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Frequently Asked Questions. What does jhfrat stand for? What is the jhfrat toolkit? The methodological weaknesses that have been identified are subsequently reflected in the under or over-detection of patients at risk of falling, and the routine use of such methods may divert attention and resources toward patients who would least benefit from preventive measures, at the expense of those who do need them.
These considerations highlight controversies and inconsistencies regarding the widespread use of these tools in the field of acute hospital care. Therefore, in order to dispel some of these uncertainties and to determine which of the available instruments offers better diagnostic performance for fall prevention as part of a range of preventive interventions to minimise risk among hospitalized patients, we present an up-to-date, detailed analysis of the existing literature illustrating the scope of measures available.
The results of this review will contribute to the implementation of best practices related to preventing falls in an acute care hospital setting. The specific objectives were to analyse the diagnostic validity and psychometric properties of the various risk assessment tools for predicting falls in acute hospitalized patients, and to compare the effectiveness of risk assessment instruments for falls and its impact on the incidence of falls by acute hospitalized patients.
Following the Cochrane Manual for Diagnostic Test Accuracy [ 29 ], this systematic review focuses on establishing the accuracy of instruments, scales or questionnaires index developed for detecting or predicting falls target condition in acute hospitalized patients, aged 16 or over patients. Systematic review, performed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions [ 29 ], and meta-analysis.
This review focuses on three types of research papers: those which develop diagnostic validity DV , those which accomplish psychometric validity PV and those which evaluate the effectiveness of fall risk assessment instruments EFRA. For any of the three types of studies, only adult patients in acute hospitals are included:. Since this study focused on acute patients, patients living in the community, rehabilitation hospitals or rehabilitation units, sub-acute, long-stay patients, institutionalized patients, did not meet the inclusion criteria.
In DV and PV studies the type of intervention criterion is not applicable. In EFRA studies, experimental studies involving the use of a falls risk assessment tool, either as a sole intervention or in conjunction with others, are accepted. In DV studies, any measure of diagnostic validity: sensitivity, specificity, predictive values, likelihood ratios, diagnostic Odds Ratio DOR , area under the curve AUC and frequency and distribution of risk factors.
In PV studies, any psychometric outcome such as reliability, internal consistency, face, criterion or construct validity and frequency and distribution of risk factors. The search languages were English, Spanish and Portuguese and the periods covered, from the date of the first study indexed in the corresponding database, up to and including 31 August In addition, linked searches were made in the references for the studies found.
Search strategies are available as an additional file see Additional file 1. For the searches, we used specific methodological filters developed by the Health Information Research Unit at McMaster University for studies of diagnostic tools and clinical prediction rules [ 30 , 31 ]. Initially, the terms used were: accidental; falls; fallers; risk assessment; assessment tool; balance; gait; validation studies; prevention; prediction; hospital units; hospitals; acute care.
In addition, we applied the terms needed to adjust the criteria for exclusion from the review, with the logical operator NOT exclusion of studies in the community and those focusing on psychiatric, paediatric and other such institutions.
The first stage of our review included a detailed assessment of the titles and abstracts to determine whether each article met the requirements for inclusion. If there was any doubt, the full text of the article was assessed to decide whether it met these criteria. To ensure the quality of the process, all records were doubly evaluated, by two blinded reviewers. After this initial process, all the references identified as potentially eligible were evaluated to see if they met the inclusion criteria for the review.
This process was again carried out in parallel by two blinded reviewers. Any discrepancies that might arise in the process were resolved by discussion between the two evaluators, assisted by the intervention of a third expert, not otherwise involved in the project.
Additionally, a pilot exercise was performed with the reviewers, for application of the inclusion criteria, on a sample of 15 items to reduce the risk of bias. For PV studies the assessment was based on the quality criteria identified for health questionnaires [ 32 ].
These quality criteria addressed the content validity, internal consistency, criterion validity, construct validity, reproducibility, longitudinal validity, responsiveness, floor and ceiling effects and interpretability. An electronic form was used to input the results of the studies included and evaluated, supported by the application RevMan 5. In addition, and to obtain data for PV and EFRA studies, the following information was included: number of items comprising the assessment tool, number of subscales if applicable , type of questions dichotomous, Likert, semantic differences, etc.
Also included on this form were the RevMan 5. Furthermore, for EFRA studies, data on intervention, randomisation, group allocation, follow-up and end-points were collected. Prior agreement will be reached on possible codes to describe the standard outcome routines for these studies. When the original studies did not clearly provide the data necessary for analysis, the authors were contacted directly for clarification or for the exact data, if possible.
DOR combines positive and negative likelihood ratios and it represents a global performance measure: how greater is the odds of having the condition among those with a positive result with the instrument versus those ones with a negative result [ 37 ].
