Translating Eye & Vision Health in Falls Prevention and Primary Health Care Recommendations

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Older person falls are costly.  Estimating monetary impacts relative to falls has been challenging.  A new analysis investigating expenditures for falls in older adults in the U.S. reveals that in 2015, estimated medical costs related to fatal and nonfatal falls in older Americans approximated $50 billion.  Medicare paid almost $29 billion, Medicaid almost $9 billion, and private/other payers $12 billion, with overall medical spending for fatal falls estimated at $754 million.  Accurate measurement and costing approaches will provide needed information on how this public health issue progresses, if interventions impact prevention, and what should be targeted in future quality measures.

There is a wealth of evidence connecting the importance of vision in prevention and primary care strategies for an array of health-related conditions and diseases, and fall risk is no exception.  The National Institute of Aging and the Centers for Disease Control and Prevention have recognized eye health and visual status play a central role in older adult falls.  Yet, last fall the USPSTF neglected to recognize the national public health importance of comprehensive eye and vision care for older adults and vision’s impacts as a determinant of fall risk by failing to recommend the comprehensive assessment of older adult vision by an eye care professional as a key factor.  The USPSTF also failed to differentiate high-value comprehensive eye care from ill-defined “vision screening” not supported by current evidence, further conflating proper eye care with fragmented low-value approaches.  This is another recent example of a missed national opportunity to improve older adult health as called out by the 2016 National Academies of Sciences, Engineering, and Medicine (NASEM) report Making Eye Health A Population Health Imperative.

The American Optometric Association has maintained a steady focus since 2016 on moving forward the multiple recommendations of the NASEM report.  Attaining desired U.S. health outcomes will require further advocacy for integrating doctors of optometry and the preventive and primary eye & vision care they provide into population health considerations throughout all of health care.   A key strategy involves the inclusion of eye and vision health and evidence within other professional clinical guidelines within the house of medicine.  Unlike the American Optometric Association’s evidence-based clinical practice guidelines which involve comprehensive health content and address a multi-disciplinary audience,  many medical specialty guidelines still make no mention of eye and vision involvement and/or risk factors related to the specific health conditions and diseases on which they focus their recommendations.  As one example, research over time has connected glaucoma and other eye-related issues to obstructive sleep apnea (OSA), yet there is nothing stated regarding questioning the patient on eye and vision history nor mention of these health issues in the American Academy of Sleep Medicine’s guidelines for OSA.

It’s important to also shine a spotlight on those making strides to embrace knowledge and on colleagues making progress.  A recent Health Affairs blog states “…a number of interventions can be used to identify older persons at risk of falls, assess individual risk factors, and intervene to reduce risk.”  The authors highlight CDC’s STEADI (Stop Early Accidents, Deaths, and Injuries) initiative and recommended algorithm for care providers to facilitate evidence-based interventions.  Primary care colleagues in family medicine have recommended a modified version of this algorithm, recognizing vision as a clinical factor in falls prevention in older adults.  An article in the AAFP journal American Family Physician provides a comprehensive review of older adult fall prevention from the primary care perspective, summarized by the authors to include the following (and as an important side note, the AAFP employs SORT taxonomy to grade the strength of recommendations for its readers in AFP publications –  an approach to translating evidence for which I’ve advocated adoption since 2008):

The algorithm suggests assessment and multifactorial intervention for those who have had two or more falls or one fall-related injury. Multifactorial interventions should include exercise, particularly balance, strength, and gait training; vitamin D supplementation with or without calcium; management of medications, especially psychoactive medications; home environment modification; and management of postural hypotension, vision problems, foot problems, and footwear. These interventions effectively decrease falls in the community, hospital, and nursing home settings. Fall prevention is reimbursed as part of the Medicare Annual Wellness Visit.”

The adapted algorithm is as follows:

falls alg

While this recommended primary care process compactly references ‘optimizing vision’ (albeit far from including detailed comprehensive eye examination language to reinforce appropriate family physician action in addressing ‘vision problems’ and doesn’t explicitly call for assessment by an eye doctor), it remains the duty of doctors of optometry and eye health advocates to make this metric explicitly clear.  It requires us to assist with efforts by the AOA and others in continuing to call out and clarify what language, interpretations, and the evidence implies for all stakeholders – including our family medicine and other physician colleagues, the public, and decision makers like USPSTF.   To improve population health, eye and vision health advocates will need to persist in acting as stated in one of my favorite advocacy mantras: “Failure to confront is permission to continue.”

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