Intervention somewhat effective in reducing serious falls
An intervention implemented in primary care settings reduced serious fall injuries among older adults but was not as effective as expected, according to a study published in the New England Journal of Medicine.
“Falls are a major public health problem and a leading cause of injury-related deaths among older Americans,” Shalender Bhasin, MD, director of research programs in men’s health, aging and metabolism at Brigham and Women’s Hospital, told Healio Primary Care. “The STRIDE study represents the largest randomized trial of fall injury prevention strategies that has been published to date. The findings have important implications for developing strategies to reduce serious fall injuries in real-world primary care practices.”
Bhasin and colleagues conducted a pragmatic, cluster-randomized trial to compare enhanced usual care with an intervention to reduce serious fall injuries.
In the intervention, participants underwent risk assessment to evaluate risk factors: strength impairment, gait, balance, medication use, postural hypotension and issues with feet or footwear, osteoporosis or vitamin D deficiency, impaired vision and home safety hazards. They were later told the standard protocol-based recommendations to manage these risk factors. Then, individualized care plans that focused on one to three of the identified risk factors were developed for each participant and approved by their primary care physicians.
Individualized care plans were implemented by specially trained nurses, and participants subsequently received follow-up care over the phone or during in-person visits to reassess their risk factors and adjust their care plan as needed.
The trial included 86 primary care practices across 10 health care systems, with 43 practices assigned to intervention (2,802 participants) and 43 practices (2,649 participants) assigned to enhance usual care. Participants in the study were aged 70 years or older and were determined to be at an increased risk for fall injury due to experiencing two or more falls or a fall-related injury in the previous year or reporting a fear of falling due to issues with balance or walking.
Bhasin and colleagues collected data on fall injuries every 4 months through phone interviews with participants. They also assessed EHR records and data from trial sites or CMS claims to identify serious adverse events every 4 months.
The researchers hypothesized that the event rate of a serious fall injury — a fracture, dislocated joint or a cut requiring closures after a fall, or a hospitalization for head injury, sprain or strain, bruising, swelling or other serious injury after fall — would decrease by 20% in the intervention group.
However, Bhasin and colleagues did not observe a significant difference in the rate of first adjudicated serious fall injury between the groups, with 4.9 events per 100 person-years of follow-up in the intervention groups and 5.3 events per 100 person-years of follow-up in the control group (HR = 0.92; 95% CI, 0.8-1.06).
In addition, Bhasin and colleagues determined that the rate of first participant-reported fall injury in the intervention group was 25.6 events per 100 person-years of follow-up, and was 28.6 events per 100 person-years of follow up among those who received usual care (HR = 0.90; 95% CI, 0.83-0.99).
According to the researchers, both groups had similar rates of hospitalization and death.
“The study reflects just how challenging it is to implement interventions to prevent fall injury in the real world,” Bhasin said. “Daily challenges such as being unable to afford transportation or the cost of follow-up care may delay or prevent access for patients to exercise interventions or other medical resources.”
In addition, he noted that adherence to assigned exercises may have been “less than optimal” among participants.
“We need to think about how to modify our health care systems to enable people to freely access effective interventions, such as exercise, to reduce fall injuries,” Bhasin said.