Research protocol paper and iSOLVE investigators

Clemson et. al. 2017 Integrated solutions for sustainable fall prevention in primary care, the iSOLVE project: a type 2 hybrid effectiveness-implementation design

Project aims

• To establish integrated processes and referral pathways at levels of GP practice and allied health services to identify older people at risk of falls and engage a whole of primary care approach to fall prevention.
• To form collaborative, information rich, working arrangements with GPs and allied health service providers.
• To improve access to appropriate fall prevention interventions for older people, ensure ongoing knowledge acquisition and sustainable action by healthcare professionals and organisations, using a multidisciplinary team approach to fall prevention that is integrated and translatable nationally.

Falls and their economic impact

• One in three people living in the community aged 65 years and over fall each year.
• Fall-related injuries accounted for the majority of all hospitalised injury cases among people aged 65 and over.⁵ Common injuries were hip fractures and head injuries which accounted for three-quarters and one-fifth of injuries respectively.⁶ One in every 10 days spent in hospital by a person aged 65 and older was attributable to an injurious fall, equating to 1.3 million patient days over the year. The average total length of stay per fall injury case was estimated to be 14 days.⁶
• Hospitalisation rates in Northern Sydney have been consistently higher than the NSW average. In 2011-12, the rate of hospitalisations from falls was 5,362 per year per 100,000 population in the Northern Sydney LHD.⁷
• Recovery from injury can be a lengthy process, which can include surgeries and rehabilitation. Research reported physiological effects such as functional decline, inactivity, loss of independence, depression and loss of confidence.^8,9
• Injury due to a fall is one of four principal diagnoses that increased the likelihood of a transfer to residential aged care (permanent or respite) from hospital.¹⁰
• One of the main causes of injury deaths in 2011-12 were unintentional falls (35%); and over 94% of fall-related injury deaths were at ages 65 and older.¹¹

Evidence & recommended solutions

• There is strong evidence that balance and strength exercises, home safety interventions and medication reviews are effective in preventing falls in older people. These are three core effective strategies recommended in the latest Cochrane Database of Systematic Reviews on Fall Prevention Interventions for older people living at home.²
• A meta-analysis of exercise interventions for fall prevention by Associate Professor Cathie Sherrington found that exercise reduced the risk of falling by 16%.¹²
• Professor Lindy Clemson conducted a meta-analysis of randomised trials of environmental interventions and found a significant reduction in the risk of falling of 21%, with higher effects for those frailer or recently hospitalised.¹³
• Dr Sabrina Pit led a successful randomised trial which demonstrated the value of medication reviews by GPs who had been updated on fall risks by a trained pharmacist.¹⁴

Implementation barriers to fall prevention strategies

• Older people think that a fall may just be a part of ‘ageing’ and do not think that they can actively do things to prevent a future fall. In contrast, it has been reported that GPs do not routinely ask older people if they have had a fall.¹⁵ These contribute to the lack of discussion about falls and fall prevention between the patient and the GP.
• A lack of engagement of multiple stakeholders in falls prevention.
• Health providers reported a lack of consultation time, the need to focus on more pressing health issues, and a lack of educational materials.
• Not many community-based organisations regularly offer evidence-based falls prevention services.
• There is no clear model for how fall prevention services can be effectively delivered in primary care.¹⁶
• Current practice which solely rely on referral to health care providers have been shown to be ineffective.^17,18 This highlights the need for active involvement of health care providers in promoting fall prevention management strategies.

The lack of fall prevention pathway has prompted the iSOLVE research project to develop an all-round structured process to implement systematic fall prevention in general practice.¹ This includes clinical decision tool, education and resources for GPs and practice staff, as well as upskilling training for allied health professionals. If GPs are able to routinely identify older patients at risk of falls, they could develop care plans targeting at managing fall risk factors and referral for evidence-based interventions.^19-21

