eMeasure Title Falls: Screening for Future Fall Risk
eMeasure Identifier
(Measure Authoring Tool)
139 eMeasure Version number 2
NQF Number 0101 GUID bc5b4a57-b964-4399-9d40-667c896f31ea
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward National Committee for Quality Assurance
Measure Developer American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Measure Developer National Committee for Quality Assurance
Endorsed By National Quality Forum
Description
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
Copyright
Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). 

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CPT(R) contained in the Measure specifications is copyright 2004-2012 American Medical Association. LOINC(R) copyright 2004-2012 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2012 International Health Terminology Standards Development Organisation. ICD-10 copyright 2012 World Health Organization. All Rights Reserved.
Disclaimer
Disclaimer Language:
These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

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Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
As the leading cause of both fatal and nonfatal injuries for older adults, falls are one of the most common and significant health issues facing people aged 65 years or older (Schneider, Shubert and Harmon 2010). Moreover, the rate of falls increases with age (Dykes et al. 2010). Older adults are five times more likely to be hospitalized for fall-related injuries than any other cause-related injury. It is estimated that one in every three adults over 65 will fall each year (Centers for Disease Control and Prevention 2012). In those over age 80, the rate of falls increases to fifty percent (Doherty et al. 2009). Falls are also associated with substantial cost and resource use, approaching $30,000 per fall hospitalization (Woolcott et al. 2011). Identifying at-risk patients is the most important part of management, as applying preventive measures in this vulnerable population can have a profound effect on public health (al-Aama 2011). Family physicians have a pivotal role in screening older patients for risk of falls, and applying preventive strategies for patients at risk (al-Aama 2011).

The risk of falling is slightly greater in the inpatient setting (Clyburn and Heydemann 2011). A recent study found that specialized inpatient fall prevention initiatives were associated with a significant reduction in fall and fall-related injury rates (Weinberg et al. 2011). The results of this study show the importance of persistent quality improvement interventions with respect to falls. The authors stated that enhanced safety awareness and accountability were both instrumental in the success of the program (Weinberg et al. 2011). Another recent study calculated the number needed to treat (NNT) to prevent one fall as 32 for a single intervention compared with seven for a multidisciplinary intervention (Hanley, Silke and Murphy 2010). With such a low NNT, this measure has the opportunity to have high impact.
Clinical Recommendation Statement
The American Geriatrics Society (AGS) along with the British Geriatrics Society (BGS) published clinical practice guidelines for the prevention of falls in older persons (Panel of Prevention of Falls in Older Persons 2011). In addition, the Assessing Care of Vulnerable Elders (ACOVE) indicators for fall assessment and management are in use (RAND 2008).

AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (Panel on Prevention of Falls in Older Persons 2011)

Rating: A Recommendation
• The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program.

Rating: A Recommendation
• A strategy to reduce the risk of falls should include multifactorial assessment of known fall risk factors and management of the risk factors identified.

Rating: A Recommendation
• The health professional or team conducting the fall risk assessment should directly implement the interventions or should assure that the interventions are carried out by other qualified healthcare professionals. 

Rationale: 
The goal of screening for falls and identifying fall risk is to prevent or reduce fall risk. A structured and standardized screening process can improve provider adherence to guideline recommendations. The AGS/BGS recommendations for fall risk assessment are based on epidemiological studies demonstrating an association between certain risk factors and falls and from experimental studies in which assessment followed by intervention demonstrated benefit. Assuming that the interventions are carried out, multifactorial falls risk assessment and management programs could be one of the most effective interventions for reducing both the risk for falling and the monthly rate of falling (Chang 2004).

Individuals who have experienced two or more falls in the last year or who have gait or balance issues have an increased likelihood of falling, therefore would benefit from multifactorial falls risk assessment. Although evidence is lacking, AGS believes there is also a potential benefit for individuals who have reported only a single fall in the last year and who do not have gait and balance issues. 

Several individual studies have shown that a multifactorial risk assessment that was not tied to intervention was not effective in reducing falls. Multifactorial falls risk assessment and management programs may be the most effective intervention for reducing both the risk for falling and the monthly rate of falling, assuming that those interventions are properly carried out (Chang 2004). Recent trials of multifactorial risk assessment followed by referral without assurance of completion of the intervention have not been proven effective.

ACOVE (RAND 2008).
Quality Indicators
• Inquiring about Falls. ALL vulnerable elders should have documentation that they were asked at least annually about the occurrence of recent falls.
• Detecting Balance and Gait Disturbances. ALL vulnerable elders should have documentation that they were asked about or examined for the presence of balance or gait disturbances at least once.
• Basic Fall Evaluation. IF a vulnerable elder reported two or more falls in the past year, or a single fall with injury requiring treatment, THEN there should be documentation that a basic fall evaluation was performed that resulted in specific diagnostic and therapeutic recommendations.
• Gait-Mobility and Balance Evaluation. IF a vulnerable elder reports or is found to have new or worsening difficulty with ambulation, balance, or mobility, THEN there should be documentation that a basic gait, mobility, and balance evaluation was performed within 6 months that resulted in specific diagnostic and therapeutic recommendations. 
• Exercise and Assistive-Device Prescription for Balance problems. IF a vulnerable elder demonstrates decreased balance or proprioception, or increased postural sway, THEN an appropriate exercise program should be offered and an evaluation for an assistive device performed.
• Exercise Prescription for Gait Problems and Weakness. IF a vulnerable elder is found to have problems with gait, strength (for example, 4 out of 5 on manual muscle testing, or the need to use his or her arms to rise from a chair), or endurance (for example, dyspnea on mild exertion), THEN an exercise program should be offered (Rubenstein 2001).

