Journal of Geriatric Physical Therapy:
Development and Validation of a Falls-Grading Scale
Davalos-Bichara, Marcela MD1,8; Lin, Frank R. MD, PhD1; Carey, John P. MD1; Walston, Jeremy D. MD2; Fairman, Jennifer E. CMI, FAMI3; Schubert, Michael C. PT, PhD1; Barron, Jeremy S. MD2; Hughes, Jennifer PhD2; Millar, Jennifer L. PT4; Spar, Anne PT4; Weber, Kristy L. MD5; Ying, Howard S. MD6; Zackowski, Kathleen M. PhD, OT4,9; Zee, David S. MD7; Agrawal, Yuri MD1
1Department of Otolaryngology-Head and Neck Surgery
2Division of Geriatrics and Gerontology
3Department of Arts as Applied to Medicine
4Department of Physical Medicine and Rehabilitation
5Department of Orthopaedic Surgery
6Department of Ophthalmology
7Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, USA.
8Escuela de Medicina Ignacio A. Santos del Tecnológico de Monterrey, Monterrey, México.
9Kennedy Krieger Institute, The Johns Hopkins Medical Institutions, Baltimore, USA.
Address correspondence to: Yuri Agrawal, MD, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21205 (firstname.lastname@example.org).
Scientific meeting presentations: 4th Pan-American Congress, International Association of Gerontology and Geriatrics, Falls Session, October 22, 2011, Ottawa, Ontario, Canada.
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Background and Purpose: The recording of fall events is usually subjective and imprecise, which limits clinical practice and falls-related research. We sought to develop and validate a scale to grade near-fall and fall events on the basis of their severity represented by the use of health care resources, with the goal of standardizing fall reporting in the clinical and research settings.
Methods: Qualitative instrument development was based on a literature review and semistructured interviews to assess face and content validity. We queried older individuals and health care professionals with expertise in the care of patients at risk of falling about clinically important differences to detect and how to optimize the scale's ease of use. To assess the scale's interrater reliability, we created 30 video-vignettes of falls and compared how health care professionals and volunteers rated each of the falls according to our grading scale.
Results: We developed the illustrated 4-point Hopkins Falls Grading Scale (HFGS). The grades distinguish a near-fall (grade 1) from a fall for which an individual did not receive medical attention (grade 2), a fall associated with medical attention but not hospital admission (grade 3), and a fall associated with hospital admission (grade 4). Overall, the HFGS exhibited good face and content validity and had an intraclass correlation coefficient of 0.998.
Conclusion: The 4-point HFGS demonstrates good face and content validity and high interrater reliability. We predict that this tool will facilitate the standardization of falls reporting in both the clinical and research settings.
Falls are a common and dangerous event among older individuals.1–4 One of the strongest established risk factors for a fall is a history of a prior fall.5,6 As such, accurate identification of a fall event is critical to the risk stratification of patients in the clinical setting.7,8 Moreover, the rigorous reporting of fall events is central to the development and assessment of strategies to reduce the risk of falls in the research setting.9,10
The reporting of fall events has numerous shortcomings. First, definitions of a fall used in both the clinical and research settings are ambiguous.9–13 Efforts have been made to consolidate the disparate definitions,14,15 for example, the Prevention of Falls Network Europe has promulgated the definition of a fall as “an unexpected event in which the participants come to rest on the ground, floor, or lower level.”16(p1619) However, not all research trials have adopted this definition.11 Furthermore, specific definitions of a fall are typically not offered in the screening and reporting tools used in the clinical inpatient and outpatient settings.5,10,12 An additional limitation in the current reporting of falls is that a near-fall, which may be important in presaging a future fall, is not uniformly contained in existing fall definitions.17–20 Finally, the clinical and functional significance of each fall event is not captured by most current definitions.9,13,21,22 These limitations in the reporting of a fall event make the ascertainment and reduction of fall risk difficult in the clinical and research settings.
In this report, we develop and validate a falls-grading scale supported by illustrations intended to standardize the reporting of near-fall and fall events based on their impact to the patient. We performed initial validation studies in a group of older individuals and health care professionals and assessed the reliability of the scale in the same health care professionals and volunteers throughout the age range. The use of a validated falls scale may help standardize the reporting of falls, with potential benefits for clinical decision-making and for research.
