Simple assessment tools help doctors break patients' falls
From the June ACP Observer, copyright © 2007 by the American College of Physicians.
By Stacey Butterfield
A few years ago, geriatrician David A. Ganz, ACP Member, MPH, was looking for a good way to screen his patients for fall risk. The array of options was a bit overwhelming.
"Everybody has their own favorite risk factor for falls. There is one review that says there are over 300 risk factors," said Dr. Ganz, who is a special fellow at the Geriatrics Research, Education and Clinical Center in Los Angeles.
The lack of a simple, practical approach can be enough to make an internist avoid the issue altogether, which many do, according to David B. Reuben, FACP, director of geriatrics at UCLA. National studies of geriatric care quality have shown that recommended care is followed about 55% of the time overall, but physicians provide only 30%-35% of recommended care for falls prevention, he said.
"There's a perception that it takes a lot of time and adds to the office visit, which is already crowded with other health problems. The fear is that fall evaluation is going to make the doctors run further and further behind," said Dr. Reuben.
This avoidance of fall evaluation is particularly concerning given the significant, and avoidable, threat that falls pose to the U.S.'s growing geriatric population. In 2001, the CDC found that falls caused more than half of nonfatal injuries that sent Americans 65 and over to the emergency room. Meanwhile, studies have shown that interventions can reduce fall rates by 30 to 40%.
Easily applied to practice
Drs. Reuben and Ganz are currently working to correct internists' misimpressions about fall assessment, and provide rapid and effective methods to assess geriatric patients' fall risk. Dr. Ganz recently completed a review of 18 studies of fall assessment to uncover the most important risk factors, while Dr. Reuben is co-leader of an ACP pilot project helping physicians to put the findings into practice.
Dr. Ganz's findings, published in the Jan. 3 Journal of the American Medical Association, were surprisingly simple. "Our first finding was that asking patients whether they had fallen in the past year was the best predictor of future fall risk. This wasn't one of our preplanned risk factors to look at, but the association was so powerful with future falls that we had to acknowledge its importance," said Dr. Ganz.
"For example, if your baseline risk of falling in the next year is 1 in 4—which is pretty typical for an older adult—if you've also had a history of falls in the past year, the risk would go up to 50/50," he said.
The second big risk factor was whether patients had a gait or balance problem, something that could be easily determined with a single question, the researchers found. "It turned out that asking patients whether they have a walking or balance problem is just as good a predictor of future falls as examining their gait or balance," said Dr. Ganz.
The research findings are easily applied to office practice, Dr. Ganz said, through asking patients two simple questions:
- Have you fallen in the past year?
- Do you have a walking or balance problem?
The questions can be listed on a pre-visit questionnaire, or included as part of the regular office visit. Physicians should not hesitate to delegate the fall screening questions to the office staff, noted Dr. Reuben. "Those are questions that a doctor doesn't need to ask. It's not like we have magic words, that people will only tell us," he said.
To further entice physicians into conducting fall screening, the CMS plans to offer financial incentives to those who do it regularly. Fall assessment is one of the performance measures included in the Physician Quality Reporting Initiative, set to begin in July. Physicians who submit reports on the designated measures to CMS will be eligible for bonuses of up to 1.5%. (More information about this is available in this month's cover story.)
"Fall assessment is appearing on the radar of many organizations looking at quality, including Medicare." —David E. Shute, ACP Member
"Fall assessment is appearing on the radar of many organizations looking at quality, including Medicare," said David E. Shute, ACP Member, medical director of Greenfield Health System in Portland, Ore.
Tools for ongoing assessment
Of course, fall screening is only the first step in improving the quality of care for fall-prone patients. Patients who say yes to either of the screening questions then need further evaluation to uncover the root causes of their heightened fall risk.
To simplify that evaluation, Dr. Reuben and colleagues developed structured visit notes for practices in the "Practice Redesign for Improved Medical Care for Elders" pilot, a cooperative project of ACP and RAND funded by a grant from the Atlantic Philanthropies. The structured note reminds physicians of all the necessary components to a thorough fall risk assessment, which can be difficult to remember otherwise, noted Dr. Ganz.
"It's particularly hard in a busy primary care practice to remember all the components of the fall evaluation," he said. He breaks down the most important risk factors for falls into seven basic components of an evaluation:
- orthostatic hypotension,
- visual acuity,
- gait and balance examination,
- medication review,
- functional status assessment,
- cognitive evaluation, and
- home hazard assessment.
"All but one of these components [home hazards] could be done by clinicians in the office," Dr. Ganz said. The structured visit note (a sample of which is available online), translates the components into specific examination procedures to determine where exactly a patient's fall risk lies.
Once internists have used these new tools to get into the rhythm of fall assessment, they can identify risk factors for falls as an ongoing part of the office visit, said Dr. Ganz. "We need to integrate fall assessment into our routine observation of the patient," he said. The transition from a chair to an examining table, for example, is a perfect opportunity to observe a patient's balance and quadriceps strength.
"The really good news about falls is that if somebody falls, you can do something about it, and lower their risk of fracture," said Dr. Reuben. "Not only are you identifying an issue, you're identifying an issue that's treatable and if you do treat it, your patient can benefit enormously."
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