Don t let falls get you down

Transcription

1 19 February 2013 Don t let falls get you down Dr Sarah J Jones, Consultant, Environmental Health Protection, Public Health Wales Insert name of presentation on Master Slide

2 Structure Epidemiology Evidence Conclusions / Recommendations

3 Background Lots of work already going on at various levels and through various organisations, e.g. NLIAH? Evaluated and effective?? Evidence based?? Coherent, joined-up? Much of what we currently do is reactive

4 Epidemiology of falls Summary of falls epidemiology, adapted from Rubenstein and Josephson (2002), Cummings and Melton (2002), Peel et al (2002)

5 Estimated population changes Based on population of each HB and population projections 60+ population estimates % change in total 60+ Wales % Betsi Cadwaladr % Powys % Hywel Dda % Abertawe Bro Morgannwg % Cwm Taf % Cardiff and Vale % Aneurin Bevan %

6 Predicting falls incidence Assumes Epidemiological data are generaliseable to Wales All older people are community dwelling Therefore data are under-estimates No interventions are in place that reduce incidence Over-estimate / evidence of effectiveness

7 Wales Epidemiology ? 100 community dwelling older people 765,200 people aged over ,100 people aged over to 60 suffer a fall each year 230,000 to 460,000 suffer a fall each year 247,200 to 494,5000 suffer a fall each year 15 to 30 fall more than once 115,000 to 230,000 fall more than once 123,600 to 247,200 fall more than once 2 to 6 suffer fracture, head injury, serious laceration 11,500 to 45,900 suffer fracture, head injury, serious laceration 12,400 to 49,400 suffer fracture, head injury, serious laceration

8 Deaths and death rates per 100,000 by cause, 2009 No. Deaths % of all injury deaths Crude Rate EASR (95% confidence intervals) MVTC (3.3 to 4.8) Fall (4.2 to 5.6) Drowning (0.6 to 1.3) Burns (0.5 to 1.1) Firearm Cut / pierce Struck by / against Poisoning (4.5 to 6.3) Other / unspecified (11.2 to 13.6) Total 1, (27.0 to 30.7) Produced by Public Health Wales and Swansea University, using ADDE & MYE (ONS)

9 Numbers of in-patient admissions and rates per 100,000 by cause, 2009 No. admissions % of all injury Crude Rate EASR (95% confidence intervals) MVTC 1, (52.8 to 58.3) Fall 20, (512.6 to 528.4) Drowning (0.6 to 1.4) Burns (13.4 to 16.4) Firearm (1.6 to 2.8) Cut / pierce 2, (73.1 to 79.6) Struck by / against 3, (134.0 to 142.9) Poisoning 7, (257.7 to 269.9) Other / unspecified 6, (217.7 to 229.0) Total 42, , ,295.6 (1,282.5 to 1,308.8) Produced by Public Health Wales and Swansea University, using PEDW (NWIS) & MYE (ONS)

10 Number Emergency Department attendances and rates per 100,000 by cause, 2009 No. ED attendances % of all attendances Crude Rate EASR (95% confidence intervals) MVTC 12, (452.8 to 468.9) Fall 44, , ,446.5 (1,432.4 to 1,460.7) Drowning Burns (32.2 to 36.8) Firearm Cut / pierce 1, (54.0 to 59.7) Struck by / against 7, (274.4 to 287.0) Poisoning (30.3 to 34.6) Other / unspecified 375, , ,684.9 (12,643.0 to 12,727.0) Total 444, , ,996.9 (14,951.3 to 15,042.6) Produced by Public Health Wales and Swansea University, using EDDS (NWIS) & MYE (ONS)

11 MVTC Fall Drowning Burns Firearm Cut / pierce Struck by / against Poisoning Other / unspecified Years Burden of injury by cause, Wales, 2009 Produced by Public Health Wales Observatory, using PEDW (NWIS) & ADDE (ONS) 25,000 Years of life lost Hosp years lived with disability Non hosp years lived with disability 20,000 15,000 10,000 5,000 0

12 Summary estimate of epidemiology of falls in Wales in 2009 Produced by Public Health Wales and Swansea University, using EDDS & PEDW (NWIS), ADDE (ONS) 252 Deaths 20,058 In-patient admissions 44,257 Attendances at Emergency Department

13 Death rate per 100,000 Fall fatality rates by age and sex, 2009 Produced by Public Health Wales and Swansea University, using ADDE & MYE (ONS) 140 Males Fem ales Age band

14 Rate per 100,000 Fall related in-patient admission rates, by age and sex, 2009 Produced by Public Health Wales and Swansea University, using PEDW (NWIS) & MYE (ONS) Males Fem ales 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Age band

15 Rate per 100,000 Fall related emergency department attendance rates, by age and sex, 2009 Produced by Public Health Wales and Swansea University, using EDDS (NWIS) & MYE (ONS) Males Fem ales 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Age band

16 Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pem brokeshire Carm arthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monm outhshire Newport Fall related admission rates, European age-standardised rates per 100,000 population and 95% confidence intervals, by local authority, 2009 Produced by Public Health Wales and Swansea University, PEDW (NWIS) & MYE (ONS) Wales = % confidence interval

17 Rate per 100,000 Local authority areas with the highest and lowest fall related in-patient admission rates per 100,000 population, 2009 Produced by Public Health Wales and Swansea University, using PEDW (NWIS) and MYE (ONS) 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Males Blaenau Gwent Fem ales Merthyr Tydfil 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Vale of Glamorgan Cardiff Age band

18 Years Relative burden of fall injuries in Wales, by sex and age, 2009 Produced by Public Health Wales and Swansea University, using PEDW (NWIS), ADDE (ONS) 1,200 Males Years of life lost Non hosp years lived with disability Hosp years lived with disability Females Years of life lost Non hosp years lived with disability Hosp years lived with disability 1, Age band Age band

19 Epidemiology part 2 Mortality estimates Around 200 deaths pa Significant underestimate In-patient burden ICD-10 codes specified All Wales data Welsh residents Trends in admissions / FCEs by age and sex, also LoS and bed days Some estimate of costs per bed day Management of expectations

20 Effect of preventing falls All Wales Current 5% effect of prevention 25% effect of prevention % Admissions % Admissions Average n occurring n occurring All admissions % % Injury admissions % % Total falls % % General falls % % General fall admissions prevented pa - mean Mean bed days per admission Mean bed days avoided Cost saving (@ per bed day; M)

21 Effect of reducing bed days Beddays per adm n Reduce beddays by 0.5 per general fall adm n Reduce beddays by 1 per general fall adm n All Wales Adm ns Beddays n % n % Total % % Injury admissions % % Total falls % % General falls % % Change in total beddays Cost saving (@ per bedday; M)

22 Epidemiology limitations IP data based on external cause codes 10% of injury discharges lack an external cause code Avoid paralysis by analysis

23 Evidence - basis Community strategies NICE, ProFaNE, AGS / BGS guidance Vast amount of information available Not possible to review evidence independently Structure loosely based on NICE

24 Evidence...

25 Evidence 2 Fraser and Dunstan, BMJ, Dec k journals, increases 3.5% pa 1.5M articles published in 2009 Echocardiography 5 papers per hour, 8 hours per day, 5 days per week 11 years, 124 days By the end years, 295 days, 408,049 papers

26 Evidence falls Fall textword Limit to 2000 to 2013 Returns 8531 articles 5 papers per hour, 8 hours per day, 5 days a week 200 articles per week Falls Prevention

27 Nature of interventions Individual multi-factorial Population based multi-factorial Population based single factor

28 Screening / risk assessment NICE (2004) Older people in contact with health care professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the falls

29 Risk assessment (2) NICE guideline group supports older people being asked about falls risk on an annual basis. AGS / BGS - annual screening A lack of hard evidence to support this position Current approaches require people to suffer injurious falls first NSC has no position on falls

30 Falls pathway Need to be picked up Community dwelling older population Falls risk factors Absent Present Gait or balance problems Other falls risk factors Not fallen Fall No / unseen / minor untreated injury Minor injury Major injury No further action GP A and E In-patient Home Falls risk factors present Death Care home Key:- Grey boxes indicate areas where interventions have historically been delivered and where work is currently underway. These include work by NLIAH and WAST. Yellow boxes indicate where the evidence base has demonstrated that intervention is effective and available in addition to what is already being done.

31 Older people living in Wales Primary care Falls case identification process Low risk of falling Faller or at risk of falling Consider general population intervention Falls risk assessment No further action at this time Recall in 1 year?

32 Screening / risk assessment (4) Once identification process is resolved a series of algorithms are available to carry out multi-factorial risk assessment Supported by evidence base

33 Gait and balance assessment Assessmen t options Gait problems increase risk of falling by 2.0 to 2.2 times Balance problems increase risk of falling by 1.8 to 3.9 times Do you have any problems with walking or balance? Screening tests No Yes See screening test algorithm Consider general population intervention Gait and / or balance problem identified (consider foot / footwear problems) No gait and / or balance problem Reason for problem known Reason for problem not known Consider general population intervention Check management, make changes if needed Balance / Exercise training programme Referral to specialist for further assessment if necessary Referral to specialist for further assessment

34 Multi Factorial assessment No definitive agreement around components Combined NICE, ProFaNE, AGS / BGS Full assessment likely to take considerable time Suggests need for specialist role in primary care Appropriate referrals needed High risk referred for more comprehensive assessment, lower risk managed through primary care

35 Population level approaches Multi factorial Include information and education, home hazard reduction, exercise programmes, policy change 6% to 33% reduction in fall injuries Not clear what each component contributes Single factor Exercise Reduces falls by 22% (sig) Education No clear evidence of effectiveness

36 Multi v Single factor Effect on falls similar with both approaches Conclusion that single interventions most acceptable and more easily targeted What about tai chi?

37 Cost effectiveness Lack of evidence at global level Would take considerable time and effort to generate such information in Wales What about tai chi?

38 Effective interventions

39 Effective interventions

40 No effect interventions

41 Evidence - problems Difficulties with translating effect sizes seen in research projects into real world

42 Conclusions Burden of falls is significant and likely to increase Coherent, high quality approach Intervention needed at all levels of prevention Expectations of what is likely to be possible need to be managed Without high quality ED data, impact will never be measureable

43 Recommendations Stand up against falling down Population level understanding that falls can be prevented Stop never fallers from becoming ever fallers Population level exercise Take a proactive approach to risk assessment Primary care screening Take a one day sooner approach to fallers admitted to hospital Ensure that current practice is good practice

44 Next steps Identify and evaluate services already in place Recommendations do not need to all be implemented at once Develop an approach to implementation that is supportive and collaborative Population level programmes need to be put in place Including ED data quality

45 Final thoughts Don t let falls get you down... Have a word.. Empower the public and professionals Treat the faller, not just the injury We don t ignore angina... There is no quick fix Long, complicated, collaborative process