Blame the champagne! At the 2012 Cochrane Colloquium’s welcome reception in Auckland, New Zealand, David Tovey (Editor in Chief of The Cochrane Library) suggested I write an editorial about why I did the Cochrane Review on the prevention of falls, its impact on my life, and its impact on practice and policy. So this editorial is about a personal journey lasting 18 years.
The original Cochrane Review on preventing falls in older people resulted from a chance encounter with Iain Chalmers, then Director of the UK Cochrane Centre, in Edinburgh in 1994. Iain's enthusiasm was infectious: with just a brief conversation he could inspire people to become involved by undertaking Cochrane Reviews. He also fostered networking by putting people in touch with potential co-authors.
My background is in nursing and I was completing a Masters degree when I met Iain. He asked about my thesis, which was a systematic review of risk factors for falling in older people: had I identified any randomised controlled trials? "Well yes, about six." "Then you should register to do a Cochrane Review." And so a title was registered.
Why is falling in older people an issue? Every year, about 30% of people over 65 living in the community have a fall, and the incidence increases with age.[1-3] Although less than 10% of falls result in a fracture, some of these, hip fractures for example, result in significant mortality.
In 1960 the literature on falling in older people was described as "very meagre", but by the 1990s there were many epidemiological studies quantifying the incidence of falls and fall-related injuries, and identifying possible risk factors for falling. So the stage was set for trials testing interventions to prevent falls by targeting these risk factors.
The protocol for the original review 'Interventions to reduce the incidence of falling in the elderly' was published in 1995 and the first version of the review, published in 1997, contained 18 trials. Most of the interventions tested fell into two broad categories: those evaluating some form of exercise; and those with multiple interventions targeting specific risk factors identified in individuals by screening. We concluded that "In view of the relatively small protective effects which may be present, and the limited nature of the evidence, new intervention programmes should receive methodologically robust evaluation."
I could never have envisaged that by 2012 there would be 219 randomised controlled trials (see Figure 1) with 139,538 participants (see Figure 2), or that the review would be used to inform the UK's National Institute for Clinical Excellence (NICE) guideline on the prevention of falls in older people, or be used around the world to inform policy and practice.
Figure 1: Cochrane Reviews of interventions for preventing falls in older people:
number of included studies, 1997 to 2012.
Figure 2: Cochrane Reviews of interventions for preventing falls in older people:
number of participants in included studies, 1997 to 2012.
I was fortunate to have a team of co-authors with a wide range of expertise. My first co-author was my husband, Bill Gillespie, a professor of orthopaedic surgery already involved in the Collaboration. Iain Chalmers suggested I contact Sallie Lamb, a physiotherapist then completing a PhD in Oxford, and now a professor there. Other co-authors on the original review were Bob Cumming (an Australian epidemiologist) and Brian Rowe (a Canadian emergency medicine specialist).
We were living in New Zealand in 2001 when we embarked on the first update. The prospect of adding 22 new trials seemed daunting, and there was now a requirement to identify and describe on-going trials as well. There were 20 of those. After completing the data extraction and quality assessment Bill and I rented a motel on the shores of Lake Tekapo for a weekend. We worked for a few hours and then went for a walk, then came back and worked some more. By the end of the weekend we had completed the first draft of the text. Clare Robertson, a falls researcher from the University of Otago, became a co-author at this time, and the title was changed to 'Interventions for preventing falls in elderly people'. In 2003, back in the UK, we added a further 22 trials for the second update.
When it became apparent that the next update was going to include over 100 trials we decided to split the review by target population. From the start we had reported community-based interventions separately from those in institutions because the participant characteristics and the environment may warrant different types of interventions. I remained the contact author for 'Interventions for preventing falls in older people living in the community' (the community review), which contained 111 trials when it was published in 2009. (By now we were back in New Zealand.) 'Interventions for preventing falls in older people in nursing care facilities and hospitals' (the institutional review) was published in 2010 and contained 41 trials. Ian Cameron and Geoff Murray were the lead authors for that review.
In October 2011 we were offered a Cochrane Incentive Award from the UK's National Institute of Health Research to complete an update of the community review. We had six months to add evidence from 54 new trials, and the review, containing 159 trials, was published in September 2012. The Cochrane Bone, Joint and Muscle Trauma Group were keen to have both the reviews updated in 2012 and offered to pay Clare Robertson and me to lead an update of the institutional review. Along with our team of co-authors led by Ian Cameron we included 22 additional trials and the update was published in December 2012.
For some updates incorporating new methodology has been more of a challenge than incorporating the additional trials. This was especially true for the introduction of risk-of-bias tables in 2008, when all 111 trials in the community review had to be assessed on five risk-of-bias items. However, changes in methodology have greatly improved the quality of reviews.
