How Do General Practitioners (GPs) Engage in Falls Prevention With Older People? A Pilot Survey of GPs in NHS England Suggests a Gap in Routine Practice to Address Falls Prevention

Factors that affect the implementation of an integrated care programme for older people with different frailty levels: a qualitative study of commissioners and provider stakeholders

INTRODUCTION

The NHS has made it mandatory for General Practices in England to proactively identify and manage older people with moderate and severe frailty since the GMS contract of 2017/2018. In Luton, stakeholders developed the Luton Framework of Frailty (LFF) to implement this national policy. The aim of this study was to explore the factors that affect the implementation of this national policy at a local level.

METHODS

In-depth interviews were conducted with 18 commissioners and service providers, all of whom were involved in providing services for older people with different frailty levels (OPDFL). Purposive and snowball sampling methods were used, with thematic analysis used for data analysis.

RESULTS

Two main themes with several sub-themes were found. The first theme was the tension within existing national policy initiatives to provide integrated care services for OPDFL, which illuminated their strengths and limitations. Participants felt that new initiatives, such as the development of Primary Care Networks and Enhanced Health in Care Homes, have improved primary care coordination. However, the traditional reactive approach for managing older people who are frail was thought to be counterproductive, when an approach that focused on prevention and early intervention would have been better. The second theme concerned the contextual factors that affect implementation of integrated care. These included having key leaders at a local level, the requirement for more funding, as well as the need for good working relationships among service providers. However, the lack of awareness about the care pathways among GPs was thought to be a reason for the variation in the implementation of the LFF. The COVID-19 pandemic was perceived as a challenge for the implementation of the LFF. Finally, polices were thought to succeed only if more resources are provided, while the term frailty should be used with caution due to the negative connotations of OPDFL towards this term.

CONCLUSION

The implementation of an integrated care programme for OPDFL can be affected by several factors. Having proactive national policies that facilitate coordination and, having key leaders locally, the need for more funding, and good working relationships, are some of the contextual factors that could facilitate a successful implementation. In contrast, the lack of awareness of the care pathways that have been introduced locally, insufficient resources to deliver the programmes efficiently and a lack of careful consideration of how the term frailty is used could hinder this being put into practice.

Determinants influencing the implementation of multifactorial falls risk assessment and multidomain interventions in community- dwelling older people: a systematic review

BACKGROUND

Multifactorial falls risk assessment and multidomain interventions are recommended by the World guidelines for falls prevention and management. To successfully implement these interventions, it is important to understand determinants influencing the implementation.

METHODS

A literature search was conducted for this systematic review on the 3 December 2021 and updated on the 3 April 2023 in five databases: PubMed (including MEDLINE), EMBASE (via Embase.com), Cochrane Central Register of Controlled Trials (via Cochrane Library), Web of Science Core Collection and CINAHL (via EBSCO). Studies were included if they reported on determinants influencing the implementation of a multifactorial falls risk assessment and/or multidomain interventions in community-dwelling older people. Editorials, opinion papers, systematic reviews and studies focusing on one population (e.g. Parkinson) were excluded. Two researchers independently screened the articles on title, abstract and full text. The quality was evaluated based on a sensitivity analysis. 'The Comprehensive Integrated Checklist of Determinants of practice' was used to categorise the determinants.

RESULTS

Twenty-nine studies were included. Determinants were classified as barriers (n = 40) and facilitators (n = 35). The availability of necessary resources is the most reported determinant. Other commonly reported determinants are knowledge, intention/beliefs and motivation at the levels of older people and healthcare professionals, fitting of the intervention into current practice, communication, team and referral processes and financial (dis)incentives.

CONCLUSIONS

Mapping of the barriers and facilitators is essential to choose implementation strategies tailored to the context, and to enhance the uptake and effectiveness of a multifactorial falls risk assessment and/or multidomain interventions.

