Summary of findings 4. Summary of findings: Multifactorial interventions compared with usual care in care facilities.

Multifactorial interventions compared with usual care for falls prevention in care facilities
Population and setting: older (≥ 65 years) residents of care facilities Intervention: multifactorial interventions (two or more categories of intervention given based on individual risk profile) Comparison: usual care (without intervention)1
Outcomes	Illustrative comparative risks* (95% CI)		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Vitamin D
Rate of falls Length of follow‐up: 6 to 12 months	Low‐risk population2		RaR 0.88 (0.66 to 1.18)	3439 (10 studies)	+ooo VERY LOW8	One additional study (31 participants) of exercise plus nutritional support reported zero falls in the intervention arm and two in the control arm.
	1000 per 1000 py	720 (550 to 950)per 1000 py
	High‐risk population3
	3500 per 1000 py	2520 (1925 to 3325)per 1000 py
Risk of falling Length of follow‐up: 6 to 12 months	Low‐risk population4		RR 0.92 (0.81 to 1.05)	3153 (9 studies)	++oo LOW9	One additional study (482 participants) reported a reduction in the proportion of recurrent fallers (difference 19%, 95% CI 2% to 36%: P = 0.03).
	250 per 1000	230 (190 to 280)per 1000
	Moderate‐risk population5
	500 per 1000	460 (380 to 515)per 1000
	High‐risk population6
	700 per 1000	644 (532 to 784)per 1000
Risk of fracture Length of follow‐up: 6 to 12 months	Average risk population7		RR 0.79 (0.30 to 2.07)	2160 (5 studies)	+ooo VERY LOW10
	42 per 1000	34 (13 to 87) per 1000
Adverse events Length of follow‐up: 11 weeks to 12 months	See comment	See comment	Not estimable.	312 (3 studies)	+ooo VERY LOW11	One trial reported a case of a fall in the intervention arm; two studies reported no adverse events.
*Illustrative risks for the control group were derived from all or subgroups of trials in care facilities reporting the outcome. The exact basis for the assumed risk for each outcome is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; py: person years; RaR: Rate Ratio; RR: Risk Ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

¹ Nine of 11 trials described the control arm as usual care not receiving the intervention. In one trial contributing data to the risk of falling and fracture, the control arm received multidisciplinary assessment without the intervention in addition to usual care; in one trial contributing data to the rate of falls and risk of falling, the control included reminiscence therapy.

² Low risk was based on the mean control risk of the 17 (bottom third) trials with the lowest rate of falls. The mean rate of falls = 1.07, rounded to 1.0 per person year; thus 1000 per 1000 person years.

³ High risk was based on the mean control risk of the 18 (top third) trials with the highest rate of falls. The mean rate of falls = 3.69, rounded to 3.5 per person year; thus 3500 per 1000 person years.

⁴ Low risk was based on the mean control risk of the 20 trials with the lowest risk of falling. The mean risk of falling = 0.268, rounded to 0.25; thus 250 per 1000 people.

⁵ Moderate risk was based on the mean control risk of the 20 trials reporting a moderate risk of falling, not described as high‐risk populations. The mean risk of falling = 0.539, rounded to 0.5; thus 500 per 1000 people.

⁶ High risk was based on the mean control risk of the 13 trials reporting a high risk of falling, including populations with a description as a high‐risk population. The mean risk of falling = 0.680, rounded to 0.7; thus 700 per 1000 people.

⁷ Risk based on the median control risk of fracture of the trials reporting this outcome. Median risk = 0.042; thus 42 per 1000.

⁸ The quality of the evidence was downgraded one level for serious risk of bias (including high risk of performance and attrition bias and baseline imbalance), one level for serious inconsistency (high heterogeneity I² = 84%) and one level for imprecision (wide CIs despite large N).

⁹ The quality of the evidence was downgraded one level for serious risk of bias (including high risk of performance and attrition bias and some uncertainty in selection bias) and one level for inconsistency (inconsistency in point estimates between studies).

¹⁰ The quality of the evidence was downgraded one level for serious risk of bias (including high risk of performance and attrition bias and baseline imbalance), one level for inconsistency (moderate heterogeneity, I² = 60%, P = 0.04) and two levels for imprecision (extremely wide confidence intervals)

¹¹ The quality of the evidence was downgraded two levels for serious risk of bias (2 of 3 trials had a high risk of baseline imbalance or incomplete outcome data), two levels for imprecision (not powered for rare events) and two levels for other reasons (concerns that adverse events were not recorded systematically and few studies reported this outcome).