Tuesday, April 26, 2011


If you ever have a chance, come here, just to rest your soul. 

Thursday, April 21, 2011

Recession and Physical Child Abuse

A paper was presneted last week at the American Association of Neurological Surgeons' annual meeting in Denver by a fourth year medical student. Mary Huang presented her study which sought to determine whether there was an association between economic downturn and abusive head trauma in children. She found that the risk of abusive head trauma doubled during a economic recession, and the severity of the injuries appeared to increase also.

Wednesday, April 20, 2011

Patient Driven Care

A greta post on Paul Levys blog, in which he proclaims following a meeting in IHI that he is no longer an advocate for patient centered care, but henceforth will be proclaiming the benefits of patient driven care. In his own words,

"What I am suggesting is that clinicians should do their best to collaborate with patients to understand their needs and desires and to jointly design plans of care that are as consistent as possible with those needs and desires."

Such a move would require a sea change in the way we practice and deliver care. It reminds me of a good friend who when i told him the difficulty I was having in getting a computer in my clinic room asked me why I needed a computer. To access UpToDate and other resources, I replied. "You mean you would look up information in front of patients?", was the stunned response.

Pauls point aligns nicely with what Maureen Bisognano said at the International Forum, that patients are our greatest unused resource. 

Sunday, April 17, 2011

Disclosure and Litigation

We are all aware of the reputation of the US legal system as litigation central for mistakes in healthcare. Surely the worst thing to do is to publicize ones mistakes in this environment? Paul Levy on his blog points out a fascinating cultural dichotomy. He explains how during his tenure as CEO of BIDMC, medical errors were publicized. He contrasts this openness with the reluctance of various European hospitals to disclose their errors. Perhaps we should be learning from our American cousins?

Lessons Learned

Just finished a book by a number of clinicians, all US based. It is outstanding. Written to honor Paul Batalden, it is a treasure chest of advice, hints, tips, aphorisms, about the practicalities of changing healthcare. Unusually I am unable to pick out a highlight, as the quality (no surprise) is uniformly excellent. Get it here.

Thursday, April 14, 2011

A vision of the future? Bilingual healthcare workers

From the inestimable Muir Gray, (thanks Tony), one possible approach to the problems facing us. Remember Einsteins definition of insanity, doing the same thing over and over and expecting different results. I think that summarizes healthcare. The model we have is designed, or rather evolved from the post war period to deal with a different set of problems. Acute self limited, or fatal illness. Coincident with the rise in healthcare technology, probably the early 50's with the development of ICUs following polio epidemics, the healthcare-industrial complex has in part generated problems and expectations that we are no longer equipped to handle. The paradigm of how care is delivered has to change radically. There is a very interesting book published in the 80's looking at how complex societies fail. The thesis and it applies equally well to complex systems is that a system evolves to deal with a complex problem, problems become more complex, hence the system becomes more complex and eventually a point of diminishing returns is reached where the inputs (think regulation, accreditation, legislation etc) consume more resources and the system collapses.
Gray provides one possible approach to this challenge. Basically the bilingualism to which he refers is that healthcare workers must be versed in not only the ability to provide clinical care to their patients,

"They need to know how to:
  • Develop systems
  • Build networks of clinicians and patients
  • Design pathways
  • Manage knowledge
  • Harness the internet’s potential
  • Engage patients
  • Create and manage programme budgets
  • Develop the right culture"
He describes this as population medicine. It is highly recommended. 

Much ado about bundles

Following yesterdays post about bundles, a couple of interesting papers from this weeks NEJM. Two studies here and here, and an editorial about reducing infection in hospitals. The two studies came to different conclusions; the first examined the efficacy of screening for MRSA in ICUs and implementing barrier precautions on all patients until their MRSA status was known. The interventions were not shown to be effective in reducing transmission of MRSA or VRE. However, and this is the really big take home message for me, in cases where hand hygeine or glovers were indicated, the compliance with these measures was as low as 62%!
In contrast, the VA study instituted a bundle approach; a MRSA bundle was instituted in 2007 and over 2 million hospital discharges were studied. The rate of health care associated MRSA infections fell by between 45% (outside ICU) and 62% (inside ICU) over a two year period.
For some expert comment, see this CDC post.

Is it better to be a dog or a medical student?

