and safe operation of a virtual ward. Our simulation was conducted in two phases. Phase 1 involved bench simulation of the platform in order to identify any obvious software issues. Phase 2 involved the development of two simulated patient scenarios that would specifically test the operation of the pathway. Nursing staff from our local nursing homes and specialist MDT members from our own department were invited to the Sim lab in order to work through the developed scenarios. Results Bench simulation of the software during phase 1 identified three significant limitations to the software developed. These were resolved before progressing to phase II testing. The simulated scenarios at our lab worked well and participants shared positive feedback regarding the pathway and technology. They found the software easy to navigate, practical and agreed unanimously to its future use. There were further minor technical issues identified that have been fed back to the software company for resolution. The simulation facilitated training using the “live” system for both the staff at our nursing homes and our own team members. Conclusion The simulation lab proved to be an ideal environment for testing both our new virtual ward pathway and the digital technology developed for its enablement. It facilitated the creation of a comprehensive process map and ensures that all stakeholders had a clear understanding of the new pathway.

Safety of In-hospital Parenteral Antiosteoporosis Therapy Following a Hip Fracture: A Retrospective Cohort

Abstract Purpose To assess the safety of zoledronic acid (ZOL) and denosumab (Dmab) administered following hip fracture in a hospital setting. Methods Patients older than 65 years were treated by a fracture liaison service following hip fracture. Generally, patients who had a glomerular filtration rate (eGFR) > 35 mL/min were treated with ZOL, whereas patients who had previously received bisphosphonates or had a eGFR between 20 and 35 mL/min were treated with Dmab. Adverse events included hypocalcemia (calcium corrected for albumin less than 8.5 mg/day), renal functional impairment (0.5 mg/dL or more increase in serum creatinine) within 30 days of treatment, or a fever (>38 °C) within 48 hours of drug administration. Results Two hundred twenty-eight and 134 patients were treated with ZOL and Dmab, respectively. Mean body temperature was elevated following ZOL administration (0.18 °C P < .001) but remained below 38 °C. Hypocalcemia occurred in 18% and 29% of the ZOL and Dmab groups, respectively (P = .009). Renal functional impairment was observed in 9 and 6 patients (4% and 5%) in the ZOL and Dmab groups, respectively (P = .8). Pretreatment calcium above 9.3 mg/dL was associated with a lower risk of posttreatment hypocalcemia (odds ratio 0.30, 95% confidence interval 0.13-0.68, P = .004). While the absolute risk of hypocalcemia was higher in the Dmab group, multivariate analysis did not find that the choice of drug was predictive of hypocalcemia. Conclusion In-hospital parenteral osteoporosis treatment was rarely associated with fever or renal function impairment but was associated with hypocalcemia. Posttreatment hypocalcemia risk did not vary significantly between patients receiving ZOL or Dmab.

The Suicide Status Form-4 (SSF-IV) as a potentially therapeutic suicide risk assessment tool.

Empirically supported suicide risk assessment and conceptualization is a central aim of the Zero Suicide model. The Suicide Status Form (SSF) is the essential document and scaffolding of the Collaborative Assessment and Management of Suicidality-Brief Intervention (CAMS-BI) and is hypothesized as an example of a psychological assessment as therapeutic intervention (PATI). However, this hypothesis has never been directly tested. N = 57 patients deemed at risk for outpatient suicidal behavior and treated as part of an inpatient psychiatric consultation and liaison service were recruited to participate in CAMS-BI at a Level 1 trauma center in the southeastern United States. During the CAMS-BI process, patients were asked to rate their subjective units of distress (SUDS) at five time points throughout the intervention (k = 285). The omnibus random intercept multilevel model revealed a significant difference in pre- to post-session ratings of SUDS across patients. Post hoc pairwise comparisons revealed no significant differences between SSF sections (e.g., Section A, Section B, and Section C) and relative reductions in SUDS; however, there was an observable trend toward a favorable effect of Section A of the SSF. The SSF may represent an example of PATI pending replication and extension of the current results.

