Prehospital and Posthospital Fall Injuries in Older US Adults

Association of Medicare Home Health Ratings With Older Adult Fall Injuries: An Instrumental Variables Analysis

OBJECTIVES

To understand the role of high-quality home health care for fall prevention.

DESIGN

A 100% sample of national Medicare claims and home health survey data (2015-2017) were used to assess fall injuries and receipt of a fall risk assessment among recently hospitalized Medicare fee-for-service home health users aged ≥66 years. Subanalyses examined patients by prior fall history status and hospital admission diagnosis type (eg, neurologic, respiratory, cardiovascular, infection, and orthopedic diagnoses). An instrumental variables design addressed potential endogeneity in home health care use by patient fall risk.

SETTING AND PARTICIPANTS

Home health agencies and Medicare fee-for-service beneficiaries.

METHODS

Multivariate regression and instrumental variables.

RESULTS

Among 962,610 patients with hospital discharges to home health, being treated by home health agencies with the highest star ratings in a person's zip code was associated with a 1.8-percentage point (ppt) (95% CI: 0.1, 3.5; P = .03) higher likelihood of receipt of fall risk assessment. There was no overall change in 30-day (-0.6 ppt, 95% CI: -1.3, 0.1; P = .09), 15-day (-0.3 ppt, 95% CI: -0.0.8, 0.2; P = .35), or 7-day fall injury risk (-0.2 ppt, 95% CI: -0.5, 0.1; P = .22), but a 1.9-ppt (95% CI: -3.9, -0.02; P = .048) lower 30-day fall injury risk for individuals with a history of falls. Effects were directionally similar by diagnosis type.

CONCLUSIONS AND IMPLICATIONS

Fall injury risk is reduced at higher-rated home health agencies. Star ratings may be adequate indicators of quality for key outcomes not explicitly measured in the ratings.

Falls prechemotherapy and toxicity-related hospitalization during adjuvant chemotherapy for breast cancer in older women: Results from the prospective multicenter HOPE trial

BACKGROUND

Older women with breast cancer frequently experience toxicity-related hospitalizations during adjuvant chemotherapy. Although the geriatric assessment can identify those at risk, its use in clinic remains limited. One simple, low-cost marker of vulnerability in older persons is fall history. Here, the authors examined whether falls prechemotherapy can identify older women at risk for toxicity-related hospitalization during adjuvant chemotherapy for breast cancer.

METHODS

In a prospective study of women >65 years old with stage I-III breast cancer treated with adjuvant chemotherapy, the authors assessed baseline falls in the past 6 months as a categorical variable: no fall, one fall, and more than one fall. The primary end point was incident hospitalization during chemotherapy attributable to toxicity. Multivariable logistic regression was used to examine the association between falls and toxicity-related hospitalization, adjusting for sociodemographic, disease, and geriatric covariates.

RESULTS

Of the 497 participants, 60 (12.1%) reported falling before chemotherapy, and 114 (22.9%) had one or more toxicity-related hospitalizations. After adjusting for sociodemographic, disease, and geriatric characteristics, women who fell more than once within 6 months before chemotherapy had greater odds of being hospitalized from toxicity during chemotherapy compared to women who did not fall (50.0% vs. 20.8% experienced toxicity-related hospitalization, odds ratio, 4.38; 95% confidence interval, 1.66-11.54, p = .003).

CONCLUSIONS

In this cohort of older women with early breast cancer, women who experienced more than one fall before chemotherapy had an over 4-fold increased risk of toxicity-related hospitalization during chemotherapy, independent of sociodemographic, disease, and geriatric factors.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE

To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs).

DATA SOURCES AND STUDY SETTING

Secondary data from Medicare were used.

STUDY DESIGN

Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities).

DATA COLLECTION

Not applicable.

PRINCIPAL FINDINGS

We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001).

CONCLUSIONS

HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Designing ergonomic toilets and bathrooms for older adults: A study on anthropometric dimensions and recommendations

AIMS

This study aimed to evaluate the ergonomic design of toilets and bathroom equipment for older adults using anthropometric measurements.

DESIGN

This was a descriptive cross-sectional study.

METHODS

Data were collected from 2,721 people aged ≥ 65 years in Turkey. Fourteen anthropometric measurements were evaluated. Body dimension characteristics were described using minimum, maximum, and arithmetic means and standard deviations and the 5th, 25th, 50th, 75th, and 95th percentiles.

RESULTS

The measurements showed that companies generally do not design bathroom toilet equipment that is suitable for older adults.

CONCLUSION

This study provides advice to designers and manufacturers on how to adapt their products to the bathroom according to users' body characteristics in order to increase person-environment fit for older people.