Rationale: There are a number of clinical approaches in addressing the serious and complex concerns involving fall risk and mobility problems in older adults. The ACOVE quality indicators can be categorized into three categories: 1) detection of the problem(s); 2) diagnosis or evaluation of the problem(s); and 3) treatment while focusing on how to prevent reoccurrence. These indicators are based on literature review and expert panel consideration (Rubenstein 2001). 

Falls and mobility problems oftentimes result from multiple, diverse and overlapping causes. Falls and gait or balance disorders represent an underlying pathologic condition that could response well to treatment but could have life threatening consequences if unrecognized. These six quality indicators were judged sufficiently valid for use as measures of the quality of fall management for the vulnerable population and could potentially serve as a basis for comparison for care provided by different health care delivery systems and the change in care for the older population over time (Rubenstein 2001).
Improvement Notation
A higher score indicates better quality.
Reference
al-Aama, T. 2011. “Falls in the Elderly: Spectrum and Prevention.” Can Fam Physician 57(7):771-6.
Reference
Centers for Disease Control and Prevention. 2012. “Falls Among Older Adults: An Overview.” (February 29) http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
Reference
Clyburn, T.A. and J.A. Heydemann. 2011. “Fall Prevention in the Elderly: Analysis and Comprehensive Review of Methods Used in the Hospital and the Home.” J Am Acad Orthop Surg 19(7):402-9.
Reference
Doherty, M., and J. Crossen-Sills. 2009. “Fall Risk: Keep your patients in balance.” The Nurse Practitioner: The American Journal of Primary Health Care 34(12):46-51.
Reference
Dykes, P.C., D.L. Carroll DL, A. Hurley A, S. Lipsitz S, A. Benoit A, F. Chang F, S. Meltzer S, R. Tsurikova R, L. Zuyov L, B. Middleton B. 2010. Fall Prevention in Acute Care Hospitals: A Randomized Trial.” JAMA . 2010;304(17):1912-1918.
Reference
Hanley, A., C. Silke, and J. Murphy. 2010. “Community-based Health Efforts for the Prevention of Falls in the Elderly.” Clin Inverv Aging 6:19-25.
Reference
Schneider, E.C., T.E. Shubert, andK.J. Harmon. 2010. “Addressing the Escalating Public Health Issue of Falls Among Older Adults.” NC  Med J 71(6):547-52.
Reference
Weinberg, J., D. Proske, A. Szerszen, K Lefkovic, C. Cline, S. El-Sayegh, M. Jarrett, K.F. Weiserbs. 2011. “An Inpatient Fall Prevention Initiative in a Tertiary Care Hospital.” Jt Comm J Qual Patient Saf 37(7):317-25.
Reference
Woolcott, J.C., K.M. Khan, S. Mitrovic, A.H. Anis, C.A. Marra. 2011. “The Cost of Fall Related Presentations to the ED: A Prospective, In-Person, Patient-Tracking Analysis of Health Resource Utilization.” Osteporos Int [Epub ahead of print].
Reference
Chang, J.T., S.C. Morton, L.Z. Rubenstein, W.A. Mojica, M. Maglione, M.J. Suttorp, E.A. Roth, P.G. Shekelle. 2004. “Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomized clinical trials.” BMJ  328:680-3.
Reference
RAND. 2008. The Quality of Health Care Received by Older Adults. Santa Monica: RAND Corporation. http://www.rand.org/content/dam/rand/pubs/research_briefs/2005/RB9051.pdf
Reference
Rubenstein, L.Z., C.M. Powers, C.H. MacLean. 2001. “Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders.” Ann Intern Med 135:686-693.
Reference
Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. 2011. “Summary of the Updated American Geriatrics Society/British
Geriatrics Society Clinical Practice Guideline for Prevention
of Falls in Older Persons.” J Am Geriatr Soc 59(1):148-157.
Definition
Future fall risk: Patients are considered at risk for future falls if they have had 2 or more falls in the past year or any fall with injury in the past year.

Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.
Guidance
None
Transmission Format
TBD
Initial Patient Population
Patients aged 65 years and older with a visit during the measurement period
Denominator
Equals Initial Patient Population
Denominator Exclusions
None
Numerator
Patients who were screened for future fall risk at least once within the measurement period
Numerator Exclusions
Not Applicable
Denominator Exceptions
Documentation of medical reason(s) for not screening for fall risk (e.g., patient is not ambulatory)
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
None