Development of the Hopkins Falls Grading Scale
The Hopkins Falls Grading Scale (HFGS) was developed to enhance the accuracy of falls reporting in the clinical and research settings. The initial development of a qualitative instrument was based on a literature review, using the keywords “falls grading scale,” “fall definition,” “falling definition,” “falls recording,” “history of falls,” “falls severity,” and “falls self-report” in PubMed. Twenty-nine manuscripts were reviewed, although none described an instrument for standardized falls reporting. Various definitions of near-falls and falls were considered, and measures of fall severity were reviewed, including distinctions based on the extent of injury or on the use of health care resources. We developed a candidate-grading scale as well as several variations whereby we altered the number of grades (4 vs 5 grades) and the basis for distinguishing among grades (based on minor vs major injury or health care resource utilization). The accompanying illustrations were created by a member of the Arts as Applied to Medicine Department at the Johns Hopkins University.
Face and Content Validity
The HFGS was assessed for its face and content validity. Face validity evaluates to what extent a scale makes intrinsic sense to potential users of the scale. Content validity assesses the value of the scale on the basis of a priori theoretical and empirical considerations.23 We measured face and content validity by conducting semistructured interviews with 4 older individuals and 12 health care professionals. The older individuals were aged 70 years and older and were recruited from a geriatrics ambulatory care center. Two of them were those with history of falls (reported a fall in the previous year) and 2 were without history of falls. The group of health care professionals was larger, given that a diversity of experts in treating older patients at risk of falls were surveyed (including 1 geriatrician, 2 otolaryngologists, 1 neurologist, 1 ophthalmologist, 1 orthopedic surgeon, 3 physical therapists, 1 occupational therapist, 1 nurse, and 1 geriatrics clinical researcher). Each of these health care professionals routinely saw older patients at risk of falls or following a fall in their clinical practices and had recently convened to form a Multidisciplinary Falls Prevention Clinic and Falls Board.
The semistructured interviews consisted of 7 open-ended questions that fostered additional discussion. The first 3 questions assessed face validity and addressed the scale's ease of use, the need for additional explanations on a back page, and the quality of the accompanying illustrations. The next 3 questions assessed content validity on the basis of a priori theoretical considerations and related to whether the distinctions among grades were clinically significant and could be accurately determined, whether any of the severity grades were equivalent and should be combined, and the need for additional considerations. The seventh question allowed for any additional comments or suggestions (Table 1). Modifications to the HFGS were implemented iteratively as the older individuals and health care professionals were interviewed.
Once the final HFGS was developed through iterative refinement based on the semistructured interviews, the interrater reliability of the HFGS was assessed. We developed 30 brief video-vignettes with actors depicting examples of each of the HFGS' grades. We then evaluated the scale's interrater reliability among the 12 health care professionals listed previously and 4 others who joined the Falls Board (including another geriatrician, ophthalmologist, and 2 physical therapists), and volunteers (who varied in age and profession and included office assistants and family members of patients). We recruited sufficient volunteers to obtain a wide age range between 23 and 95 years, representative of a cross section of the population and of potential users of the scale (given that the scale was not specifically designed for a certain age or demographic group). We taught the HFGS to the health care professionals and volunteers and then asked them to grade the fall events shown in the videos (see the Supplemental digital Content available at http://links.lww.com/JGPT/A1). The study was approved by the institutional review board at the Johns Hopkins Hospital. The overall process by which we developed and validated our instrument is outlined in Table 2.24
Interrater reliability was assessed using the intraclass correlation coefficient (ICC), calculated using a 2-way random effects model of the consistency type. The ICC for single measures was computed along with 95% confidence intervals (CI). SPSS Statistics release version 19.0 (IBM SPSS Statistics 19.0, Chicago, IL) was used for all analyses.
Development and Validation of the HFGS
During the semistructured interviews, most of the volunteers and health care professionals believed that classifying injury severity as minor or major would be ambiguous, and an exhaustive list of conditions (eg, abrasion, laceration, fracture) could not be practicably provided with each grade on the HFGS. The interview responses showed that the requirement for varying degrees of medical assistance would best capture the severity of a fall event. The participants also agreed on 4 clinically separable grades and felt that the details of the grades should be contained in the HFGS without additional explanations. Both groups judged that the illustrations represented each grade adequately.