Lots doom and gloom out there, so something to put a smile on your face, unless you are a med student!
From A cartoon guide to becoming a doctor.


Wednesday, April 13, 2011

Health care spend, any room to reduce it?

While not strictly looking at quality and cost at a hospital level, a paper just published by OECD examines the potential for savings in health expenditure. It suggest that countries can achieve savings up to 5% of GNP by all countries becoming as efficient as the best performing countries. Note that there does not appear to be much if any correlation between healthcare spend and outcomes across countries. The authors suggest that countries by reaching the level of the best performers would increase life expectancy at birth by two years; in contrast a 10% rise in health expenditure would increase life expectancy by three to four months.


Great discussion by Bob Wachter on his blog about harm, preventable harm, errors and trigger tools amongst other things. He makes the point that we should focus on eliminating preventable harm, at least in the first instance. Beth Israel Deaconess publishes on its public website details on its progress towards eliminating preventable harm.

Giving doctors orders

If you are a doc, you know that very few people order you around, apart form your kids. Maureen Dowd discusses this and its implications in todays NYT. Yet another story of a family member dying. But she can be very amusing, and this is one of her funnier and more poignant pieces.

Bundles of joy or of sorrow?

The idea of bundles makes intuitive sense, gather together some evidence based interventions and ensure they are implemented reliably all the time, sit back and watch the magic. Pronovost showed the power of bundles in his NEJM paper some years ago. An observational study by Jarman and others in the BMJ last year suggested that using various bundles in a large London hospital was associated with a large reduction in hospital mortality.
So along come the surgeons to upset the consensus. A study in Archives of Surgery compared standard institutional practice with an extended bundle of interventions, all of which had been previously demonstrated in isolation to be effective. These interventions included:

  1. No pre-operative bowel preparation
  2. Pre-operative and intra-operative patient warming
  3. Supplemental oxygen intra and post operatively
  4. Intra-operative fluid restriction
  5. Use of a surgical wound protector 
Over 200 patients were studied; main outcome measure was surgical site infection rate at 30 days as assessed by blinded infection control experts. The rate of SSI in the control group was 24%, vs. 45% in the bundle arm. Most of these SSIs were superficial.

Any explanation? Its possible that the interventions are ineffective, or less likely that they are counter synergistic, i.e. although singly beneficial, when combined they counteract one another. Alternatively even positive studies may due to chance be negative. The main concern though apart from giving ammunition to those who wish to reject the benefits of standardisation is that there will be a call for more RCTs in this and every other areas. While we have traditionally believed that RCTs are the gold standard, Ioanniddis work is even questioning this dictum. The other big problem in conducting RCTs is that we assume that apart from the intervention being studied, all other factors are uniform. This is clearly  not the case, and this has proven to be a difficult obstacle to surmount in trials of equipment such as new ventilators.

Game changing move for patient safety in US

Bob Wachter on THCB has a piece on what he calls a game changing safety initiative. Berwick and Kathleen Sibelius announced yesterday the "Partnership for Patients". This is a very ambitious well funded widely supported program. Its stated goals are to reduce preventable harm in US hospitals by 40% and preventable readmissions by 20% by 2013! It's nice to see Berwick has not lost his taste for aiming high. To quote Wachter:
  • "For the first time, it establishes safety goals and programs as a private/public partnership, with early buy in from large insurers and employers. A broad tableau of leaders from provider organizations, insurers, federal agencies, businesses, and patient groups shared the stage with Sebelius and Berwick at this morning’s announcement to highlight the partnership theme.
  • It provides large amounts of funding and technical assistance – nearly one billion dollars – both through the new CMS Innovation Center and elsewhere, to promote new knowledge and skill building.
  • Like the 100K Lives Campaign, it seeks commitments from hospital executives and boards to tackle key safety goals.
  • It provides support for collaborative networks designed to promote shared learning.
  • It rewards hospitals for achieving certain milestones with both recognition and additional resources; those that do very well will be eligible to receive funding to help other hospitals improve."
The financial stick is that by 2015, 9% of medicare reimbursement will be tied to reaching these goals.
Interestingly, the means of audit to confirm compliance with these aims will be a detailed chart which appears to me to be using the IHI global trigger tool. Exciting times.

It would appear in some ways to be modeled on the 100,000 Lives campaign in that it sets lofty goals, appeals to sentiment, has a short time frame and uses social pressure to ensure others want to join.

