Falls risk assessment and management system (FRAMS) - a decision support tool developed for general practitioners and their primary care team

Doris Young, Siaw-Teng Liaw, Nabil Sulaiman

HK Pract 2005;27:306-310

Summary

Falls are the leading cause of morbidity and mortality in people over 75 years. General Practitioners (GPs) have a vital role to play in the prevention of falls by performing proper assessment and identification of risks of falls in their older patients. We believe that a systematic assessment of individual risk is desirable and that a pro-active, multi-faceted approach to injury prevention is essential. The primary care team at University of Melbourne has created an evidence based falls risk assessment and management decision support system (FRAMS) to assist GPs and the primary care team in this role. The authors would like to share this novel tool with GPs in Hong Kong for information.

摘要

意外跌倒是七十五歲以上人仕常見的傷亡原因。在預防跌倒方面，全科醫生的角色十分重要， 可為年長病者進行全面評估識別跌倒的風險採用主動、多元化的方法進行系統化的評估來評定個別風險是值得而必須的。 墨爾本大學的基層醫療隊伍創立了一個以實証醫學為基礎的跌倒風險評估及治理支援系統(FRAMS)， 以協助全科醫生和基層醫療人員。本文作者願與香港的全科醫生分享這個新的工具。

Introduction

One third of people aged 65 and half of those over 80 fall every year.¹ Falls occur frequently, and are preventable. They create a high burden of morbidity in the community, acute hospitals and sub-acute or rehabilitation settings. Prevalence ranges from 2-5% in acute care settings to 25-40% in sub-acute care and 33% of community dwelling older people. Falling is a health condition meeting all criteria for prevention: high frequency, evidence of preventability, and high burden of morbidity.² Falls cost the Australian taxpayer $406 million/year in the management of injuries and fractures, and increased demand for hospitalisation and residential care. Therefore, with the ageing population and the high prevalence of chronic diseases amongst older people, falls prevention should be an integral part of good general practice/family physician care. This article uses a case vignette to illustrate how GPs and the primary care team can assess falls risks in their elderly patients during the consultation using an online interactive decision support programme. This innovative falls risk assessment and management system (FRAMS) has been developed by a primary care research team at University of Melbourne, Australia. It is the intention of this paper to share the information about this novel tool with family physicians in Hong Kong and not to advocate its wide adoption for use by them.

What is falls risk assessment and management system (FRAMs)?

FRAMS is an online evidence-based electronic decision support and guidelines delivery system, developed to assist GPs and health professionals to assess risks of falling for specific patients and to manage the risks.³ An extensive literature search, (Table 1) commencing with research evidence in falls prevention^4-6 with a focus on papers which utilised a prospective methodology and incorporated multivariate analyses for falls or falls injury risk, was conducted. Only about 15% of falls events are recalled in retrospective studies^7-9 and multivariate analyses are important to include the interactive influence between individual risk factors.

Critical appraisal of the six studies, which met these two criteria,^10-15 focused on the identification and weighting of falls risks. Falls risk factors were included only if they met the requirements for strength of the evidence for different levels of risk (based on odds ratios published in identified prospective studies using multi-variate analyses), relevance of screening process to assessment items and individual patient, and had a range of recommended actions corresponding to each identified risk factor. This phase guided the initial development of the ontology of the falls prevention guidelines database and the clinical model for primary and secondary falls prevention within a multidisciplinary integrated care context.

The risk factors for falls are listed in Table 2 and the relative risk (RR) was then used to weigh the risk factors (Table 3):

1. weight=0 (no evidence);
2. weight=1 (mild when RR of falls is >1 and <2 and/or is clinically important);
3. weight=2 (moderate, when RR is significant i.e. RR>2 and <3);
4. weight=3 (major contributor to falls risk, when RR>3).

A clinical model for the assessment of risks of falling and the management of the risks was developed using clinical vignettes with expert and focus groups of general practitioners and health professionals. In addition, the terminology associated with falls was explored. This model formed the basis of the information model, based on the GP Data Model, which guided the development of FRAMS.

FRAMS comes in two versions: a short version based on 6 major falls risk screening questions and a longer 14-questions version to allow detailed assessment of each individual risk factor. Users answer the questions online, with the long version taking about 30-45 minutes to complete. It is recommended that practice nurses use the longer version and the short version be used by GPs.

FRAMS analyses the responses against the weighted risks and provides an annotated risk of falling, which is colour-coded for the degree of risk, for the patient along with a management plan. The online management plan includes a recommended course of action for each risk factor: counselling about physical activity and dietary modification, environmental safety and support, recommended diagnostic procedures, therapeutics, referrals and review of strategies used. The plan can be printed to give to patients or to file in the health records.

FRAMS has been tested to date by GPs in clinical and laboratory/seminar settings only, with generally positive feedback. Apart from time taken to use the tool, some GPs also commented that FRAMS was somewhat simplistic, particularly for patients with mild risks of falling. It is therefore recommended for use for complex cases ie those with chronic diseases. For those interested to explore this, it can be accessed through website:http://www.falls.unimelb.edu.au

Case Study 1 : Mrs Chan

Mrs Chan, an 82 years old retired accountant came in for her regular check-up of her osteoarthritis in her knees. She complained that her knees sometimes give way on uneven ground and over the last three months she has stopped taking her walks following a fall and bruised her left knee. She feels unsafe on her feet. She lives at home with her husband age 83. Their son lives near by. She takes Paracetamol and Diclofenac (NSAID) for pain and an occasional Temazepam (Benzodiazepine) for sleep, and Ramipril (ACE inhibitor) and Moduretic (diuretic) for hypertension.

When using FRAMS, Mrs Chan's assessment on screen will look like this (Figures 1 and 2):

The Care Plan is the output generated upon completion of either the Risk Screening or Risk Assessment. Each Care Plan includes:

1. Date Generated
2. Patient Information - Name, Age and Gender of patient
3. Overall Risk Summary for the 6 Categories
4. General comments on the specific risk factor identified
5. Intervention recommended, including information on the Actor, Action and Evidence

Mrs Chan's care plan will look like this (Figure 3):

Conclusion

General practitioners should be encouraged to routinely and systematically assess all their older patients for falls risk as part of their comprehensive health assessments. In Australia, this applies to 75+ age group. FRAMS has been developed as a novel interactive decision support computer programme to assist GPs and the primary health care team to assess falls risk and generate a falls prevention management care plan for patients with complex health problems. Additional effort and funding are needed to market this tool for wider dissemination and adoption for use by Australian GPs. Further recommendations are to enhance FRAMS to enable other clinicians and consumers with access to the Internet, to use FRAMS as part of a comprehensive team approach to be prompted about and understand the various risks contributing to falls. This should ultimately reduce the incidence of falls.

Acknowledgement

The authors thank all contributors to the FRAMS including Christopher Pearce, Jane Sims, Keith Hill, Justin Tse, Choon-Kiat Ng and Heather Grain. The FRAMS was commissioned by the General Practice Computing Group and funded by the Department of Health and Aged Care, Australia.

Key messages

1. One third of people aged 65 and half of those over 80 falls every year.
2. Falling is a health condition meeting all criteria for prevention: high frequency, evidence of preventability, and high burden of morbidity.
3. A pro-active, multi-faceted approach to injury prevention involving older people and their carers ought to be part of good geriatric care.
4. FRAMS is a newly developed, yet to be widely implemented, novel evidence based electronic decision support tool to assist GPs to assess the falls risk of older persons with complex health needs and generate a management plan for them and their carers.