Additionally, SROC Summary Receiver Operating Characteristic curves were calculated for every analysis through the square minimum weighted by the inverse of the variance. Heterogeneity among studies was addressed using forest-plot diagrams for sensitivity and specificity and the likelihood ratio test for these two dimensions.
The latter value was calculated from the Q statistic the standardised measure of the observed heterogeneity, which is not affected by effect size units. The heterogeneity was stratified into three levels, following the criteria of Higgins et al. Prior to this, we determined whether or not the diagnostic odds ratio, using the Moses-Shapiro-Littemberg method to decide whether the points on a ROC curve should be adjusted symmetrically or asymmetrically, respectively [ 40 ].
As there was no threshold effect, the global sensitivity and specificity were calculated. This was carried out for exploring additional heterogeneity sources, by adding up co-variables to the model.
The exponential transformation of the estimated coefficients can be interpreted as the relative DOR of that co-variable and it shows the change in the diagnostic performance when the co-variable varies [ 41 ]. A concordance analysis among reviewers was carried out during the different phases of the process and this was subsequently incorporated into the results of the review, using a Kappa index.
For the different phases of analysis, the applications RevMan 5. This study deals with secondary data from original studies and therefore is not subject to the usual criteria for original research.
Nevertheless, the review participants signed an explicit statement that there is no conflict of interest. A search within different databases and webs produced a total of 2, references Table 1. After removing duplicates, there remained 2, articles, whose titles and abstracts were evaluated by blinded pairs of reviewers. After this first phase, 78 articles were selected as potentially eligible, and the full text was then read, again by blinded pairs, to assess its quality, extract data and determine its inclusion or otherwise in the meta-analysis.
Finally, 14 studies [ 15 , 20 , 22 , 23 , 25 - 27 , 42 - 48 ] were selected for this review Figure 1.
A summary of the references and the reasons for excluding the remaining 64 items is provided in Table 2. A total of 14, patients were considered in the studies selected, although several of the latter, in addition to the diagnostic validation of the instrument or instruments in question, also conducted studies of intra-observer reliability [ 48 ] inter-observer reliability [ 26 , 42 , 48 ] or the procedure leading to the development of some risk assessment scales [ 15 , 46 ].
A total of 13, patients were involved in the analysis of diagnostic accuracy. Although not all the studies provided the age and sex distribution of their populations, according to the published data these involved 5, men All the studies were performed in hospitals for acutely-ill adults.
Several of them focused on patients aged over 50 years [ 45 ], over 65 years [ 15 , 20 , 44 ], or on hospital departments that mainly treated the elderly [ 47 ]. In consequence, the overall mean age of the patients was In all cases, the diagnostic validation of the different risk assessment tools was performed prospectively.
No experimental studies were conducted Table 3. Number of participants, study design, index and comparator test, mean age and gender of selected studies. Regarding the methodological quality of the studies, some shortcomings were identified, mainly related to two aspects: the lack of blinding in outcome assessment or lack of information in this respect, and doubt as to the representativeness of the study population, generally because the article failed to stipulate how the sample size was calculated Table 4.
Although all the studies provided data enabling reproduction of the calculations of diagnostic validation, not all were included in the meta-analysis, because some scales did not contain sufficient studies for this Figure 1. The Schmid study [ 46 ] was discarded because it described the development of an assessment tool for the risk of falls but this was not subsequently tested in any of the selected studies. Therefore, and as done by this very author in a meta-analysis of the same scale [ 69 ], it was ruled out of our meta-analysis.
With respect to the study by Milisen [ 23 ] we only considered the data for patients admitted to medical and surgical units these data are available separately , but not to geriatric units, as the latter would not meet the criteria for inclusion in the present review, which is limited to acutely-ill patients.
Sensitivity analyses performed for MFS showed that after removing the Kim EAN study [ 26 ], heterogeneity was markedly improved, possibly because it included younger patients average age below 65 years , to whom lower cutoff points were applied 25 and In both cases, the mean age of the study population was less than 65 years, although the cutoff points 2 and 3 were higher than those applied in the other study included in this meta-analysis with similar characteristics in terms of the age of the sample population, namely Milisen [ 23 ] cutoff point, 1.
Although other systematic reviews and meta-analyses of assessment tools for falls by hospitalized patients have been performed [ 9 , 56 , 57 , 69 , ], ours is the first that includes only acute patients. This is particularly useful in clinical practice for identifying the behaviour of the instruments currently used exclusively in the hospital environment, where falls are among the most frequent adverse events [ 5 ], and thus are directly relevant to the development and implementation of safety policies in acute care hospitals.
