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Falling costs: the case for investmentReport to Health Quality and Safety Commission December 2012
M. Clare RobertsonA. John CampbellUniversity of OtagoDunedin, New Zealand
Why invest in falls prevention?Overview of reasons
Falls and injuries in older people are common Increasing numbers, costs, as population ages Falls can be prevented (evidence from 220
randomised controlled trials) Need to maintain independence and quality of life Effective, targeted strategies represent good value
for money (cost savings in 1 year)
Falls are common events for older people
35% of 65–79 year olds 45% of 80–89 year olds 55% of 90+ year olds
(%)
Fall(s) in previous year:
Campbell AJ et al. Age Ageing 1981;10:264–70
Impact of falls
Leading cause of injury in ≥65 year olds Fractures, traumatic brain injuries, death
Older people have the highest risk of early death or serious injury from a fall
Falls result in:Loss of confidence, fear of further fallsRestriction of activitiesReduced mobility and loss of physical functionAdmission to aged residential care
Falls cost $$$
47,000 fall related discharges in New Zealand, $205m (public hospitals) per annum Over half were aged 65+ 86% of 65+ community living (from NSW data)
49% of spending on fall related healthcare in older population is for hospital inpatients, 41% for aged residential care (UK study)
Fall with minor injury
Hip fracture,3 weeks in hospital
Hip fracture, discharge to aged residential care
$600 $47,000 $135,000
Projected fall-related hospital admissions ≥65 years, NSW, Australia, 2008 to 2051
Watson WL et al. J Safety Res 2011;42:487-92
Period effect for hip fracture incidence in New Zealand women from 1974 to 2007 and predicted incidence in 2025
Langley J et al. Osteoporos Int 2011;22:105-11
0
5
10
15
20
1Rate
ratio
(re
lative
to 1
978
-82 p
erio
d)
197
4-7
7
197
8-8
2
198
3-8
7
198
8-9
2
199
3-9
7
199
8-0
2
200
3-0
7
202
5
Period
observed
scenario_ascenario_b
Period effect - Females
Investing in falls prevention
Biggest potential for cost saving occurs in community living older people ED presentations Hospital admissions Admissions to aged residential care
Spend money on proven strategies only Careful targeting gives best value for money
Risk factors for falls Mean relative risk (Range)
Muscle weakness 4.9 (1.9–10.3) Balance deficit 3.2 (1.6–5.4) Gait deficit 3.0 (1.7–4.8) Visual deficit 2.8 (1.1–7.4) Mobility limitation 2.5 (1.0–5.3) Cognitive impairment 2.4 (2.0–4.7) Postural hypotension 1.9 (1.0–3.4) Psychotropic medications 1.7 (1.5–2.0)
Rubenstein LZ et al. Age Ageing 2006;35-S2:ii37-41
Risk factors for falls Mean relative risk (95% CI)
History of falls 3.0 (1.7–7.0) Age >80 years 1.7 (1.1–2.5)
Panel on Falls Prevention. J Am Geriatr Soc 2001;44:664-72
Just one question – a powerful risk assessment:In the last year, have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level ?
Lamb SE et al. J Am Geriatr Soc 2005;53:1618-22
Multi-component exercise programmes reduce falls
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146
No. of trials
No. of participants
Rate ratio (95% CI) Reduction in falls (%)
Group classes 16 3622 0.71 (0.63 to 0.82) 29%
Home based 7 951 0.68 (0.58 to 0.80) 32%
Tai Chi classes 5 1563 0.72 (0.52 to 1.00) 28%
Tai Chi classes, not at high risk of falls
3 1008 0.59 (0.45 to 0.76) 41%
Home safety assessment and modification programmes
No. of trials
No. of participant
s
Rate ratio (95% CI)
Reduction in falls
(%)
Home safety community living, all trials
6 4208 0.81 (0.68 to 0.97) 19%
Higher risk of falling 3 851 0.62 (0.50 to 0.77) 38%
Not selected on falls risk
3 3357 0.94 (0.84 to 1.05) 6%
Delivered by OT 4 1443 0.69 (0.55 to 0.86) 31%
Not delivered by OT 4 3075 0.91 (0.75 to 1.11) 9%
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146
Deliver to those at higher risk of falling because significantly more effective in this subgroup. Significantly more effective if delivered by an OT.
Vitamin D supplementsNo. of trials
No. of participants
Rate ratio (95% CI)
Reduction in falls
(%)
All trials community living 7 9324 1.00 (0.90 to 1.11) 0%
Selected for low levels 2 260 0.57 (0.37 to 0.89)
43%
Not selected for low levels 5 9064 1.02 (0.93 to 1.13)
(+2%)
Aged care residents 5 4603 0.63 (0.46 to 0.86) 37%
No need for a blood test. Assume low level of vitamin D if housebound, requires support services, resident in aged care, frail and dark skin or obese.