Tuesday, April 12, 2011


A quote that came through in an IHI email today about innovation:
"Innovation distinguishes between a leader and a follower"
Steve Jobs

Not sure I totally agree. Many innovators failed to benefit from their innovations, and often the mindset of an innovator is antithetical to being a leader. Nevertheless, a great quote from the man who invented Peters iPad 2, (x2)

Depression, the inside story

Anyone interested in how our system within our own lifetimes treated people should read this article. It is harrowing. Unfortunately I think mental illness is still seen as a weakness, "just snap out of it, for gods sake" is often the response. I am aware of employers who have failed in their statutory responsibility to ensure those with mental illness receive the same entitlements and protections afforded to every employee. We are not as civilized as we think.
A quote from the psychiatrist who treated the patient:
"Our patients are our best teachers. Jackie has taught me a huge amount about depression: what it feels like, the impact on sufferers’ and their family, and what does and doesn’t help.I have seen the toll taken by this ubiquitous disease, no less devastating in its impact than other chronic conditions. Jackie, an able and enthusiastic student, could barely finish her course at University, her employment prospects have been blighted, her social life restricted, and her capacity for pleasure and fulfilment curtailed. At their worst psychiatric services reinforce sufferers’ feelings of isolation and powerlessness." 

Increase comfort in the face of uncertainty

IDEO are a very interesting design and innovation firm based in California, and have done a lot of work in this area with Kaiser Permanante. They have provided assistance to the NHS Institute for Innovation and Improvement, Texas Children's Paediatric Associates, (the largest primary paediatric care network in the US) and many others. Their website is well worth checking out for anyone with an interest in healthcare innovation in its softer (i.e. not hardware, expensive drugs and hi tech equipment) guise. What caught my eye recently was a blog by an IDEO employee with the title that I have posted above. I liked their use of data from Twitter, and Google Analytics to measure the "buzz" in real time generated by their ideas.
This comes back to the point made by Maureen Bisognano recently, about using the power of patients to seek ideas. If we could measure what people believe is important judged by what they search or discuss on line, perhaps it might help us focus on what matters to patients as opposed to what matters to the "providers". Just a thought.
This I think is an area where some Irish design consultancies might find a niche.

Monday, April 11, 2011

Conservatives, tough on bacteria

Good to see politicians are getting the handwashing message.

Global Trigger Tools

Thanks to Annette and Levette. Two important pieces to check out if you are interested in trigger tools. First a paper in Health Affairs showing that the use of the Global Trigger Tool detects adverse events at a rate 10 times greater than voluntary reporting or using the AHRQ patient safety indicators.

Second, an upcoming WIHI:

The Power to Detect and Improve: Revisiting the IHI Global Trigger Tool and Adverse Events
Thursday, April 14, 2011, 7pm MT. See here for details. Both are free. The WIHI features great faculty. Check it out.

Mental illness and children

A great image showing the extent of psychoactive drug prescribing in the US. While there are many
interesting explanations for such rampant pharmaco-terrorism, this post has another purpose.

A recent story caught my eye, in fact it was so striking it kidnapped my brain. Headlined, "Is that Thorazine in the babies bottle?", it discussed the relentless rise in diagnosing and treating psychiatric illness in chilren and infants. According to the story, 500,000 children in the US are prescribed anti-psychotics! When I went looking for data about the incidence/ prevalence of psychiatric illness in children, the numbers are mind boggling. According to childstats.gov, in 2008 8% of children aged 12-17 experienced a major depressive episode. Of course, some may question this data, but it does appear that the incidence of major psychiatric illness, especially depression is rising across the Western world, and it has been suggested that the major contributor to this increase is rising economic and social inequality. If this is the case, medicating children from a very young age is not the solution, and is really only addressing the symptoms of a societal problem. For a more detailed discussion, read The Spirit Level . This is a magnificent book, likely to be seen in 50 years as the seminal public health work.

Saturday, April 9, 2011

Beware Medical School

Here is an alternative look at medical school, from ZDogg.

Poetry and Reform

In an attempt to attract younger readers, i.e. anyone less that 40, I am consciously using more relevant media and artists, well not really, I just thought this guy was great. In a week that Bob Dylan submitted his concert play list to the Chinese authorities in advance of his first Chinese concert, it's good to see that the younger generation can still protest in song, well rap.
Is this the first time that the Royal College of General Practitioners has been mentioned by a hip-hop artist? It must be the first time a Government White Paper is summarized so eloquently.


