Supplement Annals of Internal Medicine

Inpatient Fall Prevention Programs as a Patient Safety Strategy

A Systematic Review
Isomi M. Miake-Lye, BA; Susanne Hempel, PhD; David A. Ganz, MD, PhD; and Paul G. Shekelle, MD, PhD

Falls are common among inpatients. Several reviews, including 4 the following themes were associated with successful implementa-
meta-analyses involving 19 studies, show that multicomponent pro- tion: leadership support, engagement of front-line staff in program
grams to prevent falls among inpatients reduce relative risk for falls design, guidance of the prevention program by a multidisciplinary
by as much as 30%. The purpose of this updated review is to committee, pilot-testing interventions, use of information technol-
reassess the benefits and harms of fall prevention programs in acute ogy systems to provide data about falls, staff education and train-
care settings and to identify factors associated with successful im- ing, and changes in nihilistic attitudes about fall prevention. Future
plementation of these programs. We searched for new evidence research would advance knowledge by identifying optimal bundles
using PubMed from 2005 to September 2012. Two new, large, of component interventions for particular patients and by determin-
randomized, controlled trials supported the conclusions of the ex- ing whether effectiveness relies more on the mix of the compo-
isting meta-analyses. An optimal bundle of components was not nents or use of certain implementation strategies.
identified. Harms were not systematically examined, but potential
harms included increased use of restraints and sedating drugs and Ann Intern Med. 2013;158:390-396. www.annals.org
decreased efforts to mobilize patients. Eleven studies showed that For author affiliations, see end of text.

THE PROBLEM ications, and postural hypotension. The latter include poor
The reported rate of falls in acute care hospitals ranges lighting; “trip” hazards, such as uneven flooring or small
from 1.3 to 8.9 per 1000 bed-days (1). Higher rates are objects on the floor; suboptimal chair heights; and limited
reported in neurology, geriatrics, and rehabilitation wards. staff availability or skills. Because in-facility falls can be
Because falls are probably underreported, most estimates precipitated by many factors and patients who fall often
may be overly conservative (1). Defining a “fall” is a chal- have several risk factors, multicomponent interventions are
lenge in itself (2, 3). For example, the National Database of believed to be necessary for prevention. The purpose of this
Nursing Quality Indicators defines a fall as “an unplanned updated review is to reassess the benefits and harms of
descent to the floor with or without injury” (4), whereas multicomponent inpatient programs for fall prevention
the World Health Organization defines a fall as “an event and to assess the factors associated with successful imple-
which results in a person coming to rest inadvertently on mentation of such programs.
the ground or floor or some lower level” (5).
Regardless of the definition, falls occur frequently and PATIENT SAFETY STRATEGIES
can have serious physical and psychological consequences. All of the multicomponent fall prevention strategies in
Between 30% and 50% of in-facility falls result in injuries recent meta-analyses included an assessment of fall risk (of-
(6, 7). Falls are associated with increased health care use, ten the Morse Fall Scale [8] or St. Thomas’s Risk Assess-
including increased length of stay and higher rates of dis- ment Tool in Falling Elderly Inpatients [9] is used). Table 1
charge from hospitals into long-term care facilities. Even a lists additional components commonly included in multi-
fall that does not cause an injury can trigger a fear of component interventions. These typically include staff and
falling, anxiety, distress, depression, and reduced physical patient education, a bedside risk sign or an alert wristband,
activity. Family members, caregivers, and health care pro- attention to footwear, a toileting schedule, medication re-
fessionals are susceptible to overly protective or emotional view, and a review after the fall to identify causes. Al-
reactions to falls, which can affect the patient’s indepen- though most in-facility fall prevention programs are multi-
dence and rehabilitation. component interventions, none of the controlled trials
A fall is often the result of interactions between explicitly articulated a conceptual framework underpinning
patient-specific risk factors and the physical environment. its intervention. Individual components of published strat-
The former risk factors include patient age (particularly egies varied in type, intensity, duration, and targeting, and
older than 85 years), history of a recent fall, mobility im- none of the trials that evaluated multicomponent interven-
pairment, urinary incontinence or frequency, certain med- tions used the same combination of components. Table 1
of the Supplement (available at www.annals.org) shows
data about components of fall prevention strategies from
See also:
studies addressed in this review.
Web-Only
CME quiz (Professional Responsibility Credit) REVIEW PROCESSES
Supplement We identified 4 recent existing reviews that were rele-
vant to the topic of inpatient fall prevention. Reviews of
390 5 March 2013 Annals of Internal Medicine Volume 158 • Number 5 (Part 2) www.annals.org

