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Original Article

Predictive Validity of the STRATIFY for Fall Screening Assessment in Acute Hospital Setting: A meta-analysis

Seong-Hi Park1, Yun-Kyoung Choi2, Jeong-Hae Hwang3
Korean Journal of Adult Nursing 2015;27(5):559-571.
Published online: October 31, 2015

1Department of Nursing, Soonchunhyang University, Cheonan

2Department of Nursing, Korea National Open University, Seoul

3Department of Health Administration, Hanyang Cyber University, Seoul, Korea

Corresponding author: Hwang, Jeong-Hae Department of Health Administration. Hanyang Cyber University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Korea. Tel: +82-2-2290-0811, Fax: +82-2-2290-0603, E-mail: jeonghae.hwang@gmail.com
• Received: July 27, 2015   • Accepted: October 6, 2015

Copyright © 2015 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    This study is to determine the predictive validity of the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) for inpatients' fall risk.
  • Methods
    A literature search was performed to identify all studies published between 1946 and 2014 from periodicals indexed in Ovid Medline, Embase, CINAHL, KoreaMed, NDSL and other databases, using the following key words; ‘fall’, 'fall risk assessment', 'fall screening', 'mobility scale', and 'risk assessment tool'. The QUADAS-Ⅱ was applied to assess the internal validity of the diagnostic studies. Fourteen studies were analyzed using meta-analysis with MetaDisc 1.4.
  • Results
    The predictive validity of STRATIFY was as follows; pooled sensitivity .75 (95% CI: 0.72~0.78), pooled specificity .69 (95% CI: 0.69~0.70) respectively. In addition, the pooled sensitivity in the study that targets only the over 65 years of age was .89 (95% CI: 0.85~0.93).
  • Conclusion
    The STRATIFY's predictive validity for fall risk is at a moderate level. Although there is a limit to interpret the results for heterogeneity between the literature, STRATIFY is an appropriate tool to apply to hospitalized patients of the elderly at a potential risk of accidental fall in a hospital.
  • Key Words: Accidental falls; Sensitivity; Specificity; Meta-analysis
Figure 1.
Flow diagram of article selection.
kjan-27-559f1.jpg
Figure 2.
Diagnosis test accuracy of STRATIFY in total selected studies.
kjan-27-559f2.jpg
Table 1.
Characteristics of the Selected Studies
YP Authors Location Participants As FC COP Follow up 2×2Table Value (95% Confidence interval)
