Thank you for the opportunity to express our views on the draft recommendations for interventions aimed at preventing falls for older adults living in the community. The National Center for Health Research is a nonprofit think tank that conducts, analyzes, and scrutinizes research, policies, and programs on a range of issues related to health and safety. We do not accept funding from companies that make products that are the subject of our work.
We support the efforts of the U.S. Preventive Services Task Force (USPSTF) to re-evaluate its recommendations in light of new research regarding interventions for preventing falls in older adults living in the community. The USPSTF last issued these recommendations in 2012, and the only change USPSTF is suggesting is to lower the grade for vitamin D supplements to prevent falls from a “B” to a “D.” We agree with the Task Force’s revised scope of review for this particular intervention and that there is sufficient evidence to recommend against vitamin D supplements in community-dwelling older adults not known to have a vitamin D deficiency or insufficiency; however, we urge that this caveat be emphasized.
We also agree with the USPSTF that there is sufficient evidence to recommend exercise interventions for all older adults and multifactorial interventions for selected patients, depending on individual circumstances. However, we have two suggestions to improve these recommendations:
1) Regarding Key Questions, we strongly support the inclusion of quality of life as an outcome measurement in Key Question #1 (KQ1) because this is an important dimension in assessing the benefits and harms of utilizing primary care interventions to prevent falls. Considering whether and how these interventions affect quality of life will provide doctors and patients with important information for making an informed decision about which, if any, to pursue.
We strongly encourage the inclusion of a Key Question to investigate the difference between demographic subgroups for outcome measures. Conducting subgroup analyses for race/ethnicity, sex, and age (e.g. using meta-regression to look for relationships between the effect size and the covariate, or demographic variable) will enable the Task Force reviewers to evaluate the risks and benefits of fall prevention interventions for these subpopulations and determine whether recommendations should be different for certain demographic subgroups. For example, the Task Force did not conduct analyses to determine whether the interventions were beneficial for men 70-79, men 80+, women ages 70-79, and women ages 80+. Because only 7 studies reported race/ethnicity data and were comprised mostly of white participants, we recognize that racial/ethnic subgroup analyses would be limited.
2) The Task Force highlighted two issues in the “Future Research” section of the Evidence Synthesis document. One is uncertainty regarding whether altering characteristics of the intervention, including personnel, components, and intensity, will influence outcomes. Second, as the current review did not address comparative effectiveness, it is unknown whether the addition of another intervention to an effective intervention (e.g., exercise) is more beneficial. We agree that this information would be highly beneficial for older adults and providers if included in the recommendations.
We would like to draw your attention to an important study that will likely address the knowledge gaps noted above. Researchers are currently conducting a five-year cluster-randomized clinical trial funded by the Patient-Centered Outcomes Research Institute (PCORI) and the National Institute on Aging (NIA) of the National Institutes of Health (NIH). This study is evaluating an evidence-based, multifactorial, patient-centered intervention to reduce the risk of serious falls among community-dwelling older adults. The research team planned to enroll over 6,000 adults age 75 and older living in the community to receive treatment at 10 clinical sites across the country with follow-up for 20-40 months.
When results are available, this study could potentially provide very valuable information because it is the largest and most comprehensive study compared with any included in the current evidence review. We strongly encourage the USPSTF to consider integrating the results of this clinical trial into their evidence review when peer-reviewed results are available.
In conclusion, we support the USPSTF’s draft recommendations for exercise and multifactorial interventions, and against vitamin D supplements, given the available evidence. We recommend that the Task Force provide a caveat that these recommendations are not intended for older adults who are already known to have a vitamin D insufficiency; conduct subgroup analyses to determine the benefits and risks for sex, race/ethnicity, and two age groups; and integrate results of the NIH/PCORI study when they become available, as noted above. As more information becomes available about the effectiveness of particular components and intensities of exercise as well as other interventions, we encourage USPSTF to develop more specific recommendations for patients and providers.
For questions or more information, please contact Megan Polanin, PhD, at email@example.com.
National Institutes for Health, U.S. National Library of Medicine (2017, May 8). Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE; ClinicalTrials.gov Identifier: NCT02475850). Retrieved from https://clinicaltrials.gov/ct2/show/NCT02475850?term=Shalender+Bhasin&cond=falls+prevention+AND+%22Wounds+and+Injuries%22&rank=1
Patient-Centered Outcomes Research Institute (2017, October 17). Randomized Trial of a Multifactorial Fall Injury Prevention Strategy: A joint initiative of PCORI and the National Institute on Aging of the National Institutes of Health. Retrieved from https://www.pcori.org/research-results/2014/randomized-trial-multifactorial-fall-injury-prevention-strategy-joint