Andrew Lansley, greedy,
Andrew Lansley, tosser,
the NHS is not for sale you grey haired manky codger. (x4)

So the budget of the PCTs, he wants to hand to the GP’s,
Oh please. Dumb geeks are gonna buy from any willing provider,
get care from private companies.
They saw the pie and they want a piece;
Got their eyes on the P’s like mice for the cheese.
I talk truth when I ride the beat, you talk shite when you speak,
see money when you close your eyes to

So fall back — your face looks like a shrivelled up ball sack.
The stuff that you chat is bull crap, I’m sure Andy Pandy snorts crack.
Health minister, I mean sinister.
You know your public will finish ya,
is your brain really that miniature?
Give yourself an enema.

Made filthy rich by those who represent Walkers Crisps,
Mars and Pizza Hut, proved your a health slut and your always talking shit.
A hundred and thirty four pound an hour every week, that’s quite a lot of quids;
and you came to the conclusion that the food industry should be a little less strict.

Scandal disclosed that you flipped your second home.
You said your claims were within the rules, filled your pockets, took us for jokes;
so how would you cope when broke folk get ill, injured and broke,
but don’t have the dough,
to get their life back on the road, so poor die slow, and the rich take control.

(Chorus x 4)

Lansley’s white paper: “Liberating the NHS”
sets out a plan where we’ll become more like the U.S.
and care will be farmed out to private companies,
who will sell their service to the NHS via the Gps,
who will have more to do with service purchase arrangements
than anything to do with seeing their patients.

He’s been given cash
by John Nash,
chairman of Care UK:
a private healthcare provider,
who, if they have their way,
will be the biggest beneficiaries
of conservative Lib Dem policies
to privatise healthcare and pull apart the welfare state.

These plans have been slagged by patient organisations,
charities and unions,
nursing and medical institutions.
The Royal College of GPs even joined the attack,
looked closely at the proposals
and said they were crap.
Say yes for the NHS, Andrew Lansley can suck on David Cameron’s breast.
His quest is for the rich to pay less, and the poor have to stress, it’ll be one big mess.

(Chorus x 4)

Friday, April 8, 2011

International Forum and Social Movements

Helen Bevan and Maxine Power gave a wonderful hour long talk on the power of social movements, mobilising weak network connections, (in contrast to the network effects we usually think of being most powerful such as family, peers) in generating will to change. The focus was hospital based care, but I wonder how soon we will begin to see such strategies applied to the overwhelming need for society to concentrate on health and prevention.

Thursday, April 7, 2011

Amsterdam in Spring.

A great city.

Forum; motivation and morale

Both Maureen Bisognano and Helen Bevan referenced the need to capture ant tap resources that we traditionally have failed to recognise. In Maureens case, the patient is a huge resource; Helen argues that we fail to capture the intrinsic motivation of many employees. The idea is that if an organisation can tap this, productivity can increase 30-40%.

international Forum and Maureen Bisognano and hospital flow

Maureen Bisognano in her keynote speech referenced specifically Eugene Litvaks work, and the benefits accrued to Cincinnati Childrens by implementing the methods he espouses. See my previous post about Litvaks work. http://saferhealthcareireland.blogspot.com/2011/03/optimizing-patient-flow-to-enhance.html

Emily Friedman at the International Forum

Magnificent keynote from Emily Friedman about challenges and possibilities for healthcare in Cambodia, harrowing stories. www.emilyfriedman.com

Effective Crisis Management, Free WIHI session

The next WIHI should be mandatory listening, WIHI click here

Includes Uma Kotagal and Jim Conway.

Wednesday, April 6, 2011

Poster of the Forum

International Forum Quality Amsterdam

Outstanding plenary from Maureen Bisognano. talks about need to redefine healthcare leadership, both at a personal and sttructural level. Some interesting facts, medication compliance or lack of estimated to be 4th leading cause of death worldwide, accounts for >$150 billion in US health spend. Lots of opportunity to save, reduce waste, Gives various successful exemplars. Talks about need to refocus and suggests IHI Triple Aim as a useful model.

