Optimisation of ACC's fall prevention programmes for older people FINAL REPORT

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1 Optimisation of ACC's fall prevention programmes for older people FINAL REPORT November 2008 M. Clare Robertson, PhD BSc(Hons) BCom A. John Campbell, MD FRACP Dunedin School of Medicine, University of Otago Dunedin, New Zealand Contact details: Associate Professor Clare Robertson Department of Medical and Surgical Sciences Dunedin School of Medicine, PO Box 913 Dunedin 9054, New Zealand Phone: ext 8508 Fax:

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3 CONTENTS SUMMARY POINTS AND RECOMMENDATIONS 1 PURPOSE OF THIS PROJECT 4 PROJECT OBJECTIVES 4 REPORT OVERVIEW 7 SUMMARY OF FINDINGS FROM SYSTEMATIC REVIEWS 8 Interventions for community dwelling older people 8 Interventions in long term care and hospital settings 10 Preventing injury from falls 11 Relative cost effectiveness of interventions 13 Rationale for choice of interventions to be modelled 15 ESTIMATED IMPACT OF EFFECTIVE STRATEGIES 16 General approach 16 Methods and model assumptions 16 Otago Exercise Programme 20 Group exercise programmes 20 Multicomponent group exercise 20 Tai chi classes 25 Home safety assessment and modification 27 Cataract surgery 31 Assessment and multifactorial intervention 31 Multiple interventions 34 Multifaceted small group learning 34 Population approach 34 Limitations of modelling methods 37 Modelling falls strategies for the Australian population 39 RECOMMENDED STRATEGIES 41 REFERENCES 43 APPENDICES A Timeline for project B Methods used in systematic reviews C Interventions for community dwelling older people: systematic review D Interventions in long term care and hospital settings: systematic review E Preventing injury from falls: selected issues F Relative cost effectiveness of interventions: systematic review G Tables of ACC claims and costs

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5 SUMMARY POINTS AND RECOMMENDATIONS This project aimed to investigate the ways in which effective fall prevention strategies can be optimised for maximum cost effectiveness in preventing falls and injuries in older New Zealanders. Prevention of fall injuries includes 1) reducing the number of falls, 2) reducing the trauma associated with falls, and 3) maximising bone strength at all ages. The literature on maximising bone strength was outside the scope of this project. We used the current literature, meta-analyses, expert opinion, and economic modelling to estimate the potential impact of effective strategies on falls, fractures, and on healthcare costs. The main outcomes of the project are: 1) A comprehensive overview of pertinent information on the best strategies for targeting fall prevention programmes to specific groups of older people, and 2) A comparison of the efficiency (cost effectiveness) and potential for cost savings from the effective fall prevention strategies available internationally. Falls prevention literature The literature on falls prevention is large and complex, and requires expert knowledge and experience in the field to assimilate and interpret. Our three systematic reviews for this project included over 100 randomised controlled trials testing falls prevention interventions in community living older people, and 37 were in residential care facilities or hospitals. Given the number of good quality randomised controlled trials, there is no justification for using unsuccessful or untested programmes either for an individual or when choosing strategies for wider dissemination. Preventing falls prevents injuries resulting from falls, but the lack of information on injury outcomes in most of the randomised controlled trials makes estimation of the potential benefit in terms of injury prevention difficult. A systematic review of five controlled trials concluded that the population based approach to the prevention of fall related injury is effective and can form the basis of public health practice. Community living older people Exercise programmes were the most common single factor intervention evaluated (48 randomised controlled trials). Effective strategies included the Otago Exercise Programme, multicomponent group classes, and tai chi. Dynamic balance retraining may be the key component of the successful programmes. Exercise programmes that are individually tailored, progress in difficulty, and target carefully selected groups have resulted in the greatest reduction in falls and injuries. Other interventions effective in reducing falls include vitamin D supplementation in those with low vitamin D levels, cataract surgery, cardiac pacing, withdrawal of psychotropic medication, and a small group learning programme. Individual assessment and multifactorial interventions are effective in reducing falls, and this is always the method of choice for clinicians treating an individual patient. However resources are not available for every elderly New Zealand to receive this treatment. 1

