Scoping Exercise on Fallers’ Clinics Report to the National Co-ordinating Centre for NHS Service...

Scoping Exercise on Fallers’ Clinics

Report to the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO)

March 2007

prepared by

Sarah Lamb*†

Simon Gates*

Joanne Fisher*

Matthew Cooke*

Yvonne Carter*

Christopher McCabe‡

*Warwick Medical School, University of Warwick, Coventry

†Kadoorie Critical Care Research Centre, University of Oxford, Oxford

‡Leeds Institute of Health Sciences, University of Leeds, Leeds

Address for correspondence

Professor Sarah Lamb

Warwick Medical School, The University of Warwick, Coventry CV4

7AL, UK

E-mail: [email protected]

Telephone: 024 7657 4658


© NCCSDO 2007 2

Contents

Glossary 5

Acknowledgements 5

Executive Summary 6

The Report 9

Section 1 Introduction 9 1.1 Background 9

1.2 Aims and objectives 10

1.3 A definition of a fallers’ clinic 10

1.4 Overview of methods 10

Section 2 National survey of fallers’ clinics and services 12 2.1 Introduction 12

2.2 Methods 12

2.2.1 Methodology 12

2.2.2 Sampling 12

2.2.3 Data capture 13

2.2.4 Analysis 15

2.2.5 Ethical approval 16

2.3 Results 16

2.3.1 Sample 16

2.3.2 Site of the clinic 17

2.3.3 Aims of the service 18

2.3.4 Referral to the service 19

2.3.5 Eligibility criteria 20

2.3.6 Age 21

2.3.7 Attendances 22

2.3.8 Staffing 22

2.3.9 Assessment 23

2.3.10 Interventions 26

2.3.11 Post-intervention follow-up 31

2.3.12 Cost of services and economic data available 31

2.4 Summary 31

Section 3 Estimates of the effectiveness of fallers’ clinics 33 3.1 Introduction 33

3.2 Eligibility criteria 33

3.2.1 Types of studies 33

3.2.2 Population 33

3.2.3 Types of intervention 34

3.2.4 Outcomes 34

3.3 Search strategy for eligible studies 35

3.3.1 Cochrane review 35

3.3.2 Update of the Cochrane review’s searches to 2003–2006 35


© NCCSDO 2007 3

3.3.3 Specific search for studies of falls clinics 35

3.4 Review methods 35

3.5 Included and excluded studies 36

3.6 Methodological quality of included studies 37

3.6.1 Randomisation 38

3.6.2 Blinding 38

3.6.3 Losses and exclusions 38

3.6.4 Follow-up 38

3.6.5 Recording of falls outcomes 39

3.6.6 Cluster-randomised trials 39

3.7 Results 39

3.7.1 Falls 39

3.7.2 Recurrent falls 40

3.7.3 Fall-related injury 40

3.7.4 Hospitalisation 40

3.7.5 GP attendance 40

3.7.6 Emergency department attendance 40

3.7.7 Death 41

3.7.8 Move to institutional care 41

3.7.9 Health-related quality of life and physical activity 41

3.7.10 Sensitivity analysis for inclusion of cluster-randomised trials 41

3.8 Discussion 41

Section 4 Systematic review of screening instruments to predict fallers among community-living older people 84 4.1 Introduction 84

4.2 Methods 84

4.2.1 Eligibility 84

4.2.2 Search strategy 85

4.2.3 Data extraction 86

4.2.4 Quality assessment of included studies 86

4.3 Statistical analysis 86

4.4 Results 86

4.4.1 Searches 86

4.4.2 Characteristics of studies 87

4.4.3 Methodological quality 88

4.4.4 Measurement performance 88

4.5 Discussion 91

4.5.1 Design, reporting and methodological quality of existing studies 92

4.5.2 Searching for relevant studies 93

Section 5 Cost-effectiveness systematic review 115 5.1 Introduction 115

5.2 Methods 115

5.2.1 Selection criteria 116

5.2.2 Search strategy 116

5.3 Results 117

5.4 Discussion 118


© NCCSDO 2007 4

Section 6 Feasibility of constructing a cost-effectiveness model of multi-factorial interventions for falls prevention 119 6.1 Background 119

6.2 Structure and parameter specification for a cost-effectiveness model 119

6.3 Evidence on parameters in cost-effectiveness models 121

6.3.1 Patient identification and eligibility 121

6.3.2 Effectiveness 121

6.3.3 Resource utilisation 122

6.4 Discussion 122

6.5 Conclusion 124

References 125

Appendices 156

Appendix 1 Summary economic data 156

Appendix 2 Search strategies for systematic review of effectiveness of faller’s clinics 175

Appendix 3 Quality-assessment tool for systematic review of effectiveness in fallers’ clinics 180

Appendix 4 Studies excluded from the systematic review of effectiveness of fallers’ clinics 182

Appendix 5 Search strategies for the systematic review of screening instruments 184

Appendix 6 Quality-assessment tool for the systematic review of screening instruments 192

Appendix 7 Studies excluded from the systematic review of screening instruments 194

Appendix 8 Search strategy for systematic review of cost-effectiveness of fallers’ clinics 198

Appendix 9 Quality-assessment tool used for the systematic review of economic studies 200

Appendix 10 Studies excluded from the economic systematic review 204


© NCCSDO 2007 5

Glossary

CI confidence interval

FPP falls-prevention programme

FRAT Fall Risk Assessment Tool

ICC intracluster correlation coefficient

MMSE Mini Mental State Examination

NICE National Institute for Health and Clinical Excellence

NPV negative predictive value

p.a. per annum

PPA physiological profile assessment

PPV positive predictive value

ProFANE Prevention of Falls Network Europe

RCT randomised controlled trial

ROC receiver operating characteristics

RR relative risk

SD standard deviation

SWWT test Stops Walking When Talking test

TUG test Timed Up and Go test

Acknowledgements

This research was supported with a project grant from the NHS

Service Delivery and Organisation R&D Programme (SDO/139/2006).

The authors would like to thank the following members of the National

Co-ordinating Centre for NHS Service Delivery and Organisation R&D

Steering Committee – Damian O’Boyle, Emma Hawkridge, Stuart

Anderson and Donna Cox – for constructive comments during the

project.

The authors would also like to thank Rachel Potter, Tarla Patel and

Heather Cooke for their assistance with data collection, Rachel

Lancaster for advising on the development of the search strategy for

the cost-effectiveness systematic review, Christopher McCarthy for his

assistance with data extraction for the systematic review of the

effectiveness of fallers’ clinics and Christelle Evaert for her assistance

in the preparation of this report.


© NCCSDO 2007 6

Executive Summary

The National Service Framework for Older People has stated the need

for fall-prevention programmes. An appraisal of fallers’ clinics

launched by the National Institute for Health and Clinical Excellence

(NICE) was suspended because of a lack of information regarding

existing services and typology. This project aimed to determine the

feasibility of conducting economic modelling to appraise fallers’ clinics.

To achieve this a national survey of services and reviews of the

evidence of effectiveness of various models of fallers’ clinics and

screening tools were undertaken.

We have defined a fallers' clinic as ‘a facility based in either primary or

secondary health care that administers services to individuals with the

purpose of preventing falls and involves qualified health professionals

in the delivery of some or all of the assessment and intervention.’ The

national survey was conducted by contacting all falls services in the

UK by telephone or e-mail. Interviews were undertaken using a

standardised template previously developed by the Prevention of Falls

Network Europe (ProFANE) group, establishing the approach of the

clinic, its geographical base and characteristics, the assessments

undertaken and the interventions used. A total of 298 services were

identified and 231 (78%) agreed to participate. Most services were

urban (61.5%) with an equal split between community- and acute-

sector bases. Only 2% of services were based in emergency

departments. Referral was mostly from health professionals (63%),

although some had open referral systems and 3% required referral

from a doctor. Most (92%) used specified criteria for referral, with

most using falls/near falls/fear of falls (74%) and/or specified

screening tools (61%). The most common tool was the Falls Risk

Assessment Tool (FRAT). The median number of attendances was 180

per annum and most clinics were staffed by a multi-disciplinary team

(92%) although composition was highly variable. Ninety-nine per cent

undertook a multi-factorial assessment but the components varied

considerably. The majority (91%) undertook gait and balance

assessment and many undertook environment (76%), medication

(72%) and cardiovascular (69%) assessments. The most commonly

used interventions were information provision (94%), exercise (81%)

and medication review (66%). Post-intervention follow-up was

undertaken by 51% of services. The total cost of services provided in

the UK is estimated to be approximately £32 million per annum.

A systematic review of randomised studies of effectiveness of fallers’

clinics was undertaken. The search strategy included Cochrane reviews

(including repeating their search strategies) and searches of the

MEDLINE and EMBASE databases. All articles were reviewed by two

authors. A total of 202 studies were reviewed of which 18 were studies

of eligible interventions. The quality of some of the studies since the


© NCCSDO 2007 7

last Cochrane review is poor. The evidence to support multi-factorial

fall-prevention interventions is inconclusive; with a range of

conclusions from no advantage to a 20% reduction in falls. The overall

estimate of risk reduction for further falls is 0.9 (95% confidence

interval 0.8–1.0). There were no clear advantages of location, of

selecting high-risk populations or from inclusion of a doctor in the

multi-disciplinary team. There is no clear effect on subsequent fall-

related injury, health-related quality of life or health care usage.

The systematic review of screening instruments focused on

prospective studies of community-dwelling people. A range of

electronic databases were searched (MEDLINE, EMBASE, PsycINFO,

CINAHL and Social Science Citation Index Expanded). This was

supplemented by hand searching of journals. Assessment was by two

independent reviews, using recognised quality-assessment tools.

Twenty-three articles were determined to be suitable for inclusion,

which included data on 28 different screening tools. Many studies were

excluded because they failed to report the data necessary for

evaluating test performance. The tests assessed by most studies were

the Tinetti mobility test, the Stops Walking When Talking test (SWWT

test) and the Timed Up and Go test (TUG test). There was, however,

variation in cut-off points to determine a positive test, the way tests

were utilised and the definitions of outcomes. It was therefore not

possible to combine results from different studies. The Tinetti mobility

test had an overall positive predictive value (PPV) of 0.31–0.68 and a

negative predictive value (NPV) of 0.67–0.88, with a reduced PPV if

only the balance element was used. The SWWT test in an unselected

population has a high PPV (83%) and NPV (76%), although sensitivity

was low (48%).The TUG test had variable cut-offs and hence studies

could not be combined. There is insufficient evidence to reliably

determine the quality and effectiveness of the screening tests.

A third systematic review was undertaken to study the cost-

effectiveness of fallers’ clinics in the UK. An extensive search strategy

was developed from that used by NICE and searched MEDLINE,

CINAHL, EMBASE, NHS EED, OHE HEED, the National Research

Register and bibliographic review. Data extraction and appraisal used

the Drummond and Jefferson framework. No suitable studies were

found on cost-effectiveness of UK fallers’ clinics although one study is

due to report in 2007. International studies were found but cannot be

used to inform UK cost-effectiveness.

The limitation of the information available means that the

effectiveness of various models cannot be confidently assessed and

economic modelling cannot be recommended. Present service

provision is highly variable in its format and activity. Hence it is not

possible to construct a cost-effectiveness model representative of

present falls-prevention activity in the NHS. To establish cost-benefit

outcomes we need reliable data, which are not available. Present

policy recommendations are not based on high-quality evidence. More

primary research on the predictive performance of screening tools, the


© NCCSDO 2007 8

effectiveness of interventions and the cost-effectiveness of falls

prevention programmes are required. In the absence of such research,

we cannot be confident that falls-prevention programmes are an

efficient use of limited NHS resources.


© NCCSDO 2007 9

The Report

Section 1 Introduction

1.1 Background

The National Service Framework for Older People (Department of

Health, 2001) requires that the NHS establish fall-prevention

programmes. Little operational guidance was provided until publication

of the National Institute for Health and Clinical Excellence (NICE)

clinical practice guideline for the assessment and prevention of falls in

older people in 2004 (National Institute for Clinical Excellence, 2004).

This guidance is summarised below.

Case/risk identification should be undertaken by screening older

people for the occurrence of falls in the past year. Among those

reporting a fall, or considered to be at risk of falling, further

observations of balance and gait should be undertaken and ability to

benefit from strength and balance interventions should be considered.

Multi-factorial assessment should be undertaken and may include

assessments of falls history, gait/balance/mobility, muscle weakness,

osteoporosis risk, perceived functional ability and fear relating to

falling, visual impairment, cognitive impairments and neurological

examination, urinary incontinence, home hazards, cardiovascular

examination and medication review. Individualised multi-factorial

interventions should be considered; they may include strength and

balance training, home-hazard assessment and intervention, vision

assessment and referral, and medication review with

modification/withdrawal.

Practitioners who are involved in developing falls-prevention

programmes (FPPs) should ensure that such programmes are flexible

enough to accommodate participants’ different needs and preferences

and should promote the social value of such programmes.

Specialist falls services may vary among providers in the detail of

configuration, staffing and leadership. The most cost-effective

configuration is not yet established. Specialist falls services should,

however, be operationally linked to both bone health (osteoporosis)

services and cardiac pacing services.

An appraisal of fallers’ clinics was launched in 2004 by NICE but was

subsequently suspended because of lack of information regarding

existing services and their typology. The general perception before

this project was commissioned was that services have evolved

disparately in terms of selection criteria, screening procedures and

localities, and with variation in the treatment modalities offered.


© NCCSDO 2007 10

1.2 Aims and objectives

The objective of this project was to determine the feasibility of

conducting economic modelling as part of an appraisal of UK fallers’

clinics, utilising either published or unpublished sources of data.

This objective was broken down in to series of aims.

1 To identify current models of fallers’ clinics (and hence the

pathway that should be modelled) by conducting a national

survey of existing services.

2 To review the published evidence of effectiveness of various

models of fallers’ clinics, and undertake evidence synthesis to

identify factors that are likely to determine the success of fallers’

clinics, estimate parameters for economic models and identify

areas where information is lacking.

3 To formulate a framework for economic modelling of fallers’ clinics

and to determine from (1) and (2) the feasibility of conducting

economic modelling with current information.

1.3 A definition of a fallers’ clinic

There is no definition of the term fallers’ clinic in the literature. In the

initial phases of the project we developed a broad definition of a

fallers’ clinic: ‘a facility based in either primary or secondary health

care that administers services to individuals with the purpose of

preventing falls, and involves qualified health professionals in the

delivery of some or all of the assessment and intervention’ (based on

the Oxford Medical Dictionary’s definition of a clinic). Our intention

was to review the scope of this definition as the project evolved, and

as we progressed we became aware that the predominant

characteristic of a fallers’ clinic in the UK was that it was an

environment in which health professionals undertook multi-factorial

fall risk assessment, followed by some form of linked intervention.

This was consistent with the NICE guideline.

1.4 Overview of methods

In formulating our methods, we considered fallers’ clinics as complex

interventions that would potentially comprise a number of variables

affecting clinical effectiveness and cost-effectiveness. These variables

include:

• staffing and organisation;

• the population targeted, in particular the baseline risk of falling;

• local organisational issues that might influence participant

selection, for example, whether referrals are from emergency

departments or from primary care alone;

• the screening strategy used to identify participants, and whether

any targeting is used to direct intervention and resource to those

at highest risk of injury or falling;


© NCCSDO 2007 11

• treatments provided: interventions may be low intensity (e.g.

group or home exercise programmes, advice- and knowledge-

based activities) or high intensity (e.g. tailored exercise

supervised individually by a health professional, home visits,

substantial home modifications, cardiac pacing, cataract surgery).

Our aim was to design a survey to capture the breadth of these

variations in service provision, and to determine the extent to which

we could identify a typical service configuration. It was intended that

this typical configuration (which we term a pathway) would inform the

basic structure of any economic model, and indicate key variables that

should be considered.

The next step of the project was to identify what evidence is available

to parameterise each significant variable on the pathway, including an

assessment of the quality of that evidence and its relevance for the UK

NHS. A priori, we intended that this quality appraisal would encompass

a systematic review of the effectiveness of multi-factorial

interventions, screening tools and cost estimates. In addition to

utilising usual methods for synthesising effectiveness of interventions,

we intended to extract detailed information on the interventions that

have been tested in published trials. This would enable us to judge the

extent to which parameters derived from the published literature could

be used to inform a robust model of the cost-effectiveness of fallers’

clinics. We intended to model the effectiveness of clinics, in

comparison with normal care, which we assumed to consist of

responsive treatment to clinical events associated with a fall. These

would include, but not be limited to, the probability of falls, probability

of fall-related injury; costs and impact on physical activity and quality

of life associated with each fall-related event; effect of prevention

clinic on various event rates including additional service utilisation and

the cost of fall-prevention interventions delivered. We anticipated

exploring the impact of clinic skill mix and characteristics of population

within the economic model.


© NCCSDO 2007 12

Section 2 National survey of fallers’ clinics and services

2.1 Introduction

The aim of the survey was to map the current organisational structure

and process of falls clinics/units in the UK that provide falls

assessment and or intervention. The rationale was to use the

frequency of various structures and functions estimated from the

survey to identify the most commonly occurring service-delivery

model in the UK. The profile of the model could then be compared with

interventions of known effectiveness to assess the extent to which

current practice replicates evidence-based models (see below), and to

determine the extent to which the evidence base could provide robust

estimates to model commonly used service-delivery models.

2.2 Methods

2.2.1 Methodology

A nationally representative telephone-based survey was conducted. All

reported falls services were contacted by telephone. The nature of the

study was explained and services were asked to participate in the

survey. Telephone interviews were chosen as they allow clarification of

detail more readily, particularly where organisational structures cannot

be anticipated, and help to ensure complete data capture.

2.2.2 Sampling

We sampled all fallers’ clinics in the UK. From experience, we

anticipated that the clinics may be nested in various different

organisations and as no directory of services is available, would be

difficult to locate. We utilised a number of different strategies to

ensure we had, as far as possible, complete sampling. Our aim was to

map the provisions of publicly funded fallers’ services within each

Primary Care Trust or health board including those provided by social

services. Therefore, as the first stage of sampling a letter explaining

the survey of practice and a contact form requesting contact details

for clinics were sent to the lead clinicians/managers/directors of all

UK:

• Primary Care Trusts,

• physiotherapy departments,

• gerontology (or equivalent) departments,

• emergency departments,

• social services.


© NCCSDO 2007 13

We supplemented this with a number of additional information

sources. The recently completed Department of Health/British

Association of Emergency Medicine-funded survey of emergency

department services in the UK was able to identify all emergency

departments that were providing fallers’ services. A request for

contact details of clinics/units was also posted on the following

websites:

• the Interactive Chartered Society of Physiotherapy website,

www.interactivecsp.org.uk;

• the Fallers’ Project website, www.warwick.ac.uk/go/fallers.

2.2.3 Data capture

We used a standardized template for data capture in the survey of

fallers’ clinics in the UK. This template was based on a taxonomy of

fall-prevention interventions developed by the Prevention of Falls

Network Europe (ProFANE). Full details are available at

www2warwick.ac.uk/fac/med/research/hsri/emergencycare/research/f

alls_clinics_project/taxonomy/. A taxonomy is a classification system

that identifies characteristics of a system or group of systems that can

be measured objectively, and are meaningful in terms of

distinguishing important differences between systems. The ProFANE

taxonomy was developed by international practice and academic

experts in fall prevention and is designed to improve the reporting and

design of fall-prevention interventions. It identifies the various

components of a fall-prevention intervention, and provides a uniform

method of coding and describing variables. It has been used

successfully in a number of meta-analytic projects where details of

interventions have been extracted retrospectively. This was its first

application in a prospective study.

In brief, components of the ProFANE data-extraction tool are:

• approach used by the clinic [its aims, selection and exclusion

criteria (screening tools) and referral routes];

• base and characteristics (site, geographical location, responsible

organisation, size and clinical lead);

• assessments undertaken to determine treatment plan and who

performs the assessment;

• interventions used, including the type, frequency, who provides

the treatment (single/multiple/multi-factorial, exercise,

medication, surgery, psychological, environmental, social

environment, knowledge, group-based interventions, method of

follow-up/promoting adherence).

We collected a number of additional items not included in the

taxonomy. These were the organisation overseeing the clinics’

activities, the relationship with other service providers, referral routes

into the clinic and onward, relationships with other local amenities and

services, and information about process, financial and outcome data


© NCCSDO 2007 14

that might be collected routinely. NHS Trust reports were used to

estimate the base population of services: the ethnic and age mix of

the local population, the sociodemographic index and whether the

clinic was based in a rural, urban or mixed area. A full list of all

variables collected is given in Table 1.

Table 1 Variables collected in the survey of 231 UK fallers’ services

Category Item

Demographics The name of the service

The name of the NHS Trust/Primary Care Trust

Number of new attendances per year

Population size of the catchments area

Location of the service

Aims Primary aims of the service

Referrals/ eligibility

Who refers to the service

Where referrals are taken from

Eligibility criteria for referral

Eligibility criteria for attendance

Who undertakes eligibility screening

Eligibility screening tools used

Client group(s) excluded

Age range of attendees

Gender of attendees

Who undertakes the eligibility screening

Assessment Geriatric assessment

Medication assessment

Gait, balance and/or mobility assessment

Environment assessment (housing, personal mobility, personal care and protection, aids for communication)

Cardiovascular

Vision and hearing

Surgery

Urinary incontinence

Dietary

Foot

Other

Psychosocial

Functional

Psychological

Who undertakes the assessments and interventions

Assessment tools used

Intervention Geriatric assessment


Gait and balance assessment

Environment assessment (housing, personal mobility, personal care and protection, aids for communication)


© NCCSDO 2007 15

Cardiovascular

Vision and hearing

Surgery

Urinary incontinence

Dietary

Foot

Other

Psychosocial

Functional

Psychological

Who undertakes the interventions

What resources they use

Follow-up of any interventions

What onward referrals are made and by whom

Economic How many FTE/WTE staff members work in the service and their grade

How patients are transported to the service

The eligibility for transport

Whether patients are provided with written, audio or video material

Floor area of the service? (m2/ft2)

Total overall budget

Drug budget

Equipment budget

Consumables budget

Provision of lunch

FTE/WTE, full-time equivalent/whole-time equivalent.

2.2.4 Analysis

The data were collated and analysed using the SPSS statistical

software package. The majority of the analysis is based on frequency

counts. We compared service profiles across three settings: acute

care, community settings and emergency departments by analysis of

descriptive data supplemented by a Chi-squared (χ2) test. Data from

these tests are presented only where statistically significant

differences were observed. Missing data were minimal (<30% for the

worst-case variable), and occurred only in the more detailed aspects

of the survey. Most often, missing data were attributable to the

member of staff we interviewed not being full aware of all aspects of

the service. Where data were missing we dealt with it in the most

conservative manner, by making the assumption that if the

respondent did not know, or did not report the variable in response to

questioning, the service was coded as not providing that service.

Overall, as missing data were on average less than 5% our results are

not likely to be significantly biased in this respect.


© NCCSDO 2007 16

2.2.5 Ethical approval

Due to recent changes in the UK Central Research Ethics Code of

Practice (COREC), ethical approval is no longer required for service-

evaluation projects. COREC confirmed that ethics approval was not

required for this study.

2.3 Results

2.3.1 Sample

We mailed a total of 2744 introduction letters and forms requesting

contact details of falls-prevention services and key personnel, between

1 June and 31 July 2006. A second letter and request form was sent to

non-responders after 6 weeks. Returns reporting falls-prevention

services were received from 597 respondents (shown in Table 2). The

clinics/units that responded were from every region across the UK.

The majority of returns were derived through the mail shot

(n=453/597, 75.8%), but additional returns were identified from the

Interactive Chartered Society of Physiotherapy website, and through

our own Fallers’ Project website (n=144/597, 24.1%).

Table 2 The number of returns and the total number of units of service

provision identified and surveyed

Returns Number

Total returns

postal

electronic

597

453

144

Ineligible

duplicates

from countries outside the UK

no clinic

services had closed in the preceding 18 months

undergoing re-organisation, due to open in 2007

not publicly funded

245

7

27

8

6

1

Eligible

declined to take part in the survey

3 were currently undertaking a research audit

2 do not participate in surveys

classed as non-responders after multiple contacts

303

3

2

67

Total available for analysis 231

Of the 303 services identified, 231 (76%) agreed to participate in the

survey. Three units declined as they were already taking part in a

research audit, and two had a policy not to participate in surveys.


© NCCSDO 2007 17

2.3.2 Site of the clinic

The majority of services were located in an urban area (n=142/231,

61.5%). Rural services were much less frequent (n=48/231, 20.8%)

and mixed rural/urban services were reported by 41/231 (17.7%).

The name of units varied widely across the sites; most units included

mention of falls or fallers in their title, with only nine (25.7%) services

not mentioning falls or fallers in their title. Not all services called

themselves a clinic.

The site of the service was defined as the place in which the first

contact occurred with the service unit. The most common base was a

hospital (n=222/231, 96%), with a near-equal division between

community and acute hospitals (Table 3).

Table 3 Point of contact with falls-prevention team (all categories)

Point of contact with falls prevention team Number (%)

Community hospital 107 (46.3%)

Primary care 2 (0.9%)

Community based (social services) 1 (0.4%)

Community based (other) 6 (2.6%)

Acute hospital 105 (45.5%)

Acute hospital (emergency department) 5 (2.2%)

Intermediate care hospital 5 (2.2%)

Total 231

Primary care-based services were surprisingly infrequent, as were

services based in emergency departments. To simplify further data

presentation, the categories of service-unit providers were collapsed

into three main categories and the remainder of the analysis are

based on these (Table 4):

1 community (the majority of which were community hospitals),

2 acute (including intermediate care facilities),

3 emergency department.

Table 4 Summary of point of contact with falls-prevention teams

collapsed into three categories (acute, community and emergency

departments)

Point of contact with falls-prevention team Number (%)

Community (community hospital, primary care, social services, other)

116 (50.2%)

Acute (including intermediate care) 110 (47.6%)

Emergency department 5 (2.2%)

Total 231


© NCCSDO 2007 18

Emergency DepartmentCommunity Acute

80

60

40

20

0

Count

0

26

15

0

31

17

5

59

78

Urban and Rural

Rural

Urban

LocArea

Figure 1 First point of contact with the falls-prevention service by

location (n=231)

The first points of contact with the falls-prevention service are broken

down by type of location in Figure 1.

2.3.3 Aims of the service

The most commonly cited primary aims for falls-prevention services

were reducing falls (n=127/231, 55.0%), reducing health and social

care resource use (n=58/231, 25.1%). Only 19.5% of clinics reported

reducing injuries to be part of their aim (Table 5).

Table 5 Primary aims of the falls-prevention service

Aim Percentage (n)

To reduce falls 55.0 (n=127/231)

To reduce heath and social care use including hospitalisation

25.1 (n=58/231)

To reduce fall-related injuries including fractures 19.5 (n=45/231)

To improve quality of life 12.6 (n=29/231)

To increase physical activity 7.8 (n=18/231)

To reduce fear of falling 10.0 (n=23/231)

To improve function 7.4 (n=17/231)

The total number of primary aims cited exceeds the number of services as some

services cited more than one primary aim.


© NCCSDO 2007 19

2.3.4 Referral to the service

The most frequent method of entry into a service was referral from a

health or social care professional (n=143/231, 62%) (see Figure 2).

Some services operated a more open referral system, accepting in

addition to health or social care referral, self-referral (n=73/231,

32%), family referral and referral from nursing homes, voluntary

agencies and care and home support services. Eight of the services

required a referral from or approval by a doctor (n=8/231, 3%). Who

can refer to a falls service is broken down by point of contact in

Figure 3.

Other (nursing homes/voluntary services)

Doctor only

Open

Health and social care professional only

Who can refer to to your unit (collapsed)

140120100806040200

5

8

143

73

Figure 2 Who can refer to the falls service

Emergency DepartmentCommunity Acute

80

60

40

20

0

032

0

44 5

60

78

0

48

25

Other (nursing homes/voluntary services)

Doctor only

Health and social care professional only

Open

ReferWhoCate

__

Figure 3 Who can refer to the falls service by first point of contact


© NCCSDO 2007 20

2.3.5 Eligibility criteria

The majority of clinics (n=212/231, 91.8%) used some form of criteria

to determine entry into the service (inclusion or exclusion). Of those

clinics using eligibility criteria, 183/231 (79.2%) used more than one

criterion (Figure 4).

