@article {11010, title = {Prehospital and Posthospital Fall Injuries in Older US Adults}, journal = {JAMA Network Open}, volume = {3}, year = {2020}, abstract = {To date, measurement and treatment of older adult fall injury has been siloed within specific care settings, such as a hospital or within a nursing home or community. Little is known about changes in fall risk across care settings. Understanding the occurrence of falls across settings has implications for measuring and incentivizing high-value care across care settings.To estimate the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization.This cohort study is a longitudinal analysis of 12-month periods that include an anchor hospital stay using national data from 2006 to 2014. Participants included older (aged >=65 years) Medicare fee-for-service beneficiaries from the Health and Retirement Study. Weekly fall injury rates were computed for 4 periods compared with the anchor hospitalization: at baseline (1-6 months before hospitalization), just before (\<1 month before hospitalization), just after (\<1 month after hospitalization), and at follow-up (1-6 months after hospitalization). Piecewise logistic regression models estimated weekly marginal risk of fall injury within each period, adjusting for sociodemographic and health characteristics. Fall injury risks for high-risk beneficiaries with a fall injury during the anchor hospitalization were also estimated. Data analysis was performed from November 2019 to April 2020.Fall injuries.In total, 10 106 anchor hospitalizations for 4101 beneficiaries (mean [SD] age, 77.1 [7.6] years; 5912 hospitalizations among women [58.5\%]) were identified. The overall fall injury risk was 0.77\%. In adjusted models, marginal increases in weekly fall injury risk just before hospitalization (0.27 percentage points [95\% CI, 0.22 to 0.33 percentage points], or 30.0\%; P \< .001) were 4 times greater than decreases just after hospitalization (-0.18 percentage points [95\% CI, -0.23 to -0.13 percentage points], or -9.2\%; P \< .001)]. A greater risk differential before and after hospitalization was observed for patients with an inpatient fall injury (1.89 percentage points [95\% CI, 1.37 to 2.40], or 309.8\%; P \< .001; vs -0.39 percentage points [95\% CI, -0.73 to -0.04], or -11.6\%; P = .03).An episode-based assessment of fall injury illustrates substantial variability in period-specific risks over an extended period including an anchor hospitalization. Risk transitions between periods include sizable increases just before hospitalization that do not fully subside after hospital discharge. Financial incentives to coordinate hospital and posthospital care for patients at risk for fall injury are needed. These could include bundled payments for fall injury episodes that incentivize coordination across settings.}, keywords = {Fall injury, Hospitalization, Medicare}, isbn = {2574-3805}, doi = {https://doi.org/10.1001/jamanetworkopen.2020.13243}, author = {Geoffrey J Hoffman and Mary Tinetti and Ha, Jinkyung and Neil B. Alexander and Lillian C. Min} } @article {10668, title = {Measurement of Fall Injury With Health Care System Data and Assessment of Inclusiveness and Validity of Measurement Models}, journal = {JAMA Network Open}, volume = {2}, year = {2019}, pages = {e199679-e199679}, abstract = {National injury surveillance systems use administrative data to collect information about severe fall-related trauma and mortality. Measuring milder injuries in ambulatory clinics would improve comprehensive outcomes measurement across the care spectrum.To assess a flexible set of administrative data{\textendash}only algorithms for health systems to capture a greater breadth of injuries than traditional fall injury surveillance algorithms and to quantify the algorithm inclusiveness and validity associated with expanding to milder injuries.In this longitudinal diagnostic study of 13 939 older adults (>=65 years) in the nationally representative Health and Retirement Study, a survey was conducted every 2 years and was linked to hospital, emergency department, postacute skilled nursing home, and outpatient Medicare claims (2000-2012). During each 2-year observation period, participants were considered to have sustained a fall-related injury (FRI) based on a composite reference standard of having either an external cause of injury (E-code) or confirmation by the Health and Retirement Study patient interview. A framework involving 3 algorithms with International Classification of Diseases, Ninth Revision codes that extend FRI identification with administrative data beyond the use of fall-related E-codes was developed: an acute care algorithm (head and face or limb, neck, and trunk injury reported at the hospital or emergency department), a balanced algorithm (all acute care algorithm injuries plus severe nonemergency outpatient injuries), and an inclusive algorithm (almost all injuries). Data were collected from January 1, 1998, through December 31, 2012, and statistical analysis was performed from August 1, 2016, to March 1, 2019.Validity, measured as the proportion of potential FRI diagnoses confirmed by the reference standard, and inclusiveness, measured as the proportion of reference-standard FRIs captured by the potential FRI diagnoses.Of 13 939 participants, 1672 (42.4\%) were male, with a mean (SD) age of 77.56 (7.63) years. Among 50 310 observation periods, 9270 potential FRI diagnoses (18.4\%) were identified; these were tested against 8621 reference-standard FRIs (17.1\%). Compared with the commonly used method of E-coded{\textendash}only FRIs (2-year incidence, 8.8\% [95\% CI, 8.6\%-9.1\%]; inclusion of 51.5\% [95\% CI, 50.4\%-52.5\%] of the reference-standard FRIs), FRI inclusion was increased with use of the study framework of algorithms. With the acute care algorithm (2-year incidence, 12.6\% [95\% CI, 12.4\%-12.9\%]), validity was prioritized (88.6\% [95\% CI, 87.4\%-89.8\%]) over inclusiveness (62.1\% [95\% CI, 61.1\%-63.1\%]). The balanced algorithm showed a 2-year incidence of 14.6\% (95\% CI, 14.3\%-14.9\%), inclusion of 65.3\% (95\% CI, 64.3\%-66.3\%), and validity of 83.2\% (95\% CI, 81.9\%-84.6\%). With the inclusive algorithm, the number of potential FRIs increased compared with the E-code{\textendash}only method (2-year incidence, 17.4\% [95\% CI, 17.1\%-17.8\%]; inclusion, 68.4\% [95\% CI, 67.4\%-69.3\%]; validity, 75.2\% [95\% CI, 73.7\%-76.6\%]).The findings suggest that use of algorithms with International Classification of Diseases, Ninth Revision codes may increase inclusion of FRIs by health care systems compared with E-codes and that these algorithms may be used by health systems to evaluate interventions and quality improvement efforts.}, keywords = {Fall injury, Health Care, Inclusiveness}, issn = {2574-3805}, doi = {10.1001/jamanetworkopen.2019.9679}, author = {Lillian C. Min and Mary Tinetti and Kenneth M. Langa and Ha, Jinkyung and Neil B. Alexander and Geoffrey J Hoffman} } @article {9790, title = {Underreporting of Fall Injuries of Older Adults: Implications for Wellness Visit Fall Risk Screening.}, journal = {Journal of the American Geriatrics Society}, volume = {66}, year = {2018}, pages = {1195-1200}, abstract = {

