2.6 Marco legal
4.2.4. Técnicas de observación e instrumentos de colecta y procesamiento de
1.4.1 Expert advisory group
To guide and provide advice to the project, a multidisciplinary expert panel (the Falls Guidelines Review Expert Advisory Group) was established in 2008. The panel included specialists in the areas of falls prevention research, measurement and monitoring, quality improvement, change management and policy, as well as health care professions from fields including geriatric medicine, allied health and nursing. Whenever necessary, the expert panel accessed resources outside its membership. An additional external
quality reviewer was appointed to review the guidelines from an Australian perspective.
Furthermore, an internationally renowned, independent quality reviewer (with expertise in the hospital
setting) reviewed these guidelines.
1.4.2 Review methods
The guidelines were developed drawing on the following sources: • the previous version of the guidelines
• a search of the most recent literature for each risk factor or intervention
• the most recent Cochrane review of falls prevention interventions in the hospital setting • feedback from health professionals and policy staff implementing the previous guidelines • clinical advice from the expert advisory group
• guidance from external expert reviewers
• guidance from international external expert reviewers
• guidance from specialist groups (such as the Royal Australian College of General Practitioners, Australian Association of Gerontology, and Continence Foundation Australia).
The review methods used were nonsystematic, because a systematic review of each aspect of falls
prevention, for each setting (community, hospital and residential aged care facility) was beyond the capacity
and timeframe of this update of the guidelines.
Due to these constraints, it was not possible to follow the National Health and Medical Research Council’s
(NHMRC’s) detailed requirements for developing and grading clinical practice guidelines.8 In particular, search terms and details of study inclusion and exclusion criteria were not recorded; data extraction tables were not compiled for included studies; quality appraisal criteria were not systematically applied; and the body of evidence was not graded in the way set out by the NHMRC.
However, the expert group was mindful of the need for a thorough review of the evidence supporting each
recommendation. The methods used to review assessment and intervention recommendations are described
briefly below. Assessment
Assessment recommendations were based on information supplied by the clinical experts, supplemented by general literature reviews, where relevant. The text of each section describes the supporting information
and provides a rationale for each recommendation. As NHMRC methods for reviewing diagnostic
questions have not been followed, no attempt has been made to apply levels of evidence or to grade
these recommendations.
Interventions
Rapid literature searches were carried out with the aim of identifying the highest quality information for
each intervention (systematic reviews — particularly Cochrane reviews as well as, meta-analyses, and randomised controlled trials). This is in line with recommended methods for evidence based practice, where
answers are needed quickly to clinical questions based on rapid identification of the best quality literature.9 The information retrieved in this way was checked and supplemented by information from the extensive personal research databases of the clinical experts. Each chapter was reviewed by an external expert
Pa rt A In tro du cti on Economic evaluation
A systematic review of published economic evaluations was undertaken. Literature searches were carried out
in Medline (1950 to end July 2008), CINAHL (1982 to end July 2008), and EMBASE (1980 to end July 2008). MeSH terms (Economics/; or Economics, Medical/; or Economics, Hospital/; or Technology Assessment, Biomedical/; or Models, economic/) and text words for economic evaluations (cost-effectiveness, cost utility, cost benefit, economic evaluation) were combined with MeSH and text words relating to falls or to hip protectors. Reference lists of relevant studies and reviews were also searched, and Australian researchers
were contacted.
The search identified 388 abstracts. All abstracts were reviewed, and excluded if they did not appear to be
economic evaluations of either falls prevention interventions or hip protectors. Studies that included
relevant data or information were retrieved, and their full-text versions were analysed and examined for study eligibility. Across all interventions, a total of 27 papers were identified that considered the costs or economic benefits of falls prevention interventions or hip protectors. The methods, results and limitations
of these papers are discussed in the relevant intervention sections.
1.4.3 Levels of evidence
The NHMRC’s six-point rating system for intervention research was used to classify each paper according to the strength of evidence that can be derived given the specific methods used in the paper. Table 1.1 lists the six levels of evidence.
Table 1.1 National Health and Medical Research Council levels of evidence
Level Description
I Evidence obtained from a systematic review of all relevant randomised controlled trials II Evidence obtained from at least one properly designed randomised controlled trial III-1 Evidence obtained from well-designed pseudo-randomised controlled trials (alternate
allocation or some other method)
III-2 Evidence obtained from comparative studies with concurrent controls and allocation
not randomised (cohort studies), case-control studies, or interrupted time series with
a control group
III-3 Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group
IV Evidence obtained from case series, either post-test, or pretest and post-test NHMRC = National Health and Medical Research Council
Source: NHMRC10
It is possible to have methodologically sound (Level I) evidence about an area of practice that is clinically irrelevant or has such a small effect that it is of little practical importance. These issues were not formally
reviewed during this update of the guidelines (see above), but relevant issues are described in the text
of each section and were taken into account by the expert group in developing the recommendations. A particular problem in assessing evidence for falls prevention is that research studies of an intervention have often been carried out in a different setting (eg in a residential aged care setting but not in a hospital
setting). In these guidelines, the highest level of evidence for an intervention is reported regardless of the setting; however, when the research setting is not a hospital, an * is added to the level (eg Level I-*).
This shows that caution is needed when applying economic implications for that recommendation to the hospital setting.
Pa rt A In tro du cti on
1.5 Consultation
The consultation process involved a call for submissions, an online survey, multiple nationwide workshops (in all state and territory capitals and a number of regional centres), teleconferences, and targeted interviews with key stakeholders. An extensive range of useful, high-quality responses to these processes assisted in the development of the guidelines (and subsequent implementation process), as well as to
identify other areas of action.
In addition, specialist groups provided invaluable feedback on previous guidelines and draft versions of these guidelines. They included the National Injury Prevention Working Group, the Australian Association of Gerontology, the Royal Australian College of General Practitioners and the Continence Foundation of Australia.
Development of the 2005 guidelines was underpinned by an extensive consultative process, from which
these guidelines benefit.