CDC's research portfolio in older adult fall prevention: a review of progress, 1985-2005, and future research directions

PROBLEM: Falls are a leading cause of mortality and morbidity among adults age 65 and older. Population models predict steep increases in the 65 and older population bands in the next 10-15 years and in turn, public health is bracing for increased fall rates and the strain they place on health care systems and society. To assess progress in fall prevention, the Centers for Disease Control and Prevention conducted a research portfolio review to examine the quality, relevance, outcomes and successes of the CDC fall prevention program and its impact on public health. METHODS: A peer review panel was charged with reviewing 20 years of funded research and conducting a SWOT (strengths, weaknesses, opportunities, and threats) analysis for extramural and intramural research activities. Information was collected from grantees (via a survey instrument), staff were interviewed, and progress reports and products were reviewed and analyzed. RESULTS: CDC has invested over $24,900,000 in fall-related research and programs over 20 years. The portfolio has had positive impacts on research, policies and programs, increasing the public health injury prevention workforce, and delivering effective fall prevention programs. DISCUSSION: Public health agencies, practitioners, and policy makers recognize that while there are some evidence-based older adult fall prevention interventions available, many remain unused or are infeasible to implement. Specific recommendations across the public health model, include: additional research in gathering robust epidemiologic data on trends and patterns of fall-related injuries at all levels; researching risk factors by setting or sub-population; developing and testing innovative interventions; and engaging in translation and dissemination research on best practices to increase uptake and adoption of fall prevention strategies. CDC has responded to a number of suggestions from the portfolio review including: funding translation research of a proven Tai Chi fall intervention; beginning to address gaps in gender, ethnic, and racial differences in falls; and collaborating with partner organizations who share in CDC's mission to improve public health by preventing falls and reducing fall-related injuries. IMPACT ON INDUSTRY: Industry has an opportunity to develop more accessible and usable devices to reduce injury from falls (for example, hip protectors and force reducing flooring). By implementing effective, evidence-based interventions to prevent falls and reduce injuries from falls, significant decreases in health care costs can be expected.     

Advancing injury and violence prevention through data science

Introduction: The volume of new data that is created each year relevant to injury and violence prevention continues to grow. Furthermore, the variety and complexity of the types of useful data has also progressed beyond traditional, structured data. In order to more effectively advance injury research and prevention efforts, the adoption of data science tools, methods, and techniques, such as natural language processing and machine learning, by the field of injury and violence prevention is imperative. Method: The Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control has conducted numerous data science pilot projects and recently developed a Data Science Strategy. This strategy includes goals on expanding the availability of more timely data systems, improving rapid identification of health threats and responses, increasing access to accurate health information and preventing misinformation, improving data linkages, expanding data visualization efforts, and increasing efficiency of analytic and scientific processes for injury and violence, among others. Results: To achieve these goals, CDC is expanding its data science capacity in the areas of internal workforce, partnerships, and information technology infrastructure. Practical Application: These efforts will expand the use of data science approaches to improve how CDC and the field address ongoing injury and violence priorities and challenges.     

Traumatic brain injury-related hospitalizations and deaths among American Indians and Alaska natives — United States, 2008–2014

IntroductionDespite progress, injury remains the leading cause of preventable death for American Indian and Alaska Natives (AI/AN), aged 1 to 44. There are few publications on injuries among the AI/AN population, especially those on traumatic brain injury (TBI). A TBI can cause short- or long-term changes in cognition, communication, and/or emotion. Methods: To describe changes over time in TBI incidence by mechanism of injury, injury intent, and age group among AI/ANs, the CDC analyzed hospitalization and death data from the 2008–2014 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the National Vital Statistics System (NVSS), respectively. Results: From 2008-2014, the incidence of TBI-related hospitalizations increased by 32% (1,477 in 2008 to 1,945 in 2014) and resulted in a 21% increase in age-adjusted rates of people hospitalized with TBI. TBI-related deaths increased in number (569 in 2008 to 644 in 2014) and age-adjusted rate (22.7 in 2008 to 25.4 in 2014) by approximately 13% and 12%, respectively. Motor-vehicle crashes were the leading cause of TBI-related deaths among AI/ANs aged 0–54 years. Practical application: Prevention efforts should focus on increasing motor-vehicle safety and advancing prevention strategies for other leading causes of TBI, including: falls, intentional self-harm, and assaults.     