6 Residential care facilities and hospitals For those living in residential care, vitamin D supplementation is recommended. ACC has begun a phased national roll out of supplementing vitamin D in residential care facilities. In three individual trials, multifactorial interventions following individual assessment were also shown to be effective in reducing falls in residential care facilities. Effective delivery of these programmes depends on staff expertise, and in New Zealand this differs from the situation in Europe where the interventions were evaluated. There is an increased risk of falling for older hospital patients. Two multifactorial approaches have been successful in reducing falls in a mixture of acute and sub-acute wards. There are guidelines available for falls prevention programmes in both long term care and hospital settings. None of the evidence for successfully reducing falls has been from trials carried out in New Zealand. Cost effectiveness of falls prevention strategies Three randomised controlled trials tested interventions which were shown to be cost saving in subgroups in the community at high risk of falls. These were the Otago Exercise Programme, a home safety programme when delivered to those discharged from hospital who reported a previous fall, and a home based, multifactorial programme. Two controlled trials showed that a concerted population approach to fall prevention resulted in a significant reduction of medical costs, one study demonstrating a benefit to cost ratio (hospitalisations) of 26 to 1. We modelled the impact of delivering eight different effective strategies compared with no intervention to 1,000 older New Zealanders. The actual number of falls that would be prevented, and the cost of delivering the intervention were key to determining the potential value for money for each intervention. We recommend four effective strategies for implementation in New Zealand in the short term, Strategies 5 and 6 in the medium, and Strategies 7 and 8 in the longer term. Recommended falls prevention interventions 1 Otago Exercise Programme 80 years, 75 with fall in previous year 2 Tai chi classes (16 weekly classes) 60 years 3 Home safety programme delivered by experienced occupational therapist 65 years, fall in previous year, on discharge from hospital 4 Home safety programme delivered by experienced occupational therapist 75 years, severe visual impairment 5 Multicomponent exercise classes (weekly all year) 65 years, physical performance impairment(s) 6 Stepping On programme 70 years, fall in previous year 7 Home based, individualised multifactorial programme 70 years, 4 of 8 targeted risk factors 8 Cataract surgery 70 years, awaiting surgery 2

7 All eight recommended strategies are for community living older people. This reflects the strength of the current evidence and the potential to reduce falls in this setting. The results of our analyses endorse the fact that, to obtain maximum value for money for the population as a whole, effective strategies need to be targeted at those groups which have been shown to benefit most. Further promising initiatives ACC is currently funding a pilot research trial of a multifactorial and exercise programme in four long term care facilities in Auckland. A new technology, impact absorbing flooring, has been invented to reduce fractures and other injuries as a result of a fall. This flooring is estimated to be more cost effective than provision of hip protectors to those in long term care. A successful programme of medication review and advice to general practitioners by a pharmacist tested in the UK, would be appropriate for New Zealand residential care facilities. Future directions The current evidence indicating the potential for reducing falls in different settings justifies a weighting of ACC funding for falls prevention in older people of 75% in the community setting and 25% in residential care or hospitals. In funding research on injury prevention, ACC should look to answer questions where: a) there is evidence in the international literature but New Zealand conditions are likely to be different, or b) the answer cannot be provided from the literature by meta-analysis of existing studies, and primary or confirmatory research is needed. No information on falls prevention specific to Maori and Pacific populations has been identified in the literature. Research is needed to address this imbalance. Other gaps in the literature include the lack of comprehensive economic evaluations of the effective strategies in residential care or hospitals. Steps for the future include extending the economic models in this project over the longer term, such as the lifetime of people receiving the intervention. It will be important to test the predictive value of the models we developed by systematically collecting cost and effectiveness data for chosen interventions over a period of time. To aid planning and targeting of strategies for optimal value for money, the lack of information on the cost of falls to the New Zealand healthcare system, and to older people and their families, needs to be addressed. This project was funded by ACC and the Ministry of Health ( ) 3

8 PURPOSE OF THIS PROJECT ACC and the Ministry of Health funded a comprehensive evaluation of the currently available information to determine 1) the best evidence on effective strategies to prevent falls and injuries in specific population groups of older people, 2) the relative cost effectiveness and the potential for cost savings for each effective prevention strategy identified from the literature, and 3) the best action to take for high claimants to ACC as a results of injuries from falls in order to reduce further claims by this group of older people. Reducing the risk of falls and the incidence of injuries resulting from falls in older people is a priority area for ACC. Given ACC's history of requiring the best available evidence as the basis for their prevention strategies, and given our publication record and international recognition in this area of research, the evidence based information provided to ACC from this project makes a substantial contribution to the advancement of injury prevention in New Zealand. The information produced is also be relevant to the implementation of the New Zealand Preventing Injury from Falls Strategy and to researchers worldwide. Reducing the incidence of injuries resulting from falls in older people is also a priority for the Ministry of Health. The Ministry of Health is the lead agency for the Health of Older People strategy, and supports ACC on the New Zealand Injury Prevention Strategy and the New Zealand Preventing Injury from Falls Strategy. The information produced will support the Ministry of Health to ensure that the most appropriate number and type of programmes are funded to reduce falls in older people. This project used the current literature, meta-analyses, expert opinion, claimant data from ACC, and economic modelling to investigate the ways in which effective fall prevention strategies can be optimised for maximum cost effectiveness in preventing falls and injuries in older New Zealanders. PROJECT OBJECTIVES The specific objectives of the project and the process taken to achieve these objectives are outlined below. Objective 1 To provide relevant information on the best strategies for targeting fall prevention programmes to specific groups of older people: A. Specific age groups B. Different living situations: i) Community dwelling ii) Rest homes iii) Long term hospital care iv) Acute hospital C. Maori and Pacific populations D. Older people with specific disabilities (for example, visual impairment) E. People presenting at emergency departments as a result of a fall. The information needed for Objective 1 was gathered by undertaking two comprehensive systematic reviews and meta-analyses of the currently available scientific literature which were included in two reports from this project. The systematic review for strategies aimed at community living people was reported in our progress report dated 15 September 2007, and for rest homes residents and hospital inpatients in our progress report dated 15 December The information gathered in this first phase of the project was then used to develop summaries of the effectiveness of particular programmes and approaches to falls prevention in the subgroups of 4