Suboptimal osteoporosis care in hospitalized patients: a retrospective analysis of vertebral compression fractures detected on computed tomography

Vertebral compression fractures (VCFs) are the most common osteoporotic fractures. Only 1/3 of patients with VCFs are clinically diagnosed. In our institution, the Fracture Liaison Service (FLS) was launched in 2017 to improve osteoporosis management for hospitalized patients. (1) To assess osteoporosis awareness among medical providers for emergency department (ED)/hospitalized patients aged 50 or greater; (2) To estimate the rate of FLS consults or referrals to primary care providers (FLS/PCP) by primary teams. A centralized radiology system was used to examine all thoracic and lumbar computed tomography (CT) scans conducted between June 1, 2017 and June 1, 2022. 449 studies were identified with the radiologic impression “compression fracture”. 182 studies were excluded after manual chart review. 267 hospitalizations/ED visits with lumbar and/or thoracic spine CT scans were included. Referrals to FLS (26) or PCP (27) were made in 53 cases (~ 20% of the total). In the ED subgroup (131 hospitalizations), only 17 patients had FLS/PCP referrals. The “compression fracture” was mentioned in 227 (85%) discharge notes (any part), while “osteoporosis” was mentioned in only 74 (28%) hospitalizations. A statistically significant difference was found between the two groups when “osteoporosis” was mentioned in the “assessment and plan” section (p = 0.02). Our data show that the overall osteoporosis care for affected patients is suboptimal. Medical providers often overlook the presence of osteoporosis, leading to a lack of consultation with the FLS of referral to PCPs for further evaluation and treatment.

Establishing an acute rheumatology liaison service in same-day emergency care

Establishing an acute rheumatology liaison service in same-day emergency care

The Fracture Phenotypes in Women and Men of 50 Years and Older with a Recent Clinical Fracture.

We review the literature about patients 50 years and older with a recent clinical fracture for the presence of skeletal and extra-skeletal risks, their perspectives of imminent subsequent fracture, falls, mortality, and other risks, and on the role of the fracture liaison service (FLS) for timely secondary fracture prevention. Patients with a recent clinical fracture present with heterogeneous patterns of bone-, fall-, and comorbidity-related risks. Short-term perspectives include bone loss, increased risk of fractures, falls, and mortality, and a decrease in physical performance and quality of life. Combined evaluation of bone, fall risk, and the presence of associated comorbidities contributes to treatment strategies. Since fractures are related to interactions of bone-, fall-, and comorbidity-related risks, there is no one-single-discipline-fits-all approach but a need for a multidisciplinary approach at the FLS to consider all phenotypes for evaluation and treatment in an individual patient.

WP7.11 - An Audit of Geriatric Input and Analysis of The Barriers For Elderly Patients Undergoing Emergency Laparotomy

Abstract Background Older people over the age of 65 years are recognized as higher risk surgical candidates and it is therefore recommended that their care should be coordinated through a multidisciplinary team (MDT) approach involving senior geriatricians, anaesthetists and surgeons. We audited 150 geriatric patients for medical input. Further in addition to the liaison services we analysed the characteristics of this group that would have benefitted from a liaison service. Methods An audit of 150 geriatric patients undergoing emergency laparotomy was carried. Our primary outcome was to look at input from geriatricians following laparotomy. Further we assessed the clinical characteristics of these patients and analysed the complexity of medical needs to benefit from a physician input. Results Only around 10% patients received a medical/geriatric input following an emergency laparotomy. Our audit highlighted the gap that exists in the clinical care for geriatric population against the NELA recommendations. Further we were able to work out a model of implementation for a geriatric liaison service. Conclusions Management of older patients with complexity requires surgical, critical care and geriatricians to collaborate. Implementing a local service with regular MDT’s will only serve to improve care and outcomes.

SP9.5 - Peri-operative Comprehensive Geriatric Assessment (CGA): A new benchmark for Acute General Surgery patients

Abstract Aims More than 50% of patients undergoing emergency general surgery are over 65 years of age. NICE guidelines emphasise frailty assessment in acute surgical settings, particularly in the preoperative period. Similarly, the Emergency Laparotomy and Frailty (ELF) study showed associations between frailty (CFS ≥ 5) and 90-day mortality, increased complication and length of hospital stay in older emergency laparotomy patients. NELA best practice tariff (BPT) April 2023 heavily focuses on perioperative team involvement in frailer, older patients. This is an audit from a city teaching hospital, with a surgical liaison team against standards set by NELA. Methods Review of patients aged ≥ 65 undergoing emergency laparotomies between August and November 2023 (pre-intervention) then December and January 2024 (post-intervention). Data collected includes whether patients had a documented frailty score, a clearly documented CPR decision & treatment escalation plan (TEP), pre- or post-operative medical review, and advanced-care planning (ACP) post-operatively. Intervention included dedicated members of surgical liaison team following patients throughout admission, weekly meetings to discuss laparotomy patients, older patient template being created capturing ceilings of care, frailty score, and social history. Results Post intervention, improvement in clear documentation regarding escalation, frailty level. Greater level of MDT collaboration with regards to older patients undergoing laparotomies. Conclusion Changes in NELA BPT emphasise the importance of comprehensive geriatric assessment in the management of older laparotomy patients. Even a basic surgical liaison service can achieve high levels of compliance with a few simple strategies, resulting in better outcomes for patients as well as financial benefits for Trusts.