Combining user-centered design and behavioral theory to enhance health technologies: A personas-based approach for a primary-care based multifactorial falls risk assessment tool

INTRODUCTION

Multifactorial falls risk assessment tools (FRATs) can be an effective falls prevention method for older adults, but are often underutilized by health care professionals (HCPs). This study aims to enhance the use and implementation of multifactorial FRATs by combining behavioral theory with the user-centered design (UCD) method of personas construction. Specifically, the study aimed to (1) construct personas that are based on external (i.e., needs, preferences) and intrinsic user characteristics (i.e., behavioral determinants); and (2) use these insights to inform requirements for optimizing an existing Dutch multifactorial FRAT (i.e., the 'Valanalyse').

METHODS

Survey data from HCPs (n = 31) was used to construct personas of the 'Valanalyse.' To examine differences between clusters on 68 clustering variables, a multivariate cluster analysis technique with non-parametric analyses and computational methods was used. The aggregated external and intrinsic user characteristics of personas were used to inform key design and implementation requirements for the 'Valanalyse,' respectively, whereby intrinsic user characteristics were matched with appropriate behavior change techniques to guide implementation.

RESULTS

Significant differences between clusters were observed in 20 clustering variables (e.g., behavioral beliefs, situations for use). These variables were used to construct six personas representing users of each cluster. Together, the six personas helped operationalize four key design requirements (e.g., guide treatment-related decision making) and 14 implementation strategies (e.g., planning coping responses) for optimizing the 'Valanalyse' in Dutch geriatric, primary care settings.

CONCLUSION

The findings suggest that theory- and evidence-based personas that encompass both external and intrinsic user characteristics are a useful method for understanding how the use and implementation of multifactorial FRATs can be optimized with and for HCPs, providing important implications for developers and eHealth interventions with regards to encouraging technology adoption.

Preventable deaths involving falls in England and Wales, 2013-22: a systematic case series of coroners' reports

BACKGROUND

Falls in older people are common, leading to significant harm including death. Coroners have a duty to report cases where action should be taken to prevent future deaths, but dissemination of their findings remains poor.

OBJECTIVE

To identify preventable fall-related deaths, classify coroner concerns and explore organisational responses.

DESIGN

A retrospective systematic case series of coroners' Prevention of Future Deaths (PFD) reports, from July 2013 (inception) to November 2022.

SETTING

England and Wales.

METHODS

Reproducible data collection methods were used to web-scrape and read PFD reports. Demographic information, coroner concerns and responses from organisations were extracted and descriptive statistics used to synthesise data.

RESULTS

Five hundred and twenty-seven PFDs (12.5% of PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (70.8%). A high proportion of cases experienced fractures (51.6%), major bleeding (35.9%) or head injury (38.7%). Coroners frequently raised concerns regarding falls risks assessments (20.9%), failures in communication (20.3%) and documentation issues (17.5%). Only 56.7% of PFDs received a response from organisations to whom they were addressed. Organisations tended to produce new protocols (58.5%), improve training (44.6%) and commence audits (34.3%) in response to PFDs.

CONCLUSIONS

One in eight preventable deaths in England and Wales involved a fall. Addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults, but the poor response rate may indicate that lessons are not being learned. Wider dissemination of PFD findings may help reduce preventable fall-related deaths in the future.

Elderly Fall Detection Based on GCN-LSTM Multi-Task Learning Using Nursing Aids Integrated with Multi-Array Flexible Tactile Sensors

Due to the frailty of elderly individuals' physical condition, falling can lead to severe bodily injuries. Effective fall detection can significantly reduce the occurrence of such incidents. However, current fall detection methods heavily rely on visual and multi-sensor devices, which incur higher costs and complex wearable designs, limiting their wide-ranging applicability. In this paper, we propose a fall detection method based on nursing aids integrated with multi-array flexible tactile sensors. We design a kind of multi-array capacitive tactile sensor and arrange the distribution of tactile sensors on the foot based on plantar force analysis and measure tactile sequences from the sole of the foot to develop a dataset. Then we construct a fall detection model based on a graph convolution neural network and long-short term memory network (GCN-LSTM), where the GCN module and LSTM module separately extract spatial and temporal features from the tactile sequences, achieving detection on tactile data of foot and walking states for specific time series in the future. Experiments are carried out with the fall detection model, the Mean Squared Error (MSE) of the predicted tactile data of the foot at the next time step is 0.0716, with the fall detection accuracy of 96.36%. What is more, the model can achieve fall detection on 5-time steps with 0.2-s intervals in the future with high confidence results. It exhibits outstanding performance, surpassing other baseline algorithms. Besides, we conduct experiments on different ground types and ground morphologies for fall detection, and the model showcases robust generalization capabilities.

