Building an infrastructure to prevent falls in older Californians: the Fall Prevention Center of Excellence

Measurement of Fall Injury With Health Care System Data and Assessment of Inclusiveness and Validity of Measurement Models

IMPORTANCE

National injury surveillance systems use administrative data to collect information about severe fall-related trauma and mortality. Measuring milder injuries in ambulatory clinics would improve comprehensive outcomes measurement across the care spectrum.

OBJECTIVES

To assess a flexible set of administrative data-only algorithms for health systems to capture a greater breadth of injuries than traditional fall injury surveillance algorithms and to quantify the algorithm inclusiveness and validity associated with expanding to milder injuries.

DESIGN, SETTING, AND PARTICIPANTS

In this longitudinal diagnostic study of 13 939 older adults (≥65 years) in the nationally representative Health and Retirement Study, a survey was conducted every 2 years and was linked to hospital, emergency department, postacute skilled nursing home, and outpatient Medicare claims (2000-2012). During each 2-year observation period, participants were considered to have sustained a fall-related injury (FRI) based on a composite reference standard of having either an external cause of injury (E-code) or confirmation by the Health and Retirement Study patient interview. A framework involving 3 algorithms with International Classification of Diseases, Ninth Revision codes that extend FRI identification with administrative data beyond the use of fall-related E-codes was developed: an acute care algorithm (head and face or limb, neck, and trunk injury reported at the hospital or emergency department), a balanced algorithm (all acute care algorithm injuries plus severe nonemergency outpatient injuries), and an inclusive algorithm (almost all injuries). Data were collected from January 1, 1998, through December 31, 2012, and statistical analysis was performed from August 1, 2016, to March 1, 2019.

MAIN OUTCOMES AND MEASURES

Validity, measured as the proportion of potential FRI diagnoses confirmed by the reference standard, and inclusiveness, measured as the proportion of reference-standard FRIs captured by the potential FRI diagnoses.

RESULTS

Of 13 939 participants, 1672 (42.4%) were male, with a mean (SD) age of 77.56 (7.63) years. Among 50 310 observation periods, 9270 potential FRI diagnoses (18.4%) were identified; these were tested against 8621 reference-standard FRIs (17.1%). Compared with the commonly used method of E-coded-only FRIs (2-year incidence, 8.8% [95% CI, 8.6%-9.1%]; inclusion of 51.5% [95% CI, 50.4%-52.5%] of the reference-standard FRIs), FRI inclusion was increased with use of the study framework of algorithms. With the acute care algorithm (2-year incidence, 12.6% [95% CI, 12.4%-12.9%]), validity was prioritized (88.6% [95% CI, 87.4%-89.8%]) over inclusiveness (62.1% [95% CI, 61.1%-63.1%]). The balanced algorithm showed a 2-year incidence of 14.6% (95% CI, 14.3%-14.9%), inclusion of 65.3% (95% CI, 64.3%-66.3%), and validity of 83.2% (95% CI, 81.9%-84.6%). With the inclusive algorithm, the number of potential FRIs increased compared with the E-code-only method (2-year incidence, 17.4% [95% CI, 17.1%-17.8%]; inclusion, 68.4% [95% CI, 67.4%-69.3%]; validity, 75.2% [95% CI, 73.7%-76.6%]).

CONCLUSIONS AND RELEVANCE

The findings suggest that use of algorithms with International Classification of Diseases, Ninth Revision codes may increase inclusion of FRIs by health care systems compared with E-codes and that these algorithms may be used by health systems to evaluate interventions and quality improvement efforts.

Posthospital Fall Injuries and 30-Day Readmissions in Adults 65 Years and Older

IMPORTANCE

Falls are common among older adults, particularly those with previous falls and cognitive impairment and in the postdischarge period. Hospitals have financial incentives to reduce both inpatient falls and hospital readmissions, yet little is known about whether fall-related injuries (FRIs) are common diagnoses for 30-day hospital readmissions.