Improving patient care transitions from the intensive care unit to the ward by learning from everyday practice. A multicenter qualitative study

ObjectiveTo explore and describe the everyday practices (Work-As-Done) that hinder and facilitate patient care transitions from the intensive care unit (ICU) to the ward. Research method/designMultiple qualitative case studies in the ICU and various specialized wards of three Dutch hospitals. Adult patients planned to be transferred were purposively sampled on a variety of characteristics along with their relative (if present), and the ICU and ward nurses who were involved in the transition process. Data were collected by using multiple sources (i.e., observations, semi-structured interviews and a qualitative survey) and then systematically analyzed using the thematic analysis approach until saturation was reached. FindingsTwenty-six cases were studied. For each case, the actual transfer was observed. Sixteen patients, five relatives and 36 nurses were interviewed. Two patients completed the survey. Fifteen themes emerged from the data, showing that the quality of transitions is influenced by the extent to which nurses anticipate to patient-specific needs (e.g., providing timely and adequate information, orientation, mental support and aftercare) and to the needs of the counterpart to continue care (e.g., by preparing handovers) besides following standard procedures. Data also show that procedures sometimes interfere with what works best in practice (e.g., communication via a liaison service instead of direct communication between ICU and ward nurses). ConclusionsSubtle, non-technical nursing skills play an important role in comforting patients and in the coordination of care when patients are transferred from the ICU to the ward. Implications for clinical practiceThese Work-As-Done findings and their underlying narratives, that are often overlooked when focusing on quality improvement, can be used as material to reflect on own practice and raise awareness for its impact on patients. They may stimulate healthcare staff in crafting interventions for optimizing the transition process.

Examining treatment targets and equity in bone-active medication use within secondary fracture prevention: a systematic review and meta-analysis.

This systematicreview seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location. We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out asingle group proportional meta-analysis. We also extracted the proportions of patients who received aprescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions. This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes. Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.

2349 How to provide a cost-effective geriatric peri-operative service within general surgery in line with NELA BPT

Abstract Introduction More than 50% of patients undergoing emergency general surgery are >65 years. The Emergency Laparotomy and Frailty (ELF) study showed strong associations between frailty (CFS ≥ 5) and increased mortality, risks of complications, and length of hospital stay. Methods For nearly 10 years, we have had geriatric liaison input for general surgery and colorectal patients in a tertiary teaching centre. This has transformed into a fully embedded service involving consultant geriatrician, registrars and senior house offices, providing 3-day a week medical input. NELA best practice tariff (BPT) April 2023 emphasises perioperative Geriatric team involvement in frail patients aged 65 and above. The main metrics include CFS, an MDT-based risk assessment, treatment escalation decision making and perioperative geriatrician involvement. Results The service has previously demonstrated significant improvement in patient care and holistic management including reducing the length of stay in hospital (average decrease of 5.5 days). Simple job planning, use of current resources and efficiency can mean Trusts can incorporate geriatricians with essential skills to improve patient management and reach NELA BPT. Conclusion Changes in NELA BPT emphasise the importance of comprehensive geriatric assessment in the management of older laparotomy patients. Introducing a multidisciplinary geriatric liaison service into the general surgical department can achieve high levels of compliance with national guidelines, resulting in better outcomes for patients as well as financial benefits for Trusts. This is particularly pertinent given the financial constraints on many services across the NHS, this is an opportunity to increase revenue and build a geriatric workforce.

2329 A quality improvement project to improve bone health plan in trauma and orthopaedic discharge summaries

Abstract Introduction In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group (NOGG) intravenous zoledronate is the first line treatment option following a hip fracture. Aims We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner (GP), Fracture liaison service and patient. Results We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient’s admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September, 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%. Conclusion Despite the intervention, the bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture. Next step Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle. References National Osteoporosis Guideline Group.UK (NOGG),2021.

Impact of Mental Health Court Diversion on Reoffending: A Direct Comparison of Diverted and Undiverted Groups

Mental health court diversionary programs are a key strategy to address over-representation of individuals with a mental illness in the criminal justice system. The study examined 2,476 individuals identified as eligible for mental health court diversion by the Statewide Community and Court Liaison Service (SCCLS) in New South Wales (NSW), Australia and compared reoffending of those granted and not granted court diversion. Individuals not diverted had 43% higher reoffending rate than those granted diversion. Predictors of non-diversion and reoffending included younger age, being male, Aboriginal and/or Torres Strait Islander background, primary personality and/or substance use diagnosis and non-violent offence charges.

