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

1Rat

e ra

tio (r

elat

ive

to 1

978-

82 p

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d)

1974

-77

1978

-82

1983

-87

1988

-92

1993

-97

1998

-02

2003

-07

2025

Period

observedscenario_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

11www.cochranejournalclub.com

Results: exercise programmes

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%

13

Results: home safety programmes

www.cochranejournalclub.com

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%

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30%

40%

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70%

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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

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2006/07 2007/08 2008/09 2009/10 2011/12ACC Financial Year (July to June)

Num

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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

Key message Spend money on falls prevention

Benefit health, safety, and independence of older person

Benefit to family, formal and informal carers, health professionals, community

Cost savings for providers, health system Do nothing?

Unthinkable! Falls and injuries