Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis.

Introduction: Fall risk screening tools are frequently used as a part of falls prevention programs in hospitals. Design-related bias in evaluations of tool predictive accuracy could lead to overoptimistic results, which would then contribute to program failure in practice. Methods: A systematic review was undertaken. Two blind reviewers assessed the methodology of relevant publications into a four-point classification system adapted from multiple sources. The association between study design classification and reported results was examined using linear regression with clustering based on screening tool and robust variance estimates with point estimates of Youden Index (= sensitivity + specificity - 1) as the dependent variable. Meta-analysis was then performed pooling data from prospective studies. Results: Thirty-five publications met inclusion criteria, containing 51 evaluations of fall risk screening tools. Twenty evaluations were classified as retrospective validation evaluations, 11 as prospective (temporal) validation evaluations, and 20 as prospective (external) validation evaluations. Retrospective evaluations had significantly higher Youden Indices (point estimate [95% confidence interval]: 0.22 [0.11, 0.33]). Pooled Youden Indices from prospective evaluations demonstrated the STRATIFY, Morse Falls Scale, and nursing staff clinical judgment to have comparable accuracy. Discussion: Practitioners should exercise caution in comparing validity of fall risk assessment tools where the evaluation has been limited to retrospective classifications of methodology. Heterogeneity between studies indicates that the Morse Falls Scale and STRATIFY may still be useful in particular settings, but that widespread adoption of either is unlikely to generate benefits significantly greater than that of nursing staff clinical judgment.