Implementation of a Fracture Liaison Service in a tertiary hospital in Malaysia: a feasibility study.

To assess the feasibility of a Fracture Liaison Service in Malaysia and to benchmark our service against the International Osteoporosis Foundation Best Practice Framework. This feasibility study was conducted at a tertiary hospital in Malaysia from March 2021 to March 2022. Patients aged ≥ 50years admitted with fragility fractures were recruited. Excluded were those with poor prognosis or transferred out from the hospital during admission. Patients were screened, assessed, and followed up at months 4 and 12 post-fracture presentations. Data was collected using Microsoft Excel and the REDCap database. The feasibility of the Fracture Liaison Service was evaluated using the typology of feasibility. A total of 140 patients (female (93/140, 66.4%), median age 77 (IQR 72, 83), hip fractures (100/140, 65.8%)) were recruited into the Fracture Liaison Service. The recruitment rate was (140/215, 65.1%), as some patients were "missed" due to the COVID-19 pandemic. The completion rate was high (101/114, 88.6%). Among those indicated for antiosteoporosis medication, 82/100 (82%) were initiated on treatment. Various "Best Practice Standards," such as patient evaluation (140/140, 100%), fall prevention (130/140, 92.9%), and medication review standards (15/15, 100%) were high. Complicated referral pathways, inexperienced staff, lack of resources, and communication issues were some of the barriers identified while implementing the Fracture Liaison Service. Challenges were overcome by modifying the service workflow and coordinating with different departments. The Fracture Liaison Service was found to be feasible in Malaysia. It demonstrated promise in improving bone health management; however, several changes were needed to adapt the service to suit our environment.

Taking care of inpatients with fragility hip fractures: the hip-padua osteosarcopenia (Hip-POS) fracture liaison service model.

Osteoporotic fragility fractures (FF), particularly those affecting the hip, represent a major clinical and socio-economic concern. These fractures can lead to various adverse outcomes, which may be exacerbated by the presence of sarcopenia, especially among older and frail patients. Early identification of patients with FF is crucial for implementing effective diagnostic and therapeutic strategies to prevent subsequent fractures and their associated consequences. The Hip-POS program, implemented at Azienda Ospedale-Università Padova, is a Fracture Liaison Service (FLS) program to evaluate patients aged > 50years old admitted with fragility hip fractures, involving an interdisciplinary team. After the identification of patients with hip fractures in the Emergency Department, a comprehensive evaluation is conducted to identify risk factors for further fractures, and to assess the main domains of multidimensional geriatric assessment, including muscle status. Patients are then prescribed with anti-fracture therapy, finally undergoing periodic follow-up visits. During the first five months, a total of 250 patients were evaluated (70.4% women, median age 85years). Following assessment by the Hip-POS team, compared to pre-hospitalization, the proportion of patients not receiving antifracture therapy decreased significantly from 60 to 21%. The prescription rates of vitamin D and calcium increased markedly from 29.6% to 81%. We introduced the Hip-POS program for the care of older adults with hip fractures. We aspire that our model will represent a promising approach to enhancing post-fracture care by addressing the multifactorial nature of osteoporosis and its consequences, bridging the gap in secondary fracture prevention, and improving patient outcomes.

A collaborative pharmacist-led intervention to prevent hospital readmissions among elderly patients discharged from the emergency department: a retrospective cohort study

Unplanned hospital readmission is a safety and quality healthcare measure, conferring significant costs to the healthcare system. Elderly individuals, particularly, are at high risk of readmissions, often due to issues related to medication management. Pharmacists play a pivotal role in addressing medication-related concerns, which can potentially reduce readmissions. This retrospective single-centre cohort study, conducted from November 2022 to February 2023 in an emergency department, aimed to determine if integrating emergency medicine pharmacists into Emergency Department care models reduces unplanned hospital readmissions within 28 days and to identify the interventions they employ. The inclusion criteria included patients aged ≥ 65, taking ≥ 3 medications, and presenting with falls, cognition changes, or reduced mobility and were planned for discharge to home from the emergency department. Collaborating with the Emergency Department Aged Care Service Emergency Team, a pharmacist provided comprehensive medication management consultations, discharge liaison services, and other pharmacy related interventions to eligible participants whenever the pharmacist was available. Patients who met the eligibility criteria but did not receive pharmacist interventions due to the pharmacist's unavailability served as the control group. This method was chosen to ensure that the control group consisted of comparable patients who only differed in terms of receiving the pharmacist intervention. The study included 210 participants, with 120 receiving pharmacist interventions and 90 acting as controls. The results revealed a significant reduction in unplanned hospital readmissions among participants who received pharmacist interventions (10.0%, n = 12) compared to controls (22.2%, n = 20), with a notable difference of 12.2% (95% confidence interval 2.4–23.4%, p = 0.01). A total of 107 interventions were documented, emphasising medication selection recommendations (28.0%) and identification of adverse drug reactions/drug-drug interactions (21.5%) as primary areas of focus. These findings suggest that integrating skilled pharmacists into Emergency Department Aged Care Service Emergency Team (ASET) lowered the rate of unplanned hospital readmission within 28 days resulting in improved hospital performance metric outcomes. This highlights the potential role of pharmacists in addressing medication-related issues and enhancing the quality and safety of healthcare delivery, particularly for elderly patients transitioning from the ED to home care settings.

