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
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