risk factors for falls in residential care: evidence from rai … · 2011-08-18 · risk factors...

Risk Factors for Falls in Residential Care: Evidence from RAI MDS 2.0 Assessment Data

Jeff Poss, PhDDepartment of Health Studies & Gerontology

University of Waterloo

Outline• Gentle review of MDS 2.0• Issues in studying falls in MDS 2.0 data• Examination of risk factors• Scott fall risk screening tool• Results in different jurisdictions

Some Observations About FallsNiagara Falls, Ontario

drop 57mNiagara Falls, Goldstream Park, BC

drop 48mDella Falls, BC

drop 440m

• The height of the drop may not be the most important thing

• The importance of the fall may depend on who sees it

• Two people can call a fall the same thing but mean something quite different

RAI Instruments and interRAI• interRAI is a non-profit collaborative network of researchers

from over 30 countries• Develop standardized assessment instruments in the support

of evidence-based clinical practice and policy decisions• MDS 2.0 – residential care settings• RAI-HC – home care• RAI-MH – inpatient psychiatry• etc.

• www.interrai.org

Applications of interRAI Instruments

Assessment

Care Plan

Outcome Measures Quality Indicators

Resource Allocation

Prevent GamingEvaluateBest Practices

FundingNeed Determination

Report CardsQuality Improvement

Accreditation

Canadian Institute for Health Information (CIHI)

• “an independent, not-for-profit organization that provides essential data and analysis on Canada’s health system and the health of Canadians”

• Continuing Care Reporting System (CCRS) uses MDS 2.0• Jurisdictions submit MDS 2.0 data to CIHI, get support,

reports, etc.• Anonymized MDS 2.0 data come back to interRAI for:

• secondary research • new instrument development

MDS 2.0 Assessment• Developed in the U.S. for the federal Centre for

Medicare and Medicaid Services, early 90s• About 400 items covering

cognition sensorymood behaviourpsychosocial ADLcontinence disease diagnoseshealth conditions oral/nutritional/dentalskin activitiesmedications treatments

Standardized Measurement• Strives to measure with reliability and validity• Specific time frames• Documentation, training to support assessors• Assessors use all available sources• Supports comparisons across:

• time• units/facilities• provinces• countries

Example MDS 2.0 items

Are the Data OK?• Entry software supports completeness, valid responses• CIHI checks at submission• Analyses suggest there is good internal consistency,

convergent validity• When used for research, accept some level of imprecision

• Bias threatens validity, but unlikely in MDS data

• No measurement is perfect, especially in healthcare!

Instrumentation Issues: falls• MDS 2.0 has 2 fall items:

• Reassessment occurs quarterly: ~ 90 days• For data analysis, how to best determine when a

fall may have occurred?• Additional issue of determining if the fall occurred

in the facility or prior to entry

Normal MDS assessment pattern

30150

14 105 196 287 378Day of stay in facility

Issues to consider in identifying day of first fall event:- Principle of conservatism: certain that fall occurred in facility (LOS>30 days for J4a, LOS>180 days for J4b)- Don’t know exactly when fall occurred, so assign mid-point day in possible interval- Take all possible events, choose earliest one for time-to-event analysis- ‘Under-detecting’ falls early in stay due to conservative approach

‘Survival’ Plot for new admissions(Ontario LTC Homes, 2005-2008, CCRS, falls)

Proportion without a fall

Interpretation: 25% of residents experience a fall in a facility within 130 days of admission

Day of stay

Artifacts of periodic reassessment

Under-detection early in stay

Can compare falls for 2 groups

Ontario

Saskatchewan

Relative Risk• Expressed as a number, gives the degree to

which a group has higher risk of falling, compared to another group

Can compare falls for 2 groups

OntarioRelative Risk = 1.39

Saskatchewan(baseline, relative

risk=1.00 by definition)

Fun With Data

Fell in last 30 days

Relative Risk = 2.76

Fell in last 31-180 days


Unsteady Gait


Age

Relative Risk< 65: 1.0065-74: 1.1075-84: 1.2885+: 1.47

Sex

Relative Risk: 1.13(males higher risk)


Visually Impaired (D1 > 2)

Depression Symptoms (DRS > 3)

Relative Risk: 1.24

Physical Dependence (ADL)

Relative Risk: dependenceLow: 1.00Moderate: 1.75High: 1.19

Cognitive Impairment

Relative Risk: CPS ScaleLow (0,1): 1.00Moderate (2,3,4,5): 1.43High (6): 0.86

DIAGNOSES?

Arthritis?

Relative Risk: 1.02 (n/s)

Osteoporosis?

Relative Risk: 1.18

Relative Risk: 1.27

Dementia?