9 older people listed in items A to E of Objective 1. The comprehensive search of the literature was to identify randomised controlled trials testing interventions to reduce falls and fall related injuries in older people. Up to date information about all potential falls prevention programmes is needed to ensure ACC and the Ministry of Health provide a cost effective approach to falls prevention, while optimising the benefits both to older people and to their own organisations. To assist with this part of the process and to ensure complete coverage of the literature, Clare worked with Lesley Gillespie in updating the Cochrane systematic review Interventions for preventing falls in older people. Because of the rapid growth of publications in this field, this review has been split into two, one addressing prevention strategies for community living older people led by Lesley Gillespie, and one led by Professor Ian Cameron, Sydney, for those in residential care and in hospital. Clare is a co-author for both these reviews. The protocols of these two reviews have been published (Gillespie 2008; Cameron 2005). The community review is currently going through the Cochrane peer review process and may be published in the Cochrane Library in February 2009, whereas the institutional reviews is still in a draft form. Our systematic reviews, and the two Cochrane reviews in preparation, report a considerable choice of options for ACC and New Zealand health system funders and providers for strategies that are effective in reducing falls. We consequently considered each of these strategies in terms of their potential impact in reducing the number of falls and injuries, cost effectiveness, and acceptability and feasibility for delivery in New Zealand. Objective 2 Comparison of efficiency (cost effectiveness) and potential for cost savings from the effective falls prevention strategies available: A. Firstly ACC will identify the amount and proportion of spending on fall injury claims from older people in different living situations and will provide this information in summary format to the researchers. B. The researchers will then undertake a formal comparison of the cost effectiveness of effective falls prevention strategies from both the societal and ACC's perspective with the view to optimising the combination and delivery of effective programmes. Should ACC have difficulty in providing the required information then the researchers will use the best available international evidence to inform the analysis. Two further reviews of the literature were undertaken, and claims data broken down by community living and rest home claimants was received from ACC. We identified and extracted cost data from randomised controlled trials and controlled trials of falls prevention strategies that had included an economic evaluation in the study design or had reported cost outcomes. This review was included in a previous report from this project (progress report dated 15 March 2008). We also extracted data on fracture outcomes from these same trials and reported the results in a previous progress report (dated 15 June 2008). The information from all sources was used to develop the economic models addressing Objective 2 (see section of this report Estimated impact of effective strategies ). Objective 3 To work with ACC to develop a strategy to identify those who injure themselves frequently from falls and to decrease subsequent injuries and the high costs to ACC: A. Firstly ACC in conjunction with the researchers will investigate the information they have available on the characteristics of frequent claimants. B. The researchers will then work with ACC to design and implement a survey of frequent claimants in order to obtain a profile of relevant information. C. The researchers will analyse this profile and recommend strategies with the potential for reducing further fall injury claims in this particular group of older people. 5

10 Objective 3A Identifying characteristics of high claimants The collaboration with ACC to achieve this objective worked well and we are extremely grateful to Paula Eden and Lorna Bunt for their thoughtful input and practical contribution to this part of the project. Tables of data on ACC claims and payments gave information on those aged 65 and older who had a fall claim in the 2006/2007 financial year were received and attached to our progress report dated 15 March A summary of the information gathered from the tables was also provided. In general terms the tables showed that, for ACC, falls appear a high volume rather than a high cost per claimant issue. This was illustrated by the fact that 56% of the claims to date were for under $250, and 80% were under $700. Only 10% of claims were for over $1,600 and claims of over $10,000 made up 2.3% of the total. Even for people with a history of more than five claims, 80% of these in the 2006/2007 financial year were for $700 or less. In addition 82% of claims were short term, that is less than six months, with 57% less than eight weeks. When this was broken down by type of claim, 66% of claims for medical fees were for less than eight weeks and 38% of entitlement payments were over a period less than six months. The major component of the cost to ACC for fall claims for people with more than five fall claims was for medical fees (78%), with only 8% classed as entitlement payments. We also looked at further tables that gave similar types of data for those who had a fall at age 60 or older. One table of fall claims that were more than $10,000 provided a break down by diagnosis and site, and this showed that, as expected, the majority of these claims were for hip fractures, the most expensive and traumatic of injuries resulting from a fall. The claims and payments data provided valuable information for indicating the costs of fall injuries to ACC. In particular we noted the cost to ACC of falls in community living older people compared with those in rest homes. For all claims to ACC for falls for those aged 65 and older between July 2004 and June 2007, overall 12% were flagged as claims from rest home residents. For those aged 80 years and older, 24% of all falls claims were from rest home residents. The cost to ACC for all falls claims for those aged 80 years or older in 2006/07 was $8.7 million for rest home residents, and $30.1 million for those living in the community. Other claims (that is, claims excluding those for falls) made up around 24% and 36% respectively of the total incurred (other claims were $2.7 million for rest homes residents and $17.2 million for community living) people. Further ACC funding contributes to fall injuries through bulk funding to District Health Boards and to ambulance services, but as these are not broken down by type and cause of injury, the full cost of falls to ACC, and to the New Zealand health system, is not known. Objective 3B Survey high claimants Objective 3C Analyse claimant data The initial intention was to carry out a detailed survey of ACC high claimants for falls as part of this project. It was thought that healthcare costs may be saved by providing interventions targeted specifically at those who could be categorised as high claimants. It would be necessary to determine the characteristics of this group of older people in order to choose appropriate prevention approaches. However the tables provided by ACC giving the numbers and payments for claims for fall injuries showed that fall events were a high volume rather than a high cost per claimant issue for ACC. Given these findings, ACC made the decision that the planned survey of high claimants (Objective 3B) would not go ahead. This was based on the view that, for ACC to benefit in terms of cost savings from claims, targeting falls prevention initiatives at high claimants may not be a particularly useful strategy. This decision fits with the findings in the literature which gives valuable information on particular subgroups who will benefit most from falls intervention programmes and in terms of reducing healthcare resource use. 6

