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Age and Ageing 2019; 48: 337–346 doi: 10.1093/ageing/afy219 Published electronically 5 February 2019
© The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
Quality improvement strategies to prevent falls in older adults: a systematic review and network meta-analysis
ANDREA C. TRICCO1,2, SONIA M. THOMAS1, ARETI ANGELIKI VERONIKI1, JEMILA S. HAMID1, ELISE COGO1, LISA STRIFLER1,3, PAUL A. KHAN1, KATHRYN M. SIBLEY4,5, REID ROBSON1, HEATHER MACDONALD1, JOHN J. RIVA6,7, KEDNAPA THAVORN1,8, CHARLOTTE WILSON1, JAYNA HOLROYD-LEDUC9, GILLIAN D. KERR1, FABIO FELDMAN10, SUMIT R. MAJUMDAR11✠, SUSAN B. JAGLAL12, WING HUI1, SHARON E. STRAUS1,13
1Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON Canada M5B 1T8 2Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, Canada M5T 3M7 3Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON, Canada M5T 3M6 4Toronto Rehabilitation Institute, University Health Network, 550 University Avenue, 11th floor, Toronto, ON, Canada M5G 2A2 5Department of Community Health Sciences, University of Manitoba, 379–753 McDermot Ave, Winnipeg, MB, Canada R3E 0W3 6Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 6th Floor, Hamilton, ON, Canada L8P 1H6 7Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4K1 8Clinical Epidemiology Program, The Ottawa Hospital Research Institute, 501 Smyth Road, PO Box 201B, Ottawa, ON, Canada K1H 8L6 9Departments of Medicine and Community Health Sciences, University of Calgary, 1403 29th Street NW, Calgary, AB, Canada T2N 2T9 10Patient Safety & Injury Prevention, Fraser Health, 13450—102nd Avenue, Surrey, BC, Canada V3T 0H1 11Department of Medicine, University of Alberta, 5-134 Clinical Sciences Building, 11350—83rd Avenue, Edmonton, AB, Canada T6G 2G3 12Department of Physical Therapy, University of Toronto, 160-500 University Ave, Toronto, ON, Canada M5G 1V7 13Department of Geriatric Medicine, University of Toronto, 27 King’s College Circle, Toronto, ON, Canada M5S 1A1
Address correspondence to: Andrea C. Tricco, Scientist, Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada. Tel: 416-864-6060; Fax: 416-864- 5805. Email: triccoa@smh.ca ✠Deceased 19 January 2018.
Abstract
Background: Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear. Methods: We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception−April 2017). We included randomised con- trolled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently. Results: A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in
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mailto: triccoa@smh.careducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] −0.11 [95% CI, −0.18 to −0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD −0.27 [95% CI, −0.33 to −0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD −0.19 [95% CI, −0.30 to −0.01]) were both statistically superior compared to usual care. Conclusions: Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources. Systematic review registration: PROSPERO (CRD42013004151)
Keywords
falls, falling, quality improvement, older people, fall prevention, systematic review
Key points
• Numerous randomised controlled trials (RCTs) and systematic reviews have examined falls prevention quality improve- ment (QI) strategies, but the key effective elements remain unclear.
• Network meta-analysis (NMA) allows the ranking of all available falls prevention and combinations of falls prevention QI strategies for each outcome.
• Our systematic review and NMA of all available falls prevention QI strategies for older people encompassing 126 RCTs and 84,307 participants, is the first to identify effective QI strategies for preventing falls using NMA.
• We found that effective falls prevention QI strategies are multi-faceted, and including components targeting patients (such as education and reminders), as well as components targeting clinicians (such as team changes, case management and staff education) will increase likelihood of effectiveness.
• Depending on the outcome desired, our results can be tailored according to decision-maker preferences and availability of resources.
Introduction
Despite high-quality evidence of effective interventions for prevention [1–5], falls remain a common occurrence among those aged 65 years and older, representing an enormous burden to patients, their caregivers and the health care sys- tem [6, 7]. This represents a quality of care gap because high- quality evidence is not being implemented to prevent falls and injuries. In order to reduce this gap, quality improvement (QI) strategies can be considered.
QI strategies can help with the implementation of evidence-based clinical interventions, such as falls prevention programmes. QI strategies can target patients (e.g. patient education), health care providers (e.g. clinician education), and/or the health care system (e.g. financial incentives). As the population continues to age [8], QI interventions will have the potential to prevent numerous falls in the future. In a previous study of falls prevention interventions, QI strat- egies were effective at reducing injurious falls [9], but specific types of QI strategies and their combinations were not explored. The effectiveness of specific QI strategies alone or in combination for preventing falls amongst older people was explored through a systematic review and network meta-analysis (NMA).
