Meta-analysis of fall-risk tools in hospitalized adults facilitated by Joyce Kee-Hsin Chen, RN, Supervisor, Dept. of Nursing Taipei Medical University-WanFang Medical Center, TW


Harrington L, Luquire R, Vish N, Winter M, Wilder C, Houser B, Pitcher E, Qin H. (2010) Meta-analysis of fall-risk tools in hospitalized adults. J Nurs Adm. 40 (11), 483-8.


Abstract of article


The aim of the study was to identify which fall-risk tool is most accurate for assessing adults in the hospital setting.


Falls can have physical, emotional, social, and financial consequences. Risk assessment affords the first opportunity in prevention.


To standardize the use of a fall-risk tool across the Baylor Health Care System, nurse executives undertook a meta-analysis of published research on fall-risk assessment tools used with adult inpatients.


Both random-effects and fixed-effects models showed that Morse Fall Scale had significantly higher sensitivity than St Thomas’s Risk Assessment Tool (STRATIFY). Specificity of Morse Fall Scale was significantly lower than that of STRATIFY with the fixed-effects model, but the random-effects model showed the opposite. Morse Fall Scale had a significantly higher Youden index than STRATIFY with the fixed-effects model (P = .001), but the result from random-effects model indicated no significant difference (P = .117). The sensitivity, specificity, and Youden index fell within the 95% confidence intervals.


Meta-analysis is a useful methodology for evaluating current evidence when variation exists in the literature.

Rapid critical appraisal of a systematic review

Step 1: Orientation: What question did the review ask?


Population/ Problem Hospitalize adults (age>=18 y/o)
Intervention Fall-Risk Tools (MSF, STRATIFY)
Comparison Non
Outcome(s) Accurate screening (sensitivity, specificity and Youden index)
Type of question: Prognosis question  Best study design: Randomized control trail, Prospective Cohort study (Outcomes are compared for matched groups with and without exposure or risk factor), Case-control study


Step 2: How well was the review done?



Did the search find all the relevant evidence?
  • Unclear


Were the studies critically appraised?
  • No


…and were only the sufficiently valid studies included?
  • No


Did the authors “total up” the studies with summary tables and plots?
  • Yes


…and were the results similar between studies – Heterogeneity?
  • No

Discussion of the group:

  1. Searching: (1) Pubmed and MEDLINE is similar database (duplicate); (2) Supplementary search (checking the references list, citation, registered trial). (3) The search process done by Oct. 2008, but it published on Nov (2 years lag). 2010. (4) Limited search in acute hospital setting.
  2. More detail information should be add, such as the definition of fall, research setting (eg. acute in-patient hospitals, community, hospices…), length of follow-up, percentage(%) of faller, consequences of fall (injury?), quality of the research…
  3. The quality of each study included into this MA did not report in this article. It should describe how the quality of each study was assessed using predetermined quality criteria appropriate to the type of clinical question.
  4. Ideally, initial instrument development study should not be included in a meta-analysis of validation instruments study. It may over-estimate the effect of the result.
  5. The best study of prognostic question is cohort prospective study. Non-prospective study should be excluded.
  6. Length of follow-up should be long enough to detect the outcome of interest. “Time” is very important variable in this MA.
  7. The Youden index of MFS is about 0.4, the Youden index of STRATIFY is about 0.2 (pretty low). Both instruments may be useless in clinical setting.
  8. Authors did not provide statistical analysis about homogeneity, but we can see the heterogeneity among the researches (different setting, age group, wide confidence interval…). Subgroup analysis is needed.
  9. Recommendations to further project: (1) It probably difficult to find good quality pediatric assessment tools to do a SM/MA. Consider about: (2) Hospital wide falls prevention program vs. Risk assessment tool? (3) What is the definition of “fall” in pediatric population? (4)What are the different variables differ from adults in pediatric population? (5) High risk fall pediatric population (giant disturbance, cerebral palsy…) and the consequence (head injury, fracture…) of falls.