A Taxonomy and Economic Consequences of Nursing Home Falls

Improving safety and preventing falls using an evidence-based, front-line staff huddling practice: protocol for a pragmatic trial to increase quality of care in State Veterans Homes

INTRODUCTION

Falls in nursing homes are a major cause for decreases in residents' quality of life and overall health. This study aims to reduce resident falls by implementing the LOCK Falls Programme, an evidence-based quality improvement intervention. The LOCK Falls Programme involves the entire front-line care team in (1) focusing on evidence of positive change, (2) collecting data through systematic observation and (3) facilitating communication and coordination of care through the practice of front-line staff huddles.

METHODS AND ANALYSIS

The study protocol describes a mixed-methods, 4-year hybrid (type 2) effectiveness-implementation study in State Veterans Homes in the USA. The study uses a pragmatic stepped-wedge randomised trial design and employs relational coordination theory and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to guide implementation and evaluation. A total of eight State Veterans Homes will participate and data will be collected over an 18-month period. Administrative data inclusive of all clinical assessments and Minimum Data Set assessments for Veterans with a State Veterans Home admission or stay during the study period will be collected (8480 residents total). The primary outcome is a resident having any fall. The primary analysis will be a partial intention-to-treat analysis using the rate of participants experiencing any fall. A staff survey (n=1200) and qualitative interviews with residents (n=80) and staff (n=400) will also be conducted. This research seeks to systematically address known barriers to nursing home quality improvement efforts associated with reducing falls.

ETHICS AND DISSEMINATION

This study is approved by the Central Institutional Review Board (#167059-11). All participants will be recruited voluntarily and will sign informed consent as required. Collection, assessment and managing of solicited and spontaneously reported adverse events, including required protocol alterations, will be communicated and approved directly with the Central Institutional Review Board, the data safety monitoring board and the Office of Research and Development. Study results will be disseminated through peer-reviewed publications and conference presentations at the Academy Health Annual Research Meeting, the Gerontological Society of America Annual Scientific Meeting and the American Geriatrics Society Annual Meeting. Key stakeholders will also help disseminate lessons learnt.

TRIAL REGISTRATION NUMBER

NCT05906095.

Use of Sensors for Fall Prediction in Older Persons: A Scoping Review

The application of technological advances and clear articulation of how they improve patient outcomes are not always well described in the literature. Our research team investigated the numerous ways to measure conditions and behaviors that precede patient events and could signal an important change in health through a scoping review. We searched for evidence of technology use in fall prediction in the population of older adults in any setting. The research question was described in the population-concept-context format: "What types of sensors are being used in the prediction of falls in older persons?" The purpose was to examine the numerous ways to obtain continuous measurement of conditions and behaviors that precede falls. This area of interest may be termed emerging knowledge . Implications for research include increased attention to human-centered design, need for robust research trials that clearly articulate study design and outcomes, larger sample sizes and randomization of subjects, consistent oversight of institutional review board processes, and elucidation of the human costs and benefits to health and science.

Costs and benefits of multifactorial falls prevention in nursing homes in the Netherlands

OBJECTIVES

To investigate whether the implementation of a multifactorial falls intervention in nursing homes is cost-beneficial and alleviates the professional workload.

DESIGN

A comprehensive quantitative model was developed to calculate the impact of investments in multifactorial falls prevention in nursing homes in the Netherlands, comparing the fall incidence using intervention strategies in 1000 nursing home residents with the conditions of usual care over a five-year timeline.

SETTING AND PARTICIPANTS

We built a model combining several data sources regarding falls and injury prevalence in nursing home residents, health care costs, intervention costs and effectiveness, and demographic statistics.

MEASURES

The primary outcomes were number of falls and injuries, treatment hours and cost.

RESULTS

In the nursing home setting, a baseline scenario was calculated with 1471 falls incidents resulting in 345 injuries per year. The mean cost of injury related treatment and care was calculated 860 thousand euro per year and €4.63 million in five years. Implementing multifactorial intervention over five years, costing 702 thousand euro, resulted in savings in health care costs of €2.0 million, of which €1.6 million was saved in nursing home injury care. The benefits outweighed the costs: each euro invested was compensated by 2.86 euro benefit in total care, 2.31 benefit in nursing home care. Yearly 3050 nursing hours, 3100 paramedical care hours and 760 h of physician care were saved.