1. Clemson, L., Mackenzie, L., Roberts, C., Poulos, R., Tan, A., Lovarini, M., Sherrington, C., Simpson, J. M., Willis, K., Lam, M., Tiedemann, A., Pond, D., Peiris, D., Hilmer, S., Pit, S. W., Howard, K., Lovitt, L., & White, F. (2017). Integrated solutions for sustainable fall prevention in primary care, the iSOLVE project: a type 2 hybrid effectiveness-implementation design. Implementation Science, 12(1), 12. doi:10.1186/s13012-016-0529-9.
2. Gillespie, L., Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, Issue 9, Art. No.: CD007146. DOI: 007110.001002/14651858.CD14007146.pub14651853.
3. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. (2011). J Am Geriatr Soc, 59(1), 148-157. doi:10.1111/j.1532-5415.2010.03234.x
4. The Royal Australian College of General Practitioners. (2016). Preventive activities in older age: falls. Guidelines for preventive activities in general practice. 9th edition.
5. Australian Institute of Health and Welfare. (2012). Australia’s health 2012. Australia’s health series no. 13. Cat. no. AUS 156. Canberra: AIHW.
6. Australian Institute of Health and Welfare: Kreisfeld R, Pointer S, and Bradley C. (2017). Trends in hospitalisations due to falls by older people, Australia 2002–03 to 2012–13. Injury research and statistics series no. 106. Cat. no. INJCAT 182. Canberra: AIHW.
7. Harvey L, Close, JCT. (2013). Trends in fall-related hospitalisations, persons aged 65 years and over, NSW, 1998-99 to 2011-12. Sydney: Falls and Injury Prevention Group, Neuroscience Research Australia.
8. Hartholt, K. A., van Beeck, E. F., Polinder, S., van der Velde, N., van Lieshout, E. M., Panneman, M. J., van der Cammen, T. J., & Patka, P. (2011). Societal consequences of falls in the older population: injuries, healthcare costs, and long-term reduced quality of life. J Trauma, 71(3), 748-753. doi:10.1097/TA.0b013e3181f6f5e5.
9. Terroso, M., Rosa, N., Torres Marques, A., & Simoes, R. (2014). Physical consequences of falls in the elderly: a literature review from 1995 to 2010. European Review of Aging and Physical Activity, 11(1), 51-59. doi:10.1007/s11556-013-0134-8.
10. Australian Institute of Health and Welfare. (2013). Movement between hospital and residential aged care 2008–09. Data linkage series no. 16. CSI 16. Canberra: AIHW.
11. Australian Institute of Health and Welfare: Henley G and Harrison JE. (2017). Trends in injury deaths, Australia, 1999–00 to 2011–12. Injury research and statistics series no. 108. Cat. no. INJCAT 188. Canberra: AIHW.
12. Sherrington, C., Michaleff, Z. A., Fairhall, N., Paul, S. S., Tiedemann, A., Whitney, J., Cumming, R. G., Herbert, R. D., Close, J. C. T., & Lord, S. R. (2016). Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. British Journal of Sports Medicine. doi:10.1136/bjsports-2016-096547.
13. Clemson, L., Mackenzie L, Ballinger C, Close JCT, Cumming RG. (2008). Environmental interventions to prevent falls in community-dwelling older people: a meta-analysis of randomized trials. J Aging Health, 20(8), 954-971.
14. Pit, S., Byles J, Henry D, Holt L, Hansen V, Bowman D. (2007). A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial. The Medical Journal of Australia, 187(1), 23-30.
15. Kielich, K., Mackenzie, L., Lovarini, M., & Clemson, L. (2017). Urban Australian general practitioners’ perceptions of falls risk screening, falls risk assessment, and referral practices for falls prevention: an exploratory cross-sectional survey study. Australian Health Review, 41(1), 111-119. doi:https://doi.org/10.1071/AH15152.
16. Shubert, T., Smith ML, Prizer LP, Ory MG. (2013). Complexities of fall prevention in clinical settings: a commentary. The Gerontologist, 54(4), 550-558.
17. Clemson, L. (2010). Prevention of falls in the community. BMJ, 340, c2244. doi:10.1136/bmj.c2244
18. Tinetti, M. E. (2008). Multifactorial fall-prevention strategies: time to retreat or advance. J Am Geriatr Soc, 56(8), 1563-1565. doi:10.1111/j.1532-5415.2008.01800.x.
19. Mackenzie, L., & Clemson, L. (2014). Can chronic disease management plans including occupational therapy and physiotherapy services contribute to reducing falls risk in older people? Aust Fam Physician, 43(4), 211-215.
20. Mackenzie, L., Clemson L, Roberts C. (2013). Occupational therapists partnering with general practitioners to prevent falls: seizing opportunities in primary health care. Australian Occupational Therapy Journal, 60, 66-70.
21. Grant, A., Mackenzie, L., & Clemson, L. (2014). How do general practitioners engage with allied health practitioners to prevent falls in older people? An exploratory qualitative study. Australasian Journal on Ageing, 10.1111/ajag.12157. doi:10.1111/ajag.12157