Translating the Fall Prevention Recommendations Into a Covered Service: Can It Be Done, and Who Should Do It? Free

The U.S. Preventive Services Task Force (USPSTF) recently released its recommendation statement on the prevention of falls in community-dwelling older adults (1). Exercise or physical therapy and vitamin D supplementation received grade B recommendations (2). The USPSTF concluded with high certainty for exercise or physical therapy and moderate certainty for vitamin D supplementation that the net benefits are moderate (1). The USPSTF gave a grade of C to multifactorial risk assessment and management, concluding that the likelihood of benefit is small.

Some USPSTF recommendations inspire impassioned support or opposition from the public and health care providers (3, 4). Apart from disease-specific advocacy, the USPSTF recommendations have increased importance because of provisions in the Affordable Care Act that require private insurers, Medicare, and Medicaid to provide coverage (without cost-sharing or copays) for annual wellness visits and for preventive services graded A or B (5).

Because the difference between a B grade and a C grade has important implications for what fall-related preventive services individuals will probably receive, it is worth reviewing the evidence underpinning the USPSTF recommendations. The authors of the systematic review that served as the basis for the recommendations concluded that exercise and physical therapy reduced falling by about 13%, vitamin D supplementation reduced falling by 17%, and multifactorial risk assessment reduced falling by 6% (increasing to 11% when identified fall risk factors are managed) (6). The Task Force needed to set a cutoff somewhere, but determining a 13% reduction to be modest (thus qualifying for a B grade and coverage) and an 11% reduction to be small (thus qualifying for a C grade without obligate coverage) seems arbitrary. Of note, although the Task Force considered the 17% reduction of falls with vitamin D supplementation to be a modest benefit, it considered the concomitant 17% increase in renal stones to be a small (and presumably acceptable, given the B grade) harm (1).

The USPSTF had to apply systematic review and grading processes developed for screening tests, such as colonoscopy and mammography, or simple preventive interventions, such as vaccines or medications, to the more complicated situation of behavioral and multifactorial interventions. The studies that were reviewed included heterogeneous sets of activities and interventions with a spectrum of adherence. Depending on which studies are included and how they are aggregated, meta-analyses of fall prevention strategies result in different estimates of benefit, as reflected in the disparate findings among reviews of the evidence summarized in the recommendation statement (1). The Task Force acknowledged the limitations of current methods for reviewing complex preventive interventions, such as fall prevention, in older adults (6). It is working on methods for reviewing evidence and determining appropriate preventive interventions for older patients. Once these methods are developed, it is hoped that the USPSTF will rereview fall prevention evidence, particularly the multifactorial assessment and management strategies. In the meantime, the current recommendations for exercise and physical therapy must be translated into a defined program that clinicians can offer their patients and the Centers for Medicare & Medicaid Services (CMS), the major health insurer for older adults, can cover as a preventive service.

Defining the components of the exercise program may not be easy. The evidence underpinning the recommendations comes from time-limited, randomized, controlled trials involving heterogeneous populations that participated in different combinations of balance, strength, endurance, or general exercise programs in various settings under the supervision of diverse groups of experts (for example, physical therapists, nurses, and exercise physiologists). The trials provide general guidance, but not the details of how to construct or conduct a clinical exercise program. The relevant professional organizations (for example, the American Physical Therapy Association, American Occupational Therapy Association, and American Geriatrics Society) would do well to join forces to transform the evidence into a defined program that spells out who should partake in what types of exercises, the setting and duration of the exercises, and the type of monitoring or supervision the participants will receive.

To maximize effectiveness and safety, the organizations should design a multicomponent exercise program that providers can tailor to each individual's set of impairments and functional limitations (7). The goal should not only be fall prevention, but also a fuller range of benefits of exercise, such as improved sleep, reduced depression, and better cognition, as well as improvement in overall function and in such chronic diseases as heart failure, chronic obstructive pulmonary disease, and arthritis. The challenge will be in tailoring the program to individual needs while providing enough specifics for CMS to understand exactly what service it is being asked to cover.

Defining who should participate in a fall prevention exercise program will be important. Should all persons aged 65 years or older be encouraged to participate (a reasonable suggestion, given the 30% fall rate in this age group)? Should it be the subset of older adults with an elevated risk for a fall injury? If so, what valid yet clinically simple screening test should be used to identify them? Who can safely be advised to exercise on their own? Who should be supervised at non–health care sites, such as senior centers or gyms? Who would require supervision, at least initially, by a health professional, such as a physical therapist? Individuals with gait or balance dysfunctions (which will need to be defined) would certainly benefit from professionally supervised exercise sessions.

To avoid indefinite physical therapy–supervised care, it will be necessary to create indicators of when an individual should be transitioned to an independent program and, conversely, when a person may need to come back under health care supervision. It will also be important to identify objective and meaningful measures of progress and effectiveness. Given its concern about overuse and fraud, CMS will want assurance that the service is needed. Traditionally, physical therapy is delivered as 1 episode of care (for example, 2 times per week for 3 to 4 weeks). For fall prevention, it may most efficiently be delivered as brief, intermittent episodes over a longer period. By delivering the same amount of care over an extended period, the provider can modify the exercise program to ensure safe and effective progress and address new developments.

The complexities involved in translating the evidence into a defined exercise service highlight the importance of meeting early with the appropriate CMS individuals. The organizations involved in defining the fall prevention exercise program must address potential CMS concerns about overuse, fraud, and knowing what the new service is and how it is different from what providers are already doing.

Rehabilitation-oriented providers will probably take great interest in the USPSTF recommendations and any new preventive exercise program that results. But physicians, who cannot keep up with guidelines for existing conditions and currently recommended preventive services, might reasonably ask why they should care (8). Any new preventive service will likely become the responsibility of already-beleaguered primary care providers who will probably not receive sufficient reimbursement to cover the expense involved in orchestrating the screening and referral process. One reason physicians might care is that fall risk assessment—and, in the near future, management—is a measure choice in the Physician Quality Reporting System that is currently voluntary but is scheduled for mandatory implementation (9). To encourage physicians who are inclined to act, it would behoove those involved in translating the evidence into practice to make the screening required of physicians as quick and simple as possible.