CONCLUSION AND IMPLICATIONS

Implementation of customized multifactorial interventions provided by multidisciplinary teams is cost-beneficial in reduction of falls in nursing homes. The CBA model gives valuable information about the advantageous consequences (i.e. health benefits, financial benefits and reduced workload of staff) of falls prevention in nursing homes and can provide guidance to the management in structural implementation of multifactorial falls prevention.

Predicting Falls in Nursing Homes: A Prospective Multicenter Cohort Study Comparing Fall History, Staff Clinical Judgment, the Care Home Falls Screen, and the Fall Risk Classification Algorithm

OBJECTIVES

To evaluate and compare the predictive accuracy of fall history, staff clinical judgment, the Care Home Falls Screen (CaHFRiS), and the Fall Risk Classification Algorithm (FRiCA).

DESIGN

Prospective multicenter cohort study with 6 months' follow-up.

SETTING AND PARTICIPANTS

A total of 420 residents from 15 nursing homes participated.

METHODS

Fall history, clinical judgment of staff (ie, physiotherapists, nurses and nurses' aides), and the CaHFRiS and FRiCA were assessed at baseline, and falls were documented in the follow-up period. Predictive accuracy was calculated at 1, 3, and 6 months by means of sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio, Youden Index, and overall accuracy.

RESULTS

In total, 658 falls occurred and 50.2% of the residents had at least 1 fall with an average fall rate of 1.57 (SD 2.78, range 0-20) per resident. The overall accuracy for all screening methods at all measuring points ranged from 54.8% to 66.5%. Fall history, FRiCA, and a CaHFRiS score of ≥4 had better sensitivity, ranging from 64.4% to 80.8%, compared with the clinical judgment of all disciplines (sensitivity ranging from 47.4% to 71.2%). The negative predictive value (ranging from 92.9% at 1 month to 59.6% at 6 months) had higher scores for fall history, FRiCA, and a CaHFRiS score of ≥4. Specificity ranged from 50.3% at 1 month to 77.5% at 6 months, with better specificity for clinical judgment of physiotherapists and worse specificity for FRiCA. Positive predictive value ranged from 22.2% (clinical judgment of nurses' aides) at 1 month to 67.8% at 6 months (clinical judgment of physiotherapists).

CONCLUSIONS AND IMPLICATIONS

No strong recommendations can be made for the use of any screening method. More research on identifying residents with the highest fall risk is crucial, as these residents benefit the most from multifactorial assessments and subsequent tailored interventions.

Social integration and loneliness among long-term care home residents: protocol for a scoping review

INTRODUCTION

Social well-being is associated with better physical and mental health. It is also important for quality of life, including from the perspectives of those living in long-term care (LTC) homes. However, given the characteristics of the LTC home environment and the people who live there, the nature and influence of social integration and loneliness, and strategies to address them, may differ in this population compared with those living in the community. The objective of this scoping review is to provide an overview of the nature and extent of research on social integration and loneliness among LTC home residents, including a summary of how these concepts have been operationalised and any evidence from specific groups.

METHODS AND ANALYSIS

This study protocol describes the methods of a scoping review of peer-reviewed literature related to social integration and loneliness among LTC home residents. A literature search was developed by an Information Specialist and will be conducted in MEDLINE(R) ALL (in Ovid, including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily) and then translated into CINAHL (EBSCO), PsycINFO (Ovid), Scopus, Sociological Abstracts (Proquest), Embase and Embase Classic (Ovid), Emcare Nursing (Ovid) and AgeLine (EBSCO). Two reviewers will independently screen titles and abstracts of articles identified in the search. Two reviewers will then independently review full text articles for inclusion. Data extraction will also be carried out in duplicate. We will engage LTC home community members, including residents, family and staff, to refine the review questions, assist in interpreting the results and participate in knowledge translation.

