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Patients should be asked annually about falls in the past year to identify those at high risk for future falls. The risk of falling can be reduced by exercise programs focused on balance and strength training and, among persons at high risk, by assessing a standard set of risk factors for falls and addressing modifiable ones.

Background Organizational readiness assessments have a history of being developed as important support tools for successful implementation. However, it remains unclear how best to operationalize readiness across varied projects or settings. We conducted a synthesis and content analysis of published readiness instruments to compare how investigators have operationalized the concept of organizational readiness for change. Methods We identified readiness assessments using a systematic review and update search. We mapped individual assessment items to the Consolidated Framework for Implementation Research (CFIR), which identifies five domains affecting implementation (outer setting, inner setting, intervention characteristics, characteristics of individuals, and implementation process) and multiple constructs within each domain. Results Of 1370 survey items, 897 (68%) mapped to the CFIR domain of inner setting, most commonly related to constructs of readiness for implementation ( n  = 220); networks and communication ( n  = 207); implementation climate ( n  = 204); structural characteristics ( n  = 139); and culture ( n  = 93). Two hundred forty-two items (18%) mapped to characteristics of individuals (mainly other personal attributes [ n  = 157] and self-efficacy [ n  = 52]); 80 (6%) mapped to outer setting; 51 (4%) mapped to implementation process; 40 (3%) mapped to intervention characteristics; and 60 (4%) did not map to CFIR constructs. Instruments were typically tailored to specific interventions or contexts. Discussion Available readiness instruments predominantly focus on contextual factors within the organization and characteristics of individuals, but the specificity of most assessment items suggests a need to tailor items to the specific scenario in which an assessment is fielded. Readiness assessments must bridge the gap between measuring a theoretical construct and factors of importance to a particular implementation.

This paper presents novel datasets providing numerical representations of ICD-10-CM codes by generating description embeddings using a large language model followed by a dimension reduction via autoencoder. The embeddings serve as informative input features for machine learning models by capturing relationships among categories and preserving inherent context information. The model generating the data was validated in two ways. First, the dimension reduction was validated using an autoencoder, and secondly, a supervised model was created to estimate the ICD-10-CM hierarchical categories. Results show that the dimension of the data can be reduced to as few as 10 dimensions while maintaining the ability to reproduce the original embeddings, with the fidelity decreasing as the reduced-dimension representation decreases. Multiple compression levels are provided, allowing users to choose as per their requirements, download and use without any other setup. The readily available datasets of ICD-10-CM codes are anticipated to be highly valuable for researchers in biomedical informatics, enabling more advanced analyses in the field. This approach has the potential to significantly improve the utility of ICD-10-CM codes in the biomedical domain.

One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography. We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region. Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9-68.8]) to 68.8 (95% CI [57.8-79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75-84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03). ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting.

Objective We aimed to explore the construct of “high need” and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions. Methods We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus. Results The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept “high need.” Panelists explored the construct and terminology and established that individual patients’ needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately. Conclusions Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

Background The Veterans Health Administration (VA) Grant and Per Diem case management “aftercare” program provides 6 months of case management for homeless-experienced veterans (HEVs) undergoing housing transitions. To standardize and improve aftercare services, we will implement critical time intervention (CTI), an evidence-based, structured, and time-limited case management practice. We will use two strategies to support the implementation and sustainment of CTI at 32 aftercare sites, conduct a mixed-methods evaluation of this implementation initiative, and generate a business case analysis and implementation playbook to support the continued spread and sustainment of CTI in aftercare. Methods We will use the Replicating Effective Programs (REP) implementation strategy to support CTI implementation at 32 sites selected by our partners. Half ( n =16) of these sites will also receive 9 months of external facilitation (EF, enhanced REP). We will conduct a type 3 hybrid cluster-randomized trial to compare the impacts of REP versus enhanced REP. We will cluster potential sites into three implementation cohorts staggered in 9-month intervals. Within each cohort, we will use permuted block randomization to balance key site characteristics among sites receiving REP versus enhanced REP; sites will not be blinded to their assigned strategy. We will use mixed methods to assess the impacts of the implementation strategies. As fidelity to CTI influences its effectiveness, fidelity to CTI is our primary outcome, followed by sustainment, quality metrics, and costs. We hypothesize that enhanced REP will have higher costs than REP alone, but will result in stronger CTI fidelity, sustainment, and quality metrics, leading to a business case for enhanced REP. This work will lead to products that will support our partners in spreading and sustaining CTI in aftercare. Discussion Implementing CTI within aftercare holds the potential to enhance HEVs’ housing and health outcomes. Understanding effective strategies to support CTI implementation could assist with a larger CTI roll-out within aftercare and support the implementation of other case management practices within and outside VA. Trial registration This project was registered with ClinicalTrials.gov as “Implementing and sustaining Critical Time Intervention in case management programs for homeless-experienced Veterans.” Trial registration NCT05312229 , registered April 4, 2022.

