Missed Opportunities For Fall Prevention: Primary Care Follow‐up After Emergency Department Discharge In Older Adults

In this retrospective chart review of 168 adults aged 65 and older who were discharged home from 9 emergency departments (EDs) after a fall and attended at least one primary care (PCP) visit within 90 days, we characterized the fall risk assessments and interventions documented during those follow-up visits. The index fall was documented for 71% of patients, but comprehensive assessment was uncommon (gait 34%, balance 36%, vision 11%, home hazards 11%, orthostatic blood pressure 6%). Only 27% of the 120 patients prescribed a fall-risk increasing drug (FRID) had that medication specifically addressed. In each row, the red percentage is the proportion of all 168 patients who received that assessment, and the adjacent blue percentage is the proportion with a positive finding among those assessed. These findings reveal large gaps between guideline-recommended fall care and routine primary care practice after an ED visit for a fall.

ABSTRACT

Introduction

Evaluation by a primary care provider (PCP) after an emergency department (ED) visit for a fall is crucial for preventing future falls. However, little is known about the current practice of fall risk assessments and interventions across community and academic primary care clinics.

Methods

We performed a retrospective chart review of adults 65 and older discharged home after a fall from 9 EDs in Michigan. All primary care visits within 90 days of the index ED visit were included. Patients were excluded if they had a PCP outside of our health system. The primary outcome was the rate of fall risk assessments and interventions performed during primary care visits, with definitions operationalized from the CDC STEADI (Stopping Elderly Accidents, Deaths, and Injuries) recommendations.

Results

The sample included 168 older adults who attended PCP visits across 68 practices cared for by 144 different providers. A total of 277 visits were reviewed. Among all patients, 70.8% had the fall documented during primary care encounters. Rates of falls assessments varied widely, with balance (36%), gait (34%), and cognitive screens (24%) being most common and vision (11%), home hazards (11%), and fall-risk increasing drugs (27%) assessments among the least common. Among patients with positive assessments, interventions were most common for those with home hazards (88%), vision impairment (89%), and fall-risk increasing drugs (81%).

Conclusions

A minority of patients who attended PCP appointments after a fall had comprehensive assessments. However, those who did have positive assessments frequently received targeted interventions. Primary care clinicians should be better supported and incentivized to perform comprehensive fall assessments. Health systems could better integrate assessments between acute and ambulatory care settings. Further work is needed to understand the barriers to conducting comprehensive fall risk assessments across care settings and alternative care models to bridge these gaps.