11 Objective 3D Recommend strategies This aspect of the project forms the major new part of this final report. We have worked with ACC to ensure the information we provide is presented in a format that is useful to ACC and the Ministry of Health. To meet this final objective we have developed cost scenarios using the best available information: We used the evidence base in the literature and our international networks to identify interventions that are effective in reducing falls and injuries in different settings and in different subgroups of older people. We have taken into account issues such as feasibility and acceptability of the interventions, and recommend only those likely to have the potential for support by ACC, the Ministry of Health, District Health Boards, and the primary care sector. We have estimated the cost of delivering each recommended intervention at 2008 prices to 1,000 older people in a particular subgroup, and the potential impact of these programmes on New Zealand healthcare costs using data reported from randomised controlled trials in New Zealand where available (Robertson 2001a, Garrett 2008). We have ranked the identified prevention strategies in terms of effectiveness and potential value for money in preventing falls and injuries from a societal perspective. REPORT OVERVIEW This final report from the project contains an overview of the findings presented in each of the progress reports. This is followed by the main body of the report, the section Estimated impact of effective strategies, which has a detailed description of the methodology and findings from the economic models developed in the last phase of this project to compare the potential impact of effective falls prevention strategies. For ease of reading we have presented our summary points and recommendations at the beginning of this document. We have summarised our findings and our recommendations for the next steps to be taken in New Zealand to reduce falls and related injuries in older New Zealanders. Appendices to the final report A separate document Optimisation of ACC s fall prevention programmes for older people: appendices to final report has been compiled to incorporate the results from all our progress reports for this project. The timeline for the project is provided in Appendix A. We describe the methods used in compiling the systematic reviews (Appendix B), and summarise the findings from the systematic review of interventions for community living older people (Appendix C), those in long term care or in hospital (Appendix D), relevant issues on preventing injury from falls (Appendix E), the systematic review on economic evaluation of interventions reported within randomised controlled trials (Appendix F), and in Appendix G the tables ACC generated showing ACC claims and costs. 7

12 SUMMARY OF FINDINGS FROM SYSTEMATIC REVIEWS Prevention of fall injuries includes 1) reducing the number of falls, 2) reducing the trauma associated with falls, and 3) maximising bone strength at all ages. The literature on maximising bone strength was outside the scope of this project. Three systematic reviews, and a literature overview on selected topics concerning falls injury reduction, were completed as part of this project. A summary from each review is provided in this section, and the methodology used and the full report from each review as included in the progress reports are provided again in the Appendices of this final report. These reviews were essential to the project because the Cochrane review on falls prevention interventions is now out of date (Gillespie 2003). We divided the literature reviews into those addressing falls prevention in community living older people, and strategies aimed at people in long term care or in hospital. This is because the characteristics of people in terms of falls risk factors in these settings differ, and the types of effective intervention strategies and the health professionals who will deliver them may also differ. Terminology used In this project we divide interventions into single factor, multiple and multifactorial programmes. These terms are defined in the taxonomy for falls prevention interventions developed by ProFaNE (Prevention of Falls Network Europe), funded by the European Commission. Single interventions address one type of risk factor for falls whereas multiple and multifactorial programmes have multiple components and address more than one type of risk factor. Examples of single interventions are exercise programmes and vitamin D supplementation. Multifactorial interventions include a risk assessment with programme components to address the identified risks for each individual. In a multiple programme, the same components are delivered to each individual. In the falls prevention literature the lack of standard terminology when reporting results from clinical trials is problematic. The main difficulty is differentiating the results concerning the number of falls during the trial (falls), from the number of participants who had a fall (fallers). For this project we have chosen to use rate of falls and the term rate ratio for results comparing the number or rate of falls in the intervention group compared with the control group, and risk of falling and the term risk ratio for comparisons concerning number (proportion) of fallers. We did not pool these two types of results (falls, fallers) in our meta-analyses, as they each indicate quite different aspects concerning effectiveness of the intervention. A rate ratio is the preferred statistic because it answers the question Were the number of falls reduced by the intervention? A risk ratio, the cruder statistic of the two, addresses whether more people fell in the intervention group compared with the control group during the trial. Our own research has included the choice of appropriate statistical techniques for analysing the results of falls prevention trials (Robertson 2005). Interventions for community dwelling older people A total of 103 randomised controlled trials testing a falls prevention programme in a community setting were identified and reviewed (41,348 participants) (see report dated 15 September 2007). Since then eight more randomised controlled trials have been identified. These will be included in the Cochrane systematic review due to be published next year, therefore we have not added them to the review in this project. In the 103 trials identified and meeting the inclusion criteria for the community setting, the interventions tested were: 81 single factor interventions 29 multifactorial programmes 11 multiple intervention programmes 8