Developing the Patient Falls Risk Report: A Mixed-Methods Study on Sharing Falls-Related Clinical Information from Home Care with Primary Care Providers

If interRAI home care information were shared with primary care providers, care provision and integration could be enhanced. The objective of this study was to co-develop an interRAI-based clinical information sharing tool (i.e., the Patient Falls Risk Report) with a sample of primary care providers. This mixed-methods study employed semi-structured interviews to inform the development of the Patient Falls Risk Report and online surveys based on the System Usability Scale instrument to test its usability. Most of the interview sample (n = 9) believed that the report could support patient care by sharing relevant and actionable falls-related information. However, criticisms were identified, including insufficient detail, clarity, and support for shared care planning. After incorporating suggestions for improvement, the survey sample (n = 27) determined that the report had excellent usability with an overall usability score of 83.4 (95% CI = 78.7-88.2). By prioritizing the needs of end-users, sustainable interRAI interventions can be developed to support primary care.

Implementing Falls Prevention in Primary Care: Barriers and Facilitators

Purpose

Limited information is available concerning primary care providers’ encountered barriers and facilitators when implementing falls prevention and providing interventions in a real-life setting. This study aimed to identify barriers and facilitators when i) implementing a falls risk assessment strategy at GP practices and among community nurses and ii) providing evidence-based falls prevention interventions in a real-life setting to independently living, frail older people.

Methods

A researcher’s journal was maintained during the implementation of a falls risk assessment strategy, which entailed notes from informal conversations with GPs, practice nurses and community nurses. After implementation, two online focus groups with GPs, practice and community nurses, physio- and exercise therapists were conducted. Data were thematically analyzed.

Results

Data were collected from 32 GPs, 13 practice nurses, eight community nurses, nine physiotherapists, and two exercise therapists. The GPs and nurses acknowledged that falls prevention is part of their job, meaningful, and that they have sufficient knowledge and skills to offer falls prevention. Collaboration, a previously implemented care program for older people, resources, reimbursement for interventions, and patients’ motivation, awareness and health issues were considered to be important factors for the implementation of falls prevention. Physio- and exercise therapists described collaboration with different disciplines, receiving sufficient referrals, reimbursements, intensity and set-up of the interventions, and patients’ motivation, expectations, goals, self-confidence, awareness, and health issues as important factors when providing falls prevention interventions.

Conclusion

This study identified care provider-, context-, patient-, and innovation (strategy)-related barriers and facilitators when implementing falls prevention and providing interventions in primary care. Development of a more successful implementation strategy should focus on intensifying collaboration, reimbursement for interventions, availability of resources, and patients’ lack of motivation and health issues. Hence, falls prevention may become more structurally applied, reducing a major threat for the quality of life of independently living older people.

Identification and management of frail patients in English primary care: an analysis of the General Medical Services 2018/2019 contract dataset

OBJECTIVES

The aim of this study was to explore the extent of implementation of the General Medical Services 2018/2019 'frailty identification and management' contract in general practitioner (GP) practices in England, and link implementation outcomes to a range of practice and Clinical Commissioning Group (CCG) factors.

DESIGN

A cross-sectional study design using publicly available datasets relating to the year 2018 for all GP practices in England.

SETTINGS

English general practices.

DATA

The analysis was conducted across 6632 practices in 193 CCGs with 9 995 558 patients aged 65 years or older.

OUTCOMES

Frailty assessment rates, frailty coding rates and frailty prevalence rates, plus rates of medication reviews, falls assessments and enriched Summary Care Records (SCRs).

