ACC Optim Report[1]

8/3/2019 ACC Optim Report[1]

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Opt im isa t ion o f ACC's fa l l p reven t ion p rogramm esfor o lder peop le

FINA L REPORTNovember 2008

M. Clare Robert son, PhD BSc(Hon s) BComA. Jo hn Cam pbe l l , MD FRACP

Dunedin Schoo l o f Medic ine , Univer s i ty o f OtagoDuned in , New Zea land


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CONTENTS

SUMMARY POINTS AND RECOMMENDATIONS 1

PURPOSE OF THIS PROJECT 4

PROJECT OBJECTIVES 4

REPORT OVERVIEW 7

SUMMARY OF FINDINGS FROM SYSTEMATIC REVIEWS 8Interventions for community dwelling older people 8Interventions in long term care and hospital settings 10Preventing injury from falls 11Relative cost effectiveness of interventions 13Rationale for choice of interventions to be modelled 15

ESTIMATED IMPACT OF EFFECTIVE STRATEGIES 16General approach 16Methods and model assumptions 16Otago Exercise Programme 20Group exercise programmes 20

Multicomponent group exercise 20Tai chi classes 25

Home safety assessment and modification 27Cataract surgery 31Assessment and multifactorial intervention 31Multiple interventions 34

Multifaceted small group learning 34Population approach 34

Limitations of modelling methods 37

Modelling falls strategies for the Australian population 39RECOMMENDED STRATEGIES 41

REFERENCES 43


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SUMMA RY POINT S AND RECOMMENDATIONS

This project aimed to investigate the ways in which effective fall prevention strategiescan 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 literatureon maximising bone strength was outside the scope of this project.

We used the current literature, meta-analyses, expert opinion, and economic modelling toestimate the potential impact of effective strategies on falls, fractures, and on healthcarecosts.

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, and2) 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 werein residential care facilities or hospitals.

Given the number of good quality randomised controlled trials, there is no justificationfor using unsuccessful or untested programmes either for an individual or when choosingstrategies for wider dissemination.

Preventing falls prevents injuries resulting from falls, but the lack of information oninjury 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


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Residential care facilities and hospitals For those living in residential care, vitamin D supplementation is recommended. ACChas 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. Effectivedelivery of these programmes depends on staff expertise, and in New Zealand this differsfrom the situation in Europe where the interventions were evaluated.

There is an increased risk of falling for older hospital patients. Two multifactorialapproaches have been successful in reducing falls in a mixture of acute and sub-acutewards.

There are guidelines available for falls prevention programmes in both long term careand hospital settings. None of the evidence for successfully reducing falls has been fromtrials 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 OtagoExercise Programme, a home safety programme when delivered to those discharged fromhospital who reported a previous fall, and a home based, multifactorial programme.

Two controlled trials showed that a concerted population approach to fall preventionresulted in a significant reduction of medical costs, one study demonstrating a benefit tocost ratio (hospitalisations) of 26 to 1.

We modelled the impact of delivering eight different effective strategies compared withno 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 shortterm, 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


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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 whichhave 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 carefacilities.

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 thecommunity 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 likelyto be different, or

b) the answer cannot be provided from the literature by meta-analysis of existingstudies, and primary or confirmatory research is needed.

No information on falls prevention specific to Maori and Pacific populations has beenidentified 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 bysystematically collecting cost and effectiveness data for chosen interventions over a

period of time.


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PURPOSE OF THI S PROJ ECT

ACC and the Ministry of Health funded a comprehensive evaluation of the currentlyavailable information to determine 1) the best evidence on effective strategies to prevent falls andinjuries 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, and3) the best action to take for high claimants to ACC as a results of injuries from falls in order toreduce further claims by this group of older people.

Reducing the risk of falls and the incidence of injuries resulting from falls in older peopleis 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 internationalrecognition 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 ZealandPreventing Injury from Falls Strategy and to researchers worldwide.

Reducing the incidence of injuries resulting from falls in older people is also a priorityfor 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 theMinistry of Health to ensure that the most appropriate number and type of programmes arefunded to reduce falls in older people.

This project used the current literature, meta-analyses, expert opinion, claimant data fromACC, and economic modelling to investigate the ways in which effective fall preventionstrategies can be optimised for maximum cost effectiveness in preventing falls and injuries inolder New Zealanders.

PROJECT OBJ ECTIV ES

The specific objectives of the project and the process taken to achieve these objectivesare outlined below.