13 A total of 121 interventions were tested. The most common intervention was an exercise programme (48 were tested) and 12 used vitamin D supplementation. No information on falls specific to Maori and Pacific populations was identified in the literature. Interim results from a randomised controlled trial where monofocal glasses were provided to the intervention group were reported at the 3 rd Australian and New Zealand Falls Prevention Society Conference in Melbourne in October 2008 (Haran 2008). Falls were reduced in those who tended to walk outside frequently, adding to the evidence that for older people who wear glasses, monofocal not bi-focal or multifocal glasses are recommended while walking. The pooled results from meta-analyses of trials with the same or similar interventions showed that the following interventions were effective in reducing falls in community living older people. Interventions successful in reducing falls in community living older people Number of randomised Pooled rate ratio controlled trials pooled (95% confidence interval) Otago Exercise Programme (0.52 to 0.83) Tai chi classes (0.50 to 0.73) Group exercise programmes (0.62 to 0.81) Home safety programmes (0.64 to 1.07) At high risk of falls (0.56 to 0.84) Psychotropic medication withdrawal (0.16 to 0.74) Cataract removal (0.49 to 0.91) Cardiac pacing (0.23 to 0.75) Multifactorial/multiple interventions (0.65 to 0.88) Pooled risk ratio (95% confidence interval) Vitamin D supplementation (0.75 to 1.00) In the pooled analysis, assessment and multifactorial interventions were effective in reducing falls, and this approach is recommended in falls prevention guidelines (NHS 2004, American Geriatrics Society 2001). However care is needed when planning the implementation of this strategy. In a recent randomised controlled trial in Upper Hutt, falls were not reduced when a falls nurse co-ordinator delivered this evidence based intervention (Elley 2008). It may be that this type of approach is more effective when referral to other health professionals is not the major mode of implementation. Vitamin D supplementation in our pooled analysis of falls risk did not quite meet significance (the upper limit of the 95% confidence interval included 1.00). It may be that this intervention is more effective in those with a low vitamin D level (preliminary results from the Cochrane community review update to be published in 2009). Although this medication is low cost, the cost of GP time and the blood test to determine vitamin D level would need to be considered in determining the cost effectiveness of this approach in the community. In one trial during winter months, an anti-slip device (Yaktrax Walker) reduced the rate of outdoor falls in community living people aged 65 or more who had fallen in the previous year, compared with the control group wearing usual winter footwear (McKiernan 2005). Interventions not successful in reducing falls in the community Currently there are several interventions trialed that were not effective in reducing falls. These include exercise programmes with only one type of exercise, for example resistance training only, walking groups, impact exercises, computerised balance exercises, agility training only, weight bearing exercises only, step up step down exercise only, and stretching and weight shifting exercises. Other interventions that have been tested and were not effective include 9

