Kupu Taurangi Hauora o Aotearoa

What it means to fall • leading cause of injury in 65+ year olds • loss of confidence, fear of further falls

• for frail elderly with osteoporotic fractures • almost 50% will require long term care • 25% die early

Trends in inpatient falls reported as SSEs

Ministerial expectations 2012/2013

• set targets for falls reduction – work with DHBs – take a sector-wide view – provide evidence to underpin programmes – monitor and evaluate

What work is already being done?

Findings in the ‘mapping project’

• many organizations had well developed programmes and reporting systems, some do not

• no standardization or consistency in strategies (or measurement) used nationally, regionally or within districts

A key recommendation

• that key stakeholders collaborate to direct the development of approaches, tools and resources which can be applied consistently at national, regional and local levels.

broadly based Expert Advisory Group set up

defined scope of programme in relation to

• ACC leadership for New Zealand Injury Prevention Strategy and National Falls Prevention Strategy

• the Commission’s brief for Health Quality and Safety

• the direction to work across the sector

REDUCING HARM FROM FALLS a national programme to reduce harm from falls in care settings

Where do costs/volumes lie? Findings in the NZIER report

Accepted ACC claims for falls 2010/2011

DHB inpatients (2,600)

Residential care (10,500)

Community (551,500)

TRIPLE AIM Individual Improved quality, safety and experience of care System Improved health and equity for all populations Population Best value for public health resources.

Falling costs:

the case for

investment

Report to Health Quality and Safety Commission

December 2012

M. Clare Robertson

A. John Campbell University of Otago

Dunedin, 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 and costly

35% of 65–79 year olds

45% of 80–89 year olds

55% of 90+ year olds

0

10

20

30

40

50

60

65–79 80–89

Age

90+

(%)

Fall(s) in previous year:

Campbell AJ et al. Age Ageing 1981;10:264–70

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

erio

d)

1974

-77

1978

-82

1983

-87

1988

-92

1993

-97

1998

-02

2003

-07

2025

Period

observed

scenario_a

scenario_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

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

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

Recommended strategies

1. 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

Return on investment

Intervention (target group) Reduction

in falls

(%)

Cost

per

client

($NZ

2008)

Return on

investment

in 1 year

Reduction in

fall related

hospital

admissions

aged 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%

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

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

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%

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

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 supplements

No. of

trials

No. of

participants

Rate ratio

(95% CI)

Reductio

n 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:CD007146

Cameron ID et al. Cochrane Database Sys Rev 2012;12:CD005465

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 2011/12

ACC Financial Year (July to June)

Nu

mb

er

of

65+

fall

cla

ims b

y t

ho

se i

n

resid

en

tial

care

0%

10%

20%

30%

40%

50%

60%

70%

80%

Perc

en

tag

e o

f V

itam

in D

Pre

scri

bin

g

65+ residential falls Vitamin D prescribing

Note: not necessarily a causal link

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:CD007146

Cameron ID et al. Cochrane Database Sys Rev 2012;12:CD005465

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

Preparing a useful resource

What would be helpful?

What FAQs?