Multiple criteriaSingle criteriaNo criteria

200

150

100

50

0

Count

183

2118

Figure 4 Services using multiple and single criteria for eligibility to the

service

The most common inclusion criteria were:

• falls, near falls or fear of falling (n=170/231, 73.6%),

• a published or unpublished screening tool (n=141/231, 61%),

• age (n=82/231, 35.5%),

• taking three or more medications (n=58/231, 25.1%).

Only 7.8% (n=18/231) of clinics used no criteria. None of the services

used gender as an eligibility criterion.

Published screening tools were used by 51/231 (22.1%) clinics, and

the remainder of clinics using screening tools used their own tool

(88/231, 38.1%) (Figure 5).


© NCCSDO 2007 21

Own toolNonePublished tool

100

80

60

40

20

0

Count

51

8886

Figure 5 Utilisation of published screening tools

The most commonly reported published screening tool was the Falls

Risk Assessment Tool (FRAT), which was reported to be used in 29

clinics (Table 6).

Table 6 Screening tools

Tool Frequency

Fall Risk Assessment Tool (FRAT) (Nandy et al., 2004) 29

Performance-Oriented Mobility Assessment (POMA) (Tinetti 1986) 1

NICE guidelines (National Institute for Clinical Excellence, 2004) 4

Falls Risk Assessment Score for the Elderly (FRASE) (Cannard, 1996)

7

Timed Up and Go (TUAG) test (Podsiallo and Richardson, 1991) 4

BERG balance test (Berg et al., 1992) 4

Confidence balance (CONFbal) (Simpson et al., 1998) 3

Fear of Falling Scale (FFS) (Wolpe and Lang, 1964) 1

Mini Mental Score (Folstein et al., 1975) 3

MORSE scale (Morse et al., 1989b) 1

Survey of Activities and Fear of Falling in the Elderly (SAFFE) (Lachman et al., 1998)

1

Other 3

The total number of published screening tools exceeds the number used as some

services utilised more than one published tool.

2.3.6 Age

The age range for clients attending the service was wide, from 16 to

105 years. The majority of services were limited to clients over


© NCCSDO 2007 22

60 years (n=145/231, 62.8%) but over one-third of services could be

attended by people aged 15 or over (n=82/231, 35.5%).

2.3.7 Attendances

The number of new attendances per year was reported by 142/231

services (61.5%) (see Figure 6). Two services were unable to report

attendance statistics for the year as they had only opened recently.

The median number of new attendances per year was 180 (range 10–

1700).

2000150010005000

Attend

50

40

30

20

10

0

Frequency

Mean =265.426Std. Dev. =283.3856

N =142

Figure 6 Reported attendance at falls clinics able to provide this

information

2.3.8 Staffing

The predominant staffing structure comprised a multi-disciplinary

team (n=212/231, 91.8%). The remaining services were

uni-disciplinary (n=18/231, 7.8%).

There was considerable diversity in team structure. Disciplines

mentioned included doctor, nurse, occupational therapist,

physiotherapist, postural instructor, technical instructor, rehabilitation

and physiotherapy assistants, exercise instructor, clinical exercise

specialist, generic technician, podiatrist, falls co-ordinator, pharmacist,

psychologist, social worker, speech and language therapists, dietician,

local government officer, advisor, handy person, falls-prevention

advisor (age concern) and health visitor.

Physiotherapists were the most frequently mentioned member of staff,

followed by nurse, occupational therapist and doctor. Of the 212

multi-disciplinary teams 187/212 (88.2%) included a physiotherapist,

163/212 (76.9%) included a nurse, 162/212 (76.4%) included an

occupational therapist and 123/212 (58%) included a doctor.

All four disciplines (physiotherapist, nurse, occupational therapist and

doctor) were found to comprise 70/231 (30.3%) of teams. Teams


© NCCSDO 2007 23

were more likely to have this configuration if they were based in an

acute-sector hospital (Figure 7).

Figure 7 Skills mix by setting

2.3.9 Assessment

Multi-factorial assessment was undertaken by 228/231 (98.7%) of

services. The components of the assessment varied across services.

The most common assessments were gait and balance (n=210/231,

90.9%), environment (n=176/231, 76.2%), medication review

(n=167/231, 72.3%), cardiovascular (n=160/231, 69.3%), vision

(n=135/231, 58.4%), cognitive function (n=124/231, 53.6%), foot

(n=123/231, 53.2%), nutrition (n=118/231, 51.1%), bone health

(n=107/231, 46.3%) and hearing (n=80/231, 34.6%).

Gait and balance assessment

The majority of services undertook a gait and balance assessment

(n=210/231, 90.9%). There were a wide variety of measures used

(Table 7). However, many measures failed to meet the criteria for the

definition of a gait and balance test as they were not observed tests of

performance of function, gait analysis, balance and/or strength (Lamb

et al., 2005).

Emergency Department

Community Acute

100

80

60

40

20

0

Count

5

90

65

0

26

44

Other skill mix

All four disciplines

Skill Mix


© NCCSDO 2007 24

Table 7 Gait and balance assessment tools

Assessment tools

180° Turn Elderly Mobility Score

Outside Mobility

1-leg stand Morse fall scale

BERG balance test Posture

Exercise tolerance Physiological Profile Approach

Flexibility Romberg

Falls Risk Assessment Score for the Elderly (FRASE)

Strength

Falls Risk Assessment Tool (FRAT) Tandem Stand

Functional reach Tinetti

Gait analysis Timed walk

3-metre

10-metre

Guide to Action Transfers

Hip fracture scale Timed Up and Go test (TUG test)

Internal and external shoulder rotation Timed Unsupported Stand (TUS)

Environment assessment

An environment assessment is designed to determine hazards in a

person’s home environment including inside and outside the home,

aids for personal mobility and communication and signalling, and for

personal care and protection (Lamb et al., 2005). The majority of

services undertake this assessment (n=176/231, 76.2%).

Foot assessment

A foot assessment was undertaken by 123/231 services (53.2%).

Vision assessment

The majority of services undertook an assessment of the patient’s

vision (n=135/231, 58.8%) either informally by asking clients whether

they were having difficulty seeing or when they last had their eyes

examined, or formally using an assessment tool. Of services that

utilised an assessment tool the most commonly used was the Snellen

chart (n=29/231, 12.6%).


An assessment of the client’s medication was undertaken by 167/231

services (72.3%).


© NCCSDO 2007 25

Cardiovascular assessment

A cardiovascular assessment was undertaken at 160/231 services

(69.3%). Components of the assessment mentioned by the services

are listed in Table 8.

Table 8 Cardiovascular procedures


Blood pressure

lying and standing

lying and sitting

24-hour monitoring

ambulatory assessment

Electrocardiogram

Echocardiogram

Tilt table testing

Sinus carotid massage

Listen to heart

24-tape

Incontinence assessment

Incontinence was assessed by 124/231 services (53.7%).

Cognitive and mental health assessment

Cognition was assessed by 124/231 services (53.5%). Commonly

used tools are shown in Table 9.

Table 9 Tests used to measure cognition and mental health

Assessment Number (%)

Cognitive

mini-mental

Mini Mental State Examination (MMSE)

Abbreviated mental test (AMT) score

Geriatric Depression Scale

Middlesex Elderly Assessment of Mental State (MEAMS)

Hospital Anxiety and Depression Scale (HADS)

124/231 (53.6%)

Comprehensive geriatric assessment

A total of 120/231 services (51.9%) reported undertaking an

assessment which was consistent with the definition of a

comprehensive geriatric assessment.

Nutrition

Over half the clinics assessed nutritional status (n=118/231, 51.1%).


© NCCSDO 2007 26

Bone health assessment

Fewer than half of the units reported undertaking an assessment of

bone health (n=107/231, 46.3%).

Hearing assessment

An assessment of the patients’ hearing was undertaken by 80/231

services (34.6%). Assessments of hearing were more likely to be

undertaken in the community setting (n=51/80) than in an acute

setting (n=26/80).

Other assessments

Other less commonly used assessments included daily functioning and

fear of falling.

2.3.10 Interventions

Most clinics utilised the traditional formulation of a multi-factorial

intervention; that is, multiple interventions matched to the findings of

the risk assessments undertaken (n=192/231, 83.1%). The most

commonly used intervention components were:

• knowledge: information provision (94% of clinics),

• exercise (89% of clinics),

• medication review (66% of clinics).

Knowledge: information and/or educational provision

Almost all services (n=215/231, 93.2%) provided information to

clients. The most common format was written, and some clinics

provided information in more than one format (Table 10). The topics

most commonly addressed were exercise, alcohol, benefits and

services available, bone health, continence, diet, environmental

hazards, foot care, getting up off the floor, medication and vision care.

This was in addition to published materials by the Department of

Health and voluntary organisations such as Age Concern (Table 11).

Table 10 Information format

Information Number (%)

No information provided 13/231 (5.6%)

Written information provided 215/231 (93.2%)

Video information provided 26/231 (11.3%)

Audio information provided 22/231 (9.6%)

The total number of types of information provided exceeds the number of

services as some services issued information in more than one format.


© NCCSDO 2007 27

Table 11 Topics for information leaflets

Written information leaflets

Staying steady

General health care

Osteoporosis

Benefits available

Avoiding slips, trips and broken hips

Safety in the home

Message in a bottle

Lighting in the home; changing lights bulbs, etc.

Some services also ran a formal educational programme (n=112/231,

48.5%). Typically sessions are run parallel to an exercise intervention

and cover the following topics:

• environmental hazards, home safety,

• lighting,

• flooring,

• vision, eye care,

• footwear, foot care,

• general health,

• continence,

• alcohol,

• medication,

• nutrition.

The most common format for formal educational interventions were

talks (n=109/231, 47.1%), given either by members of the team or

by invited external speakers such as a pharmacist or podiatrist. Other

speakers included representatives of Help the Aged and Age Concern.

A video was used by 3/231 services (1.3%).

Exercise intervention

Use of an exercise intervention was reported by 188/231 services

(81.4%). The majority of exercise programmes were undertaken at

the service location with some undertaken either at home and/or in

the community (note that the total number of exercise venues

exceeds 100% as some services offer more than one type of exercise

programme):

• supervised in the service location (n=182/231, 78.8%),

• in the client’s home (n=104/231, 45%),

• based in the community (n=48/231, 38.4%).

Exercise provision was varied, with some services combining

supervised and unsupervised home programmes, or unsupervised

home exercise, and some using a combination of an initial supervised

programme with progression to community-based programmes. The


© NCCSDO 2007 28

mean number of sessions per week was 1 (standard deviation

±0.04 weeks). The length of the programme varied from 2 to 24

weeks with a mean of 8 weeks (standard deviation ±2.96 weeks).

Four services (4/231, 1.7%) did not specify an end point to the

programme as it was dependent on the client’s progress.

Improving gait, balance, co-ordination and function (n=132/231,

57.1%), strength and resistance (n=73/231, 31.6%) and flexibility

(n=45/231, 19.5%) were the three most frequently cited purposes of

the exercise intervention. Others were improving endurance

(n=18/231, 7.8%), general physical activity (n=12/231, 5.2%) and a

practical demonstration of getting up off the floor (n=14/231, 6.0%).

Medication intervention

Following medication review, the majority of services (n=61/231,

26.5%) undertook a direct intervention to alter a prescription by

either modifying or removing medications (Table 12). A smaller

number of services (n=38/231, 16.5%) undertook an indirect

intervention (Table 12), referring patients to their GP (n=32/231,

13.9%), a pharmacist (n=4/231, 1.7%) or consultant (n=2/231,

1.4%) for the prescription modification. Just over 20% of services did

not intervene on medication.

Table 12 Intervention options following medication assessment

Medication intervention Number (%)

No intervention 48/231 (20.8%)

Direct intervention, including

withdrawing medication

reducing medication

substituting medication

provision of medication

advice

61/231 (26.5%)

Indirect intervention, including

doctor recommends changes to GP

pharmacist recommends changes to GP

referral to GP

referral to pharmacist

referral to consultant

38/231 (16.5%)

Bone health intervention

Fifty-five services (55/231, 23.8%) reported using an intervention

following a bone health assessment. Thirty services reported making

direct changes to prescriptions (30/231, 13.0%), including

commencing calcium, vitamin D and bisphosphates. Twenty-five clinics

(n=25/231, 18.5%) referred on to the client’s GP, consultant, or

pharmacist.


© NCCSDO 2007 29

Vision intervention

Following vision assessment, the most common management strategy

was onward referral to the optometrist or ophthalmologist (n=63/231,

27.2%), with 10/231 (4.3%) referring clients to their GP and 8/231

(3.5%) undertaking a vision intervention within the clinic. The

remainder did not report an intervention on vision, despite reporting

undertaking assessments in this domain.

Hearing intervention

The majority (n=37/231, 16.0%) of services referred on to an

audiology clinic, day hospital or GP following a hearing assessment.

Only 8/231 (3.5%) services undertook direct intervention (removal of

ear wax).

Environmental, personal mobility, prevention and signalling

interventions

The most commonly reported interventions were modifications to the

internal dwelling (n=80/231, 34.6%). The types of modification

undertaken were provision of bath/hand rails, raised toilets seats,

toilet frames, removal of rugs, cooking aids, lighting and trolleys.

Some services undertook these modifications themselves, with the

remainder referring on to social services, community occupational

therapist or a handy person.

Very few services (n=10/231, 4.3%) dealt with major external

modifications or substantial changes to lighting, flooring or bathrooms,

or with the provision of ramps or external rails. Just over 100 services

(n=102/231, 44.2%) referred these modifications to social services,

community occupational therapists or the Handy Man service. The

remainder made no intervention on the external dwelling.

Surprisingly, only a minority of services reported dealing with aids for

personal mobility. Interventions reported were prescription of walking

aids and provision of wheelchairs (n=77/231, 33.3%). Referral was

used where large aids such as electric wheelchairs were indicated

(n=67/231, 29%).

Only a minority of clinics reported intervening in the area of

protection. Interventions under this category were hip protectors

and/or safe footwear. Only a minority of services provided hip

protectors or safe footwear (n=39/231, 16.9%), with 67/231 services

(29%) either referring the client onwards or providing advice and

recommendations about hip protectors or safe footwear.

Only a minority of services reported addressing the need for signalling

devices. Twenty-five services (25/231, 10.8%) provided signalling

devices, and 72/231 (31.2%) either referred on or provided advice

about signalling devices. Onward referral was usually to home care

managers for community alarms. The information leaflets provided

were for LifeLine or CareLine.


© NCCSDO 2007 30

Incontinence intervention

The majority of services made an onward referral following an

incontinence assessment (n=74/231, 32.0%). The remaining either

undertook an intervention (n=15/231, 6.5%), including pelvic floor

exercises, the provision of incontinence items such as urinary bottles

and pads, and treatment of urinary-tract infections, or some other

treatment (n=11/231, 7.6%) (Table 13).

Table 13 Referral/intervention options following incontinence

assessment

Referral/intervention options

Refer to disciplines

urology (retention, spasms)

Interventions

medicate, antibiotics for urinary-tract infections

provide bottles

pads

incontinence pack

physiotherapy, exercises

Investigations

bladder scanner

MSU

Refer to health professionals

district nurse

GP

incontinence specialist team/nurse

occupational therapist

MSU, mid-stream urine specimen.

Surgery intervention

Surgical interventions included treatment for cataracts, pacemakers

and urinary-tract surgery. The majority of services made an onward

referral (n=62/231, 26.9%), either directly (n=47/231, 20.2%) or via

the client’s GP (n=15/231, 6.5%). Podiatry was offered by 20/231

(8.7%) of clinics, with some services referring on (n=48/231, 20.3%).


© NCCSDO 2007 31

Other interventions

Other interventions mentioned by the services sampled are listed in

Table 14.

Table 14 Other interventions

Item Number (%)

Practices (getting up off, travelling on the bus ) 14/231 (6.0%)

Outside walking 9/231 (3.9%)

Falls workbook 4/231 (1.7%)

Risky movements (carrying objects, etc.) 3/231 (1.3%

Peer mentors 1/231 (0.4%)

2.3.11 Post-intervention follow-up

Follow-up was undertaken by 118/231 services (51.1%). The

approach taken by the majority of services (75/231, 75%) was face-

to-face follow-up, either bringing clients back to the service or visiting

them at home. One service used written follow-up (1/231, 0.4%),

28/231 (12.1%) followed-up clients by telephone and the remainder

9/231 (3.9%) varied their approach, using either telephone or face-to-

face depending on the client. The length of the follow-up period varied

across services from 2 to 52 weeks; the mean number of weeks

follow-up was 21 (standard deviation ±16.9 weeks). The minimum

number of follow-up sessions was one and the maximum four. For

those providing follow-up, the usual mode of provision was one

session (56/231, 24.2%).

2.3.12 Cost of services and economic data available

Cost data are provided in Appendix 1. The average cost of providing

services in the acute sector was estimated to be £171,340 per annum

(p.a.) based on 79 services reporting these data. The average cost of

community services was £109,691 p.a. based on 78 services. The

average cost of emergency-based services was £175,430 p.a. based

on four services. The estimated grand total cost of fallers’ clinics is

£32,448,847 p.a.

2.4 Summary

The main components of a fallers’ clinic provided in the UK can be

described from this survey. The most common patient pathway is:

• access to the service is via referral from a health or social care

professional;

• a falls clinic based in a community or secondary care hospital;

there are likely to be some differences in costs between these two

environments;


© NCCSDO 2007 32

• most services utilise eligibility criteria; the most common criteria

are previous falls and/or a published or unpublished screening

instrument;

• the most frequently used screening instrument is the FRAT;

• all clients undergo multiple assessments;

• these assessments will be undertaken predominantly in the

service setting;

• Allied Health Professionals are the most commonly cited members

of the falls-prevention team; about half of the services utilise a

physician;

• the assessments used vary substantially between services, in

terms of number, combination and type.

• nearly all use an assessment of gait and balance, although the

quality of the assessments used is questionable; thereafter,

common assessments are environment, medication review,

cardiovascular and vision;

• assessments of bone health are surprisingly few, suggesting a

poor link-up to bone health services;

• interventions are most likely to be multiple, and the most

commonly reported combination of treatments is knowledge-

based interventions, exercise and medication review;

• the number of exercise sessions offered is low;

• onward referral is used in a number of models;

• follow-up is implemented by approximately 50% of services;

• routine data collection is poor.


© NCCSDO 2007 33

Section 3 Estimates of the effectiveness of fallers’ clinics

3.1 Introduction

There are some good-quality reviews of the effectiveness of fall-

prevention interventions available (e.g. Gillespie et al., 2003; Chang

et al., 2004), but none evaluates fallers’ clinics per se. All needed to

be updated to include recent evidence. There were a number of new

trials that needed to be considered. Our objectives were as follows.

1 To update the evidence relating to fallers’ clinics.

2 To determine whether any interventions currently included in the

review are similar to existing models of fallers’ clinics, and

whether they could provide robust estimates for economic

modelling. This involved an appraisal of intervention content that

was undertaken using the taxonomy tool, allowing us to link the

results of the survey and review more closely.

3 To conduct stratified meta-analyses to give estimates of

interventions’ effectiveness in different groups of patients

targeted by existing settings of fallers’ clinics, screening strategy

(low versus high risk) and intensity of intervention (characterised

by whether or not a medical doctor was included in the team).

4 Outcome measures were extended beyond current reviews to

consider fall-related injury, medical care and death, institutional

care and health-related quality of life.

5 To identify areas where there is insufficient information on

important outcomes.

3.2 Eligibility criteria

3.2.1 Types of study

Randomised controlled trials (RCTs; both individually and cluster-

randomised) and quasi-randomised studies were included.

Non-randomised studies such as cohort studies were excluded because

of their increased risk of bias.

3.2.2 Population

The population covered was older people (using any definition) living

in the community, not in nursing homes or hospitals. Studies of

particular patient groups (e.g. people who have had a stroke) were

included.


© NCCSDO 2007 34

3.2.3 Types of intervention

Studies were included if they evaluated an intervention fulfilling the

definition of a fallers’ clinic compared with a control treatment (most

often usual care) or compared with another intervention.

There is no definition of the term fallers’ clinic in the literature. In the

initial phases of the project we developed a broad definition of a

fallers’ clinic: ‘A facility based in either primary or secondary health

care that administers health services to individuals with the purpose of

preventing falls, and involves qualified health professionals in the

delivery of some or all of the assessment and intervention’ (based on

the Oxford Medical Dictionary definition of a clinic). Our intention was

to review the scope of this definition as the project evolved. For this

systematic review we included studies of interventions that fulfilled the

following criteria:

1 multi-factorial falls risk assessment; that is, assessment of more

than one risk factor for falling, undertaken with a view to either

predicting the likelihood of falling and/or identifying potentially

modifiable risk factors;

2 interventions to reduce the risk of falls are provided or arranged

by the clinic;

3 intervention is delivered to individuals, not at community or

population level;

4 comparator was either usual care or a control intervention (as

opposed to a second experimental treatment).

Studies were included regardless of whether the risk assessment and

delivery of interventions was undertaken in peoples’ homes or in a

central clinic.

3.2.4 Outcomes

Studies were included if they reported quantitative data on one or

more of the following outcomes:

• number of fallers or falls;

• recurrent falls (two or more falls in a 12-month period);

• fall-related injury:

• peripheral fractures;

• soft-tissue injuries (as defined by individual studies).

In addition, the following secondary outcomes were recorded:

• hospitalisation;

• unscheduled health service contacts;

• death;

• move to institutional care;

• health-related quality of life;

• physical activity/mobility.


© NCCSDO 2007 35

Studies were not included if they did not provide any data on any of

the falls outcomes, or they reported only surrogate outcomes such as

balance or strength.

3.3 Search strategy for eligible studies

Multiple search strategies were used to locate eligible studies for the

review.

3.3.1 Cochrane review

All studies located by the Cochrane review of Interventions for

preventing falls in elderly people (as published in The Cochrane

Library, Issue 3, 2006, last updated July 2003; Gillespie et al., 2003)

were considered for inclusion in this review. We considered all studies

included, excluded, ongoing and awaiting assessment.

3.3.2 Update of the Cochrane review’s searches to

2003–2006

We repeated the search strategy used by the Cochrane review,

covering the years 2003–2006, including seven electronic databases

(CENTRAL, MEDLINE, EMBASE, CINAHL, National Research Register,

PsycINFO, Social Sciences Citation Index). The search strategy was

used as published in the Cochrane review for MEDLINE, EMBASE and

CINAHL, with the correction of one typographic error. It was

translated into the correct syntax for PsycINFO, Social Sciences

Citation Index and CENTRAL.

The Cochrane review also searched the Cochrane Bone, Joint and

Muscle Trauma Group’s register, but this is not a publicly available

resource so it was not possible to repeat this search. All of the entries

in this database are ultimately transferred to CENTRAL, but the

group’s register is more up to date. Its omission therefore may

exclude some recent studies that are not indexed in other databases.

3.3.3 Specific search for studies of falls clinics

A specific search for studies of falls clinics was conducted in MEDLINE

and EMBASE, to determine whether searching using additional terms

specifically describing falls clinics would locate any additional studies

(see Appendix 2).

3.4 Review methods

The results of the searches were assessed by two authors of this

study, and potentially eligible papers were obtained as full reports.

These were evaluated further against the eligibility criteria, and

decisions were made about inclusion of each study. Disagreements

were referred to a third author and resolved by discussion.


© NCCSDO 2007 36

We extracted data from each included study onto a form designed for

this review. This included characteristics of the study, quality

assessment and outcome data. Characteristics of the interventions

were extracted using the ProFANE taxonomy for studies of fall

prevention. Quality assessment used the tool used in the Cochrane

review, with the addition of two questions specifically about cluster-

randomised trials (Appendix 3).

We used random-effects analysis for statistical combination of the

results of studies, because there was substantial heterogeneity

between studies in their populations, the interventions they evaluated,

the definitions of the outcomes used and the duration of follow-up. We

measured statistical heterogeneity in all analyses using the I2 statistic.

For studies that followed up participants for more than 12 months, we

used data collected at 12 months if they were available. For studies

with less than 12 months of follow-up, we used the longest duration

reported. We performed three subgroup analyses, stratifying by:

1 hospital-based versus primary care-/community-based;

2 high-risk population versus unselected population;

3 falls clinic team including a doctor versus not including a doctor.

For the third subgroup analysis, studies were classified as including a

doctor if a doctor was involved performing assessments or delivering

interventions that were provided by the clinic. Interventions were

classified as not including a doctor if treatments recommended as a

result of assessments were delivered by the participant’s GP or other

doctors not involved in the clinic. We performed interaction tests as

described by Deeks (2001) to investigate whether there was evidence

of differences in treatment effects between the subgroups. We did not

calculate interaction test statistics when one of the subgroups

contained only one or no trials.

Cluster-randomised trials were included in the analyses along with

individually randomised trials. To do this, the number of outcomes and

the denominator were adjusted to account for clustering by dividing by

the design effect. If the reports of the cluster-randomised trials gave

an estimate of the intracluster correlation coefficient (ICC), this was

used to calculate the design effect. If not, we used a value of 0.01 for

the ICC to include these studies in the figures, and we performed

sensitivity analyses assuming a range of ICC values from 0.001 to 0.1

to assess their effect on the results.

3.5 Included and excluded studies

The updated electronic search covering 2003–2006 retrieved 1087

records. Two hundred and nine studies from the Cochrane review were

considered for inclusion; however, seven studies listed as ongoing in

this review could not be located and were therefore not considered.

The specific searches for falls clinic studies retrieved 142 and 217

studies from MEDLINE and EMBASE respectively. No additional eligible


© NCCSDO 2007 37

studies were retrieved from the searches; therefore, we did not

extend the searches to other databases.

After screening of the titles and abstracts, 43 full papers were

obtained and considered in detail for eligibility. Of these, 18 were

comparisons of eligible interventions with a control group or usual

care, and hence were included. Twenty-five were excluded. Reasons

for exclusion are given in Appendix 4.

Characteristics of the 18 included studies are summarised in Table 15.

Fifteen studies randomised participants to receive some form of multi-

factorial risk assessment followed by individualised interventions

based on its findings, compared with usual care, which involved no

specific falls risk assessment or intervention. Three studies made a

slightly different comparison (Tinetti et al., 1994; Shaw et al., 2003;

Lord et al., 2005); they performed multi-factorial risk assessment on

all participants, who were then randomised either to receive

interventions to address the risk factors discovered by the

assessment, or to receive no interventions. Hence in these three

studies the control group received the assessments. These three

studies are included in analyses with the other studies because it was

considered unlikely that assessment alone would have an appreciable

effect on outcomes such as falls.

Two studies were cluster-randomised (Tinetti et al., 1994; Coleman et

al., 1999). One used physicians as the unit of randomisation (Tinetti)

and included 16 clusters with an average size of 18.8 participants.

Coleman et al. (1999) used the physician practice as the unit of

randomisation and included nine clusters with the same average size,

18.8 participants. The design effect assumed for presentation of these

studies in the figures (using an ICC of 0.01) was therefore 1.18. The

other 16 studies were individually randomised.

Two studies (Wagner et al., 1994, Coleman et al., 1999) did not

provide information on the number of participants included in

analyses, giving only the percentage with each outcome. For inclusion

in analyses we have assumed that there were no missing data and the

denominator is the number randomised. It is likely that there were in

fact some missing data in these studies and that the denominators we

have used are slightly too large. We contacted the first author of each

study to request the denominator data but did not receive any replies.

The characteristics of the interventions used in the included studies

are summarised using the ProFANE taxonomy in Tables 16 and 17.

3.6 Methodological quality of included studies

The methodology of the studies and the results of the quality

assessment are summarised in Table 18.


© NCCSDO 2007 38

3.6.1 Randomisation

Only five of the 16 individually randomised studies reported methods

of random allocation that had secure allocation concealment, and one

of these stated that allocations were concealed but did not describe

how. The other 11 studies did not report adequate information to

allow assessment of their randomisation methods. No studies reported

quasi-random allocation or any other methods that were clearly

inadequate.

3.6.2 Blinding

Blinding of participants and personnel delivering the interventions was

generally not possible in these trials. One study (van Haastregt et al.,

2000) achieved partial blinding of care providers by ensuring that

doctors were not aware of patients’ allocations; however, the nurses

who provided the intervention were not blinded.

Several trials used partial blinding of outcome assessment by ensuring

that personnel who were reviewing outcomes or interviewing

participants were not aware of allocations (i.e. investigator blinded).