ETHICS AND DISSEMINATION

Ethics approval is not required. We will present findings at conferences and publish in a peer-reviewed journal. Ultimately, we hope to inform future observational and interventional research aimed at improving the health and quality of life of LTC home residents.

Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults

BACKGROUND

Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety.

OBJECTIVE

We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults.

DESIGN

Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims.

SETTING

US nursing homes (NHs).

PARTICIPANTS

Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator).

MEASUREMENTS

Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics.

RESULTS

The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk.

CONCLUSIONS

Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.

Improving the quality of life of aged care residents through the joy of food: The Lantern Project

OBJECTIVE

Mealtimes directly impact the quality of life of residents in aged care. The objective of The Lantern Project is to improve the dining experience of aged care residents to reduce malnutrition risk through improving dietary intake, meal.

METHODS

A transdisciplinary team of aged care professionals and resident advocates was formed as a collaboration collectively known as The Lantern Project.

RESULTS

This paper outlines the journey and timeline of The Lantern Project collaboration since its inception and the interplay between the monthly stakeholder meetings and inter-related research projects demonstrating improved outcomes.

CONCLUSION

Transdisciplinary collaboration offers well-grounded benefits and realistic strategies sensitive to the complexity of the aged care setting.

"There's No Place Like Home": A Scoping Review on the Impact of Homelike Residential Care Models on Resident-, Family-, and Staff-Related Outcomes

BACKGROUND

There is increasing emphasis on promoting "homelike" residential care models enabling care-dependent people to continue living in a self-determined manner. Yet, little is known about the outcomes of homelike residential care models.

PURPOSE

We aimed to (1) identify homelike residential care models for older care-dependent people with and without dementia, and (2) explore the impact of these models on resident-, family-, and staff-related outcomes.

DESIGN AND METHODS

We applied a scoping review method and conducted a comprehensive literature search in PubMed, Embase, and CINAHL in May 2015.

RESULTS

We included 14 studies, reported in 21 articles. Studies were conducted between 1994 and 2014, most using a quasi-experimental design and comparing the Eden Alternative (n = 5), nondementia-specific small houses (eg Green House homes) (n = 2), and dementia-specific small houses (n = 7) with usual care in traditional nursing homes. The studies revealed evidence of benefit related to physical functioning of residents living in dementia-specific small houses and satisfaction with care of residents living in nondementia-specific small houses compared with those living in traditional nursing homes. We did not find other significant benefits related to physical and psychosocial outcomes of residents, or in family- and staff-related outcomes.

IMPLICATIONS

The current evidence on homelike residential care models is limited. Comparative-effectiveness research building on a clear theoretical framework and/or logic model and including a standardized set of resident-, family-, and staff-related outcomes, as well as cost evaluation, is needed to provide a stronger evidence base to justify the uptake of more homelike residential care models.

Cost-effectiveness of droxidopa in patients with neurogenic orthostatic hypotension: post-hoc economic analysis of Phase 3 clinical trial data

OBJECTIVE

Falls are associated with neurogenic orthostatic hypotension (nOH) and are an economic burden on the US healthcare system. Droxidopa is approved by the US FDA to treat symptomatic nOH. This study estimates the cost-effectiveness of droxidopa vs standard of care from a US payer perspective.

METHODS

A Markov model was used to predict numbers of falls and treatment responses using data from a randomized, double-blind trial of patients with Parkinson's disease and nOH who received optimized droxidopa therapy or placebo for 8 weeks. The severity of falls, utility values, and injury-related costs were derived from published studies. Model outcomes included number of falls, number of quality-adjusted life-years (QALYs), and direct costs. Incremental cost-effectiveness ratios (ICERs) were calculated. Outcomes were extrapolated over 12 months.

RESULTS

Patients receiving droxidopa had fewer falls compared with those receiving standard of care and gained 0.33 QALYs/patient. Estimated droxidopa costs were $30,112, with estimated cost savings resulting from fall avoidance of $14,574 over 12 months. Droxidopa was cost-effective vs standard of care, with ICERs of $47,001/QALY gained, $24,866 per avoided fall with moderate/major injury, and $1559 per avoided fall with no/minor injury. The main drivers were fall probabilities and fear of fall-related inputs.

