Life-space mobility (LSM) is a holistic measure of resilience to physical decline and social isolation in later life. To promote its use as an outcome in geriatric studies and in clinical practice, this review paper explains the concept of LSM; outlines available questionnaires for LSM assessment, provides an overview of associations between LSM and other outcomes, and discusses emerging methods to measure LSM using wearable sensors. Based on performed activity around a central geographical anchor, LSM aims to quantify the observed contraction of daily activities associated with ageing. Several questionnaires are available to assess LSM in different contexts: the University of Alabama Life-Space Assessment and the Life-Space Questionnaire (community settings), the Nursing Home Life-Space Diameter (nursing home settings) and Life Space at Home (for house-bound populations). Some studies using GPS trackers to calculate life-space parameters reported promising results. Although these techniques reduce data collection burden, battery life and older people's willingness to wear a tracker require further improvement before they can be used more widely. Regardless of the assessment method used, LSM was associated with measures of functional and cognitive abilities, nursing home admission and mortality. The current availability of instruments, the ongoing development of less burdensome data collection techniques, and evidence of construct validity support a case for promoting integration of LSM assessments into geriatric research studies and clinical practice. Ultimately, this will provide a more holistic view on older people's health and wellbeing.

Background Audit and feedback (A&F) is a common quality improvement strategy with highly variable effects on patient care. It is unclear how A&F effectiveness can be maximised. Since the core mechanism of action of A&F depends on drawing attention to a discrepancy between actual and desired performance, we aimed to understand current and best practices in the choice of performance comparator. Methods We described current choices for performance comparators by conducting a secondary review of randomised trials of A&F interventions and identifying the associated mechanisms that might have implications for effective A&F by reviewing theories and empirical studies from a recent qualitative evidence synthesis. Results We found across 146 trials that feedback recipients’ performance was most frequently compared against the performance of others (benchmarks; 60.3%). Other comparators included recipients’ own performance over time (trends; 9.6%) and target standards (explicit targets; 11.0%), and 13% of trials used a combination of these options. In studies featuring benchmarks, 42% compared against mean performance. Eight (5.5%) trials provided a rationale for using a specific comparator. We distilled mechanisms of each comparator from 12 behavioural theories, 5 randomised trials, and 42 qualitative A&F studies. Conclusion Clinical performance comparators in published literature were poorly informed by theory and did not explicitly account for mechanisms reported in qualitative studies. Based on our review, we argue that there is considerable opportunity to improve the design of performance comparators by (1) providing tailored comparisons rather than benchmarking everyone against the mean, (2) limiting the amount of comparators being displayed while providing more comparative information upon request to balance the feedback’s credibility and actionability, (3) providing performance trends but not trends alone, and (4) encouraging feedback recipients to set personal, explicit targets guided by relevant information. Electronic supplementary material The online version of this article (10.1186/s13012-019-0887-1) contains supplementary material, which is available to authorized users.

BackgroundAudit and feedback aims to guide health professionals in improving aspects of their practice that need it most. Evidence suggests that feedback fails to increase accuracy of professional perceptions about clinical performance, which likely reduces audit and feedback effectiveness. This study investigates health professionals’ perceptions about their clinical performance and the influence of feedback on their intentions to change practice.MethodsWe conducted an online laboratory experiment guided by Control Theory with 72 intensive care professionals from 21 units. For each of four new pain management indicators, we collected professionals’ perceptions about their clinical performance; peer performance; targets; and improvement intentions before and after receiving first-time feedback. An electronic audit and feedback dashboard provided ICU’s own performance, median and top 10% peer performance, and improvement recommendations. The experiment took place approximately 1 month before units enrolled into a cluster-randomised trial assessing the impact of adding a toolbox with suggested actions and materials to improve intensive care pain management. During the experiment, the toolbox was inaccessible; all participants accessed the same version of the dashboard.ResultsWe analysed 288 observations. In 53.8%, intensive care professionals overestimated their clinical performance; but in only 13.5%, they underestimated it. On average, performance was overestimated by 22.9% (on a 0–100% scale). Professionals similarly overestimated peer performance, and set targets 20.3% higher than the top performance benchmarks. In 68.4% of cases, intentions to improve practice were consistent with actual gaps in performance, even before professionals had received feedback; which increased to 79.9% after receiving feedback (odds ratio, 2.41; 95% CI, 1.53 to 3.78). However, in 56.3% of cases, professionals still wanted to improve care aspects at which they were already top performers. Alternatively, in 8.3% of cases, they lacked improvement intentions because they did not consider indicators important; did not trust the data; or deemed benchmarks unrealistic.ConclusionsAudit and feedback helps health professionals to work on aspects for which improvement is recommended. Given the abundance of professionals’ prior good improvement intentions, the limited effects typically found by audit and feedback studies are likely predominantly caused by barriers to translation of intentions into actual change in clinical practice.Trial registrationClinicalTrials.gov NCT02922101. Registered 26 September 2016.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0727-8) contains supplementary material, which is available to authorized users.