14 hormone replacement treatment, nutrient supplementation, falls education alone, and cognitive behavioural programmes. A recent randomised controlled trial has shown that an intervention aimed at reducing falls by improving vision actually significantly increased, rather than decreased, the rate of falls (Cumming 2007). Although vision should be optimal and cataract removal does prevent falls, older people should be advised to be extremely careful while adjusting to major changes in lens prescriptions. Interventions in long term care and hospital settings In addition to the randomised controlled trials in the community, a total of 37 randomised controlled trials meeting the inclusion criteria and testing programmes for those in rest homes and in hospital patients (both acute and long term acre) were identified (see report dated 15 December 2007). Eight of the trials were carried out in acute- or sub-acute wards in hospitals, or a combination of these wards (2,862 inpatients; 1,146 men; 1,716 women), and the remaining 29 trials were in long term care facilities (17,291 residents; 3,765 men; 13,481 women; 45 gender not specified). The interventions tested were: 26 single factor interventions (6 were tested in hospital wards) 11 multifactorial programmes (3 were tested in hospital wards) 4 multiple intervention programmes (none was tested in a hospital) A total of 41 interventions were tested. The most common single factor intervention was an exercise programme (11 were tested) and six trials used vitamin D supplementation. Three trials of multifactorial interventions showed good success in residential care homes in Europe (Becker 2003, Dyer 2004, Jensen 2002). Components of the interventions included educating staff on fall prevention, implementing exercise programmes, modifying the environment, supplying and repairing aids, reviewing drug regimens, providing free hip protectors, and having post-fall problem solving conferences. However, it may not be possible to deliver these interventions in a similar way in New Zealand given the different levels of staff expertise. It should also be noted that one falls prevention intervention in New Zealand rest homes significantly increased, rather than decreased, the rate of falls (Kerse 2004). This illustrates the fact that falls prevention is not an intuitive process, and only some interventions or combination of interventions will work in different settings and in different subgroups of older people. One promising intervention that would be appropriate for New Zealand was a medication review in rest home residents by a pharmacist (Zermansky 2006). After six months there was a reduction in the number of drug changes and in the number of falls. It was noted that general practitioners do not regularly review residents medications, but in this UK trial did accept 76% of the pharmacist s recommendations. Meta-analyses pooling results from trials with the same or similar interventions showed that the following were effective in reducing falls in people in residential care facilities and in hospital. Key findings from the systematic review follow. Interventions successful in reducing falls in long term care facilities and hospitals Number of randomised Pooled rate ratio controlled trials pooled (95% confidence interval) Residential care facilities Vitamin D supplementation (0.48 to 0.87) Hospital inpatients Multifactorial interventions (0.54 to 0.88) 10

15 Summary of findings Although falls are three times more common in long term care facilities than in community living older people, fewer randomised controlled trials testing effectiveness were identified in this setting (37 versus 111 now in the community). Vitamin D supplementation was the only intervention, when trials testing this approach were pooled, to show a significant benefit in terms of falls reduced in long term care facilities. In three individual trials in Europe, falls were reduced by using a multifactorial approach in a long term care setting. Effective delivery of these programmes depends on staff expertise, and in New Zealand this differs from the situation in Europe where the interventions were evaluated. Overall the current trials demonstrate no benefit on falls in using an exercise progamme alone. However, the types of exercise programmes tested have varied and do not appear to emulate successful community based exercise programmes. In a hospital setting there is an increased risk of falling for older people. Two multifactorial approaches have been successful in reducing falls in a mixture of acute and sub-acute wards. There are guidelines available for falls prevention programmes in both long term care and hospital settings. None of the evidence for successfully reducing falls has been from trials carried out in New Zealand. Preventing injuries from falls Extracting and pooling the information on injury as a result of a fall from the falls intervention trials identified proved problematic as the definitions of injuries differed markedly in the trials, or there was no definition of injury provided. A limited number of studies included in the systematic reviews reported the number of participants in each group who had a fracture as a result of a fall during the trial. This outcome is more robust as fractures can be verified by X-ray. We pooled fracture risk ratio data when appropriate, and when there were results from two or more studies available to pool. Interventions successful in reducing fractures in falls prevention trials Number of randomised Pooled risk ratio controlled trials pooled (95% confidence interval) Hip fractures Residential care facilities Multifactorial interventions (0.24 to 0.98) Fracture (any site) Community living Group exercise programme (0.16 to 0.72) Summary and implications of findings from fall related injuries reported in the randomised controlled falls prevention trials Although there has been a rapid growth in the number of randomised controlled trials published that tested falls prevention interventions in older people, only 27% (38 of 140) of the trials reported injury events or falls resulting in medical care being sought. Marked variations in the definition of a fall related injury event in the trials meant that these data, even if reported, could not be pooled. 11