Objectives The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) Study cluster-randomized 86 primary care practices in 10 healthcare systems to a patient-centered multifactorial fall injury prevention intervention or enhanced usual care, enrolling 5451 participants. We estimated total healthcare costs from participant-reported fall injuries receiving medical attention (FIMA) that were averted by the STRIDE intervention and tested for healthcare-system-level heterogeneity and heterogeneity of treatment effect (HTE). Methods Participants were community-dwelling adults age ≥ 70 at increased fall injury risk. We estimated practice-level total costs per person-year of follow-up (PYF), assigning unit costs to FIMA with and without an overnight hospital stay. Using independent variables for treatment arm, healthcare system, and their interaction, we fit a generalized linear model with log link, log follow-up time offset, and Tweedie error distribution. Results Unadjusted total costs per PYF were $2,034 (intervention) and $2,289 (control). The adjusted (intervention minus control) cost difference per PYF was -$167 (95% confidence interval (CI), -$491, $216). Cost heterogeneity by healthcare system was present (p = 0.035), as well as HTE (p = 0.090). Adjusted total costs per PYF in control practices varied from $1,529 to $3,684 for individual healthcare systems; one system with mean intervention minus control costs of -$2092 (95% CI, -$3,686 to -$944) per PYF accounted for HTE, but not healthcare system cost heterogeneity. Conclusions We observed substantial heterogeneity of healthcare system costs in the STRIDE study, with small reductions in healthcare costs for FIMA in the STRIDE intervention accounted for by a single healthcare system. Trial registration Clinicaltrials.gov (NCT02475850).

