Impact of a Hospital Mobility Program on Function after Discharge

 描述(由申请人提供)： 有强有力的证据表明，老年人的残疾在很大程度上是由导致住院的疾病和伤害造成的。数据显示，住院大大增加了发展为新的或恶化的残疾的可能性，以及从残疾中恢复的可能性降低。我们的工作表明，即使在控制了疾病严重程度和合并症之后，低流动性也与不良后果有关，包括日常生活能力(ADL)下降、疗养院安置和死亡。研究住院期间增加流动性的影响的干预研究很少，通常是衡量住院结果，如住院时间。然而，在我们由退伍军人管理局资助的研究中，我们发现，接受了医院内活动干预的患者在出院后一个月的社区活动水平显著高于常规护理，其中包括每天两次的步行辅助，以及解决行动障碍、设定活动目标和鼓励患者行走的行为策略。这项初步工作仅限于对65岁的≥退伍军人进行一个月的随访。在我们对医院流动性计划的影响的了解中仍然存在一些重要的差距：1)医院流动性计划研究尚未使用随机对照试验(RCT)设计来评估影响；2)参与者的实际步数和步行时间尚未被测量；3)出院后30天后的结果尚未得到检查；以及4)最有可能从此类干预中受益的患者的特征尚未确定。对于这项高影响力的研究，我们建议在五个退伍军人医院病房中使用阶梯式楔形整群随机设计，在年龄为≥50岁的退伍军人队列中比较活动计划(MP)和常规护理(UC)。我们将使用院内和院后评估来检查MP组和UC组出院后一年的活动能力和不良后果，包括功能下降、疗养院入院、急诊科就诊、住院和死亡。我们的总体假设是，在住院期间提供行走帮助的医院活动计划将减少观察到的与住院相关的活动丧失和不良后果，并且MP和UC之间的这种差异将在整个一年的随访期内保持。本研究项目的主要目的是测试活动计划在恢复到院前活动状态或更好状态以及减少住院后一年的不良后果(包括功能下降、急诊就诊、住院、入住疗养院和死亡)方面的有效性；并确定在住院后一年活动干预对恢复到院前活动状态或更好状态和减少不良结果的影响的特征。成功的活动干预可以防止丧失活动能力或加快恢复到入院前的水平，这可能会显著影响成千上万住院患者的生活质量，减少残疾。这一研究方向有可能改变向所有患者提供的医院护理标准。

 DESCRIPTION (provided by applicant): There is strong evidence that disability among older adults is largely driven by illnesses and injuries that lead to hospitalizations. Data shows the likelihood of developing new or worsening disability, as well as a reduced likelihood of recovery from disability, is greatly increased with hospitalization. Our work has shown low mobility to be associated with adverse outcomes including decline in activities of daily living (ADLs), nursing home placement and death, even after controlling for illness severity and comorbidity. Intervention studies examining the effect o increasing mobility during hospitalization are sparse and typically measure in-hospital outcomes such as length of stay. However in our VA-funded study, we showed patients who received an in-hospital mobility intervention that included twice daily assistance with walking and a behavioral strategy that addressed barriers to mobility, setting of mobility goals, and encouraged patients to walk, had a clinically significant higher level of community mobility at one month post-discharge compared to usual care. This preliminary work was restricted to only one month of follow-up of veterans who were ≥ 65 years of age. A number of important gaps remain in our understanding of the impact of a hospital mobility program: 1) hospital mobility program studies have not used a randomized controlled trial (RCT) design to evaluate the impact; 2) the actual number of steps and time spent walking by participants has not been measured; 3) outcomes beyond 30 days post-discharge have not been examined; and 4) characteristics of patients most likely to benefit from this type of intervention has not been identified. For this high impact stud we propose to use a stepped wedge cluster randomization design on five VA hospital wards to compare a mobility program (MP) to usual care (UC) among a cohort of veterans age ≥ 50 years. We will examine mobility and adverse outcomes including functional decline, nursing home admission, emergency department (ED) visits, hospitalization and death in the MP and UC groups in the year after hospital discharge using in-hospital and post-hospital assessments. Our overarching hypothesis is that a hospital mobility program that provides assistance with ambulation during hospitalization will reduce the observed loss of mobility and adverse outcomes associated with hospitalization and this difference between MP and UC will be maintained throughout the year follow-up period. The major aims of this research project are to test the effectiveness of a mobility program on recovery to pre-hospital mobility status or better and reduction of adverse outcomes including functional decline, ED visits, hospitalization, nursing home admission and death in the year after hospitalization; and to identify characteristics that modify the effect of the mobility intervention on recovery to pre-hospital mobility status or better and reduction of adverse outcomes in the year after hospitalization. A successful mobility intervention that prevents loss of mobility or quickens recovery to pre-hospital levels could significantly impact quality of life and reduce disability for thousands of hospitalized patients. This line of research has the potential to change the standard of hospital care provided to all patients.