Adoption of Evidence-Based Fall Prevention Practices in Primary Care for Older Adults with a History of Falls

A multifactorial approach to assess and manage modifiable risk factors is recommended for older adults with a history of falls. Limited research suggests that this approach does not routinely occur in clinical practice, but most related studies are based on provider self-report, with the last chart audit of United States practice published over a decade ago. We conducted a retrospective chart review to assess the extent to which patients aged 65+ years with a history of repeated falls or fall-related health-care use received multifactorial risk assessment and interventions. The setting was an academic primary care clinic in the Pacific Northwest. Among the 116 patients meeting our inclusion criteria, 48% had some type of documented assessment. Their mean age was 79 ± 8 years; 68% were female, and 10% were non-white. They averaged six primary care visits over a 12-month period subsequent to their index fall. Frequency of assessment of fall-risk factors varied from 24% (for home safety) to 78% (for vitamin D). An evidence-based intervention was recommended for identified risk factors 73% of the time, on average. Two risk factors were addressed infrequently: medications (21%) and home safety (24%). Use of a structured visit note template independently predicted assessment of fall-risk factors (p = 0.003). Geriatrics specialists were more likely to use a structured note template (p = 0.04) and perform more fall-risk factor assessments (4.6 vs. 3.6, p = 0.007) than general internists. These results suggest opportunities for improving multifactorial fall-risk assessment and management of older adults at high fall risk in primary care. A structured visit note template facilitates assessment. Given that high-risk medications have been found to be independent risk factors for falls, increasing attention to medications should become a key focus of both public health educational efforts and fall prevention in primary care practice.

Introduction

Falls are the leading cause of unintentional injury-related deaths and non-fatal injuries in people aged 65 years and older (1). Falls predispose to injury, loss of independence, decreased mobility, hospitalization, nursing home placement, and early death (1–3). Each year, accidental falls result in over two million emergency department (ED) visits (1), and fall-related injury care costs exceed $30 billion annually (4). Of particular concern, rates of fall-related ED visits and hospitalizations are increasing (5, 6), and the proportion of older adults in the population is growing, creating an epidemic of falls. Clearly, prevention of falls and the injuries that they cause is a pressing public health issue.

Most falls in community-dwelling older adults result from a combination of risk factors (7–10). A multifactorial approach to assess and manage modifiable risk factors has been identified as an effective intervention for individuals with a history of falls (7–10). However, the extent to which this evidence has penetrated into routine health-care practice in the United States remains unclear (11–18). Data from over a decade ago from community-based primary care practices suggest that translation of fall-prevention evidence into practice was limited, with fall-focused physical examinations and treatment plans present in less than a third of medical records of patients who had sustained a fall (Order Now