Setting Total (n) M:F (n) M±SD (year) Aged criteria TP FP FN TN SN SP DOR
2013 Kim et al.a1) Korea Neurology and rehabilitation wards 1,026 484:542 56.4±14.9 ＞20 N ≥1 ≥2 Until discharge 27 263 5 731 0.84 (0.67~0.94) 0.74 (0.73~0.74) 15.0 (5.43~44.9)
2011 Barker et al.a2) Australia Medical and surgical wards 263 137:126 61.3±20.6   S ≥1 UR Until discharge 8 17 15 223 0.35 (0.18~0.54) 0.93 (0.91~0.96) 7.00 (2.33~20.9)
2011 Marschollek et al.a3) Germany Geriatric inpatients 50 (46) 13:37 81.3   S ≥1 ≥2 Until discharge 15 20 4 7 0.79 (0.62~0.92) 0.26 (0.14~0.35) 1.31 (0.27~6.65)
2008 Vassallo et al.a4) UK Rehabilitation ward 200 77:123 80.9   C ≥1 ≥2 Until discharge 42 98 9 51 0.82 (0.71~0.91) 0.34 (0.30~0.37) 2.43 (1.04~5.84)
2008 Webster et al.a5) Australia Medical and Surgical wards 788 260:528 77.7±7.9 ＞65 N ≥1 ≥2 Until discharge 59 272 13 444 0.82 (0.71~0.90) 0.62 (0.61~0.63) 7.41 (3.86~14.47)
2007 Kim et al.a6) Singapore Medical and Surgical wards 5,489 2,842:2,647 55.0±19.0 ＞18 N ≥1 ≥2 Until first fall 33 1,341 27 4,088 0.55 (0.42~0.68) 0.75 (0.75~0.75) 3.73 (2.17~6.41)
2007 Milisen et al.a7) Belgium Medical and Surgical wards 2,568 1,148:1,420 67.2±18.4   N ≥1 ≥2 Until discharge 122 997 14 1,435 0.90 (0.83~0.94) 0.59 (0.59~0.59) 12.54 (7.00~22.90)
2006 Haines et al.a8) Australia Rehabilitation and aged care 122 38:84 79.0±9.0   S ≥1 ≥2 Until discharge 20 47 6 49 0.77 (0.58~0.90) 0.51 (0.46~0.55) 3.48 (1.18~10.68)
2006 Smith et al.a9) UK Stroke rehabilitation units 359 (225) 176:183 78.0 (34~100)   S ≥1 ≥2 12 weeks after discharge 6 18 47 154 0.11 (0.05~0.21) 0.90 (0.88~0.92) 1.09 (0.36~3.14)
2005 Vassallo et al.a10) UK Medical wards 135 49:86 83.8±8.0   C ≥1 ≥2 Until discharge 15 38 7 75 0.68 (0.47~0.85) 0.66 (0.62~0.70) 4.23 (1.46~12.65)
2005 Jester et al.a11) UK Hip fracture pts. in orthopaedic unit 90 (60) 20:70 60~81   N ≥1 ≥2 Unrepor ted 1 14 1 44 0.50 (0.03~0.97) 0.76 (0.74~0.78) ( 3.14 (0.08~125.08)
2004 Papaioannou et al.a12) Canada General medical units 620 282:338 78.0±7.7 ＞65 N ≥1 ≥2 Unrepor ted 31 234 3 352 0.91 (0.75~0.98) 0.60 (0.59~0.60) 15.54 (4.48~64.53)
2003 Coker & Olivera13) Canada Geriatric unit with Parkinson's dz. etc. 432 134:298 81.0   N ≥1 ≥2 Until discharge 73 171 38 150 0.66 (0.57~0.74) 0.47 (0.44~0.49) 1.69 (1.05~2.71)
1997 Oliver et al.a14) UK Elderly care and rehabilitation units 837 - 80~83 ＞65 N ≥1 ≥2 8 weeks 139 155 11 532 0.93 (0.87~0.96) 0.77 (0.76~0.78) ( 43.37 (22.17~87.00)