16 Information gained from the falls prevention trials about the number of participants who sustained a fracture as a result of a fall is more robust since fractures can be verified by X-ray, but a limited number of trials reported this outcome. Three trials of multifactorial programmes in residential care reported the number of participants with a hip fracture as a result of a fall during the trial. The pooled risk ratio showed a significant reduction in fractures, but this finding needs to be viewed with caution due to the very small number of hip fracture events recorded. Pooling the risk ratio for sustaining a fracture from the three trials of exercise programmes in the community showed the number with fractures were significantly reduced. However, this result also must be viewed with caution as it represents only 6% (3 of 48) of the trials testing exercise programmes in the community. In addition, the exercise programmes differed in that two were group exercise programmes and one tested a home based programme for people with Parkinson s Disease. Given the small number of trials with fracture data available for pooling, this information did not provide definitive data we could confidently use in developing the models reported in this document. Hip protectors and safety flooring Currently there are several biomechanical means of reducing the trauma resulting from falls being developed and tested. Two that aim to prevent fractures from falls are hip protectors and safety flooring. Hip protectors Hip fractures, the most costly and traumatic injury from a fall, result almost exclusively from a simple fall and the impact of the greater trochanter with the floor (Dargent-Molina 1996, Norton 1997). Studies have addressed the problem by using hip protectors, but compliance has been estimated at only 25-30% (Chan 2000). Further problems with hip protectors result from displacement of the pads from the greater trochanter region prior to the fall. In the New Zealand study of the circumstances and consequences of falls in residential care, 35 falls occurred with hip protectors being worn at the time (Butler 2004). There were no hip fractures when residents fell wearing hip protectors, but over the 18 month period there were 12 hip fractures in the 917 falls without a hip protector in place. ACC has already investigated this approach by commissioning a review on the potential effectiveness of hip protectors in New Zealand residential care facilities, plus a cost effectiveness evaluation, both of which have informed this project. The evidence for effectiveness in preventing hip fractures indicates that hip protectors should be offered on an individual basis, and provision of hip protectors have formed part of the successful individualised multifactorial interventions in two trials in residential care facilities (Becker 2003, Jensen 2002). Safety flooring The researchers have been collaborating with the New Zealand inventor in the development and testing of an innovative new flooring material designed specifically to absorb energy on impact (Robertson 2006). This has the potential to reduce the number of fractures and other injuries as a result of falls in elderly people, especially those living in long term care (Cali 1995). Compared with known injury prevention programmes, this strategy has the advantage of being a long term approach plus eliminating the problems of individual compliance (Drahota 2007). A cost effectiveness evaluation of the new flooring has been carried out at the School of Population Health, University of Auckland by health economist Dr Paul Brown (Brown 2008). For residential care facilities this flooring material is more cost effective than supplying hip protectors, and has the potential to be cost saving from ACC s perspective. 12

17 We reported the results of our own study comparing gait patterns and balance of elderly women walking and standing on three different types of flooring at the 3 rd Australian and New Zealand Falls Prevention Society Conference in Melbourne in October 2008 (Robertson 2008). There were no differences in balance meaures or in gait patterns between a standard noncompliant flooring (vinyl), a compliant flooring (carpet with good quality underlay) and Kradal, the new safety flooring manufactured by Acma Industries in Upper Hutt, Wellington. We concluded that Kradal had the potential to reduce fractures without affecting balance or walking patterns. Relative cost effectiveness of interventions ACC and the Ministry of Health require not only evidence of effectiveness but also value for money when funding and supporting falls prevention strategies. Economic evaluation is the systematic, explicit analysis of alternative courses of action, assessed in terms of both costs and consequences. Economic evaluations provide a measure of efficiency for the purposes of decision making by comparing the costs and the consequences of alternative programmes (Drummond 2005). There are four main types of economic evaluations: 1) cost analysis, 2) cost effectiveness analysis, 3) cost utility analysis, and 4) cost benefit analysis. In a total of eight trials in a community setting, a comprehensive economic evaluation was reported for the seven different interventions tested (eight cost effectiveness analyses, one cost utility analysis, see report dated 15 March 2008). We found no comprehensive economic evaluations in the trials in residential care or in hospital. An article on the cost effectiveness of withdrawal of fall-risk-increasing medications in older people attending geriatric outpatients has recently been published (van der Velde 2008). When extracting data from the 103 randomised controlled trials in the community and 37 in an institutional setting identified in our systematic reviews, we noted the following economic evaluations had been carried out within these trials: For 8 trials testing an intervention in the community setting, the costs of delivering the intervention were reported For 1 intervention tested in a long term care setting, the costs of delivering the intervention were reported For 1 intervention in the community and 2 in a long term care setting, the costs of some healthcare use during the trial was reported, but no comprehensive economic evaluations were undertaken No information was reported on the costs or cost effectiveness of delivering a falls prevention programme in a hospital setting In a total of 8 trials in a community setting, a comprehensive economic evaluation was reported for the 7 different interventions tested (8 cost effectiveness analyses, one cost utility analysis). Investigation of the cost effectiveness of effective interventions has provided information on the likely value for money of several types of approach in the community setting, but none in long term care and hospitals. For our final recommendations we considered relevant information from peer reviewed articles of controlled (but not randomised) trials, and papers published on the web but not in peer reviewed journals. Examples of interventions evaluated and reported in this way include a medical vigilance system to reduce patient falls in hospital, cost effectiveness of methods to prevent hip fractures, a further economic evaluation of the Otago Exercise Programme tested in a controlled trial (Robertson 2001d), and the Queensland Stay on your feet programme (Beard 2006). The results from this systematic review were used to develop the models in the section of this report Estimated impact of effective strategies (see Tables 1, 6, 8, 10, 12, and 18). 13