On the basis of the responses to the interviews, we developed the 4-point HFGS (Figure 1). Grade 1 is defined as a near-fall, when an individual slips, trips, or loses his or her balance without falling to the ground or to a lower level. A grade 2 fall is defined as a fall to the ground or to a lower level without obtaining medical assistance. A grade 3 fall is defined as a fall to the ground or to a lower level when medical assistance was obtained but the individual was not admitted to the hospital. A grade 4 fall was defined as a fall to the ground or to a lower level with hospitalization. The final product of this iterative process demonstrated good face and content validity.
In the reliability analysis using the 30 video-vignettes depicting near-fall and fall events, we observed a high interrater reliability for application of the HFGS, with an ICC of 0.998 for the complete sample with a 95% CI of 0.997 to 0.999 (P < .001). When calculating the ICC among health care professionals and volunteers separately, both subgroups had a high ICC of 0.995 (95% CI: 0.992–0.997) and 0.996 (95% CI: 0.994–0.998), respectively (P < .001).
We developed the illustrated 4-point HFGS to standardize reporting of the nature and severity of a fall event. The need for standardization is well-recognized, given that the case definition of a fall influences clinical decision-making and the results of research studies.17 The use of the HFGS to characterize each index fall event should be supplemented by measuring the frequency of falls, the rate of falls per person year, and the time to a fall event; a prospective daily calendar with monthly reporting is considered the gold standard for collecting these data.9,16,25,26 Additional outcomes to consider include fear of falling, physical activity level, and health-related quality of life.16
The HFGS, which distinguishes between near-falls and falls and classifies fall severity based on the use of health care resources, exhibited good face and content validity and high interrater reliability, even given the small sample sizes used in the validity and reliability analyses. One group previously suggested classifying falls based on etiology into extrinsic falls (caused by factors external to the individual) and intrinsic falls (due to biologic characteristics of the individual),27 although a limitation of this grading system is that falls are frequently multifactorial and cannot be accurately or reproducibly attributed to one factor.6,27 The focus of the HFGS on health care utilization after a fall is supported by other studies that have found that both health care professionals and patients usually focus on the consequences of the fall.12 It should be noted that the HFGS relies on self-report, which is subject to the individual's physical and cognitive state and has been associated with under- and overreporting of falls in several studies.21,22,28,29
A few authors have suggested that grading falls on the basis of utilization of resources reflects geographic differences in patterns of practice rather than severity of falls.9 Other authors suggest that the presence or absence of a radiologically confirmed peripheral fracture may be a good way to capture the severity of injuries from falls.16 Our semistructured interviews with volunteers and health care professionals suggested that patients are much less likely to report a medical diagnosis (eg, a radiologically confirmed fracture) accurately than a visit to the emergency department or a stay in the hospital. The classification of injuries is difficult, and some studies suggest that the self-report of injuries is less accurate than the self-report of fall events.16,28 As an initial application, the HFGS may be used longitudinally to assess fall events within single individuals (ensuring high internal consistency) or cross-sectionally to compare fall rates and severity across populations with relatively homogeneous health care systems (eg, individual US states). Further studies of the criterion validity of the HFGS, in which the individual grades are correlated with factors that contribute to fall risk (such as vision and balance control) as well as for their ability to predict morbidity and mortality, will be required to corroborate the validity of this scale.23
The HFGS is a simple, valid, and reliable method designed to standardize fall reporting among patients, clinicians, and researchers. A more uniform and objective grading system will allow for improved risk stratification of patients and better decision-making in the clinical setting. In addition, a standardized scale could facilitate a more rigorous assessment of strategies to reduce the risk of falls and the development of evidence-based clinical guidelines in the research setting.
The authors thank the members of the Falls Board at the Johns Hopkins Hospital for their contribution to the development of the falls-grading scale. They also thank Carolina Trevino and Richard T. Penninger for helping with the creation of the falls video-vignettes.
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falls classification; falls definition; falls reporting
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