Does the Improved Coordination of Care for Fall- and Fracture Prevention in Oslo Have Effect on the Rate of Hip Fractures, Need of Nursing Homes or Death?
Conditions: Fall Injury, Hip Fractures
Sponsor: Norwegian Institute of Public Health

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Study Protocol and Statistical Analysis Plan 
 
 
 
 
 
 
 
Does the Improved Coordination of Care 
for Fall- and Fracture Prevention in Oslo 
Have Effect on the Rate of Hip Fractures, 
Need of Nursing Homes or Death?   
 
RCN296587 
 
January 2. 2023 

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The study is an evaluation of a new patient follow-up for fall- and fracture prevention in the 
municipality of Oslo with improvement of coordination of care for elderly (65 years or older, 65+) at 
risk of fall injuries.  
The two major innovations in this initiative are 1) the systematic approach to improving care 
coordination within the health care system as well as 2) including osteoporosis evaluation in the fall 
risk assessment in order to reduce risk of fall related fractures.  
In this study, the two city boroughs of Nordstrand and Østensjø, who initiated the intervention, are 
compared with a control group consisting of the other 13 city boroughs of Oslo in a controlled before 
and after study design.    
The care coordination implemented is in line of the framework Øvretveit used in his summary review 
“Does clinical coordination improve quality and save money?” (2011)i, and which WHO later adopted 
in their practice brief “Continuity and coordination of care” (2018)ii.  The major steps in the 
intervention in Oslo are as follows:  
 
 
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Needs assessment and user involvement. The intervention started with the chief medical 
officers in the areas of intervention realizing the health burden of hip fractures within their 
boroughs, as well as the lack of care coordination in the delivery of preventive measures. 
The steps of the intervention were developed as a cooperative effort with the local health 
professionals who delivered the services, the chief medical officers in the boroughs and 
specialists in geriatrics, osteoporosis and injuries at Oslo University Hospital.  
 
• 
Case finding of individuals with increased risk of a fall injury. In the start of the intervention 
this was primarily done within the boroughs through physiotherapists and occupational 
therapists who looked for patients with increased risk of falling in their clinical practices. 
Education on fall risks and possible follow-up was also given to the General Practitioners 
(GPs) and at the community centers for case finding.  
From September 2017 the Injury Clinic at Oslo University Hospital started sending so-called 
“fall reports” to the boroughs when 65+ patients with fall related injuries had been treated 
at the clinic, assisting the boroughs in identifying cases and targeting this high-risk 
population in their preventive initiatives.  
 
• 
Shared, collaborative single point of entry to care in the boroughs. This is the address to 
where the fall reports from the Injury Clinic were sent. The same address was conveyed to 
the GPs and the other health professionals to send messages whenever a need for falls risk 
assessment and intervention was detected. On the receiving end of this address, is a care 
coordinator with extensive knowledge about the local health care system and the fall 
prevention pathway who forwards the messages to launch the right follow-up.  
 
• 
A cross-sectoral plan for follow-up with role clarification. This was a major part of 
improving the coordination of care. Who identifies the elderly at risk of fall injuries and 
how (case finding)? Who performs the fall risk assessments? What measures are taken to 
reduce risk, who delivers these interventions and how are the at-risk-patients recruited 
into the follow-up? Both the leadership and those who delivered the services within the 
boroughs were included in the planning process. The cross-sectoral plans were developed 
both separately within the two boroughs and some parts in coordination with the Injury 

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Clinic, specialists at the University Hospital and the Department of Public Health of the 
Municipality of Oslo.  
 
• 
Interdisciplinary teams were established in the two boroughs, consisting of those who did 
fall risk assessments through home visits. The teams consisted mainly of physiotherapists 
and occupational therapists. Nurses, nutritionists, and clinical pharmacologist were added 
later. These teams received referrals for risk assessments from the single point of entry, 
sent from the Injury Clinic as fall reports and as well messages from by other health 
professionals within the boroughs.   
 
• 
Tools for multifactorial falls and fracture risk assessment, leading to tailored interventions 
were developed as instruments to ensure the quality of care. The content of these 
assessment tools was based on best-practice and evidence-based, but the format was 
adapted by local health professionals to fit their practices and workflow.   
 
