Falls prevention education for older adults during and after hospitalization: a systematic review and meta-analysis



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Falls prevention education for older adults during and after hospitalization: A systematic review and meta-analysis

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Den-Ching Angel Lee

3/1/2013


Contents


Search string terms and limiters applied to databases 3

Calculation of effect size estimates of primary outcomes 4

Table of risk ratio, confidence interval and standard error of studies used for meta-analysis 6

Forest plots of meta-analysis, subgroup meta-analysis and a priori meta-analysis 17

Characteristics of included studies 28

Characteristics of excluded studies 71




Search string terms and limiters applied to databases


(older adult OR older people OR older patient* OR aged OR elderly OR geriatric) AND (information OR counselling OR consultation OR advice OR discuss* OR education OR pamphlet* OR brochure* OR video OR media OR publication OR leaflet* OR internet) AND ( attitude* OR motivation OR intention OR participat* OR program OR prevent* OR adherence OR change OR action OR health beliefs OR awareness) AND (fall* OR fall* risk* OR accidental fall*) AND ( hospital* OR community OR discharge OR transition OR post hospitali*ation)

  • Ovid MEDLINE limiters: English, human, aged 65

  • PsycINFO limiters: Human, English language, aged 65 years or older

  • CINAHL limiters: English language, aged 65+years, human and research articles

  • Scopus limiters: English, aged, humans and journal. Inverted commas were used for phrasing health beliefs, fall* risk*, accidental fall and post hospitalisation.

  • Cochrane central register of control trials: No limiter


Calculation of effect size estimates of primary outcomes




  • For outcome i) The proportion of patients who became fallers and outcome iii) Proportion of patients who had an injurious fall (relative to all patients)

  • STATA (version 12, college station TX) was used to calculate a relative risk.

  • An integer of one was added to each cell in the 2x2 contingency table if there was a zero cell so as to obtain a finite odds ratio.



  • For studies that involved allocation of intervention and control conditions to hospital wards rather than individual patients (eg. cluster randomised trials, parallel control group studies), 95% confidence interval of the ratio was adjusted before pooling using the approach of White and Thomas (White and Thomas 2005)and the intra-cluster correlation coefficient reported by Cumming (2008)study.

  • Adjustment of 95% confidence interval for clustering used in cluster randomised trials

  • Step 1: To calculate design effect (DE) for the study:

DE= 1+ (n per cluster-1) x Intra cluster coefficient

Where n per cluster =

Intra cluster coefficient=0.014 from Cumming (2008)


  • Step 2: To calculate standard error (normal) for the study:

Standard error (normal)=

  • Step 3: To calculate standard error (corrected) for studies:

Standard error (corrected) =Standard error (normal) x

  • For outcome ii) Rate of falls, outcome iv) Rate of injurious falls, outcome v) Rate of hospital admission due to falls and outcome vi) Rate of emergency department presentations due to falls

  • if hazard ratios or incidence rate ratio were not provided, an estimate of the relative rate using the formula for calculating a relative risk (Altman and Deeks 2002)was calculated where the number of fallers was replaced with the number of falls in each group and the number of non-fallers with the number of patient days in each group.

  • Previous research has shown that this relative rate approach produced similar point estimates to survival analysis and negative binomial analysis approaches, however the relative rate approach produces 95% confidence intervals that are too narrow in range (Haines and Hill 2011). To account for this, an inflation factor was determined from two trials included in this review that had the same patient-level data that was calculated from a negative binomial regression (Haines 2004 and 2011). An inflation factor of 1.24 and 1.39 was required and therefore we decided to multiply the log natural standard error of relevant estimates by 1.3 in order for its 95% confidence intervals to be the same width as that from the negative binomial regression generated incidence rate ratio. This improved the estimate for inclusion in the meta-analysis (Haines and Hill 2011).These estimates were also inflated to account for the intra-cluster correlation as described above if warranted by the study design.



Table of risk ratio, confidence interval and standard error of studies used for meta-analysis


Table 6.1 Studies of hospitalized older adults (Targeted multifactorial fall prevention programme that consisted of educational component)

Study

(year)


Fallers

Rate of falls

Fallers with injury

Rate of injurious fall

RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


Haines (2004)

0.78

(-0.2485)



0.56

(-0.5798)



1.06

(0.0583)


0.1628

0.7086

(-0.3445)



0.55

(-0.5978)



0.91

(-0.0943)




0.1249













0.7098£

(-0.3428)



0.3364a

(-1.0896)




1.4978a

(0.404)



0.3810a

Haines

(2006)