YP=year of publication; M:F=male:female; As=assesser; FC=falls criteria; COP=cut off point; TP=true positive; FP=false positive; FN=false negative; TN=true negative; SN=sensitivity; SP=specificity; DOR=diagnosis odds ratio; N=nurses; S=staff members; C=clinicians; UR=unreported.

Table 2.
Summary Results of Meta-analysis
Categories   Studies (n) Results of pooled diagnostic test accuracy (95% Confidence interval) Results of sROC curve
Sensitivity Specificity Positive likelihood ratio Negative likelihood ratio Diagnostic odds ratio AUC SE (AUC) Q* SE (Q*)
  I2 (%) x2   I2 (%) x2
Total   14 0.75 (0.72~0.78) 93.2 191.81** 0.69 (0.69~0.70) 97.8 587.43** 2.02 (1.63~2.50) 0.40 (0.23~0.71) 5.23 (2.84~9.64) 0.75 0.04 0.69 0.03
≥65 elderly with G & RW 3 0.80 (0.71~0.88) 0.0 0.34 0.39 (0.33~0.45) 78.2 9.19* 1.28 (1.07~1.54) 0.53 (0.34~0.82) 2.47 (1.40~4.35) 0.78 0.13 0.72 0.11
Setting G & RW 5 0.87 (0.83~0.91) 55.0 8.89 0.70 (0.68~0.71) 97.2 143.39** 1.96 (0.12~3.40) 0.32 (0.13~0.75) 6.20 (1.58~24.41) 0.94 0.06 0.88 0.08
General wards 6 0.77 (0.72~0.82) 90.7 54.01** 0.70 (0.69~0.70) 98.5 331.48** 2.21 (2.08~2.35) 0.36 (0.21~0.63) 7.09 (4.31~11.68) 0.78 0.02 0.72 0.02
Specific disease pts. 3 0.48 (0.40~0.56) 95.7 47.05** 0.63 (0.59~0.67) 98.0 102.20** 1.24 (1.05~1.46) 0.85 (0.58~1.25) 1.59 (1.06~2.37) 0.58 0.03 0.56 0.03
Sex ratio M＜F (1＜1.5) 7 0.74 (0.69~0.79) 36.9 9.50 0.55 (0.53~0.58) 92.1 76.06** 1.51 (1.18~1.93) 0.52 (0.37~0.72) 3.01 (1.73~5.26) 0.71 0.06 0.66 0.05
M≒F 6 0.67 (0.62~0.72) 96.4 140.00** 0.71 (0.70~0.72) 98.6 351.32** 2.44 (2.05~2.91) 0.38 (0.15~0.95) 6.52 (3.00~14.17) 0.80 0.03 0.73 0.02
Age (Average years) ＞65 only 3 0.89 (0.85~0.93) 64.0 5.56 0.67 (0.65~0.69) 96.5 56.35** 2.72 (1.78~4.17) 0.16 (0.07~0.37) 1 17.18 (5.02~58.75) 0.81 0.30 0.75 0.27
≤60 4 0.76 (0.70~0.81) 93.8 48.18** 0.71 (0.70~0.72) 98.9 284.46** 2.65 (2.05~3.42) 0.37 (0.17~0.78) 8.10 (3.85~17.03) 0.81 0.04 0.74 0.03
70~79 4 0.63 (0.55~0.70) 96.7 90.57** 0.64 (0.61~0.66) 95.8 70.66** 1.98 (1.62~2.43) 0.38 (0.07~2.08) 4.52 (1.62~12.65) 0.74 0.03 0.68 0.03
≥80 5 0.80 (0.76~0.84) 87.8 32.89** 0.63 (0.60~0.65) 97.6 67.63** 1.69 (0.93~306) 0.42 (0.16~1.08) 4.08 (0.96~17.38) 0.77 0.16 0.71 0.14
Assessor Nurses 8 0.81 (0.78~0.84) 89.0 63.53** 0.69 (0.68~0.70) 98.0 353.14 2.34 (1.83~2.98) 0.29 (0.15~0.54) 8.47 (3.55~20.20) 0.76 0.06 0.70 0.05
Staff members 4 0.40 (0.32~0.50) 93.8 48.54** 0.81 (0.77~0.84) 97.5 119.24** 1.66 (0.97~2.82) 0.75 (0.48~1.16) 2.53 (1.04~6.14) 0.64 0.09 0.61 0.07
Age (≥65) & assesser Nurses assessed 4 0.90 (0.86~0.92) 46.1 5.57 0.62 (0.61~0.64) 96.5 84.59** 2.57 (1.91~3.47) 0.17 (0.10~0.28) 1 15.77 (7.02~35.43) 0.85 0.19 0.78 0.17
Staff members assesse d 3 0.42 (0.32~0.52) 95.8 48.15** 0.71 (0.66~0.76) 97.3 75.03** 1.28 (0.95~1.72) 0.74 (0.34~1.57) 1.77 (0.83~3.79) 0.60 0.07 0.58 0.05
Research Scale ≥500 6 0.85 (0.81~0.88) 88.4 43.14** 0.70 (0.69~0.71) 98.2 279.69** 2.61 (2.09~3.26) 0.22 (0.10~0.45) 1 12.03 (5.55~26.10) 0.79 0.05 0.73 0.04
＜500 8 0.59 (0.53~0.64) 91.4 81.11** 0.64 (0.61~0.67) 97.6 290.88** 1.48 (1.19~1.84) 0.67 (0.49~0.93) 2.46 (1.59~3.80) 0.65 0.04 0.61 0.03

ROC curve=receiver operating characteristic curve; AUC=area under the curve; SE=standard error; G & RW=Geriatric and rehabilitation wards; M=male; F=female; *p＜.01; **p＜.001.