Downloaded From: http://annals.org/ on 03/23/2013

 Inpatient Fall Prevention Programs as a Patient Safety Strategy Supplement

fall prevention in community-based settings were excluded. Key Summary Points

To identify relevant reviews, we used methods described by
The rate of falls in acute care hospitals ranges from
Whitlock and colleagues (10). See the Supplement for a
approximately 1 to 9 per 1000 bed-days.
complete description of the search strategies, evidence ta-
bles, and a literature flow diagram. These reviews were High-quality evidence shows that multicomponent inter-
supplemented with the results of a search by Hempel and ventions can reduce risk for in-hospital falls by as much
colleagues (11), which was done for a report that addressed as 30%.
prevention of inpatient falls. Hempel and coworkers used
16 existing reviews and reports to identify additional per- The optimal bundle of components is not established, but
common components include risk assessments for patients,
tinent sources and searched PubMed, CINAHL, and the
patient and staff education, bedside signs and wristband
Web of Science for relevant literature not yet covered in
alerts, footwear advice, scheduled and supervised toileting,
reviews. The search included randomized, controlled trials;
and a medication review.
nonrandomized trials; and before-and-after studies in
English-language publications that addressed falls in the Harms of multicomponent interventions are unclear be-
acute care hospital setting. Searches were conducted from cause they have not been studied systematically, but they
2005 through September 2012. may include the potential for increased use of restraints
and sedating drugs and decreased efforts to mobilize
Previous Studies and Reviews
patients.
The 4 systematic reviews are a 2008 review from the
Cochrane Collaboration by Cameron and colleagues (12), Evidence about successful implementation of multicompo-
a 2008 review by Coussement and coworkers (13), a review nent interventions suggests that the following are impor-
by Oliver and colleagues originally published in 2007 (14) tant factors: leadership support, engagement of front-line
and then updated in 2010 as a narrative review (1), and a clinical staff in the design of the intervention, guidance by
2012 review by DiBardino and colleagues (15). All 4 re- a multidisciplinary committee, pilot-testing the interven-
views scored well on the assessment of multiple systematic tion, and changing nihilistic attitudes about falls.
reviews (AMSTAR) criteria for systematic reviews (11 out
of 11, 10 out of 11, 10 out of 11, and 8 out of 11,
respectively), which evaluates such items as comprehensive-
ness of the search, assessment of the quality of included hospitals, in the general population or older adult popula-
studies, and methods for synthesizing the results (16). The tion. We were looking for “pivotal studies,” defined by
Cochrane review searched for randomized trials to assess Shojania and colleagues (17) as trials that may call into
the effectiveness of fall reduction interventions for older question the results of an existing review. Studies were
adults in nursing care facilities and hospitals (12). Of the screened by a clinician and nonclinician, each of whom
41 included trials, 11 were conducted in hospital settings, was experienced in systematic reviews. This search identi-
4 of which addressed multicomponent interventions. The fied 2 new relevant studies, both of which showed statisti-
review by Coussement and coworkers identified 4 multi- cally significant improvements in intervention groups
component studies, 2 of which were included in the Co- when compared with control groups and which we discuss
chrane review (13). The review by Oliver and colleagues briefly later. We also describe a third study because of its
used broader inclusion criteria than the Cochrane review, unique design. Because Oliver and coworkers’ 2010 update
which led to the inclusion of 43 trials, case– control stud- used Downs and Black (18) to assess the quality of indi-
ies, and observational cohort studies (14). Thirteen of these vidual studies, we did the same for the 2 new studies. We
studies were classified as multicomponent inpatient inter- assessed the strength of evidence across studies using a
ventions. Oliver and coworkers’ updated narrative review framework developed for the Agency for Healthcare Re-
focused directly on hospital fall prevention and discussed search and Quality patient safety review (19). To identify
17 multicomponent studies spanning from 1999 to 2009, studies in which a principal goal was reporting on imple-
which include the 6 trials in the Cochrane and Cousse- mentation, we surveyed the results of our updated search
ment and colleagues’ reviews (1, 13). The recent review by and queried experts for additional studies.
DiBardino and coworkers (15) identified 6 primary re- This review was supported by the Agency for Health-
search studies in the acute care inpatient setting, 3 of care Research and Quality, which had no role in the selec-
which were included in the Oliver and colleagues’ 2010 tion or review of the evidence or the decision to submit the
update. manuscript for publication.
Supplemental Search
Our supplemental search started with studies identi- BENEFITS AND HARMS
fied by Hempel and coworkers, focusing on individual and Benefits
cluster randomized, controlled trials with large sample sizes Table 2 presents details about the 21 effectiveness
that assessed multicomponent interventions in acute care studies included in previous reviews or our updated search.
www.annals.org 5 March 2013 Annals of Internal Medicine Volume 158 • Number 5 (Part 2) 391