Reviews have also improved immensely in appearance over the years, largely through impressive enhancements to Review Manager, the software used to prepare Cochrane Reviews, and the online publishing. The Cochrane Style Guide, has also improved consistency, and I greatly enjoyed being part of the working group that developed the first edition under the leadership of Harriet MacLehose. Other new initiatives have raised unexpected challenges such as recording podcasts or conducting interviews with journalists as a result of of the publisher's press releases. One journalist even published how I managed to fall into a creek wearing my bifocals!
Has the effort been worth it? It is difficult to assess the review's impact on policy and practice, but it has been one of the most frequently accessed reviews in the Cochrane Database of Systematic Reviews in recent years and was the most cited review in 2011. Obviously these are just surrogate measures, but hopefully this indicates that the review is being used for teaching and in clinical practice. The reviews have contributed to numerous fall-prevention guidelines in addition to the 2004 NICE guideline, for example the Australian Commission on Safety and Quality in Health Care's 2009 guidelines for the community, hospitals, and residential aged care facilities, and the American Geriatrics Society/British Geriatrics Society 2010 guideline. More recently the US Centers for Disease Control and Prevention (CDC) have produced a fall-prevention package (STEADI), which has drawn on the Cochrane Reviews, as well as the CDC's own searches. In addition, the New South Wales Department of Health in Australia has produced a policy directive on the prevention of falls and harm from falls among older people.
What motivated me to keep updating the review, especially when I didn't hold an academic or a clinical post? Obviously I felt responsible for it, although taking on a Cochrane Review is a bit like having a baby: you have no idea what the long-term involvement is going to be when you embark on it! There have certainly been rewards on a personal level. There is an immense feeling of satisfaction on the completion of a review, knowing that we've made a complex review as concise and readable as we possibly can, and that it will be used around the world.
There have been professional rewards as well. For my co-authors who are university employees the review publications have been valued research outputs. Being up-to-date with the literature has helped when formulating new research projects, we've spoken at conferences, authored invited journal articles and editorials, and we've written reports for national organisations. We've also participated in international networks such as the Prevention of Falls Network Europe (ProFaNE). Sallie Lamb was co-leader of ProFaNE's Workpackage 1, which developed a consensus definition of a fall and other core outcomes for use in trials, and the ProFaNE taxonomy for classifying fall prevention interventions. My in-depth knowledge of review methodology has resulted in my current involvement with a group developing an Australian/New Zealand hip fracture management guideline.
I couldn't have maintained this review without a great team of co-authors. Apart from Bill and Clare who are here in Dunedin with me, we are a group of 'virtual' colleagues, linked to the review electronically and to each other by email. Despite never having met as a group we have developed strong friendships by working together over a long period of time. The support of Helen Handoll and Lindsey Elstub at the Cochrane Bone, Joint and Muscle Trauma Group's editorial base has also been invaluable.
The community review now contains 159 trials and would benefit from being split into separate reviews for each intervention. This will enable more in-depth exploration of components, such as the duration and intensity of the interventions, and characteristics of the healthcare personnel and participants involved. After 18 years of feeling responsible, I now feel ready to let go and will not be completing any more updates. Bill and I have greatly enjoyed being part of the Collaboration but we decided we would retire after the 2012 Colloquium in Auckland. However, Clare and I were subsequently invited to write a clinical evidence summary for a high-profile journal. How could we refuse? And we've been responding to feedback on one of the reviews, and here I am writing an editorial for The Cochrane Library. It's not so easy to retire from the Collaboration.
Lesley D Gillespie
Honorary Senior Research Fellow, Department of Medicine, Dunedin School of Medicine, University of Otago, New Zealand. email@example.com
How to cite: Gillespie LD. Preventing falls in older people: the story of a Cochrane Review [editorial]. Cochrane Database of Systematic Reviews 2013 28 Feb;2:ED000053. DOI:10.1002/14651858.ED000053.
1. Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age and Ageing 1990;19:136-41. DOI:10.1093/ageing/19.2.136.
6. Gillespie LD, Gillespie WJ, Cumming R, Lamb S, Rowe BH. Interventions for preventing falls in the elderly (Cochrane Review). The Cochrane Library 1997, Issue 4. Oxford: Updated Software.
8. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012 Sep 12;9:CD007146. DOI:10.1002/14651858.CD007146.pub3.
9. Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012 Dec 12;12:CD005465. DOI:10.1002/14651858.CD005465.pub3.
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15. NSW Department of Health. Prevention of falls and harm from falls among older people: 2011-2015. www.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_029.pdf (accessed 7 January 2013).
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17. Lamb SE, Becker C, Gillespie LD, Smith JL, Finnegan S, Potter R, et al. Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions. Trials 2011;12:125. DOI:10.1186/1745-6215-12-125.
Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available upon request) and declares (1) no receipt of payment or support in kind for any aspect of the article; (2) no financial relationships with any entities that have an interest related to the submitted work; (3) that there are no other relationships or activities that could be perceived as having influenced, or giving the appearance of potentially influencing, what was written in the submitted work.
Image credit: Lesley Gillespie
Contact the Editor in Chief, Dr David Tovey (firstname.lastname@example.org): Feedback on this editorial and proposals for future editorials are welcome.