ANALYSIS

Summary statistics were calculated and multilevel negative binomial regression analysis was used to investigate relationships of the six outcomes with explanatory factors.

RESULTS

14.3% of people aged 65 years or older were assessed for frailty, with 35.4% of these-totalling 5% of the eligible population-coded moderately or severely frail. 59.2% received a medications review, but rates of falls assessments (3.7%) and enriched SCRs (21%) were low. However, percentages varied widely across practices and CCGs. Practice differences in contract implementation were most strongly accounted for by their grouping within CCGs, with weaker but still important associations with some practice and CCG factors, particularly healthcare demand-related factors of chronic caseload and (negatively) % of patients aged 65 years or older.

CONCLUSION

CCG appears the strongest determinant of practice engagement with the frailty contract, and fuller implementation may depend on greater engagement of CCGs themselves, particularly in commissioning suitable interventions. Practices understandably targeted frailty assessments at patients more likely to be found severely frail, resulting in probable underidentification of moderately frail individuals who might benefit most from early interventions. Frailty prevalence estimates based on the contract data may not reflect actual rates.

24-Months Cluster-Randomized Intervention Trial of a Targeted Fall Prevention Program in a Primary Care Setting

BACKGROUND

Falls and fall-related injuries are common in community-dwelling older persons. Longitudinal data on effective fall prevention programs are rare.

OBJECTIVE

Therefore, we evaluated a 4-months multi-component exercise fall prevention program in a primary care setting on long-term effects over 24 months on falls and concomitant injuries in older community-dwelling persons with high risk of falling.

DESIGN AND SETTING

In the Prevention of Falls (PreFalls) study, forty general practitioners in Germany were cluster-randomized (1:1) into an intervention group (IG) or control group (CG). Three hundred seventy-eight independently living people with high risk of falling (78.1 ± 5.9 years, 75% women) were assigned to IG (n = 222) or CG (n = 156).

INTERVENTION AND MEASUREMENTS

Patients in IG took part in a 4-months multi-component exercise program comprising strength and balance exercises (28 sessions); patients in CG received no intervention. Primary outcome measure was number of falls over 24 months, analyzed by a patient-level, linear mixed Poisson model. Secondary endpoints were number of fall-related injuries, changes in physical function, fear of falling, and mortality.

RESULTS

After 24 months, the IG demonstrated significantly fewer falls (IRR = 0.63, p = 0.021), injurious falls (IRR = 0.69, p = 0.034), and less fear of falling (p = 0.005). The mortality rate was 5.0% in IG and 10.3% in CG (HR = 0.51, 95% CI: 0.24 to 1.12; p = 0.094).

CONCLUSIONS

In older community-dwelling persons with high risk of falling, a short-term multi-component exercise intervention reduced falls and injurious falls, as well as fear of falling over 24 months.

Is Fall Risk Systematically Evaluated in Memory Clinics? A National Survey of Practice in France

BACKGROUND

Falls are a major health problem in older persons but are still under-diagnosed and challenging to prevent. Current guidelines do not target high-risk populations, especially people living with dementia. In France, people with neurocognitive disorders are mainly referred to memory clinics (MCs).

OBJECTIVE

We aimed to survey the routine practice of physicians working in MCs regarding fall risk assessment.

METHODS

We conducted a cross-sectional survey in France from January to May 2019 among physicians working in MCs, through an anonymous online questionnaire: twenty-seven questions about the physician's background and their practice of fall risk assessment, especially use of clinical and paraclinical tools. We compared the results according to the age and the specialty of the physician.

RESULTS

We obtained 171 responses with a majority of women (60%) and geriatricians (78%). All age classes and all French regions were represented. Most of respondents (98.8%) stated that they address gait and/or falls in outpatient clinic and 95.9%in day hospitals. When asked about how they assess fall risk, fall history (83%) and gait examination (68.4%) were the most widely used, while orthostatic hypotension (24%) and clinical standardized tests (25.7%) were less common. Among standardized tests, One-leg Balance, Timed Up and Go Test, and gait speed measurements were the most used. Geriatricians had more complete fall risk assessment than neurologists (e.g., 56%versus 13%for use of standardized tests, p < 0.0001).