Preventing alcohol-related traffic injury: a health promotion approach

The conditions that give rise to drinking and driving are complex, with multiple and interrelated causes. Prevention efforts benefit from an approach that relies on the combination of multiple interventions. Health promotion provides a useful framework for conceptualizing and implementing actions to reduce drinking and driving since it involves a combination of educational, behavioral, environmental, and policy approaches. This review draws on data from a range of settings to characterize the effectiveness of various interventions embedded within the health promotion approach. Interventions considered part of the health promotion approach include: (1) economic interventions (2) organizational interventions, (3) policy interventions, and (4) health education interventions, including the use of media, school and community education, and public awareness programs. Effective health promotion strengthens the skills and capabilities of individuals to take action and the capacity of groups or communities to act collectively to exert control over the determinants of alcohol-impaired driving. There is strong evidence for the effectiveness of some components of health promotion, including economic and retailer interventions, alcohol taxation, reducing alcohol availability, legal and legislative strategies, and strategies addressing the servers of alcohol. There is also evidence for the effectiveness of sobriety checkpoints, lower BAC laws, minimum legal drinking age laws, and supportive media promotion programs. Other interventions with moderate evidence of effectiveness include restricting alcohol advertising and promotion, and actions involving counter advertising. Health education interventions alone that have insufficient evidence for effectiveness include passive server training programs, school drug and alcohol education programs, community mobilization efforts, and health warnings. Because each intervention builds on the strengths of every other one, ecological approaches to reducing alcohol-impaired driving using all four components of the health promotion model are likely to be the most effective. Settings such as schools, workplaces, cities, and communities offer practical opportunities to implement alcohol-impaired driving prevention programs within this framework.     

Aging without injury in the United States requires action today

Introduction: In 2017, unintentional injuries were the seventh leading cause of death among older adults (age ≥ 65), resulting in over 55,000 deaths. Falls accounted for more than half of these deaths. Given that older adults are the fastest growing age group in the United States, we can anticipate that injuries will become an even greater health concern in the near future. Methods: Aging without injury is possible. There are evidence-based strategies that can reduce falls. However, older adults may not realize that falls can be prevented or they may be afraid to admit their fear of falling or difficulty with walking as these issues may signal their inability to live independently. Results: In this commentary, we will highlight what the Centers for Disease Control and Prevention is doing to prevent older adult falls. We also highlight the importance of broadening older adults' awareness about falls to successfully empower them to begin contemplating and preparing to adopt fall prevention strategies that can help them age in place. Conclusions: Older adult falls are common and can result in severe injury and death but they can be prevented. Broadening older adults' awareness about falls can empower them to take the actions necessary to reduce their fall risk. Practical applications: Increasing awareness about falls can help older adults, healthcare providers, and local and state health departments take steps to reduce fall risk.     

Announcing the CDC guideline for prescribing opioids for chronic pain

This guideline provides recommendations for primary care providers who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses: (a) when to initiate or continue opioids for chronic pain; (b) opioid selection, dosage, duration, follow-up, and discontinuation; and (c) assessing risk and addressing harms of opioid use. This guideline is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including abuse, dependence, overdose, and death (Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.)     

Self-reported falls and fall-related injuries among persons aged>or=65 years--United States, 2006

PROBLEM: In 2005, 15,802 persons aged>or=65 years died from fall injuries. How many older adults seek outpatient treatment for minor or moderate fall injuries is unknown. METHOD: To estimate the percentage of older adults who fell during the preceding three months, the Centers for Disease Control and Prevention (CDC) analyzed data from two questions about falls included in the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey. RESULTS: Approximately 5.8 million (15.9%) persons aged>or=65 years reported falling at least once during the preceding three months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least one day. DISCUSSION: This report presents the first national estimates of the number and proportion of persons reporting fall-related injuries associated with either doctor visits or restricted activity. SUMMARY: The prevalence of falls reinforces the need for broader use of scientifically proven fall-prevention interventions. IMPACT ON INDUSTRY: Falls and fall-related injuries represent an enormous burden to individuals, society, and to our health care system. Because the U.S. population is aging, this problem will increase unless we take preventive action by broadly implementing evidence-based fall prevention programs. Such programs could appreciably decrease the incidence and health care costs of fall injuries, as well as greatly improve the quality of life for older adults.     