18 Summary of findings from the costs, cost effectiveness and cost utility analyses in the randomised controlled trials Although there has been a rapid growth in the number of randomised controlled trials published that tested falls prevention interventions in older people, analyses of the costs and cost effectiveness of the interventions within the trials to date is limited. Comprehensive cost effectiveness analyses were carried out in only eight of the 140 randomised controlled trials included in the systematic reviews of falls prevention interventions. All eight trials tested strategies that were effective in reducing falls in community living older people. For three interventions, the Otago Exercise Programme, psychotropic medication withdrawal, and a home safety programme effective in reducing falls in people with severe visual impairment, the costs of delivering the programmes and the cost effectiveness in New Zealand have been established. One trial in community living older people reported a cost utility analysis and extended the time period of the analysis from the trial duration to the participants remaining lifetime. There are limitations in using quality of life years gained (QALYs) for economic evaluations of complex interventions for older people since these interventions result in multiple benefits not captured by QALYs (Harwood 2008). We have not found quality of life measures sensitive to change in our falls prevention studies despite the beneficial outcomes of the trials. The negative effect on health related quality of life is larger for self reported fear of falling than for falls or a fracture (Iglesias 2008). The information provided by these comprehensive economic evaluations indicates there is some, although limited, evidence that falls prevention strategies can be cost saving during the trial period, and may also be cost effective over the participants remaining lifetime. The results of these analyses also endorse the fact that, to obtain maximum value for money, effective strategies need to be targeted at particular subgroups of older people. The cost of delivering the intervention and health service costs for participants during the trial were available for only one of the trials in residential care. No cost effectiveness analyses in this setting were reported. For the randomised controlled trials in a hospital setting, no cost data or cost effectiveness analyses were reported. Other findings ACC estimated that supplementation with vitamin D in residential care could lead to a reduction of over 5,000 falls, and 330 claims to ACC, potentially saving an estimated $NZ 2.3 million in the 2008/2009 financial year (Williams 2008). A paper presented at the 3 rd Australian and New Zealand Falls Prevention Society Conference in Melbourne in October 2008 investigated the incremental cost effectiveness of fall risk screening in hospitals (Haines 2008). The conclusion was that preventing inhospital falls with a targeted falls prevention intervention approach using physiotherapist clinical judgement, was more cost effective than a no intervention approach. Two controlled trials showed that a concerted population approach to fall prevention resulted in a significant reduction of medical costs, one study demonstrating a benefit to cost ratio (hospitalisations) of 26 to 1 (Beard 2006), Tinetti 2008). 14

19 Rationale for choice of interventions to be modelled ACC and the Ministry of Health require information to use for supporting strategies which will give the most benefit in terms of effectiveness and cost effectiveness in reducing falls and injuries. The approaches also need to be acceptable and feasible for the New Zealand healthcare system. In choosing approaches to recommend, we took into account the type of intervention, the health professionals delivering the intervention, the different settings, and characteristics of potential participants including age group. We considered the evidence carefully for all these factors and selected the following effective interventions to investigate further: the Otago Exercise Programme, tai chi and multicomponent exercise classes, home safety assessment and modification programmes delivered to selected subgroups of older people, cataract surgery, multifactorial programmes aimed at the person s individual fall risk factors, and two multiple approaches the multifaceted group learning programme Stepping On, and a population approach. We modelled the likely impact of these interventions when delivered to 1,000 older New Zealanders. The methods used and the results of the modelling are reported in the next section of this report. Several further strategies that were shown to be effective in reducing falls in the randomised controlled trials were considered but not investigated further. These include cardiac pacing, an effective treatment for a very select subgroup of older people, and the gradual withdrawal of psychotropic medications, which our own research has shown was successful in reducing falls in people regularly taking these medications (Campbell 1999, Robertson 2001d). While withdrawal of sleeping medication is recommended for a motivated individual, there are several problems to be overcome for widespread dissemination. We consider the resources needed to implement this approach would be considerable. GPs would need training and incentives to prescribe withdrawal to their patients. This would involve outreach visits (oneon-one visits to GPs by a pharmacist or other health professional) and primary care professional meetings led by a respected expert. In our trial we found people reluctant to withdraw from their medication, and one month after the end of the trial, eight of the 17 who had withdrawn successfully, had restarted their medication. We consider that a psychologist would need to be involved in order to improve uptake and adherence, and provide support and advice on alternative methods for sleep, in order to prevent people restarting their psychotropic medication. We have not modelled the potential impact of the two types of successful interventions in residential care and hospitals. Our meta-analyses and those of others conclude that vitamin D supplementation is an effective strategy to reduce falls, particularly for those in residential care facilities. It is accepted therefore that this strategy should be used for falls prevention in this setting. As ACC has recently commenced implementation of this strategy nationally (Williams 2008), we have not investigated this approach further in this project. Although three trials of multifactorial interventions have shown good success in rest homes in Europe (Becker 2003, Dyer 2004, Jensen 2002), the New Zealand situation means that fewer staff have been trained and are available to implement the components of the strategies. ACC is currently funding a pilot trial of an exercise programme and a multifactorial approach based on the Green Box in four Auckland rest homes. We are co-investigators for this research which is led by Associate Professor Ngaire Kerse at the School of Population Health, University of Auckland. A multifactorial approach was effective in longer stay hospital patients in Australia (Haines 2004), but no data were available on the costs of this particular intervention. District Health Boards are required to have an in-hospital falls prevention policy, and should use the published guidelines until more research is available. 15

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