CONCLUSION

Almost all physicians addressed the question of fall in MC, but practices are widely heterogeneous. Further investigations are needed to standardize fall risk assessment in MCs.

Systematic Review and Meta-Analysis of Intervention Studies with General Practitioner Involvement Focused on Falls Prevention for Community-Dwelling Older People

Objectives: Falls are a significant health problem for the ageing population. This review aimed to identify effective falls prevention interventions with involvement of general practitioners (GPs). Methods: Systematic review of randomised controlled trials conducted from 1999-2019, with meta-analysis. Searches located 2736 articles. A quality assessment was conducted of all included studies. Results: 21 randomised controlled trials met the inclusion criteria and 19 studies could be included in a meta-analysis. Overall, studies were not effective for reducing multiple falls (Relative Risk (RR) 1.16, 95% CI .97-1.39 and p = .10) or reducing one or more falls (RR .91, 95% CI: .82-1.01 and p = .08), but were effective for reducing injurious falls (RR .76, 95% CI: .66-.87 and p = .001). Discussion: Studies involving the GP in an active role and aligned with the primary care context were effective. The fidelity of interventions was limited by independent GP decisions and older participants being required to initiate the intervention.

Implementation and Evaluation of a Fall Risk Screening Strategy Among Frail Older Adults for the Primary Care Setting: A Study Protocol

BACKGROUND

Falls are an increasing problem among older people. There are several evidence-based interventions available to prevent falls. However, these are not always well implemented in the primary care setting. General practitioners (GPs) are often the first point of contact for health issues, making them the designated professionals for providing falls prevention. Because GPs are often unaware which patients have a high fall risk and patients themselves do not always know they have a high fall risk, this study aims to evaluate the implementation of a targeted fall risk screening strategy among independently living, frail older people in the primary care setting.

MATERIALS AND METHODS

The targeted fall risk screening strategy used in this study consists of tools for screening high fall risk and for identifying the underlying cause(s) of the high fall risk, an accredited training course in falls prevention for professionals, and service provision by certified physio- and exercise therapists who are able to offer evidence-based falls prevention interventions. This targeted fall risk screening strategy will be implemented in the primary care setting and evaluated at the level of the GP practice and at the level of the patient by using the RE-AIM model of Glasgow et al. In a pre-posttest design, data will be collected of the total number of frail older people who are screened, referred and enrolled for fall-preventive care. Furthermore, barriers and facilitators of the implementation of the fall risk screening strategy will be identified by conducting focus groups and interviews with the care providers and frail older patients. Additionally, the influence of the falls prevention interventions on frail older patients will be evaluated by using a pre-posttest design with a 12-month follow-up period during which data are collected regarding patients' stability, mobility, strength, balance, self-efficacy, health status, and daily activities.

STUDY REGISTRATION

This study is approved by the Medical Ethics Committee Brabant, the Netherlands (NL61582.028.17/ P1732) and registered at the Netherlands Trial Register, NL7917.

Exploring enablers and barriers to accessing health services after a fall among people with intellectual disability

BACKGROUND

Adults with intellectual disability experience high rates of falls making falls prevention an important health need. The purpose of the study was to seek perspectives of older adults with intellectual disability and their caregivers to (a) explore the experiences of older adults with intellectual disability when seeking healthcare services after a fall and (b) identify enablers and barriers when taking up evidence-based falls recommendations.

METHOD

A qualitative exploratory study was undertaken as part of a prospective observational cohort study. Semi-structured interviews were conducted with a purposeful sample. Data were analysed thematically using Colaizzi's method.

RESULTS

Seventeen interviews were conducted (n = 21). Emergent themes demonstrated that participants had limited knowledge about falls prevention. Enablers included individualizing falls prevention strategies. Barriers included not being offered access to established falls prevention pathways.

CONCLUSION

There is an urgent need to develop high-quality falls prevention services for older adults with intellectual disability.