3.6.3 Losses and exclusions

The proportion of randomised participants excluded from analyses

varied widely between trials. In five studies, losses and exclusions by

the end of follow-up were more than 20%. Principles of intention to

treat (i.e. that all participants are included in the analysis, and that

participants are analysed in the groups to which they were

randomised) were adhered to poorly in a number of studies. For

example, Hogan et al. (2001) excluded participants who did not

adhere to the protocol or were admitted to institutional care, and

Close et al. (1999) omitted those who did not complete the 12-month

follow-up. Where possible, we have restored participants

inappropriately excluded.

3.6.4 Follow-up

Follow-up duration was very variable, ranging from 2 months (Huang

and Acton, 2004) to 3 years (Jitapunkul, 1998). Thirteen studies

reported outcomes for a 12-month follow-up period, and three of

these studies performed a longer follow-up. Three studies presented

data for 6-month follow-up only (Gallagher and Brunt, 1996;

Lightbody et al., 2002; Whitehead et al., 2003), Huang and Acton

(2004) only for 2-month follow-up and Jitapunkul (1998) for 3-year

follow-up only. The variation in follow-up duration is likely to introduce

heterogeneity to the results. One study (Fabacher et al., 1994) used

different methods for follow-up of the two trial arms; for the

intervention group follow-up data were collected at a home visit, but

the control group were interviewed by telephone. This has the

potential to produce spurious differences between the groups.


© NCCSDO 2007 39

3.6.5 Recording of falls outcomes

Eleven studies used reliable methods to collect information on falls;

most used a diary or calendar to be returned at predefined intervals,

plus telephone contact if a calendar was not returned or if a fall was

reported. Three studies recorded falls only at intervals during

follow-up, and four studies collected falls data only at the end of the

follow-up period. These are likely to be significantly less accurate

methods.

3.6.6 Cluster-randomised trials

Of the two cluster-randomised trials included in the review, one

(Coleman et al., 1999) reported the use of adequate analytical

methods to take clustering into account but the other (Tinetti et al.,

1994) did not.

Overall, the mean quality score for studies was 21.3 out of a possible

maximum of 33, ranging from 16 to 26 (data shown in Table 18).

3.7 Results

The results of meta-analyses are summarised as forest plots (Figures

8–11), and statistics for interaction tests for the subgroup analyses

are given in Table 19.

3.7.1 Falls

Data on the number of fallers or the number of falls were available

from 18 studies. One study (Gallagher and Brunt, 1996) gave only the

mean number of falls in each group (intervention 1.7 compared with

control 2.1) but no standard deviations, and hence this study could

not be included in any meta-analysis.

Seventeen studies reported the number of people in each group who

experienced one or more falls. The overall analysis of the number of

fallers suggests a small reduction in the intervention group [relative

risk (RR) 0.9, 95% confidence interval (CI) 0.8–1.0], but there is

considerable heterogeneity between the studies (I2=59.5%). None of

the stratified analyses showed a statistically significant difference in

effect between the subgroups; there is therefore no evidence that the

location of the clinic, whether or not the population has risk factors for

falls or whether or not the team includes a doctor have any effect on

the number of participants that will fall.

We intended to include analysis of the fall rate (i.e. number of falls per

unit time of follow-up), but this was not possible for two reasons.

First, only two studies provided accurate data on the overall duration

of follow-up for each group. Second, the results were extremely

heterogeneous and statistical combination of them would not be

meaningful. These data were therefore omitted.


© NCCSDO 2007 40

3.7.2 Recurrent falls

Four studies reported recurrent falls. Close et al. (1999) and Hogan et

al. (2001) reported the number of participants who reported three or

more falls, whereas Lord et al. (2005) and van Haastregt et al. (2000)

reported those who had two or more falls. The overall analysis

suggested a reduction in recurrent falls in the intervention group

(RR 0.76, 95% CI 0.58–0.99), but again there was considerable

heterogeneity (I2=76%). Interaction statistics could not be calculated

for any of the stratified analyses because one of the subgroups

contained only one trial. The effect was larger (RR 0.44, 95% CI 0.28–

0.69) in the one hospital-based study that included a doctor in the

team (Close et al., 1999) than in the three other studies (RR 0.98,

95% CI 0.77–1.24).

3.7.3 Fall-related injury

Eight studies reported fall-related injury. Heterogeneity was

substantial (I2=55.7%), but there was no suggestion of an overall

treatment effect (RR 0.90, 95% CI 0.68–1.20). The heterogeneity

may be partly due to the differences in the outcomes recorded by the

different studies (Table 20); there were substantial differences

between studies in the types of injuries that were reported. There was

no evidence of any differences between the subgroups in the stratified

analyses.

3.7.4 Hospitalisation

Nine studies reported hospitalisation. Overall, there was very low

heterogeneity (I2=0%) and no evidence of a treatment effect

(RR 0.82, 95% CI 0.63–1.07). There was no evidence of a difference

between the subgroups in any of the stratified analyses.

3.7.5 GP attendance

This outcome was reported by one study (Lightbody et al., 2002),

which showed an increase in fall-related GP attendance in the

intervention group (RR 1.39, 95% CI 1.11–1.74).

3.7.6 Emergency department attendance

Fall-related emergency department attendance was reported by four

studies. Heterogeneity was moderate (I2=39%) and there was no

evidence of an overall effect (RR 0.96, 95% CI 0.72–1.27). There was

no evidence of a different effect in the subgroup of interventions that

included a doctor, in the one stratified analysis for which an

interaction statistic could be calculated.


© NCCSDO 2007 41

3.7.7 Death

Fourteen studies reported the number of participants that died during

follow-up. Overall, there was no evidence of a difference between the

groups (RR 0.96, 95% CI 0.73–1.27), and heterogeneity was very low

(I2=0%). The stratified analyses showed no evidence of any difference

between the subgroups.

3.7.8 Move to institutional care

Five studies reported the number of participants who moved to

institutional care during follow-up. Overall, there was no evidence of a

difference between the groups (RR 0.92, 95% CI 0.59–1.43; I2=0%),

and there was no evidence of any difference between the subgroups in

two stratified analyses.

3.7.9 Health-related quality of life and physical

activity

These outcomes were not reported by any studies.

3.7.10 Sensitivity analysis for inclusion of

cluster-randomised trials

Using values between 0.001 and 0.1 for the ICC for the two cluster-

randomised trials made very little difference to the analyses, and for

no outcome were the conclusions changed.

3.8 Discussion

The research literature has grown substantially since the last update

of the Cochrane review of fall-prevention effectiveness, and of the

literature review informing the NICE guideline on fall prevention.

Unfortunately, the quality of some of the more recent studies is poor.

The overall quality of the existing evidence from RCTs is not high. The

majority were small, and many had methodological drawbacks that

may leave them open to bias. For example, only five out of 18 studies

reported secure methods of allocation concealment. The sample sizes

of most studies were relatively small, and were insufficient to detect

modest but potentially clinically important differences. None of the

trials incorporate an estimate of the multi-factorial programmes on

health-related quality of life, or other metrics commonly utilised in

health economic appraisal. Only one study reported a parallel

economic evaluation that collected costs of the intervention and

resource in a methodological acceptable format. Unfortunately this

study was based in the USA, making it difficult to generalise to the UK

setting and health service system. No large-scale, high-quality RCTs

have yet been conducted, and there is therefore scope for such

studies to resolve the uncertainty about the effectiveness of this type

of intervention.


© NCCSDO 2007 42

The evidence to support the effectiveness of multi-factorial

fall-prevention interventions from existing studies is inconclusive.

There is substantial statistical heterogeneity between the trials. This

means that, in terms of reducing the number of fallers, the estimate of

effectiveness is uncertain, and not robust. The range of possibilities

spans from multi-factorial interventions being no more effective than

control interventions, or alternatively, that they may reduce falls by as

much as 20%. The average estimate of effectiveness is a 10%

reduction in the number of people falling. The overall analysis is of

borderline statistical significance in favour of multi-factorial fall

prevention being effective, and if a figure were to be selected for

economic analysis, the overall estimate of RR 0.9 (95% CI 0.8–1.0) is

the most robust. However, use of this estimate would require

knowledge of the cost implication of falls in general as opposed to falls

that result in injury.

There were no clear differences in effectiveness between hospital- and

primary care-based studies, populations with risk factors and

unselected populations and interventions that included a doctor.

The heterogeneity in falls outcomes is likely to be partly due to the

differences between studies in the populations they recruited and the

assessments and interventions that they provided. Studies varied in

the exact set of assessments of fall risks that they performed, and in

the interventions that were provided to address these risk factors.

Methodological heterogeneity is also likely to play a part; studies were

variable in their methodological quality and duration of follow-up.

Analysis of the fall rate ratio was expected to control for differences in

the follow-up duration and hence reduce heterogeneity; however, in

fact heterogeneity was highest in this analysis. Data to calculate rates

were available in only a small sub-set of papers, and hence are not

presented.

There were no clear effect on fall-related injury and use of health care

services. No effect was seen on analysis of fall-related injury, although

there was substantial heterogeneity in this analysis, which may have

been partly due to differing definitions of this outcome. Injury rates

could be estimated from these studies, both within- and between-

group differences. However, there are substantial differences in the

way that injuries have been reported, and these should be considered.

A recent international consensus conference concluded that the only

robust method of measuring injury was to estimate the rate of

peripheral fracture. None of the studies reported these rates.

One study suggested that GP attendance was increased by a multi-

factorial intervention, whereas the analysis of emergency department

attendance suggested no effect. Three studies report the effect on

unspecified medical care, but these data are of little use to economic

modelling, because the costs of different types of medical care can

vary substantially. These results appear to be inconsistent, but the

differences may be due to chance or methodological heterogeneity.


© NCCSDO 2007 43

Table 15 Characteristics of included studies

Study (country)

Setting

(recruitment; assessment)

Population characteristics

Inclusion/ exclusion criteria

Comparison Assessments Interventions Outcomes reported

Close et al. 1999

(UK)

ED; day hospital and home

Age: 78.2 (SD 7.6)

Sex: 68% female

Cognition: not stated

Aged ≥65

Presented to ED after a fall

Excluded if cognitive impairment and no regular carer, or non-English speaking

Medical and OT assessment and referral compared with no assessment

Medical assessment (day hospital):

Comprehensive general examination

Visual acuity

Balance

Cognition

Affect

Prescribing practice

OT assessment (home):

Functional independence

Environmental hazards

Psychological consequences of fall

Interventions to modify risk factors if possible

Referral to relevant services or day hospital

Advice and education about home safety

Minor home modifications made

Minor equipment supplied by OT

Referral to social or hospital services

Falls

Recurrent falls

Fall-related injury

Death

Move to institutional care

Coleman et al. 1999

(USA)

Primary care; primary care

Age: 77.3 (SD not given)

Sex: 48.5% female

Cognition: not

Aged ≥65

Patients of 9 practices; those with highest risk

Half-day chronic care clinics every 3–4 months compared with

Four-part assessment: 1. Physician and nurse assessment for planning chronic

Not specified Falls

Health-related quality of life


© NCCSDO 2007 44

Study (country)

Setting





stated scores for functional decline in each practice selected

Exclusions: too ill to participate, moderate to severe dementia, residence in nursing home, terminal illness

usual care disease management

2. Pharmacist assessment

3. Self-management group session

4. provision of health status assessment information to the practice team

Davison et al. 2005

(UK)

ED; hospital and home

Age: 77 (SD 7)

Sex: 72.2% female

Cognition: MMSE median 28.5

Aged ≥65

Presenting to ED with a fall or fall-related injury

At least one additional fall in previous year

Exclusions: cognitively impaired, >1 previous episodes of

Multi-factorial assessment and intervention compared with usual care

Medical assessment (hospital):

Vision

Neurological examination


Laboratory blood tests

Physiotherapy assessment (home):

Referral to optician or ophthalmologist

Advice on avoidance of factors precipitating orthostatic hypotension

Modification of medication

Compression stockings

Fludrocortisone

Falls

Fall-related injury

Hospitalisation

Death


© NCCSDO 2007 45

Study (country)

Setting





syncope, immobile, lived >15 miles from hospital, registered blind, aphasic, clear medical explanation for fall

Gait and balance (Performance Oriented Mobility Score)

Feet, footwear and assistive devices

OT assessment (home):

Home environmental hazards

and midodrine

Dual chamber cardiac pacing

β-Adrenergic antagonists

Gait re-education and functional training programme

Provision of assistive devices

Footwear modification

Referral to chiropody

Interventions for home hazards

Fabacher et al. 1994

(USA)

Community; home

Age 72.7 (SD 5.8)

Sex: 2.3% female

Cognition: not given

US veterans aged ≥70, not currently enrolled in a Veterans Association outpatient clinic

Exclusions: terminal disease, dementia

Home Assessment Program for Successful Aging (HAPSA) compared with no intervention

Home assessment by physician’s assistant or nurse:

Medical history

Medication review

Hearing

Vision

Height and

Personalised letter to each participant detailing findings and recommendations

Follow-up visits by volunteers or staff at 4-month intervals, to assist in carrying out

Falls

Hospitalisation


Death


© NCCSDO 2007 46

Study (country)

Setting





weight

Blood pressure

Oral inspection

Health behaviour

Mental status

Depression

ADL/IADLs

Gait and balance

Blood tests

Home environment

recommendations

Gallagher and Brunt 1996

(Canada)

Community; home

Age: 74.6 (SD not given)

Sex: approx 80% female


Aged ≥60

Fall in previous 3 months

No exclusions specified

Comprehensive falls risk assessment, counselling and motivational video compared with usual care

Nurse home assessment:

Physical health (checklist of 26 problems)

IADLs

Sickness Impact Profile

Blood pressure

Vision

Cognition (Folstein’s MMSE)

Gait

Total number of faults in gait

Counselling session providing feedback about result of risk assessment

Falls

Unscheduled health service contacts

Death

Health-related quality of life


© NCCSDO 2007 47

Study (country)

Setting





Static balance

Handgrip dynamometry

Chair stand

Medications

Home safety checklist

Gill et al. 2002

(USA)

Primary care; home

Age: 83.2 (SD 5.1)

Sex: 79.8% female

Cognition: MMSE mean 26.5 (SD 6.3)

Aged ≥75

Physically frail (more than 10 seconds to perform rapid gait test or could not stand from seated position with arms folded)

Excluded if unable to walk, undergoing physical therapy, did not speak English, diagnosis of dementia or scored <20

Home assessment by physical therapist followed by interventions compared with

health educational program (six monthly home visits) plus six monthly phone calls

Home assessment by physical therapist (average of 16 visits), assessed:

Impaired ability to move in bed or outdoors, to transfer from one position to another or indoor gait

Impairment in balance or range of motion

Presence of environmental hazards

Instruction in techniques to facilitate activity

Training in use of assistive devices

Removal of environmental hazards

Exercises

Removal of hazards

Repairs and installation of equipment and lighting

Falls

Death


Physical activity (disability score)


© NCCSDO 2007 48

Study (country)

Setting





on MMSE, life expectancy <12 months, had stroke, myocardial infarction, hip fracture or hip or knee replacement surgery within last 6 months

Hogan et al. 2001

(Canada)

Community; home

Age: 77.7 (SD 6.8)

Sex: 71.8% female

Cognition: MMSE mean 27.7 (SD 2.0)

Aged ≥65

Fall within past 3 months

Qualifying fall not during high-risk activity, in hospital or because of syncope or stroke, and not resulting in lower-extremity fracture

In-home assessment and development of individualised treatment plan compared with usual care

Home assessment by geriatric medicine specialist, nurse, OT or PT. Assessed:


Balance and mobility

Neurological and sensory impairment

Behaviour

Leg disability

Drug and alcohol use

Advice on environmental hazards

Referral to PT or exercise programme

Advice on assistive devices

Referral to optometrist or ophthalmologist

Behavioural advice

Exercises for leg disability or referral to exercise programme

Falls

Recurrent falls

Time to first fall

Fall-related injury

Fall-related hospitalisation


© NCCSDO 2007 49

Study (country)

Setting





Postural hypotension

Suggestions for drugs, alcohol and postural hypotension

Treatment plan to decrease fall risk devised

Recommendations in writing to participants, attending physician and referral source

Huang and Acton 2004

(Taiwan)

Community; home

Age: 72.0 (SD 5.7)

Sex: 45.8% female


Aged ≥ 65

Community living

Living in registered households


Standard and individualized fall prevention compared with standard fall prevention (written information) only

Home visits by researcher:

Gait and balance (Tinetti mobility scale)

Family support (Family APGAR scale)

Fear of falling (Falls Efficacy Scale)

Medications

Environmental safety

Individualised teaching and brochure based on subject’s risk factors

Falls

Jitapunkul 1998

Community; home

Age: 75.6 (SD 5.8)

Aged ≥70

Interviewed

Home visit and screening

Home visit by non-professional

Appropriate action taken,

Falls

Hospitalisatio


© NCCSDO 2007 50

Study (country)

Setting





(Thailand) Sex: 65.6% female


in previous study

questionnaire every 3 months compared with no intervention

Screening questionnaire including Barthel ADl index, Chula ADL index, fall surveillance questions; if ADL scores declined by >2 points or >1 fall in 3-month period, nurse or geriatrician visited to assess

including education, drugs, aids, rehabilitation, referral to hospital or social services Visits repeated as necessary until problem resolved

n

Death

Lightbody et al. 2002

(UK)

ED; home

Age: median 75, IQR 70–81

Sex: 74.4% female


Aged ≥65; discharged from ED after a fall

Excluded if admitted to hospital as a result of the fall, lived in institutional care, lived out of area

Falls nurse intervention compared with usual care

Home risk assessment by nurse

Medication,

Electrocardiogram

Blood pressure

Cognition

Vision

Hearing

Vestibular dysfunction

Balance

Mobility

Feet and

Referral to primary care, social services, relatives, etc.

Falls

Fall-related injury

Fall-related hospitalisation


Death


© NCCSDO 2007 51

Study (country)

Setting





footwear


Lord et al. 2005

(Australia)

Community; home

Age: 80.3 (SD 4.5)

Sex: 67.9% female


Aged ≥75

Randomly drawn from health insurance database

Excluded if minimal English, blind, Parkinson’s disease, Short Portable Mental Status Questionnaire score less than 7

PPA plus extensive intervention compared with PPA plus minimal intervention compared with PPA plus no intervention

PPA performed on all participants Unclear who performed assessments

Extensive intervention: PPA report, profile of test results and specific written recommendations. Counselling session to explain report

Individualised exercises, referral to eye specialist, eye surgery, counselling for strategies to compensate for reduced peripheral sensation, as appropriate

Minimal intervention

Report outlining falls risk, profile of test results, specific recommendations

Falls

Recurrent falls

Fall-related injury

Death


© NCCSDO 2007 52

Study (country)

Setting





Instruction sheets for home exercises and brief training session; list of exercise groups provided; written advice about vision and peripheral sensation

Newbury et al. 2001

(Australia)

Primary care; home

Age: mean 79.3

Sex: 63% female


Aged ≥75

Community living

Recruited from GP lists


75+ health assessment compared with usual care

Home visit from nurse assessed:

Hearing

Vision

Physical condition

Medication

Compliance

Vaccination, alcohol and tobacco use

Cognition

Depression

ADL

Mobility

Nutrition

Social

Housing

Problems found outlined in letter to GP

Falls

Death



© NCCSDO 2007 53

Study (country)

Setting





Pardessus et al. 2002

(France)

ED; home

Age: 83.2 (SD 7.8)

Sex: 78.3% female


Aged ≥65.

Able to return home after hospitalisation for falling

Excluded: cognitive impairment (mini mental test <24), no phone, lived >30 km from hospital, fall secondary to cardiac, neurologic, vascular or therapeutic problems

Home visit and assessment compared with usual care

Home visit from physical medicine and rehabilitation doctor and ergotherapist

ADL

Some IADLs

Transfers

Mobility


Environmental hazards modified where possible or advice given if modification impossible Hospital social worker contacted to discuss problems after visit

Falls

Hospitalisation

Death


Shaw et al. 2003

(UK)

ED; hospital

Age: 84 (SD 6.6)

Sex: 80% female

Cognition: MMSE median 13

Aged ≥65

Cognitive impairment and dementia (MMSE <24), presented to ED after a fall

Excluded if unable to walk, medical diagnosis that

Multi-factorial assessment and intervention compared with assessment followed by usual care

Multi-factorial clinical assessment for all participants at baseline, performed by doctor, PT and OT:

Medical history

Drugs

Management of untreated medical problems

Medication review

Referral to optician or ophthalmologist

Psychogeriatric assessment

Compression

Falls

Time to first fall

Fall-related injury

Hospitalisation



© NCCSDO 2007 54

Study (country)

Setting





was likely cause of fall, unfit for investigation within 4 months, unable to communicate, lived more than 15 miles from site of recruitment, no person in regular contact

Vision

Electrocardiogram

Depression

Cardiovascular

Performance- oriented mobility assessment

Walking aids, feet and footwear


hosiery, fludrocortisone or midodrine

Pacemaker

Supervised home exercise programme

Provision of walking aids and footwear

Chiropody referral

Home hazard modification

Death

Tinetti et al. 1994

(USA)

Primary care; home

Age: 77.9 (SD 5.3)

Sex: 69% female

Cognition: MMSE score ≥25, 84%

Aged ≥70

Enrolees of health maintenance organisation, independent ambulation, residence outside nursing home, score of ≥20 on MMSE, no participation in vigorous

Multi-factorial assessment and intervention compared with assessment followed by usual care

Multi-factorial assessments done for all participants

Home assessment by nurse/PT; nurse assessed:

History of falls

Medication

Depressive symptoms

Chronic diseases

Behavioural recommendations or medication changes for postural hypotension

Education about sedative-hypnotic agents

Nonpharmacologic treatment of sleep problems

Medication review with physician

Falls

Fall-related injury

Hospitalisation


Death


© NCCSDO 2007 55

Study (country)

Setting





sports or walking in month before enrolment, at least one risk factor


ADL

Falls efficacy scale

Sickness Impact Profile (ambulation and mobility)

Vision

Hearing

Home hazards

PT assessed:

Strength and joint impairment

Balance and transfer skills

Walking and stability

Transfer skills training

Environmental alterations

Gait training

Balance or strength exercises

van Haastregt et al. 2000

(The Netherlands)

Primary care; home

Age: 77.2 (SD 5.1)

Sex: 66% female


Aged ≥70

Community living

Two or more falls in previous 6 months or score ≥3 on Sickness Impact Profile mobility

Nurse home visits compared with usual care

Nurse home assessment on 5 occasions over 1 year:

Fear of falling

Mobility

Physical health

Drugs

ADL

Social functioning

Advice, referral and other actions aimed at dealing with observed problems

Falls

Recurrent falls

Fall-related injury



© NCCSDO 2007 56

Study (country)

Setting





control scale

Excluded if bedridden, wheelchair-dependent, terminally ill, on waiting list for nursing home or receiving home care from community nurse

Cognitive functioning

Psychosocial functioning

Home safety

Wagner et al. 1994

(USA)

Primary care; primary care

Age: mean 72.5

Sex: 60% female


Aged ≥65

Ambulatory and independent in ADL

Sampled from people receiving care from Seattle Group Health Cooperative clinics

Excluded if too ill to participate

Disability and fall-prevention nurse visit and interventions compared with chronic disease prevention visit versus usual care

All participants had baseline assessment, nurse visit reviewed risk factors at baseline assessment and also assessed:

Hearing

Blood pressure

Specific interventions for six risk factors as needed:

Inadequate exercise, high-risk alcohol use, increased fall risk, high-risk prescription drug use, impaired vision, impaired hearing.

Exercise class

Referral to alcohol treatment

Falls

Fall-related injury

Hospitalisation for falls

Medically attended falls


© NCCSDO 2007 57

Study (country)

Setting





programme

Home safety inspections, drug review by pharmacist, referral to audiological evaluation, information about community resources to allow poor vision to

maintain activity

Whitehead et al. 2003

(Australia)

ED; home Age: 77.8 (SD 7.0)

Sex: 71.4% female


Aged ≥65

Fall-related presentation to ED

Excluded if living in nursing home, cognitive impairment (MMSE <25/30) without resident carer, could not speak English,

Fall risk profile and individualised risk-reduction strategy compared with usual care

Authors’ own fall risk screening questionnaire (questions not specified in paper); fall risk profile derived from this Questionnaire administered during home visit by researcher

Customised strategy devised based on fall risk profile; GP sent letter highlighting risk factors and suggesting interventions:

Review of medication

Home assessment by OT

Participation in exercise programme

Assessment at interdisciplinary

Falls


© NCCSDO 2007 58

Study (country)

Setting





severe or terminal illness

fall and balance clinic

Assessment of osteoporosis risk

ADL, Activities of Daily Living; ED, emergency department; IADL, Instrumental Activities of Daily Living; IQR, interquartile range; MMSE,

Mini Mental State Examination; OT, occupational therapy or therapist; PPA, physiological profile assessment; PT, physical

therapist; SD, standard deviation.

57


© NCCSDO 2007 59

Table 16 Characteristics of interventions in emergency department-based studies

Close et al. 1999

Davison et al. 2005



Shaw et al. 2003


Age X X X X X X

Demographics

Previous falls X X X X X X

Chronic diseases/symptoms X

Medication

Screening tool

Selection

Specific exclusions X X X X

Hospital (emergency department)

X X X X X X

Residential care

Primary care

Site of recruitment

Community (home)

Hospital X X X

Residential care

Primary care

Site of delivery

Community (home) X X X X X

Doctor X X X X

Nurse X X

Physiotherapist X X

Occupational therapist X X X

Delivered by

Pharmacist


© NCCSDO 2007 60

Non-professionals X

Geriatric assessment X

Validated fall risk

Gait and balance X X X X X

Cardiovascular assessment X X X X

Medication review X X X

Vision X X X X

Foot assessment X X X

Psychological assessment X X X

Environment (dwelling units) X X X X X

Environment (public outdoor)

Environment (aids for personal care and protection)

X X X

Assessments

Other X X

Exercise (supervised) X X

Exercise (unsupervised) X

Medication X X X

Surgery X X

Psychological X

Environment/assistive devices X X X X X

Social environment

Knowledge X X X

Interventions

Referral X X X X X


© NCCSDO 2007 61

Table 17 Characteristics of interventions in primary care/community based studies

Coleman

et al.

1999

Fabacher

et al.

1994

Gallagher

and

Brunt

1996

Gill

et al.

2002

Hogan

et al.

2001

Huang

and

Acton

2004

Jitapunkul

1998

Lord

et al.

2005

Newbury

et al.

2001

Tinetti

et al.

1994

van

Haastregt

et al.

2000

Wagner

et al.

