Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals : A Stepped-Wedge, Cluster Randomized Trial

Abstract

Background: In trials, hospital walking programs have been shown to improve functional ability after discharge, but little evidence exists about their effectiveness under routine practice conditions.

Objective: To evaluate the effect of implementation of a supervised walking program known as STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) on discharge to a skilled-nursing facility (SNF), length of stay (LOS), and inpatient falls.

Design: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT03300336).

Setting: 8 Veterans Affairs hospitals from 20 August 2017 to 19 August 2019.

Patients: Analyses included hospitalizations involving patients aged 60 years or older who were community dwelling and admitted for 2 or more days to a participating medicine ward.

Intervention: Hospitals were randomly assigned in 2 stratified blocks to a launch date for STRIDE. All hospitals received implementation support according to the Replicating Effective Programs framework.

Measurements: The prespecified primary outcomes were discharge to a SNF and hospital LOS, and having 1 or more inpatient falls was exploratory. Generalized linear mixed models were fit to account for clustering of patients within hospitals and included patient-level covariates.

Results: Patients in pre-STRIDE time periods (n = 6722) were similar to post-STRIDE time periods (n = 6141). The proportion of patients with any documented walk during a potentially eligible hospitalization ranged from 0.6% to 22.7% per hospital. The estimated rates of discharge to a SNF were 13% pre-STRIDE and 8% post-STRIDE. In adjusted models, odds of discharge to a SNF were lower among eligible patients hospitalized in post-STRIDE time periods (odds ratio [OR], 0.6 [95% CI, 0.5 to 0.8]) compared with pre-STRIDE. Findings were robust to sensitivity analyses. There were no differences in LOS (rate ratio, 1.0 [CI, 0.9 to 1.1]) or having an inpatient fall (OR, 0.8 [CI, 0.5 to 1.1]).

Limitation: Direct program reach was low.

Conclusion: Although the reach was limited and variable, hospitalizations occurring during the STRIDE hospital walking program implementation period had lower odds of discharge to a SNF, with no change in hospital LOS or inpatient falls.

Primary funding source: U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (Optimizing Function and Independence QUERI).

Figure 1.. Study flow diagram.

Light blue indicates pre-STRIDE periods, gray indicates implementation period (STRIDE launch), dark blue indicates post-STRIDE periods. * One of 4 randomized sites decided not to participate 2 months after randomization, citing inadequate staff capacity, and was replaced with an additional site that was able to follow the stepped wedge sequence ^† Two of these sites also had a recruitment call in Block 1 (declined both times) ^‡ Numbers within time interval represent the number of eligible hospitalizations; number of eligible hospitalizations with at least one STRIDE walk is presented in parentheses

Figure 2.

Plots of Odds Ratios and associated 95% Confidence Intervals for covariates from generalized linear mixed model fit using PROC GLIMMIX to discharge to SNF outcome for first hospitalization including all covariates (primary model)