1. The first assessment tool developed, was an interdisciplinary assessment checklist for 
home visits. The main areas that were assessed was gait and need for physiotherapy 
and exercise, safety in home environment, need of medical examination, sight, 
footwear, nutrition status, and support network. This assessment tool has been 
revised and improved several times in accordance with developing evidence and user 
preferences.  
2. The second tool developed was a checklist for the GPs consisting of a list of medical 
conditions to consider in patients who had fallen, suggested blood work, guidelines 
for osteoporosis evaluation, tools for medication review and a description of referral 
pathways.  
3. The third assessment tool developed, was for the doctors at the Injury Clinic to help 
them to evaluate whom of the fall injury patients to refer for further follow up in the 
boroughs and/or the geriatric department for falls risk assessment and/or 
osteoporosis evaluation. A secretary assisted in the logistics of sending the fall reports 
to the single point of entry in the boroughs.  
4. FRAX, an established fracture risk assessment tool, was introduced to all health 
professionals, but to the GPs in particular.  
 
• 
Information sharing. Standardized messaging was introduced from the actors responsible 
for the case finding to those who did falls risk assessment and further to those who 
performed risk-reducing measures. For instance, the fall reports from the Injury Clinic were 
a specified type of message with a planned follow-up. Involving the GP in the information 
loop was key to improve coordination. 
 
• 
Primary and specialist care referral pathways and processes. The referral pathway to the 
geriatric departments was strengthened with the aim of both increasing the number of 
referrals and for the referrals to be more appropriate, with focus on patients with multi 
morbidity, polypharmacy, and suspected syncopes. Furthermore, access to osteoporosis 
evaluation and intravenous treatment of osteoporosis with zoledronic acid was improved.  
 
• 
Champions in the two boroughs, at the Injury Clinic and in the Public Health Department 
of Oslo were chosen, aiming to create enthusiasm and carry the intervention forward 
within their organizations. The champions in the boroughs worked in close coordination 

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with the two Chief medical officers of the boroughs. The intervention received yearly 
grants (“Samhandlingsmidler”) from a joint committee from the Specialist and Primary 
health care in Oslo for improving coordination of care from August 2016, which made it 
possible to allocate time for working on this project. The yearly grants amounted to 0,3 – 
1 yearly salary mainly distributed between the champions, so most of the intervention 
used resources within the normal budget and activity. The champions mobilized colleagues 
and experts, developed the assessment tools, educated of health professionals and were 
a driving force in expanding the intervention.  
 
• 
Tailored interventions to reduce risk of falls and fractures. The two intervention boroughs 
already offered, as all other boroughs in Oslo, strength and balance exercise groups and 
had occupational therapists who did home safety assessments on referral before study 
start. The new care coordination led to a mapping of the existing variety of exercise groups, 
and some increase both in the number and variety of the exercise options. Other 
interventions like safety measures at home, different aids, nutrition, osteoporosis 
treatment, medication assessment and geriatric evaluation was also better described and 
made available. The extensive mapping of the local intervention possibilities was useful 
and was utilized as a menu to choose from when tailoring interventions for the individual 
after a multi factorial risk assessment.  
 
• 
Collaborative training and education were offered for all health care professionals involved 
in the fall prevention pathways; all those involved in case finding, coordination, risk 
assessments and preventative interventions. The champions were responsible for 
organizing the education. This was offered in a smaller scale within local health centers 
and clinics, gatherings for all the GPs within the two boroughs, and from august 2018 
through bigger events arranged annually by the Public Health Department in Oslo.  The 
education focused on what may increase the risk of falling, osteoporosis, effect of different 
interventions, and sharing of practices and experiences.  
 
• 
The main technology enabler in this intervention, was the digitalization in 2018 of the 
home visit assessment tool in the Electronic Patient Records (EPR) for the boroughs. In 
addition, a way of registering falls in the same EPR as well as a clear routine for how to 
document the multifactorial assessment and the follow up within this system, was a great 
support for those who did the home assessments and follow-up interventions.  
Digitalization of the fall reports in 2018 from the Injury Clinic, also was an improvement.  
 
 
 
Timeline 
Improving care coordination is a process. The investigators have, however, chosen to define these 
dates as the start of intervention, as this was the time when the systematic needs assessment 
together with the interdisciplinary and cross-sectoral approach to the fall-risk-prevention-problem, 
started.  
These were the milestones which were chosen as start dates of the intervention:  

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1. Start of intervention in Nordstrand borough is set to January 1, 2015.   
The Chief Medical Officer in Nordstrand mobilized the health professionals in a systematic needs 
assessment.  They improved case finding, developed a checklist for multifactorial falls risk 
assessment through home visits, recruited more elderly at risk into exercise programs, and started 
education of health professionals including the GPs in coordination with the geriatricians at the 
University Hospital and local nursing homes.  They also improved primary prevention with winter 
road safety measures and education of the general elderly population on fall risks and safety 
measures.  
After Østensjø and the Injury Clinic at Oslo University Hospital joined the intervention in September 
2016, the intervention in Nordstrand was done in collaboration and coordinated with these partners.  
 
