Kupu Taurangi Hauora o Aotearoa

Kupu Taurangi Hauora o Aotearoa

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.

REDUCING HARM FROM FALLS a national programme to reduce harm from falls in care settings 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

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 (%) 60 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 50 40 30 20 10 0 65 79 80 89 Age 90+ 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

1974-77 1978-82 1983-87 1988-92 1993-97 1998-02 2003-07 2025 Period effect for hip fracture incidence in New Zealand women from 1974 to 2007 and predicted incidence in 2025 20 15 observed scenario_a scenario_b Period effect - Females 10 5 1 0 Period Langley J et al. Osteoporos Int 2011;22:105-11

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) 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

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) Otago Exercise Programme (community living 80 years) Vitamin D supplements (aged care residents) Home safety by OT (previous faller on hospital discharge) Reduction in falls (%) Cost per client ($NZ 2008) Return on investment in 1 year Reduction in fall related hospital admissions aged 65+ 40% 213-549 1.9 10% 37% Minimal 7.0 (to ACC) 36% 251-369 Not available 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 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% Gillespie LD et al. Cochrane Database Sys Rev 2012;9:CD007146

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

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 Home safety community living, all trials No. of trials No. of participant s Rate ratio (95% CI) Reduction in falls (%) 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% 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.

MidCentral DHB aged residential care -vitamin D dispensed 100% 90% 80% Target = 75% 70% 60% 50% 53% 57% 62% 63% 69% 70% 71% 74% 40% 30% 39% 20% 10% 0% 15% Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12

Number of 65+ fall claims by those in residential care Percentage of Vitamin D Prescribing ACC claims for falls in aged residential care ACC claims for falls in ARC vs Vitamin D prescribing 16000 80% 14000 70% 12000 60% 10000 50% 8000 40% 6000 30% 4000 20% 2000 10% 0 2006/07 2007/08 2008/09 2009/10 2011/12 ACC Financial Year (July to June) 65+ residential falls Vitamin D prescribing 0% 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% 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

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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