Hip protectors efficacy and barriers to adoption to prevent fall-related injuries in older adults: findings and recommendations from an international workgroup

The Journal of Safety Research has partnered with the Injury Center at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA, to briefly report on some of the latest findings in the research community. This report is the sixth in a series of CDC articles. This conference on Hip Protector Use was held at Boston University in June, 2004 under the sponsorship of the Injury Center. Hip fractures from falls are a major threat to the health and well-being of older adults. One approach to hip fracture prevention is the use of hip protectors (HPs), soft padding or hard shells embedded within specially designed underwear. This conference brought together experts to discuss the efficacy and barriers to using HP. Conclusions from the conference included the need for HP product specifications and standards of safety and efficacy, testing protocols, and efficacy trials. While no single entity was identified to advance these initiatives, this effort should be international and should involve collaboration between researchers, health care providers and policy-makers, and HP manufacturers. Plans are already underway for a second international conference in Europe to follow-up these recommendations and develop strategies for implementation.     

Seeking to improve care for young patients: Development of tools to support the implementation of the CDC Pediatric mTBI Guideline

IntroductionThe Centers for Disease Control and Prevention (CDC) Pediatric Mild Traumatic Brain Injury (mTBI) Guideline was created to help standardize diagnosis, prognosis, and management and treatment of pediatric mTBI. This paper describes the process CDC used to develop educational tools, and a dissemination and implementation strategy, in support of the CDC Pediatric mTBI Guideline.MethodsTwo qualitative data collection projects with healthcare providers who care for pediatric patients were conducted. In-depth interviews were used in both projects. Project One examined healthcare providers' guideline use and dissemination preferences. Project Two assessed perceptions of the CDC Pediatric mTBI Guideline educational tools.ResultsProject One brought to light four key areas related to Guideline usage and dissemination preferences, specifically a need for: (1) partnership with professional medical societies; (2) integration into electronic health records, mobile apps, and websites; (3) development of continuing medical education (CME) opportunities; and (4) dissemination through healthcare system leadership. In Project Two, healthcare providers reported that the CDC Pediatric mTBI Guideline educational tools were well-organized, clear and easy to navigate, and informative. Healthcare providers also requested more information on the Guideline methodology.DiscussionAssessment of pediatric healthcare providers' current use of clinical guidelines and preferences for educational tools yielded important insights that helped inform CDC's dissemination and implementation strategy for the Pediatric mTBI Guideline.Practical applicationsThe findings from these data collection projects can also inform other guideline implementation and dissemination efforts among healthcare providers.     

Special Report from the CDC: Strengthening social connections to prevent suicide and adverse childhood experiences (ACEs): Actions and opportunities during the COVID-19 pandemic

Introduction: During this time ofintensified hardship and disruption due to the SARS-CoV-2 (COVID-19) pandemic, communities, practitioners, and state and local governments have had to rapidly implement and adapt strategies that support mental health and wellbeing during a global pandemic. Prior to the COVID-19 pandemic, suicide was the 10th leading cause of death in the United States, and at least half of the top 10 leading causes of death have been associated with adverse childhood experiences (ACEs). A number of established risk factors for suicide and ACEs may have been exacerbated by the pandemic, including loneliness and lack of connectedness. Method: This article briefly considers the effects of COVID-19 on social connection and outlines the importance of adapting and developing programming and resources that address suicide and ACEs prevention during a time of infrastructure disruption. Practical Applications: The COVID-19 pandemic has affected the ways that many individuals are able to safely interact and socially connect due to public health prevention strategies implemented to slow the spread of COVID-19. Local, city, and state government, community organizations, and public health and medical practitioners should consider the adaptation and development of existing and new programming, resources, and activities that support and strengthen social connection. In addition to implementing programs, policies may help address systemic and structural barriers to social connection, such as access to parks and open space, public transportation, or digital connectivity.     