Objec t ive 1 To p r ov ide r e l e va n t i n f o r ma t ion on t he be s t s t r a t e g i e s f o r t a rge t i ng f a l lp revent ion programm es to spec i f ic g roups of o lder people :A. Specific age groupsB. Different living situations:

i) Community dwellingii) Rest homes


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older people listed in items A to E of Objective 1. The comprehensive search of the literature wasto 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 isneeded 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 Interventionsfor preventing falls in older people. Because of the rapid growth of publications in this field, thisreview 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 inresidential care and in hospital. Clare is a co-author for both these reviews. The protocols of thesetwo reviews have been published (Gillespie 2008; Cameron 2005). The community review iscurrently going through the Cochrane peer review process and may be published in the CochraneLibrary in February 2009, whereas the institutional reviews is still in a draft form.

Our systematic reviews, and the two Cochrane reviews in preparation, report aconsiderable choice of options for ACC and New Zealand health system funders and providersfor strategies that are effective in reducing falls. We consequently considered each of thesestrategies in terms of their potential impact in reducing the number of falls and injuries, costeffectiveness, and acceptability and feasibility for delivery in New Zealand.

Objec t ive 2 Compa r i son o f e f f i c i e nc y ( c os t e f f e c t i ve ne s s ) a nd po t e n t i a l f o r c o s t s a v ingsf r om t he e f f e c t i ve f a l l s p r e ve nt i on s t r a t e g i e s a va i l ab l e :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 insummary 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 theview to optimising the combination and delivery of effective programmes. Should ACChave difficulty in providing the required information then the researchers will use the bestavailable international evidence to inform the analysis.

Two further reviews of the literature were undertaken, and claims data broken down bycommunity living and rest home claimants was received from ACC. We identified and extractedcost data from randomised controlled trials and controlled trials of falls prevention strategies thathad included an economic evaluation in the study design or had reported cost outcomes. Thisreview 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 todevelop the economic models addressing Objective 2 (see section of this report Estimated


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Objec t ive 3A I de n t i f y ing c ha r a c t e r i s t i c s o f h igh c l a ima n t s

The collaboration with ACC to achieve this objective worked well and we are extremelygrateful 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 2008. A summary of the information gathered from the tableswas also provided. In general terms the tables showed that, for ACC, falls appear a high volumerather than a high cost per claimant issue. This was illustrated by the fact that 56% of the claimsto 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. Inaddition 82% of claims were short term, that is less than six months, with 57% less than eightweeks. 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 fivefall 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 atage 60 or older. One table of fall claims that were more than $10,000 provided a break down bydiagnosis and site, and this showed that, as expected, the majority of these claims were for hipfractures, 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 andolder 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 homeresidents.

The cost to ACC for all falls claims for those aged 80 years or older in 2006/07 was $8.7million 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 totalincurred (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 fundingto 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 notknown.

Objec t ive 3B Objec t ive 3C Sur ve y h igh c l a ima n t s A na lyse c l a ima n t da t a

Th i iti l i t ti t t d t il d f ACC high l i t f f ll


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Objec t ive 3D Rec omm e nd s t r a t e g i e s

This aspect of the project forms the major new part of this final report. We have workedwith ACC to ensure the information we provide is presented in a format that is useful to ACC andthe Ministry of Health.

To meet this final objective we have developed cost scenarios using the best availableinformation: 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 pricesto 1,000 older people in a particular subgroup, and the potential impact of these

programmes on New Zealand healthcare costs using data reported from randomisedcontrolled 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 eachof the progress reports. This is followed by the main body of the report, the section Estimatedimpact of effective strategies, which has a detailed description of the methodology and findingsfrom the economic models developed in the last phase of this project to compare the potentialimpact 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 thenext steps to be taken in New Zealand to reduce falls and related injuries in older NewZealanders.

Appendices to the final reportA separate document Optimisation of ACCs 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


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SUMM ARY OF FIN DINGS FROM SYSTEMA TI C REVIEWS

Prevention of fall injuries includes 1) reducing the number of falls, 2) reducing thetrauma associated with falls, and 3) maximising bone strength at all ages. The literature onmaximising bone strength was outside the scope of this project.

Three systematic reviews, and a literature overview on selected topics concerning fallsinjury reduction, were completed as part of this project. A summary from each review is providedin 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 wereessential to the project because the Cochrane review on falls prevention interventions is now outof date (Gillespie 2003).

We divided the literature reviews into those addressing falls prevention in communityliving 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 thetypes of effective intervention strategies and the health professionals who will deliver them mayalso 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 interventionsdeveloped by ProFaNE (Prevention of Falls Network Europe), funded by the EuropeanCommission. Single interventions address one type of risk factor for falls whereas multiple andmultifactorial programmes have multiple components and address more than one type of risk factor. Examples of single interventions are exercise programmes and vitamin Dsupplementation. Multifactorial interventions include a risk assessment with programmecomponents to address the identified risks for each individual. In a multiple programme, thesame components are delivered to each individual.

