Safety Intervention Fails to Reduce Falls At One Year Post-Surgery

A multicomponent safety intervention designed to simplify patient medication lists and remove household hazards did not reduce falls among older adults within the first year following an elective surgery procedure, researchers found.

As the U.S. population continues to age, falls following elective surgical procedures are becoming a significant public health issue, with post-surgery patients suffering falls at rates up to three times higher than other community-dwelling adults, Bradley A. Fritz, MD, of the Washington University School of Medicine in St. Louis, Missouri, and colleagues explained in JAMA Network Open. "In the U.S.," they noted, "more than 25,000 individuals 75 years or older died of fall-related injuries in 2016, and that number has increased consistently since the turn of the millennium."

Given the close follow up and health care system interaction during elective inpatient procedures, the pre- and postoperative periods offer an ideal window for the application of fall prevention interventions.

Fritz and colleagues conducted a prespecified secondary analysis of data from the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized clinical trial to assess the efficacy of a multicomponent fall intervention—consisting of patient education, medication review, a home safety assessment, and occupational therapy home visits—in reducing the incidence of patient-reported falls within one year post-elective surgery. They also examined the intervention’s impact on physical and mental quality of life, as determined using the physical composite summary (PCS-12) and mental composite summary (MCS-12) of the Veterans RAND 12-item health survey.

"In this prospective propensity score–matched cohort study, a multicomponent fall prevention intervention was not associated with a change in fall incidence during the first year after a major elective surgical procedure," Fritz and colleagues found. "This result remained unchanged in subgroup analyses examining patients confirmed to receive each component of the intervention. In analyses of secondary outcomes, patients in the intervention group had better quality of life at 1 year after a surgical procedure compared with matched patients in the control group, as measured by both the PCS-12 and MCS-12."

However, they added that the reasons behind the latter findings are unclear. As a result, they concluded that additional fall interventions may be required to improve patient adherence and reduce post-surgical falls.

The ENGAGES clinical trial was conducted at a single academic medical center—Barnes-Jewish Hospital in St. Louis—from Jan. 16, 2015 to May 7, 2018, and it evaluated the effect of an electroencephalography-guided anesthesia intervention on postoperative delirium. For the secondary analysis, all ENGAGES participants, regardless of study arm, were offered the multicomponent safety intervention; patients in the control group of the present study were selected from the Systematic Assessment and Targeted Improvement of Services Following Yearly Surgical Outcomes Surveys (SATISFY-SOS) prospective observational cohort study, which created a registry of patient-reported postoperative outcomes at the same single center.

The intervention group received a fall prevention intervention consisting of four components:

• First, patients were given a copy of the Tailoring Interventions for Patient Safety fall information sheet to learn strategies to avoid in-hospital falls.
• Second, a geriatric psychiatrist reviewed the patient’s home medication list for drugs or combinations that could increase fall risk, then discussed recommendations for amending their medication list with the patient’s surgeon.
• Third, patients completed the Home Safety Self-Assessment Tool (HSSAT, version 4)to identify safety hazards at home.
• Fourth, patients with a preoperative history of falls and living within 45 miles of the hospital were eligible for a home visit from an occupational therapist. The therapist then conducted the Westmead Home Safety Assessment to identify hazards in the home; a contractor installed any necessary architectural changes, and the therapist trained patients on all modifications.

The study cohort consisted of 1,396 patients (median age 69 years; 52.9% male). Of these, 698 received the intervention while the remaining 698 were in the control group and received usual care.

Fritz and colleagues found that adherence to individual components of the intervention was modest, ranging from 22.9% for completion of the self-administered home assessment survey to 28.2% for implementation of recommended medication changes.

"Falls within 1 year after surgical procedures were reported by 228 of 698 patients (32.7%) in the intervention group and 225 of 698 patients (32.2%) in the control group," they reported. "No significant difference was found in falls between the two groups (standardized risk difference, 0.4%; 95% CI, −4.5% to 5.3%). After adjusting for preoperative quality of life, patients in the intervention group had higher physical composite summary scores (3.8 points; 95% CI, 2.4-5.1 points) and higher mental composite summary scores (5.7 points; 95% CI, 4.7-6.7 points) at 1 year compared with patients in the control group."

Fritz and colleagues noted that the pragmatic design of their study was meant to mimic real-world conditions; thus, the study authors assumed that intervention uptake among patients might be incomplete.

"Reasons for low uptake are unknown, but it is plausible that patients received information on many topics preoperatively and did not prioritize the home safety assessment," Fritz and colleagues suggested. "In addition, only 28.2% of the medication changes recommended by the geriatric psychiatrist were reflected in discharge medication lists. It is unknown whether the lack of medication changes among the remaining patients were a result of disagreement with the psychiatrist’s recommendation, lack of consideration of the recommendation, or changes in patient status. Furthermore, it is unknown whether some of the discontinued medications were later resumed or whether newly prescribed medications were associated with increases in fall risk. Incomplete intervention uptake was the motivation for the performance of subgroup analyses involving patients who confirmed completion of each intervention. Although some subgroup analyses were limited by small samples, the lack of difference between groups in any of these analyses makes it less likely that incomplete intervention adherence was the sole explanation for the primary analysis results."

As for the finding of improved quality of life in the intervention group versus the control group, Fritz and colleagues recommended taking it with a grain of salt.

"Given that the intervention was not associated with reductions in postoperative falls, the pretest probability for finding an association between the intervention and improved quality of life was low," they wrote. "The intervention may have been associated with reductions in other postoperative complications or adverse drug effects, which could have in turn mediated improved quality of life. Reliable information about postoperative complications among both groups was not available to allow further exploration."

They added that, while the two study groups were well balanced in terms of preoperative characteristics, they cannot rule out unmeasured confounders that could explain the association. "Furthermore, the difference in PCS-12 scores between the groups was small, although the observed difference in MCS-12 scores was large enough to be clinically meaningful. In comparison, the Strategies to Reduce Injuries and Develop Confidence in Elders clinical trial 30 did not find a meaningful impact of a fall prevention intervention on quality of life," they wrote.

Study limitations included that falls may not have been reported accurately; unmeasured confounders might be differently distributed between the two study groups; the modest adherence may have altered the results; the number of risk factors considered were limited; and the single-center design may limit generalizability.

Fritz reported receiving grants from the Foundation for Anesthesia Education and Research and the National Institutes of Health (NIH) during the conduct of the study. Coauthor Ben Abdallah reported receiving grants from the NIH during the conduct of the study. Coauthor Wildes reported receiving grants from the National Institute on Aging during the conduct of the study. Coauthor Lenze reported receiving grants from the Covid-19 Early Treatment Fund, the Emergent Venture Fast Grants program through Mercatus Center at George Mason University, the Patient-Centered Outcomes Research Institute, and Takeda Pharmaceutical Company and personal fees from Boehringer Ingelheim, Janssen Pharmaceuticals, and Prodeo outside the submitted work. Coauthor Stark reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.

Fritz BA, et al "Association of a perioperative multicomponent fall prevention intervention with falls and quality of life after elective inpatient surgical procedures" JAMA Netw Open 2022; 5(3): e221938.