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Clinical Question
What system-level changes are effective in reducing falls and injuries in the elderly?
Bottom line
The results of 126 randomized controlled trials (RCTs) indicate that changing the structure or organization of care teams is the only way to decrease the rate of injurious falls. However, combinations of care management, staff training, and patient education can decrease the number of patients who fall. Readers interested in this issue will want to read the original article for more details of the complex interventions. 1a-
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Government
Setting: Various (meta-analysis)
Synopsis
These authors performed a systematic review and network meta-analysis on 126 RCTs with 84,307(!!!) participants. The trials were of various quality improvement/system engineering strategies to decrease falls in the elderly. To find these studies, the authors searched several databases and registries, conference abstracts, and reference lists of included studies. After having been trained to a high level of proficiency, pairs of authors assessed potential studies for inclusion and methodologic quality. If disagreements occurred, a third author resolved them. Since quality improvement activities come in many shapes, sizes, and level of complexity, the authors employed a coder who independently applied a pre-established classification framework. Most of the participants were women and two thirds had no prior fall history. More than half the trials did not report medication use. Most of the studies (57%) took place in the home, 28% took place in clinics, 27% in the community, 15% in hospitals, 16% in chronic care facilities, and 8% in retirement homes (some studies took place in multiple settings). The RCTs ranged from 22 to 5310 participants; the cluster RCTs ranged from 80 to 10,558 participants. Overall, the studies were of modest quality. Using network meta-analysis, the authors determined that changing the structure or organization of care teams (addition of a team member, use of multidisciplinary teams, or the expansion or revision of roles) had a greater effect on reducing injurious falls than usual care (odds ratio [OR] 0.57 [95% CI 0.33 - 0.99). Compared with usual care, the number of patients who fell was much lower when there was a combination of case management, patient reminders, and staff education (OR 0.18; 0.07 - 0.47) and when there was a combination of case management and patient reminders (OR 0.36; 0.13 - 0.97). The authors were unable to perform network analyses on hospitalizations, emergency department visits, or outpatient visits.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI