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 Fa lls 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) Fall with minor injury Hip fracture, 3 weeks in hospital Hip fracture, discharge to aged residential care $600$47,000$135,000

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. Osteoporos Int 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. Muscle weakness4.9(1.9–10.3) Balance deficit3.2(1.6–5.4) Gait deficit3.0(1.7–4.8) Visual deficit2.8(1.1–7.4) Mobility limitation2.5(1.0–5.3) Cognitive impairment2.4(2.0–4.7) Postural hypotension1.9(1.0–3.4) Psychotropic medications1.7(1.5–2.0 ) Rubenstein LZ et al. Age Ageing 2006;35-S2:ii37-41

10. History of falls3.0(1.7–7.0) Age >80 years1.7(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

11. 11 www.cochranejournalclub.com Results: exercise programmes

12. 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 classes1636220.71 (0.63 to 0.82)29% Home based79510.68 (0.58 to 0.80)32% Tai Chi classes515630.72 (0.52 to 1.00)28% Tai Chi classes, not at high risk of falls 310080.59 (0.45 to 0.76)41%

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

14. 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 642080.81 (0.68 to 0.97)19% Higher risk of falling38510.62 (0.50 to 0.77)38% Not selected on falls risk333570.94 (0.84 to 1.05)6% Delivered by OT414430.69 (0.55 to 0.86)31% Not delivered by OT430750.91 (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.

15. Vitamin D supplements No. of trials No. of participants Rate ratio (95% CI) Reductio n in falls (%) All trials community living793241.00 (0.90 to 1.11)0% Selected for low levels22600.57 (0.37 to 0.89)43% Not selected for low levels590641.02 (0.93 to 1.13)(+2%) Aged care residents546030.63 (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

16. Multifactorial approach -target person’s risk factors No. of trials No. of participant s Rate ratio (95% CI) Reduction in falls (%) Community living1995030.76 (0.67 to 0.86)24% Hospital inpatients464780.69 (0.49 to 0.96)31% Aged care residents728760.78 (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

17. 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

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 Geriatr Soc 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 N ote: not necessarily a causal link

23. 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

24. 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%213-5491.910% Vitamin D supplements (aged care residents) 37%Minimal7.0 (to ACC) Not available Home safety by OT (previous faller on hospital discharge) 36%251-369Not available 4.7% Tai Chi classes (≥70 years)28%303-3691.60.5% Falls clinic (presenting to ED after a fall) 59%18701.02.0%

25. 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 impairme nt 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 resident s

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 