In the falls prevention literature the lack of standard terminology when reporting resultsfrom clinical trials is problematic. The main difficulty is differentiating the results concerning thenumber 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 resultscomparing 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 theyeach indicate quite different aspects concerning effectiveness of the intervention. A rate ratio isthe preferred statistic because it answers the question Were the number of falls reduced by theintervention? A risk ratio, the cruder statistic of the two, addresses whether more people fell inthe intervention group compared with the control group during the trial. Our own research hasincluded the choice of appropriate statistical techniques for analysing the results of fallsprevention trials (Robertson 2005).


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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 populationswas 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 FallsPrevention Society Conference in Melbourne in October 2008 (Haran 2008). Falls were reducedin those who tended to walk outside frequently, adding to the evidence that for older people whowear 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 interventionsshowed that the following interventions were effective in reducing falls in community livingolder people.

Interventions successful in reducing falls in community living older peopleNumber of randomised Pooled rate ratiocontrolled trials pooled (95% confidence interval)

Otago Exercise Programme 3 0.66 (0.52 to 0.83)Tai chi classes 5 0.60 (0.50 to 0.73)Group exercise programmes 9 0.71 (0.62 to 0.81)Home safety programmes 3 0.83 (0.64 to 1.07)

At high risk of falls 2 0.69 (0.56 to 0.84)Psychotropic medication withdrawal 1 0.34 (0.16 to 0.74)Cataract removal 2 0.67 (0.49 to 0.91)Cardiac pacing 1 0.42 (0.23 to 0.75)Multifactorial/multiple interventions 11 0.75 (0.65 to 0.88)

Pooled risk ratio

(95% confidence interval)Vitamin D supplementation 9 0.86 (0.75 to 1.00)

In the pooled analysis, assessment and multifactorial interventions were effective inreducing falls, and this approach is recommended in falls prevention guidelines (NHS 2004,American Geriatrics Society 2001). However care is needed when planning the implementationof 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 bethat this type of approach is more effective when referral to other health professionals is not themajor mode of implementation.

Vitamin D supplementation in our pooled analysis of falls risk did not quite meetsignificance (the upper limit of the 95% confidence interval included 1.00). It may be that thisintervention is more effective in those with a low vitamin D level (preliminary results from the


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hormone replacement treatment, nutrient supplementation, falls education alone, and cognitive behavioural programmes.

A recent randomised controlled trial has shown that an intervention aimed at reducingfalls 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 randomisedcontrolled trials meeting the inclusion criteria and testing programmes for those in rest homes andin 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 acombination of these wards (2,862 inpatients; 1,146 men; 1,716 women), and the remaining 29trials 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 showedgood success in residential care homes in Europe (Becker 2003, Dyer 2004, Jensen 2002).Components of the interventions included educating staff on fall prevention, implementingexercise programmes, modifying the environment, supplying and repairing aids, reviewing drugregimens, 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 Zealandgiven the different levels of staff expertise.

It should also be noted that one falls prevention intervention in New Zealand rest homessignificantly increased, rather than decreased, the rate of falls (Kerse 2004). This illustrates thefact that falls prevention is not an intuitive process, and only some interventions or combinationof 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 medicationreview in rest home residents by a pharmacist (Zermansky 2006). After six months there was areduction 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 pharmacists recommendations.

Meta-analyses pooling results from trials with the same or similar interventions showedthat the following were effective in reducing falls in people in residential care facilities and inhospital. Key findings from the systematic review follow.


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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 effectivenesswere identified in this setting (37 versus 111 now in the community).

Vitamin D supplementation was the only intervention, when trials testing this approachwere pooled, to show a significant benefit in terms of falls reduced in long term carefacilities.

In three individual trials in Europe, falls were reduced by using a multifactorial approachin 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 theinterventions 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. Twomultifactorial approaches have been successful in reducing falls in a mixture of acute andsub-acute wards.

There are guidelines available for falls prevention programmes in both long term careand hospital settings. None of the evidence for successfully reducing falls has been fromtrials 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 inthe trials, or there was no definition of injury provided. A limited number of studies included inthe systematic reviews reported the number of participants in each group who had a fracture as aresult 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 fromtwo or more studies available to pool.

Interventions successful in reducing fractures in falls prevention trials

Number of randomised Pooled risk ratiocontrolled trials pooled (95% confidence interval)Hip fracturesResidential care facilitiesMultifactorial interventions 3 0.49 (0.24 to 0.98)

( )


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Information gained from the falls prevention trials about the number of participants whosustained 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 ratioshowed a significant reduction in fractures, but this finding needs to be viewed withcaution 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, theexercise programmes differed in that two were group exercise programmes and onetested a home based programme for people with Parkinsons Disease.

Given the small number of trials with fracture data available for pooling, this informationdid not provide definitive data we could confidently use in developing the modelsreported 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 protectorsand safety flooring.