Effectiveness of the CDC HEADS UP online training on healthcare providers’ mTBI knowledge and self-efficacy

Background: Many healthcare providers do not consistently implement recommendations contained in clinical guidelines on mild traumatic brain injury (mTBI). As such, the Centers for Disease Control and Prevention (CDC) created the HEADS UP to Healthcare Providers online training to promote uptake of five key recommendations in the CDC Pediatric mTBI Guideline. Methods: Using data from modules in the CDC HEADS UP to Healthcare Providers online training, healthcare providers’ self-reported knowledge and self-efficacy prior to and immediately following completion of the training was analyzed. Results: Improvements for 8 out of the 10 knowledge questions had a high level of practical significance. The knowledge question with the highest level of practical significance pre- to post-test improvement was for the key guideline recommendation on neuroimaging (pre-test correct: 70.2%; post-test correct: 87.8%; (p < 0.0001, Cohen’s g = 0.39). Four out of the six questions had a self-efficacy level increase of a high level of practical significance (r > 0.50) between the pre- and post-tests. The self-efficacy question with pre- to post-test improvement with the highest level of practical significance was “I am confident in my ability to manage the return to sports progression for my patients” (p < 0.001; r = 0.54). Conclusions: The HEADS UP to Healthcare Providers online training led to significant improvements in knowledge and self-efficacy related to mTBI diagnosis and management. Expanded use of this training among healthcare providers who commonly provide care for pediatric patients with mTBI may be beneficial. Practical Applications: This study highlights several factors guideline developers may take into consideration when creating an implementation tool, such as using health behavior theories, working with partners and key stakeholders, and focusing on digital-based tools.     

Action-Oriented Support for Occupational Safety and Health Programs in Some Developing Countries in Asia

Action-oriented support programs have been increasingly playing vital roles in promoting safety and health in developing countries in Asia. This paper studied achievements of 3 action-oriented support programs: the WISE program for small enterprises, the WIND program for farmers, and the POSITIVE program for workers and trade unions. Special attention was paid to how the programs have strengthened local efforts for sustainable actions in safety and health improvements. The results showed that there were significant achievements in action-oriented support programs in the region, including a large number of improvement examples, integration into government policies, and network support through employers’ and workers’ organizations. Participatory, action-oriented training tools such as action-checklists, local good example photos, and group work methods played key roles in the effective implementation of the programs. It was of note that there were a number of local efforts to extend the coverage of action-oriented support even to hard-to-reach workers such as home-based workers, rural workers, and ethnic minorities. The efforts included the equal participation in the training by female and male farmers, shortened and weekend training programs, photo sheets showing local good examples, and reasonable fee collection for better sustainability. In conclusion, action-oriented support programs provided local people with concrete means to promote safety and health improvements. The successful programs commonly focused on local initiatives and were built on local wisdom and resources.     

Unintentional injury deaths in children and youth, 2010–2019

Background: Unintentional injuries are the leading cause of death for children and youth aged 1–19 in the United States. The purpose of this report is to describe how unintentional injury death rates among children and youth aged 0–19 years have changed during 2010–2019. Method: CDC analyzed 2010–2019 data from the National Vital Statistics System (NVSS) to determine two-year average annual number and rate of unintentional injury deaths for children and youth aged 0–19 years by sex, age group, race/ethnicity, mechanism, county urbanization level, and state. Results: From 2010–2011 to 2018–2019, unintentional injury death rates decreased 11% overall—representing over 1,100 fewer annual deaths. However, rates increased among some groups—including an increase in deaths due to suffocation among infants (20%) and increases in motor-vehicle traffic deaths among Black children (9%) and poisoning deaths among Black (37%) and Hispanic (50%) children. In 2018–2019, rates were higher for males than females (11.3 vs. 6.6 per 100,000 population), children aged < 1 and 15–19 years (31.9 and 16.8 per 100,000) than other age groups, among American Indian or Alaska Native (AIAN) and Blacks than Whites (19.4 and 12.4 vs. 9.0 per 100,000), motor-vehicle traffic (MVT) than other causes of injury (4.0 per 100,000), and rates increased as rurality increased (6.8 most urban [large central metro] vs. 17.8 most rural [non-core/non-metro] per 100,000). From 2010–2011 to 2018–2019, 49 states plus DC had stable or decreasing unintentional injury death rates; death rates increased only in California (8%)—driven by poisoning deaths. Conclusion and Practical Application: While the overall injury death rates improved, certain subgroups and their caregivers can benefit from focused prevention strategies, including infants and Black, Hispanic, and AIAN children. Focusing effective strategies to reduce suffocation, MVT, and poisoning deaths among those at disproportionate risk could further reduce unintentional injury deaths among children and youth in the next decade.     