OBJECTIVES: To compare the accuracy of and factors affecting the accuracy of self-reported fall-related injuries (SFRIs) with those of administratively obtained FRIs (AFRIs).

DESIGN: Retrospective observational study SETTING: United States PARTICIPANTS: Fee-for-service Medicare beneficiaries aged 65 and older (N=47,215).

MEASUREMENTS: We used 24-month self-report recall data from 2000-2012 Health and Retirement Study data to identify SFRIs and linked inpatient, outpatient, and ambulatory Medicare data to identify AFRIs. Sensitivity and specificity were assessed, with AFRIs defined using the University of California at Los Angeles/RAND algorithm as the criterion standard. Logistic regression models were used to identify sociodemographic and health predictors of sensitivity.

RESULTS: Overall sensitivity and specificity were 28\% and 92\%. Sensitivity was greater for the oldest adults (38\%), women (34\%), those with more functional limitations (47\%), and those with a prior fall (38\%). In adjusted results, several participant factors (being female, being white, poor functional status, depression, prior falls) were modestly associated with better sensitivity and specificity. Injury severity (requiring hospital care) most substantively improved SFRI sensitivity (73\%).

CONCLUSION: An overwhelming 72\% of individuals who received Medicare-reimbursed health care for FRIs failed to report a fall injury when asked. Future efforts to address underreporting in primary care of nonwhite and healthier older adults are critical to improve preventive efforts. Redesigned questions-for example, that address stigma of attributing injury to falling-may improve sensitivity.

}, keywords = {Doctor visits, Falls, Medicare linkage, Medicare/Medicaid/Health Insurance}, issn = {1532-5415}, doi = {10.1111/jgs.15360}, author = {Geoffrey J Hoffman and Ha, Jinkyung and Neil B. Alexander and Kenneth M. Langa and Mary Tinetti and Lillian C. Min} }