T. Franklin Williams

Falls in Older Adults:

Implementing Research in

Practice

University of Leuven

February, 2012

Mary Tinetti MD

Phases in the research

• First phase: Acquire the evidence

– Establish falling as a health condition warranting attention

– Determine whether and how falls can be prevented

• Second phase: Implement the evidence – Disseminate the evidence

– Incorporate the evidence into practice

Falls in the community: Frequency and

Morbidity

• 30% of adults 70+ fall each year

– with age (50% by 80+)

• 10% of falls → serious injury (fracture, TBI, soft tissue ) • 8% persons 70+ → ED after fall;

Morbidity and consequences

Independent of demographic, medical, cognitive, and psychosocial factors, Non-injurious and injurious falls lead to: • ↓ daily living, social and physical

activities

• ↑ Risk long term NH 5 fold

• $24000 extra health costs

Determine whether and how falls can

be prevented

• Can persons at risk be identified (who)? • Can factors leading to

falls be identified (why)?

• Can falls be prevented (based on who and why)?

Predict who falls and why: Geriatric

syndrome model

Falls occur when older adult with:

• accumulated effect of multiple impairments / conditions that compromise stability or risk of injury (Predisposing factors)

• exposed to

precipitating factor(s) –

environmental or intrinsic

Predisposing factors: Falls, injuries*

• ↓ Strength

• Impaired balance, gait

• Vision impairment • Psychoactive meds *↑ risk ≥ 2-fold

• ↓ Postural BP

• Cognitive

impairment • Foot problems • Depression • 4+ medications

Risk of falls by number of predisposing

risk factors

0 20 40 60 80 100

P

e

rc

e

n

t

F

a

ll

in

g

0 1 2 3 4+

Number of Risk Factors

8%

19%

32%

60%

78%

Yale FICSIT

Frailty and Injuries: Cooperative Studies

of Intervention Techniques

Yale FICSIT

Aim

:

• Hypothesis: Risk of falling with # risk factors → risk of falling ↓ by reducing

risk factors

Yale FICSIT

• Design: cluster RCT

• Population: 301 community living persons 70+ with ≥ 1 fall risk factor

• Intervention: Standardly-tailored multifactorial, multidisciplinary

intervention targeted at 6 modifiable risk factors

Yale FICSIT: Targeted risk factors

TI (153) SV (148)

•Postural hypotension 46% 39%

•Sedative use 19% 18%

•4+ Prescriptions 42% 49%

•↓ Leg strength 37% 49%

•↓ Arm strength 22% 24%

•Balance/gait impair 62% 69%

Multifactorial, targeted intervention

• Feasible - 85% enrolled; 80% adhered

• Safe - No injuries during 20,000 unsupervised exercise sessions

• Effective

–↓ % who fell by 25% –↓ rate of falling by 31%

• Cost-effective – 2 yr. health costs

$2000 less in TI vs. SV

First phase: Acquiring the evidence

• Falling established as a health condition warranting attention

• Risk of falls predictable and falls preventable

• In retrospect, THE EASY PART!

– Disconnect between evidence (>60 RCTS) and practice (ignored)

Second Phase: Implementing the

evidence in practice

• Disseminate the evidence

Implement evidence in practice

• Scale up; diffusion, spread, translating, dissemination

• Emerging field of implementation science; practice change

• Used to be a backwater activity • Recent increased credibility

Connecticut Collaboration for Fall

Prevention (CCFP)

Funded by the Donaghue Foundation and the National

CCFP: Aims

• Aim 1: To disseminate effective fall prevention practices and encourage clinicians to adopt them

• Aim 2: To determine effect on serious fall injury and fall-related health utilization

• Aim 3: To identify barriers and facilitators to adopting fall-related practices

CCFP Methods: Initial tasks

• Increase awareness of importance of fall prevention

• Determine core intervention to disseminate • Develop practice materials (checklists;

manuals; passbooks, website)

• Establish referral patterns among ED, PT, homecare, 1°care

• Address payment for clinical services

Increase clinicians and public’s

awareness

of falling as a

preventable cause of morbidity:

website, bus ads, posters, brochures, media…

Recommended Practices

Provider/ Facility

Assess/ Refer

Risk Factor Management Gait

Bal.