Since V. Scott [ ] and T. Haines [ 56 ] published their systematic reviews of fall risk assessment tools in , there were no new updates focused on that instruments concerning acute hospitalized patients. In the present review, 9 [ 23 , 25 - 27 , 42 - 45 , 48 ] of the 14 selected studies have been published since , allowing an update of knowledge available on this topic.
This is one of the strengths of this study. Another strength of this review is that contemplated studies assessing the psychometric properties of the fall risk assessment instruments. However, these results did not include the calculation of the DOR and some of the studies that were included were excluded from our analysis as not meeting the inclusion criteria.
Moreover, we also considered another four studies published subsequently with data for these assessment tools [ 27 , 42 , 43 , 48 ]. These three tools have been compared by their simultaneous application in a sample of hospitalized adult patients [ 26 ]. However, in the present meta-analysis, HFRM II proved to be the worst of the three instruments considered, due to its lower sensitivity 0.
In another study in which four risk assessment instruments STRATIFY, Tinetti, Downton and Tullamore were tested simultaneously in an acute patient hospital environment [ 47 ], STRATIFY was completed most easily and in the least time; furthermore, it also presented the best predictive validity, although it was the least sensitive of the four.
The short time required to administer this assessment scale and the fact that it is readily understandable for medical staff are very relevant factors in an acute hospital setting where work loads are high and periodic reassessments of patients are advisable.
In previous systematic reviews of this question, one of the inclusion criteria was that the selected studies should conduct a prospective validation of assessment tools for falls [ 9 , 69 , ]. In the systematic review and meta-analysis carried out by Haines in [ 56 ] one of the practical implications described was that although retrospective evaluations are still valuable for generating initial results and identifying the tools and cutoff points that may be useful in clinical practice, less weight should be given to their results than to those obtained from prospective studies, with respect to selecting a detection tool for use in clinical practice.
In coherence with this view, all the studies included in the present review conducted a prospective validation of the various instruments examined. Nine of the fourteen studies had been published since the completion of the above-mentioned systematic review.
The acute phase of the disease and changes in medication can affect both mobility and the physical and cognitive status, and therefore hospitals need an instrument that can be used quickly and easily so that repeated assessments of these patients may be carried out [ 10 ]. In the only study in which a reassessment was carried out with MFS [ 27 ] the mean age of the patients was below 65 years The condition of these younger patients would presumably improve over time, and so their risk is more difficult to identify with this scale.
However, as discussed above, in only one of the studies in which MFS was tested was a reassessment performed. Thus, further research is needed, including reassessment both with MFS and with the other instruments in order to achieve a more realistic analysis of this circumstance. It should be borne in mind that, in general, it is difficult to accurately predict the risk of falls among hospitalized adult patients who are subjected to external risk factors, specific to the hospital environment and which are not taken into account by any of the assessment instruments described.
This review and meta-analysis may also be affected by the limitations of the primary studies analysed. First, knowledge of the number of patients suffering a fall is always dependent on the voluntary reporting of this fact by the healthcare staff, and so falls may occur that are not reported, which would to some extent invalidate the results obtained in these studies.
Second, the review may be affected by contamination related to the implementation of other actions taken to prevent falls in the different environments studied, and by a possible Hawthorne effect. Another possible limitation concerns the search language: in the present review, the search languages used were limited to English, Spanish and Portuguese, and four studies were excluded for this reason [ - ].
In short, despite the findings obtained, our analysis of the various studies clearly shows that the behaviour of these risk assessment instruments varies considerably depending on the population and the environment in which they are administered.
In consequence, we cannot recommend the generalised adoption of any single method without its prior testing in the healthcare setting of the intended implementation. Moreover, it should be recalled that these instruments, or the actions taken including their use, will not be effective if healthcare personnel do not ensure patient safety procedures are followed, and this aspect remains to be investigated in the case of falls by hospitalized patients.
A study of safety and security in Spanish hospitals reported that the majority of healthcare staff This aspect, noted above as one of the limitations of our study, and the question of compliance by personnel with procedures established to prevent adverse events, are issues which must be addressed in order to achieve an effective culture of safety within hospitals.
Thomas risk assessment tool in falling elderly inpatients. JMMA performed the statistical analysis. All authors helped with the interpretation of the data. MAG and JMMA drafted the first version of the manuscript, and all authors contributed to subsequent versions and revised it critically for important intellectual content. All authors read and approved the final manuscript. Search strategies. Search strategies on databases and webs, with number of references obtained in each of them.
We would like to thank to the Department of Nursing of the University of Malaga and to the Research Unit in Hospital Costa del Sol for their help and editorial advice during the preparation of this paper.
National Center for Biotechnology Information , U. Published online Apr 2. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Marta Aranda-Gallardo: se.
Received Oct 19; Accepted Mar This article has been cited by other articles in PMC.
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