LIMITATIONS

A limitation of the current study is the reliance on falls data from a randomized controlled trial where the placebo group served as the proxy for standard of care. Data from a larger patient population, reflecting 'real-life' patient use and/or comparison with other agents used to treat nOH, would have been a useful complement, but these data were not available.

CONCLUSION

Using Markov modeling, droxidopa appears to be a cost-effective option compared with standard of care in US clinical practice for the treatment of nOH.

Characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To determine characteristics and effectiveness of prevention programs on fall-related outcomes in a defined setting.

DESIGN

Systematic review and meta-analysis.

SETTING

A clearly described subgroup of nursing homes defined as residential facilities that provide 24-hour-a-day surveillance, personal care, and limited clinical care for persons who are typically elderly and infirm.

PARTICIPANTS

Nursing home residents (N = 22,915).

MEASUREMENTS

The primary outcomes were number of falls, fallers, and recurrent fallers.

RESULTS

Thirteen studies met the inclusion criteria. Six fall prevention programs were single (one intervention component provided to the residents), one was multiple (two or more intervention components not customized to individual fall risk), and six were multifactorial (two or more intervention components customized to each resident's fall risk). Meta-analysis found significantly fewer recurrent fallers in the intervention groups (4 studies, relative risk (RR) = 0.79, 95% confidence interval (CI) = 0.65-0.97) but no significant effect of the intervention on fallers (6 studies, RR = 0.97, 95% CI = 0.84-1.11) or falls (10 studies, RR = 0.93, 95% CI = 0.76-1.13). Multifactorial interventions significantly reduced falls (4 studies, RR = 0.67, 95% CI = 0.55-0.82) and the number of recurrent fallers (4 studies, RR = 0.79, CI = 0.65-0.97), whereas single or multiple interventions did not. Training and education showed a significant harmful effect in the intervention groups on the number of falls (2 studies, RR = 1.29, 95% CI = 1.23-1.36).

CONCLUSION

This meta-analysis failed to reveal a significant effect of fall prevention interventions on falls or fallers but, for the first time, showed that fall prevention interventions significantly reduced the number of recurrent fallers by 21%.

Prevalence of falls with minor and major injuries and their associated factors among older adults in long-term care facilities

Aims and objectives.  The objectives of this study were to determine the prevalence of falls with minor and major injuries and identify their risk factors. Background.  Falls among residents of long-term care facilities (LTCF) constitute a significant health issue. Design.  This is a secondary analysis of a cross-sectional study carried out among older people (n = 2332). Methods.  This is a descriptive study focusing on the secondary analysis of a cross-sectional study carried out with a group of older people (n = 2332) in 28 LTCF in Quebec City, Canada. Research assistants collected original data for each resident from two sources: structured simultaneous interviews with two nurses per unit from each of the homes and a review of the residents' medical files. Results.  7.2% of subjects had a fall leading to minor injuries and 10.1% a fall leading to major injuries. Risk factors associated with fall-related minor injury are young age, male gender and cognitive impairment. Factors associated with fall-related major injury were functional autonomy and length of stay. In further statistical analysis, controlling for functional autonomy, disruptive behaviours and neuroleptic use were found associated with fall-related major injury. Conclusions.  This study demonstrates that the factors associated with fall-related minor injury are different from those associated with fall-related major injury. Relevance to clinical practice.  This study suggests that nurses working with LTCF residents who are concerned about the prevention of fall-related major injury, may contribute to a reduction in such falls through optimal management of behavioural problems and neuroleptic use.

Cost per fall: a potentially misleading indicator of burden of disease in health and residential care settings

RATIONALE

Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person.

METHOD

Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study.

RESULTS

The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year).

CONCLUSIONS

This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use.