1994

Age X X X X X X X X X X X X

Demographics

Previous falls X X X

Chronic diseases/

symptoms

X X

Medication

Screening tool

Selection

Specific exclusions X X X X X X

Hospital (emergency

department)

Residential care

Primary care X X X X X X

Site of recruitment

Community (home) X X X X X X

Hospital

Residential care

Primary care X X

Site of delivery

Community (home) X X X X X X X X X X

Doctor X X X

Nurse X X X X X X X X X

Delivered by

Physiotherapist X X X


© NCCSDO 2007 62

Occupational

therapist

X

Pharmacist X

Non-professionals X X

Geriatric assessment X

Validated fall risk X

Gait and balance X X X X X X

Cardiovascular

assessment

X X X X

Medication review X X X X X X X X X

Vision X X X X X

Foot assessment

Psychological

assessment

X X X X X

Environment

(dwelling units)

X X X X X X X X X

Environment (public

outdoor)

Environment (aids for

personal care and

protection)

Assessments

Other X X X X X X X X X X X

Exercise (supervised) X X X X

Exercise

(unsupervised)

X X X X

Medication X X X

Interventions

Surgery

Unclear

X


© NCCSDO 2007 63

Psychological

Environment/assistive

devices

X X X X

Social environment

Knowledge X X X X X X X X X X

Referral

X X X X X X X


© NCCSDO 2007 64

Table 18 Methodology and methodological quality of included studies

Quality-assessment scores Study Randomisation Number randomi-sed

Blinding Losses/

exclusions

Follow-up

Notes

A B C D E F G H J K L X Y

Close et al. 1999

Individually randomised by random-number table held independently of the investigators (no further information)

397 No blinding 93 (23.4%)

No falls data included for those who died or moved to institutional care

12 months

Fairly large difference in numbers randomised between groups (184 and 213); stated to be attributable to chance when no mechanism for balancing numbers used

Analyses restricted to those who completed study

2 2 1 3 1 1 1 3 3 3 3 – –

Coleman et al. 1999

Cluster-randomised by physician practice

9 clusters

169 participants

No blinding 12 months: 27 (16.0%)

24 months: 42 (24.9%)

12 and 24 months

2 3 1 3 1 1 3 2 1 1 3 Yes No

Davison et Individually 313 Outcomes 31 (9.9%) 12 1 2 2 3 1 1 1 3 3 3 3 – –


© NCCSDO 2007 65

Quality-assessment scores

al. 2005 randomised States ‘computer-generated block randomisation’ but no information on how it was used

self-reported but processed blinded Participants clinicians not blinded

months

Fabacher et al. 1994

Individually randomised Cards in sealed envelopes, done over phone by study personnel Numbering not mentioned

254 No blinding 59 (23.2%) 12 months

Follow-up done in different ways for the two groups; home visit for intervention group, phone for control group

2 2 1 2 1 1 1 3 1 2 3 – –

Gallagher and Brunt 1996

Individually randomised. No information on methods

100 No blinding 0 (0%) 6 months

1 3 1 2 1 1 1 3 1 3 2 – –

Gill et al. 2002

Individually randomised ‘Computer-generated algorithm’ but no information


1 3 1 3 1 1 1 3 3 2 3 – –


© NCCSDO 2007 66


on how it was used

Hogan et al. 2001

Individually randomised States allocation sequence concealed in locked cabinet prior to allocation but no further information on methods

152 Research assistant contacting participants about falls blinded Participants and caregivers not blinded

13 (8.6%) 12 months

Participants who did not adhere to protocol or were admitted to an institution were excluded from analysis

2 2 2 3 1 1 1 3 3 3 3 – –

Huang and Acton 2004

Individually randomised

No information on methods


1 1 1 3 1 1 1 3 1 3 2 – –

Jitapunkul 1998



160 No blinding 44 (27.5%) 3 years 1 2 1 2 1 1 1 1 2 1 3 – –


Individually randomised Unclear whether allocations concealed before assignment


1 2 1 2 1 1 1 3 3 3 2 – –


© NCCSDO 2007 67


Lord et al. 2005

Individually randomised States allocations were concealed but no information on how this was implemented


Falls data available for more participants than completed 12-month follow-up Suggests follow-up was incomplete for some

3 2 1 3 1 1 3 3 3 3 3 – –

Newbury et al. 2001

Individually randomised by sealed numbered envelopes

100 Researchers blind to intervention status when assessing patients Patients and caregivers not blinded

11 (11%) 12 months

3 2 2 1 1 1 1 3 1 1 3 – –


Individually randomised by random-number table


60 No blinding 0 (0%) 12 months

1 3 1 3 1 1 1 3 1 2 3 – –

Shaw et Individually 308 Blinded outcome

34 (11.0%) 12 3 2 3 3 1 1 1 3 3 3 3 – –


© NCCSDO 2007 68


al. 2003 randomised

Computer- generated random numbers, assignment done by independent researcher blind to baseline data

assessment

(216/308 completed follow-up; 70.1%)

months

Tinetti et al. 1994

Cluster-randomised by physician

16 clusters

301 participants

Blinded interviewers assessed falls

Participants and caregivers not blinded

10 (3.3%) 12 months

3 2 2 3 1 1 1 3 3 3 3 No No


Individually randomised ‘Computer generated random numbers’

No information on method of assignment

316 Doctors blinded; nurses doing home visits not blinded Participants not blinded

12 months: 64 (20.3%)

18 months: 81 (25.6%)

12 and 18 months

1 2 1 3 1 2 1 3 2 3 3 – –

Wagner et al. 1994


No information

1559 No blinding 89 (5.7%) 12 and 24 months

Numbers analysed in each group

1 1 1 3 1 1 1 2 3 1 3 – –


© NCCSDO 2007 69


on methods not given; outcomes reported as percentages only


Individually randomised Numbered, sealed opaque envelopes


3 1 1 3 1 1 1 3 3 3 2 – –

See Appendix 3 for the quality-assessment tool used.


© NCCSDO 2007 70

Table 19 Results of interaction tests

Hospital×community Risk factors×unselected Doctor×no doctor Outcome

χ2 P χ2 P χ2 P

Fallers 0 1 2.61 0.11 0 1

Fall-related injury 0.1 0.75 0.42 0.52 0.1 0.75

Hospitalisation 0.75 0.39 0.06 0.81 1.12 0.29

ED attendance – – – – 2.8 0.09

Death 1.47 0.23 1.58 0.21 0.19 0.66

Move to institutional care 0.3 0.58 – – 0.3 0.58

ED, emergency department.

Table 20 Details of fall-related injuries included in outcomes

Study Injuries reported

Close et al. 1999 Serious injury (fracture or dislocation)

Davison et al. 2005 Fractured neck of femur, other fracture

Gill et al. 2002 Fall-related fracture (fractures were of hand, hip, coccyx, shoulder)

Lord et al. 2005 Falls resulting in injury (self report, no definition)

Shaw et al. 2003 Major injury (not defined)

Tinetti et al. 1994 Serious injury due to fall: fracture, head injury requiring hospitalisation, joint dislocation or severe sprain, lacerations requiring suturing


Injurious fall (not defined)

Wagner et al. 1994 Injurious falls (self reported, no definition given)


© NCCSDO 2007 71

Figure 8 Analyses including all studies


© NCCSDO 2007 74

Figure 9 Analyses stratified by location of clinic


© NCCSDO 2007 78

Figure 10 Analyses stratified by whether or not population was selected

for risk factors


© NCCSDO 2007 82

Figure 11 Analyses stratified by whether or not the team included a

doctor


© NCCSDO 2007 85

Section 4 Systematic review of screening instruments to predict fallers among community-living older people

4.1 Introduction

Identification of older people at high risk of falling would theoretically

allow targeting of fall-prevention interventions to those most likely to

benefit from them. A large number of possible screening instruments

have been proposed that may be able to predict fallers, including tests

of balance and gait, and scores based on a person’s risk factors for

falls. In this review we aim to assess the evidence about the accuracy

of screening tests for predicting fallers, and indicate where more

research is needed.

4.2 Methods

4.2.1 Eligibility

Studies were included if they satisfied the following eligibility criteria:

1 prospective cohort studies that evaluated the performance of one

or more screening tests for predicting fallers;

2 the population was elderly people living in the community;

3 falls were recorded prospectively; that is, participants were

followed-up for falls occurring after the screening test was

performed;

4 follow-up was at least 3 months;

5 data were presented on sensitivity, specificity, positive predictive

value (PPV), negative predictive value (NPV) or receiver operating

characteristics (ROC) curves, for falls or fall-related injuries.

We included studies of older people living in the community and in

residential care environments where they were substantially

independent. We excluded hospital populations and residential care

situations where participants were not independent. A few studies

which recruited participants in hospital but followed them up after

discharge (hence recording falls among people living in the

community) were included.

We excluded studies that used a screening test to ‘predict’ falls that

had already occurred. In these retrospective studies performance on

the screening test is related to a patient’s history of falls. This study

design may give misleading results because past falls may affect test

performance, and hence overestimate the accuracy of screening

instruments. Moreover, this design does not represent a real-life

clinical situation, in which clinicians need to predict future falls.


© NCCSDO 2007 86

We included studies that assessed the performance of tests that have

been proposed or are used for prediction of fallers in clinical practice.

Studies that built a multivariate model and then assessed its

performance were not included. Some individual risk factors; for

example, previous falls, could be used clinically for prediction of falls.

However, it was not possible to include them in this review because

most of the studies that have evaluated them were risk-factor studies

that analysed their data using multiple-regression techniques and did

not report the relevant data or summary statistics.

Studies had to report the number of people positive and negative on

the screening test (or a range of cut-off values if appropriate), and the

number of people with falls or fall-related injuries within a specified

duration of follow-up for each of these groups, or summary statistics

such as the sensitivity and specificity. Studies were not included if

they reported results as odds ratios or risk ratios, without the raw

data from which sensitivity, specificity, PPV and NPV could be

calculated. A duration of follow-up of at least 3 months was required

for inclusion, although reliable identification of fallers requires much

longer follow-up than this. This was reflected in the quality

assessment, where 12 months or more of follow-up was required for

the highest-quality grading.

4.2.2 Search strategy

Electronic search

We searched MEDLINE (1966 to July 2006), EMBASE (1980 to July

2006), PsycINFO (1975 to July 2006), CINAHL, Social Science Citation

Index and Social Science Citation Index Expanded (all 1970 to July

2006). Searches were conducted in July 2006.

We based the search strategy on the search strategy of van der

Weijden et al. (1997), which was found to be the most effective in a

recent review (Leeflang et al., 2006). We added extra terms to this

search strategy, because it is likely that eligible studies for this review

would not use terms usually associated with diagnostic studies in their

title or abstract. The extra terms were ‘risk assessment’ or

‘assessment tool’, and the names of known possible screening

instruments. The search strategies used for each database are given

in Appendix 5.

Review articles and reference lists

We considered for inclusion all studies included in four earlier reviews

(Perell et al., 2001; Jarnlo, 2003; Myers, 2003; Oliver et al., 2004).

We also inspected the reference lists of all eligible studies to identify

any further studies that were cited by them.


© NCCSDO 2007 87

Hand searching

We conducted a hand search of two volumes of two journals, to

estimate the number of eligible articles that might have been missed

by the electronic search. The two journals were selected at random

from the last six volumes of journals with five or more papers in the

list of papers to be considered for inclusion. The volumes searched

were Journal of the American Geriatrics Society, volume 50 (2002),

and Physical Therapy, volume 83 (2003). The hand search found no

additional eligible articles.

4.2.3 Data extraction

Data were extracted by two reviewers independently, and

discrepancies resolved by discussion or by reference to a third

reviewer.

4.2.4 Quality assessment of included studies

We used a modified version of the QUADAS quality-assessment tool

(Whiting et al., 2003). Three items (numbers 4, 7 and 10) were

omitted as they were not applicable to this review and other questions

were rephrased to be relevant to this review. The quality-assessment

tool is given in Appendix 6.

4.3 Statistical analysis

For each study, the specificity, sensitivity, PPV and NPV were either

extracted from the paper or calculated from the data extracted from

the paper, where this was possible. We planned to carry out

meta-analyses combining the results of independent studies that used

the same screening test with the same cut-off point to determine

positive tests, measured the same outcome and used similar

populations. In fact there were only a few studies that could be

combined, and excessive heterogeneity among them meant that this

would not be meaningful. Hence, no meta-analyses were performed.

Results were tabulated, giving the sensitivity, specificity, PPV, NPV and

95% CI for each screening test in each study.

4.4 Results

4.4.1 Searches

The electronic search yielded 3028 citations. Of these, 116 were

selected for further consideration based on their title and abstract, and

full reports obtained. The search of the reference lists of the review

articles and all selected studies yielded an additional nine potentially

eligible studies, which were also obtained as full reports. One hundred

and twenty five full reports were considered (Table 21). Twenty-three

studies were eligible and included in the review. Studies excluded from


© NCCSDO 2007 88

the review are given in Appendix 7. Thirty-three studies included

ineligible populations, which were either hospital patients (31 studies)

or populations including all age groups (two studies). Falls data were

not collected prospectively in 19 studies, and 11 studies did not

provide information on falls. Many of these assessed the relationship

of a screening test with another marker of falls risk, often another

screening test. Twenty-four studies did not report relevant data; these

included multiple-regression analyses of risk factors, and studies that

evaluated screening tests but did not present the required statistics or

the raw data.

Nineteen of 23 included studies were located by the electronic search,

three from reference lists of other studies that were considered for

inclusion, and one from a previous review article.

4.4.2 Characteristics of studies

Of the 23 eligible studies (Table 22), 19 either presented quantitative

data for 2×2 tables of the numbers of fallers and non-fallers who were

positive and negative for one or more screening tests, or these data

could be calculated from information given. Two studies (Nandy et al.,

2004; Smith et al., 2006) presented sensitivity, specificity, PPV and

NPV, and two (Stel et al., 2003; Lin et al., 2004) reported the area

under the ROC curve for the tests they included.

In the majority of studies (17) participants were community residents,

but in six they were living in residential care or retirement

communities. They were stated to be substantially independent in all

studies. Three studies (Hyndman and Ashburn, 2004; Andersson et

al., 2006; Smith et al., 2006) recruited patients who had recovered

from a stroke, and one (Bloem et al., 2001) studied patients with

Parkinson’s disease. These studies were considered separately from

the studies of the general population as their risks of falling are

substantially different. The remainder of the studies (19) recruited

unselected populations of elderly people, although many excluded

those with cognitive impairment or specific diagnoses.

In total the 23 included papers reported data for 28 different

screening tests. The tests assessed by the most studies were: Tinetti

mobility scale (including studies using just the balance component; six

studies), the Stops Walking When Talking test (SWWT test; four

studies) and the Timed Up and Go test (TUG test; four studies).

However, in most cases even where studies used the same test, there

were differences in the cut-off value used to determine a positive test,

or in the way the test was performed (see Discussion, section 4.5).

Also, the definitions of falls outcomes differed between studies. Some

studies reported all falls, but others reported recurrent falls or

excluded some types of fall from their outcome (Table 22). These

differences are likely to introduce heterogeneity into the comparisons

between studies.


© NCCSDO 2007 89

4.4.3 Methodological quality

Table 23 gives the quality-assessment scores for the 23 studies.

Follow-up period

Follow-up periods were variable, from 3 months to 5 years. Only two

studies had less than 6 months’ follow-up, and 11 had 12 months or

more.

Recording of falls

Only 9/23 studies (39%) used falls diaries, calendars or other

prospective methods of recording falls. The remainder either used

participant recall at predefined intervals or at the end of the follow-up

period only. With long follow-up periods these methods may lead to

under-reporting.

Reporting of tests

The majority of studies (18/23, 78%) reported screening tests in

sufficient detail or gave references to a description elsewhere. In some

cases, where several studies evaluated the same test, it was not

possible to be sure that the test was performed in the same way in

different studies. For example, four studies evaluated SWWT, but two

of them gave insufficient detail about implementation of the screening

tests, so it is possible that it was performed in a different way from

the other studies. In the case of the Tinetti balance and gait scales,

there were differences in scoring and the number of assessments

performed between studies.

Blinding

Only a few studies reported measures to ensure that assessment of

falls outcomes was not influenced by knowledge of the screening test

results. In most studies falls were self-reported and it was not clear

whether participants knew whether their test result had classified

them as high or low risk for falls. In the studies that reported blinding

methods, it was the clinicians who assessed falls and decided whether

they qualified as outcomes who were blinded.

Losses and exclusions

In most studies (17/23, 74%) losses and exclusions were fewer than

20%. A few had greater than 30% losses and exclusions, leading to a

possibility of bias in these studies.

4.4.4 Measurement performance

Table 24 includes results for studies of populations not selected for a

particular disease that provided raw data, or the values of sensitivity,

specificity, PPV and NPV. Table 25 includes the results for studies that

presented results as ROC curves. Results are tabulated separately for


© NCCSDO 2007 90

studies of Parkinson’s disease (Table 26) and post-stroke (Table 27)

populations.

Tinetti mobility test

Six studies evaluated the Tinetti mobility score, and/or its balance and

gait components. All of them were studies of unselected populations,

and one (Lin et al., 2004) presented results only as an ROC curve.

Four studies provided data on the balance scale, two on the gait scale

and three on the combined mobility scale. The number of assessments

performed and scoring systems varied between studies. One study

(Tinetti et al, 1986) analysed recurrent falls rather than all falls, so its

results are incompatible with the others. No two studies used the

same cut-off point and scoring system so no meta-analysis was

performed.

For the three studies that provided data on the overall mobility scale,

the sensitivities varied between 0.27 (Hale et al., 1992) and 0.76

(Tinetti et al, 1986), whereas the specificities were from 0.52 (Raiche

et al., 2000) to 0.83 (Tinetti et al 1986, 1986; Hale et al., 1992). Two

out of three studies had sensitivity greater than 70% and two had

specificity over 80%. The PPVs were between 0.31 and 0.68, and

NPVs between 0.67 and 0.88.

For the balance scale alone, three studies provided data (Tinetti et al,

1986; Trueblood et al., 2001; Verghese et al., 2002). Tinetti et al

(1986) found a high sensitivity of 0.80 (for recurrent falls), and

Verghese et al. (2002) similarly found a fairly high sensitivity (0.62)

when using a cut-off value of 10/16. Trueblood et al. (2001), using a

higher cut-off value of 12/16, found a sensitivity of only 0.23. All of

these tests had a specificity of greater than 0.70. NPVs were uniformly

high (78–89%), but PPVs were lower than those for the combined

mobility scale, ranging from 0.20 to 0.59.

One study (Lin et al., 2004) reported results for the balance scale

using ROC curve statistics. The area under the ROC curve was 0.559

(no CI given), suggesting that the test was not good at predicting

fallers.

Two studies provide data on the gait scale alone (Tinetti, 1986;

Trueblood et al., 2001), but used different cut-off values and

outcomes. Their results were inconsistent for sensitivity and

specificity, but similar for PPV (0.43 and 0.46) and NPV (0.86 and

0.81).

Stops Walking When Talking (SWWT)

Four studies evaluated this test, one of which (Hyndman and Ashburn,

2004) assessed its relationship to both falls and recurrent falls. Two of

the studies were in post-stroke populations (Hyndman and Ashburn,

2004; Andersson et al., 2006), one in Parkinson’s disease (Bloem et

al., 2001), and the fourth used an unselected population


© NCCSDO 2007 91

(Lundin-Olsson et al., 1997). As the populations and ways in which the

test was implemented varied, no meta-analysis has been conducted.

In an unselected population, the test appeared to have high PPV

(83%) and NPV (76%), although sensitivity was low (48%).

In post-stroke populations, both studies had PPV and NPV for falls of

around 60%, although sensitivities and specificities were variable. In

the one study of a Parkinson’s disease population, the SWWT test was

not good at predicting recurrent fallers (sensitivity of 12% and PPV of

29%).

Timed Up and Go (TUG)

Three studies assessed the TUG test, using different cut-off values

(from 14 to 20 seconds) and different populations and durations of

follow-up. Hence no meta-analysis was conducted. One study

(Andersson et al., 2006) assessed the test in a post-stroke population.

The two studies in unselected populations (Okumiya et al., 1998;

Trueblood et al., 2001) used different cut-off values (16 and 20

seconds respectively). The longer cut-off in Trueblood et al. (2001)

performed very poorly (sensitivity 10% and PPV 27%).

One other study (Lin et al., 2004) reported the ROC area under the

curve as 0.61 (no CI given), but there was no information on the best

performing cut-off value. It was the best-performing of four screening

tests in this study.

Berg Balance Scale

The Berg Balance Scale was assessed by two studies, one conducted

in a post-stroke population. Both studies used a cut-off of 45/56 for

considering a test positive (i.e. high risk), but differences in their

populations mean that meta-analyses were not possible. Andersson et

al. (2006) found that sensitivity, specificity, PPV and NPV were similar

(between 58 and 69%) in a population of recovering stroke patients,

but Bogle Thorbahn and Newton (1996) found sensitivity of 53% and

specificity of 92% in an unselected population. PPV was 73% and NPV

was 84% in this study, although CIs were wide because of its small

size.

Mobility Interaction Fall (MIF) chart

This screening test was evaluated in two studies by Lundin-Olsson et

al. (2000, 2003). There was considerable heterogeneity between the

results, however, so they have not been combined. The earlier study

found high values of sensitivity and specificity (0.85 and 0.82

respectively), which were not confirmed by the later and larger study

(0.43 and 0.69). PPV and NPV were similarly higher in the earlier

study.


© NCCSDO 2007 92

Other tests

Twenty-one other tests were assessed by only one included study. Of

the studies of unselected populations, the best results were the

Coalition for Community Falls Prevention (CCFP screen; Killough,

2005) and the Downton Index (Rosendahl et al., 2003), which both

had a sensitivity of over 80%, with a PPVs of 51 and 68%

respectively.

4.5 Discussion

There was not adequate evidence to determine with any confidence

how good any screening test was at predicting fallers. Only a few tests

were evaluated by several studies, and differences among them in the

performance of the tests, populations, cut-off values and outcomes

meant that no meta-analyses were possible. At present, therefore, it is

not possible to provide a quantitative summary of the accuracy of any

fall-risk screening tool. For robust determination of the accuracy of

screening tests, further high-quality studies are needed. These should

seek to use compatible study designs to allow pooling of their results

in future systematic reviews.

There is currently very little good-quality evidence about the

performance of any of the screening tools most commonly used by

falls clinics in the UK. The FRAT was evaluated by only one study

(Nandy et al., 2004). Although this study had a reasonably large

sample size it suffered from high loss to follow-up, use of only a

6-month follow-up period and not using the most reliable method for

collecting falls data. Data for three cut-off points were presented. They

all had high specificity and NPV, but sensitivity varied from 59% with

two risk factors as the cut-off to 15% with four risk factors.

Conversely, PPV was 43% with two risk factors and 58% with four.

The Tinetti balance, gait and mobility scales were evaluated by the

most studies, but differences among the cut-off points and outcomes

used precluded any combination of results. Moreover, it was clear that

the test procedures differed between studies. Tinetti (1986) described

the screening tool as comprising 13 balance assessments and nine gait

assessments, without any description of the scoring system to be

used. In a different paper (Tinetti et al., 1986) the scale is described

as consisting of eight balance tests with a maximum score of 15 and

eight gait tests with a maximum score of 13, giving a total maximum

score of 28. Of the studies that used both balance and gait

assessments, Raiche et al. (2000) had 14 balance items (scored out of

24) and 10 gait items (scored out of 16), to give a total score out of

40. Hale et al. (1992) similarly had a total score of 40, but gave no

information about the numbers of items assessed, and used a different

cut-off value for determining a positive test (30/40 compared with

36/40). Trueblood et al. (2001) had a total of 16 items in the gait and

balance subscales, with maximum scores of 12 and 16 respectively, to

give a maximum total of 28. Two studies used only the balance


© NCCSDO 2007 93

assessments. Verghese et al. (2002) used a nine-item balance and

mobility scale, scored from 0 to 16 (the paper stated that gait

assessment was not used), and Lin et al. (2004) had a 13-item

balance scale, scored 0–26. Because of the variation in the

assessments performed, the cut-off values used and the outcomes

recorded, it was not possible to combine any of these results in

meta-analyses.

4.5.1 Design, reporting and methodological quality

of existing studies

A large number of studies were excluded from this review because

they used poor study designs. Nineteen studies evaluated screening

tools but did not collect falls data prospectively. Instead, they

performed screening tests and evaluated their relationship with

historical falls. This study design may give quite different results from

use of the tests in clinical practice, where prediction of future falls is

the aim. For example, Shumway-Cook et al. (2000) used a

retrospective design to assess the performance of the TUG test, and

found a sensitivity and specificity of 87%. In contrast, the two

prospective studies included in this review found considerably lower

sensitivities of 54 and 10%.

Some other excluded studies assessed the relationship of a screening

test to a ‘gold standard’ (usually another screening test) rather than

measuring falls. This is potentially misleading; no screening test is

perfect for measuring falls and agreement between two tests does not

necessarily mean that they will be good at predicting falls. At present

there is no screening test that has been shown to be accurate enough

to be regarded as a gold standard. For example, Whitney et al. (2005)

analysed correlations of TUG with the Physiological Profile Assessment

(PPA), a comprehensive falls risk assessment. They found that TUG

performance was related to PPA falls risk measured by PPA, but this

does not give an assessment of the accuracy of TUG for predicting

falls.

There were methodological drawbacks to many of the existing studies.

The most common problem was poor recording of falls outcomes; the

majority of studies did not use the most reliable methods. Many

follow-up periods were too short; less than half of the included studies

(11/23) followed participants for 12 months or more. Losses to

follow-up were also an issue in some studies, with 30% or more lost

by some studies. Reporting of results was in some cases poor; in

some cases the raw data for 2×2 tables of test results against falls

could be deduced, but in others they could not. Some relevant studies

were excluded because they reported the results as odds ratios or

other statistics.


© NCCSDO 2007 94

4.5.2 Searching for relevant studies

Studies relevant to this review may have been difficult to locate

because they may not have included search terms for diagnostic

studies in their title and abstract. We tested the accuracy of our

search strategy against two earlier reviews that included studies

relevant to this review (Perell et al., 2001; Jarnlo, 2003). It located

16/21 studies included in Perell et al. (2001) and 15/23 included in

Jarnlo (2003). Examination of the studies not located revealed that

none of them was eligible for this review. They were generally poorly

described in their titles and abstracts, without any terms describing

their population or methodology, and hence would be difficult to locate

with any electronic search strategy. This emphasised the importance

of additional searching of reference lists to locate relevant studies for

this review.

A question that has not yet been answered is how good does a

screening test need to be to be useful in assessing people for falls

risk? The answer will depend on the use to which it is to be put. As a

first screen to identify people who may benefit from more detailed

assessment, it may be sufficient to have a high NPV, so that people

not at high risk for falls are excluded from further assessment.

Modelling studies may help to determine what are the most important

features of a test for these purposes.

Table 21 Inclusion and exclusion of studies

Number of studies

Included 23

Non-eligible population (hospital or non-elderly) 33

No falls outcome 11

Not prospective falls data 19

Relevant data not reported 25

Non-English language 6

Study could not be located 3*

Duplicate publication 1

Discussion paper; no data 3

Insufficient duration of follow-up 1

*One conference abstract, reference apparently incorrect; one error in electronic

database (wrong year; correct reference was considered for eligibility);

one journal could not be located.


© NCCSDO 2007 95

Table 22 Characteristics of included studies

Study Inclusion/exclusion Population Screening tests

Outcomes Number recruited

Losses/exclusions Follow-up duration

Notes

Andersson et al. 2006

Community living discharged stroke patients

First ever stroke

Treated in Orebro University Hospital

Excluded: subarachnoid haemorrhage

Age: mean 73.4, range 33–94

Sex: 55% male

Prev. falls: ?

Cognitive impairment: 38%

Visual impairment: 34%

BBS

SWWT

TUG

diffTUG

All self- reported falls

196 55 (28%) 6/12 months

(50% followed up at 6 months and 50% at 12 months)

Selection of patients for treatment in stroke unit

A few non-old people included

Bergland and Laake 2005

Female ≥75 years

Randomly selected from Oslo census file

Excluded: Unable to get to research office

Major cognitive impairment

Unable to stand for >60 seconds

Age: mean 80.3, range 75–93

Sex: 0% male

Prev falls: 41%

Cognitive impairment: ?

Visual impairment:?

Getting up from lying on the floor

All falls

Falls with serious injuries: fractures, joint dislocations, lacerations requiring sutures, other high-impact soft-tissue injuries

328 21 (6%) 12 months

Bloem et al. 2001

59 Parkinson’s disease patients with good response to

Age: 60.2, SD 9.1

Sex: 49% male

Retropulsion test

Romberg test

Recurrent falls: ≥2 falls (self-reported)

114 0 6 months Population was a mixture of Parkinson’s

89


© NCCSDO 2007 96




Notes

treatment and 55 age-matched controls

Ambulant community resident

MMSE ≥24

Excluded: Other neurological disorder, visual or orthopaedic problems interfering with balance

Prev. falls: 33.3%

Cognitive impairment: MMSE 28.6 SD 1.7

Visual impairment: ?

Tandem stance (eyes closed)

Tandem stance (eyes open)

SWWT

disease patients and non-Parkinson’s ‘controls’

Bogle Thorbahn and Newton 1996

Volunteer independent-living residents of two life care communities

Excluded if unable to follow directions of test

Age: mean 79.2, SD 6.2

Sex: 24% male

Prev falls: ?



BBS All self- reported falls

66 12 (18%) 6 months

Cwikel et al. 1998

Aged ≥60, functional independence, able to be interviewed

Age: mean 71.5

Sex: 42% male

Prev falls: 20.6%



Elderly Fall Screening Test (EFST)

All falls (self-reported)

361 78 (22%) 12 months


© NCCSDO 2007 97




Notes

Hale et al. 1992

Community living consecutive patients of a family practice Aged ≥65, ambulatory, mentally competent (no dementia and able to answer questions), not acutely ill

Age: mean 74.7

Sex: 19.6% male

Prev falls 27.5%

Cognitive impairment: 0%


Tinetti mobility test

Physician mobility score estimate

Physician fall risk estimate

All falls 120 18 (15%) 12 months

Hyndman and Ashburn 2004

Diagnosis of stroke

Independently mobile (with walking aid if used)

‘Oriented to place and time’

Able to complete questionnaires

Excluded: bed or chair bound

Required assistance to mobilise

Other neurological conditions

Acute conditions impeding mobility or

Age: Mean 68, range 42–84

Sex: 57% male

Prev falls: ?

