gms | German Medical Science

Falls are common in the elderly, causing fractures - in particular femoral fractures - associated with economic costs of more than 1 billion EUR (around USD 1.06 billion) per year in Germany. Studies found that multifactorial prevention programs can reduce falls and femoral fractures in nursing homes. However, usually short time periods have been investigated and evidence for long-term effectiveness is missing. Therefore, we followed-up a multifactorial fall and fracture prevention program (BF2P2) in Bavarian nursing homes. In 2007, BF2P2 was firstly implemented in 256 pioneering Bavarian nursing homes, and has been shown to reduce femoral fractures in the first year. After 2007, remaining Bavarian nursing homes implemented BF2P2 in three further time-lagged waves. The aim of this study was to examine long-term effectiveness of BF2P2 in all nursing homes in terms of reducing femoral fractures, and to investigate differences in the effectiveness between implementation waves, in particular, between pioneering nursing homes of the first wave and nursing homes of later waves.

Our longitudinal study was based on claims data from 2004 through 2013 provided by a statutory health insurance company. The unbalanced panel contained information on 802 nursing homes participating in BF2P2 with 10 quarterly periods before and 15 after implementation as well as their residents aged 65 years or older (N=85,148). To model femoral fractures per resident and quarterly period, a generalized linear model for correlated data (Generalized Estimating Equations) was applied. Independent variables were time, the binary variable implementation of BF2P2 as indicator for the effectiveness of a participation and the interaction term implementation*time in order to quantify changes in the long-term effectiveness over time. We both adjusted for and stratified per implementation wave, respectively. The regression models were adjusted for sex, age, care level and prior fracture of residents, as well as for size and ownership of nursing homes.

The descriptive analysis did not show any clear trend of fracture rates over time, which could be related to BF2P2. Furthermore, fracture rates increased per wave, and were higher for women, high age, residents with care level 1 and a prior fracture, compared to their counterparts, respectively. The multivariate analysis revealed that none of the intervention variables were significant. Solely a reduction of the likelihood of femoral fractures in the first implementation wave in a shortened time period was observed. Furthermore, resident characteristics showed significant estimates (p<0.001). Women compared to men, rising age, decreasing care level and a prior fracture were positively associated with the likelihood of a femoral fracture.

The regression results cannot confirm the hypothesis that BF2P2 reduces the number of femoral fractures in the long run. However, there were differences in the effectiveness between implementation waves. The restriction of the transient reduction of femoral fractures to the first wave may be explainable by a higher motivation of nursing homes starting first with BF2P2. Furthermore, high risk groups for femoral fractures by sex, age, care level and prior fracture could be identified.

Although we could not observe a long-term effectiveness of BF2P2 among all Bavarian nursing homes, the results suggest that BF2P2 is in principle able to modestly reduce femoral fractures. However, it seems difficult to maintain a better standard in fall and fracture prevention over a period of several years. Efforts should be directed to further identify factors which determine the long-term effectiveness. Possible aspects may be motivation as well as education and adherence of the nursing home staff, which may be subject to frequent fluctuation over time.