Estimating the Cost of Serious Injurious Falls in a Canadian Acute Care Hospital

Les chutes représentent 40 pour cent des accidents d’hôpitaux et leurs conséquences vont de zéro à des blessures graves. Le but de cette étude a été d’estimer le coût moyen à l’hôpital de la durée du séjour (DS) associée aux chutes liées aux préjudices graves dans un hôpital de soins actifs. Nous avons utilisé les données de gestion des risques et des bases de données qui représentent les frais associés à une blessure grave après une chute à l’hôpital. On a comparé trente-sept patients blessés à 2,330 contrôles en utilisant le diagnostic le plus responsable médical, et par l’âge et par le sexe des patients. En utilisant les t-tests et la regréssion multivariée, on a comparé le coût et la DS. Les coûts moyens pour ceux qui se sont grièvement blessés en tombant, et pour les contrôles sans chutes, étaient DC 44,203 $ et DC 13,507 $ tandis ceux de la DS était, respectivement, 45 et 11 jours. Le coût des soins d’hospitalisation pour un patient qui a subi une chute résultante en blessures graves était 30,696 $ (95% IC : $25,158 – $36,781) supérieur au coût pour quelqu’un qui ne s’est pas tombé. Les gestionnaires d’hôpitaux jouent un rôle de premier plan en créant des programmes dans le réseau pour prévenir les chutes et réduire les coûts hospitaliers.

The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes: a systematic review

BACKGROUND

Physical restraint was introduced as the primary measure to maintain patient safety in preventing falls. However, physical restraints may lead to complications such as functional loss, immobility, delirium, pressure sore, and even falls or injuries. Despite all these negative effects and many alternatives that are available, physical restraint is still commonly used in hospitals and nursing homes. Hence, it is crucial to understand the effectiveness of physical restraints in protecting adult patients from falling.

OBJECTIVE

The overall objective was to examine the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes.

INCLUSION CRITERIA

This review considered quantitative designs, including randomised controlled trials, quasi-experimental studies, cohort studies, case control studies and case series/reports.The participants of this review were male and female adult patients aged 18 years or over who are on authorized physical restraints in acute care hospitals and nursing homes.This review focused on studies that investigated physical restraint as an intervention for reducing falls among adults in acute care hospitals and nursing homes.The outcomes of interest were the number of individuals receiving restraints who fall, or the rate or number of falls in acute hospitals and nursing homes.

SEARCH STRATEGY

A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken, followed by a second search using all identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. All searches were limited to English Language studies and there was no limit in the timeframe.

ASSESSMENT OF METHODOLOGICAL QUALITY

The quality of the included studies was subjected to assessment by two independent reviewers using the standardised critical appraisal tools from the Joanna-Briggs Institute from the JBI-MAStARI (Joanna Briggs Institute-Meta-Analysis of Statistics Assessment and Review Instrument).

DATA EXTRACTION

Data was extracted from included papers using the standardised extraction tool from the JBI MASTARI.

DATA SYNTHESIS

Due to the heterogeneous nature of the study methods, the findings of this review are presented in a narrative summary.

RESULTS

Nine studies were included in the review. The majority of the findings showed that physical restraints were not associated with the reduction in falls and decreased restraint use did not contribute to more falls.

CONCLUSION

From the overall results, physical restraints are not effective in reducing falls or injuries among adults in acute care hospitals and nursing homes.National standards and application guides for physical restraints are recommended. The use of physical restraints should be assessed by trained staff based on individualised need and consideration of patient's autonomy and integrity. The awareness of appropriate physical restraint usage should be enhanced among the healthcare professionals.Large multicentre research to determine the risk and benefit ratio of physical restraints and to examine the effectiveness of alternative measures, different number of bedrails, intermittent restraint use and restraint reduction programs are needed respectively.

Comparative effectiveness of implementing evidence-based education and best practices in nursing homes: effects on falls, quality-of-life and societal costs

OBJECTIVES

The aim was to conduct a comparative effectiveness research study to estimate the effects on falls, negative affect and behavior, and the associated societal costs of implementing evidence-based education and best practice programs in nursing homes (NHs).

DESIGN

A quasi-experimental design, a variant of a cluster randomized trial of implementation research examining transfer of research findings into practice, was used to compare outcomes among three groups of residents in 15 nursing homes per group.