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 Supplement Inpatient Fall Prevention Programs as a Patient Safety Strategy

nology application that includes a risk assessment and tai-

Table 1. Intervention Components in Studies of Inpatient
lored signage, patient education, and plan-of-care compo-
Falls Prevention Programs
nents. Adjusted fall rates in the intervention units (3.15 per
1000 patient days [CI, 2.54 to 3.90]) were lower than
Component Studies Including This Component, n
those of control units (4.18 per 1000 patient days [CI,
Patient education 11
Bedside risk sign 10
3.45 to 5.06]), yielding a rate difference of 1.03 (CI, 0.57
Staff education 9 to 2.01). A particularly strong effect was found in patients
Alert wristband 7 aged 65 years or older (rate difference, 2.08 per 1000 pa-
Footwear 7
Review after fall 7 tient days [CI, 0.61 to 3.56]).
Toileting schedules 7 In the second study, which we also judged to have low
Medication review 6 risk of bias, Ang and colleagues (20) randomly assigned
Environment modification 5
Movement alarms 5 patients in 8 medical wards of an acute care hospital in
Bedrail review 4 Singapore to a target intervention or usual care. An assess-
Exercise 4 ment tool was used to match high-risk patients with
Hip protectors 3
Urine screening 2 appropriate interventions, in addition to an educational
Vest, belt, or cuff restraint 1 session tailored to patient-specific risk factors, in the inter-
vention group. Both groups received usual care, which in-
cluded environmental modifications, review of medications
and fall history, and generic fall prevention advice. The
The 4 reviews we identified reached similar conclusions. proportion of patients with at least 1 fall in the interven-
The reviews by Cameron and colleagues (12) and Oliver tion group was 0.4% (CI, 0.2% to 1.1%), whereas in the
and coworkers (14) found that multicomponent in-facility control group it was 1.5% (CI, 0.9% to 2.6%), for a rela-
prevention programs result in statistically and clinically sig- tive risk reduction of 0.29 (CI, 0.1 to 0.87).
nificant reductions in rates of falls. Cameron and col- One other study worth noting, by van Gaal and col-
leagues included 6478 older adults from 4 randomized tri- leagues (39, 40), evaluated a program that targeted 3 pa-
als in a pooled analysis that found a 31% decrease in the tient safety practices (pressure ulcers, urinary tract infec-
rate of falling (pooled rate ratio [RR], 0.69 [95% CI, 0.49 tions, and fall prevention) simultaneously. They found an
to 0.96] and a 27% decrease in the incidence of falls when overall positive effect on development of any adverse event,
compared with usual care among 3 trials involving 4824 a composite measure of pressure ulcers, urinary tract infec-
participants (RR, 0.73 [CI, 0.56 to 0.96]) (12). Oliver and tions, and falls. The study was not powered to assess falls
coworkers (14) included 5 randomized trials and 8 before- separately, but it is worth noting that the point estimate for
and-after studies in a pooled analysis that found an 18% the relative risk reduction in falls was 0.69, which is within
decrease in the rate of falling (RR, 0.82 [CI, 0.68 to 1.00]). the range of results reported in other studies and meta-
Coussement and colleagues (13) included 2 randomized analyses. The value of this study is the demonstration of
trials, 1 before-and-after study, and 1 cohort study and simultaneous improvements in several safety intervention tar-
found a pooled RR similar to that of Oliver and coworkers; gets that may be relevant to the same patient population.
however, this effect was not quite statistically significant
(RR, 0.82 [CI, 0.65 to 1.03]). DiBardino and colleagues’ Harms
review (15) pooled data from 6 studies (including 1 ran- Most trials of fall prevention programs did not report
domized trial, 1 quasi-experimental study, and 4 before- any harms, although 1 reported constipation from intake
and-after studies) and found a pooled odds ratio of 0.90 of vitamin D (13). Whether trials explicitly assessed the
(CI, 0.83 to 0.99). The studies included in these reviews possibility of harms was mostly unclear. Despite little em-
used interventions with 3 to 7 components and compared pirical evidence, concern exists that some fall prevention
them with control participants who received usual care (for interventions may lead to harms. For example, Oliver and
example, “control ward had no trial intervention” [23] and colleagues (1) detailed many potential harms, including
control participants who “followed conventional routines” [33]). those that would result from increased use of restraints or
We rated the first trial identified in our update search sedating medications.
as having a low risk of bias. In this cluster randomized trial,
Dykes and coworkers (24) compared the fall rates in 8
units at 4 urban U.S. hospitals over a 6-month period.
Control units in each hospital received usual care, which IMPLEMENTATION CONSIDERATIONS AND COSTS
included fall risk assessments, signage for high-risk pa- Structural organizational characteristics, existing qual-
tients, patient education, and manual documentation in ity and safety infrastructure, patient safety culture, team-
patient records. The intervention units at each hospital work, and leadership are believed to be important contexts
tested the Falls Prevention Tool Kit, which was developed for understanding the effectiveness of fall prevention pro-
by the study team. This kit is a health information tech- grams (41, 42).
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 Inpatient Fall Prevention Programs as a Patient Safety Strategy Supplement

