Measuring healthcare quality in case studies of fall prevention programs

Falls

The authors attempted to find a new way of measuring falls -- they were dissatisfied with the previous measure used -- and they argued that all aspects can be measured by the number of events divided by the number of opportunities for that event to occur.

In regards to falls, they argued that if you wanted to know how many falls resulted in fractures you would use the numerator as the number of patient falls that resulted in fractures and the denominator would be the totality of falls. So for instance if there were 20 falls that resulted in fractures and 100 falls altogether it would be 20/100 otherwise read as 20%. The numerator tells you what you want to study / question or investigates, and this -- the authors say -- can be as general or as specific as possible.

The problem is how you define falls. The authors in questions, for instance, say that it took them 8 months to arrive at a mutually agreed definition:

What might seem to a layperson a straightforward concept can be quite complicated.

For example, does a "fall" have to result in the patient being on the floor? Can a patient "fall" if that patient is being assisted onto a chair by a caregiver? Does a "fall" have to be observed by another to distinguish it from a collapse or a faint? (p.30)

Their definition was arrived at only because all agreed.

The measures mentioned in this case study can be used in a great deal of instances, but mainly, it seems to me, when these instances are more specific and deal with less abstract or unclear situations. The example that the authors give f falls resulting in fractures is an excellent instance of where it can be used since fractures are clear (we all agree on that) and the term 'falls' has been cohesively defined.

On the other hand, there may be some instances where the measure may result in uncertainty such as when attempting to measure falls that result in decreased quality of life for victim or that result in internal harm. These are definitions that are more abstract, therefore, more difficult to define and more difficult to pin down in a quantitative manner as the author attempt to do in this case.

Even when defining more concrete possibilities, we can sometimes run into difficulties. For instance, if we want to measure the amount of time that patients' falls resulted in death, this may be a difficult measure to use for the following reasons:

1. Death may not follow right away. How long does it take until we use their measure to definitively conclude that death resulted from falls x percent of time/

2. How do we know that death was the result of the fall and not any other additional or alternative cause?

Let's look at some of the most common factors of falls that are studied in regards to the elderly:

The risk of falling increases with age and is greater for women than for men.

Two-thirds of those who experience a fall will fall again within six months.

A decrease in bone density contributes to falls and resultant injuries.

Failure to exercise regularly results in poor muscle tone, decreased strength, and loss of bone mass and flexibility.

At least one-third of all falls in the elderly involve environmental hazards in the home.

(K.R. Tremblay Jr., and C.E. Barber (12/05)

Some of these instances can be measured using the suggested measurements, but not all of them can.

The risk of falling increases with age and is greater for women than for men.

Given agreed upon definition for 'fall, this statement can be adequately studied with the suggested measurement since both age and gender are undeniably and irrefutably clear.

Two-thirds of those who experience a fall will fall again within six months.

This statement is less amenable to measurement since we do not always know when falls will occur nor will the fall be totally to the ground or a fall against something else. More so, falls can be caused by both intentional and unintentional stimuli and they can be caused in various ways. Sometimes, they are less easy, if often impossible to avoid. Conditions being unequal here, it is more difficult to use the measure conclusively in this instance.

A decrease in bone density contributes to falls and resultant injuries.

This may be investigated with the suggested measure since bone density can be quantified. 'Resultant injury' needs to be explicitly defined.