Nonfatal injuries following Hurricane Katrina--New Orleans, Louisiana, 2005

The Journal of Safety Research has partnered with the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA, to briefly report on some of the latest findings in the research community. This report is the fourth edition in a series of CDC articles. BACKGROUND: An active injury and illness surveillance system was established by the Centers for Disease Control and Prevention (CDC) along with the Louisiana Department of Health and Hospitals (LDHH) in the aftermath of Hurricane Katrina in functioning hospitals and medical clinics. RESULTS: The surveillance system recorded 7,543 nonfatal injuries among residents and relief workers between September 8-October 14, 2005. The leading mechanisms of injury identified in both groups were fall and cut/stab/pierce, with a greater proportion of residents compared to relief workers injured during the repopulation period. Clean-up was the most common activity at the time of injury for both groups. CONCLUSION: Injuries documented through this system underscore the need for surveillance of exposed populations to determine the injury burden and initiate injury prevention activities and health communication campaigns.     

Fall-related traumatic brain injury deaths and hospitalizations among older adults--United States, 2005

PROBLEM: Among older adults, both unintentional falls and traumatic brain injuries (TBI) result in significant morbidity and mortality; however, only limited national data on fall-related TBI are available. METHOD: To examine the relationship between older adult falls and TBI deaths and hospitalizations, CDC analyzed 2005 data from the National Center for Health Statistics' National Vital Statistics System and the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample. RESULTS: In 2005, among adults>or=65 years, there were 7946 fall-related TBI deaths and an estimated 56,423 hospitalizations for nonfatal fall-related TBI in the United States. Fall-related TBI accounted for 50.3% of unintentional fall deaths and 8.0% of nonfatal fall-related hospitalizations. SUMMARY: These findings underscore the need for greater dissemination and implementation of evidence-based fall prevention interventions.     

Implementation of participatory organizational change in long term care to improve safety

Introduction: Long Term Care (LTC) facilities are fast-paced, demanding environments placing workers at significant risk for injuries. Health and safety interventions to address hazards in LTC are challenging to implement. The study assessed a participatory organizational change intervention implementation and impacts. Methods: This was a mixed methods implementation study with a concurrent control, conducted from 2017 to 2019 in four non-profit LTC facilities in Ontario, Canada. Study participants were managers and frontline staff. Intervention sites implemented a participatory organizational change program, control sites distributed one-page health and safety pamphlets. Program impact data were collected via Survey (self-efficacy, control over work, pain and general health) and observation (Quick Exposure Checklist). Interviews/focus groups were used to collect program implementation data. Results: Participants described program impacts (hazard controls through equipment purchase/modification, practice changes, and education/training) and positive changes in culture, communication and collaboration. There was a statistically significant difference in manager self-efficacy for musculoskeletal disorder (MSD) hazards between the control and intervention sites over time but no other statistical differences were found. Key program implementation challenges included LTC hazards, staff shortage/turnover, safety culture, staff time to participate, and communication. Facilitators included frontline staff involvement during implementation, management support, focusing on a single unit, training, and involving an external program facilitator. Conclusion: A participatory program can have positive impacts on identifying and reducing MSD hazards. Key to success is involving frontline staff in identifying hazards and creating solutions and management encouragement on a unit working together. High turnover rates, staffing shortages, and time constraints were barriers as they are for all organizational change efforts in LTC. The implementation findings are likely applicable in any jurisdiction. Practical Application: Implementing a participatory organizational change program to reduce MSD hazards is feasible in LTC and can improve communication and aid in identification and control of hazards.     

A review of CDC's Web-based Injury Statistics Query and Reporting System (WISQARS™): Planning for the future of injury surveillance

IntroductionThe Centers for Disease Control and Prevention (CDC) developed the Web-based Injury Statistics Query and Reporting System (WISQARS^TM) to meet the data needs of injury practitioners. In 2015, CDC completed a Portfolio Review of this system to inform its future development.MethodsEvaluation questions addressed utilization, technology and innovation, data sources, and tools and training. Data were collected through environmental scans, a review of peer-reviewed and grey literature, a web search, and stakeholder interviews.ResultsReview findings led to specific recommendations for each evaluation question.ResponseCDC reviewed each recommendation and initiated several enhancements that will improve the ability of injury prevention practitioners to leverage these data, better make sense of query results, and incorporate findings and key messages into prevention practices.