OBJECTIVE

To compare fall-related readmissions with other leading rehospitalization diagnoses, including for patients at greatest risk of readmission.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of the Hospital Cost and Utilization Project's Nationwide Readmissions Database of nationally representative US hospital discharges among Medicare beneficiaries aged 65 years and older from January 1, 2013, to November 30, 2014. The prevalence and ranking of FRIs compared with other diagnostic factors for 30-day unplanned hospital-wide readmissions were determined, overall and for 2 acute geriatric cohorts, classified by fall injury or cognitive impairment diagnoses observed at the index admission. Analyses were also stratified by patient discharge disposition (home, home health care, skilled nursing facility). Analyses were conducted from February 1, 2018, to February 26, 2018.

MAIN OUTCOMES AND MEASURES

Unplanned hospital-wide readmission within 30 days of discharge.

RESULTS

From the database, 8 382 074 eligible index admissions were identified, including 746 397 (8.9%) in the FRI cohort and 1 367 759 (16.3%) in the cognitive impairment cohort. Among the entire 8 382 074-discharge cohort, mean (SD) age was 77.7 (7.8) years and 4 736 281 (56.5%) were female. Overall, 1 205 962 (14.4%) of index admissions resulted in readmission, with readmission rates of 12.9% for those with a previous fall and 16.0% for patients with cognitive impairment. Overall, FRIs ranked as the third-leading readmission diagnosis, accounting for 60 954 (5.1%) of all readmission diagnoses. Within the novel acute geriatric cohorts, FRIs were the second-leading diagnosis for readmission both for patients with an FRI at index admission (10.3% of all readmission diagnoses) and those with cognitive impairment (7.0% of all readmission diagnoses). For those with an FRI at index admission and discharged home or to home health care, FRIs were the leading readmission diagnosis.

CONCLUSIONS AND RELEVANCE

This study found that posthospital FRIs were a leading readmission diagnosis, particularly for patients originally admitted with a FRI or cognitive impairment. Targeting at-risk hospitalized older adults, particularly those discharged to home or home health care, is an underexplored, cost-effective mechanism with potential to reduce readmissions and improve patient care.

Receipt of Caregiving and Fall Risk in US Community-dwelling Older Adults

BACKGROUND

Falls and fall-related injuries (FRI) are common and costly occurrences among older adults living in the community, with increased risk for those with physical and cognitive limitations. Caregivers provide support for older adults with physical functioning limitations, which are associated with fall risk.

DESIGN

Using the 2004-2012 waves of the Health and Retirement Study, we examined whether receipt of low (0-13 weekly hours) and high levels (≥14 weekly hours) of informal care or any formal care is associated with lower risk of falls and FRIs among community-dwelling older adults. We additionally tested whether serious physical functioning (≥3 activities of daily living) or cognitive limitations moderated this relationship.

RESULTS

Caregiving receipt categories were jointly significant in predicting noninjurious falls (P=0.03) but not FRIs (P=0.30). High levels of informal care category (P=0.001) and formal care (P<0.001) had stronger associations with reduced fall risk relative to low levels of informal care. Among individuals with ≥3 activities of daily living, fall risks were reduced by 21% for those receiving high levels of informal care; additionally, FRIs were reduced by 42% and 58% for those receiving high levels of informal care and any formal care. High levels of informal care receipt were also associated with a 54% FRI risk reduction among the cognitively impaired.

CONCLUSIONS

Fall risk reductions among older adults occurred predominantly among those with significant physical and cognitive limitations. Accordingly, policy efforts involving fall prevention should target populations with increased physical functioning and cognitive limitations. They should also reduce financial barriers to informal and formal caregiving.

Examining Contextual Influences on Fall-Related Injuries Among Older Adults for Population Health Management

The objectives were to assess the associations between fall-related injuries (FRIs) treated in the emergency department (ED) among older adults in California and contextual county-level physical, social, and economic characteristics, and to assess how county-level economic conditions are associated with FRIs when controlling for other county-level factors. Data from 2008 California ED discharge, Medicare Impact File, and County Health Rankings were used. Random effects logistic regression models estimated contextual associations between county-level factors representing economic conditions, the built environment, community safety, access to care, and obesity with patient-level FRI treatment among 1,712,409 older adults, controlling for patient-level and hospital-level characteristics. Patient-level predictors of FRI treatment were consistent with previous studies not accounting for contextual associations. Larger and rural hospitals had higher odds of FRI treatment, while teaching and safety net hospitals had lower odds. Better county economic conditions were associated with greater odds (ß=0.73, P=0.001) and higher county-level obesity were associated with lower odds (ß=-0.37, P=0.004), but safer built environments (ß=-0.31, P=0.38) were not associated with FRI treatment. The magnitude of association between county-level economic conditions and FRI treatment attenuated with the inclusion of county-level obesity rates. FRI treatment was most strongly and consistently related to more favorable county economic conditions, suggesting differences in treatment or preferences for treatment for FRIs among older individuals in communities of varying resource levels. Using population health data on FRIs, policy makers may be able to remove barriers unique to local contexts when implementing falls prevention educational programs and built environment modifications.