Methods
Protocol
A protocol was prepared using the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) Protocols Statement [10], registered with PROSPERO (CRD42013004151), and published [11]. An integrated knowledge translation approach was used, whereby the sys- tematic review team included knowledge users who posed the research question, and were invited to participate in all steps of the review. The PRISMA-NMA extension [12] was followed for the reporting of results (see Appendix P in the supplementary data, available at Age and Ageing online), which are related to another paper examining all clinical interven- tions for falls prevention in addition to QI strategies [9].
Eligibility criteria
Eligible studies were randomised controlled trials (RCTs). Quasi-randomised trials were excluded. The RCTs had to include patients aged 65 years or older and any type of set- ting (e.g. living independently in the community, long-term care) was eligible for inclusion. The RCT had to examine one of 13 QI strategies that were adapted from the US
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Agency for Healthcare Research and Quality, which are out- lined in Box 1 [13, 14]. The comparators examined in the RCTs were usual care or other falls prevention QI strategies.
The knowledge users identified primary (number of injurious falls and number of fall-related hospitalisations) [15] and secondary (number of fallers, fall-related emer- gency department visits, fall-related physician visits, frac- tures, intervention-related harms, and quality of life and health utility [measured by 36-Item or 12-item Short Form
Survey (SF-36 or SF-12), SF-36 physical and mental sum- mary component measures and health utility measured by EuroQol-5D (EQ-5D)] outcomes of interest [16, 17].
Data sources
A search strategy was developed and peer-reviewed using PRESS [18] by experienced librarians, and published [11]. Subsequently, the following databases were searched from
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Box 1. Falls prevention quality improvement strategies
Strategy Description Examples
QI strategies targeting health care providers (clinic or care team) 1) Case management Any system for coordinating diagnosis, treatment, or routine
management of patients (e.g. arrangement for referrals, follow-up of test results) by a person or multidisciplinary team in collaboration with, or supplementary to, the primary-care clinician. If the study called the intervention ‘case management’ we classified it as such
Nurse functioning as case management role, which included assessment of patient status, planning, evaluation of adherence to dietary/medication recommendation, advocacy, home visits, and care coordination
2) Team changes Changes to the structure or organisation of the primary health care team (adding team member, multidisciplinary teams, expansion or revision of professional roles)
Modifying a geriatric outpatient clinic to include assessment by a nurse and physiotherapist, in addition to a geriatrician
3) Facilitated relay of
info to clinicians
Clinical information collected from patients and transmitted to clinicians by means other than the existing medical record (excluding conventional means of correspondence between clinicians.)
Communicating a patient’s medication information to care providers in the long-term care facilities including the family physician, nursing staff, and community physician
4) Continuous QI Interventions explicitly identified as involving the techniques of continuous QI, total quality management, or plan-do-study-act, or any iterative process for assessing quality problems, developing solutions to those problems, testing their effects, and then reassessing the need for further action
Weekly continuous quality improvement meetings to discuss progress of individual participants and to help maximise their success in the intervention
5) Audit & feedback Summary of clinical performance of health care delivered by an individual clinician or clinic over a specified period, which was then transmitted back to the clinician. This strategy was strictly based on clinical data and excluded clinical skills
Providing data on the number of patients with missing tests to the clinician
6) Staff education Interventions for staff designed to promote increased understanding of principles guiding clinical care or awareness of specific recommendations for a target disorder or population of patients
Includes conferences or workshops, distribution of educational materials (written, video or other), and educational outreach visits
7) Clinician reminders Paper-based or electronic systems intended to prompt a health professional to recall patient-specific information (e.g. most recent HbA1c value) or to do a specific task (e.g. foot examination)
Development of a Fall Prevention Tool Kit software (decision support system) to prompt physicians when evaluating a patient
QI strategies targeting health system 8) Financial incentives Interventions with positive or negative financial incentives directed at
providers (e.g. linked to adherence to some process of care or achievement of some target outcome). This strategy also includes positive or negative financial incentives directed at patients or system-wide changes in reimbursement
Examples are gym memberships, drug assistance programs, free medications.