Experience and Hospital Context Influence Fall Prevention Practice by Physical Therapists: A Survey Study

BACKGROUND

Falls in and following hospitalization are common and problematic. Little is understood about the factors that impede or promote effective implementation of fall prevention practices.

PURPOSE AND RELEVANCE

Physical therapists are commonly consulted for acute care patients at risk for falling. The purpose of this study is to understand therapist perceptions of their effectiveness in fall prevention and to explore the impact of contextual factors on practice patterns to prevent falls surrounding hospitalization.

METHODS

Survey questions were tailored to the constructs of hospital culture, structural characteristics, networks and communications, and implementation climate, in addition to inquiries regarding practice patterns and attitudes/beliefs.

RESULTS

Overall, 179 surveys were analyzed. Most therapists (n = 135, 75.4%) affirmed their hospital prioritizes best practices for fall prevention, although fewer agreed that therapists other than themselves provide optimal fall prevention intervention (n = 105, 58.7%). Less practice experience was associated with greater odds of affirming that contextual factors influence fall prevention practice (odds ratio 3.90, p < .001). Respondents who agreed that their hospital system prioritizes best practices for fall prevention had 14 times the odds of believing that their system prioritizes making improvements ( p = .002).

CONCLUSIONS/IMPLICATIONS

As experience influences fall prevention practice, quality assurance and improvement initiatives should be used to ensure minimum specifications of practice.

Real-world safety of neurohormonal antagonist initiation among older adults following a heart failure hospitalization

AIMS

To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established.

METHODS AND RESULTS

We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3.

CONCLUSIONS

Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events.

Trends in fall-related encounters and predictors of non-transport at a US Emergency Medical Services Agency

Non-transport to a hospital after emergency medical services (EMS) encounters for falls is common. However, incident factors associated with non-transport have not been well studied, especially beyond older adults. The objectives of this study are to (1) describe trends in fall-related EMS utilisation among adult patients from 2010 to 2018; (2) describe incident characteristics by age; and (3) identify incident factors associated with non-transport following a fall. This retrospective observational study includes prehospital clinical records data on falls from a large ambulance service in Minnesota, USA. Multivariable logistic regression was used to assess the independent association between non-transport and the following factors: sex, age, race, previous fall-related EMS encounter, incident location and primary impression. Of 62,835 fall-related encounters studied, 14.7% (9,245) did not result in transport by EMS. Fall calls were less common among younger people and the location and medical conditions primarily treated by an EMS provider during a 9-1-1 call differed greatly from those occurring among patients 65 and older. Factors most strongly associated with an increased risk of non-transport in the multivariable model were a primary impression of 'No apparent illness/injury' (OR = 34.5, 95% CI = 30.7-38.7), falling in a public location (OR = 2.09, CI = 1.96-2.22) and having had a fall-related EMS encounter during the prior year (OR = 1.15, CI = 1.1-1.2). Falls that occur in public locations, in patients with a previous fall, or result in no clinical detection of apparent illness or injury have a significantly increased odds of non-transport. Non-transport fall incidents in the United States require significant agency resources. Knowledge about the incident factors associated with non-transport calls is informative for development of alternative models for prehospital care delivery and initiatives to better serve patients.

Cognitive Frailty and Falls in a National Cohort of Older Chinese Inpatients

Previous studies have investigated the association between cognitive frailty and falls among older adults in community; however, no study investigated this relationship among older patients living in hospital. This study aimed to examine the relationship of cognitive frailty with falls among older inpatients in Chinese hospital.

METHODS

This analysis consisted of 9192 older inpatients aged 65 years or over from six hospitals in China. We used FRAIL scale and Mini-Cog to assess frailty and cognitive impairment, respectively. A generalized estimating equation was used to examine the relationship between cognitive frailty and falls at 30-day follow-up.

RESULTS

Among 9192 older inpatients enrolled in this present study, the mean (SD) age was 72.40(5.72) years, with 3850(41.88%) women. The cross-sectional analysis found that after controlling for variables (age, gender, education, depression, and hospital ward cluster effect), hospitalized patients with cognitive frailty, frailty only, or cognitive impairment only at baseline were all associated with history of falls (P<0.05). At 30-day follow-up, generalized estimating equation with full-adjustment showed that inpatients with cognitive frailty were at greater risk of falls than those of non-frail and cognitive intact (OR=3.0,95%CI:1.32-6.83). This association was also observed in individuals with frailty only (OR=2.11,95%CI:1.04-4.27) but not for patients with cognitive impairment only((OR=1.11,95%CI:0.43-2.85).

CONCLUSION

Our study suggested that hospitalized Chinese older adults with cognitive frailty were independently associated with falls. Early screening frailty and cognitive impairment were significant for older patients by clinicians, and corresponding interventions, exercise training and nutritional programs, should be implemented to prevent falls.