Skip Navigation
American College of Physicians Logo
  • Subscribe
  • Submit a Manuscript
  • Sign In
    Sign in below to access your subscription for full content
    INDIVIDUAL SIGN IN
    Sign In|Set Up Account
    You will be directed to acponline.org to register and create your Annals account
    INSTITUTIONAL SIGN IN
    Open Athens|Shibboleth|Log In
    Annals of Internal Medicine
    SUBSCRIBE
    Subscribe to Annals of Internal Medicine.
    You will be directed to acponline.org to complete your purchase.
Annals of Internal Medicine Logo Menu
  • Latest
  • Issues
  • Channels
  • CME/MOC
  • In the Clinic
  • Journal Club
  • Web Exclusives
  • Author Info
Advanced Search
  • ‹ PREV ARTICLE
  • This Issue
  • NEXT ARTICLE ›
Editorials |7 August 2012

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

Mary E. Tinetti, MD; Jennifer S. Brach, PhD, PT

Mary E. Tinetti, MD

Jennifer S. Brach, PhD, PT

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From Yale School of Medicine, New Haven, CT 06520, and University of Pittsburgh, Pittsburgh, PA 15260.

    Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1472.

    Requests for Single Reprints: Mary E. Tinetti, MD, Yale University School of Medicine, Department of Internal Medicine/Geriatrics, Harkness A 318, 367 Cedar Street, New Haven, CT 06520-8025; e-mail, mary.tinetti@yale.edu.

    Current Author Addresses: Dr. Tinetti: Yale University School of Medicine, Department of Internal Medicine/Geriatrics, Harkness A 318, 367 Cedar Street, New Haven, CT 06520-8025.

    Dr. Brach: University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260.

×
  • ‹ PREV ARTICLE
  • This Issue
  • NEXT ARTICLE ›
Jump To
  • Full Article
  • FULL ARTICLE
  • FULL ARTICLE
      1. References
  • Figures
  • Tables
  • Supplements
  • Audio/Video
  • Summary for Patients
  • Clinical Slide Sets
  • CME / MOC
  • Comments
  • Twitter Link
  • Facebook Link
  • Email Link
More
  • LinkedIn Link
  • CiteULike Link
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.

References

  1. Moyer
    VA
    .  
    U.S. Preventive Services Task Force
    Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement
    Ann Intern Med
    2012
    157
    197-204
  2. Grading the quality of evidence and the strength of recommendations. GRADE Working Group Web site. Accessed at www.gradeworkinggroup.org/intro.htm on 8 June 2012.
  3. Nelson
    HD
    ,  
    Tyne
    K
    ,  
    Naik
    A
    ,  
    Bougatsos
    C
    ,  
    Chan
    BK
    ,  
    Humphrey
    L
    .  
    U.S. Preventive Services Task Force
    Screening for breast cancer: an update for the U.S. Preventive Services Task Force
    Ann Intern Med
    2009
    151
    727-37, W237-42
    PubMed
  4. Moyer
    VA
    .  
    U.S. Preventive Services Task Force
    Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement
    Ann Intern Med
    2012
    157
    120-34
  5. Koh
    HK
    ,  
    Sebelius
    KG
    .  
    Promoting prevention through the Affordable Care Act
    N Engl J Med
    2010
    363
    1296-9
    PubMed
    CrossRef
  6. Leipzig
    RM
    ,  
    Whitlock
    EP
    ,  
    Wolff
    TA
    ,  
    Barton
    MB
    ,  
    Michael
    YL
    ,  
    Harris
    R
    .  
    et al.
    U.S. Preventive Services Task Force Geriatric Workgroup
    Reconsidering the approach to prevention recommendations for older adults
    Ann Intern Med
    2010
    153
    809-14
    PubMed
    CrossRef
  7. Guralnik
    JM
    ,  
    Ferrucci
    L
    ,  
    Balfour
    JL
    ,  
    Volpato
    S
    ,  
    Di Iorio
    A
    .  
    Progressive versus catastrophic loss of the ability to walk: implications for the prevention of mobility loss
    J Am Geriatr Soc
    2001
    49
    1463-70
    PubMed
    CrossRef
  8. Østbye
    T
    ,  
    Yarnall
    KS
    ,  
    Krause
    KM
    ,  
    Pollak
    KI
    ,  
    Gradison
    M
    ,  
    Michener
    JL
    .  
    Is there time for management of patients with chronic diseases in primary care?
    Ann Fam Med
    2005
    3
    209-14
    PubMed
  9. Centers for Medicare & Medicaid Services. Physician Quality Reporting System. Baltimore: Centers for Medicare & Medicaid Services; 2012. Accessed at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html on 7 June 2012.

