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The BGS Falls Section responded to a systematic review published in the BMJ suggesting that evidence for falls-clinic-style multifaceted falls interventions may not be as cost-effective as suggested in earlier guidelines.

The paper* was the product of government funded NIHR commissioned work under the Service Development and Organisation (SDO) programme (2006). The negative results of the analysis by Gates confirms the findings of other reviews that there is no evidence yet from clinical trials to show that fractures or other serious injuries are reduced by falls prevention services, or that falls prevention services are cost effective. The main reason for this is that large enough studies with at risk older people given intensive targeted interventions have not been conducted.

Where this report differs from previous reviews of the evidence, is in finding no definite evidence of reduction in the number of fallers and in being unable to comment on falls rates reduction through inadequate data. For an individual patient, a reduction in the rate of falls would be important even if that person remained an “occasional faller”. Why is there inconsistency between this report and the conclusions of the NICE guidance group? This is partly because papers selected for the review were different, and there were also minor differences in analysis methods. Importantly it is not because there have been new convincingly negative trials of multifactorial interventions since NICE guidance was published in 2004.

The studies selected for the analysis in this report were quite heterogenous, both in terms of trial participants and of the interventions used, and although they employed subgroup analysis to explore the possibility that particular types of interventions may have benefit, the resultant numbers are too small for safe conclusions to be drawn. Therefore, we think that no definite conclusions can be drawn from this study as to whether what is actually happening in Falls clinics is effective or not for falls, injuries or the quality of life of older people. There is no justification for disinvestment or to abandon the aspirations of the NSF to develop falls and fracture prevention strategies.

In this apparent confusion there are some certainties that should be kept firmly in mind. There is clear evidence of benefit in fracture reduction if fallers who sustain such an injury receive secondary fracture prevention, yet recent large scale audits in primary and secondary care in the NHS have shown that the majority fail to receive such interventions. While we may have less clear cut evidence for overall falls rate reduction as the assessments and interventions are far more complex, there is a public health imperative to address this issue as hospital admission rates for fallers in the older age range is growing at an alarming rate (more than 10% per year in the last two years).

There is clear need for further research on specific aspects of falls prevention as well as how best to organise services to deliver these interventions. It is important that the recently announced increase in government funding for the MRC earmarked for research on frailty in older people addresses the real clinical problems of older people. This requires collaborations between clinical service providers and universities. In the meantime we need to direct strength and balance training and multi-professional multi-disciplinary falls services at larger numbers of the highest risk groups who have a combination of a falls history and a prior fracture or osteoporosis.

Finbarr Martin
Chairman
BGS Falls and Bone Health Section

*Shifting the focus in fracture prevention from osteoporosis to falls
Teppo L N Järvinen, Harri Sievänen, Karim M Khan, Ari Heinonen and Pekka Kannus BMJ 2008;336;124-126 doi:10.1136/bmj.39428.470752.AD

BGS Newsletter, March 2008
Issue 15 ISSN 1748-6343 15