Rides to the intervention or parking are not included
QI strategies targeting patients 9) Promotion of self-
management
Provision of equipment or access to resources to promote self- management. If the study called the intervention promotion of self-management, personalised goal-setting, or action-planning, we included it here. (We generally thought this a more active strategy than education of patients)
Problem-solving skills, tracking number of steps, fit bit, self-help groups, working with patient to develop strategies to reduce risk of falling
10) Patient Reminders Any effort to remind patients about upcoming appointments or important aspects of self-care. If the intervention included case management, reminders to patients needed to be explicit
Reminders via postcards or telephone calls
11) Patient education-
written materials,
videos, lectures, other
Patient education related to health Note: a pamphlet/leaflet that only explains exercises does not count as patient education
Pamphlets, booklets, brochures on fall prevention, videos, classes, lectures, workshops, unspecified instructions/ advice to prevent falls
12) Motivational
interviewing
‘a directive and client-centred counselling style that relies upon identifying and mobilising the client’s intrinsic values and goals to stimulate behaviour change (Miller & Rollnick, 2002), thus encouraging client and family involvement in all aspects of care.’
Restructuring misconceptions to promote a view of falls risk and fear of falling as controllable, setting realistic goals for increasing activity in a safe manner (taking personal capabilities into account)
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inception until April 2017: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Ageline. In addition, trial registries, conference abstracts, reference lists of included RCTs, and references of related systematic reviews were searched. Authors of relevant RCTs were emailed to obtain additional or unpublished data.
Study selection
The eligibility criteria and screening explanation document were calibrated on a random sample of 50 citations. After 75% agreement was achieved, pairs of reviewers screened all citations and potentially relevant full-text articles inde- pendently. Conflicts were resolved by a third reviewer.
Data abstraction
A data abstraction form was developed in Excel with an accompanying guidance document, and calibrated using a 5% random sample of included studies. After calibration, all data were independently abstracted by pairs of reviewers. To increase consistency, all discrepancies were resolved by a third reviewer. As falls prevention QI strategies are complex interventions, which are difficult to classify [19], all studies were coded independently by a knowledge user and a meth- odologist, using the pre-established coding guide for QI strategies.
Risk-of-bias appraisal
The Cochrane Effective Practice and Organisation of Care (EPOC) Group’s risk-of-bias tool was used to appraise the internal validity of included RCTs [20]. The tool was cali- brated using a random sample of five included studies. Subsequently, each included RCT was appraised by inde- pendent pairs of reviewers. Conflicts were resolved by a third reviewer.
Data synthesis and analysis
All analyses were conducted by an experienced statistician who used the metafor and netmeta packages [21–23] in R stat- istical version 3.3.3 [24] software and the netfunnel command in STATA 13.0 [25–28]. Pooled odds ratios (ORs) for dichotomous data, which were converted to the absolute risk differences (ARDs) using standard formulae [29] and mean differences (MD) for continuous data were estimated using pairwise random-effects meta-analysis. RCTs report- ing dichotomous outcomes with zero events across all arms were excluded from the analysis. RCTs reporting continu- ous outcomes with missing measures of variance (e.g. standard deviation) were included in the analysis, with standard errors imputed using established methods, if feas- ible [30,31]. Cluster-RCTs were adjusted using an effective sample size and intracluster correlation coefficient (ICC) for each cluster-RCT [13, 14]. The between-study variance in both meta-analysis and NMA was estimated using the DerSimonian and Laird method [32,33]. In each meta-
analysis, heterogeneity was quantified using the I2- measure [34]. The mean control event rate across included studies was calculated for each outcome when possible.
For outcomes forming a connected network of falls pre- vention interventions, random-effects NMA was conducted using a common within-network between-study variance (τ2) across treatment comparisons. To surmount small-study effects [35], RCTs with 100 or fewer patients across all treat- ment arms were excluded from analysis. A comparison- adjusted funnel plot was drawn for each outcome with at least 10 studies to examine small-study effects [27] by estimating the overall treatment effect for each comparison under the fixed-effect meta-analysis model and ordering all interven- tions based on the potential for effectiveness and target.
In order to predict the interval within which a new RCT treatment effect would lie, a 95% predictive interval was cal- culated [36]. The NMA assumptions were tested a priori, first by assessing transitivity and comparing all potential effect modifiers across treatment comparisons, and then evaluating consistency between different sources of evidence in the net- work using the design-by-treatment model [37]. Several effect modifiers were considered (see Appendix A in the supplementary data, available at Age and Ageing online). If results suggested global inconsistency, then local inconsist- ency was examined within each loop in a network separately using the loop-specific method [38,39]. If results suggested local inconsistency or important heterogeneity, or over 10 RCTs were available, and the number of RCTs was larger than the number of the included interventions, a subgroup NMA was conducted considering the aforementioned effect modifiers. Sensitivity analyses were conducted on the risk of bias results for the primary outcomes. All interventions were ranked using P-scores measuring the mean extent of certainty that a treatment is better when compared to the remaining treatments in the network [40]. P-scores were depicted across all outcomes in a rank-heat plot (http://rh.ktss.ca/) [41]. Both meta-analysis and NMA treatment effect estimates were presented along with 95% confidence intervals (CI).
