Case study
4 Falls prevention interventions
4.4 Multiple interventions
There are effective multiple interventions available and the evidence can be used for both an individual and a public health approach to falls prevention.7,51
In a 14-month randomised controlled trial in Sydney, small-group learning (two-hour weekly sessions for seven weeks) led to a significant 31% reduction in the rate of falls in people living in the community who had reported a fall in the previous 12 months. Falls prevention programs often take the form of group learning sessions run by community organisations. An ad hoc approach may not be effective, and therefore not cost effective in preventing falls, so these community organisations should consider using the Stepping On Program instead.
The Stepping On Program emphasises behaviour change to avoid falls. The program includes sessions on falls risk appraisal, exercise, home hazards, strategies to move around the local community, safe footwear, vision as a risk factor for falls, vitamin D, hip protectors, medication management, mastering safe mobility, and a home visit to follow through the falls prevention strategies and activities, and to assist with home adaptations and modifications if required. A booster session is held after three months.
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Despite methodological limitations of the studies reviewed (five controlled but not randomised trials), the consistency of findings in a Cochrane systematic review led to the conclusion that a population-based approach to the prevention of falls-related injury is effective and can form the basis of public
health practice.51
Two controlled trials also provide evidence that a concerted population approach to falls prevention will result in lower use of health care and reduced costs.78,79 The cost-benefit evaluation of the Stay On Your Feet program in Queensland compared hospital records (admissions) between a matched sample and the intervention areas (see below).80
The program activities were based in the community and aimed at older people (aged ≥55 years).78 They included selective advertising using specialty products, mass media campaigns, distribution of educational material (pamphlets, manuals, booklets), partnerships with GPs and other health professionals and workers, partnerships with local government, workshops, and training sessions regarding home modifications and appropriate exercises. The risk factors addressed were balance and gait problems, insufficient exercise, inappropriate footwear, poor vision, medication use, underlying medical conditions and environmental hazards.
A nonrandomised study from the United States compared rates of injuries from falls in a region that was exposed to interventions to change clinical practice (522 primary care clinicians, 133 outpatient rehabilitation facilities, 26 home care agencies, 7 acute care hospitals with emergency departments and 41 senior centres) with a region that had not been exposed to such interventions (460 primary care clinicians, 146 outpatient rehabilitation facilities, 7 acute hospitals and emergency departments, and 43 senior centres).79 A multidisciplinary team used the media, websites, posters, brochures, educational materials, opinion leaders, advertising and outreach visits to everyone in the main group of clinicians and facilities being targeted. Results showed that between the pre-intervention period and the evaluation period, the falls-related use of medical services increased in the usual care region compared with the intervention region (adjusted rate ratio 0.89; 95%CI 0.86 to 0.92). The authors concluded that dissemination of evidence about falls prevention, coupled with interventions to change clinical practice, may reduce falls-related injuries in older people.
4.4.1 Economic evaluation
The Stay On Your Feet program (a community-based program of footwear, vision, medication, environment and physical activity assessments) was conducted in northern New South Wales resulting in cost savings associated with reduced hospitalisations.80 The total cost for 950 participants of implementation was 1996A$805 579 over the four years from 1992–93 to 1995–96, including A$23 750 out-of-pocket participant costs. The analysis estimated savings from reduced hospitalisations, but did not calculate a cost per fall prevented.
A nonrandomised comparison of intervention and control regions in the United States showed an 11% relative reduction in the use of falls-related medical services in intervention regions.79 The authors estimated that this may have led to potential savings of US$21 million in health care costs (based on an average acute care cost of US$12 000 per event); however, the authors did not report the total cost of implementing the intervention and did not calculate an incremental cost-effectiveness ratio.
Johansson et al conducted a modelled economic evaluation of a community-based nonpharmaceutical program for preventing hip fractures in older people in Sweden.81 The community safety program consisted of structural environment changes (including local neighbourhoods and individual home assessments) and individual measures, such as safety promotion lectures and group-based balance exercises. Effectiveness was assessed using a quasi-experimental time series analysis before the intervention (1990–1995) and after the intervention (1996–2001). Results were modelled over a lifetime and indicated improved health outcomes, both in terms of life years and QALYs (quality-adjusted life years). The authors reported a Swedish krona (SEK) 71 000 cost saving when only the program-related costs (2004SEK 6.45 million) and the costs of hip fractures averted (2004SEK 6.52 million) were considered. No incremental cost-effectiveness ratio was reported.