Sustainability of community-based fall prevention programs: a systematic review

BACKGROUND

Fall prevention programs may be implemented but not sustained. We conducted a systematic review to identify any theories, models, frameworks, influencing factors or interventions for sustaining fall prevention programs in the community.

METHODS

Peer-reviewed publications describing, investigating, or evaluating program sustainability were accessed. A narrative review was conducted to compare and synthesize study findings.

RESULTS

Nineteen publications were included. Three conceptual frameworks were identified describing how programs may be better sustained. While ongoing financial support and the participation of older people were commonly reported influences, other factors specific to the type of program and setting were also reported. Planning, training, and collaboration between program stakeholders may facilitate sustainable programs.

IMPACT ON INDUSTRY

Organizations can use these findings when planning for sustainable programs. However more robust empirical studies are needed to confirm the value of conceptual frameworks, the critical factors and most effective interventions for sustaining community-based fall prevention programs.

Implementing the evidence for preventing falls among community-dwelling older people: a systematic review

PROBLEM AND OBJECTIVE

The translation of the evidence-base for preventing falls among community-dwelling older people into practice has been limited. This study systematically reviewed and synthesised the effectiveness of methods to implement falls prevention programmes with this population.

METHODS

Articles published between 1980 and May 2010 that evaluated the effects of an implementation strategy. No design restrictions were imposed. A narrative synthesis was undertaken.

RESULTS

15 studies were identified. Interventions that involved the active training of healthcare professionals improved implementation. The evidence around changing the way people who fall are managed within primary care practices, and, layperson, peer or community delivered models was mixed.

IMPACT ON INDUSTRY

Translating the evidence-base into practice involves changing the attitudes and behaviours of older people, healthcare professionals and organisations. However, there is a need for further evaluation on how this can be best achieved.

Use of a postfall assessment tool to prevent falls

Nursing research in fall prevention should not only identify etiologic risk factors to fall but seek to identify underlying causes, whenever possible. Few studies have investigated the use of a comprehensive postfall assessment tool (PFAT) by nurses as an intervention for the prevention of recurrent falls, especially one that prompts nurses to consider all potential causes through a categorization scheme. This study tested use of a comprehensive PFAT as an intervention, prospectively, facility-wide for 1 year by registered nurses using a pretest-posttest design. A 29.4% reduction in the fall rate (z = 3.89, p < .001), 27.6% decline in total falls experienced by all fallers (p < .001), and a 34.0% decline for recurrent fallers (p = .025) from preintervention to intervention year was observed when trained nurses categorized falls according to perceived causes. These declines are likely due to consistent and rigorous use by trained nursing staff, prompting their critical examination of each fall.

It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults

Systematic evidence reviews support the efficacy of physical activity programs and multifactorial strategies for fall prevention. However, community settings in which fall prevention programs occur often differ substantially from the research settings in which efficacy was first demonstrated. Because of these differences, alternative approaches are needed to judge the adequacy of fall prevention activities occurring as part of standard medical care or community efforts. This paper uses the World Health Organization Innovative Care for Chronic Conditions (ICCC) framework to rethink how fall prevention programs might be implemented routinely in both medical and community settings. Examples of innovative programs and policies that provide fall prevention strategies consistent with the ICCC framework are highlighted, and evidence where available is provided on the effects of these strategies on processes and outcomes of care. Finally, a "no wrong door" approach to fall prevention and management is proposed, in which older adults who are found to be at risk of falls in either a medical or community setting are linked to a standard fall risk evaluation across three domains (physical activity, medical risks, and home safety).