Falls Prevention Services - where's the evidence?
a GP's perspective

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The rather mischievous edition of the BMJ on 18 January - which on the BBC at least completely eclipsed the work of Sallie Lamb's team - once again calls into question how well the peer-reviewers check references at the BMJ!

I worry that the Department of Health (DH) will use this to return to a position where falls interventions, particularly expensive integrated falls services are seen as the principal solution to fractures (rather than falls) with the more evidence-based based osteoporosis indicators hanging on to the coat tails! In secondary care, osteoporosis lags well behind falls and the first RCP audit showed this.

Jarvinen et al imply a 50% reduction in fractures and quote 5 papers. One is Tash Masud's paper on cataracts which does show a fracture reduction but this may not be transferrable to visual interventions generally, where no benefit was seen (Cumming RG et al, Improving Vision to Prevent Falls in Frail Older People: A Randomized Trial. Journal of the American Geriatrics Society. 2007;55(2):175-81). The PROFFET study did not show a statistically significant fracture reduction and 23% of the randomised patients were excluded from the statistical analysis. Two of the other studies did not even have fracture as an outcome and one was a comparison between two wards i.e. a cluster randomised controlled trial of two.

We need better falls prevention care in the older faller who has fractured. With the current doubts about efficacy for falls interventions in hospitals, care homes and now the community, we should not increase this activity at the expense of osteoporosis treatment where this is directed at the high risk patients. We need to perhaps concentrate more on the ‘evidence based’ strength and balance programmes, as John Campbell is recommending.

Integrated falls clinics are good in getting older patients with frailty related falls into a comprehensive geriatric assessment but are not a solution to fracture prevention as there are far too many who need to be seen.

We discussed at the RCP symposium in November, the fact that there would never be an RCT big enough to demonstrate fracture efficacy from falls interventions. That may be true, but if the incidence rate (hip fracture following fall) is so low and the effect size (falls intervention to stop a fracture) also so small that we cannot demonstrate this then it is most unlikely that any falls service as currently structured and with present throughput is likely to have any noticeable effect on fracture incidence.

If we were to be generous and say that the people seen in a falls clinic were saved one out of the three of the falls they might expect in the next 12 months, then at the present rate of throughput and the estimated rate of fractures following a fall, 0.84 hip fractures would be saved per 100,000 of the population per year at a cost of £51,000, according to the health economic data in the SDO report underpinning the Gates paper. The same amount of money could DXA and provide alendronate for a year to 485 new patients presenting with a low trauma fracture which, interestingly, is almost the exact number of postmenopausal women presenting with a new fracture each year in a population of the same size!

My views about the QOF osteoporosis indicators are that having seemingly been recommended by the Expert Review Group and accepted by the GPC they may be sacrificed at the time of writing to increased evening opening hours for GP surgeries. Our view may be that this is a reasonable subject for negotiation but using QOF resources is inappropriate as there is no link to improved health outcomes or care utilisation. My take on it is that No. 10 is directing the agenda at Richmond House and despite 84% of the population being satisfied with GP opening hours, the commuters win out. If extended opening had been part of the bargaining around dropping 24/7 GP cover, I suspect it would have been accepted, but not now as GPs have had pay restraint for two years and feel they have earned the real-terms salary increase in over-delivering QOF. Gordon Brown and the DoH probably feel they have got less out of the new contract than the BMA as GPs are earning more money for less hours availability over the week, which makes the government look bad and so they have got to have a victory here. I think this was decided months ago and all the weeks we put into the QOF review process and all the hard evidence we were asked to attest to was set up to fail. The GPC are now attempting to out-flank the DoH to the moral high ground on the basis of ‘we want old people to have better osteoporosis care, heart failure and PVD treatment and you are just after the commuter vote’.

The argument is about 10 minutes difference per week per 1000 patients between the GPC and the NHS employers. There must be a compromise if we could get both sides to agree and if both sides want it.

Assuming about 50% of hip fractures have a prior fracture and only 20% guideline care and that conservatively this could reduce fracture risk by 35% then down the line every year we delay implementation of NHS-wide FLS and QOF will cost 8000 potentially preventable hip fractures or 200,000 bed days, 1600 deaths and double that number unable to live independently.

Jon Bayly

References
Jarvinen TLN, Sievanen H, Khan KM, Heinonen A, Kannus P. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ. 2008 January 19, 2008;336(7636):124-6.

Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ. 2008 January 19, 2008;336(7636):130-3.

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