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    Predictive Validity of the STRATIFY for Fall Screening Assessment in Acute Hospital Setting: A meta-analysis
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    DOI: https://doi.org/10.7475/kjan.2015.27.5.559
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    Predictive Validity of the STRATIFY for Fall Screening Assessment in Acute Hospital Setting: A meta-analysis
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    DOI: https://doi.org/10.7475/kjan.2015.27.5.559
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    Predictive Validity of the STRATIFY for Fall Screening Assessment in Acute Hospital Setting: A meta-analysis
    Image Image
    Figure 1. Flow diagram of article selection.
    Figure 2. Diagnosis test accuracy of STRATIFY in total selected studies.

    Figure 1.

    Figure 2.

    Predictive Validity of the STRATIFY for Fall Screening Assessment in Acute Hospital Setting: A meta-analysis

    Characteristics of the Selected Studies

    YP Authors Location Participants As FC COP Follow up 2×2Table Value (95% Confidence interval)
    Setting Total (n) M:F (n) M±SD (year) Aged criteria TP FP FN TN SN SP DOR
    2013 Kim et al.a1) Korea Neurology and rehabilitation wards 1,026 484:542 56.4±14.9 ＞20 N ≥1 ≥2 Until discharge 27 263 5 731 0.84 (0.67~0.94) 0.74 (0.73~0.74) 15.0 (5.43~44.9)
    2011 Barker et al.a2) Australia Medical and surgical wards 263 137:126 61.3±20.6   S ≥1 UR Until discharge 8 17 15 223 0.35 (0.18~0.54) 0.93 (0.91~0.96) 7.00 (2.33~20.9)
    2011 Marschollek et al.a3) Germany Geriatric inpatients 50 (46) 13:37 81.3   S ≥1 ≥2 Until discharge 15 20 4 7 0.79 (0.62~0.92) 0.26 (0.14~0.35) 1.31 (0.27~6.65)
    2008 Vassallo et al.a4) UK Rehabilitation ward 200 77:123 80.9   C ≥1 ≥2 Until discharge 42 98 9 51 0.82 (0.71~0.91) 0.34 (0.30~0.37) 2.43 (1.04~5.84)
    2008 Webster et al.a5) Australia Medical and Surgical wards 788 260:528 77.7±7.9 ＞65 N ≥1 ≥2 Until discharge 59 272 13 444 0.82 (0.71~0.90) 0.62 (0.61~0.63) 7.41 (3.86~14.47)
    2007 Kim et al.a6) Singapore Medical and Surgical wards 5,489 2,842:2,647 55.0±19.0 ＞18 N ≥1 ≥2 Until first fall 33 1,341 27 4,088 0.55 (0.42~0.68) 0.75 (0.75~0.75) 3.73 (2.17~6.41)
    2007 Milisen et al.a7) Belgium Medical and Surgical wards 2,568 1,148:1,420 67.2±18.4   N ≥1 ≥2 Until discharge 122 997 14 1,435 0.90 (0.83~0.94) 0.59 (0.59~0.59) 12.54 (7.00~22.90)
    2006 Haines et al.a8) Australia Rehabilitation and aged care 122 38:84 79.0±9.0   S ≥1 ≥2 Until discharge 20 47 6 49 0.77 (0.58~0.90) 0.51 (0.46~0.55) 3.48 (1.18~10.68)
    2006 Smith et al.a9) UK Stroke rehabilitation units 359 (225) 176:183 78.0 (34~100)   S ≥1 ≥2 12 weeks after discharge 6 18 47 154 0.11 (0.05~0.21) 0.90 (0.88~0.92) 1.09 (0.36~3.14)
    2005 Vassallo et al.a10) UK Medical wards 135 49:86 83.8±8.0   C ≥1 ≥2 Until discharge 15 38 7 75 0.68 (0.47~0.85) 0.66 (0.62~0.70) 4.23 (1.46~12.65)
    2005 Jester et al.a11) UK Hip fracture pts. in orthopaedic unit 90 (60) 20:70 60~81   N ≥1 ≥2 Unrepor ted 1 14 1 44 0.50 (0.03~0.97) 0.76 (0.74~0.78) ( 3.14 (0.08~125.08)
    2004 Papaioannou et al.a12) Canada General medical units 620 282:338 78.0±7.7 ＞65 N ≥1 ≥2 Unrepor ted 31 234 3 352 0.91 (0.75~0.98) 0.60 (0.59~0.60) 15.54 (4.48~64.53)
    2003 Coker & Olivera13) Canada Geriatric unit with Parkinson's dz. etc. 432 134:298 81.0   N ≥1 ≥2 Until discharge 73 171 38 150 0.66 (0.57~0.74) 0.47 (0.44~0.49) 1.69 (1.05~2.71)
    1997 Oliver et al.a14) UK Elderly care and rehabilitation units 837 - 80~83 ＞65 N ≥1 ≥2 8 weeks 139 155 11 532 0.93 (0.87~0.96) 0.77 (0.76~0.78) ( 43.37 (22.17~87.00)