Table 2. Abridged Evidence Tables*

Study, Year Study Design Setting Participants Quality Outcome

(Reference) Score†
Ang et al, 2011 (20)‡ RCT 8 medical wards; acute care; Singapore 1822 patients 25 Significantly fewer falls
Barker et al, 2009 (21) Before-and-after Small; acute care; Australia 271 095 patients 16 Significantly fewer injuries
Barry et al, 2001 (22) Before-and-after Small; long-stay and rehabilitation; All patients admitted to 15 Significantly fewer injuries
Ireland 95 beds for 3 y
Brandis, 1999 (7) Before-and-after Acute; Australia All patients admitted to 11 Nonsignificantly fewer falls
500 beds for 2 y
Cumming et al, Cluster RCT 24 wards; acute and rehabilitation; 3999 patients 27 Nonsignificantly fewer falls
2008 (23) Australia
Dykes et al, Cluster RCT 8 units; medical; urban United States All patients admitted or 27 Significantly fewer falls
2010 (24)‡ transferred to units over
6-mo study period
Fonda et al, 2006 (25) Before-and-after 4 wards; elderly acute and 3961 patients 20 Significantly fewer falls
rehabilitation; Australia
Grenier-Sennelier et al, Before-and-after 400 beds; rehabilitation; France All admitted patients over 11 Significantly fewer falls
2002 (26) 4y
Haines et al, 2004 (27) RCT 3 wards; subacute, rehabilitation, and 626 patients 26 Significantly fewer falls
elderly; Australia
Healey et al, 2004 (28) Cluster RCT 8 wards; acute and rehabilitation; 3386 patients 26 Nonsignificantly fewer falls
3 hospitals; United Kingdom
Koh et al, 2009 (29) Cluster RCT 2 hospitals; acute; Singapore All admissions over 1.5 y 14 Nonsignificantly fewer falls
Krauss et al, 2008 (30) Before-and-after General medicine; acute academic All admissions over 18 mo 18 Nonsignificantly fewer falls
hospital; United States
Mitchell and Jones, Before-and-after 1 acute and 1 subacute ward; 32 beds; All patients admitted to 16 Nonsignificantly fewer falls
1996 (31) Australia 32 beds for 6 mo
Oliver et al, 2002 (32) Before-and-after Elderly medical unit; acute hospital; 3200 patients admitted 8 Nonsignificantly greater falls
United Kingdom annually; data over 2 y
Schwendimann et al, Before-and-after 300 beds; internal medical, geriatric, 34 972 admissions 15 Nonsignificantly fewer falls
2006 (6) and surgical; Switzerland
Stenvall et al, RCT 3 wards; orthogeriatric, geriatric, 199 patients 25 Significantly fewer falls
2007 (33) orthopedic; Sweden
Udén et al, 1999 (34) Before-and-after Geriatric department; acute hospital; 379 patients 12 Nonsignificantly greater falls
Sweden
van der Helm et al, Before-and-after Internal medical and neurology wards; 2670 patients 11 Nonsignificantly greater falls