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146Cameron ID et al. Cochrane Database Sys Rev 2012;12:CD005465
Multifactorial approach-target person’s risk factors
No. of
trials
No. of participant
s
Rate ratio (95% CI)
Reduction in falls
(%)
Community living 19 9503 0.76 (0.67 to 0.86) 24%
Hospital inpatients 4 6478 0.69 (0.49 to 0.96) 31%
Aged care residents 7 2876 0.78 (0.59 to 1.04) 22%
Assessment of the individual, then treatment based on individual’s risk factors
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146Cameron ID et al. Cochrane Database Sys Rev 2012;12:CD005465
Falls prevention programme with most research internationally
Set of exercises that improve muscle strength and balance Prescribed at home by physiotherapist or nurse Designed and evaluated in New Zealand
4 trials, 1016 participants, aged 65 to 97 Falls and injuries reduced by 35% Used nationally and world wide
e.g. Centers for Disease Control, USA
Otago Exercise Programme
Instructor’s manual:www.acc.co.nz/otagoexerciseprogramme
Otago Exercise Programme
Cost saving in ≥80 year olds living at home Robertson MC et al. BMJ 2001;322:697-701
Best value for money Davis JC et al. Br J Sports Med 2010;44:80-9
Reduction in healthcare costs =1.9 x cost of delivery Hektoen LF et al. Scand J Pub Health 2009;37:584-9
55% reduction in risk of death Thomas S et al. Age Ageing 2010;49:664-72
Significantly improves cognitive performance Liu-Ambrose T et al. J Am Geriatr Soc 2008;56:1821-30
Effective strategies in care Residential aged care facilities (43 trials)
Vitamin D supplements (40% reduction) Exercise programmes? Medication review? Multifactorial interventions?
Hospitals (17 trials) Additional physiotherapy (64% fewer fallers) Unit specialising in geriatric orthopaedic care compared with
standard orthopaedic ward (66% reduction) Individually targeted multifactorial interventions (31% reduction
but effect noted only after 45 days) More falls on carpet than vinyl floors
Cameron ID et al. Cochrane Database Sys Rev 2012;12:CD005465
National programmes
ACC is supporting an injury prevention project for residents in aged residential care Vitamin D supplements
Health Quality and Safety Commission – Reducing Harm from Falls A national programme to reduce harm from falls in
people in care settings
MidCentral DHB aged residential care-vitamin D dispensed
15%
39%
53%57%
62% 63%69% 70% 71%
74%
Target = 75%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12
ACC claims for falls in aged residential care
ACC claims for falls in ARC vs Vitamin D prescribing
0
2000
4000
6000
8000
10000
12000
14000
16000
2006/07 2007/08 2008/09 2009/10 2011/12ACC Financial Year (July to June)
Nu
mb
er o
f 65
+ f
all
clai
ms
by
tho
se i
n
resi
den
tial
car
e
0%
10%
20%
30%
40%
50%
60%
70%
80%
Per
cen
tag
e o
f V
itam
in D
Pre
scri
bin
g
65+ residential falls Vitamin D prescribing
Note: not necessarily a causal link
Economic evaluations within randomised controlled trials
Otago Exercise Programme cost saving in ≥80 year olds living at home
Home safety programme cost saving in ≥65 year olds with a previous fall recently discharged from hospital
Multifactorial intervention at home cost saving in ≥70 year olds (targeting 8 risk factors for falls)
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146
Preventing falls saves healthcare costs in 1 year
Return on investmentIntervention (target group) Reduction
in falls (%)
Cost per
client ($NZ 2008)
Return on investmentin 1 year
Reduction in fall related
hospital admissionsaged 65+
Otago Exercise Programme(community living ≥80 years)
40% 213-549 1.9 10%
Vitamin D supplements (aged care residents)
37% Minimal 7.0 (to ACC)
Not available
Home safety by OT (previous faller on hospital discharge)
36% 251-369 Not available
4.7%
Tai Chi classes (≥70 years) 28% 303-369 1.6 0.5%
Falls clinic (presenting to ED after a fall)
59% 1870 1.0 2.0%
Recommended strategies1. Multiple-component exercise programmes
Otago Exercise Programme (≥80 years, delivered at home) Group classes (≥75 years) Tai Chi classes (for more active older people)
2. Vitamin D supplements for all older people with a risk factor for low levels of vitamin D
3. Home safety assessment and modification by OT Previous faller discharged from hospital Severe visual impairment
4. Multifactorial approach – assessment of the individual, treatment based on identified risk factors Individual presenting to GP, ED with a fall, falls clinic, hospital
admission, aged care residents