Cognitive impairment: Middlesex Elderly Assessment of mental state score median 12 (range 8–12)


SWWT Falls not as a result of major intrinsic event or overwhelming hazard

65 2 (3%) 6 months Small number of non-elderly people included


© NCCSDO 2007 98




Notes

balance (lower limb amputation or joint replacement)

Killough 2001

Community-dwelling

Age ≥65

Ability to walk for 6 m

Could follow directions and answer survey questions

No information CCFP fall risk screen


Reported as abstract only

Lin et al. 2004

Aged ≥65

Living in one of six rural villages

Not hospitalised or bed-ridden

Age: mean 73.4

Sex: 59.1% male

Prev falls: 10.6%

Cognitive impairment: 53.6% (mild or severe)


TUG

Functional reach

One leg stance

Tinetti balance

All falls 1200 402 (33.5%) 12 months

Results given as odds ratio and AUC

Lundin-Olsson et al. 1997

Living in sheltered accommodation

Able to walk without aids

Able to follow simple instructions


Sex: 28% male

Cognitive impairment: MMSE median

SWWT Falls indoors 58 0 (0%) 6 months


© NCCSDO 2007 99




Notes

21.5, IQR 18–26



Residents of a residential care facility aged ≥65

Age: median 82, range 66–99

Sex: 39.3% male

Prev falls: 47%

Cognitive impairment: MMSE median 21, range 12–26

Visual impairment: 21.8%

MIF chart Falls indoors 78 0 6 months


Residents of four residential care facilities aged ≥65


Age: 83.2, SD 6.8

Sex: 30.3% male

Prev falls: ?


Visual impairment:

MIF

Staff judgement

Falls indoors including those resulting form acute medical events

208 0 (0%) 6 months


© NCCSDO 2007 100




Notes

22.1%

Nandy et al. 2004

Random sample of people aged over 65

living in one primary care group area contacted


Sex: 45% male

Prev falls: 25.4%Cognitive impairment: ?


FRAT part 1 All falls 510 165 (32.4%) 6 months

Okumiya et al. 1998

Participants in Kahoku Longitudinal Aging Study; non-fallers at start of study

Age: ?

Sex: ?

Prev falls: ?



TUG All falls 278 35 (12.6%) 5 years Results also presented as odds ratio for Button score and visuospatial cognitive performance test

Raiche et al. 2000

Participants in control group of RCT

Random sample of 225 from electoral list over 75


Tinetti balance scale


Rosendahl et al. 2003

Residents of one residential care facility in Feb 1994 or moved in during

Age: mean 81, SD 6

Sex: 28% male

Downton index

Indoor falls

Falls not caused by acute illness

78 0 (0%) 12 months


© NCCSDO 2007 101




Notes

subsequent year

Aged ≥65


Prev falls: ?

Cognitive impairment: MMSE median 21, IQR 12–26


or drug side effects

Smith et al. 2006

All patients with diagnosis of acute stroke admitted to six participating stroke rehabilitation units

Age: median 78, range 34–100

Sex: 49% male

Prev falls: 18%

Cognitive impairment: Abbreviated mental test ≤6: 23%

Visual impairment: 12.4%

STRATIFY All falls 284 50 (17.6%) 3 months Small number of non-elderly people included

Population characteristics include 75 people included in inpatient study

Stel et al. 2003

Subset of participants in LASA cohort study Random sample of elderly people in three regions of The Netherlands

328 participants who fell in previous year


Sex: 45.4% male

Prev falls: 15.9%

Cognitive

Mediolateral sway

Handgrip strength

Leg extension strength

Tandem stand

Recurrent falls ≥2 falls

439 21 (4.8%) 12 months

Results given as ROC AUC


© NCCSDO 2007 102




Notes

plus random sample of 196 of 746 who did not fall were invited

impairment: ?


Studenski et al. 1994

Aged ≥70

Lived within 30 mile radius of Durham Veterans Affairs hospital

Receive care in ambulatory care clinics

Excluded: Terminal illness

Blindness

Acute illness

Severe cognitive impairment (MMSE <18) and no caregiver to assist with falls monitoring


Sex: 100% male

Prev falls: 50.6%



Mobility screen (6 item, high/low risk)

Mobility skills assessment (13 item)

Risk preference (3 item)

Environmental threat (not clear how scored)

Recurrent falls: two or more falls not due to loss of consciousness, acute illness, unusual activities or unusually hazardous environment

325 19 (5.8%) 6 months

Tinetti 1986

First-time admissions to intermediate care

Excluded: <60 years old

Did not walk as a means of transportation

Age: mean 79, range 61–92

Sex: 32% male

Prev falls: ?


Visual

Balance score (0–28)

Gait score (0–13)

Mobility score (0–28)

Recurrent falls (≥2 falls under circumstances in which a fit person could have resisted the external

79 0 3 months


© NCCSDO 2007 103




Notes

Admitted for less than 3 months

Unable to participate

impairment: ? hazard if there was one)

Trueblood et al. 2001

Living in community and retirement centres. Aged ≥60

Able to stand for at least 5 minutes

Able to walk at least 40 feet

Excluded: Cognitive deficit (MMSE ≤24)

Underlying neurological problems (Parkinson’s or cerebral vascular accident)


Sex: 19.2% male

Prev falls: 50%


Visual impairment:?

Tinetti POMA

TUG

Modified CTSIB

Limits of Stability (LOS)

All falls 198 18 (9.1%) 6 months

Vellas et al. 1997

Participants in Albuquerque Falls Study: volunteers >60 years old, no serious medical conditions



Sex: 41% male

Prev falls: ?

Cognitive impairment (MMSE <30): 45.6%


One leg balance

Falls not as a result of violent blow, loss of consciousness or sudden onset of paralysis

Falls for which medical attention was

364 48 (13.2%) 3 years


© NCCSDO 2007 104




Notes

sought

Verghese et al. 2002

Participants in Einstein Aging Study – randomly selected Medicare recipients in the Bronx

Aged ≥65

Excluded: Severe visual loss interfering with completion of tests

Not speaking English or Spanish

institutionalisation


Sex: 43% male

Prev falls: 28%


Visual impairment: 0%

Tinetti balance and mobility screen

Timed gait

Walking while talking tasks (WWT simple and WWT complex)

All falls 60 1 (1.7%) 12 months

?, data not given; AUC, area under the curve; BBS, Berg Balance Scale; CCFP, Coalition for Community Falls Prevention; CTSIB, Clinical

Test for Sensory Interaction in Balance; diffTUG, difference between times for TUG with and without carrying a glass of water;

IQR, interquartile range; MIF, Mobility Interaction Fall; MMSE, Mini Mental State Examination; POMA, Performance-Oriented

Mobility Assessment; STRATIFY, St Thomas’s Risk Assessment Tool in Falling Elderly Inpatients; SWWT, Stops Walking When

Talking; TUG, Timed Up and Go.


© NCCSDO 2007 105

Table 23 Quality-assessment scores

Quality-assessment criteria Study

1 2 3a 3b 5 6 8 9 11 12 13 14a 14b 15 16


2 2 2 1 3 3 2 3 2 3 1 2 2 3 3


3 3 3 3 3 3 3 3 2 2 3 3 3 3 3

Bloem et al. 2001

1 2 2 3 3 3 3 3 1 3 3 3 3 3 2

Bogle Thorbahn and Newton 1996

3 2 2 2 3 3 3 3 1 3 2 3 3 3 3

Cwikel et al. 1998

3 3 3 1 1 3 3 3 3 2 2 2 3 3 2

Hale et al. 1992

3 3 3 3 3 3 3 3 2 2 3 3 3 3 2


2 3 2 3 3 3 3 3 2 3 2 3 3 3 3

Killough 2001 2 2 3 2 2 2 1 3 2 1 3 3 2 3 1

Lin et al. 2004

3 3 3 2 1 3 3 3 2 2 1 1 1

2 1


2 1 2 1 3 3 2 1 2 3 3 3 3 3 3


3 3 2 2 3 3 3 2 2 3 3 3 3 3 3


3 3 2 3 3 3 3 3 2 3 2 3 3 3 3

Nandy et al. 2004

3 3 2 1 3 3 3 3 2 2 1 3 3 3 2

Okumiya et al. 1998

2 1 3 1 2 3 2 3 2 1 2 3 1 1 2

Raiche et al. 2000

3 1 3 3 2 3 2 3 2 2 3 3 3 3 3


3 2 3 3 3 3 3 3 2 3 3 3 2 3 3

Smith et al. 2006 3 3 1 1 2 3 3 3 2 3 3 3 3 3 3

Stel et al. 2003

1 2 3 3 3 3 3 3 2 2 1 1 3 2 3


2 3 2 3 3 3 3 3 3 3 3 3 3 1 3

Tinetti 1986 3 2 1 3 3 3 3 3 3 2 3 3 3 3 3


3 3 2 1 3 3 3 3 2 2 2 3 3 3 2

Vellas et al. 1997 3 3 3 2 3 3 3 2 2 1 1 3 2 3


© NCCSDO 2007 106

Quality-assessment criteria Study

1 2 3a 3b 5 6 8 9 11 12 13 14a 14b 15 16


3 3 3 2 3 3 3 3 3 3 3 3 3 3 3


© NCCSDO 2007 107

Table 24 Results for sensitivity, specificity, positive predictive value and negative predictive value

Screening tool/study Outcome Cut-off value used Sensitivity (95% CI)

Specificity

(95% CI)

PPV

(95% CI)

NPV

(95%

Berg Balance Scale (BBS)

Bogle Thorbahn and Newton 1996 Falls 45/56 0.53

(0.27, 0.79)

0.92

(0.79, 0.98)

0.73

(0.43, 0.90)

0.84

(0.70, 0.92)

Coalition for Community Fall Prevention Screen

Killough 2005 Falls Not stated 0.83

(0.69, 0.92)

0.51

(0.39, 0.62)

0.51

(0.40, 0.62)

0.83

(0.69, 0.91)

Downton index

All falls ≥3/11 0.81

(0.67, 0.91)

0.4

(0.23, 0.59)

0.68

(0.56, 0.79)

0.57

(0.37, 0.76)


Falls not due to illness or drugs

≥3/11 0.77

(0.60, 0.90)

0.3

(0.17, 0.46)

0.47

(0.35,0.60)

0.62

(0.41, 0.79)

Elderly Fall Screening Test (EFST)

Cwikel et al. 1998 Falls ≥2/5 0.49

(0.38, 0.61)

0.83

(0.77, 0.89)

0.62

(0.49, 0.72)

0.75

(0.68, 0.81)

FRAT

2 risk factors 0.59

(0.48, 0.70)

0.80

(0.74, 0.84)

0.43

(0.34, 0.53)

0.88

(0.84, 0.92)

3 risk factors 0.42

(0.32, 0.54)

0.92

(0.88, 0.94)

0.57

(0.43, 0.69)

0.86

(0.83, 0.89)

Nandy et al. 2004

Falls

4 risk factors 0.15

(0.09, 0.26)

0.97

(0.94, 0.99)

0.58

(0.37, 0.77)

0.82

(0.77, 0.86)


© NCCSDO 2007 108


Specificity

(95% CI)

PPV

(95% CI)

NPV

(95%

Getting up from lying on the floor

Falls 0.2

(0.14, 0.27)

0.77

(0.69, 0.83)

0.46

(0.35, 0.58)

0.49

(0.42, 0.55)


Fall-related injury 0.33

(0.21, 0.46)

0.81

(0.76, 0.86)

0.3

(0.20, 0.42)

0.83

(0.78, 0.87)

75% Limits of Stability

Reaction time


Falls 0.43

(0.26, 0.63)

0.56

(0.48, 0.64)

0.16

(0.10, 0.26)

0.83

(0.75, 0.89)

End-point excursion


Falls 0.6

(0.41, 0.77)

0.55

(0.46, 0.63)

0.21

(0.14, 0.31)

0.87

(0.79, 0.93)

Maximum excursion


Falls 0.63

(0.44, 0.80)

0.46

(0.38, 0.54)

0.19

(0.13, 0.28)

0.86

(0.77, 0.92)

Movement velocity


Falls 0.33

(0.17, 0.53)

0.76

(0.68, 0.83)

0.22

(0.12, 0.36)

0.85

(0.78, 0.90)

Directional control


Falls

>1 SD from age-based mean

0.43

(0.26, 0.63)

0.54

(0.46, 0.62)

0.16

(0.10, 0.25)

0.83

(0.74, 0.89)

Mobility Interaction Fall chart

Lundin-Olsson et al. 2000 Falls 0.85

(0.68, 0.95)

0.82

(0.68, 0.92)

0.78

(0.62, 0.88)

0.88

(0.75, 0.95)


© NCCSDO 2007 109


Specificity

(95% CI)

PPV

(95% CI)

NPV

(95%


(0.34, 0.53)

0.69

(0.59, 0.78)

0.58

(0.47, 0.69)

0.55

(0.46, 0.63)

Mobility screen

Falls 0.74

(0.64, 0.83)

0.57

(0.50, 0.63)

0.40

(0.32, 0.47)

0.85

(0.78, 0.90)


Recurrent falls 0.84

(0.70, 0.93)

0.53

(0.47, 0.60)

0.23

(0.17, 0.30)

0.95

(0.90, 0.98)

Modified CTSIB

Firm surface eyes closed


Falls >1 SD from age-based mean

0.43

(0.26, 0.63)

0.61

(0.52, 0.69)

0.18

(0.11, 0.28)

0.84

(0.76, 0.90)

Firm surface eyes open Trueblood et al. 2001


0.20

(0.08, 0.39)

0.93

(0.87.0.96)

0.35

(0.17, 0.59)

0.85

(0.79, 0.90)

Foam surface eyes closed



0.13

(0.04, 0.31)

0.81

(0.73, 0.87)

0.12

(0.05, 0.27)

0.82

(0.75, 0.88)

Foam surface eyes open



0.37

(0.20, 0.56)

0.66

(0.58, 0.74)

0.18

(0.10, 0.29)

0.84

(0.76, 0.89)

One leg balance

Vellas et al. 1997 Injurious falls 0.36

(0.25, 0.48)

0.77

(0.72, 0.82)

0.31

(0.22, 0.42)

0.81

(0.75, 0.85)

Stops walking when talking


(0.26, 0.70)

0.95

(0.82, 0.99)

0.83

(0.55, 0.95)

0.76

(0.62, 0.86)


© NCCSDO 2007 110


Specificity

(95% CI)

PPV

(95% CI)

NPV

(95%

Timed gait

≥12 s 1.00

(0.75, 1.0)

0.24

(0.13, 0.39)

0.27

(0.17, 0.48)

1.00

(0.74, 1.00)

≥14 s 0.77

(0.46, 0.95)

0.57

(0.41, 0.71)

0.33

(0.19, 0.51)

0.9

(0.74, 0.96)


Falls

≥18 s 0.39

(0.14, 0.68)

0.85

(0.71, 0.94)

0.42

(0.19, 0.68)

0.83

(0.70, 0.91)

Tinetti balance scale

Tinetti et al 1986 Recurrent falls <10/15 0.8

(0.59, 0.93)

0.74

(0.60, 0.85)

0.59

(0.42, 0.74)

0.89

(0.77, 0.95)

Trueblood et al. 2001 Falls <12/16 0.23

(0.10, 0.42)

0.91

(0.85, 0.95)

0.33

(0.17, 0.55)

0.86

(0.79, 0.90)

<8/16 0.08

(0.00, 0.36)

0.91

(0.79, 0.98)

0.20

(0.04, 0.62)

0.78

(0.65, 0.87)

<9/16 0.23

(0.05, 0.54)

0.8

(0.66, 0.91)

0.25

(0.09, 0.53)

0.79

(0.65, 0.88)


Falls

<10/16 0.62

(0.32, 0.86)

0.7

(0.54, 0.82)

0.36

(0.20, 0.57)

0.86

(0.72, 0.94)

Tinetti gait scale

Tinetti et al 1986 Recurrent falls <9/13 0.68

(0.47, 0.85)

0.63

(0.49, 0.76)

0.46

(0.31, 0.62)

0.81

(0.67, 0.90)

Trueblood et al. 2001 Falls <8/12 0.2 0.95 0.43 0.86


© NCCSDO 2007 111


Specificity

(95% CI)

PPV

(95% CI)

NPV

(95%

(0.08, 0.39) (0.90, 0.98) (0.21, 0.67) (0.79, 0.90)

Tinetti mobility scale

Hale et al. 1992 Falls <30/40 0.27

(0.14, 0.44)

0.83

(0.72, 0.91)

0.48

(0.28, 0.68)

0.67

(0.56, 0.76)

≤33/40 0.51

(CI not reported)

0.74

(CI not reported)

Not reported Not reportedRaiche et al. 2000

Falls

≤36/40 0.7

(0.56, 0.82)

0.52

(0.44, 0.59)

0.31

(0.23, 0.40)

0.85

(0.77, 0.90)

Tinetti 1986 Recurrent falls <19/28 0.76

(0.55, 0.91)

0.83

(0.71, 0.92)

0.68

(0.49, 0.82)

0.88

(0.77, 0.94)

Timed Up and Go (TUG)

Okumiya et al. 1998 Falls 16s 0.54

(0.42, 0.67)

0.73

(0.65, 0.79)

0.44

(0.34, 0.55)

0.8

(0.73, 0.86)

Trueblood et al. 2001 Falls 20s 0.1

(0.02, 0.27)

0.95

(0.90, 0.98)

0.27

(0.10, 0.57)

0.84

(0.78, 0.89)

WWT complex

≥26 s 0.54

(0.25, 0.81)

0.85

(0.71, 0.94)

0.5

(0.27, 0.73)

0.87

(0.74, 0.94)

≥30 s 0.39

(0.14, 0.68)

0.91

(0.79, 0.98)

0.56

(0.27, 0.81)

0.84

(0.71, 0.92)


Falls

≥33 s 0.39

(0.14, 0.68)

0.96

(0.85, 1.00)

0.71

(0.36, 0.92)

0.85

(0.72, 0.92)


© NCCSDO 2007 112


Specificity

(95% CI)

PPV

(95% CI)

NPV

(95%

WWT simple

≥16 s 0.54

(0.25, 0.81)

0.61

(0.45, 0.75)

0.28

(0.14, 0.48)

0.82

(0.66, 0.92)

≥18 s 0.46

(0.19, 0.75)

0.76

(0.61, 0.87)

0.35

(0.17, 0.59)

0.83

(0.69, 0.92)


Falls

≥20 s 0.46

(0.19, 0.75)

0.89

(0.76, 0.96)

0.55

(0.28, 0.79)

0.85

(0

WWT, walking while talking tasks.


© NCCSDO 2007 113

Table 25 Results reported as summary ROC curves or similar

Study Screening test Outcome ROC AUC

95% CI

TUG 0.610 Not given

One-leg standing 0.527 Not given

Functional reach 0.509 Not given

Lin and Wang 2004

Tinetti balance

Falls

0.559 Not given

Mediolateral sway (n=161)

0.67 (0.57, 0.77)

Tandem stand (n=161) 0.61 (0.49, 0.73)

Leg extension strength (n=419)

0.58 (0.51, 0.64)

Stel et al. 2003

Handgrip strength (n=419)

Recurrent falls

0.57 (0.51, 0.64)

AUC, area under the curve.


© NCCSDO 2007 114

Table 26 Results for Parkinson’s disease population

Test Outcome Sensitivity Specificity PPV NPV

Retropulsion test 0.29

(0.10, 0.56)

0.89

(0.81, 0.94)

0.31

(0.14, 0.56)

0.88

(0.80,0.93)

Romberg test 0.18

(0.04, 0.43)

1

(0.96, 1.00)

1

(0.44, 1.00)

0.87

(0.80, 0.92)

Tandem stance (eyes closed) 0.88

(0.64, 0.99)

0.46

(0.36, 0.57)

0.22

(0.14, 0.34)

0.96

(0.86, 0.99)

Tandem stance (eyes open) 0.53

(0.28, 0.77)

0.84

(0.75, 0.91)

0.36

(0.20, 0.55)

0.91

(0.84, 0.95)

Bloem et al. 2001

SWWT

Recurrent falls

0.12

(0.02, 0.36)

0.95

(0.88, 0.98)

0.29

(0.08, 0.64)

0.86

(0.78, 0.91)


© NCCSDO 2007 115

Table 27 Results for post-stroke populations

Test Outcome Cut off Sensitivity Specificity PPV NPV

BBS 45/56 0.63

(0.50, 0.75)

0.65

(0.53, 0.75)

0.58

(0.46, 0.69)

0.69

(0.58, 0.78)

SWWT 0.15

(0.06, 0.28)

0.97

(0/90, 1.00)

0.78

(0.45, 0.94)

0.61

(0.52, 0.70)

TUG 14 s 0.5

(0.34, 0.66)

0.79

(0.66, 0.88)

0.59

(0.42, 0.74)

0.72

(0.60, 0.81)


diffTUG

Falls

4.5 s 0.17

(0.06, 0.36)

0.95

(0.86, 0.99)

0.63

(0.31, 0.86)

0.70

(0.59, 0.79)

Falls 1 s 0.53

(0.34, 0.72)

0.70

(0.51, 0.84)

0.62

(0.43, 0.78)

0.62

(0.46, 0.76)


SWWT

Recurrent falls

1 s 0.73

(0.45, 0.92)

0.69

(0.54, 0.81)

0.42

(0.26, 0.61)

0.89

(0.75, 0.96)

Smith et al. 2004 STRATIFY Falls ≥2 0.16

(0.09, 0.26)

0.86

(0.81, 0.92)

Not calculable

Not calculable

BBS, Berg Balance Scale.


© NCCSDO 2007 116

Section 5 Cost-effectiveness systematic review

5.1 Introduction

In 2003 the economic costs of falls in the UK was estimated to be

£981 million (Scuffham et al., 2003). The majority of costs were

incurred for inpatient admissions and long-term care costs for patients

75 years and older. Given the expected increase in the over 65-year-

old population these costs are likely to increase the ‘burden’ on the

NHS and personal social services attributable to falls in older people

(Scuffham et al., 2003). Reducing falls that may result in inpatient

admissions and or long-term care costs is a key aim set out in the

National Service Framework for Older People (Department of Health,

2001).

NICE guidance for the assessment and prevention of falls in older

people (National Institute for Clinical Excellence, 2004) explored

factors that increase peoples’ risk of falling, assessment methods for

identifying people at risk of falling, the effectiveness of hip protectors,

the user experience of falls-prevention services and the clinical

effectiveness and cost-effectiveness for preventing falls, preventing

further falls and rehabilitation. Although cost-effectiveness data for

falls prevention were reviewed, this reflected an international

perspective, and included studies from New Zealand, Australia and the

USA; no data were obtained on the cost-effectiveness of interventions

for the prevention of falls in older people in the UK (National Institute

for Clinical Excellence, 2004).

NICE have proposed the provision of additional guidance from the

Technology Appraisal programme that aims ‘to appraise the clinical

and cost-effectiveness of fallers’ clinics for the assessment and

prevention of falls’. However, the appraisal was suspended due to

insufficient evidence and the lack of a definition of a fallers’ clinic.

Preparatory work has been commissioned, designed to underpin the

continuance of the planned guideline by NICE, and this update of the

cost-effectiveness systematic review forms part of the commissioned

programme.

5.2 Methods

This review explored whether any new evidence on the resources

utilised in the provision of FPPs for older people, reflecting the UK

perspective, has been published since the completion of the NICE

guideline review in 2004.


© NCCSDO 2007 117

5.2.1 Selection criteria

Types of study

All types of cost and cost-effectiveness study designs were considered.

Types of participant and setting

Older people, women and men, who had fallen or were at risk of

falling, living in the community and participating in a falls-prevention

intervention programme in the UK were included.

Types of intervention

Any interventions comparing the cost and cost-effectiveness of falls

prevention compared with control intervention, usual care, or no

intervention were included.

Types of outcome

Cost-benefit, cost-effectiveness and/or cost utility outcomes in terms

of health-care resource utilisation resulting from a falls-related

diagnosis were included:

• treatment cost in primary and secondary care,

• diagnostic cost in primary and secondary care,

• hospital admission,

• quality-of-life measures,

• mortality.

Additional resource use resulting from the implementation of

interventions was also included.

5.2.2 Search strategy

The search strategies (Appendix 8) utilised by NICE were modified (by

C. McCabe) to include variants of Short-form 36 and Quality Of

Wellbeing, and the addition of the following search terms: vas, hrqol,

utility, preference and value, and are given in Appendix 8.

In this update of the NICE guideline for the assessment and

prevention of falls in older people we searched:

• MEDLINE, Ovid 1966 to August week 3 2006;

• CINAHL, Ovid 1982 to August week 3 2006;

• EMBASE, Ovid 1996 to week 34 2006;

• NHS EED, from 2003 to August 2006;

• OHE HEED, from 2003 to August 2006;

• National Research Register (www.nrr.nhs.uk/search.htm),

relevant ongoing projects;

• reference-list search of retrieved and relevant articles.


© NCCSDO 2007 118

5.3 Results

The results of the search and the sifting process are summarised in

Figure 12. Data extraction and appraisal were undertaken using a

modified version of the Drummond and Jefferson framework (shown in

Appendix 9; Drummond and Jefferson, 1996). Excluded studies are

given in Appendix 10.

Figure 12 The sifting process

Although 242 articles contained key terms including cost, cost-

effectiveness, economic or economic evaluation, falls prevention and

falls there where no additional studies of community-dwelling older

people who had fallen or were at risk of falling participating in falls-

prevention interventions that was the subject of a cost-effectiveness

analysis published in the UK in the intervening period since the

publication of the NICE systematic review in 2004.

The implementation of well-designed trials of FPPs with effective

evaluation, including an economic evaluation, is costly in terms of time

and money and may account for the lack of subsequent evidence. The

need for cost-effectiveness analysis of FPPs is widely acknowledged

within the falls-prevention community. However, of the four ongoing

falls-prevention studies reported on the National Research Register

only one is reporting that they intend to undertake a cost-

effectiveness analysis of their programme.

A large UK study (Masud et al., 2006) of community-dwelling, high-

risk older women and men participating in a multi-factorial

intervention designed to reduce the incidence of falls is currently being

undertaken; the study is expected to take 3 years to complete and is

due to report at the end of 2007. However, it is not possible to

Electronic database search n=3942 (854 duplicates) Reference list search n=77

Titles screened for relevance (n=1740 rejected)

Full papers screened for relevance n=62

Titles and abstracts screened for relevance (n=1363 rejected)

Studies included n=0

Total articles retrieved: N=3165


© NCCSDO 2007 119

comment on whether these studies will provide sufficient quality

evidence required for the construction of a UK cost-effectiveness

model for effective falls prevention in older people.

Cost-effectiveness analyses of FPPs have been undertaken

internationally, including in Australia (Beard et al., 2006), New

Zealand (Campbell et al., 2005) and Denmark. In addition, a FPP

study with cost-effectiveness analysis is currently being undertaken in

The Netherlands (Hendriks et al., 2005).

5.4 Discussion

At this time there are no published cost-effectiveness studies of falls-

intervention programmes, to inform the policy question of whether

falls-intervention programmes for older community-dwelling

population are cost-effective in the UK NHS.


© NCCSDO 2007 120

Section 6 Feasibility of constructing a cost-effectiveness model of multi-factorial interventions for falls prevention

6.1 Background

The National Service Framework for Older People (Department of

Health, 2001) and the NICE guideline on falls prevention (National

Institute for Clinical Excellence, 2004) both recommended that

Primary Care Trusts in the UK should implement FPPs. However,

neither document provided detailed guidance on the organisation or

content of these programmes.

In 2004, a proposed Appraisal of Fallers Clinics as part of the NICE

Technology Appraisal Programme was suspended because of a lack of

information necessary to produce a scope for the document; most

notably, the inability to describe current service provision.

This project was commissioned, in part, to establish whether it was

feasible to provide the evidence base necessary for the appraisal of

fallers clinics to be recommenced. To this end, we have surveyed NHS

organisations to provide a detailed description of the falls-prevention

activities currently ongoing and the resources required. We have also

undertaken a systematic review of the evidence for the performance of

screening tools and the effectiveness of interventions for falls

prevention.

In this section we describe the evidence required to undertake a

robust cost-effectiveness analysis of FPPs and consider whether the

evidence matches this specification. We then consider whether further

research is required before a robust cost-effectiveness analysis is

feasible, and if so, what that research should be.

6.2 Structure and parameter specification

for a cost-effectiveness model

The proposed model considers the cost-effectiveness of a FPP in a

community-dwelling population; that is, it excludes older people living

in residential and/or nursing homes.

