Elizabeth Eckstrom, MD, Oregon Health & Science University
A bad fall can become that disastrous inflection point of old age, the swerve into dependence, expensive care, and declining health. Numerous studies have suggested modest and inexpensive ways that falls can be prevented. Late last year, a meta-analysis published in JAMA that included more than 50 randomized trials showed that two interventions—exercise and vision correction—reduced the chances of falling by 38%.
But implementation of efforts to screen older people for fall risk—and to intervene before falls occur—have been scattershot at best. “I don’t think we need more studies—we’re studying studies of studies,” says Dorothy Baker, a senior research scientist at Yale and one of the country’s leading fall researchers. “We need more attention to ‘how do we move evidence into practice?’”
There are logistical and financial obstacles to implementation, according to Baker and other researchers. Busy physicians have a difficult time fitting the screening and other prevention efforts into appointments. Workflows and electronic health records may need changing. Some patients should be referred to a physical therapist—or perhaps a pharmacist should get involved. Tapping into that kind of outside help can be a challenge for smaller practices.
All of this requires time and money up front, notes David Reuben, MD, chief of the division of geriatrics at the David Geffen School of Medicine at UCLA and a principal investigator of a large-scale, randomized fall-prevention study. “Before [fall prevention] saves a nickel in reduced costs, or before it prevents one fracture, there is an investment.”
Patients will certainly benefit from fewer falls, and hospital systems or physicians might get some payoff in quality scores or patient satisfaction surveys. But financially, “the majority of the savings would go to the insurer,” says Reuben.
Fall-prevention studies go back more than two decades. One of the most frequently cited studies was published in 1994 in the New England Journal of Medicine. Led by one of Baker’s Yale colleagues, the study found that a mix of exercise and medication adjustments helped to reduce falls in older adults.
The more recent JAMA meta-analysis sorted through the evidence for 39 interventions and identified exercise, vision correction, and safety-related changes to the patient’s home as the most beneficial. Better nutrition, specifically calcium and Vitamin D supplements, also helped. But studies are often tightly controlled to ensure that participants comply. Real life is messier and more inconsistent. Reuben says the difference is why fall-prevention research findings have to be taken with a grain of salt.
Reuben is a principal investigator for one of the largest ongoing studies of fall prevention called STRIDE (Strategies to Reduce Injuries and Develop Confidence in Elders). It is looking at whether clinicians can implement a fall-prevention program across rural, urban, and suburban treatment settings to assess and address particular vulnerabilities of patients. For some, the problem might be poor balance. Others may have shoes that make them unsteady. Fall hazards at home include slippery rugs and poor lighting.
Reuben and his colleagues have enrolled more than 5,000 Americans, ages 70 and older, who have an elevated risk of falling and then randomized them to an intervention that includes care by a nurse trained in fall prevention or to usual care. STRIDE, which Reuben anticipates will have results by 2020, is tracking the number of serious falls in both groups.
Another key part is looking at follow-through. Patients might tell a clinician that they’ll attend an exercise program, Reuben says, “but will they do it?” The study is not looking at costs, because that’s not part of the mandate of its primary funder, the Patient-Centered Outcomes Research Institute. If the intervention does result in fewer serious fall-related injuries, future research will likely look at the cost-effectiveness of the approach, Reuben says.
Fall prevention already has some cost-effectiveness evidence, says Elizabeth Eckstrom, MD, who helped launch a fall-prevention effort in an internal medicine clinic at Oregon Health & Science University in Portland. She references a 2015 study of three exercise interventions that saved money, with tai chi reaping the largest net savings of $530 per participant per year.
Results from research conducted by Baker and her Yale colleagues have been instrumental in persuading the Connecticut state legislature to allocate funds for fall prevention. The state’s most recent funding is about $375,000 for a one-year period, ending in June 2018.
For most clinicians, setting up a fall-prevention effort is far harder than it might seem, says Eckstrom, who is chief of geriatrics in the division of general internal medicine and geriatrics at OHSU. A clinician with the right kind of training can assess a patient for fall risk and take some preventive steps, such as making a few medication changes, in about five minutes, Eckstrom says. But for a complicated patient with multiple risk factors, those five minutes could easily morph into 15.
Since 2013, Eckstrom has helped to lead an effort at OHSU’s internal medicine and geriatrics clinic to screen all patients aged 65 or older for fall risk. Flexibility is important. Clinicians can postpone the screening if they have an unusually large number of patients who are due on a given day, she says. During the last six months of last year, more than 1,700 adults were screened. The data on their fall risk is still being calculated, but roughly 20% to 25% have been identified as at least somewhat vulnerable, she says.
Patients frequently are swift to embrace any guidance once they realize that a debilitating spill isn’t an inevitable part of aging, Eckstrom says. “A lot of people say, ‘I’m so afraid of falling. But I have never talked about it with my doctor because I’m afraid they’ll put me in a nursing home.’”
Payers are not completely oblivious to fall prevention and cover some services that mitigate the risk. Eckstrom notes that Medicare currently covers physical therapy for a patient with balance or other walking difficulties as well as ophthalmology appointments. Some Medicare Advantage plans include Silver Sneakers, an exercise program designed for older adults. Doctors also can bill Medicare for a longer visit if they incorporate medication counseling, Eckstrom says.
One inherent challenge is that Medicare is still geared toward paying for medical services, such as physical therapy; there’s no CPT code for tai chi. “A lot of what we’re doing here is not medical care—it’s more health promotion,” Baker says.
What will it take to incentivize more comprehensive fall-prevention efforts? Eckstrom is hopeful that STRIDE will produce encouraging results and, eventually, cost-effectiveness evidence that will spur Medicare and other payers to cover screening and intervention.
After all, it’s the insurers, primarily Medicare, that pay the bills related to falls that might have been prevented—if only some money had been invested upstream, says Eckstrom. “They pay for that broken hip, and they pay for that bleed in your head.”