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 events for
older people
(%)
Fall(s) in previous year:



35% of 65–79 year olds
45% of 80–89 year olds
55% of 90+ year olds
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 falls
 Restriction of activities
 Reduced mobility and loss of physical function
 Admission to aged residential care
Falls cost $$$
Fall with
minor injury
Hip fracture,
3 weeks in hospital
Hip fracture, discharge to
aged residential care
$600
$47,000
$135,000

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)
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
Period effect - Females
20
observed
scenario_a
scenario_b
15
10
5
Period
Langley J et al. Osteoporos Int 2011;22:105-11
2025
2003-07
1998-02
1993-97
1988-92
1983-87
1978-82
1974-77
1
0
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








Muscle weakness
Balance deficit
Gait deficit
Visual deficit
Mobility limitation
Cognitive impairment
Postural hypotension
Psychotropic medications
4.9
3.2
3.0
2.8
2.5
2.4
1.9
1.7
(1.9–10.3)
(1.6–5.4)
(1.7–4.8)
(1.1–7.4)
(1.0–5.3)
(2.0–4.7)
(1.0–3.4)
(1.5–2.0)
Rubenstein LZ et al. Age Ageing 2006;35-S2:ii37-41
Risk factors for falls


History of falls
Age >80 years
3.0
1.7
(1.7–7.0)
(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 Geriatr Soc 2001;44:664-72
Lamb SE et al. J Am Geriatr Soc 2005;53:1618-22
Results: exercise programmes
www.cochranejournalclub.com
11
Multi-component exercise
programmes reduce falls
No. of
trials
No. of
Rate ratio (95% CI)
participants
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%
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146
Results: home safety programmes
www.cochranejournalclub.com
13
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%)
5
4603
0.63 (0.46 to 0.86)
37%
Aged care residents
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146
Cameron ID et al. Cochrane Database Sys Rev 2012;12:CD005465
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.
Multifactorial approach
-target person’s risk factors
No.
No. of
of
participant
trials
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%
Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146
Cameron ID et al. Cochrane Database Sys Rev 2012;12:CD005465
Assessment of the individual, then treatment based on individual’s risk factors
Otago Exercise Programme

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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

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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
Otago Exercise Programme

Cost saving in ≥80 year olds living at home


Best value for money


Hektoen LF et al. Scand J Pub Health 2009;37:584-9
55% reduction in risk of death


Davis JC et al. Br J Sports Med 2010;44:80-9
Reduction in healthcare costs =1.9 x cost of delivery


Robertson MC et al. BMJ 2001;322:697-701
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
100%
90%
80%
Target = 75%
70%
69%
60%
62%
70%
71%
74%
63%
57%
50%
53%
40%
39%
30%
20%
10%
15%
0%
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
16000
80%
14000
70%
12000
60%
10000
50%
8000
40%
6000
30%
4000
20%
2000
10%
0
0%
2006/07
2007/08
2008/09
ACC Financial Year (July to June)
65+ residential falls
Note: not necessarily a causal link
2009/10
Vitamin D prescribing
2011/12
Percentage of Vitamin D Prescribing
Number of 65+ fall claims by those in
residential care
ACC claims for falls in ARC vs Vitamin D prescribing
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 investment
Intervention (target group)
Reduction
in falls
(%)
Cost
per
client
($NZ
2008)
Return on Reduction in
investment fall related
in 1 year
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%
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
4.

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
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 