The first decision to be made in specifying the model structure is how

patients present to the service. Are they identified opportunistically

when they contact another NHS service or is there a pro-active search

process? The results of the survey suggest that the majority of

services operating in the NHS identify participants opportunistically

when they contact another NHS service.


© NCCSDO 2007 121

Once candidates for the service have been identified the next decision

to be made in specifying the model structure is whether the

candidates are subject to triage to establish eligibility prior to further

assessment and/or the preventive intervention. The survey

demonstrates that this process varies in content and format, with

some services using a screening tool and others using more simple

criteria. Where there is initial triage prior to intervention, data on the

performance of the triage criteria are required. The information

required is the sensitivity and specificity of the screening tool and/or

triage factors as the expected health outcomes and resource utilisation

differ between the four groups of true negative, true positive, false

negative and false positive. It will also be necessary to identify the

resource utilisation associated with the triage process used.

For each group of patients in the treated arm and the patients in the

untreated arm it will be necessary to identify the expected resource

use and event rate over time. This will include the resources used for

the intervention and the resources used in treating fall-related events.

Given that the argument for falls prevention is that falls are a

significant cause of major injury in the elderly, which is associated

with substantial morbidity and mortality, the appropriate time horizon

is a lifetime one. Failure to adopt a lifetime horizon will produce a

biased estimate of the cost-effectiveness of the intervention. Thus,

event-rate data will be required for sufficient follow-up to allow a

reliable estimate of event rates out to 20 years, assuming that

participants are aged 65 years or more at the time of the intervention.

As fall-related events range from extremely minor to fatal, with an

associated difference in their resource implications, the event-rate

data will have to be at a sufficient level of disaggregation to allow an

accurate representation of these differential impacts. At a minimum it

will be necessary to differentiate fall-related injuries into peripheral

fractures, hip fractures and head injuries.

Depending upon the severity of the fall-related injury, the individual

may or may not be fit to return to independent living. The model will

therefore have to capture the resource, morbidity and mortality

implications of being discharged to different residential settings

including home, residential care and nursing care.

In addition to the implications for resource utilisation of the different

fall-related events it would be desirable to attach quality-of-life

weights (utilities) to each category of event. Where events are known

to increase the subsequent mortality risk, the post-event mortality will

be required.

In the next section we summarise the findings of the review with

regard to the evidence needs of the model.


© NCCSDO 2007 122

6.3 Evidence on parameters in cost-effectiveness models

6.3.1 Patient identification and eligibility

The majority of falls-prevention services required a referral from

another NHS or social service. Approximately 25% of services that

provided information on this to the survey operated an open referral

process. The remainder required referral from a health professional,

although there was some variation in the categories of health

professional who could refer. None of the services operated a

pro-active identification processes.

The survey found that the approximately 90% of falls-prevention

services operated eligibility criteria. The most common criteria used

were previous falls or ‘near falls’, age, a short screening tool and/or

polypharmacy. Most falls-prevention services used more than one

criterion.

Only a minority (33%) of falls-prevention services used a published

screening tool to assess a risk of falling. A third used a screening tool

of their own devising and a third did not use any screening tool

beyond the referral eligibility criteria. The systematic review of

published screening tools established that ‘At present it is not possible

to provide a quantitative summary of the accuracy of any fall-risk

screening tool.’ The review of the screening instruments found no

evidence that quantified the relationship between screening tools and

the underlying risk of fall or fall-related injury.

If it is impossible to identify the baseline risk of falling – the proportion

of patients who will be correctly and incorrectly allocated to the four

groups of false positive, false negative, true positive and true negative

– then it is impossible to establish the incremental outcomes or costs

associated with an effective falls-prevention treatment even when

there is evidence of its relative effectiveness from an RCT. Research in

this area should be a priority.

6.3.2 Effectiveness

There is a substantial literature reporting RCTs of falls-prevention

interventions, although there are methodological limitations to most of

the studies. This report presents an exhaustive set of meta-analyses.

Whether falls have a significant effect depends upon which outcome

measure is considered. The meta-analyses suggest that, using

conventional standards of evidence, FPPs may have a small impact

upon the incidence of falls in the follow-up period (RR 0.9, 95% CI

0.8–1.0). However, the evidence does not support a conclusion that

FPPs impact upon fall-related injuries (RR 0.97, 95% CI 0.73–1.28),

mortality (RR 1.0, 95% CI 0.78–1.27) or the transition to institutional

care (RR 0.92, 95% CI 0.66–1.29), nor that FPPs impact upon

emergency department attendance (RR 0.98, 95% CI 0.74–1.29) or


© NCCSDO 2007 123

hospital admissions (RR 0.85, 95% CI 0.69–1.04). They may,

however, lead to increased GP attendances (RR 1.39, 95% CI 1.11–

1.74).

As the rationale for FPPs is that they will impact upon the morbidity,

mortality and resource use associated with falls (NICE Falls Guideline

Scope; www.nice.org.uk/page.aspx?o=30591), whereas the evidence

base on effectiveness is sufficient to parameterise these parts of a

cost-effectiveness model, it is possible to draw the conclusion that

FPPs are as likely to exacerbate as ameliorate the problems that they

are designed to address. In this context, the value of constructing a

cost-effectiveness model may be less than originally expected.

6.3.3 Resource utilisation

The published literature is of very little use in identifying the resource

implications of falls and fall-prevention programmes in the UK. None of

the published economic evaluations were of UK NHS FPPs and thus the

resource use and unit costs cannot be easily generalised to the UK

NHS. Some studies provide top-down estimates of the total cost of

falls to the UK NHS – notably Scuffham et al. (2003) – but these

estimates do not provide the level of detail required to characterise

the cost parameters in a cost-effectiveness model.

The detailed survey of FPPs undertaken as part of this study provides

the most detailed description of the resource use in an NHS context to

date. It is clear that there is substantial variation in the resources

consumed by FPPs in different settings: in terms of the staffing

requirements, accommodation and the combination of assessments

and interventions provided. From the survey we cannot conclude that

there is any degree of consensus as to the model of FPP that should be

utilised in the NHS, nor can we confidently link the majority of the

FPPs we have identified to interventions for which there is RCT

evidence.

It would be possible to specify resource use of some of the

interventions reported in published RCTs by contacting authors for

additional data, and to utilise unit-cost data collected in the survey.

However, there are two significant limitations. First, there is

considerable disparity between the interventions reported in the

survey and those described adequately in the literature. Second, it

would be necessary to undertake further data collection to attach

resource-use and unit-cost data to the post-intervention events (e.g.

fall-related injuries, admission to hospital, referral to residential care)

that would also be an important element of any cost-effectiveness

analysis.

6.4 Discussion

There is a large volume of NHS activity that falls under the umbrella of

falls prevention. However, the degree of variation in content of this


© NCCSDO 2007 124

activity and the evidence base for its effectiveness is even greater.

The limitations of the evidence base for FPPs are such that it would not

allow us to confidently differentiate between what works and does not

work within the portfolio of FPPs. This is perhaps unsurprising given

the mandate to provide FPPs from both the National Service

Framework for Older People (Department of Health, 2001) and the

NICE guideline on falls prevention (National Institute for Clinical

Excellence, 2004) without detailed direction. Against this background

it would not be possible to construct a cost-effectiveness model that

was representative of current falls-prevention activity in the NHS.

The review of the evidence base identifies a number of challenges to

the construction of a cost-effectiveness model of ideal practice in falls

prevention. The first of these is the lack of reliable validated tools for

identification of the baseline risk of falling. Without this it is impossible

to identify the magnitude of benefit from the FPP; and identifying the

magnitude of benefit from the treatment is essential to calculating an

incremental cost-effectiveness ratio.

Whereas there are a number of RCTs of FPPs the duration of follow-up

for the trials is generally short and there are concerns regarding the

robustness of the follow-up in some of the studies. To establish the

cost-effectiveness of the interventions in the long term it is important

to know whether the effects are sustained or not, and whether repeat

intervention can maintain the effectiveness in the longer term. The

evidence base is weak in this regard, although extrapolations from this

type of data can be, and often are, made.

Arguably the most important finding of the effectiveness review is that

the FPPs that have been subject to an RCT do not have a significant

effect on the outcomes which provide the policy basis for

recommending their implementation in the NHS; that is, falls-related

injuries, hospitalisation and emergency department attendance. We

can speculate as to why this may be the case; for example, it might

be that the factors that predispose towards sustaining an injury in fall

are likely to represent a barrier to engagement in a clinical trial, or it

might be that the FPP tests do not act on the factors that predispose

to an injury from fall. Whatever the explanation, the current evidence

base cannot be interpreted as a foundation for the widespread

implementation of the FPPs to reduce the incidence of falls-related

injuries and the associated morbidity, mortality and resource use.

The RCTs identified in this review are relatively small and of short

duration. It may be that the underlying event rate of interest, falls-

related injury, is too small for them to have provided strong evidence

for an effect. Thus, there may be value in undertaking a much larger

trial powered to identify a difference in fall-related injury. However,

researchers may also need to revisit the underlying aetiological model

of fall-related injuries and establish a firm evidence base on the

causes of fall-related injuries prior to designing interventions that

clearly address those causes.


© NCCSDO 2007 125

Any future trial of an FPP should be designed to ensure that it provides

unbiased and robust evidence on the following:

1 the untreated risk of falls and fall-related injuries;

2 the sensitivity and specificity of screening tools used to determine

eligibility for services;

3 the impact of the intervention on falls, fall-related injuries,

mortality, health-related quality of life and utilisation of health

and social care resources in primary, secondary and community

care;

4 the resource utilisation associated with the intervention;

5 the impact of the intervention on health-related quality of life.

Of particular importance is the use of a published and validated risk-

assessment tool delivered in a standardised manner and interpreted

according to standard and validated rules.

6.5 Conclusion

At the present time, the evidence base is insufficient to support the

construction of a cost-effectiveness model to assess the question of

what is the incremental cost-effectiveness of a FPP in the prevention

and management of fall-related injuries and the associated morbidity

and mortality, for a community-dwelling UK population, from the

perspective of the NHS and social services.


© NCCSDO 2007 126

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Appendices

Appendix 1 Summary economic data

Service Point of contact with falls-prevention team, location, new attendances p.a. (population size of catchment area)

Breakdown of cost: budget hospital transport cost*

beverages provided floor space staff costs

Total cost

1 Community, urban, 180

Budget: ‘Comes with the day hospital budget’

Clinic transport: 85% (£15,300)

Lunch§: Yes @£1.70 (£306) Partial staff information

Consultant†: £10,376.60

£25,982.60


Clinic transport: 100% patients transported

Transported for assessment (£24,200) Transport for exercise**: £32,000

Floor space††: 371.61 m2

(£61,070.39)

No staff information

£117,270.39

3 Community, rural, 440

Clinic transport: 75% (£33,000) Exercise transport**: £25,200

Floor space††: 355 m2 (£58,340.70) £24,019.60 Consultant‡: £5534.32 Partial staff information

£146,094.62

4 Community, urban, 186 (390,000)

Budget: overall £7380 (this is for 2006 and is not recurrent)

Clinic transport: by mini bus (community transport) Partial staff information: £49,705.04

£57,085.04


Salary full £100,673.10

£100,673.10

6 Community, rural, 108 (150,000)

Budget: ‘Part of overall day hospital budget’

Clinic transport: own transport

£32,365.74


© NCCSDO 2007 158

or we provide hospital transport Salary full: £21,649.10 Consultant‡: £10,716.64


Budget: consumables budget, £5000

Equipment budget (not delineated from overall budget) Drug budget (not allowed to prescribe)

Cost of falls work undertaken by generalists is unknown

Clinic transport: 50% (£4650)

Floor space††: 31.56m2

(£5186.57) Partial staff information: £73,000.00 Consultant‡: £11,068.64 SPR¶: £5144.48

£104,049.69

8 Community, urban and rural, 82

Budget: ‘We don’t have any budget. We are all ward based and all lose time on the ward as a result of the clinic. We use the same equipment as we use for our ward patient.’

Clinic transport: they have to make their own way, which means that many patients lose out; no funding for transport

Salary full: £87,814.19

£87,814.19

9 Community, urban and rural, 40 (122,725)

Budget: overall £130,000 Salary full: 155,705.08

£285,705.08


Clinic transport: 80% (£12,320)

Exercise transport cost**: £23,040 Floor space††: 43.19 m2 (£7097.84) Salary full £46,768.21

£89,226.05

11 Community, urban and rural (157,050)

Budget: overall £78,903 Equipment: 0 Consumables: £4000 Drugs: 0 Clinic transport: staff visit the patients in their own homes

Floor space††: 30.66 m2 (£5038.66) Partial staff information

£83,941.66


Budget: £58,000 for salaries covers the satellite clinics and additional integrated working

£84,928.75


© NCCSDO 2007 159

across services some staff seconded free from services

Clinic transport: 10% (£3000) hospital taxis used for health clinic venue; mainly public transport/friends and family

Salary full: £22,821.92 Consultant‡: £1106.83


Salary full: £154,435.40 Consultant‡: £51,883

£206,318.40


Budget: £149,760

Clinic transport: social services transport

Floor space††: 42 m2 (£6902.28) Partial staff information: £118,026.80

£274,689.08


Budget: overall: As part of 11PA job plan (approx 1 PA per week) Consumables: outpatient budget

Clinic transport: hospital transport/own transport

Consultant‡: £103,766

£103,766


Partial staff information Consultant‡: £8297.52

£8297.52


Clinic transport: hospital transport, voluntary agency

Floor space††: 12 m2 (£1972.08)

£1972.08

18 Community, urban Partial staff information Consultant†: £10,376.60

£10,376.60


Budget: overall £116,000 Equipment: £2000

Clinic transport: by ambulance or voluntary car

Floor space††: 242 m2 (£39,770.28) Partial staff information £24,456.30

£182,226.58


Budget: overall £130,000 £50,060.56

£180,060.56

21 Community, urban (500,000)

Salary full: £28,218.96 £28,218.96

22 Community, urban (500,000)

Partial staff information £24,301.16

£24,301.16


© NCCSDO 2007 160


Budget: overall £160,000 Equipment: £20,000 Drugs: nil

Clinic transport: people visited at home; for falls programme transport is by community transport, paid for by the service


£266,054.10


Clinic transport: hospital transport 75% (£4950) Partial staff information Consultant‡: £8301.48

£13,251.48


Budget: staff costs, each from individual budget relating to OT (£5000), physiotherapist (£7700) and nursing (£7700) Transport costs to bring patients to hospital, part of larger transport budget, minimal admin/postage costs absorbed in whole hospital budget

Clinic transport: own transport, ambulance

Floor space††: 40 m2

(£6573.60) Salary full: £15,255.90

£42,229.50

26 Community, urban and rural

Budget: overall £30,000 Consumables: £500

Clinic transport: mostly by relatives or by subsidised volunteer driver service

Hospital transport difficult to access Partial staff information Consultant‡: £6037.44

£36,537.44


Budget: overall £259,000 Equipment: £9000 Drugs: nil

Clinic transport: patients provide their own transport; where a person is house-bound either a home visit is offered or we have access to ambulance transport provided through another intermediate care team; this has very strict criteria Salary full: £259,714.60

£518,714.60


© NCCSDO 2007 161


Salary full: £86909.94 £86,909.94


Floor space††: 64 m2 (£10517.76) Salary full: £26811.84

£37,329.60

30 Community, urban Partial staff information Consultant†: £10,376.60

£10,376.60

31 Community, rural, 10 (2400)

Budget: overall £600

Clinic transport: three came in hospital transport, last group (the rest came on their own)

Floor space††: 25 m2 (£4108.50) Salary full: £4624.40

£9332.90


Clinic transport: own or hospital transport

Floor space††: 66 m2 (£10,846.44) Salary full: £34,298.88

£45,145.32


Partial staff information Consultant‡: £6037.44

£6037.44


Budget: FPP budget within whole physiotherapist budget

Clinic transport: transport for those with none available


(£16,434) Partial staff information £12,220.76

Consultant‡: £5537.32

£34,192.08


Budget: FPP budget within whole physiotherapist budget

Clinic transport: transport for those with none available


(£16,434) Partial staff information £12,220.76

Consultant‡: £5537.32

£34,192.08


Budget: £2000

Equipment: £200

Consumables: nil

Drugs: nil

Clinic transport: own transport, occasionally hospital transport booked


£32,625.52


© NCCSDO 2007 162

(£14,657.48) Salary full: £15,968.04

37 Community, urban Clinic transport: hospital transport 75% Exercise transport cost**: £21,600 Salary full: £117,715.73

£139,315.73


Clinic transport: hospital transport 80% (£33,600)


Partial staff information (£25,812.88) £76,022.18

£135,435.06

39 Community, urban and rural (163,000)

Salary full: £198,471.40 £198,471.40


Budget: £50,000

Clinic transport: hospital transport, voluntary schemes, fairly occasional, they can drive Partial staff information £72,559.26


£132,935.86

41 Community, urban Salary full: £40,573.99 £40,573.99

42 Community, urban Salary full: £145,756.80 £145,756.80



Clinic transport: hospital transport 95% (£39,520) Exercise transport cost**: £53,200


(£61,627.50) Salary full: £75,482.44

£300,829.94



Clinic transport: hospital transport 95% (£39,520) Exercise transport cost**: £53,200

Floor space††: 187.50 m2 Salary full: £75,482.44

£270,016.19


Budget: overall £21,841

Clinic transport: hospital or private transport Salary full: £165,174.90

£187,015.90


Salary full: £57,842.20 Consultant‡: 41,507.40

£99,349.60


© NCCSDO 2007 163


Budget: £15,000 total funding level 1

Clinic transport: either make their own way to the class or we can provide dial-a-ride buses to transport them to and from the classes

£15,000



Consultant‡: £15,564.90

£54,442.01



(£37,370.92) Salary full: £95,820.73

£133,191.65



(£26,458.74) £26,458.74



Clinic transport: patient transport service; ambulance service; voluntary car/bus; own transport


(£19,909.79)

£21,109.79

52 Community, urban, 1,300 (35,000)


£38,877.11


Budget: £84,000 integrated into ward budget

Clinic transport: hospital transport 50% (£10,400)


(£5710.81) Partial staff information £40,567.56 Consultant†: £10,376.60

£151,054.97



(£9160.31) Partial staff information £10,366.40

£19,526.71


Salary full: £4541.46 Consultant†: £9685.06 SPR¶: £4501.42

£18,727.94


‘Only budget available is for 371/2 hours band 7 falls co-ordinator.’

Clinic transport: own transport and hospital transport


(£8687.01) Salary full: £4146.56

£23,210.17


© NCCSDO 2007 164



Partial staff information Consultant†: £10,376.60

£10,376.60


Clinic transport: hospital transport 25% (£2600)

Exercise transport cost**: £800


(£12,946.71) Salary full: £86,615.42

£102,962.13

59 Community, urban, 24,116


(£24,386.41)

Partial staff information £71,363.80 Consultant‡: £103,766

£199,516.21


Salary full: £61,190.80 £61,190.80

61 Community, rural Budget: overall £79,206


£148,854.32



£69,648.32


Partial staff information £4909.52 Consultant†: £10,376.60

£30,798.17



(£8833.26) Salary full: £88,909.95

£97,743.21



(£6902.28) £6902.28

66 Community, urban £169,240.60 £169,240.60


Salary full: £169,240.60 Consultant†: £10,376.60

£179,617.20


Budget: ‘Don’t have one specifically for falls clinic. Annual cost is approx £20,000.’

Clinic transport: via Primary Care Trust in-house transport system, escorted by physiotherapist assistant

Floor space††: 200m2 (£32,868) Salary full: £22,984.02

£75,852.02



Clinic transport: own this is an area of concern but no budget for this

£46,626.58


© NCCSDO 2007 165


(£11,908.08) Partial staff information £9718.50

70 Community, urban and rural

£162,427.70 £162,427.70


Floor space††: 10.41 m2 (£1710.78) Partial staff information £61,597.29


£73,684.67



£61,597.29


Partial staff information £18,659.52 Consultant†: £10,376.60

£29,036.12



Clinic transport: hospital transport 65% (£2795) Exercise transport cost**: £35,100

£59,750

75 Community, urban, 110,091

Overall budget: £21,855 Partial staff information £20,732.80

£42,587.80



Clinic transport: hospital transport 75% dedicated ambulance (£40,500) Exercise transport cost**: £25,200 Salary full: £156,043.20

£583,743.72

77 Community, urban and rural, 50 (6654)


Clinic transport: patients are encouraged to make their own transport arrangements however transport can be arranged via the ambulance service patient transport


(£13,327.97) Partial staff information Consultant‡: £3018.72

£263,723.69

78 Community, urban Budget: overall £79,206

Clinic transport: usually take approx. five new patients per clinic with approximately three follow-ups Partial staff information

£520,487.20


© NCCSDO 2007 166

£441,281.20

Total £8,555,958.64/78=£109,691.78

1 Acute, urban, 210 (250,000)

Budget: ‘Linked budget with the day hospital so not able to separate.’

Clinic transport: 60–70% (£13,650)

£13,650

2 Acute, urban, 240 (230,500)

Floor space††: 5.57 m2 (£915.37) Partial staff information Consultant†: £10,376.60

£11,291.97

3 Acute, urban, 180 (300,000)


£10,376.60

4 Acute, urban, 180 (300,000)


£10,376.60

5 Acute, rural, 180 (300,000)


£10,376.60

6 Acute, urban and rural, 255


£137,851.40

7 Acute, urban, 50 (69,000)

Floor space††: 600 m2 (£98,604) Partial staff information Consultant‡: £311,329.80

£409,933.80

8 Acute, urban, 550 (191,151)

Salary full: £149,597.40 Consultant‡: £20,753.20

£170,350.60

9 Acute, urban, 1700 (260,000)

Budget: £328,045.00 (overall)

£12,446.00 (equipment)

£7164.00 (consumables)

£745.00 (drugs)

Clinic transport: ambulance transport (£56,700)

Exercise transport cost**: £29,400

Lunch: not available


(£74,133.77) Salary full: £158,988 Consultants†: £77,305.67 SPR¶: £337,708

£1,062,280.44

10 Acute, urban, 72 (250,000)

Budget: £420,000 (falls clinic shared budget with rapid access for the elderly clinic)

£420,000

11 Acute, urban, 312 (3,200,000)

Transport: 1 in 6 (52) (£5200) £5200

12 Acute, urban, 80 (200,000)

Budget: overall, as part of 11PA job plan (approx 1 PA per

£10,376.60


© NCCSDO 2007 167

week) Consumables: outpatient budget

Salary full: Consultant†: £10,376.60

13 Acute, combination, 384 (225,000)

No specific budget

Transport: 10% (£3840)

Exercise cost**: £2520 Partial staff information Consultant‡: £10,376.60

SPR¶: £3858.36

£20,594.96

14 Acute, combination, 384 (225,000)

Partial staff information Consultant‡: £10,376.60

SPR¶: £3858.36

£14,234.96

15 Acute, urban (35,500)

Budget: £400,000

Clinic transport: 0% Exercise transport: 0

£400,000

16 Acute, urban, 208 Clinic transport: 60% ambulance (£12,480) Exercise transport cost**: £24,000

Floor space††: 240 m2 (£39,441.60) Salary full: £38,681.40

Consultant‡: £11,068.64

SPR¶: £2572.24

£128,243.88

17 Acute, urban, 50 Budget of from general elderly fund

Clinic transport: hospital transport: 75% (£3750) Salary full: £63,310.28 Consultant‡: £11,068.64

£78,128.92


Budget: £160,000 Equipment: £6000 revenue, however most equipment Is purchased on capital as opposed to revenue; capital funding is held centrally in the Trust and not just for this unit Consumables: £4000 Drug: £7000 ward budget

However, consultants also have associated drug budget and drugs can be requested for the unit on this budget as well

Clinic transport: patients are either transported to the hospital by ambulance or make their own arrangements to

£222,253.96


© NCCSDO 2007 168

come either by car, taxi or public transport

Floor space††: 150 m2 (£45,651) Partial staff information Consultant‡: £16,602.96

19 Acute, rural, 50 (26,765)




(£60,805.80) Partial staff information £2726.79 Consultant‡: £8301.48

£435,827.07

20 Acute, urban, 92 (240,000)


£10,376.60

21 Acute, urban, 700 (330,000)

Budget: overall: £344,640

Equipment: £7035 Consumables: £1016

Clinic transport: ambulance service from day unit, own transport

Floor space††: 472 m2 (£77,568.48) Partial staff information Consultants‡: £171,213.90

Registrar¶: £5146.03

£598,568.41

22 Acute, urban and rural, 332 (250,000)

Transport: pay nominal amount for transport supplied by the unit

Floor space††: 148.64 m2 Partial staff information (£24,427.50) £65,177.81

£89,605.31


Salary full: consultant‡: £121,755.04

£121,755.04

24 Acute, urban and rural

Salary full: £43,216.80 Consultant‡: £19,370.12

£62,586.92

25 Acute, urban, 440 (180,000)

Clinic transport: hospital transport 2/3 (£29,333) Exercise transport cost**: £21,333 Partial staff information Consultant†: £10,376.60

£61,042.60


Floor space††: 60.03 m2 (£9865.33) Salary full: £34,531.42

£44,396.75

27 Acute, urban and No budget £36,000


© NCCSDO 2007 169

rural, 72 Clinic transport: hospital transport 100% (£7200) Exercise transport cost**: £28,800

28 Acute, urban, 79 (144,477)

Budget: overall £159,983 This does not include management costs from community rehabilitation services; also does not include doctor and pharmacist Falls equipment budget is under the Integrated Community equipment service and there for does not have a separate budget

Consumables: non-pay budget £8747 Drugs: nil

Transport: some patients make their own way, others are offered hospital transport

Floor space††: 15 m2 (£2465.10) Partial staff information £120,851.90 Consultant‡: £10,376.85 SPR¶: £4822.95

£298,499.80

29 Acute, urban, 144 (250,000)


£10,376.60

30 Acute, urban, 150 (300,000)


£10,376.60

31 Acute, urban, 100 No specific budget

Clinic transport: ambulance service where appropriate Partial staff information Consultant‡: £103,766

£103,766

32 Acute, urban, 50 (500,000)

Falls budget works within a larger budget

Clinic transport: own or hospital transport Partial staff information Consultant‡: £103,766

£10,376.60

33 Acute, urban Partial staff information Consultant†: £10,376.60

£10,376.60

34 Acute, rural, 40 (12,000)


£10,376.60

35 Acute, urban, 144 (300,000)


£10,376.60


© NCCSDO 2007 170

36 Acute, urban, 350 (24,800)


(£35,497.44) Salary full: £59,343.85 Consultant‡: £103,766

£198,607.29

37 Acute, urban Partial staff information Consultant†: £10,376.60

£10,376.60

38 Acute, urban, 90 Floor space††: 184 m2

(£30,238.56) Partial staff information £32,486.69

£62,725.25

39 Acute, urban, 450 (200,000)

Lunch§: £1336.20

Consultant†:

£10,376.60

£11,712.80

40 Acute, urban, 120 (90,000)

Budget: overall £100,000 £100,000

41 Acute, urban, 1000 (300,000)

Clinic transport: hospital transport 91% (£9100) Salary full: £134,803.20

£143,903.20

42 Acute, urban, 420 (130,000)

Partial staff information £217,801.90 Consultant‡: £415,064

£632,865.90

43 Acute, urban, 420 (130,000)

Clinic transport: hospital transport 80% (£33,600) Exercise transport cost**: £40,000 Partial staff information £217,801.90 Consultant‡: £415,064

£706,465.90

44 Acute, rural, 60 (3672)


(£26,458.74) £26,458.74

45 Acute, urban, 336 Budget: overall £21,841


£187,015.90

46 Acute, urban, 174 (53,226)


Clinic transport: mostly ambulance transport but patients encouraged to arrange own transport


(£749,444.63) Salary full: £69,790.80 Consultant‡: £51,884.25

£873,523.68

47 Acute, urban, 70 Clinic transport: hospital transport 90% (£6300) Exercise transport cost**: £60,480


(£246,510)

£354,797.40


© NCCSDO 2007 171

Partial staff information Consultant‡: £41,507.40

48 Acute, urban, 62 Salary full: £341,027.70 £341,027.70

49 Acute, rural, 655 Salary full: £152,001.90 £152,001.90

50 Acute, urban Budget: overall £181,628


£392,824.40

51 Acute, rural, 180 Budget: overall £37,987

Clinic transport: hospital transport 60%(£10,800)


(£147,906) Partial staff information £45,689.60 Consultant†: £10,376.60

£252,759.20

52 Acute, urban, 605 Clinic transport: hospital transport 100%

50% Ambulance £30,250 50% Voluntary transport‡‡: £907.50 Exercise transport cost¶¶: £18,540


(£17,420.04) Salary full: £21,509.84

£88,627.38

53 Acute, urban, 468 Partial staff information £60,609.33 Consultant‡: £69,608.99

£130,218.32

54 Acute, urban, 500 Floor space††: 14.86 m2

(£2242.09) Partial staff information £26,300.61 Consultant†: £103,766

£132,308.70

55 Acute, urban, 162 (210,000)

Budget: £1000 equipment budget


(£12,095.42) Partial staff information Consultant†: £10,376.60

£23,472.02




£20,800


Clinic transport: hospital transport 50% (£4000) Exercise transport cost**: £16,800

£20,800

58 Acute, urban, 1446 Budget: clinic held within £67,863.29


© NCCSDO 2007 172

general hospital department

Physiotherapist

Consumables budget: hip protectors £25,000 Transport: Self-arranged via GP/ambulance service Partial staff information £32,486.69 Consultant†: £10,376.60


(£3789.68) Partial staff information Consultant†: £10,376.60

£14,166.28


Budget: overall £143,951 Equipment budget: £1795 Consumables: no budget Drug budget: £360.00

Clinic transport: hospital transport 45% Exercise transport cost**: £360 Salary full: £143,875.20 Consultant†: £10,376.60

£298,562.80

61 Acute, urban, 90 (248,700)

Clinic transport: hospital transport 100% (£9000) Exercise transport cost**: £3200 Partial staff information £143,875.20 Consultant†: £10,376.60

£166,451.80

62 Acute, urban, 160 Budget: overall £247,377

Clinic transport: hospital transport 100%, patient transport service (£1600) Exercise transport cost**: £28,800

Lunch§: £761.60


(£24,386.41) Salary full: £66,167.20 SPR¶: £1929.18

£371,021.39

63 Acute, urban, 100 (1100)

Partial staff information Consultant‡: £103,766

£103,766

64 Acute, urban, 200 (216,905)

Total overall budget for day hospital: £247,377

Equipment: £645.00 Consumables: £525.00

Drug budget: £7000

Clinic transport: hospital transport 65%, patients utilise

£463,027.15


© NCCSDO 2007 173

hospital transport (£13,000)


(£15,512.05) Partial staff information £118,140.90 Consultant‡: £20,753.20

SPR¶: £48,244

65 Acute, urban, 24 (22,000)

Budget: overall £79,206 Equipment: £1300 Consumables: £840 Drugs: none

Clinic transport: community car scheme


(£11,756.88)

£90,962.88

66 Acute, urban Lunch§: £544

Partial staff information Consultant†: £10,376.60 SPR¶: £48,244

£59,164.60

67 Acute, urban Budget: £20,000


(£6737.94)

£26,737.94

68 Acute, urban, 42 (150,000)


(£6737.94) £6737.94

69 Acute, urban and rural, 150 (100,000)

Budget: ‘1 PA a week of consultant time.’