Enhancing interprofessional interagency collaboration for minoritized and low-income children with chronic illnesses.

Children with chronic illnesses present unique health, psychosocial, and learning challenges. Due to the complexities surrounding their needs, these children and their families often encounter multilayered barriers when accessing educational services and health care management. Medical-family-school interprofessional interagency collaborations (IIC) are needed to facilitate information sharing across institutions, treatment alignment among care partners, and equitable and high-quality school-based service delivery. This article presents a novel hospital-based school consultative liaison service, the Educational Achievement Partnership Program (EAPP), which conducts IIC with the families, schools, hospitals, and community care partners of children with chronic illnesses. We explore disproportionalities in IIC services among low-income and racially/ethnically minoritized children and examine ways to increase IIC service access and utilization. Results demonstrate that systematic changes targeting in-person communication with families significantly increased minoritized and low-income children's EAPP participation. Despite this increase, differences occurred between minoritized and White children's utilization through all stages of EAPP service delivery. These results underscore the importance of ongoing IIC service evaluation to examine the effectiveness of implementation components. We discuss implications and highlight opportunities for similar medical-family-school IIC under a school psychologist-led medical liaison consultative approach. We conclude that IIC is best fostered through innovations in communication models, graduate training, practice, and research. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Older Adult Self‐Harm: A Descriptive Study

ABSTRACTSelf‐harm is a public health problem and is associated with higher suicidal intent and greater suicidal risk in older adults. This retrospective cross‐sectional study examines psychosocial characteristics, service provision and outcomes in patients attending a mental health liaison service (MHLS) with self‐harm attempt in Lincolnshire. The authors also investigate demographic, psychiatric and clinical factors related to self‐harm and discharge destination.

Exploring practice and perspectives on shared decision-making about osteoporosis medicines in Fracture Liaison Services: the iFraP development qualitative study

SummaryInterviews and focus groups with patients, FLS clinicians, and GPs identified challenges relating to clinical and shared decision-making about bone health and osteoporosis medicines. Findings will inform the development of the multicomponent iFraP intervention to address identified training needs and barriers to implementation to facilitate SDM about osteoporosis medicines.PurposeThe iFraP (improving uptake of Fracture Prevention treatments) study aimed to develop a multicomponent intervention, including an osteoporosis decision support tool (DST), to support shared decision-making (SDM) about osteoporosis medicines. To inform iFraP intervention development, this qualitative study explored current practice in relation to communication about bone health and osteoporosis medicines, anticipated barriers to, and facilitators of, an osteoporosis DST, and perceived training needs.MethodsPatients attending an FLS consultation (n = 8), FLS clinicians (n = 9), and general practitioners (GPs; n = 7) were purposively sampled to participate in a focus group and/or telephone interview. Data were transcribed, inductively coded, and then mapped to the Theoretical Domains Framework (TDF) as a deductive framework to systematically identify possible barriers to, and facilitators of, implementing a DST.ResultsInductive codes were deductively mapped to 12 TDF domains. FLS clinicians were perceived to have specialist expertise (knowledge). However, clinicians described aspects of clinical decision-making and risk communication as difficult (cognitive skills). Patients reflected on decisional uncertainty about medicines (decision processes). Discussions about current practice and the proposed DST indicated opportunities to facilitate SDM, if identified training needs are met. Potential individual and system-level barriers to implementation were identified, such as differences in FLS configuration and a move to remote consulting (environmental context and resources).ConclusionsUnderstanding of current practice revealed unmet training needs, indicating that using a DST in isolation would be unlikely to produce a sustained shift to SDM. Findings will shape iFraP intervention development to address unmet needs.