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4.5 Multifactorial interventions
Multifactorial interventions include assessing an individual’s risk of falling, and then arranging referral or providing direct treatment to reduce the risks. To date, 31 randomised controlled trials of multifactorial interventions aimed at preventing falls have been reported.7 A Cochrane review concluded that
multifactorial interventions are effective in reducing the rate of falls but do not, overall, have a significant effect on the risk of falling in older people living in the community. The meta-analyses showed a high level of heterogeneity between studies, indicating that the interventions varied significantly in terms of their effectiveness. Subgroup analyses could not resolve whether including higher risk participants or increasing the intensity of interventions were factors in determining the effectiveness of interventions.
Another systematic review did not find an overall effect of multifactorial programs on the risk of falling.82 The authors suggested that this may have been because the low intensity of some of the included programs lessened the pooled effect. This second systematic review also found bigger effects on the risk of falling in trials of interventions that were delivered as part of the trial compared with interventions that involved only referrals to programs.82
Some studies have tested a multifactorial intervention in a specific population, such as people presenting to the emergency department with a fall,83,84 or people admitted to hospital and showing a functional decline.85 Other studies have included people selected randomly from the community50,86,87 or people with specified falls risk factors.39,88
Tinetti et al evaluated a multifactorial intervention program that reduced falls in older people in the community.88 This program was tested at the Yale site of the multicentre FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) trials. Interventions targeting eight specific risk factors identified at baseline assessment were compared with social visits. Interventions included medication review, behavioural change recommendations, education and training, and home exercise programs. During one year of follow-up, 47% of the control group fell compared with only 35% of the intervention group and there was a significant 31% reduction in falls.
Another trial found that a medical and occupational therapy assessment and subsequent tailored
intervention resulted in a significant decrease in fall rates over a one-year period.19 Participants in this trial were people who had been attended to in an emergency department following a fall. The trial reported a substantial and significant reduction in the risk of falling (61%) and the risk of recurrent falls (67%). The effectiveness of multifactorial interventions may be sensitive to differences between health care systems and networks at both local and national levels. For example, a trial by Hendriks et al89 in The Netherlands aimed to reproduce the successful multifactorial intervention reported by Close from the United Kingdom.19 However, their intervention did not prevent falls significantly. Major differences
in the health system in The Netherlands compared with that in the United Kingdom made it difficult to make timely contact with the appropriate health professionals and implement the interventions when needed. The fact that the risk of falling was not reduced in the trial may be due to these health care differences, rather than to sample variation, because ineffective falls prevention interventions have also been reported from The Netherlands in other trials.67,90
Multifactorial interventions form the basis of many falls prevention services, but the interventions examined in randomised controlled trials are complex, and their effectiveness may depend on factors yet to be determined.
4.5.1 Multifactorial versus single interventions
Since most falls occur as a result of a combination of factors, in theory, the benefits of multifactorial interventions should be greater than single interventions. However, a meta-analysis found that single intervention approaches were just as effective in reducing falls as multifactorial prevention programs.91 There is a risk that older people may become confused or be offered conflicting advice when several interventions are attempted. In a trial of older people with severe visual impairment, participants who received a home safety program benefited more than those receiving the home safety program plus the Otago Exercise Programme.45 A study in New Zealand found that multifactorial interventions containing this exercise program did not prevent falls when offered within a usual health care setting.92 Therefore, when multifactorial interventions are delivered, they should be done so in a staged and integrated manner.
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4.5.2 Economic evaluation
Rizzo et al conducted an economic evaluation in a cluster randomised controlled trial of Tinetti’s home-based multifactorial intervention.93 This intervention consisted of medication adjustments, environmental modifications and individualised exercise.88 The authors reported a mean intervention cost of 1993US$925 ($588–1346), and lower mean total health care costs in the intervention group overall (intervention US$8310 compared with usual care US$10 439). The differences in these costs varied with falls risk (high risk, defined as four or more of the eight specified risk factors: intervention US$10 537 compared with usual care US$14 232; low risk [three or fewer risk factors]: intervention US$6026 compared with usual care US$5232). For the mixed high and low-risk population, and in the high-risk subgroup, the intervention was more effective and less costly than usual care. In the low-risk subgroup, the intervention had a cost-effectiveness ratio of US$2771 per fall prevented, and US$11 417 for preventing a fall that would require medical care.
In an Australian analysis of a multidisciplinary assessment and referral over 12 months, Day et al reported an intervention cost of 2008A$1196.97–1342.28 per person.138 Over 12 months, the cost per fall prevented ranged from A$796.24 to A$892.20 (with the higher cost program) per fall prevented, and the cost per hospital admission averted ranged from A$39 812 to A$44 645 (with the higher cost program). Hendriks et al undertook an economic evaluation of a randomised controlled trial of a multidisciplinary intervention in The Netherlands.94 The authors reported a mean intervention cost of 2004€385, slightly lower mean total costs in the intervention (€4857) compared with control groups (€4991), and no significant differences in falls or in QALYs, concluding that, compared with usual care, the program was not cost effective in their setting.