Relative Risk: 1.30

Parkinson’s?

Relative Risk: 0.99 (n/s)

Stroke?

Relative Risk: 1.61

Diabetic retinopathy?

OTHERS

Relative Risk: 1.45

Cane, walker, or crutch

Relative Risk: 0.49 (protective)

Lifted mechanically

Factor Relative RiskFell last 30 days 2.76Fell last 31 to 180 days 1.59Unsteady gait 1.78Age >85 vs <65 1.47Male 1.13Visually impaired 1.21Depressive symptoms 1.24ADL (moderate versus independent) 1.75Cognitive (moderate versus intact) 1.43Arthritis 1.02 (n/s)Osteoporosis 1.18Alzheimer’s/other dementia 1.27Parkinson’s 1.30Stroke 0.99 (n/s)Diabetic Retinopathy 1.61Cane/walker/crutch 1.45Lifted mechanically 0.49 (protective)

SCOTT FALL RISK SCREENING TOOL for Residential Care

Scott Fall Risk Screening Tool• 11 Risk factors:Factor Weight2+ falls last 6 months 6Impaired mobility, balance, gait 2Altered mental state 2Unsafely attempts to get out of bed 2Move to facility in past month 1Dizziness or vertigo 1Generalized weakness 1Alternations in urinary/bowel elimination 1More than 7 medications 1Benzodiazepine or psychotropic medications 2Immobile -5

Scott Fall Risk Screening Tool• Attempt to ‘cross-walk’ these 11 factors to MDS

2.0 items• Test and refine using available data

10 Factors, Ontario LTC, new admissions(Leave out ‘move to facility in last month’)

Factor PrevalenceRelative Risk

bi-variateRelative Risk, multi-variate

2+ falls 4.8% 2.54 2.37Mobility, balance, gait 70.8% 1.76 1.54Altered mental state 66.9% 1.27 1.16Unsafely out of bed 16.7% 1.27 1.26Dizziness/vertigo 2.2% 1.31 n/s Weakness 60.2% 1.19 1.15Incontinence 11.7% 1.60 1.287+ medications + criteria 51.4% 1.18 1.14Psychotropic meds 56.0% 1.16 n/s Immobile 31.0% 0.74 (protective) n/s

Scott Risk Scale, 10 factorsFall in first 200 days

0%10%20%30%40%50%60%70%80%90%

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1516

-17

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Scott Risk Scale Value

Scott (10 factors)

Scott Risk Scale, 7 significant factorsFall in first 200 days

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Scott (7 factors)

Scott Risk Scale, 7 factors, re-weightedFall in first 200 days

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Scott (10 factors)

Universal High High + unsafeambulation


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Scott (7 factors)

Universal(38%)

High(57%)

High + unsafeambulation (5%)


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Scott (7 factors), collapsed into 3 groups

Scott Risk Scale, 7 significant itemsre-scaled, collapsed to 3 categories: Falls in Ontario LTC

homes, new admissions, n=9701

Relative RiskUniversal: 1.00High: 1.84High +: 3.89

Scott Risk Scale, 7 significant itemsre-scaled, collapsed to 3 categories: Falls in Saskatchewan



Scott Risk Scale, 7 significant itemsre-scaled, collapsed to 3 categories: Falls in Nova Scotia



Scott Risk Scale, 7 significant itemsre-scaled, collapsed to 3 categories: Falls in Ontario CCC

Hospitals, new admissions, n=122,502


Scott Risk Scale, 7 significant itemsre-scaled, collapsed to 3 categories: Fractures (J4c, J4d)

(Ontario, Saskatchewan, Nova Scotia combined)


Back to Ontario & Saskatchewan

OntarioAverage Scott risk

score: 4.5

SaskatchewanAverage Scott risk

score: 4.0

Can Risk Adjust Falls• Ontario compared to Saskatchewan, relative risk:

• Unadjusted: 1.39• Adjusted for Scott risk tool: 1.29

Discussion & Summary• MDS 2.0 assessment data demonstrate characteristics that

support examination of falls in residential care• Among MDS items, a recent fall is the most useful item in

predicting a future fall• Functional/clinical items generally better at predicting a future

fall than diagnoses• The Scott fall risk screening tool differentiates fall risk in

residential care• Can be used to identify residents with highest fall risk, target

interventions• Administratively, can monitor both falls and falls risk using

MDS 2.0 data

Future work• B.C. Data• More Canadian MDS 2.0 data coming:

• Ontario finishing roll-out in LTC• Expect more western provincial data to CIHI/CCRS

risk factors for falls in residential care: evidence from rai … · 2011-08-18 · risk factors...

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