During the evaluation period, the adjusted rate of serious fall-related injuries in the intervention region was 9% lower than that in the usual-care region, and the adjusted rate of fall-related use of medical services was 11% lower. These differences persisted beyond the intervention and evaluation periods. Over half the targeted clinicians and facilities in the intervention region received CCFP team visits during the intervention period.
Although there have been several trials of fall-prevention strategies,10,11
few efforts have been made to evaluate translation of this evidence into clinical practice. The Assessing Care of Vulnerable Elders 2 (ACOVE-2) project is one study that focused on primary care physicians.42
Our project was the first attempt to disseminate evidence regarding fall-related injuries from randomized, controlled trials to clinicians from multiple disciplines. Therefore, there are no benchmarks against which to measure effectiveness. Clinical trials of multicomponent interventions have shown reductions ranging from 2 to 37% (mean, 27%).11
The Yale FICSIT trial, the primary source of evidence for CCFP, showed a 31% reduction in the rate of falls.21
Decline in effectiveness is expected when moving from trials (in which most participants receive a tightly controlled intervention) to clinical practice (in which a smaller proportion receive an intervention and the intervention is not as tightly controlled). Relative rate reductions of 9% in serious fall-related injuries and 11% in fall-related use of medical services represent a successful translation from research to clinical practice.
We used a nonrandomized design because a randomized one was not feasible. Although such a design is complex, the hierarchical, longitudinal analysis of a quasi-experimental design with a blinded outcome assessment can account for multiple levels of variability and minimize bias.41,43
The creation of a single intervention region and a single administrative usual-care region was necessary, given the intense nature of the intervention. Although the two regions were similar in population characteristics, additional unmeasured characteristics may have confounded the results.
Although the fall-related use of medical services was lower in the intervention region than in the usual-care region, rates increased in both regions. For persons who were 70 years of age or older, rates also increased nationally, from 56.9 per 1000 person-years in 2001 to 62.6 in 2004.44
Several factors may explain why rates in the usual-care region were higher, and increased more, than the national rates. First, our study population included 3 to 4% more persons than those included in the CMS denominator files, a factor that inflated our rates slightly. Second, we reported adjusted rates; the unadjusted rate in the usual-care region in 2001, 64.2, was closer to the national rate. Third, since Connecticut mandates the use of E-codes, it is likely that the use of such codes is higher in Connecticut than in states that do not mandate such use. Connecticut also levies fines if data are inaccurate or need to be revised, thereby encouraging complete and accurate reporting by hospitals. Fourth, rates of use of emergency departments and hospitals for any cause for persons 70 years of age or older increased in both the usual-care region (by 15%) and the intervention region (by 17%) between the preintervention period and the evaluation period. These rates were similar to the 22% increase seen in the usual-care region for fall-related use of medical services. Such use of services in the intervention region increased by only 5%, much less than the increase in the rate of use for any cause (17%) or in the national rate for fall-related use (10%).
We cannot exclude the possibility that there were differential changes between the two regions in coding practices or in the likelihood that older adults who fell would seek care. However, coders at the hospitals were unaware of the study, and CHIME staff members were unaware of the study hypothesis or which was the intervention region. Because persons with serious injuries essentially always seek care and these encounters are thoroughly coded, it was unlikely that observed differences in serious injuries in the two regions were the result of differential care seeking or coding.
Because no single intervention has proved to be exceptionally effective, we used multiple practice-change interventions.29–33
We cannot definitively state which components were most effective. However, in qualitative interviews that were reported previously, the intervention team identified enlisting working groups of local clinicians, repeating face-to-face (outreach) contacts over time, and using outreach to older adults as key strategies.20,22
We cannot determine which group or combination of groups (e.g., primary care clinicians or staff members involved in home care, rehabilitation, or senior centers) accounted for the observed differences in the rates between the two regions.
We previously reported on the adoption of fall-related practices after CCFP intervention.20,22–25
For example, 50% of primary care clinicians reported referring patients for balance disturbances, and 88% reported performing medication reviews.22
Among home care clinicians, more than 80% reported addressing postural hypotension, balance disturbances, multiple medications, and home hazards for at least some patients.25
Similar rates for instituting balance and gait treatments were reported by outpatient rehabilitation.23
We relied on clinician self-report, which may overestimate actual practices, because we could not directly measure practice behaviors. We also could not ascertain similar clinician practices in the usual-care region.
It is not possible to accurately determine the costs of the CCFP interventions or cost-effectiveness because, unlike trials in which investigators control the intervention, most activities occurred during clinical practice and training sessions. However, the intense efforts required are reflected in the number of encounters (). The increase in fall-related practices that were reported may have increased health costs, although many of the activities were incorporated into practices already performed. Methods are needed for tracking costs for this type of intervention.
Although a causal effect between CCFP efforts and the lower rates of serious fall-related injuries and use of medical services cannot be proved, at least three factors suggest that CCFP’s efforts accounted for differences observed. First, there were no other known secular trends that might explain the differences. Second, the lower rates were specific to fall-related use of medical services, whereas rates of use for any cause increased slightly more in the intervention region than in the usual-care region. Third, the divergence in rates coincided with intervention efforts.
Despite recognition of the need to improve the transfer of evidence from randomized, controlled trials into practice and evaluate the effectiveness of interventions in real-world settings, few such studies have been reported.17–19
Methods that were used in this project can inform efforts to enhance the adoption of evidence-based practices.17
From a clinical and public health perspective, the 11% relative reduction in the use of fall-related medical services in the intervention region, as compared with the usual-care region, translated into approximately 1800 fewer emergency department visits or hospital admissions. In addition to discomfort and disability averted, this decrease represents a potential savings of more than $21 million in health care costs on the basis of an average acute care cost of $12,000 per event.45
Although savings must be weighed against costs incurred in providing fall-related risk assessment and management, the recommended treatments represent good clinical practice apart from fall prevention because they bestow additional health benefits. Our findings must be replicated elsewhere, but they suggest that the dissemination of evidence to clinicians about fall prevention when coupled with practice-change interventions results in the adoption of effective strategies to prevent falls and may reduce the number of falls and injuries.