Subgroup of Haines 2004:

cognitive intact participants only



1.59

(0.4637)


0.71

(-0.3425)



3.58

(1.2754)


0.4127

0.4526

(-0.7927)



0.16a

(-1.8326)



1.25a

(0.2231)


0.5200a

























Haines (2006)

Subgroup of Haines 2004: cognitive impaired participants only



1

(0)


0.43

(-0.8440)



2.34

(0.8502)


0.4322

0.6172

(-0.4826)



0.25a

(-1.3863)



1.54a

(0.4318)


0.4656a

























Ang

(2011)


0.29*

(-1.2379)



0.1*

(-2.3026)



0.89*

(-0.1165)



0.5577

0.30y

(-1.2040)



0.10y

(-2.3026)



0.91y

(-0.0943)



0.5633

0.6013£

(-0.5086)



0.1441

(-1.9370)



2.5087

(0.9198))



0.7288




Cumming

(2008)


1.0469£

(0.0459)


0.704¢

(-0.351)



1.557¢

(0.4428)



0.2025¢


0.96x

(-0.0408)




0.72x

(-0.33)


1.28x

(0.25)


0.1468

1.2002£

(0.1825)


0.6471¢

(-0.4352)



2.2260 ¢

(0.8002)


0.3152¢


1.12x

(0.1133)


0.71x

(-0.3425)




1.77x

(0.5710)



0.233

Dykes

(2010)


0.7618£

(-0.2721)



0.1923¢

(-1.6486)



3.017¢

(1.1044¢)



0.7023¢

0.7536

(-0.2829)



0.5752

(-0.553)


0.9873

(-0.0128)




0.1378




1.1681£

(0.1554)


0.01¢a

(-4.6746)



146.26¢a

(4.9854)


2.4644¢a

Vassallo

(2004)


0.7027£

(-0.3528)



0.3364¢

(-1.0894)



1.4679¢

(0.3838)


0.3758¢

1.070£

(0.0676)


0.473¢a

(-0.7487)



2.4203¢a

(0.8839)


0.4165¢a

0.4889£

(-0.7156)



0.1189¢

(-2.1297)



2.0107¢

(0.6985)


0.7215¢













Von R-Kruse

(2007)


0.7740

(-0.2562)



0.6827

(-0.3816)



0.8775

(-0.1307)



0.0640

0.82b

(-0.1985)



0.73

(-0.3147)



0.92

(-0.0834)



0.0590













0.84b

(-0.1744)



0.67

(-0.4005)



1.04

(0.0392)


0.1122

Healey

(2004)














0.705

(-0.3496)




0.3021¢a

(-1.1969)




1.6449¢a

(0.4977)



0.4323¢a














1.352

(0.3016)


0.2253¢a

(-1.4904)



8.1141¢a

(2.0936)


0.9143¢a


RR rate ratio

ln log natural

CI confidence interval

SE standard error



Data supplied by trial author on contact

£rate ratio calculated by review author

*Adjusted rate ratio provided by trial author for age and gender (time to first fall)



yHazard ratio provided by trial author adjusted for age and gender

¢Corrected by review author for clustering using intracluster correlation coefficient 0.014 given in Cumming (2008) paper

xIRR adjusted for clustering, length of stay and previous falls by trial author

aAdjusted by inflation factor calculated by author

b Incidence rate ratio provided by trial author

Table 6.2 Studies of hospitalized older adults (education intervention only)

Study

(year)


Fallers

Rate of falls

Fallers with injury

Rate of injurious fall

RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


Haines (2011)

0.74

(-0.3011)



0.48

(-0.7340)



1.15

(0.1398)


0.2229

0.83

(-0.1863)



0.54

(-0.6162)



1.27

(0.2390)


0.2182













1.22

(0.1989)


0.69

(-0.3711)



2.20

(0.7885)


0.2958

Haines

(2011)


Subgroup: cognitive intact participants only

0.51

(-0.6733)



0.28

(-1.2730)



0.94

(-0.0619)



0.3090

0.43

(-0.8440)




0.24

(-1.4271)



0.78

(-0.2485)



0.3007













0.53

(-0.6349)



0.23

(-1.4697)



1.22

(0.1989)


0.4256

Haines

(2011)


Subgroup: cognitive impaired participants only

1.38

(0.3221)


0.70

(-0.3567)



2.75

(1.0116)


0.3490

1.48

(0.3920)


0.86

(-0.1508)



2.53

(0.9282)


0.2753













2.63

(0.9670)


1.19

(0.1740)


5.84

(1.7647)


0.0444

Clarke

(2012)


0.2842£

(-1.2581)



