Falling costs: the case for investment

1. 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

2. 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)

3. 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

4. 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 falls • Restriction of activities • Reduced mobility and loss of physical function • Admission to aged residential care

5. 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)

6. Projected fall-related hospital admissions ≥65 years, NSW, Australia, 2008 to 2051 Watson WL et al. J Safety Res 2011;42:487-92

7. Period effect for hip fracture incidence in New Zealand women from 1974 to 2007 and predicted incidence in 2025 Langley J et al. OsteoporosInt 2011;22:105-11

8. 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

9. 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

10. Risk factors for fallsMean relative risk (95% CI) • History of falls 3.0 (1.7–7.0) • Age >80 years 1.7 (1.1–2.5) 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 ? Panel on Falls Prevention. J Am GeriatrSoc 2001;44:664-72 Lamb SE et al. J Am GeriatrSoc 2005;53:1618-22

11. Results: exercise programmes www.cochranejournalclub.com

12. Multi-component exercise programmes reduce falls Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146

13. Results: home safety programmes www.cochranejournalclub.com

14. Home safety assessment and modification programmes 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.

15. Vitamin D supplements No need for a blood test. Assume low level of vitamin D if housebound, requires support services, resident in aged care, frailand 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

16. Multifactorial approach-target person’s risk factors 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

17. Otago Exercise Programme • 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 Instructor’s manual: www.acc.co.nz/otagoexerciseprogramme

18. 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 GeriatrSoc 2008;56:1821-30

19. 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

20. 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

21. MidCentral DHB aged residential care-vitamin D dispensed

22. ACC claims for falls in aged residential care Note: not necessarily a causal link

23. Economic evaluations within randomised controlled trials Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146 Preventing falls saves healthcare costs in 1 year Otago Exercise Programmecost saving in ≥80 year olds living at home Home safety programmecost 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)

24. Return on investment

25. Recommended strategies • Multiple-component exercise programmes • Otago Exercise Programme (≥80 years, delivered at home) • Group classes (≥75 years) • Tai Chi classes (for more active older people) • Vitamin D supplements for all older people with a risk factor for low levels of vitamin D • Home safety assessment and modification by OT • Previous faller discharged from hospital • Severe visual impairment • 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

26. 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 