2006 (35) acute hospital; the Netherlands
Vassallo et al, Cohort 3 wards; rehabilitation; United 825 patients 25 Nonsignificantly fewer falls
2004 (36) Kingdom
von Renteln-Kruse and Before-and-after Elderly acute and rehabilitation wards; 7254 patients 17 Significantly fewer falls
Krause, 2007 (37) Germany
Williams et al, Before-and-after 3 medical wards and 1 geriatric unit; 1357 admitted patients 17 Significantly fewer falls
2007 (38) Australia during 6-mo
intervention

RCT ⫽ randomized, controlled trial.

* From reference 1.
† Downs and Black Quality Score (18), evaluated by Oliver and colleagues (1)— except for entries in italics, which were evaluated by Ms. Miake-Lye and Dr. Shekelle.
‡ New studies added from updated search.

Structural Organizational Characteristics Existing Infrastructure

Studies evaluating fall prevention programs were done Existing organizational infrastructure was described
in various geographic areas and settings, including the rarely, with only 5 of the 21 studies describing this for their
United States, Australia, the United Kingdom, Sweden, settings. In 4 studies, this description was limited to their
Singapore, France, Switzerland, the Netherlands, and Ger- usual fall prevention care. The fifth study provided a more
many (see Table 3 of the Supplement). Several were con- explicit statement, namely, “prior to this study none of the
ducted in an academically affiliated or teaching hospital. wards carried out specific fall assessments or interven-
Sizes of hospitals varied from small (fewer than 100 beds) tions . . . there was no specialist falls clinic or other falls
to large (greater than 500). Some studies encompassed sev- service available at this hospital” (28). Two studies re-
eral hospitals (for example, 4), and others involved multi- ported on the presence or absence of information systems
ple wards. These data show that fall prevention programs that could be used in fall prevention programs (24, 26).
have been implemented in hospitals of varying size, loca-
tion, and academic or teaching status. No studies reported Patient Safety Culture, Teamwork, and Leadership
on financial concerns (for example, how patient care or the Although some studies briefly mentioned patient
interventions were financed), although 1 U.S. study men- safety culture, teamwork, or leadership, only 4 studies pre-
tioned the potential effect of reimbursement on the em- sented expanded explanations of those factors. Grenier-
phasis on fall prevention (24). Sennelier and colleagues (26) used a framework from Shor-
www.annals.org 5 March 2013 Annals of Internal Medicine Volume 158 • Number 5 (Part 2) 393