Hip protectorsHip 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 fromdisplacement 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 residentialcare, 35 falls occurred with hip protectors being worn at the time (Butler 2004). There were nohip fractures when residents fell wearing hip protectors, but over the 18 month period there were12 hip fractures in the 917 falls without a hip protector in place.

ACC has already investigated this approach by commissioning a review on the potentialeffectiveness of hip protectors in New Zealand residential care facilities, plus a cost effectivenessevaluation, both of which have informed this project.

The evidence for effectiveness in preventing hip fractures indicates that hip protectorsshould be offered on an individual basis, and provision of hip protectors have formed part of thesuccessful individualised multifactorial interventions in two trials in residential care facilities(Becker 2003, Jensen 2002).


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We reported the results of our own study comparing gait patterns and balance of elderlywomen 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 non-compliant flooring (vinyl), a compliant flooring (carpet with good quality underlay) and Kradal,the new safety flooring manufactured by Acma Industries in Upper Hutt, Wellington. Weconcluded 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 valuefor money when funding and supporting falls prevention strategies. Economic evaluation is thesystematic, explicit analysis of alternative courses of action, assessed in terms of both costs andconsequences. Economic evaluations provide a measure of efficiency for the purposes of decisionmaking by comparing the costs and the consequences of alternative programmes (Drummond2005). There are four main types of economic evaluations: 1) cost analysis, 2) cost effectivenessanalysis, 3) cost utility analysis, and 4) cost benefit analysis. In a total of eight trials in acommunity setting, a comprehensive economic evaluation was reported for the seven differentinterventions tested (eight cost effectiveness analyses, one cost utility analysis, see report dated15 March 2008). We found no comprehensive economic evaluations in the trials in residentialcare or in hospital. An article on the cost effectiveness of withdrawal of fall-risk-increasingmedications 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 37in an institutional setting identified in our systematic reviews, we noted the following economicevaluations had been carried out within these trials:

For 8 trials testing an intervention in the community setting, the costs of deliveringthe intervention were reported

For 1 intervention tested in a long term care setting, the costs of delivering theintervention 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 comprehensiveeconomic 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 evaluationwas reported for the 7 different interventions tested (8 cost effectivenessanalyses, one cost utility analysis).

Investigation of the cost effectiveness of effective interventions has provided informationon the likely value for money of several types of approach in the community setting, but none in


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Summary of findings from the costs, cost effectiveness and cost utility analysesin 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 costsand cost effectiveness of the interventions within the trials to date is limited.

Comprehensive cost effectiveness analyses were carried out in only eight of the 140randomised controlled trials included in the systematic reviews of falls preventioninterventions. All eight trials tested strategies that were effective in reducing falls incommunity living older people.

For three interventions, the Otago Exercise Programme, psychotropic medicationwithdrawal, and a home safety programme effective in reducing falls in people withsevere visual impairment, the costs of delivering the programmes and the costeffectiveness in New Zealand have been established.

One trial in community living older people reported a cost utility analysis and extendedthe time period of the analysis from the trial duration to the participants remaininglifetime. 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 foundquality 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 islarger for self reported fear of falling than for falls or a fracture (Iglesias 2008).

The information provided by these comprehensive economic evaluations indicates thereis some, although limited, evidence that falls prevention strategies can be cost savingduring the trial period, and may also be cost effective over the participants remaininglifetime.

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 thetrial were available for only one of the trials in residential care. No cost effectivenessanalyses in this setting were reported.

For the randomised controlled trials in a hospital setting, no cost data or costeffectiveness 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).


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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 fallsand injuries. The approaches also need to be acceptable and feasible for the New Zealandhealthcare system. In choosing approaches to recommend, we took into account the type of intervention, the health professionals delivering the intervention, the different settings, andcharacteristics of potential participants including age group.

We considered the evidence carefully for all these factors and selected the followingeffective interventions to investigate further: the Otago Exercise Programme, tai chi andmulticomponent exercise classes, home safety assessment and modification programmesdelivered to selected subgroups of older people, cataract surgery, multifactorial programmesaimed at the persons individual fall risk factors, and two multiple approaches the multifacetedgroup learning programme Stepping On, and a population approach. We modelled the likelyimpact of these interventions when delivered to 1,000 older New Zealanders. The methods usedand 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 therandomised 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 gradualwithdrawal of psychotropic medications, which our own research has shown was successful inreducing 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 theresources needed to implement this approach would be considerable. GPs would need trainingand incentives to prescribe withdrawal to their patients. This would involve outreach visits (one-on-one visits to GPs by a pharmacist or other health professional) and primary care professionalmeetings 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 beinvolved in order to improve uptake and adherence, and provide support and advice on alternativemethods 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 inresidential care and hospitals. Our meta-analyses and those of others conclude that vitamin Dsupplementation is an effective strategy to reduce falls, particularly for those in residential carefacilities. It is accepted therefore that this strategy should be used for falls prevention in thissetting. 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 resthomes in Europe (Becker 2003, Dyer 2004, Jensen 2002), the New Zealand situation means thatfewer 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


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ESTIMA TED IMPACT OF EFFECTI VE STRATEGIES

Genera l approac hIn this section of the project we have estimated the likely impact on healthcare costs of

the interventions shown in the systematic reviews to be effective in reducing falls and with goodrationale for dissemination in New Zealand. The economic models we have developed are aimedat assisting in clinical and health policy decision making regarding falls prevention strategies for older people. They involve assumptions and are intended to give an indication only of the relativeimpact of each intervention.