2. Start of intervention in Østensjø borough is set to September 1, 2016. 
Østensjø started a collaboration with Nordstrand borough and the Injury Clinic in September 2016 
after a grant proposal (“Samhandlingsmidler”) was awarded funding. This led to a development of a 
formal multifactorial falls and fracture risk assessment tool for GPs, a revision of the interdisciplinary 
falls risk assessment tool from Nordstrand for home visits, establishing referral pathways within 
primary care and with specialist care established. In addition, education programs for both GPs and 
other health professionals in primary care was strengthened. Local champions were chosen and 
interdisciplinary working groups were established.  
 
3. The Injury Clinic supported case finding from September 2017 
All municipalities started receiving fall reports regarding consenting patients with fall injuries treated 
at the Injury Clinic at the University Hospital in Oslo from September 2017.  This improved the case 
finding in both Nordstrand and Østensjø, who already had a coordinated care plan in place, which 
were presumed to be the crucial part of the intervention. The 13 other municipalities did not have 
the same coordinated care. Their patients received care as usual, which varied between the 
boroughs.  
 
4. The end of the study period is set to December 31. 2019 
The intervention in Oslo expanded to include most of the city boroughs after 2019. From January 
2020 five more boroughs started care coordination, another five during 2021 and further one in 
2022. The end of the study period with comparison between the two boroughs who started this 
intervention and the others, is therefore set to the end of 2019, before the 13 others began their 
systematic coordination of care.  
 
 
 
 

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Statistical Analysis Plan 
 
The investigators will use a controlled before and after study design to evaluate this intervention.   
 
The cohort 
All elderly 65 age or older in Oslo are included in Oslo Fall Cohort with registry data from Statistics 
Norway, the National Population Registry, Norwegian Patient Registry (NPR), and the Electronic 
Patient Records for the health services in the local municipalities. Data is available on all participants 
from 2010 and the investigators will start following them from January 2012 until December 2019 
with the intervention starting as specified in the timeline (see above). The study will follow each 
cohort participants prospectively and analyze the data by Cox proportional hazards regression or 
similar. 
Fall injury will be included as a time-varying exposure variable. The individuals in the cohort are all 
registered as non-fallers until they are registered with a new fall injury in the NPR database, when 
they shift status to fallers.    
 
Exposure categories  
• 
Fallers in the intervention boroughs 
Fallers 65+ years from the borough of Nordstrand from January 1. 2015 
Fallers 65+ years from the borough of Østensjø from September 1. 2016 
 
• 
Fallers in the control boroughs 
Fallers 65+ years from all the 13 other boroughs of Oslo. 
 
• 
Non-fallers 
All non-fallers from the complete Oslo population 65+ years. 
 
Main analysis: In the main analysis (2015-2019), fallers from the two intervention boroughs, 
Nordstrand (from January 2015) and Østensjø (from September 2016), will be compared with fallers 
from the control boroughs during the intervention.  In addition, the two categories of fallers will also 
be compared with the non-fallers. A similar analysis will be performed before the intervention 
started using data from 2012-2013. Any differences between the intervention and control boroughs 
before the intervention started will be taken into account. 
 
In a secondary analysis, the total incidence (not restricted to fallers) of hip fracture in the 
intervention boroughs will be compared with the incidence of hip fracture in the control boroughs, 
and a similar comparison will be made before the intervention started. Adjustment for possible time 
trends will be considered.   
 
Primary outcome variables 

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• 
Hip fracture 
• 
Admittance to nursing home, long term 
• 
Death (all-cause mortality) 
Secondary outcome variables 
• 
Other fall injuries 
 
In each analysis, participants with a hip fracture or living in a nursing home at baseline will be 
excluded. 
 
Statistical power 
According to statistics from NPR before the intervention started, around 22% of the home dwelling 
elderly treated for a fall injury came from the intervention boroughs of Nordstrand and Østensjø. 
If 22% of the patients with falls are exposed to the fall prevention intervention and 607 of all fallers 
suffer a hip fracture during a follow-up of five years (2015-2019), it will enable us to detect a relative 
risk reduction of 24% (RR= 0.76) at the 0.05 significance level with a power of 80%.  
 
Data management and analysis 
The Cohort Data is stored at Services for Sensitive Data (TSD) at the University of Oslo.  
The analysis in the evaluation is based on registry data and no analysis relating the intervention to 
the outcomes has been done before registration in clinicaltrials.gov. The outcome variables are the 
same as indicated in the study protocol in the grant application to the Norwegian Research Council 
(NRC) in 2018.  
 
 
 
 
i https://www.health.org.uk/publications/does-clinical-coordination-improve-quality-and-save-money 
ii http://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033-eng.pdf?ua=1