Article type
Abstract
Background
A 2018 Cochrane Collaboration review of interventions to prevent falls in older people living in care facilities found a lack of evidence for the effectiveness of multifactorial and medication review interventions. However, meta-analyses had high heterogeneity unexplained by prespecified subgroup analyses.
Objectives
To update the 2018 Cochrane review and incorporate the novel methodology of qualitative comparative analysis (QCA) to inform conclusions about the effectiveness of fall-prevention interventions in care facilities.
Methods
The Cochrane review was updated to December 2022, with generic inverse variance meta-analyses of randomized controlled trials reporting the rate of falls (rate ratio, RaR) or risk of falling (risk ratio, RR). QCA was conducted for multifactorial and medication optimization interventions to identify configurations of conditions associated with successful trial outcomes. For multifactorial interventions, this was informed by a thematic analysis of trial authors’ views to develop a theory of drivers of trial effectiveness that captures implementation context (intervention component analysis, ICA). For medication optimization, the QCA was informed by a recommendation from the European Geriatric Medicine Society 2022 position paper. There was no consumer involvement.
Results
Pooled analysis of multifactorial trials did not demonstrate a significant reduction in falls (RaR = 0.87, 95% CI = 0.69-1.10, 12 trials, I² = 87%; RR = 0.90, 95% CI = 0.80-1.01, 11 trials, I² = 32%). A subgroup analysis informed by QCA found trials that implement interventions with facility staff engagement and tailored intervention delivery considering residents' individual circumstances (eg, living with dementia) reduce falls (RaR = 0.61, 95% CI = 0.54-0.69, 7 trials, I² = 0%; RR = 0.76, 95% CI = 0.66-0.89, 5 trials, I² = 0%; subgroup differences P ≤ 0.01). Pooled analysis of medication optimization interventions did not demonstrate a reduction in falls (RaR = 0.91, 95% CI = 0.72-1.15; I² = 86%; RR = 0.95, 95% CI = 0.87-1.04; I² = 6%). QCA did not identify trial features likely to explain trial outcomes.
Conclusions
Utilizing qualitative evidence to inform meta-analysis subgroups through QCA informed by ICA to capture the context and implementation of interventions can inform clear conclusions. The additional detail obtained can indicate how to implement interventions to best improve resident outcomes. QCA based on intervention features alone may not adequately capture the complexity of factors that contribute to the outcome of fall-prevention interventions in this setting.
A 2018 Cochrane Collaboration review of interventions to prevent falls in older people living in care facilities found a lack of evidence for the effectiveness of multifactorial and medication review interventions. However, meta-analyses had high heterogeneity unexplained by prespecified subgroup analyses.
Objectives
To update the 2018 Cochrane review and incorporate the novel methodology of qualitative comparative analysis (QCA) to inform conclusions about the effectiveness of fall-prevention interventions in care facilities.
Methods
The Cochrane review was updated to December 2022, with generic inverse variance meta-analyses of randomized controlled trials reporting the rate of falls (rate ratio, RaR) or risk of falling (risk ratio, RR). QCA was conducted for multifactorial and medication optimization interventions to identify configurations of conditions associated with successful trial outcomes. For multifactorial interventions, this was informed by a thematic analysis of trial authors’ views to develop a theory of drivers of trial effectiveness that captures implementation context (intervention component analysis, ICA). For medication optimization, the QCA was informed by a recommendation from the European Geriatric Medicine Society 2022 position paper. There was no consumer involvement.
Results
Pooled analysis of multifactorial trials did not demonstrate a significant reduction in falls (RaR = 0.87, 95% CI = 0.69-1.10, 12 trials, I² = 87%; RR = 0.90, 95% CI = 0.80-1.01, 11 trials, I² = 32%). A subgroup analysis informed by QCA found trials that implement interventions with facility staff engagement and tailored intervention delivery considering residents' individual circumstances (eg, living with dementia) reduce falls (RaR = 0.61, 95% CI = 0.54-0.69, 7 trials, I² = 0%; RR = 0.76, 95% CI = 0.66-0.89, 5 trials, I² = 0%; subgroup differences P ≤ 0.01). Pooled analysis of medication optimization interventions did not demonstrate a reduction in falls (RaR = 0.91, 95% CI = 0.72-1.15; I² = 86%; RR = 0.95, 95% CI = 0.87-1.04; I² = 6%). QCA did not identify trial features likely to explain trial outcomes.
Conclusions
Utilizing qualitative evidence to inform meta-analysis subgroups through QCA informed by ICA to capture the context and implementation of interventions can inform clear conclusions. The additional detail obtained can indicate how to implement interventions to best improve resident outcomes. QCA based on intervention features alone may not adequately capture the complexity of factors that contribute to the outcome of fall-prevention interventions in this setting.