    YP=year of publication; M:F=male:female; As=assesser; FC=falls criteria; COP=cut off point; TP=true positive; FP=false positive; FN=false negative; TN=true negative; SN=sensitivity; SP=specificity; DOR=diagnosis odds ratio; N=nurses; S=staff members; C=clinicians; UR=unreported.

    Summary Results of Meta-analysis

    Categories   Studies (n) Results of pooled diagnostic test accuracy (95% Confidence interval) Results of sROC curve
    Sensitivity Specificity Positive likelihood ratio Negative likelihood ratio Diagnostic odds ratio AUC SE (AUC) Q* SE (Q*)
      I2 (%) x2   I2 (%) x2
    Total   14 0.75 (0.72~0.78) 93.2 191.81** 0.69 (0.69~0.70) 97.8 587.43** 2.02 (1.63~2.50) 0.40 (0.23~0.71) 5.23 (2.84~9.64) 0.75 0.04 0.69 0.03
    ≥65 elderly with G & RW 3 0.80 (0.71~0.88) 0.0 0.34 0.39 (0.33~0.45) 78.2 9.19* 1.28 (1.07~1.54) 0.53 (0.34~0.82) 2.47 (1.40~4.35) 0.78 0.13 0.72 0.11
    Setting G & RW 5 0.87 (0.83~0.91) 55.0 8.89 0.70 (0.68~0.71) 97.2 143.39** 1.96 (0.12~3.40) 0.32 (0.13~0.75) 6.20 (1.58~24.41) 0.94 0.06 0.88 0.08
    General wards 6 0.77 (0.72~0.82) 90.7 54.01** 0.70 (0.69~0.70) 98.5 331.48** 2.21 (2.08~2.35) 0.36 (0.21~0.63) 7.09 (4.31~11.68) 0.78 0.02 0.72 0.02
    Specific disease pts. 3 0.48 (0.40~0.56) 95.7 47.05** 0.63 (0.59~0.67) 98.0 102.20** 1.24 (1.05~1.46) 0.85 (0.58~1.25) 1.59 (1.06~2.37) 0.58 0.03 0.56 0.03
    Sex ratio M＜F (1＜1.5) 7 0.74 (0.69~0.79) 36.9 9.50 0.55 (0.53~0.58) 92.1 76.06** 1.51 (1.18~1.93) 0.52 (0.37~0.72) 3.01 (1.73~5.26) 0.71 0.06 0.66 0.05
    M≒F 6 0.67 (0.62~0.72) 96.4 140.00** 0.71 (0.70~0.72) 98.6 351.32** 2.44 (2.05~2.91) 0.38 (0.15~0.95) 6.52 (3.00~14.17) 0.80 0.03 0.73 0.02
    Age (Average years) ＞65 only 3 0.89 (0.85~0.93) 64.0 5.56 0.67 (0.65~0.69) 96.5 56.35** 2.72 (1.78~4.17) 0.16 (0.07~0.37) 1 17.18 (5.02~58.75) 0.81 0.30 0.75 0.27
    ≤60 4 0.76 (0.70~0.81) 93.8 48.18** 0.71 (0.70~0.72) 98.9 284.46** 2.65 (2.05~3.42) 0.37 (0.17~0.78) 8.10 (3.85~17.03) 0.81 0.04 0.74 0.03