Clinic transport: hospital or own transport Partial staff information Consultant†: £10,376.60

£10,376.60



(£1983.58) Salary full: consultants‡: £9056.16

£11,039.74


(£1983.58) £1983.58

72 Acute, rural, 63 Clinic transport: hospital transport 98% (£6100)

Hospital transport**: £28,224 Salary full: £162,427.70

£196,751.70

73 Acute, urban Floor space††: 650 m2

(£106,821) £106,821

74 Acute, urban, 416 Clinic transport: hospital transport 60%(£24,960)


Lunch§: £1278.40

£175,556.62


© NCCSDO 2007 174


(£106,821) Partial staff information £3896.62 Consultant†: £10,376.60

75 Acute, urban, 352 Lunch§: £1088

Partial staff information £3896.62 Consultant†: £10,376.60

£153,612.22

76 Acute, urban, 200 (550,000)

Partial staff information £3896.62 Consultant‡: £8301.48

£12,198.10

77 Acute, urban, 282 (144,477)

Budget: overall £159,983 This does not include management costs from community rehabilitation services; also does not include doctor and pharmacist Falls equipment budget is under the Integrated Community equipment service and there for does not have a separate budget

Consumables: non-pay budget is £8747 Drugs: nil

Clinic transport: 100% community transport


(£2465.10) Salary full: £441,281.20 £120,851.90 Consultant‡: £10,376.60 SPR¶: £4822.95

£739,780.75

78 Acute, rural, 27 (32,428)


(£328,680) Salary full: £21,627.76

£350,307.76

79 Acute, urban (1,000,000)


Consultant‡: £103,766 Consultant†: £10,376.60

£185,506.40

Total £13,535,894.20/79=£171,340.43

1 Emergency department, urban, 1100


[caution: this seems to be referring to whole of emergency department] (£111,7512)§§

£111,7512.00

2 Emergency department, urban

Salary full: £326,822.90 £326,822.90

3 Emergency Salary full: £326,822.90 £326,822.90


© NCCSDO 2007 175

department, urban




£24,038.63




£24,038.63

Total: £1,819,235.06/5=£363,847.01

Total excluding emergency department 1: £701,723.06/4=£175,430.77

Acute: (mean cost per service £171,340.43 based on 79 acute services reporting

data)*(110 acute services)=£18,847,447.30 grand total for acute

services. Community: (mean cost per service £109,691.78 based on 78

services reporting data)*(116 community services)=12,724,246.48 grand

total for community services. Emergency department: (mean cost per

service £175,430.77 based on four services reporting data)*(five

emergency departments reporting data)=£877,153.85 grand total for

emergency departments. Grand total=£32,448,847.63.

ED, emergency department; OT, occupational therapist; PA, physician assistant;

SPR, specialist registrar.

*The cost of a one-way journey is £50.13. (Curtis L, Netten A. Unit Costs of

Health and Social Care: PSSRU University of Kent: available from

http://www.pssru.ac.uk/uc/uc2006contents.htm, 2006.)

†Consultant hours unspecified based on 1PA, annual salary equates to

£10,376.60.

‡Annual salary estimated mid-point of consultant grade (£103,766).

¶Average estimated salary of a Specialist Registrar, excluding other increments,

£48,244.

§Lunch calculated from the number of new attendances and average number of

patients that would attend exercise sessions during the year.

**Exercise transport cost calculated £100 per each patient, based on the

percentage reported to use hospital transport.

†† Estimated cost of maintenance per floor space, obtained from Estates Return

Information Collection (ERIC) – The Department of Health (June 2006).

‡‡Maximum charge £3.00.

¶¶Exercise transport cost calculated on 50% using hospital transport per £100

and 50% using voluntary transport per £3.00.

§§Floor space for entire ward and does not reflect the size used for falls.


© NCCSDO 2007 176

Appendix 2 Search strategies for systematic review of effectiveness of fallers’ clinics

Replication of the Cochrane review’s search for 2003–2006

MEDLINE, EMBASE and CINAHL

As published in Cochrane review with correction to error.

PsycINFO

1 exp Clinical Trials/

2 exp placebo/

3 ((clinical or controlled or comparative or placebo or prospective$

or random$) adj (trial or study)).mp. [mp=title, abstract, subject

headings, table of contents, key concepts]

4 (random$ adj (allocat$ or allot$ or assign$ or basis$ or divid$ or

order$)).mp. [mp=title, abstract, subject headings, table of

contents, key concepts]

5 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).mp.

[mp=title, abstract, subject headings, table of contents, key

concepts]

6 (cross?over$ or (cross adj over$)).mp. [mp=title, abstract,

subject headings, table of contents, key concepts]

7 ((allocat$ or allot$ or assign$ or divid$) adj (condition$ or

experiment$ or intervention$ or treatment$ or therap$ or

control$ or group$)).mp. [mp=title, abstract, subject headings,

table of contents, key concepts]

8 1 or 2 or 3 or 4 or 5 or 6 or 7

9 exp Falls/

10 (falls or faller$ or falling).mp. [mp=title, abstract, subject

headings, table of contents, key concepts]

11 9 or 10

12 exp Aging/

13 (elderly or senior$ or older or geriatric or old people).mp.

[mp=title, abstract, subject headings, table of contents, key

concepts]

14 12 or 13

15 8 and 11 and 14

Social Science Citation Index

1 TS=(accidental AND fall*)


© NCCSDO 2007 177

2 TS=(fall*)

3 TS=(falls or faller* or falling)

4 TS=(aged or older or elderly or senior* or geriatric* or old

people)

5 #4 AND #3

6 TS=((clinical or controlled or comparative or placebo or

prospective* or random*) AND (trial or study))

7 TS=(random* AND (allocat* or allot* or assign* or basis* or

divid* or order*))

8 TS=((singl* or doubl* or trebl* or tripl*) AND (blind* or mask*))

9 TS=(crossover* or (cross AND over))

10 TS=((allocat* or allot* or assign* or divid*) AND (condition* or

experiment* or intervention* or treatment* or therap* or

control* or group*))

11 #10 OR #8 OR #7 OR #6

12 #11 AND #5

CENTRAL

1 exp accidental falls/ (MeSH term)

2 (falls or faller*)

3 1 or 2

4 exp aged/ (MeSH term)

5 (older or senior* or elderly)

6 4 or 5

7 3 and 6

Additional searches extending to include additional terms for population and specific terms for falls clinics

Additional terms for falls clinics:

Fall$ clinic

Fall$ service

Fall$ and (risk assess$ or multifactorial or interdisciplinary or

multidisciplinary or multifacet$ or multicomponent)

Additional terms for old people:

older or senior$ or elderly or old people or geriatric$

MEDLINE

1 randomized controlled trial.pt.

2 controlled clinical trial.pt.

3 randomized controlled trials.sh.


© NCCSDO 2007 178

4 random allocation.sh.

5 double blind method.sh.

6 single blind method.sh.

7 1 or 2 or 3 or 4 or 5 or 6

8 (animals not human).sh.

9 7 not 8

10 clinical trial.pt.

11 exp clinical trials/

12 (clin$ adj trial$).ti,ab.

13 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).ti,ab.

14 placebos.sh.

15 placebo$.ti,ab.

16 random$.ti,ab.

17 research design.sh.

18 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17

19 18 not 8

20 19 not 9

21 comparative study.sh.

22 exp evaluation studies/

23 follow up studies.sh.

24 prospective studies.sh.

25 (control$ or prospectiv$ or volunteer$).ti,ab.

26 21 or 22 or 23 or 24 or 25

27 26 not 8

28 27 not (9 or 20)

29 exp accidental falls/

30 (falls or faller$).tw.

31 29 or 30

32 exp aged/

33 (older or senior$ or elderly).tw.

34 32 or 33

35 (old people or geriatric$).mp. [mp=title, abstract, subject

headings, heading word, drug trade name, original title, device

manufacturer, drug manufacturer name]

36 34 or 35

37 9 or 20

38 31 and 36 and 37

39 limit 38 to yr="2003 - 2006"


© NCCSDO 2007 179

40 (fall$ adj clinic).mp. [mp=title, abstract, subject headings,

heading word, drug trade name, original title, device


41 (fall$ adj service).mp. [mp=title, abstract, subject headings,



42 (fall$ and (risk assessment or multifactorial$ or interdisciplinary

or multidisciplinary or multifacet$ or multicomponent)).mp.

[mp=title, abstract, subject headings, heading word, drug trade

name, original title, device manufacturer, drug manufacturer

name]

43 40 or 41 or 42

44 37 and 38 and 43

45 34 and 37 and 43

46 44 or 45

47 31 and 34 and 37

48 39 not 47

49 46 or 48

EMBASE

1 exp Randomized controlled trial/

2 exp Double Blind Procedure/

3 exp Single Blind Procedure/

4 exp Crossover Procedure/

5 1 or 2 or 3 or 4

6 ((clinical or controlled or comparative or placebo or prospective$

or randomi#ed) adj3 (trial or study)).tw.

7 (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or

order$)).tw.

8 ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.

9 (cross?over$ or (cross adj1 over$)).tw.

10 ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or

experiment$ or intervention$ or treatment$ or therap$ or

control$ or group$)).tw.

11 6 or 7 or 8 or 9 or 10

12 5 or 11

13 Animal/ not Human/

14 12 not 13

15 Falling/

16 (falls or fallers).tw.

17 15 or 16

18 exp Aged/


© NCCSDO 2007 180

19 (elderly or senior$ or older).tw.

20 18 or 19

21 17 and 20

22 14 and 21




24 (fall$ adj clinic).mp. [mp=title, abstract, subject headings,



25 (fall$ adj service).mp. [mp=title, abstract, subject headings,



26 (fall$ and (risk assessment or multifactorial$ or interdisciplinary

or multidisciplinary or multifacet$ or multicomponent)).mp.



name]

27 24 or 25 or 26

28 20 or 23

29 14 and 17 and 28

30 limit 29 to yr="2003 - 2006"

31 14 and 20 and 27

32 14 and 28 and 27

33 31 or 32

34 30 not 22

35 33 or 34


© NCCSDO 2007 181

Appendix 3 Quality-assessment tool for systematic review of effectiveness in fallers’ clinics

Score Comments

A Was the assigned treatment adequately concealed prior to allocation?

3=Method did not allow disclosure of

assignment

2=Small but possible chance of

disclosure of assignment

1=States random, but no description or

quasi-randomised

B Were the outcomes of patients who withdrew described and included in the analysis (intention to treat)?

3=Intention to treat analysis based on

all cases randomised possible or

carried out

2=States number and reasons for

withdrawal but intention-to-treat

analysis not possible

1=Inadequate detail

C Were the outcome assessors blinded to treatment status?

3=Effective action taken to blind

assessors

2=Small or moderate chance of

unblinding of assessors

1=Not mentioned or not possible

D Were the treatment and control group comparable at entry?

3=Good comparability of groups, or

confounding adjusted for in analysis

2=Confounding small; mentioned but

not adjusted for

1=Large potential for confounding, or

not discussed

E Were the subjects blind to assignment status after allocation?


subjects


unblinding of subjects


© NCCSDO 2007 182

1=Not possible, or not mentioned

(unless double-blind), or possible,

but not done

F Were the treatment providers blind to assignment status?


treatment providers


unblinding of treatment providers

1=Not possible, or not mentioned, or

possible, but not done

G Were care programmes, other than the trial options, identical?

3=Care programmes clearly identical

2=Clear but trivial differences

1=Not mentioned, or clear and

important differences in care

programmes

H Were the inclusion and exclusion criteria clearly defined?

3=Clearly defined

2=Poorly defined

1=Not defined

J Were the outcome measures used clearly defined?

3=Clearly defined

2=Poorly defined

1=Not defined

K Was ascertainment of fall and other outcomes reliable?

3=Diary or active registration

2=Interval recall

1=Participant recall at end of study

period

L Was the duration of surveillance clinically appropriate?

3=1 year or more (duration of stay for

hospital studies)

2=Less than 1 year

1=Not defined

X Cluster-randomised studies only. Did analysis adjust for clustering correctly?

Yes/No

Y Cluster-randomised studies only. Were estimates of ICCs presented?

All outcomes/Some outcomes/No


© NCCSDO 2007 183

Appendix 4 Studies excluded from the systematic review of effectiveness of fallers’ clinics

Study Reason for exclusion

Barr et al. 2005 RCT of fracture risk screening

Campbell et al. 2005 RCT of exercise and home hazard modification; not multi-factorial assessment and intervention

Clemson et al. 2004 RCT of Stepping on, a small group-based educational programme; non-eligible intervention

Crome et al. 2000 Published as abstract only

Cumming et al. 1999 RCT of environmental hazard assessment and modification; other risk factors not assessed

Day et al. 2002 RCT; three interventions each targeting single risk factor (vision, home hazards, exercise); non-eligible interventions

Gitlin et al. 2006 RCT of multi-component intervention to reduce functional difficulties, fear of falling and home hazards; falls not reported; fear of falling only

Haines et al. 2004 RCT of multi-factorial risk assessment and intervention in subacute hospital ward population; non-eligible population

Hall et al. 1992 RCT of nurse home visits and personal care plan; no falls outcome reported

Hebert et al. 2001 RCT of nurse-led multi-dimensional preventive programme to prevent functional decline; main outcome was functional decline, defined as increase of ≥5 points on SMAF score, admission to nursing home or long-term care, or death; no falls outcome reported

Hendriks et al. 2005 Ongoing study

Hornbrook et al. 1994 RCT of home safety assessment and weekly group meetings; not individualised fall-prevention interventions; non-eligible comparison

Jitapunkul 1998 RCT of 3-monthly home visits; non-eligible comparison

Kingston et al. 2001 Numerical data on falls not reported

Masud et al. 2006 Ongoing study

McEwan et al. 1990 RCT of nurse home assessment and intervention; no falls outcome reported

Nikolaus and Bach 2003

RCT comparing CGA plus diagnostic home visit and home intervention with CGA with recommendation and usual care at home; both groups received multi-factorial assessment and intervention

Reuben et al. 1999 RCT of outpatient CGA plus intervention to improve adherence to recommendations; no falls outcome reported.


© NCCSDO 2007 184

Robson et al. 2003 RCT of Steady as you go (SAYGO); a two group session intervention; non-eligible intervention

Rubenstein et al. 1990 RCT of post-fall assessment and preventive and therapeutic interventions, in long-term residential care; non-eligible population

Steadman et al. 2003 RCT of balance training

Steinberg et al. 2000 RCT of multi-component intervention targeting fall risk factors; cluster-randomised by National Seniors Association branches, but apparently no replication within arms (one cluster per arm); excluded on methodological grounds

Stevens et al. 2001 RCT of home hazard assessment compared with no home hazard assessment

van Rossum et al. 1993

RCT of preventive home visits by nurses; no quantitative data on falls reported

Yates et al. 2001 RCT of fall risk reduction programme; no falls outcome reported

CGA, Comprehensive Geriatric Assessment.


© NCCSDO 2007 185

Appendix 5 Search strategies for the systematic review of screening instruments

MEDLINE



3 1 or 2

4 exp aged/


6 4 or 5

7 (old people or geriatric$).mp. [mp=title, original title, abstract,

name of substance word, subject heading word]

8 6 or 7

9 (risk assessment or assessment tool).mp.

10 (POMA or B-POMA or performance orient$ mobility).mp.

[mp=title, original title, abstract, name of substance word,

subject heading word]

11 STRATIFY.mp. [mp=title, original title, abstract, name of

substance word, subject heading word]

12 FRHOP.mp. [mp=title, original title, abstract, name of substance

word, subject heading word]

13 falls risk for hospitalised older people.mp. [mp=title, original title,

abstract, name of substance word, subject heading word]

14 (PPA or physiological profile assessment).mp. [mp=title, original

title, abstract, name of substance word, subject heading word]

15 (FSST or four square step test).mp. [mp=title, original title,


16 Functional reach test.mp. [mp=title, original title, abstract, name

of substance word, subject heading word]

17 ((timed up and go) or TUG or TUGT or timed up & go).mp.



18 berg balance scale.mp. [mp=title, original title, abstract, name of


19 dynamic gait index.mp. [mp=title, original title, abstract, name of


20 (((one leg or one-leg) and (stand or stance)) or OLST).mp.




© NCCSDO 2007 186

21 (Peter James Centre Fall Risk assessment tool or PJC-FRAT).mp.



22 (falls risk assessment tool or FRAT).mp. [mp=title, original title,


23 activities-specific balance confidence.mp. [mp=title, original title,


24 (downton fall risk index or downton index).mp. [mp=title, original


25 ((home falls and accidents screening tool) or HOME FAST).mp.



26 (activities of daily vision scale or ADVS).mp. [mp=title, original


27 morse fall scale.mp. [mp=title, original title, abstract, name of


28 elderly fall screening test.mp. [mp=title, original title, abstract,


29 (tinetti balance and (score or scale)).mp. [mp=title, original title,


30 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or

21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29

31 (specificity or screening or false positive or false negative or

accuracy or (predictive and value$) or reference value$ or ROC or

likelihood ratio).mp. [mp=title, original title, abstract, name of


32. 9 or 30 or 31

33 3 and 8 and 32

EMBASE

1 falling/


3 1 or 2

4 exp aged/


6 4 or 5




8 6 or 7





© NCCSDO 2007 187


name]

11 STRATIFY.mp. [mp=title, abstract, subject headings, heading

word, drug trade name, original title, device manufacturer, drug

manufacturer name]

12 FRHOP.mp. [mp=title, abstract, subject headings, heading word,

drug trade name, original title, device manufacturer, drug

manufacturer name]

13 falls risk for hospitalised older people.mp. [mp=title, abstract,

subject headings, heading word, drug trade name, original title,

device manufacturer, drug manufacturer name]

14 (PPA or physiological profile assessment).mp. [mp=title, abstract,



15 (FSST or four square step test).mp. [mp=title, abstract, subject



16 Functional reach test.mp. [mp=title, abstract, subject headings,






name]

18 berg balance scale.mp. [mp=title, abstract, subject headings,



19 dynamic gait index.mp. [mp=title, abstract, subject headings,






name]




name]

22 (falls risk assessment tool or FRAT).mp. [mp=title, abstract,



23 activities-specific balance confidence.mp. [mp=title, abstract,




© NCCSDO 2007 188

24 (downton fall risk index or downton index).mp. [mp=title,

abstract, subject headings, heading word, drug trade name,

original title, device manufacturer, drug manufacturer name]




name]

26 (activites of daily vision scale or ADVS).mp. [mp=title, abstract,



27 morse fall scale.mp. [mp=title, abstract, subject headings,



28 elderly fall screening test.mp. [mp=title, abstract, subject



29 (tinetti balance and (score or scale)).mp. [mp=title, abstract,







likelihood ratio).mp. [mp=title, abstract, subject headings,



32 9 or 30 or 31

33 3 and 8 and 32

CINAHL



3 1 or 2

4 exp aged/


6 4 or 5

7 (old people or geriatric$).mp. [mp=title, original title, abstract,


8 6 or 7






© NCCSDO 2007 189

11 STRATIFY.mp. [mp=title, original title, abstract, name of


12 FRHOP.mp. [mp=title, original title, abstract, name of substance

word, subject heading word]

13 falls risk for hospitalised older people.mp. [mp=title, original title,


14 (PPA or physiological profile assessment).mp. [mp=title, original


15 (FSST or four square step test).mp. [mp=title, original title,


16 Functional reach test.mp. [mp=title, original title, abstract, name

of substance word, subject heading word]




18 berg balance scale.mp. [mp=title, original title, abstract, name of


19 dynamic gait index.mp. [mp=title, original title, abstract, name of








22 (falls risk assessment tool or FRAT).mp. [mp=title, original title,


23 activities-specific balance confidence.mp. [mp=title, original title,


24 (downton fall risk index or downton index).mp. [mp=title, original





26 (activities of daily vision scale or ADVS).mp. [mp=title, original


27 morse fall scale.mp. [mp=title, original title, abstract, name of


28 elderly fall screening test.mp. [mp=title, original title, abstract,


29 (tinetti balance and (score or scale)).mp. [mp=title, original title,





© NCCSDO 2007 190



likelihood ratio).mp. [mp=title, original title, abstract, name of


32 9 or 30 or 31

33 3 and 8 and 32

PsycINFO

1 exp falls/

2 (falls or faller$ or falling).tw.

3 1 or 2

4 exp Aging/


6 4 or 5

7 (old people or geriatric$).mp. [mp=title, abstract, heading word,


8 6 or 7



[mp=title, abstract, heading word, table of contents, key

concepts]

11 STRATIFY.mp. [mp=title, abstract, heading word, table of


12 FRHOP.mp. [mp=title, abstract, heading word, table of contents,

key concepts]

13 falls risk for hospitalised older people.mp. [mp=title, abstract,

heading word, table of contents, key concepts]

14 (PPA or physiological profile assessment).mp. [mp=title, abstract,


15 (FSST or four square step test).mp. [mp=title, abstract, heading

word, table of contents, key concepts]

16 Functional reach test.mp. [mp=title, abstract, heading word, table

of contents, key concepts]



concepts]

18 berg balance scale.mp. [mp=title, abstract, heading word, table


19 dynamic gait index.mp. [mp=title, abstract, heading word, table




concepts]


© NCCSDO 2007 191



concepts]

22 (falls risk assessment tool or FRAT).mp. [mp=title, abstract,


23 activities-specific balance confidence.mp. [mp=title, abstract,


24 (downton fall risk index or downton index).mp. [mp=title,

abstract, heading word, table of contents, key concepts]



concepts]

26 (activites of daily vision scale or ADVS).mp. [mp=title, abstract,


27 morse fall scale.mp. [mp=title, abstract, heading word, table of


28 elderly fall screening test.mp. [mp=title, abstract, heading word,


29 (tinetti balance and (score or scale)).mp. [mp=title, abstract,






likelihood ratio).mp. [mp=title, abstract, heading word, table of


32 9 or 30 or 31

33 3 and 8 and 32

Social Science Citation Index and Social Science Citation Index Expanded 1970–July 2006

#28 #27 AND #26 AND #3

#27 #25 OR #24 OR #23 OR #22 OR #21 OR #20 OR #19 OR #18

OR #17 OR #16 OR #15 OR #14 OR #13 OR #12 OR #11 OR

#10 OR #9 OR #8 OR #7 OR #6 OR #5 OR #4

#26 #2 OR #1

#25 TS=(tinetti balance and (score or scale))

#24 TS=elderly fall screening test

#23 TS=morse fall scale

#22 TS=(activites of daily vision scale or ADVS)

#21 TS=((home falls and accidents screening tool) or HOME FAST)

#20 TS=(downton fall risk index or downton index)


© NCCSDO 2007 192

#19 TS=activities-specific balance confidence

#18 TS=(falls risk assessment tool or FRAT)

#17 TS=(Peter James Centre Fall Risk assessment tool or PJC-FRAT)

#16 TS=(((one leg or one-leg) and (stand or stance)) or OLST)

#15 TS=dynamic gait index

#14 TS=berg balance scale

#13 TS=((timed up and go) or TUG or TUGT or timed up & go)

#12 TS=Functional reach test

#11 TS=(FSST or four square step test)

#10 TS=(PPA or physiological profile assessment)

#9 TS=(falls risk for hospitalised older people)

#8 TS=FRHOP

#7 TS=STRATIFY

#6 TS=(POMA or B-POMA or performance orient* mobility)

#5 TS=(specificity or screening or false positive or false negative or

accuracy or (predictive and value*) or reference value* or ROC

or likelihood ratio)

#4 TS=(risk assessment or assessment tool)

#3 TS=(aged or older or elderly or senior* or geriatric* or old

people)

#2 TS=(falls or faller* or falling)

#1 TS=(accidental AND fall*)


© NCCSDO 2007 193

Appendix 6 Quality-assessment tool for the systematic review of screening instruments

QUADAS criterion Interpretation for this review

Scoring

1 Was the spectrum of patients representative of the patients who will receive the test in practice?

1 Was the spectrum of patients representative of the patients who will receive the test in practice?

3: Consecutive series or random selection of eligible people

2: Unclear

1: Not consecutive or random series

2 Were selection criteria clearly described?

2 Were selection criteria clearly described?

3: Sufficient detail that selection process could be replicated

2: Incomplete information

1: No information

3a Did recording of falls use adequate follow-up period?

3: At least 12 months

2: 6–12 months

1: Less than 6 months

3 Is the reference standard likely to classify the target condition correctly?

3b Did recording of falls use an accurate method?

3: Prospective data collection; falls diary or calendar

2: Data collected at intervals

1: Recall at end of follow-up only

4 Is the period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

4 Is the period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

Not used: not relevant to this review

5 Did the whole sample, or a random selection of the sample, receive verification using a reference standard of diagnosis?

5 Was falls data recorded for all participants?

3: If it was clear that there was no selection of patients to be followed up for falls


© NCCSDO 2007 194

2: Possibility of selection

1: Clear selection

6 Did patients receive the same reference standard regardless of the index test result?

6 Was falls data collected in the same way for all participants regardless of screening test result?

3: Clear that methods of data collection did not differ

2: Unclear: no information

1: Clear differences

7 Was the reference standard independent of the index test (i.e. the index test did not form part of the reference standard)?

7 Was the reference standard independent of the index test (i.e. the index test did not form part of the reference standard)?

Not used: not relevant to this review

8 Was the execution of the index test described in sufficient detail to permit replication of the test?

8 Was the screening test described in sufficient detail to permit replication of the test?

3: Details of exactly how test was implemented

2: Partial information

1: Insufficient information

9 Was the execution of the reference standard described in sufficient detail to permit its replication?

9 Was the duration of follow-up and method of ascertainment of falls status reported in sufficient detail to permit replication?