0.0063£

(-5.0672)



2.1938£

(0.7856)


1.4931£













0.4630£

(-0.7700)



0.0097£

(-4.6356)




4.2534£

(1.4477)


1.5519£













£rate ratio calculated by review author (one added to all cells in 2x2 table due to zero odds ratio, Clarke 2012)

Table 6.3 Studies of post hospitalized older adults (education intervention only)

Study

(year)


Fallers

Rate of falls

Fallers with injury

Rate of injurious fall

RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(lnRR)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


Hill

(2011)


1.34b(0.2927)

0.76(-0.2744)

2.37(0.8629)

0.2901

1.18b

(0.1655)


0.71

(-0.3425)



1.96

(0.6729)


0.2590













1.00b

(0)


0.6

(-0.5108)



1.66

(0.5068)


0.2596

Rucker (2006)

4.3¥(1.4586)

0.9

(-0.1054)



19.8

(2.9857)


0.7885







































Study

(year)


Rate of hospital admissions

Rate of accident and emergency admissions

RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


Hill

(2011)


0.5b

(-0.6931)



0.2

(-1.6094)



1.28

(0.2469)


0.4735













Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge-follow up to a randomized controlled trial

¥ OR adjusted for study sites, white race and previous fracture provided by trial author

b IRR Complete program vs control provided by trial author

Table 6.4 Studies of post hospitalized older adults (Multifactorial falls prevention program that consisted of education component)

Study

(year)


Fallers

Rate of falls

Fallers with injury

Rate of injurious fall

RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


Batchelor

(2012)


0.83

(-0.1863)



0.6

(-0.5108)



1.14

(0.1310)


0.1637

1.1b

(0.0953)


0.63

(-0.4620)



1.90

(0.6419)


0.2816













1.57b

(0.4511)


0.73

(-0.3147)



3.4

(1.2238)


0.3925

Close

(1999)














0.39ϕ

(-0.9416)



0.23

(-1.4697)



0.6

(-0.5108)



0.2446

























Lightbody

(2002)


0.9469£

(-0.0546)



0.6377

(-0.4499


1.4060

(0.3407)


0.2017

0.8246£§

(-0.1929)



0.6119 a

(-0.4912)



1.111a

(0.1054)


0.1522a

























McQueen

(2003)














0.1667£

(-1.7916)



0.0314a

(-3.6769)



1.0982a

(0.0937)


0.9619a

























Nikolaus

(2003)














0.69b

(-0.3711)



0.51

(-0.6733)



0.97

(-0.0305)



0.1640













0.8499£

(-0.1627)



0.6321a

(-0.4587)



1.1423a

(0.1331)


0.1509a

Russell

(2010)


1.11

(0.1044)


0.95

(-0.0513)



1.31

(0.2700)


0.0820

0.87Đ

(-0.1393)



0.65

(-0.4308)



1.17

(0.1570)


0.1499













1.08Ɵ

(0.0770)


0.78

(-0.2485)



1.48

(0.3920)


0.1634

Whitehead (2003)

1.7ʄ

(0.5306)


0.7

(-0.3567)



4.4

(1.4816)


0.4689







































Study

(year)


Rate of hospital admissions

Rate of accident and emergency admissions

RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


RR

(ln)


Lower range 95%CI

(ln)


Upper range 95%CI

(ln)


SE ln


Close

(1999)


0.61ϕ

(-0.4943)



0.35

(-1.050)


1.05

(0.0488)


0.2803













Lightbody

(2002)


0.8£

(-0.2231)



0.2037a

(-1.5912)



3.1424a

(1.145)


0.6980a

0.7414£

(-0.2992)



0.4322a

(-0.8388)



1.27a

(0.239a)



0.2753a

Russell

(2010)


2.33z

(0.8459)


0.71

(-0.3425)



7.67

(2.0373)


0.6071

1.03

(0.0296)



0.68

(-0.3857)



1.54

(0.4318)


0.2085

zAdjusted rate ratio for medical conditions, balance, independence of activity of daily living, cognitive status, balance, age, site of recruitment and English speaking provided by trail author

ϕ Odds ratio adjusted for Barthel and AMT score, previous falls provided by trial author

£ Rate ratio calculated by review author

§ Rate ratio calculated by review author from diary record of falls

Đ Adjusted rate ratio for previous falls, English speaking, balance and independence of activity of daily living provided by trail author

Ɵ Adjusted rate ratio for previous falls and balance provided by trial author

ʄ Odds ratio provided by trial author

aAdjusted by inflation factor calculated by author

bIncidence rate ratio provided by trial author



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