Among the elderly, falls are all too common and their results can be devastating. The Centers for Disease Control and Prevention (CDC) report that, in 2013, more than 2.5 million older adults were treated in emergency departments after falling and approximately 25,500 died due to fall-related injuries such as head trauma, fractures, dislocations and soft tissue damage. The medical costs of falls were $34 billion in 2013, not including indirect costs, which can be much higher.
Perhaps more troublesome is the fact that falls often trigger a series of adverse events that contribute to functional decline and loss of independence. Even after recovery, those who have fallen are more likely to avoid physical and social activities, leading to functional deficits, reduced mobility, social isolation and eventually, the need for an assisted living environment. Falls also increase the risk of early death.
While falling is a major public health problem in the elderly population, a growing body of research shows that fall injuries can be prevented if properly addressed in the primary care practice setting. The National Institute on Aging (NIA) and the Patient-Centered Outcomes Research Institute (PCORI) have recently joined forces to support the largest research study on fall injury prevention funded to date, called Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE). The nationwide, five-year study began its pilot phase in 2014 and will continue through 2019, aiming to evaluate a comprehensive strategy designed to prevent fall injuries in the primary care setting — including risk assessment, individualized care plans and intensive follow-up.
BWHC is playing a key role in this research in several ways. First, Shalender Bhasin, MD, director of Research Programs in Men’s Health, Aging and Metabolism at BWH and director of the Boston Claude D. Pepper Older Americans Independence Center (OAIC), a NIA-funded center for geriatric research, is one of three Principal Investigators of STRIDE. (The two others are Thomas Gill, MD, of Yale School of Medicine and David Reuben, MD, of the David Geffen School of Medicine at the University of California, Los Angeles.) Second, BWHC is part of the Partners HealthCare site, one of ten STRIDE sites nationwide; Patricia Dykes, PhD, RN, FAAN, FACMI, senior nurse scientist and program director for the BWH Center for Patient Safety Research and Practice and Center for Nursing Excellence, serves as Principal Investigator of the Partners site. Third, seven BWHC primary care practices are participating in the study. Over time, the STRIDE team hopes to be able to integrate its findings at BWH and other Partners hospitals.
“Predicting and preventing fall injuries and the cascade of progressive decline that often follows in older adults is complex,” said Jackie Somerville, PhD, RN, chief nurse and senior vice president of Patient Care Services. “It requires knowledge not only of the person’s medical comorbidities, but of the context of how this person lives and functions in their world. To gain this broad perspective requires a village.”
The STRIDE village includes more than 100 investigators across 86 primary care clinics that have enrolled as STRIDE practices within ten health care systems (or “sites”) nationwide, including Partners HealthCare. These study sites are distributed across 12 U.S. states and located in urban, suburban and rural communities. Having completed a pilot phase, the study is now in the process of enrolling more than 6,000 participants aged 75 years or older over the next three years. An effort is underway to include patients from different racial and ethnic groups as study participants. By making the study as diverse as possible, researchers ensure that their findings will be applicable to a wide range of patients.
STRIDE primary care practices in each site are randomized so that half provide patients with usual care and the remaining half offer the study intervention. Participants enrolled at intervention clinics are first assessed for their risk of falling with an in-depth questionnaire, whereas screening can vary highly in clinical settings. “Outside of this study, providers have very limited time to assess falling risk,” said Dykes, who explained that given conflicting priorities, fall screening may not be a high priority for patients who present to primary care practices with acute conditions. “In intervention clinics in the STRIDE study, a nurse who has been specially trained as a falls care manager (FCM) will spend one full hour identifying risk factors and barriers to treatment.” Those who screen positive (indicating a high risk of falling) work closely with the FCM to develop a personalized prevention plan.
The FCM uses a technique called motivational interviewing to engage with patients and determine their risk factors for falling and works with the patient and primary care providers to develop an individualized, comprehensive care plan addressing those risk factors. Risk factors for a fall can range from vision loss and hazards in the home setting to medication side effects and lack of strength or balance. The FCM refers patients to the appropriate services, such as an exercise program to increase strength or an eye doctor to prescribe new glasses. “Each plan is carefully tailored to each patient so it meets their precise needs and addresses all barriers,” said Bhasin.
The FCM is also responsible for following up with patients to ensure that they are implementing the care plan. If patients encounter barriers such as transportation or timing, the FCM works with them to address those barriers so they can follow through. Patients at all clinics will be followed for up to three years to evaluate the study’s effects.
“We work with patients to find solutions that they can incorporate into their lives and follow up with them to ensure they are doing so, all the while stressing that these solutions will help them preserve their independence,” said Yvette Wells, RN, BSN, Partners falls care manager. “Ultimately, I am optimistic that this study will result in fewer falls for our patients.”
What makes the STRIDE study unique is that it implements a new system of care for at risk patients in real primary care settings on a broad scale. “This study is evidence-based, so we are not testing anything new,” explained Dykes. Added Bhasin: “Over the last 30 years, researchers have learned much about what prevents falls in the pristine settings of clinical trials, but there has been little change in practice and the incidence of fall injuries remains high. With STRIDE, we are taking these research findings and implementing them in the clinical setting where we can truly evaluate their effectiveness.”
Another aspect of the research that sets it apart from other studies is the extensive collaboration it requires. “STRIDE is made possible by the engagement and partnership of an extraordinarily talented multidisciplinary team, which includes patients and stakeholders, nurses and nurse scientists, physical therapists, physicians, and our colleagues in Research Management,” said Bhasin, citing a number of key contributors to the study’s success, including Dykes; Nancy Latham, PhD, PT, Study Director and a member of the BWH faculty; Wells; Maureen Fagan, DNP, WHNP-BC, MHA, executive director of the Center for Patients and Families and associate chief nurse for OB/GYN at BWH, who is a STRIDE co-investigator and chair of the National Patient and Stakeholder Council; Patricia Fitzgerald, the STRIDE Study Manager; Priscilla Gazarian, PhD, RN, Nurse Director for the STRIDE study ; Libby Hohmann, MD, Chair of the Central IRB; Shehzad Basaria, MD, Chief Medical Safety Officer for STRIDE; Richard Eder, cIRB liaison for STRIDE; Anne Klibanski, MD, Chief Academic Officer for PHS. “I call them all the dream team.”
“A fall can have catastrophic effects that can drastically change someone’s life,” said Bhasin. “We are committed to changing the way these patients are cared for to improve their outcomes and quality of life.”