Tuesday, April 5, 2011

Quality Education

excellent piece from BMJ Q&S concerning education and training in healthcare quality and safety. The authors make a number of valid points.

There is a lack of suitably qualified experts in the area of health Quality and Safety to provide education
The traditional approach o education imposes an artificial barrier between clinical and improvement work; the two must be seen to be two sides of the same coin.
A consequence of this barrier is that front line staff fail to understand the true significance of quality improvement
This last point is one that has not previously occurred to me; the traditional method of teaching, asking questions, implies to the learner that every question and every problem has a solution, which is patently not the case.

The authors provide a framework to transform the way such training is delivered.

QI becomes an integral part of clinical practice and training
Students and teachers become co-learners, along with patients, families, and non clinical staff
QI is seen to result not from "great individuals", but from a team approach to problem solving
The end result is not judged by answering questions correctly, but how effectively a problem is solved.

Monday, April 4, 2011

Hot off the press

Just published, a supplement to BMJ Quality and safety, all open access, looks like some great stuff.


I am currently reading John Wennbergs "Tracking Medicine". There are some great insights, and I cannot recommend it enough. One of the most striking pieces I came across relates to the belief, now vanished, that tonsillectomy was critical for a healthy childhood:
"The American Child Health Association’s research design used a random sampling of 1,000 New York City school children. On examination by a school physician, 60% were found to have already had a tonsillectomy, and of the remaining 40%, nearly half were deemed in need of the operation. To make sure that no one in need of a tonsillectomy was left out, the association arranged for the children not selected for tonsillectomy to be reexamined by another group of physicians. The second wave of physicians recommended that 40% of these children have the operation. Still not content that unmet need had been adequately detected, the association arranged for a third examination of the twice-rejected children by another group of physicians. On the third try, the physicians produced recommendations that another 44% should have the operation. By the end of the three-examination process, only 65 children of the original 1,000 emerged from the screening examination without a recommendation for tonsillectomy. If the association had put those 65 children through additional rounds of examination, it seems likely that virtually every last one would have been recommended for surgery, a thought that gives new meaning to the phrase “no child left behind.”
While we may laugh at such a practice, are we really that different? Look at the variation you practice yourself, let alone the variation amongst your colleagues, and then remember that the variation within an institution is far less than variation between hospitals. As Wennberg says,

"Thus regions have characteristic “surgical signatures” and regions with high rates of a surgery in the early 1990s still tend to have high rates today, and the cumulative effect is to expose large numbers of patients to surgical interventions that they may or may not have wanted." 

To screen or not to screen? That is the question.

Screening arouses great passion, well greatish. Sticking to prostate cancer, there has been a back and forth argument for many years. There is no doubt that using prostate specific antigen testing detects many cancers; however the key question remains whether finding these cancers impacts survival. In other words, would many of these men die with rather than because of their prostate cancer. According to Wennberg, if 1000 men are screened for 10 years, 1 cancer will be found and treated successfully, 4 men will die of their cancer regardless and 50 men will be over-diagnosed and over-treated.
A study just published finds that over a 20 year period, there is no differnece in death rate form prostate cancer between those screened and unscreended.
Again, this points to the potential for reducing variation and reducing costs in healthcare.


There is increasing interest in the benefits of simulation to ensure improved outcomes in healthcare. A piece in the Economist piqued my interest in this area. They describe a story I had never heard before, involving the role of former US President Jimmy Carter in dealing with a reactor meltdown in Canada in 1952. Carter led a 23 man team to disassemble a reactor near Ottawa that partially melted down. Such was the radiation exposure that each person was limited to 90 seconds at the core. To ensure that the process went as smoothly as possible in such adverse conditions,
"The team built an exact replica of the reactor on a nearby tennis court, and had cameras monitor the actual damage in the reactor's core. "When it was our time to work, a team of three of us practised several times on the mock-up, to be sure we had the correct tools and knew exactly how to use them. Finally, outfitted with white protective clothes, we descended into the reactor and worked frantically for our allotted time," he wrote. "Each time our men managed to remove a bolt or fitting from the core, the equivalent piece was removed on the mock-up."
The take home message is no surprise, simulation to be successful must be as realistic as possible, with real time feedback. A paper published in January in PCCM reports that with increasing use of simulation of cardiac arrest in a children's hospital, survival post cardiac arrest increased to 50%, substantially above the national average.