BackgroundAudit and feedback (A&F) enjoys widespread use, but often achieves only marginal improvements in care. Providing recipients of A&F with suggested actions to overcome barriers (action implementation toolbox) may increase effectiveness.ObjectiveTo assess the impact of adding an action implementation toolbox to an electronic A&F intervention targeting quality of pain management in intensive care units (ICUs).Trial designTwo-armed cluster-randomised controlled trial. Randomisation was computer generated, with allocation concealment by a researcher, unaffiliated with the study. Investigators were not blinded to the group assignment of an ICU.ParticipantsTwenty-one Dutch ICUs and patients eligible for pain measurement.InterventionsFeedback-only versus feedback with action implementation toolbox.OutcomeProportion of patient-shift observations where pain management was adequate; composed by two process (measuring pain at least once per patient in each shift; re-measuring unacceptable pain scores within 1 hour) and two outcome indicators (acceptable pain scores; unacceptable pain scores normalised within 1 hour).Results21 ICUs (feedback-only n=11; feedback-with-toolbox n=10) with a total of 253 530 patient-shift observations were analysed. We found absolute improvement on adequate pain management in the feedback-with-toolbox group (14.8%; 95% CI 14.0% to 15.5%) and the feedback-only group (4.8%; 95% CI 4.2% to 5.5%). Improvement was limited to the two process indicators. The feedback-with-toolbox group achieved larger effects than the feedback-only group both on the composite adequate pain management (p<0.05) and on measuring pain each shift (p<0.001). No important adverse effects have occurred.ConclusionFeedback with toolbox improved the number of shifts where patients received adequate pain management compared with feedback alone, but only in process and not outcome indicators.Trial registration numberNCT02922101.

Background Audit and feedback (A&F) is more effective if it facilitates action planning, but little is known about how best to do this. We developed an electronic A&F intervention with an action implementation toolbox to improve pain management in intensive care units (ICUs); the toolbox contained suggested actions for improvement. A head-to-head randomised trial demonstrated that the toolbox moderately increased the intervention’s effectiveness when compared with A&F only. Objective To understand the mechanisms through which A&F with action implementation toolbox facilitates action planning by ICUs to increase A&F effectiveness. Methods We extracted all individual actions from action plans developed by ICUs that received A&F with (n = 10) and without (n = 11) toolbox for 6 months and classified them using Clinical Performance Feedback Intervention Theory. We held semi-structured interviews with participants during the trial. We compared the number and type of planned and completed actions between study groups and explored barriers and facilitators to effective action planning. Results ICUs with toolbox planned more actions directly aimed at improving practice (p = 0.037) and targeted a wider range of practice determinants compared to ICUs without toolbox. ICUs with toolbox also completed more actions during the study period, but not significantly (p = 0.142). ICUs without toolbox reported more difficulties in identifying what actions they could take. Regardless of the toolbox, all ICUs still experienced barriers relating to the feedback (low controllability, accuracy) and organisational context (competing priorities, resources, cost). Conclusions The toolbox helped health professionals to broaden their mindset about actions they could take to change clinical practice. Without the toolbox, professionals tended to focus more on feedback verification and exploring solutions without developing intentions for actual change. All feedback recipients experienced organisational barriers that inhibited eventual completion of actions. Trial registration ClinicalTrials.gov, NCT02922101. Registered on 26 September 2016.

Background The knowledge, skills, and confidence to manage one’s own health is termed patient activation and can be assessed using the Patient Activation Measure (PAM). This measure is increasingly recommended for use in chronic kidney disease (CKD), but there is a need to better understand patient activation within this population. This work aimed to explore the association of PAM with patient-reported outcomes, namely symptom burden and health-related quality of life (HRQoL), to understand the relationship between patient activation and outcomes which are of importance to people with CKD. Methods Non-dialysis, dialysis, and kidney transplant patients from 14 renal units across England completed a survey comprising questionnaires assessing patient activation, symptom burden, and HRQoL. Latent class analysis (LCA) was used to determine HRQoL and symptom burden subgroups in the data. Multinomial logistic regression analyses were performed to investigate the associations between patient activation and symptom burden and HRQoL classes separately, adjusting for age, gender, ethnicity, deprivation and treatment modality. Results Three thousand thirteen participants (mean age 61.5 years, 61.8% males, and 47% haemodialysis) were included in the analysis. Patient activation was strongly associated with both the HRQoL and symptom burden classes identified, with highly activated patients more likely to report higher HRQoL (P = < 0.0001; OR 29.2, 95% CI 19.5–43.9) and fewer symptoms (P = < 0.0001; OR 25.9, 95% CI 16.8–40.2). Conclusion Lower activation levels are associated with a higher symptom burden and reduced HRQoL across the trajectory of CKD stages and treatment modalities. Therefore, targeted and holistic self-management support focussing on improving activation may have the potential to improve aspects of health experience which are valued by individuals living with kidney disease.

Healing of non‐traumatic skin ulcers is often suboptimal. Prognostic tools that identify people at high risk of delayed healing within the context of routine ulcer assessments may improve this, but robust evidence on which factors to include is lacking. Therefore, we scoped the literature to identify which potentially prognostic factors may warrant future systematic reviews and meta‐analyses. We conducted electronic searches in MEDLINE and Embase to identify studies in English published between 1997 and 2017 that tested the association between healing of the three most common non‐traumatic skin ulcers encountered by health care professionals (venous leg, diabetic foot, and pressure ulcers) and patient characteristics, ulcer characteristics, and results from clinical investigations. We included 42 studies that investigated factors which may be associated with the healing of venous leg ulcers (n = 17), diabetic foot ulcers (n = 15), and pressure ulcers (n = 10). Across ulcer types, ulcer characteristics were most commonly reported as potential prognostic factors for healing (n = 37), including the size of the ulcer area (n = 29) and ulcer duration at first assessment (n = 16). A total of 35 studies investigated the prognostic value of patient characteristics (n = 35), including age (n = 31), gender (n = 30), diabetes (n = 22), smoking status (n = 15), and history of deep vein thrombosis (DVT) (n = 13). Of these studies, 23 reported results from clinical investigations as potential prognostic factors, with the majority regarding vessel quality. Age, gender, diabetes, smoking status, history of DVT, ulcer area, and ulcer duration at time of first assessment warrant a systematic review and meta‐analysis to quantify their prognostic value for delayed ulcer healing.

Background: Hyponatremia is a common electrolyte disorder. Multiple organizations have published guidance documents to assist clinicians in managing hyponatremia. We aimed to explore the scope, content, and consistency of these documents. Methods: We searched MEDLINE, EMBASE, and websites of guideline organizations and professional societies to September 2014 without language restriction for Clinical Practice Guidelines (defined as any document providing guidance informed by systematic literature review) and Consensus Statements (any other guidance document) developed specifically to guide differential diagnosis or treatment of hyponatremia. Four reviewers appraised guideline quality using the 23-item AGREE II instrument, which rates reporting of the guidance development process across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Total scores were calculated as standardized averages by domain.