Muscle

streng Post. _BP

Vision _Med.

adjust Env

EDs _X

Acute

hospitals X X X

X

Rehab _{X X X X}

Home

care X X X X X X

1º MDs

X X X X X X

CCFP Methods to increase

fall-related practices

• Followed Implementation Science methods – Composite of professional change

strategies → enhance knowledge,

skills, behavior

– No one strategy ideal or effective – multiple strategies most effective

Methods to increase fall-related

practices

• Buy in from leaders; champions; early adopters; train the trainers

• Working groups; local participation in planning and implementation

• Patient-mediated (patients request fall management)

Methods to increase fall- related

practices

• Outreach visits (academic detailing)

• Time consuming but necessary…

Health providers targeted

• E.D.s and hospitals: 7

• Home care: 27 agencies (>200 staff)

• Rehab. facilities:130 offices (>300

PTs / OTs)

• °1 care: 212 offices (>500 doctors

and nurses)

Encounters with Clinicians / Facilities

Clinicians/facilities Outreach visits

Older adults

Primary doctors 175 --MDs - not 1º Care 26 --Home care 116 --Rehab (PT/OT) 194 --Hospital discharge

coordinators

101

--Other Clinicians / Facilities Clinicians/facilities Outreach visits Older adults Pharmacists Emergency medical responders 102

Assisted living 136 1180 Subacute facilities 185 ~3000 Senior centers 99 4608

0 10 20 30 40 50 60 70 80 90 100

Home Care Agencies Outpatient Rehabilitation Offices Primary Care Offices Senior Centers (n=26) (n=133) (n=212) (n=41) P e rc e n ta g e

Aim 2

• To compare serious fall injury and fall-related utilization rates in a region in Connecticut

exposed to CCFP interventions relative to a usual care

region.

Aim 2 Methods

• Design: Non randomized

• Sampling units – local post office areas

• Primary outcome: ED or hospital for serious fall injury (hip fracture, other fracture, serious head injury, joint dislocation)

• Secondary outcome: ED or hospital for fall-related event

Characteristics of regions

Female 61.3 61.4

White 91.8 92.3

Education ≤high school 66.9 63.8 <$15,0 000 income 23.3 22.9 >$75,000 income 14.3 18.2 Persons 65+poverty status 7.6 7.2 Persons 65+ in institution 7.4 5.3 Noninstit. 65+ w. disability 24.0 24.0

Pre-Intervention Intervention Evaluation

26 28 30 32 34 36 Usual Care Intervention

10/1999 - 9/2001 10/2001 - 9/2004 10/2004 - 9/2006

R a te p e r 1 0 0 0 P e rs o n s 7 0 Y e a rs a n d O ld e r

Pre-Intervention Intervention Evaluation

60 65 70 75 80 85 90 Usual Care Intervention

10/1999 - 9/2001 10/2001 - 9/2004 10/2004 - 9/2006

R a te p e r 1 0 0 0 P e rs o n s 7 0 Y e a rs a n d O ld e r

Serious fall injury / fall-related utilization rates in intervention vs. usual care regions

CCFP: What we found

• There were fewer srious fall injuries in intervention than control area, but… • Many barriers and challenges to

implementing fall-related practices despite compelling evidence

– for clinicians

– for payers ( Medicare-CMS)

Aim 3

To identify barriers to implementing fall-related practices

Challenges for clinicians: Knowledge

• Clinicians and older adults unaware of falling and fall prevention

• Patients aren’t asking for it

• Clinicians do not understand other’s roles and skills (e.g. MD, home care nurse, PT)

• Fragmentation of health care- who does what, where?

Challenges for clinicians: Skills

• Perceived lack of expertise

• Multi-factorial nature of fall evaluation and management

• Initiating behavioral interventions • Working with multiple disciplines

• Competing demands from coexisting conditions: how to balance/

Health care system challenges

• Fragmentation among multiple clinicians in multiple settings

• Need to coordinate and refer across settings and provider groups

• No coordination between health care and community facilities

• Disconnect between who provides the prevention services and who saves

Challenges for health care payers

• High potential cost of services

• Multiple components -? sinlge vs.

multiple payment to whom?

evidence-based?; too variable • Too easy to manipulate (fraud)

More successful implementation

• Physical therapy

– progressive balance) – New source of clients

and services

• Home care

– Assess fall risk,

– postural blood pressure – role of medications, – environmental

Less successful implemntation

• Physicians

– Fall risk

– Pstural blood pressure – Medications

• Emergency and hospitals

– Fall risk

– Referral for fall prevention

Collaborators

• D. Baker • M. Gottschalk • M. King • D. Acampora • J. Agostini • H. Allore • L. Bianco • C. Brown • P. Charpentier • W. Chou

• L. Graff

• G. Hawthorne-Jones • R. Fortinsky

• L. Leo-Summers • T. Murphy

• J. O’Leary • J. Preston • Cheney and Co. • Katzman

• 3000+ clinicians, providers, administrators