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 beenshown to improve functional ability after discharge, but littleevidence exists about their effectiveness under routine practiceconditions. Objective: To evaluate the effect of implementation of asupervised walking program known as STRIDE (AssiSTed EaRlyMobIlity 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 to19 August 2019. Patients: Analyses included hospitalizations involving patientsaged 60 years or older who were community dwelling andadmitted for 2 or more days to a participating medicine ward. Intervention: Hospitals were randomly assigned in 2 strati-fied blocks to a launch date for STRIDE. All hospitals receivedimplementation support according to the Replicating EffectivePrograms framework. Measurements: The prespecified primary outcomes weredischarge to a SNF and hospital LOS, and having 1 or moreinpatient falls was exploratory. Generalized linear mixed mod-els werefit to account for clustering of patients within hospitalsand included patient-level covariates. Results: Patients in pre-STRIDE time periods (n=6722) weresimilar to post-STRIDE time periods (n=6141). The propor-tion of patients with any documented walk during a poten-tially eligible hospitalization ranged from 0.6% to 22.7% perhospital. The estimated rates of discharge to a SNF were13% pre-STRIDE and 8% post-STRIDE. In adjusted models,odds of discharge to a SNF were lower among eligiblepatients 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 nodifferences in LOS (rate ratio,1.0 [CI, 0.9 to 1.1]) or havingan 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 walk-ing program implementation period had lower odds of dis-charge to a SNF, with no change in hospital LOS or inpatientfalls. Primary Funding Source: U.S. Department of VeteransAffairs Quality Enhancement Research Initiative (OptimizingFunction and Independence QUERI).