Date Published: May 24, 2019
Publisher: Public Library of Science
Author(s): Anna Barker, Peter Cameron, Leon Flicker, Glenn Arendts, Caroline Brand, Christopher Etherton-Beer, Andrew Forbes, Terry Haines, Anne-Marie Hill, Peter Hunter, Judy Lowthian, Samuel R. Nyman, Julie Redfern, De Villiers Smit, Nicholas Waldron, Eileen Boyle, Ellen MacDonald, Darshini Ayton, Renata Morello, Keith Hill, Carol Brayne
Abstract: BackgroundFalls are a leading reason for older people presenting to the emergency department (ED), and many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program—RESPOND—had an effect on falls and fall injuries in older people presenting to the ED after a fall.Methods and findingsCommunity-dwelling people aged 60–90 years presenting to the ED with a fall and planned for discharge home within 72 hours were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (Mini-Mental State Examination > 23). Recruitment occurred between 1 April 2014 and 29 June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised (1) home-based risk assessment; (2) 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy, and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis—217 randomised to RESPOND and 213 to control. The mean age of participants was 73 years; 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43–0.99]; P = 0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51–1.29]; P = 0.374). The rate of fractures was significantly lower in the RESPOND group compared with the control (0.05 versus 0.12; IRR 0.37 [95% CI 0.15–0.91]; P = 0.03), but there were no significant differences in other secondary outcomes between groups: ED presentations, hospitalisations or falls risk, falls efficacy, and quality of life. There were two deaths in the RESPOND group and one in the control group. No adverse events or unintended harm were reported. Limitations of this study were the high number of dropouts (n = 93); possible underreporting of falls, fall injuries, and hospitalisations across both groups; and the relatively small number of fracture events.ConclusionsIn this study, providing a telephone-based, patient-centred falls prevention program reduced falls but not fall injuries, in older people presenting to the ED with a fall. Among secondary outcomes, only fractures reduced. Adopting patient-centred strategies into routine clinical practice for falls prevention could offer an opportunity to improve outcomes and reduce falls in patients attending the ED.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12614000336684).
Partial Text: The growing number of emergency department (ED) presentations by older people is a challenge to healthcare services worldwide [1–3]. Falls are the leading cause of ED presentations in people aged 60 years and older  and account for almost 50% of all incident injury presentations . In the United Kingdom, an estimated 4 million emergency presentations for falls occur annually . A recent United States study estimated that the number of fall-related injuries treated in the ED increased from 1.6 million in 2001 to 2.4 million in 2012, and this is projected to increase to 5.7 million by 2030 . The cost of ED visits for nonfatal fall injuries in the US in 2012 was estimated to amount to US$8.2 billion . Falls result from a combination of risk factors that relate to both the individual and the environment. Prevention programs aim to reduce, eliminate, or manage identified risk factors via multifactorial interventions . There is good evidence for interventions to reduce falls in older people living in the community [10,11]. Despite this, when similar interventions are applied to those presenting to the ED with a fall, there is a lack of effectiveness [12–15]. This may be due to low levels of intervention prescription by ED staff and/or low uptake of interventions by older people. Only 3 in every 100 older patients presenting to the ED with a fall receive guideline care  and only 1 in 5 participants (21%) reported in a pooled analysis of RCTs had full adherence to prescribed home-based falls exercise programs . The ED may be a challenging environment in which to deliver falls prevention interventions, as staff, workflows, and processes are focused on managing the acute care needs of a patient (e.g., injury assessment and management) as opposed to prevention. Older people who experience a fall that leads to an ED attendance are frailer, have multimorbidity, complex social issues, and more severe injuries when compared with those who do not attend the ED as a result of a fall [18,19]. These differences highlight that different falls prevention interventions may be needed to address the more complex ED population.
In this study, RESPOND, a telephone-based, patient-centred intervention led to a significant reduction in falls but not fall injuries in older people who presented to the ED with a fall. There was also an apparent reduction in fractures, but no change in hospitalisations, ED presentations, death, fall risk, falls efficacy, or quality of life. RESPOND adopted some different delivery approaches compared with traditional falls prevention interventions. The use of telephone-delivered goal setting, motivational interviewing, and coaching using positive health messages aimed to provide person-centred care in evidence-based fall prevention strategies. There were only four risk factors targeted in RESPOND, in contrast to open targeting of multiple identified falls risk factors in prior studies. This targeted approach was a deliberate strategy to optimise implementation and uptake.