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

This feature is available only to Registered Users

Subscribe/Learn More
Submit a Comment

0 Comments

PDF
Not Available
Citations
Citation

Tinetti ME, Brach JS. Translating the Fall Prevention Recommendations Into a Covered Service: Can It Be Done, and Who Should Do It?. Ann Intern Med. ;157:213–214. doi: 10.7326/0003-4819-157-3-201208070-00014

Download citation file:

  • Ris (Zotero)
  • EndNote
  • BibTex
  • Medlars
  • ProCite
  • RefWorks
  • Reference Manager

© 2019

×
Permissions

Published: Ann Intern Med. 2012;157(3):213-214.

DOI: 10.7326/0003-4819-157-3-201208070-00014

10 Citations

See Also

Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement
View MoreView Less

Related Articles

Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement
Annals of Internal Medicine; 157 (3): 197-204
Preventing Falls in Older Adults Who Live in Community Settings: U.S. Preventive Services Task Force Recommendation
Annals of Internal Medicine; 157 (3): I-40
Guideline: USPSTF recommends exercise and multifactorial interventions for fall prevention in older adults
Annals of Internal Medicine; 169 (4): JC14
Review: Postdischarge home interventions can increase or decrease falls in older adults
Annals of Internal Medicine; 169 (2): JC10
View MoreView Less

Journal Club

Guideline: USPSTF recommends exercise and multifactorial interventions for fall prevention in older adults
Annals of Internal Medicine; 169 (4): JC14
Review: Postdischarge home interventions can increase or decrease falls in older adults
Annals of Internal Medicine; 169 (2): JC10
In hospital rehabilitation units, adding individualized fall-prevention education to usual care reduced falls
Annals of Internal Medicine; 163 (4): JC13
Review: Acute geriatric unit care reduces falls, delirium, and functional decline
Annals of Internal Medicine; 158 (12): JC11
View MoreView Less

Related Point of Care

Low Back Pain
Annals of Internal Medicine; 160 (11): ITC6-1
Osteoarthritis
Annals of Internal Medicine; 147 (3): ITC8-1
Peripheral Arterial Disease
Annals of Internal Medicine; 146 (5): ITC3-1
View MoreView Less

Related Topics

Geriatric Medicine
Healthcare Delivery and Policy
Prevention/Screening

Geriatric Medicine, Healthcare Delivery and Policy, Prevention/Screening.

PubMed Articles

Pushing arterial-venous plasma biomarkers to new heights: A model for personalised redox metabolomics?
Redox Biol 2019;
Static monocular visual cues can decrease the vestibular-evoked balance response at low frequencies.
Gait Posture 2019;
View More

Results provided by: PubMed

CME/MOC Activity Requires Users to be Registered and Logged In.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
The Comments Feature Requires Users to be Registered and Logged In.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
link to top

Content

  • Home
  • Latest
  • Issues
  • Channels
  • CME/MOC
  • In the Clinic
  • Journal Club
  • Web Exclusives

Information For

  • Author Info
  • Reviewers
  • Press
  • Readers
  • Institutions / Libraries / Agencies
  • Advertisers

Services

  • Subscribe
  • Renew
  • Alerts
  • Current Issue RSS
  • Latest RSS
  • In the Clinic RSS
  • Reprints & Permissions
  • Contact Us
  • Help
  • About Annals
  • About Mobile
  • Patient Information
  • Teaching Tools
  • Annals in the News
  • Share Your Feedback

Awards and Cover

  • Personae (Cover Photo)
  • Junior Investigator Awards
  • Poetry Prize

Other Resources

  • ACP Online
  • Career Connection
  • ACP Advocate Blog
  • ACP Journal Wise

Follow Annals On

  • Twitter Link
  • Facebook Link
acp link acp
silverchair link silverchair

Copyright © 2019 American College of Physicians. All Rights Reserved.

Print ISSN: 0003-4819 | Online ISSN: 1539-3704

Privacy Policy

|

Conditions of Use

This site uses cookies. By continuing to use our website, you are agreeing to our privacy policy. | Accept
×

You need a subscription to this content to use this feature.

×
PDF Downloads Require Access to the Full Article.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
INSTITUTIONAL SIGN IN
Open Athens|Shibboleth|Log In
Annals of Internal Medicine
PURCHASE OPTIONS
Buy This Article|Subscribe
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
Access to this Free Content Requires Users to be Registered and Logged In. Please Choose One of the Following Options
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×