Saturday, April 2, 2011

Bertrand Russell on the scientific method

"Aristotle maintained that women have fewer teeth than men; although he was twice married, it never occurred to him to verify this statement by examining his wives' mouths"

Friday, April 1, 2011

Dr Yoda & the Pirates of the Caribbean

Rather than review some health related news stories, I thought Dr ZDogg would do a better job.
Have a great weekend.

Angry Bird Medicine

A wonderful title to a great blog entry on the BMJ blogs site. Talking about reducing medicine to an App that can be downloaded to ones phone. He has a fantastic quote, “6 years of medical school and 10 years of training can now be put onto an App and sold for a few dollars – where did I go wrong?”

I dont think a 99 cent app on your phone is going to take the place of a doctor just yet, but the natural progression is that knowledge becomes a commodity, it moves down the value chain, and it no longer becomes cost effective for a particular expert to broker that knowledge. So for example, there is no reason why someone with hypertension cant be monitored at home, blood pressure readings relayed by phone to a central station and feedback given around diet, medications etc, all without the person ever leaving home.

Disruptive Innovation & healthcare education

One of the great difficulties in bringing safety and quality to the fore in healthcare is that although it impacts everyone, no specialty sees it as their responsibility to take the lead, itself a damning sign of the inability of the profession to see the critical merits of teamwork and systems thinking. The IHI set up its Open School some years ago in an attempt to bring this knowledge directly to healthcare students. My impression is that it is certainly proving successful, but it is the nature of such developments to take many years to fully bear fruit. But bear fruit it will. The message is too compelling and students will naturally ask why they are not being exposed to this area by their own teachers. It's all part of a bottom up approach to change. As an example, I suggest you check out this video, part of the course materials for the Open School.

Learned Helplessness

It has struck me repeatedly that there is a huge degree of learned helplessness in the public sector around the world. I am unsre why this should be the case. Does it reflect a risk averse culture? An overly bureaucratic one in which every action must be backed by a memo? Who knows? The great pity is that one of the great motivating forces for skilled professionals is to have pride and autonomy on their work. See the video, (thanks John F) for a great example of the phenomenon.

Public Reporting of Surgical Outcomes

In this weeks Lancet, a discussion around public reporting of surgical outcomes. Specific mention is made of the Society for Cardiothoracic Surgery in Great Britain and Ireland. Since 2005, the society has made outcome data freely available to the public; this has been associated with a 50% reduction in risk adjusted mortality, i.e. half as many people have died as would have been expected to die.

In terms of cost savings, the program costs £1.5 million annually, but is estimated to save £5 million per year in reduced length of stay costs.

While clinicians may be resistant to public reporting of data, it is inevitable. My opinion is that it is better to be proactive, seek to develop such databases and ensure the data represents as accurately as possible the reality, i.e. risk adjusted. 

Trends in youth mortality around the world

Published in The Lancet today, an analysis of WHO data looking at mortality trends in children and young adults around the world over the last 50 years. There have been dramatic improvements in mortality reduction around the world, as much as a 93% reduction in children aged 1-4. The smallest reduction occurred in young men, aged 15-24. More focus should be directed on reducing mortality in this group. However, this is a very encouraging and optimistic paper, showing that greta work can be achieved.

Statistics for dummies.

For anyone who love data, check this out. Rosling is magnificent and can summarise in 4 minutes of pictures what may are unable to do in a book. Wealth increases health.
Also see his website. www.gapminder.org

Reduced work hours for doctors

In both Europe and the US, there has been a push to reduce the hours worked by doctors. This has been based on the belief that tired doctors make more mistakes. An article in this weeks BMJ points out that to date there is no evidence that these measures have brought about an improvement in safety. Why should this be? There are many possible explanations, but in my view, these reductions in working hours have been implemented without taking a fundamental look at how doctors work. in other words, a dramatic change in work hours should have been accompanied by a radical restructuring of shifts, handovers, continuity and so on. It is likely that this has not occured. The other problem is that junior doctors work hour and patterns evolved to match those of senior physicians. The work patterns of these senior doctors also needs to be considered and modified.

Thank you for the music

Falls are an major problem for the elderly. An interesting piece in this weeks Archives of Internal Medicine reports that using music to in effect co-ordinate walking substantially reduces the risk of falls in a community based elderly population.