PCAG Falls Audit

Falls Risk Assessment

Falls Assessment

Suggested procedure for using the Falls Audit Tool

Falls Risk Assessment (the details)

Coding

Introduction

The PCAG Falls audit has been written as part of the SLA with Leicestershire PCTs. It consists of 2 stages and it is important to keep the distinction clear to avoid confusion.

1) A Falls Risk Assessment (a screening procedure for those not on the Falls Register [those Read coded: At risk of falls 14OC] to identify those at highest risk of falls in the target population of those aged 75 and over. Those at increased risk are placed on a Falls Register)

2) A Falls Assessment (an intervention for those on the Falls Register, aiming to reduce the risk of falls)

Falls Risk Assessment

The workload that would be involved in individually assessing annually each person aged 75 and over against the 18 or so known risk factors for falls would be considerable and is currently un-resourced in primary care. However, much of that information will be available in well-kept clinical records. PCAG has therefore developed a method of performing an electronic falls risk assessment as part of the housekeeping of the Falls Register.

Patients with a record of a fall in the previous year will be automatically added to the register. Other patients will have their risk assessed electronically through a scoring system and those scoring highly will be added to the Falls Register also.

Practices will run the PCAG Falls Housekeeping Miquest query set and analyse the results using the spreadsheet provided, in the same way as housekeeping other disease registers. This generates a list of patients who are not already on the register, and calculates their associated risk score. Practices can then sort these lists by usual doctor and chose a threshold score. Patients scoring above this can be added to the disease register. (In EMIS LV we have created a facility for adding the Falls Register code [At risk of falls-14OC] automatically for those with scores above threshold. Patients scoring 2 or more points below the threshold can also have the code indicating falls risk assessment done [Falls risk assessment complete-9Og2] added to their record automatically)

Patients who score just below the threshold may need a notes review by usual doctor / nurse to decide if they are to be added to the register, given that data sets are inevitably incomplete and a number of these patients may have had unrecorded falls or risk factors.

This should enable practices to develop and maintain a Falls Register quickly. We have not made provision for removing individuals from the Falls Register at present. The numbers of patients who will undergo intervention to reduce their risk to the extent that further review will be unnecessary is likely to be small. However, this may need to change as experience of the audit develops. See below for details of the performance of our falls risk assessment test.

Falls Assessment

The PCAG Falls Recall set can be used to recall those on the Falls Register but who have not had a Falls Assessment in the previous year. (This could also be done easily using the clinical systems search facilities.) The assessment could be done in the practice or by a PCT-lead falls service. A template has been produced to facilitate a review of the risk factors for the patient and to record any interventions.

The PCAG audit is an electronic audit that will look at both the Falls Risk Assessment and the Falls Assessment processes and report on the size of the Falls Register and interventions undertaken. The audit will be available on the PCAG website in the usual way.

Suggested procedure for using the Falls Audit Tool

1) Load the Falls template

2) Run Falls Housekeeping.

3) Decide what threshold score to use in adding patients to the register. Practices with little time or resource may wish to set a high threshold to reduce the potential workload. In EMIS LV you can add patients to the register from Excel directly based on their score. Alternatively it can be done manually using the template.

4) Record that a falls risk assessment has been done either automatically in LV manually (for low scoring patients). Check borderline patients to see if clinicians feel at sufficient risk to add to register and record risk assessment done.

5) Deliver Falls Assessment to patients on the Falls register. Recall set can be used to call them in.

6) Run PCAG Falls audit to assess progress and interventions and return response files to PCAG for analysis.

Falls Risk Assessment (the details) 

The electronic Falls Risk Assessment looks for codes indicating the following risks:-

Age/sex risk  - females over 80

Gait problem

Coordination

Power

Vision

Hearing 

Cognition

Psychiatry

Cvs - the presence of cardiovascular disease

Neuro - the presence of Parkinsonism

Incontinence

Arthritis

Alcohol - intake above 10 units per week or a code indicating alcohol problems

Foot

Osteoporosis - Not a risk factor as such - but such patients are at higher risk of injury if they do fall

Med_type - benzodiazepines, major tranquillizers, tricyclic antidepressants

Med_Number>3 - 4 or more regular repeat items - (as the Episode Type does not always work in existing Miquest Interpreters this search currently looks for >=4 different medication issues in the last 3months - ie some may be acute issues.)

To test the viability of this approach the housekeeping set was run on all target patients in 1 practice (511 patients over 74 yo and no fall recorded, 44 patients over 74 with fall recorded in last year) and the odds ratios (OR) calculated for each risk factor. These were compared with published data (see www.nice.org.uk and Falls) to see if the data available could reasonably be used to assess risk.

The practice derived OR's do show a rough match with published data, which is reassuring. (We would not expect an exact one given that the codes used will not map directly to the definitions used in the studies and that data quality in practice is unlikely to match data recording in research studies.) For some of the factors the OR's are less than 1. This probably represents a problem with data recording and the low prevalence of some of these risk factors. I have kept them, nevertheless, because the PCAG data is only based on one practice.

Individually these risk factors have poor specificity and sensitivity.

However taken together it is possible to distinguish at least some fallers from non-fallers on the basis of their risk factor profile. The risk factors have been weighted (using Excel Solver) to maximise the difference between the two curves and so optimise the specificity of the screening test. These weightings are used in the Housekeeping analysis spreadsheet to generate patient scores. The housekeeping analysis program automatically requests that practice return to us their risk factor table, which is anonymised, so that we can use this data to refine the weightings based on feedback from multiple practices and hopefully improve the risk factor weighting over time.

The specificity and sensitivity of the risk factor screen and the risk of a fall for those at different thresholds for a practice with a comprehensive clinical database is:-

In choosing the threshold a judgement will need to be made concerning workload implications vs pick up rate of potential fallers (and potential inconvenience to patients of recall for an intervention from which they may not benefit)

David Shepherd July 2004