METHODS

Forty-five NHs participated in one of three conditions: (1) standard training, (2) training and implementation modules provided to facility staff, or (3) staff training and implementation modules augmented by surveyor training. After application of exclusion and matching criteria, nursing homes were selected at random within three regions of New York State. Outcomes were assessed using medical records and the Minimum Data Set (MDS).

RESULTS

The main finding was of a significant reduction of between 5 and 12 annual falls in a typical nursing home. While both intervention groups resulted in fall reduction, the larger and significant reduction occurred in the group without surveyor training. A significant reduction in negative affect associated with training staff and surveyors was observed. Net cost savings from fall prevention was estimated.

CONCLUSIONS

A low cost intervention targeting dissemination of evidence-based best practices in nursing homes can result in the potential for fall reduction, and cost savings.

Incidence and cost of serious fall-related injuries in nursing homes

BACKGROUND

Fall-related injuries (FRIs) result in morbidity and mortality for patients, as well as unnecessary expense to health care institutions.

OBJECTIVES

(a) Estimate the incidence of falls and FRIs with a nursing home as the source of admission in Veterans Administration (VA) and non-VA facilities. (b) Estimate the cost of hospitalizations for each level of FRI severity.

RESEARCH DESIGN

Retrospective analysis of falls and FRI resulting in a hospitalization whose source of admission was a VA nursing home.

DATA

Falls and FRIs were obtained from Minimum Data Set (MDS) reports (January 2007-June 2009). Costs were obtained from the VA Decision Support System reports and Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) reports (2000-2006).

MEASURES

Incidence of falls, fracture incidence, number of hospitalizations for FRIs, and costs associated with hospitalization for by level of FRI severity.

RESULTS

Fall incidence was 10.6% in VA and 13.1% in CMS facilities. Fracture incidence was 0.9% in VHA and 1.65% in CMS facilities. Over a 3-year period, there were 2,400 admissions to VHA hospitals for FRI, with 55.4% hip fractures and10.1% intracranial injuries, with an average cost of US$23,723 per admission. Over a 9-year period, there were 141,308 admissions from nursing homes to non-VA hospitals for FRIs, with 38.8% hip fractures, 35.7% other fractures, and 11.1% intracranial injuries, with an average cost of US$31,507 per admission.

CONCLUSIONS

Prevention program emphasis should shift away from a focus on preventing falls as a measure of quality care to decreasing FRIs. These findings support implementation of injury prevention programs for the elderly that reduces risk for injury as the primary outcome.

Cost of falls in old age: a systematic review

SUMMARY

The purpose of this study was to review the evidence of the economic burden of falls in old age. This review showed that falls are a relevant economic burden. Efforts should be directed to fall-prevention programmes.

INTRODUCTION

Falls are a common mechanism of injury and a leading cause of costs of injury in the elderly. The purpose of this study was to review for the first time the evidence of the economic burden caused by falls in old age.

METHODS

A systematic review was conducted in the databases of PubMed, of the Centre for Reviews and Dissemination and in the Cochrane Database of Systematic Reviews until June 2009. Studies were assessed for inclusion, classified and synthesised. Costs per inhabitant, the share of fall-related costs in total health care expenditures and in gross domestic products (GDP) were calculated. If appropriate, cost data were inflated to the year 2006 and converted to US Dollar (USD PPP).

RESULTS

A total of 32 studies were included. National fall-related costs of prevalence-based studies were between 0.85% and 1.5% of the total health care expenditures, 0.07% to 0.20% of the GDP and ranged from 113 to 547 USD PPP per inhabitant. Direct costs occurred especially in higher age groups, in females, in hospitals and long-term care facilities and for fractures. Mean costs per fall victim, per fall and per fall-related hospitalisation ranged from 2,044 to 25,955; 1,059 to 10,913 and 5,654 to 42,840 USD PPP and depended on fall severity. A more detailed comparison is restricted by the limited number of studies.

CONCLUSION

Falls are a relevant economic burden to society. Efforts should be directed to economic evaluations of fall-prevention programmes aiming at reducing fall-related fractures, which contribute substantially to fall-related costs.