Downloaded From: http://annals.org/ on 03/23/2013

 Supplement Annals of Internal Medicine

Inpatient Fall Prevention Programs as a Patient Safety Strategy

A Systematic Review
Isomi M. Miake-Lye, BA; Susanne Hempel, PhD; David A. Ganz, MD, PhD; and Paul G. Shekelle, MD, PhD

Falls are common among inpatients. Several reviews, including 4 the following themes were associated with successful implementa-
meta-analyses involving 19 studies, show that multicomponent pro- tion: leadership support, engagement of front-line staff in program
grams to prevent falls among inpatients reduce relative risk for falls design, guidance of the prevention program by a multidisciplinary
by as much as 30%. The purpose of this updated review is to committee, pilot-testing interventions, use of information technol-
reassess the benefits and harms of fall prevention programs in acute ogy systems to provide data about falls, staff education and train-
care settings and to identify factors associated with successful im- ing, and changes in nihilistic attitudes about fall prevention. Future
plementation of these programs. We searched for new evidence research would advance knowledge by identifying optimal bundles
using PubMed from 2005 to September 2012. Two new, large, of component interventions for particular patients and by determin-
randomized, controlled trials supported the conclusions of the ex- ing whether effectiveness relies more on the mix of the compo-
isting meta-analyses. An optimal bundle of components was not nents or use of certain implementation strategies.
identified. Harms were not systematically examined, but potential
harms included increased use of restraints and sedating drugs and Ann Intern Med. 2013;158:390-396. www.annals.org
decreased efforts to mobilize patients. Eleven studies showed that For author affiliations, see end of text.

THE PROBLEM ications, and postural hypotension. The latter include poor
The reported rate of falls in acute care hospitals ranges lighting; “trip” hazards, such as uneven flooring or small
from 1.3 to 8.9 per 1000 bed-days (1). Higher rates are objects on the floor; suboptimal chair heights; and limited
reported in neurology, geriatrics, and rehabilitation wards. staff availability or skills. Because in-facility falls can be
Because falls are probably underreported, most estimates precipitated by many factors and patients who fall often
may be overly conservative (1). Defining a “fall” is a chal- have several risk factors, multicomponent interventions are
lenge in itself (2, 3). For example, the National Database of believed to be necessary for prevention. The purpose of this
Nursing Quality Indicators defines a fall as “an unplanned updated review is to reassess the benefits and harms of
descent to the floor with or without injury” (4), whereas multicomponent inpatient programs for fall prevention
the World Health Organization defines a fall as “an event and to assess the factors associated with successful imple-
which results in a person coming to rest inadvertently on mentation of such programs.
the ground or floor or some lower level” (5).
Regardless of the definition, falls occur frequently and PATIENT SAFETY STRATEGIES
can have serious physical and psychological consequences. All of the multicomponent fall prevention strategies in
Between 30% and 50% of in-facility falls result in injuries recent meta-analyses included an assessment of fall risk (of-
(6, 7). Falls are associated with increased health care use, ten the Morse Fall Scale [8] or St. Thomas’s Risk Assess-
including increased length of stay and higher rates of dis- ment Tool in Falling Elderly Inpatients [9] is used). Table 1
charge from hospitals into long-term care facilities. Even a lists additional components commonly included in multi-
fall that does not cause an injury can trigger a fear of component interventions. These typically include staff and
falling, anxiety, distress, depression, and reduced physical patient education, a bedside risk sign or an alert wristband,
activity. Family members, caregivers, and health care pro- attention to footwear, a toileting schedule, medication re-
fessionals are susceptible to overly protective or emotional view, and a review after the fall to identify causes. Al-
reactions to falls, which can affect the patient’s indepen- though most in-facility fall prevention programs are multi-
dence and rehabilitation. component interventions, none of the controlled trials
A fall is often the result of interactions between explicitly articulated a conceptual framework underpinning
patient-specific risk factors and the physical environment. its intervention. Individual components of published strat-
The former risk factors include patient age (particularly egies varied in type, intensity, duration, and targeting, and
older than 85 years), history of a recent fall, mobility im- none of the trials that evaluated multicomponent interven-
pairment, urinary incontinence or frequency, certain med- tions used the same combination of components. Table 1
of the Supplement (available at www.annals.org) shows
data about components of fall prevention strategies from
See also:
studies addressed in this review.
Web-Only
CME quiz (Professional Responsibility Credit) REVIEW PROCESSES
Supplement We identified 4 recent existing reviews that were rele-
vant to the topic of inpatient fall prevention. Reviews of
390 5 March 2013 Annals of Internal Medicine Volume 158 • Number 5 (Part 2) www.annals.org