Sources of dataThe systematic reviews in this project provided information on which interventions are

effective in reducing falls in each of the settings and for each subgroup outlined in Objective 1.The systematic review of cost outcomes and economic evaluations reported in the randomisedcontrolled trials provided information on the incremental cost effectiveness compared with usualcare for several, but not all, of the effective interventions. Cost effectiveness and cost utilityanalyses do not attempt to put a monetary value on the fall events that were prevented by theintervention. The measure of relative cost effectiveness and cost utility in these studies isexpressed as a ratio of the dollar amount for healthcare as a result of delivering the programme,compared with usual care per fall event prevented, or per QALY gained.

For the models in this section we have combined information on effectiveness of falls prevention strategies obtained from the literature, with information on the costs of programmedelivery and the consequences of programme delivery in terms of health care costs incurred or averted. In addition to the randomised controlled trials in the systematic review, we have used

published information on effectiveness and cost effectiveness from controlled trials, that is, trialsin which participants were not randomised to the groups used for comparison purposes. If the cost

per person of delivering the intervention in the trial was not available we have calculated this touse as an estimate.

The modelsWe have intentionally kept the models as simple and transparent as possible. In each

model we estimated the likely total costs incurred, or cost savings, if the intervention is deliveredto 1,000 participants. First we estimated the number of falls per person receiving the interventionthat were prevented over a one year period in the relevant clinical trial. We then used the

incremental cost per fall prevented reported in the trial, or if this was not available, an estimate of the mean cost per person for delivering the intervention and a mean cost of a potential fall event,and extrapolated the likely total costs or cost savings after one year for 1,000 participants.

M e t h o d s a n d m o d e l a s s u m p t i o n sThe main assumption in the models developed in this section of the report is that the


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Viewpoint of the models

We have stated the perspective taken for estimating healthcare use and costs in each particular model. Wherever possible we have used a societal perspective the broadest perspective because of the broad nature of the problems caused by falls (Drumond 2005). This perspective considers not only costs to the health system, but also to the fallers themselves, their carers, and their families. The models could be used by ACC to estimate the impact from their own perspective by substituting the price ACC pays, or is willing to pay, per person for deliveryof a particular intervention, and the average cost to ACC of fall events in the subsample andsetting of the older people being targeted.

TimeframeFor simplicity and ease of comparison, all our models are based on estimates of the

number of falls prevented during one year only from the start of the intervention. One exceptionis the model for 16 weeks of tai chi classes, where falls were monitored for only six months in thetrial with cost effectiveness information available (Voukelatos 2007).

The benefit of an intervention will not always cease after programme delivery ceases. For example, if people who receive an exercise programme keep exercising, the benefits willcontinue for no further costs. Similarly for equipment provided and behaviour change sustained

long term following a home safety programme. Therefore the timeframe of one year taken islikely to underestimate the cost effectiveness of the interventions.

Target groupIn each of the models we have assumed that the group being targeted and choosing to

participate in the real world setting would be similar to the group who took part in the trial (theone being used as the basis for the particular model), in terms of age group and presence of other fall risk factors.

Measure of effectivenessThe interventions chosen for this section were those shown in randomised controlled

trials to be effective in significantly reducing the rate of falls. There is no justification for usingunsuccessful or untested programmes either for an individual or when choosing strategies for wider dissemination.

In clinical trials, the effectiveness of a falls prevention intervention is expressed as anincidence rate ratio the rate of falls during the trial for the intervention group compared with(divided by) the rate of falls in the control group. Since the control group is arbitrarily assignedan incidence rate of 1.00, an incidence rate ratio of 0.60 indicates there was a 40% reduction inthe rate of falls in the intervention compared with the control group during the trial. When theupper limit of the 95% confidence interval for the incidence rate ratio is below 1.00, theinterpretation of the trial results is that fall events were significantly reduced by the intervention.

However the impact of the intervention in terms of fall events prevented, and thereforeth t ti l f t i g i h lth d d th t l b f f ll d i j i


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The number of falls per person in the intervention group during the trial, and thereduction in falls calculated as the difference between falls per person in the control and

intervention groups, is generalisable to New Zealanders in the same age group and withsimilar characteristics in terms of fall risk who would accept the intervention if offered.