Fall prevention and injury protection for nursing home residents

Recognizing that risk factors for falls are multifactorial and interacting, providers require guidance on the components, intensity, dose, and duration for an effective fall and fall injury prevention program. Administrators of health care facilities require guidance on resources needed for these programs. Clear guidance does not exist for specifying the right combination of interventions to adequately protect specific at-risk populations, such as nursing home residents with dementia or osteoporosis. Staff education about fall prevention and resident fall risk assessment and reassessments has become part of standards of practice; however, the selection, specificity, and combination of fall prevention and injury protection interventions are not standardized. To address these gaps, this team of researchers conducted a critical examination of selected intervention studies relevant to nursing home populations. The objectives of this literature review were to (1) examine the selection and specificity of fall prevention and injury protection interventions described in the literature since 1990; (2) evaluate the strength of evidence for interventions that both prevent falls and protect residents from fall-related injury; and, (3) provide clinical and policy guidance to integrate specific interventions into practice.

Fall-related hospitalization and facility costs among residents of institutions providing long-term care

PURPOSE

The purpose of this study was to estimate hospital and long-term-care costs resulting from falls in long-term-care facilities (LTCFs).

DESIGN AND METHODS

The study used a retrospective, pre/post with comparison group design. We used matching, based on propensity scores, to control for baseline differences between fallers and non-fallers. We estimated residents' propensity to fall from demographics, comorbidities, and reimbursement in the pre-period. The matched sample included 1,130 fallers and 1,130 non-fallers who were residents of a large, multifacility long-term-care chain. Cost estimates were based on information in the Minimum Data Set and were defined as hospital and LTCF reimbursements. We estimated fall-related costs as the difference between changes in costs for fallers and non-fallers from the pre- to post-period.

RESULTS

Fallers were substantially more likely to suffer fractures and hospitalizations in the post-period than were non-fallers. Fall-related LTCF and hospital costs were $6,259 (95% confidence interval = $2,034-$10,484) per resident per year. About 60% of this amount was attributable to higher hospitalization costs. Fallers were more likely to be discharged to hospitals or to die.

IMPLICATIONS

Falls in LTCFs are associated with costs of about $6,200 per resident per year. These results provide baseline estimates that one may use to estimate the cost-effectiveness of interventions to reduce fall rates.

Costs and compensation of work-related injuries in British Columbia sawmills

OBJECTIVE

To estimate the costs of work-related injury in a cohort of sawmill workers in British Columbia from the perspective of the workers' compensation system.

METHODS

Hospital discharge records were extracted from 1989 to 1998 for a cohort of 5786 actively employed sawmill workers. A total of 173 work-related injury cases were identified from these records using the International classification of diseases-ninth revision (ICD-9) external cause of injury codes and the responsibility of payment schedule. Workers' compensation records were extracted and matched with hospital records by dates and ICD-9 diagnosis codes. All costs were converted into 1995 constant Canadian dollars using the Provincial General Consumer Price Index for the non-healthcare costs and Medical Consumer Price Index for the healthcare costs. A 5% discounting rate was applied to adjust for the time value of money. For the uncompensated cases, costs were imputed from the compensated cases using the median cost for a similar nature of injury.

RESULTS

370 hospitalisation events due to injury were captured, and by either of the two indicators (E Codes or payment schedules), 173 (47%) hospitalisation events due to injury, were identified as work related. The median healthcare cost was 4377 dollars and the median non-healthcare cost was 16,559 dollars for a work-related injury. The median non-healthcare and healthcare costs by injury were falls, 19,978 dollars and 5185 dollars; struck by falling object, 32,398 dollars and 8625 dollars; struck against, 12,667 dollars and 5741 dollars; machinery related, 26,480 dollars and 6643 dollars; caught in or between, 24,130 dollars and 4389 dollars; and overexertion, 7801 dollars and 2710 dollars. The total cost was 10,374,115 dollars for non-healthcare and 1,764,137 dollars for healthcare. The compensation agency did not compensate 874,871 dollars (8.4%) of the non-healthcare costs and 200,588 dollars (11.4%) of the healthcare costs.

CONCLUSION

Eliminating avoidable work-related injury events can save valuable resources.