3: Sufficient detail

2: Partial information

1: Insufficient information

10 Were the index test results interpreted without knowledge of the results of the reference standard?

10 Were the index test results interpreted without knowledge of the results of the reference standard?

Not used: not relevant to this review because falls data always collected after screening tests

11 Were the reference standard results interpreted without knowledge of the results of the index test?

11 Was assessment of falls done without knowledge of the screening test results?

3: Reliable measures reported to ensure that participants and clinicians assessing falls were unaware of screening test results

2: Possible blinding but insufficient detail

1: Not done or not mentioned

12 Were the same clinical data 12 Were data on age, sex 3: All reported


© NCCSDO 2007 195

available when test results were interpreted as would be available when the test is used in practice?

and diagnoses reported?

2: Only one or two reported

1: None reported

13 Were uninterpretable/intermediate test results reported?

13 Were test results reported for all participants (including unclear/uninterpretable test results)?

3: All participants accounted for in screening test results

2: Partial explanation

1: Insufficient or no information

14a Were screening test and falls reported for all participants who entered the study?

3: >80%

2: 70–80%

1: <70%

14 Were withdrawals from the study explained?

14b Were withdrawals from the study explained?

3: Complete statement of losses and withdrawals

2: Partial explanation

1: Insufficient or no information

Additional (non-QUADAS) criteria

15 Were data presented for all screening tests performed?

3: Results for all screening tests

1: One or more screening tests omitted from results

16 Were methods of analysis adequately described and free from error?

3: Correct analysis and sufficient detail

2: Appears correct but insufficient detail to be sure

1: Errors in analytical method


© NCCSDO 2007 196

Appendix 7 Studies excluded from the systematic review of screening instruments


Ashton et al. 1989 Hospital

Avdic and Pecar 2006 Relevant data not presented

Becker et al. 2005 Relevant data not presented

Berg et al. 1992 Relevant data not presented

Bergland et al. 2002 Relevant data not presented

Bergland et al. 2006 Non-English

Berryman et al. 1989 Hospital

Billek-Sawhney et al. 2002 No falls outcome

Bloem et al. 2000 Duplicate publication

Boulgarides et al. 2003 Relevant data not presented

Brauer et al. 2000 Relevant data not presented

Chandler et al. 2001 Relevant data not presented

Chiari et al. 2002 Hospital

Chiu et al. 2003 Not prospective

Clark et al. 2005 Relevant data not presented

Coker and Oliver 2003 Hospital

Colon-Emeric 2002 No falls outcome

Conley et al. 1999 Hospital

Conley 2005 Hospital

Cornali et al. 2004 Hospital

Covinsky et al. 2001 Relevant data not presented

Dargent Molina et al. 1999 No falls outcome

Delbaere et al. 2006 Not prospective

Di Fabio and Anacker 1996 Not prospective

Di Fabio and Seay 1997 No falls outcome

Dite and Temple 2002 Not prospective

Duncan et al. 1992 Relevant data not presented

Eagle et al. 1999 Hospital

Forrester et al. 1999 Hospital

Franzen et al. 1998 Not prospective

Fritz et al. 2001 Not prospective

Galinsky et al. 2000 Non-English


© NCCSDO 2007 197

Gerdhem et al. 2005 Relevant data not presented

Gill-Body et al. 2002 Not prospective

Gulich and Zeitler 2000 Non-English

Gunther et al. 2002 Not prospective

Haines et al. 2006 Hospital

Harada et al. 1995 No falls outcome

Hausdorff et al. 2000 Not located

Hausdorff et al. 2001 Relevant data not presented

Heinze 2002 Non-English

Hellstrom et al. 2002 No falls outcome

Hendrich et al. 1995 Hospital

Hill et al. 1999 Relevant data not presented

Hill et al. 2004 Hospital

Hotchkiss et al. 2004 Not prospective

Izumi et al. 2002 Follow-up too short

Jester et al. 2005 Hospital

Kahnert et al. 2004 Not prospective

Kinn and Hood 2001 Hospital

Lafont et al. 1998 Discussion

Large et al. 2006 Hospital

Lasagna et al. 1997 Discussion

Lindsay et al. 2004 Hospital

Lord and Clark 1996 Relevant data not presented

Lord and Dayhew 2001 Not prospective

MacAvoy et al. 1996 Hospital

Macrae et al. 1992 Not prospective

Maki et al. 1994 Relevant data not presented

Maki 1997 Relevant data not presented

Maly et al. 1997 No falls outcome

Moore et al. 1996 Hospital

Morse et al. 1989a Hospital

Morse et al. 1989b Not prospective

Myers et al. 1998 No falls outcome

Myers 2003 Hospital

Newton et al. 2002 No falls outcome

Nyberg et al. 1996 Hospital

O'Connell et al. 2002 Hospital

Oliver et al. 1997 Hospital


© NCCSDO 2007 198

Olsson et al. 2005 Hospital

Pal et al. 2005 Relevant data not presented

Papaioannou et al. 2004 Hospital

Porath et al. 2002 Non-eligible population

Price et al. 1998 Hospital

Prosser and Candy 1997 Hospital

Rose et al. 2002 Not prospective

Ruchinskas 2003 Relevant data not presented

Satterwhite et al. 2002 Not prospective

Schwendimann et al. 2006 Hospital

Shumway-Cook et al. 2000 Not prospective

Southard et al. 2005 No falls outcome

Stalenhoef et al. 2002 Relevant data not presented

Stel et al. 2003 Relevant data not presented

Stretanski et al. 2002 Relevant data not presented

Talley et al. 2003 Not located

Thapa et al. 1996 Relevant data not presented

Thomas and Lane 2005 Not prospective

Tinetti 1986 Discussion

Topper et al. 1993 Relevant data not presented

Tromp et al. 2001 Relevant data not presented

Vaillant et al. 2006 Not prospective

van Heuvelen et al. 2005 Non English

Van Swearingen et al. 1998 Not prospective

van Vaerenbergh and Broos 1990 Non English

Vassallo et al. 2005 Hospital

von Renteln-Kruse and Krause 2004 Hospital

Whitney et al. 2005 No falls outcome

Wijnia et al. 2006 Non-eligible population

Woo et al. 1999 Relevant data not presented

Yauk et al. 2005 Hospital

Zisselman and Robinson 1998 Not located


© NCCSDO 2007 199

Appendix 8 Search strategy for systematic review of cost-effectiveness of fallers’ clinics

1 exp Aged/

2 Geriatrics/

3 (old or older or elder or elderly or senior or geriatric$ or aged).tw.

4 1 or 2 or 3

5 Accidental Falls/

6 (fall or falls or falling or fallen or fell or faller or fallers or slip or

slipped or trip or tripped).tw.

7 5 or 6

8 4 and 7

9 Economics.mp. or Economics/

10 exp "Costs and Cost Analysis"/

11 economic value of life.mp. or "Value of Life"/

12 exp Economics, Hospital/

13 exp Economics, Medical/

14 exp Economics, Nursing/

15 exp Models, Economic/

16 Economics, Pharmaceutical/

17 exp "Fees and Charges"/

18 exp Budgets/

19 ec.fs.

20 (cost or costs or costed or costly or costing$).mp. [mp=title,

subject heading word, abstract, instrumentation]

21 (Economic$ or Pharmaeconomic$ or price$ or pricing$).mp.

[mp=title, subject heading word, abstract, instrumentation]

22 Quality-Adjusted Life Years/

23 Economic burden.tw.

24 "Cost of Illness"/

25 exp "Quality of Life"/

26 Quality of Life.tw.

27 Life Quality.tw.

28 hql.tw.

29 (sf 36 or sf36 or sf thirtysix or sf thirty six or short form 36 or

short form thirtysix or short form thirty six or shortform 36).tw.

30 qol.tw.

31 (euroqol or eq5d or eq 5d).tw.

32 qaly$.tw.


© NCCSDO 2007 200

33 quality adjusted life year$.tw.

34 hye$.tw.

35 health$ year$ equivalent$.tw.

36 health utilit$.tw.

37 hui.tw.

38 (health$ adj2 year$ adj2 equivalent$).tw.

39 quality of wellbeing$.tw.

40 (quality adj2 of adj2 wellbeing$).tw.

41 ((quality adj2 of adj2 wellbeing$) or (quality adj2 of adj2 well-

being$) or (quality adj2 of adj2 well adj being$)).mp. [mp=title,

subject heading word, abstract, instrumentation]

42 ((quality adj2 of adj2 wellbeing$) or (quality adj2 of adj2 well-

being$)).mp. or (quality adj2 of adj2 well adj being$).tw.

[mp=title, subject heading word, abstract, instrumentation]

43 41 or 42

44 qwb.tw.

45 quality of well being.tw.

46 (qald$ or qale$ or qtime$).tw.

47 vas.tw.

48 hrqol.tw.

49 utility.tw.

50 preference.tw.

51 value.tw.


20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or

31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 43 or

44 or 45 or 46 or 47 or 48 or 49 or 50 or 51

53 8 and 52

54 limit 53 to (yr="2003 - 2006")


© NCCSDO 2007 201

Appendix 9 Quality-assessment tool used for the systematic review of economic studies

1 Study question: what is the research question?

Is the economic importance of the research question adequately outlined? Yes No Not Clear Not appropriate

Is the hypothesis being tested, or question being addressed, clearly stated? Yes No Not Clear Not appropriate

Have all viewpoint(s) for the analysis been clearly stated? Yes No Not Clear Not appropriate

Have all viewpoint(s) for the analysis been adequately justified? Yes No Not Clear Not appropriate

2 Selection of alternatives

Is the rationale for choice of the alternative programmes or

intervention/s for comparison clearly stated? Yes No Not

Clear Not appropriate

Is the rationale for choice of the alternative programme/s or

intervention/s for comparison adequately justified? Yes No Not


Is the alternative intervention/s described in sufficient detail to enable the reader to assess the relevance?

Yes No Not Clear

Not appropriate

3 Form of evaluation

Is the form/s of evaluation used clearly stated? Yes No Not Clear

Not appropriate

Is a clear justification given for the form/s of evaluation chosen in relation to the question/s being addressed?

Yes No Not Clear

Not appropriate

4 Effectiveness data

Is economic evaluation based on a single effectiveness study, e.g. clinical RCT?

Yes No Not Clear

Not appropriate

Is economic evaluation based on a multiple effectiveness studies? Yes No Not Clear

Not appropriate

Was the selection of the study population adequately described? Yes No Not Clear

Not appropriate


© NCCSDO 2007 202

Was the selection of the study population appropriate? Yes No Not Clear

Not appropriate

Was the method of allocation adequately described?

Yes No Not Clear

Not appropriate

Was the method of allocation appropriate? Yes No Not Clear

Not appropriate

Was the data analysed by intention to treat? Yes No Not Clear

Not appropriate

Was the data analysed by evaluable cohort? Yes No Not Clear

Not appropriate

Were effect size/s with confidence intervals reported? Yes No Not Clear

Not appropriate

If CIs were not reported, how was uncertainty on effectiveness parameters described?

Described Not described

See comment

Was the method of data synthesis adequately reported? Yes No Not Clear

Not appropriate

5 Benefit measurement and valuation

Was the primary outcome measure/s for the economic evaluation

clearly stated? Yes No Not


If health benefits analysis has been undertaken, have details of the methods used been clearly reported?

Yes No Not Clear

Not appropriate

If changes in productivity analysis have been undertaken, what method was used?

Human-Capital

Friction-Cost

Other

If changes in productivity analysis have been undertaken, have they been reported separately?

Yes No Not Clear

Not appropriate

If changes in productivity analysis have been undertaken, has their relevance to the study question been discussed?

Yes No Not Clear

Not appropriate

6 Costing

Have the quantities of resources been reported separately from

the prices (unit costs) of those resources? Yes No Not



© NCCSDO 2007 203

Have the methods for the estimation of both quantities and prices (unit costs) been clearly reported?

Yes No Not Clear

Not appropriate

Have the methods for the estimation of both quantities and prices (unit costs) been justified?

Yes No

Has the currency and price date been reported? Yes No Not Clear

Not appropriate

Have details of adjustment for inflation been reported? Yes No Not Clear

Not appropriate

Have details of currency conversion been reported? Yes No Not Clear

Not appropriate

7 Modelling

If data modelling was undertaken, was the method reported? Yes No Not Clear

Not appropriate

Were the key parameters clearly stated? Yes No Not Clear

Not appropriate

Was the choice of the model adequately justified? Yes No Not Clear

Not appropriate

8 Adjustments for timing of costs and benefits

Has the time frame for which the costs and benefits are considered been reported?

Yes No Not Clear

Not appropriate

Have the discount rate/s been reported? Yes No Not Clear

Not appropriate

Has choice of discount rate/s been justified? Yes No Not Clear

Not appropriate

If costs or benefits are not discounted, has this been adequately justified?

Yes No Not Clear

Not appropriate

9 Allowance for uncertainty

Have details of all statistical analysis undertaken been adequately described?

Yes No Not Clear

Not appropriate

Have confidence intervals around the main variables been Yes No Not Not


© NCCSDO 2007 204

reported? Clear appropriate

Has a sensitivity analysis been performed? Yes No Not Clear

Not appropriate

If yes, what type of sensitivity analysis was used? 1-way Multi-way

Probabilistic

Other

Has the sensitivity analysis been adequately described? Yes No Not Clear

Not appropriate

10 Presentation of results

Has an incremental analysis been reported? Yes No Not Clear

Not appropriate

Have all relevant comparisons been reported? Yes No Not Clear

Not appropriate

Have major outcomes been presented in an aggregated form? Yes No Not Clear

Not appropriate

Have major outcomes been presented in a disaggregated form? Yes No Not Clear

Not appropriate

Has the uncertainty on the ICER been reported? Yes No

If uncertainty on the ICER has been reported what method was used?

CI CEAC Scatter plot on the cost effectives plane

Other

Are comparisons with other health care interventions appropriately similar in study methods and settings?

Yes No Not Clear

Not appropriate

Has the answer to the original study question been given? Yes No Not Clear

Not appropriate

Are the conclusions drawn appropriate given the data reported? Yes No Not Clear

Not appropriate

CEAC, cost-effectiveness acceptability curve; ICER, incremental cost-effectiveness ratio.


© NCCSDO 2007 205

Appendix 10 Studies excluded from the economic systematic review


Dejaeger 2003 Article in Dutch

Haya and Castelo-Branco 2003

Article in Spanish

Panneman et al. 2003 Costs of accidental fall injuries in the EU resulting from the use of benzodiazepines; not fall prevention

Robinson 2003 Description of cost

Dutcher and Miller 2003 Description of cost relating to the USA

McClure et al. 2006 Description of costs

Anonymous 2003 Description of costs

Schuffham et al. 2003 Description of costs

Todd and Skelton 2004 Description of costs

Paterson et al. 2003 Description of costs

Robinson 2003 Description of costs

Lawrence et al. 2005 Description of hip-fracture costs

Lansley et al. 2004 Designed to enable independent living, not fall prevention

Schousboe et al. 2005 Economic study undertaken in the USA

Masud et al. 2006 In progress, data available 2008

Thomas 2003 Individual study, do not meet criteria

Tinker 2004 No account of the benefits of falls prevention

Wolf et al. 2003 No cost data

Landis et al. 2005 No cost data

Kannus et al. 2005 No cost data

Davison et al. 2005 No cost data

Sitoh et al. 2003 No cost data

Evans and Rowlands 2004 No cost data

Parker et al. 2006 No cost data

Meyer et al. 2003 No cost data

Melton III et al. 2004 No cost data

Bischoff-Ferrari et al. 2005 No cost data

Irwin et al. 2004 No cost data

Gass and Dawson-Hughes 2006

No cost data


© NCCSDO 2007 206

Kannus et al. 2003 No cost data

O'Mahony 2006 No cost data

Birks et al. 2003 No cost data

Kooijman et al. 2005 No cost data

Simpson and Jones 2004 No cost data

Bischoff-Ferrari et al. 2004 No cost data

Leslie et al. 2003 No cost data

Birks et al. 2003 No cost data

Liu 2006 No cost data

Hulme et al. 2004 No cost data

Broadhurst et al. 2003 No cost data

Thames Valley Primary Care Research Partnership 1999

No cost data

Consortium KCHNTRD 1997 No cost data

NHS Executive South East 1995–1997

No cost data

Taylor-Piliae 2003 No cost data

Kinirons 2003 No cost data

Shaw et al. 2003 No cost data

Latham et al. 2003a No cost data

Marks and Allegrante 2004 No cost data

Tinetti 2003 No cost data

Morgan and Virnig 2004 No cost data

Clemson et al. 2004 No cost data

Steadman et al. 2003 No cost data

Parker et al. 2006 No cost data

Woolf and Akesson 2003 No cost data

Van Schoor et al. 2003 No cost data; non-UK

Taylor et al. 2004 No cost-effectiveness data for falls prevention

Grant et al. 2005 No cost-effectiveness data for falls prevention

Lotrich and Pollock 2005 No cost-effectiveness data for falls prevention

Weatherall 2004 No cost-effectiveness data for falls prevention

Harwood et al. 2005 No cost-effectiveness data for falls prevention

Weir and Culmer 2004 No cost-effectiveness data for falls prevention

Close and McMurdo 2003 No cost-effectiveness data for falls prevention

Newton et al. 2003 No cost-effectiveness data for falls prevention

Close 2005 No cost-effectiveness data for falls prevention

Chang et al. 2004 No cost-effectiveness data for falls prevention


© NCCSDO 2007 207

McCreadie and Tinker 2005 No cost-effectiveness data for falls prevention

Owen et al. 2003 No cost-effectiveness data for falls prevention

Trivedi et al. 2003 No cost-effectiveness data for falls prevention

Ettinger 2003 No cost-effectiveness data for falls prevention

Runge and Schacht 2005 No cost-effectiveness data for falls prevention

Schacht et al. 2005 No cost-effectiveness data for falls prevention

Schulman et al. 2005 No cost-effectiveness data for falls prevention

Magnus et al. 2005 No cost-effectiveness data for falls prevention

De Moraes Barros 2006 No cost-effectiveness data for falls prevention

Wagg 2004 No cost-effectiveness data for falls prevention

Swithinbank et al. 2004 No cost-effectiveness data for falls prevention

Sherritze 2003 No cost-effectiveness data for falls prevention

Shaw et al. 2000 No cost-effectiveness data for falls prevention

Edwards 2003 No cost-effectiveness data for falls prevention

Carpenter 2004 No cost-effectiveness data for falls prevention

Crome 2003 No cost-effectiveness data for falls prevention

Anonymous 2005 No cost-effectiveness data for falls prevention

Beghe et al. 2004 No cost-effectiveness data for falls prevention

British Association of Emergency Medicine 2005

No cost-effectiveness data for falls prevention

Toulotte et al. 2003 No cost-effectiveness data for falls prevention; non-UK

Solomon et al. 2003 No cost-effectiveness data for falls prevention; non-UK

Bischoff-Ferrari et al. 2004 No cost-effectiveness data for falls prevention

Sawka et al. 2005 No cost-effectiveness data for falls prevention

Wanless 2004 No cost-effectiveness data for falls prevention

Scaf-Klomp et al. 2003 No cost-effectiveness data for falls prevention; non-UK

Hayes 2004 No cost-effectiveness data for falls prevention

Nandy et al. 2004 No cost-effectiveness data for falls prevention

Ruchinskas 2003 No cost-effectiveness data for falls prevention

Pils et al. 2003 No cost-effectiveness data for falls prevention

Myers and Nikoletti 2003 No cost-effectiveness data for falls prevention

Roudsari et al. 2005 No cost-effectiveness data for falls prevention; non-UK (USA)

Pluijm et al. 2006 No cost-effectiveness data for falls prevention; non-UK

Rucker et al. 2006 No cost-effectiveness data for falls prevention; non-UK (Canada)


© NCCSDO 2007 208

Richardson et al. 2005 No cost-effectiveness data for falls prevention

Ozcan et al. 2005 No cost-effectiveness data for falls prevention

Becker et al. 2005 No cost-effectiveness data for falls prevention

Lubbeke et al. 2005 No cost-effectiveness data for falls prevention

Keys and Tress 2004 No cost-effectiveness data for falls prevention

Hanssens and Reginster 2003 No cost-effectiveness data for falls prevention

McClung 2003 No cost-effectiveness data for falls prevention

Swanenburg et al. 2003 No cost-effectiveness data for falls prevention

Millward et al. 2003 No cost-effectiveness data for falls prevention

Montgomery et al. 2003 No falls data

Smith et al., 2004 No falls data

McCarthy et al. 2004 No falls data

Hopley et al. 2004 No falls data

Spillman 2004 No falls data (changes in chronic disability among the elderly in USA)

Eng et al. 2003 Non-UK

Brennan nee Saunders et al. 2003

Non-community-dwelling population

Meyer et al. 2005a Non-community-dwelling population

Oliver et al. 2005 Non-community-dwelling population

Ellis et al. 2006 Non-community-dwelling population

Chappel et al. 2004 Non-community-dwelling population

Honkanen et al. 2005 Non-community-dwelling population

Hofmann et al. 2003 Non-community-dwelling population

Honkanen 2003 Non-community-dwelling population

Kapp 2003 Non-community-dwelling population

Kuchynka et al. 2004 Non-community-dwelling population

Warnke et al. 2004 Non-community-dwelling population

Mitani and Komatsu 2004 Non-community-dwelling population

Maurer et al. 2004 Non-community-dwelling population

Sieri and Beretta 2004 Non-community-dwelling population

Boustani and Sloane 2003 Non-community-dwelling population

Theodos 2003 Non-community-dwelling population

Mamun et al. 2003 Non-community-dwelling population

Helbostad 2005 Non-community-dwelling population

Collins et al. 2004 Non-community-dwelling population

Bruyere et al. 2005 Non-community-dwelling population

Lubbeke et al. 2005 Non-community-dwelling population; non-UK


© NCCSDO 2007 209

McMurdo and Harper 2004 Non-community-dwelling population

Neyens et al. 2006 Non-community-dwelling population; non-UK

Schnelle et al. 2003 Non-community-dwelling population; non-UK

Barnett et al. 2003 Non UK

Sorensen et al. 2006 Non-community-dwelling population

Lord et al. 2003 Non-UK

Costa et al. 2006 Non-UK

Fosnight et al. 2004 Non-UK

Scranton et al. 2005 Non-UK

Stevens 2005 Non-UK

Latham et al. 2003b Non-UK

Murray et al. 2005 Non-UK

McLean et al. 2004 Non-UK

Moller 2005 Non-UK

Titler et al. 2005 Non-UK; descriptions of cost of hospitalisation following a fall

Asplund 2004 Non-UK; no cost-effectiveness data for falls prevention

Papaioannou et al. 2003 Non-UK; no cost-effectiveness data for falls prevention

Izumi et al. 2002 Non-UK

Dharmarajan and Norkus 2004

Non-UK

Moller 2005 Non-UK (Australia)

Day et al. 2002 Non-UK (Australia)

Hu and Wagner 2005 Non-UK (cost related to USA)

Spottke et al. 2005 Non-UK (Germany)

Segal et al. 2005 Non-UK (Israel)

Fayad et al. 2003 Non-UK (Lebanon)

Hendriks et al. 2005 Non-UK (Maastricht, The Netherlands)

Vu et al. 2005 Non-UK (Melbourne, Australia)

Bosma et al. 2004 Non-UK (The Netherlands)

Meerding et al. 2006 Non-UK (The Netherlands)

Beard et al. 2006 Non-UK (NSW, Australia)

Hall and Hendrie 2003 Non-UK (Perth, Australia)

Guimarães and Farinatti 2005 Non-UK (Rio de Janeiro)

Brown 2004 Non-UK (South Australia)

The National Center for Injury Prevention and Control 2006

Non-UK (USA)


© NCCSDO 2007 210

Siris et al. 2004 Non-UK (USA)

Department of Veterans Affairs 1999–2002

Non-UK (USA)

Braithwaite et al. 2003 Non-UK (USA)

Reuben et al. 2003 Non-UK (USA)

Powell et al. 2006 Non-UK (USA)

Vladeck 2005 Non-UK (USA)

Darkow et al. 2005 Non-UK (USA)

Finkelstein et al. 2005 Non-UK (USA)

Sweeney and Chiriboga 2003 Non-UK (USA); no falls/cost data

Haumschild et al. 2003 Non-UK (USA)

LaStayo et al. 2003 Non-UK (USA)

Lipscomb et al. 2003 Non–UK (USA)

Carroll et al. 2005 Non-UK (USA) estimate of the direct medical costs of falls

Marks et al. 2003 Non-UK (USA) description of costs

Hendrie et al. 2004 Non-UK (Western Australia)

Meyer et al. 2005b Non-UK; non-community-dwelling population

Rollins 2003 Non-UK study

Swinburn and Sager 2003 Non-UK study (Australia)

O'Sullivan et al. 2004 Non-UK study (Dublin, Ireland)

Stokes et al. 2005 Non-UK study (Ireland)

Colon-Emeric et al. 2003 Non-community-dwelling participants; non-UK

Bush 2003 Non-community population

Johansson 2003 Not cost-effectiveness data

Honkanen 2004 Not cost-effectiveness study

Dubey and Terme 2004 Not cost-effectiveness study

Dowse 2003 Not cost-effectiveness study

Jansson et al. 2004 Not falls prevention

Smith et al., 2004 Not falls prevention

Montgomery et al. 2003 Not falls prevention

Grandjean et al. 2006 Not falls prevention

Ohsfeldt et al. 2004 Not falls prevention

Kolanowski et al. 2004 Not falls prevention

Beer and Giles 2005 Not falls-prevention intervention

Tinker 2004 Not related to falls

Ballard and Cream 2005 Not relevant

Alexander and Goldberg 2005 Not relevant


© NCCSDO 2007 211

Burl et al. 2003 Not relevant

Odegard 2006 Not relevant

Newton et al. 2006 Not relevant

Neubauer 2004 Not relevant

Grigor et al. 2004 Not relevant

Esquenazi 2004 Not relevant

Allum and Carpenter 2005 Not relevant

Lamb et al. 2005 Not relevant

Kobelt et al. 2005 Not relevant; non-UK

West et al. 2004 Not relevant

Kuh et al. 2005 Not relevant

Ljung et al. 2005 Not relevant

Noyes et al. 2004 Not relevant

Romeo and Knapp 2006 Not relevant

Iyer 2004 Not relevant

Cravens 2006 Not relevant

Lipscomb et al. 2003 Not relevant

McDonald and Robb 2004 Not relevant

Ranson and Emmett 2003 Not relevant

Turnbull 2003 Not relevant

Feinberg et al. 2004 Not relevant

Jones and Perese 2003 Not relevant

Kelly and Dowling 2004 Not relevant

Kai et al. 2003 Not relevant

Black and Wood 2005 Not relevant

Bagust et al. 2006 Not relevant (coronary artery stenting)

Ahmad Hasali et al. 2005 Not relevant to falls

Huang 2003 Not relevant

Spottke et al. 2005 Non-UK (Germany)

Webster et al. 2004 Non-UK (USA)

Resnick 1995 Pre-2003

Wilson and Datta 2001 Pre-2003

Wong et al. 2002 Pre-2003

Ytterstad 1996 Pre-2003

Simons et al. 2001 Pre-2003

Sharma et al. 2001 Pre-2003

Owens et al. 1997 Pre-2003

Nagata-Kobayashi et al. 2002 Pre-2003


© NCCSDO 2007 212

Jonsson et al. 1995 Pre-2003

Cowper et al. 1998 Pre-2003

Eldridge et al. 2005 Reports a cost-effectiveness model to inform the design of a future trial

Parsons et al. 2001 Pre-2003 pilot study for the Eldridge (2005) paper

Rubenstein and Josephson 2005

Article in Spanish

Gillespie et al. 2003 Studies that incorporated an economic review; pre-2003

Gaugler et al. 2003 The economic study was undertaken in New Jersey/Ohio, USA

Noyes et al. 2004 The economic study was undertaken in the USA

Zaloshnja et al. 2005 Unintentional home-injuries cost for USA

Shea et al. 2006 Withdrawn

This document was published by the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO) research programme, managed by the London School of Hygiene & Tropical Medicine.

The management of the Service Delivery and Organisation (SDO) programme has now transferred to the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton. Prior to April 2009, NETSCC had no involvement in the commissioning or production of this document and therefore we may not be able to comment on the background or technical detail of this document. Should you have any queries please contact [email protected].

Disclaimer: This report presents independent research commissioned by the National Institute for Health Research (NIHR). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the SDO programme or the Department of Health.

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