Teriparatide, currently only available in brand form in the United States, is a costly drug approved for the treatment of postmenopausal osteoporotic women who are at high risk of fracture. Because market exclusivity for brand teriparatide expired in August 2019 in the US, we sought to understand the potential health economic impact of the availability of generic or biosimilar (generic/biosimilar) teriparatide. We examined the cost‐effectiveness of daily teriparatide for 2 years followed by weekly alendronate for 10 years (ie, sequential teriparatide/alendronate) compared with alendronate alone for 10 years in community‐dwelling white osteoporotic women with prior vertebral fracture at ages 65, 70, 75, and 80. Using an updated version of previously validated Markov microsimulation models, we obtained incremental cost‐effectiveness ratios (ICERs) (dollars [ $] per quality‐adjusted life year [QALY]) with a willingness‐to‐pay (WTP) of $ 150,000 per QALY from a societal perspective with a lifelong time horizon. In the base case, we estimated the annual cost of teriparatide to be$20,161, based on the assumption of 10% brand usage (at a cost of $ 27,618) and 90% generic/biosimilar usage (priced 30% lower than brand). The ICERs of sequential teriparatide/alendronate compared with alendronate alone were greater than$280,000 per QALY at all ages examined. In deterministic sensitivity analyses, results were sensitive to teriparatide's cost, with the cost of a generic/biosimilar product needing to be 65% to 85% lower than brand for sequential teriparatide/alendronate to be cost‐effective. In probabilistic sensitivity analyses, under the assumption that the annual cost of teriparatide was $ 20,161, the probabilities of sequential teriparatide/alendronate being cost‐effective were less than 4% at a WTP of $150,000 per QALY. In conclusion, among community‐dwelling older osteoporotic women with prior vertebral fracture in the US, even with the potential availability of generic/biosimilar teriparatide, sequential teriparatide/alendronate would not be cost‐effective unless the cost of generic/biosimilar teriparatide were heavily discounted with respect to the current brand cost. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Background Care coordination tools and toolkits can be challenging to implement. Practice facilitation, an active but expensive strategy, may facilitate toolkit implementation. We evaluated the comparative effectiveness of distance coaching, a form of practice facilitation, for improving the implementation of care coordination quality improvement (QI) projects. Methods We conducted a mixed methods evaluation of the Coordination Toolkit and Coaching (CTAC) initiative. Twelve matched US Veterans Health Administration primary care clinics were randomized to receive coaching and an online care coordination toolkit (“coached”; n  = 6) or access to the toolkit only (“non-coached”; n  = 6). We did interviews at six, 12, and 18 months. For coached sites, we‘ly collected site visit fieldnotes, prospective coach logs, retrospective coach team debriefs, and project reports. We employed matrix analysis using constructs from the Consolidated Framework for Implementation Research and a taxonomy of outcomes. We assessed each site’s project(s) using an adapted Complexity Assessment Tool for Systematic Reviews. Results Eleven sites implemented a local CTAC project. Eight sites (5 coached, 3 non-coached) used at least one tool from the toolkit. Coached sites implemented significantly more complex projects than non-coached sites (11.5 vs 7.5, 95% confidence interval 1.75–6.25, p  < 0.001); engaged in more formal implementation processes (planning, engaging, reflecting and evaluating); and generally had larger, more multidisciplinary QI teams. Regardless of coaching status, sites focused on internal organizational improvement and low-intensity educational projects rather than the full suite of care coordination tools. At 12 months, half the coached and non-coached sites had clinic-wide project implementation; the remaining coached sites had implemented most of their project(s), while the remaining non-coached sites had either not implemented anything or conducted limited pilots. At 18 months, coached sites reported ongoing effort to monitor, adapt, and spread their CTAC projects, while non-coached sites did not report much continuing work. Coached sites accrued benefits like improved clinic relationships and team QI skill building that non-coached sites did not describe. Conclusions Coaching had a positive influence on QI skills of (and relationships among) coached sites’ team members, and the scope and rigor of projects. However, a 12-month project period was potentially too short to ensure full project implementation or to address cross-setting or patient-partnered initiatives. Trial registration NCT03063294 .

Background/Objectives: This study examines factors associated with child overweight/obesity (OW/OB), pre-COVID-19 and during the COVID-19 pandemic, among all U.S. children aged 10–17 years, with or without developmental disabilities (DD) and, separately, among the subgroup of children diagnosed with a DD. Methods: Using data from the National Survey of Children’s Health (NSCH, 2018–2021), we applied descriptive statistics and multivariate logistic regression analyses to estimate the odds ratios of associations between family resilience, screen time, and childhood overweight/obesity. Family resilience measures families’ communication and problem-solving behaviors. Screentime is time spent on TV, computer, cellphone or electronic devices. Results: In descriptive analyses, during COVID-19, 35.8% of all children were identified as OW/OB compared to 32.8% pre-COVID-19—a weighted increase of 3.0%. Among children with developmental disabilities, OW/OB increased from 37.4% to 39.3%. Children reporting ≥4 h of screentime use increased from pre-COVID-19 to during COVID-19 in both groups (All Children: pre-COVID: 33.5%, during COVID: 41.6%; Developmental Disabilities: pre-COVID: 39.9%, during COVID: 49.4%). Among all children, there was a positive and strong association between screentime use and OW/OB at both pre- and during COVID-19 years. Children belonging to households with low family resiliency had 1.31 times the odds of being overweight/obese (95% CI, 1.06–1.63, p < 0.05) before the pandemic. However, these results were not significant after the pandemic. Conclusions: Prevalence of overweight/obesity in all children and children with DD during the COVID-19 pandemic continued to rise. Screentime was found to be a key determinant in increased weight status. Contrary to our hypothesis, family resilience failed to emerge as a significant protective factor for OW/OB; additional research is needed to explore the protective role of family resiliency on childhood obesity. Study findings may provide insights into developing best practices and tailored interventions with early OW/OB screening and programs tailored towards the youngest group of children aged 10–12 years or below.