Results
Study selection
A total of 10,650 citations and 1,210 full-text articles were screened (Figure 1). Of these, 126 RCTs (84,307 partici- pants) involved a relevant QI strategy with a relevant com- parator were included (Figure 1, see Appendix B in the supplementary data, available at Age and Ageing online). None of the included studies were written in languages other than English; one paper was a dissertation [42].
Study and participant characteristics
The mean of ages of participants across studies ranged between 65 and 88 years across the 126 included RCTs (Table 1, see Appendix C in the supplementary data, available at Age and Ageing online). Most RCTs included a high propor- tion (over 50%) of female participants (89%) (Table 1, see
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http://rh.ktss.ca/Appendix C in the supplementary data, available at Age and Ageing online), and included a mixture of participants with and without a previous history of falling (66%). The number of medications used by participants was not reported in most RCTs (59%).
The majority of the RCTs were published in 2004 or later (77%), and conducted mainly in Europe (39%) and Australia/New Zealand (33%) (Table 1, see Appendix D in the supplementary data, available at Age and Ageing online). The studies were most frequently conducted in a home set- ting (57%), clinic (28%), or community (27%), with a lower proportion occurring in a hospital (15%), chronic care (16%), or retirement home (8%) setting. The number of included participants ranged from 22 to 5,310 for patient RCTs, and 80 to 10,558 for cluster-RCTs (3–842 clusters).
Risk of bias
The majority of the included RCTs were assessed as having a low risk of bias for random sequence generation (69% low;
30% unclear; 1% high), allocation concealment (58% low; 40% unclear; 2% high), similar baseline outcome measures (82% low; 13% unclear; 6% high), similar baseline characteristics (80% low; 10% unclear; 10% high), incomplete outcome data (77% low; 8% unclear; 15% high), blinding (93% low; 3% unclear; 4% high), and other bias (69% low; 22% unclear; 9% high) (see Appendices E and F in the supplementary data, available at Age and Ageing online). However, the majority of the RCTs were assessed as having an unclear risk of bias for contamination (58% unclear; 40% low; 2% high) and selective outcome report- ing (56% unclear; 41% low; 2% high) (see Appendices E and F in the supplementary data, available at Age and Ageing online). The comparison-adjusted funnel plots suggested no evidence of publication bias or small-study effects (see Appendix G in the supplementary data, available at Age and Ageing online).
Outcome results
Twenty-two studies included less than 100 patients and were excluded from the analysis [43–64]. All pairwise
Figure 1. Study flow.
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meta-analysis results can be found in Appendix H in the supplementary data, available at Age and Ageing online. Across all NMAs, no evidence of significant inconsistency was indicated (see Appendix I in the supplementary data, available at Age and Ageing online). The overall NMA results for each outcome, with a focus on the QI strategy effects relative to usual care are presented below. The results from all significant treatment comparisons can be found in Appendix I in the supplementary data, available at Age and Ageing online. Subgroup and sensitivity analyses are sum- marised in Table 2, and all the P-scores from the overall NMAs, subgroup, and sensitivity analyses can be found in Appendices J and K in the supplementary data, available at Age and Ageing online. The rank-heat plot is presented in Appendix L in the supplementary data, available at Age and Ageing online.
Injurious falls
NMA for number of injurious falls included 29 RCTs (26,326 patients), with a total of 18 QI strategies examined (see Appendix M Panel A in the supplementary data, avail- able at Age and Ageing online). The average event rate for the usual care group was 31.79%. Across all 171 comparisons, 3 (1.75%) were statistically significant (see Appendix I in the supplementary data, available at Age and Ageing online). The QI intervention of team changes was statistically superior in reducing the risk of injurious falls relative to usual care (OR, 0.57 [95% CI, 0.33–0.99]; ARD −0.11 [95% CI, −0.18 to −0.002]). All studies of team changes were in mixed settings. An additional 12 single or multifactorial interventions were also superior to usual care, but the differences did not reach statistical significance. While five interventions were inferior (i.e. associated with increased falls) to usual care, none of these differences were statistically significant (see Appendix I in the supplementary data, available at Age and Ageing online). Subgroup and sensitivity analyses can be found in Appendices A and J in the supplementary data, available at Age and Ageing online.