Effectiveness calculated as the number of falls prevented per person gives a better estimation of likely impact in the real world than the number of falls prevented per

person year. In the trials, falls were generally monitored for one year, but in real life, thenumber of falls prevented per person taking part in the programme would be the measureof success.

Adherence to the interventionThe use of clinical trial results for developing our models means that the levels of

adherence to the intervention and the drop out rate are assumed to be similar to those in therelevant trial. In some cases adherence rates may be greater, in some cases lower, particularly if less experienced or motivated staff deliver the programme or a different subgroup of older peopleare offered the same programme. Particular subgroups (for example frail or unfit individualstaking part in an exercise programme; fitter people in good health) may respond differently tovarying levels and amounts of professional assistance and support (King 2006). Predictors of

adherence are specific to each intervention and cover a wide range of physiological,demographic, psychosocial, health related, and environmental factors.

Estimation of costs in 2008The trials reported cost outcomes in different currencies and from different years. To

enable comparison of these costs we present all monetary values in the reported currency and alsoin 2008 New Zealand dollars. We first used Purchasing Power Parity values in the year of the

prices to convert the currency to New Zealand dollars, and then inflated this value to 2008 prices

using a Reserve Bank of New Zealand web calculator based on the New Zealand consumer priceindex (http://www.rbnz.govt.nz/inflationcalculator/calculate.do).

Costs of implementing the interventionAn assumption in each of the models is that the average cost for delivering the intervention

to 1,000 participants will be similar to the average cost as reported in the relevant trial. That is: 1)a similar recruitment strategy will be used and the uptake rate will be similar, 2) costs of trainingstaff to deliver the programme will be similar, 3) there will be a similar input in terms of time bythose delivering the programme and the same salary levels, and 4) administration and the costs of equipment and other resources will be similar.

When the cost of delivering the intervention was not reported in the trial, we estimated theaverage cost per person by identifying the cost items that were required and valuing these items at2008 New Zealand prices. We used 25% of resource use to estimate the cost of overheads (officeaccommodation, administration, financial services, computer use, and depreciation of equipment

d f i g th g )


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In the two years of this trial, 22% (77 of 358) of the falls resulted in healthcare services being used (Robertson 2001a). Of note is the fact that hospital admission costs made up 90% of the total fall related costs. This means that fall related hospital admission costs averted are a goodindication of the potential healthcare cost savings as a result of preventing fall injuries.

In a randomised controlled trial of women and men aged 75 years and older with a fall inthe previous year carried out in the Hutt Valley in 2005, the healthcare costs related to falls weremonitored for six months for the first 202 participants (Garrett 2008). Of the 97 falls reportedduring this time period, 18 (19%) required medical care but there were no hospital admissions,and the median cost of a fall (societal cost) was $153.53 ($169.38 at 2008 prices).

Cost effectiveness of the interventionThe incremental cost effectiveness ratios reported in the clinical trials were of three main

types: 1) the ratio was the incremental cost of delivering the intervention compared with usualcare per fall event prevented during the trial (the difference between the costs of delivery of theintervention and the costs of the control group activity if any, divided by the difference in thenumber of falls in the control group and the intervention group), 2) the incremental costs used tocalculate the ratio included not only the cost of delivering the intervention, but also all fall relatedhealthcare costs during the trial, and 3) the incremental costs used to calculate the ratio includedall healthcare costs during the trial, whether or not related to falls.

An assumption of our models is that the incremental cost per fall prevented reported for a particular intervention compared with usual care in the relevant clinical trial, is generalisable tothe New Zealanders in the same age group and with similar characteristics in terms of fall risk who would accept the same intervention if offered.

Costs or cost savings from delivering each interventionWe have used two ways of calculating the total costs or cost savings from delivering the

intervention to 1,000 participants. When an incremental cost effectiveness ratio was available

from the trial, we arrived at our estimate by multiplying the incremental cost per fall prevented bythe likely number of falls that would be prevented in one year. When a cost effectiveness ratiowas not available, we first estimated the likely savings in healthcare costs from the falls thatwould be prevented in one year, and took the total costs or cost savings to be the difference

between the cost of programme delivery to the 1,000 participants and these potential healthcarecost savings. The assumptions here are that all the data used in these calculations are accurate,appropriate, and generalisable.

An outline of each intervention, and tables showing the sources of data used in themodels and the models themselves, are provided in the next section.


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Otago Exerc i se Programm eThe strong research base for this home based, muscle strengthening and balance

retraining programme comes from our own research group at the Dunedin School of Medicine,University of Otago. This is the only falls prevention programme with more than one trialdemonstrating effectiveness in reducing falls and injuries (Campbell 1997, Robertson 2001b,Robertson 2001c). Overall in four trials with 1,016 people aged 65 years to 97 years in nine citiesand towns in New Zealand, the Otago Exercise Programme reduced the rate of both falls and fallinjuries by 35% (Robertson 2002). Subgroups benefiting most were those aged 80 and older, andthose with a previous fall. The Programme was effective when delivered by a research

physiotherapist and by nurses, trained and supervised by the physiotherapist.

