FALLS IN THE ELDERLY

The Centers for Medicare and Medicaid Services (CMS) worked collaboratively with the Centers for Disease Control and Prevention (CDC) and on October 1, 2008, enacted new payment provisions: Medicare will no longer reimburse hospitals for a higher-paying DRG when one of eight selected hospital-acquired conditions develops during the hospital stay. The CMS heralded this move as an effort to align financial incentives with the quality of care, thereby promoting both quality and efficiency.

Hospital falls and trauma were included as one of the eight conditions that, the CMS argues, "should not occur after admission to the hospital." But, writing in the New England Journal of Medicine, Dr. Sharon K. Inouye of Harvard Medical School, and colleagues, "argue that because falls have proved to be such an intractable problem despite broad efforts to reduce them, they should not be included on a list of avoidable medical errors that result in hospitals not being paid." Each year, they point out about one third of persons who are 65 years of age or older living in community settings fall at least once. The percentage is 50% among those 80 years of age or older

There is little argument that hospital falls fulfill the first two criteria outlined by Congress — they are high-cost and high-volume, and they result in the assignment of a case to a higher-paying DRG. Some 3 to 20% of inpatients fall at least once during their hospital stay; these falls result in injuries, increased lengths of stay, malpractice lawsuits, and more than $4,000 in excess charges per hospitalization. Thus, hospital falls represent a major patient-safety problem and may complicate a patient's care and treatment. Yet we believe that the inclusion of falls and trauma in this initiative is misguided: it implies both that hospital falls occur as the result of lapses in the health care system and that they can reasonably be prevented through the application of evidence-based guidelines. Most important, their inclusion may have unintended consequences that may cause greater harm than the falls that the initiative is meant to prevent.

But, says the New England Journal of Medicine (NEJM), falls and injuries can occur even when hospitals provide the best possible care and unlike other hospital-acquired conditions that were selected by the CMS, falls are often the result not of medical errors but of diseases, impairments, and appropriate uses of medications and other treatments.

The CMS's statement that the selected conditions should not occur after admission to the hospital presumes that the conditions were not present before hospitalization — which is not true in the case of falls.

Of greatest concern the NEJM points out, is that the heightened focus on fall prevention will probably have unintended consequences. If hospitals are scrutinized for the occurrence of falls, the natural tendency will be to focus on such events even at the expense of competing (and perhaps more important) outcomes. Unintended consequences are likely to include a decrease in mobility and a resurgence in the use of physical restraints in a misguided effort to prevent fall-related injuries. Physical restraints have long been used because they are believed to prevent falls. Studies have shown, however, that not only do they not reduce the risk of falls or related injuries, but they are associated with increased rates of complications, including immobility, functional loss, delirium, agitation, pressure sores, asphyxiation, and death. Moreover, accumulating evidence suggests that restraints may actually increase the risk of falling or sustaining an injury from a fall.

The inclusion of hospital falls in the new Medicare initiative appears to be premature at best; at worst, it may be harmful to the very patients it is intended to protect and may ultimately increase the costs of Medicare because of its unintended consequences, concludes the NEJM.


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