The Cochrane systematic review and meta-analysis has shown a reduction in the rate of falls with multifactorial interventions. However, the implementation of such strategies in the “real world” setting has been difficult. With the volume of data on falls prevention interventions available since the early FICSIT trials (Frailty and Injuries: Cooperative Studies of
Intervention Techniques), it would not be unreasonable to expect falls prevention interventions to now be common-place in injury prevention strategies in well health resourced countries. The FICSIT trials were a group of 8 clinical trials based in the United States of America, which examined interventions to address physical frailty and injuries in older people. These trials were the first nationally sponsored approach to falls and frailty interventions and were unique in their use of a common database for 8 different trial interventions. (121) Many of the interventions investigated in the FICSIT trials became the basis for further studies included in the Cochrane reviews since 2003. (80-82) Dr Mary Tinetti, a leading light in falls research and the lead investigator in the Yale FICSIT trial, wrote a commentary following the publication of the Hendriks et al. (94) and Elley et al. (90) studies, examining the difficulty in translation of the research into practice. (122) She
described some residual doubt as to the effectiveness of these interventions and the significant resource implications to institute these strategies in usual care based on a meta- analysis by Gates et al. (38) This meta-analysis concluded that multifactorial falls prevention interventions were not effective in the reduction of the rate of falls or risk of falling in older
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people in the community and attending the E.D. (123) Dr Tinetti examined the effect of direct provision of falls prevention interventions, highlighting that a positive effect on the risk of falling was more commonly seen in those trials that provided direct intervention. Direct interventions were those were the research team provided and coordinated falls prevention interventions rather than a referral based intervention with no direct input into management. The provision of these interventions requires the appropriately trained staff. A meta-analysis of exercise interventions by Sherrington et al. demonstrated that successful programmes require progressive increase in balance challenge and progressive resistance training to show the greatest effect. (124) And interventions with higher intensity of input from the
intervention team (doctor, nurse, allied health) providing greater support for the older person and their General Practitioner were more successful, but this would not be standard practice. (122, 123)
From a research perspective, Lord et al. outlined strategies to enhance the translation of research to the Australian clinical setting. (125) The strategies they discussed encompass elements of clinical care, development of a professional society to focus on falls prevention, and to develop health policy to both address current clinical concerns and to advance a research agenda to address falls prevention. Despite the large volume of research already discussed in this thesis, there remain unanswered questions. How are these falls prevention interventions best delivered, and should specific groups be targeted with different falls prevention interventions? If interventions are confined to those who access hospital-based healthcare, how do we know which fallers will gain the greatest benefit from these
interventions, and who should be provided with supportive care? To date the development of falls prevention services, differ across the Australian healthcare system, and therefore, there
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remains no standardised approach to determining the success of such clinical interventions. These issues remain the focus of policy development and the research agenda in Australia.
1.8.1 Falls clinics in Australia
The implementation of falls prevention strategies in Australia has seen the development and growth of “Falls Clinics”. Hill et al. conducted a survey of 20 of these clinics throughout Australia in 2000, with a 75% response rate (n=15). (126) There was no reported
standardised approach to the model of care provided by these services. The clinics were variously staffed by allied health professionals especially physiotherapists and occupational therapists, Geriatricians and Rehabilitation Medicine specialists and nurses. The assessments took on average 130 minutes to complete and the wait for assessment could take up to 16 weeks. The provision of targeted interventions relied on a combination of existing services and that provided by the clinic. Assessment tools were not standardised and there was limited formal evaluation of the effectiveness of the interventions provided. These clinics were resource, staff and time intensive and in the main required the older person to attend the clinic rather than provide care in their home. This variation in practise, along with the variation in methodology in the design of multifactorial falls prevention interventions, highlights the difficulty of implementing evidence into practice.
Currently the practise of some falls clinics is not to directly provide all interventions to reduce the risk of falls, but to refer to appropriate services. This is no different to the referral only methodology of some of the falls prevention intervention trials that have had negative results. One could argue that it is not a surprise that interventions driven through general practice are not effective since too much is left to the General Practitioner to assess and
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organise. It may be that interventions through General Practice would be more effective if the General Practitioner were provided with the results of a falls risk assessment and given advice on an approach to the management of these risks including details on how to access the resources needed for specific interventions. It has been demonstrated that developing practice guidelines is not enough to effect change in practice and that there are competing issues that prevent maximum adherence to falls prevention guidelines. (119) The
complexities of implementing falls prevention strategies in primary care are illustrated by the review by Shubert et al. (127) In the U.S. there are a range of guidelines including those from the United States Preventative Services Taskforce (USPSTF). The variations in these
guidelines and the fact that there are variations in approach to older people depending on their physical fitness, increases the risk of older people not receiving adequate falls prevention interventions. Providing General Practitioners with advice on falls prevention strategies following a falls risk assessment may be a more practical solution and less resource intensive. However, the Cochrane review demonstrates that studies dependent upon General Practitioner driven referrals to be ineffective in reducing falls. (80) The success of these interventions may be dependent upon the ease of access to appropriate falls prevention strategies rather than a lack of enthusiasm on the behalf of the General Practitioner. Alternatively falls prevention interventions which have been provided by a dedicated falls prevention service appear to be more effective in reducing falls based on the studies included in the Cochrane meta-analysis. (80) A comprehensive approach to falls prevention was prosecuted by Close and McMurdo for the U.K., with guidelines which addressed all aspects of falls prevention from community to primary care, with a significant focus on specialist-led assessment of risk and a tailored management plan. (128) Some argue that this type of resource intensive service is limited in the capacity to deal with an anticipated increasing number of older people who fall and will be available to the few who live in regions with the
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resources and expertise to provide a “Rolls Royce” service. (129) To further examine this tension between models of care, we think that studies that directly compare a more enhanced General Practice based model of falls prevention versus a hospital-based, specialist-led service are warranted.