ACC provided the research funding for the first two trials, and has supported nationwidedissemination of the Programme for some time. Training of physiotherapists as exerciseinstructors or to train and supervise nurses to deliver the Programme is through a website co-ordinated by the Auckland University of Technology. ACC published a manual for instructorsand provides the manual free of charge to all New Zealand health professionals (ACC 2003). TheOtago Exercise Programme is now used routinely throughout the world.

The evidence for effectiveness and cost effectiveness reported in the literature issummarised in Table 1. Results from the West Auckland trial showed that the Otago ExerciseProgramme was cost saving for those aged 80 years and older (see also Table 18). A further randomised controlled trial of the programme is in progress in Vancouver, Canada. Interimresults show that the Programme reduced falls in the first 74 people in the trial. Further excitingresults show that executive functioning was significantly improved in those receiving the exercise

programme compared with the control group (Liu-Ambrose 2008). This may help explain themechanism whereby exercise reduces falls, that is, not only by improving balance and musclestrength, but also by improving cognitive performance.

Table 2 shows the results of modelling the impact of the Otago Exercise Programme based on three separate controlled trials, and in different age groups (Robertson 2001a, Robertson2001b, Robertson 2001c). Recruitment of clients could be through general practitioners, A & Edepartments for those presenting with a fall, and other health professionals.

There is good evidence for ACC, the Ministry of Health, and District Health Boards tocontinue supporting the Otago Exercise Programme in the home based format. A current pilottrial in Dunedin led by Dr Stephanie Woodley is testing whether group classes will be as effectivein improving strength and balance measures, but is not powered for falls.

Meantime the home based approach is endorsed by a recent finding from a survey of 5,440 people aged 54 and older in the UK (Yardley 2008). Over 60% of respondents said they

would consider doing a home based strength and balance training programme at home (36.4%said they would definitely do it), whereas only 22.6% would definitely attend group exercisesessions.

Gr o u p e x e r c i s e p r o g r am m e sM l i i


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Table 1. Effectiveness and cost effectiveness of delivering the Otago ExerciseProgramme compared with no exercise programme for one year in three clinical trials

StudyCurrency

Targetgroup

Relativereductionin rate of

falls(95% CI

forincidence

rateratio)

Number of fallsprevented per

person receivingthe intervention*

Incrementalcost per

person fordelivering

intervention$NZ 2008($NZ yearof prices)

ICER fordelivery of

intervention$NZ 2008($NZ yearof prices)

ICER fordelivery andfall related

hospitaladmissions

averted$NZ 2008

($NZ year of prices)

Robertson2001a

$NZ 1995Women

80 years

32%(0.52 to

0.90)

0.540(152/11788/116)

$213 ($173) $418 ($314)

Robertson

2001b $NZ 1998Womenand men

75 years

46%(0.32 to

0.90)

0.255(109/11980/121)

$549 ($432) $2,291($1,803)

$197 ($155)

Womenand men

80 years

61%(0.14 to

1.05)

0.611(81/6143/60)

$549 ($432) $867 ($682) $732 ( $576)

Robertson2001c

$NZ 1998Women and

men 80years

30%(0.59 to

0.84)

0.275(105/120198/330)

$531 ($418) $1,930($1,519)

CI denotes confidence interval.ICER denotes incremental cost effectiveness ratio (incremental cost per fall prevented).

$NZ denotes New Zealand dollars.*Numbers in brackets are raw data used for this calculation (number of falls in control group/number in control group minus number of falls in intervention group/number in intervention group).Main outcome results are reported in Campbell 1997.Negative values indicate cost savings.


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Table 2. Estimated impact of delivering the Otago Exercise Programme for one yearto 1,000 participants

StudyScenario

Target group

Cost fordelivery to

1,000participants

$NZ 2008

Number of falls

preventedfor 1,000

participants

Cost of fallsprevented *

for 1,000participants

$NZ 2008

Totalcost/cost

saving * for1,000

participants$NZ 2008

Robertson 2001a

Delivered by research physiotherapistWomen 80 years

$213,000 541(2,703) $361,303($1,806,514) $148,303

Robertson 2001b Delivered by nurse

Women and men 75years

$549,000 255 $50,197

Women and men 80

years

$549,000 611 $447,400

Robertson 2001c Delivered by nurse

Women and men 80years

$531,000 275 $201,300

$NZ denotes New Zealand dollars.*Negative values indicate cost savings.Estimated using average cost of a fall $NZ668.43 (at 2008 prices, societal perspective) from

Robertson 2001a (women 80 years).Estimated from cost per fall prevented ($NZ197 per fall prevented, 2008 prices) reported inRobertson 2001b ( 75 years see Table 1).Estimated from cost saving per fall prevented ($NZ732 per fall prevented, 2008 prices) reportedin Robertson 2001b ( 80 years see Table 1).