    70~79 4 0.63 (0.55~0.70) 96.7 90.57** 0.64 (0.61~0.66) 95.8 70.66** 1.98 (1.62~2.43) 0.38 (0.07~2.08) 4.52 (1.62~12.65) 0.74 0.03 0.68 0.03
    ≥80 5 0.80 (0.76~0.84) 87.8 32.89** 0.63 (0.60~0.65) 97.6 67.63** 1.69 (0.93~306) 0.42 (0.16~1.08) 4.08 (0.96~17.38) 0.77 0.16 0.71 0.14
    Assessor Nurses 8 0.81 (0.78~0.84) 89.0 63.53** 0.69 (0.68~0.70) 98.0 353.14 2.34 (1.83~2.98) 0.29 (0.15~0.54) 8.47 (3.55~20.20) 0.76 0.06 0.70 0.05
    Staff members 4 0.40 (0.32~0.50) 93.8 48.54** 0.81 (0.77~0.84) 97.5 119.24** 1.66 (0.97~2.82) 0.75 (0.48~1.16) 2.53 (1.04~6.14) 0.64 0.09 0.61 0.07
    Age (≥65) & assesser Nurses assessed 4 0.90 (0.86~0.92) 46.1 5.57 0.62 (0.61~0.64) 96.5 84.59** 2.57 (1.91~3.47) 0.17 (0.10~0.28) 1 15.77 (7.02~35.43) 0.85 0.19 0.78 0.17
    Staff members assesse d 3 0.42 (0.32~0.52) 95.8 48.15** 0.71 (0.66~0.76) 97.3 75.03** 1.28 (0.95~1.72) 0.74 (0.34~1.57) 1.77 (0.83~3.79) 0.60 0.07 0.58 0.05
    Research Scale ≥500 6 0.85 (0.81~0.88) 88.4 43.14** 0.70 (0.69~0.71) 98.2 279.69** 2.61 (2.09~3.26) 0.22 (0.10~0.45) 1 12.03 (5.55~26.10) 0.79 0.05 0.73 0.04
    ＜500 8 0.59 (0.53~0.64) 91.4 81.11** 0.64 (0.61~0.67) 97.6 290.88** 1.48 (1.19~1.84) 0.67 (0.49~0.93) 2.46 (1.59~3.80) 0.65 0.04 0.61 0.03

    ROC curve=receiver operating characteristic curve; AUC=area under the curve; SE=standard error; G & RW=Geriatric and rehabilitation wards; M=male; F=female; *p＜.01; **p＜.001.
    Table 1. Characteristics of the Selected Studies

    YP=year of publication; M:F=male:female; As=assesser; FC=falls criteria; COP=cut off point; TP=true positive; FP=false positive; FN=false negative; TN=true negative; SN=sensitivity; SP=specificity; DOR=diagnosis odds ratio; N=nurses; S=staff members; C=clinicians; UR=unreported.

    Table 2. Summary Results of Meta-analysis

    ROC curve=receiver operating characteristic curve; AUC=area under the curve; SE=standard error; G & RW=Geriatric and rehabilitation wards; M=male; F=female; *p＜.01; **p＜.001.

    Table 1.

    Table 2.

    Korean J Adult Nurs : Korean Journal of Adult Nursing

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