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Table 1. Summary of patient and study characteristics
Patient characteristics
Number of RCTs % of RCTs (n = 126)
Age (mean) 65–74.99 years 30 23.8 75–84.99 years 73 57.9 ≥85 years 9 7.1 NR 14 11.1
Female (%) 0–49.99% 9 7.1 50–69.99% 42 33.3 70–89.99% 54 42.9 90–100% 16 12.7 NR 5 4.0
History of falls All have history of falls 30 23.8 Mixed history of falls 83 65.9 NR 13 10.3
Medications takena
0–4 medications 25 19.8 ≥5 medications 27 21.4 NR 74 58.7
Study characteristics
Year of publication 1992–96 4 3.2 1997–2001 9 7.1 2002–6 23 18.3 2007–11 43 34.1 2012–17 47 37.3
Continent Europe 49 38.9 Australia/New Zealand 41 32.5 North America 19 15.1 Asia 16 12.7 Multi 1 0.8
Study design Parallel RCT 103 81.7 Cluster RCT 23 18.3
Site Multi-centre 83 65.9 Single centre 43 34.1
Settingsb
Home 72 57.1 Clinic 35 27.8 Community 34 27.0 Hospital 19 15.1 Chronic care 20 15.9 Retirement home 10 7.9 NR 2 1.6
Sample Size Patient RCTs 22–99 20 19.4 100–199 25 24.3 200–299 15 14.6 300–999 37 35.9 1,000–5,310 6 5.8
Cluster RCTs 80–499 8 34.8 500–999 7 30.4 1,000–3,999 5 21.7 4,000–10,558 3 13.0
Continued
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 1. Continued
Patient characteristics
Number of RCTs % of RCTs (n = 126)
Study duration 110 and >100% due to studies reporting multiple settings.
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Fall-related hospitalisations
For falls-related hospitalisations, eight RCTs (4,887 patients) with 10 treatments were included. NMA was not possible because of network disconnectivity. No pairwise meta-analysis was possible across all pairwise comparisons (see Appendix H in the supplementary data, available at Age and Ageing online).
Number of fallers
NMA for the number of fallers included 61 RCTs (40 128 patients), examining 35 QI interventions (see Appendix M Panel B in the supplementary data, available at Age and Ageing online). The total event rate for the usual care group was 39.50%. Across all 595 comparisons, 27 (4.5%) were statistically significant (see Appendix I in the supplementary data, available at Age and Ageing online). Combined case management, patient reminders and staff education were statistically superior in reducing the number of fallers rela- tive to usual care (OR, 0.18 [95% CI, 0.07–0.47]; ARD
−0.29 [95% CI, −0.35 to −0.16]). Combined case manage- ment and patient reminders were also statistically superior to usual care in reducing the number of fallers (OR, 0.36 [95% CI, 0.13–0.97]; ARD −0.20 [95% CI, −0.32 to −0.007]). An additional 28 single or multifactorial interven- tions were superior to usual care, but the differences were not statistically significant. While four interventions were inferior to usual care, none were statistically significant. Subgroup and sensitivity analyses are summarised in Table 2 and Appendices A and J in the supplementary data, avail- able at Age and Ageing online.
Emergency department visits
For number of emergency department visits, four RCTs (1,280 patients) with five treatments were included. Pairwise meta-analysis was not possible across any comparisons (see Appendix H in the supplementary data, available at Age and Ageing online).
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Table 2. Statistically significant additional analysis results for the outcome of number of fallers
Intervention (versus usual care) OR (95% CI) Direction of result
Subgroup: follow-up 12 months (36 studies, 22,692 patients) Patient education 0.73 (0.54–0.98) Reduced risk Patient education + self-management 0.50 (0.26–0.99) Reduced risk Patient education + staff education 0.59 (0.40–0.88) Reduced risk Patient education + team changes 0.59 (0.40–0.86) Reduced risk Case management + patient reminders + staff education 0.18 (0.07–0.45) Reduced risk Case management + motivational interviewing + patient education + team changes 0.33 (0.12–0.88) Reduced risk
Subgroup: age 75% (21 studies, 11,375 patients) Patient education + team changes 0.24 (0.07–0.87) Reduced risk Case management + patient reminders + staff education 0.18 (0.06–0.56) Reduced risk
Subgroup: Medication use ≥5 (15 studies, 8,634 patients) Patient education 0.18 (0.05–0.69) Reduced risk Patient education + team changes 0.24 (0.07–0.81) Reduced risk
Subgroup: medication use

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