Downloaded From: http://annals.org/ on 03/23/2013

 Inpatient Fall Prevention Programs as a Patient Safety Strategy Supplement

cessful implementation. Some themes, such as education or Acknowledgment: The authors thank Aneesa Motala, BA; Sydne New-
training and leadership support, are often included in gen- berry, PhD; and Roberta Shanman, MLS.
eral lists of factors for successful implementation of any
intervention, whereas themes that may be more specific to Financial Support: From the AHRQ, U.S. Department of Health and
fall prevention programs include development and guid- Human Services (contracts HHSA-290-2007-10062I, HHSA-290-2010-
00017I, and HHSA-290-32001T). Dr. Ganz was supported by a Career
ance by a multidisciplinary committee and changing the
Development Award from the Veterans Affairs Health Services Research
prevailing attitudes of nihilism with respect to falls. & Development Service, Veterans Health Administration, U.S. Depart-
Our findings that multicomponent fall prevention ment of Veterans Affairs through the Veterans Affairs Greater Los An-
programs are effective in inpatient settings may seem at geles Health Services Research & Development Center of Excellence
odds with recent U.S. Preventive Services Task Force rec- (project VA CD2 08-012-1).
ommendations not to automatically do a multifactorial fall
assessment in community-dwelling adults aged 65 years or Potential Conflicts of Interest: Dr. Hempel: Grant (money to institu-
older (48). However, there is no contradiction because, tion): AHRQ. Dr. Ganz: Grant (money to institution): AHRQ, Veterans
although the goal is to prevent falls in both community- Affairs Health Services Research and Development Service. Dr. Shekelle:
Consultancy: ECRI Institute; Employment: Veterans Affairs; Grants/grants
dwelling and hospitalized patients, the settings are differ-
pending: AHRQ, Veterans Affairs, Centers for Medicare & Medicaid
ent. The hospital environment is more tightly controlled Services, National Institute of Nursing Research, Office of the National
than the outpatient setting, where it is more difficult to Coordinator; Royalties: UpToDate. Ms. Miake-Lye: None disclosed.
ensure that risk factors for falls are appropriately managed. Disclosures can also be viewed at www.acponline.org/authors/icmje
In fact, as Tinetti and Brach (49) note, community-based /ConflictOfInterestForms.do?msNum⫽M12-2569.
multifactorial programs achieve greater reduction in falls
when identified risk factors are actually managed. Requests for Single Reprints: Paul G. Shekelle, MD, PhD, RAND
Our review has several limitations. Like all reviews, we Corporation, 1776 Main Street, Santa Monica, CA 90401; e-mail,
are limited by the quality and quantity of the original re- shekelle@rand.org.
search articles. Also, we did not do an exhaustive update of
existing reviews. With several previous reviews reaching Current author addresses and author contributions are available at
consistent results, including a total of 19 effectiveness stud- www.annals.org.
ies, we focused instead on identifying “pivotal studies” that
may call into question the conclusions of previous reviews.
None were found; additional large randomized, controlled References
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