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Table 3. Effectiveness and cost of weekly multicomponent group exerciseclasses compared with no exercise classes for one year

StudyCurrency

Target group

Relativereduction in rateof falls (95% CI

for incidencerate ratio)


person receivingthe intervention*

Incrementalcost per


intervention$NZ 2008

Barnett 2003

65 years,

1 physical performanceimpairment

40%

(0.36 to 0.99)

0.341

(0.9460.605)

$547

$NZ denotes New Zealand dollars.CI denotes confidence interval.*Numbers in brackets are data used for this calculation (rate of falls in control groupminus rate of falls in intervention group, no raw data reported).No cost outcomes reported.

Cost per person for one year of classes, based on estimations in Table 4.

Table 4. Estimated cost of exercise classes for 83 participants for one year as in Barnett 2003

Unit cost Total costCost item Resource use $NZ 2008 $NZ 2008Training costsExercise instructors (n=3) 3 hours each 52.00 468Materials Manuals, photocopying 30.00 90Supervisor 3 hours 95.00 285RecruitmentAdvertisements 3 newspaper advertisements 250.00 750Staff time* 30 minutes per person recruited 24.00 1992Programme deliveryExercise instructor 1.5 hours per class, 37 classes for 7

streams, 12 people per class 52.00 20202Venue hire 1 hour per class, total 37 classes for 7

streams 30.00 7770Ankle cuff weights 1 per person 15.00 1245Manual for home exercise,

diary to record home exercise 1 per person 5.00 415Tea/coffee Per person for each class 1 00 3071


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Table 5. Estimated impact of delivering multicomponent exercise classes to 1,000participants for one year

StudyTarget group

Cost fordelivery to

1,000participants

$NZ 2008

Number of falls

preventedfor 1,000

participants



$NZ 2008

Totalcost/cost

saving * for1,000


Barnett 2003

65 years,

1 physical performanceimpairment

$547,000 341 $227,935 $319,065

$57,759 $489,241

$NZ denotes New Zealand dollars.*Negative values indicate cost savings.Cost per person for one year of classes based on estimations in Table 4.Estimated using average cost of a fall $NZ668.43 (at 2008 prices, societal perspective) from

Robertson 2001a (women 80 years).Estimated using median cost of a fall $NZ169.38 (at 2008 prices, societal perspective) from Garrett2008 (women and men 75 years).


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The screening tool included an inability to stand from a 45 cm high chair in less than twoseconds, a need to step to maintain balance when performing a near-tandem balance test, and aninability to catch a rod dropped from above the hand within 300 milliseconds. The structuredexercise classes were held for an hour each week over four terms for one year (37 classes in all).Accredited exercise instructors taught the classes.

Table 3 shows the evidence for effectiveness of the intervention; there were no costoutcomes in the trial. We estimated the cost of delivering the classes in 2008 New Zealanddollars (Table 4). Table 5 shows the estimated impact if 1,000 people were recruited and took

part in the classes for a year.There have been other effective group exercise programmes in terms of relative rate

reduction published, but with insufficient data on falls and intervention details to estimate the

costs and impact (Lord 2003, Skelton 2005).A recent systematic review of exercise programmes to prevent falls concludes with the

following key messages (Robertson 2007): Many different risk factors contribute to falls but muscle weakness and poor balance

underlie most falls. The most common components of successful exercise programmes to reduce falls are

moderate intensity strength training against resistance and dynamic balance retraining, but there are insufficient good quality negative studies to determine whether some typesof exercises are ineffective.

Exercise programmes that are individually tailored, progress in difficulty, and targetcarefully selected groups at high risk, have so far resulted in the greatest absolutereduction in falls and injuries.

Researchers should make programme details available so that those running falls prevention programmes in particular settings or subgroups of older people can useeffective, evidence based interventions.

Tai chi classesTai chi has been shown to improve balance and has been suggested as a form of exercise

to reduce falls since the successful trial by Wolf and colleagues (Wolf 1996). In this trial 72 participants aged 70 and older attended tai chi classes twice a week for 15 weeks. Falls were asecondary outcome of the study and were monitored for seven to 20 months. Compared with the138 participants receiving computerised balance training or health education classes, the rate of falls was reduced by 47.5%.

A further larger trial by Wolf, this time in a frailer group of older people and with a moreintense version of tai chi, after 48 weeks showed a non-significant reduction in the rate of falls(Wolf 2003). There are now three other trials with data available for pooling. Participants in thetrial with the largest reduction in the rate of falls (55%) were physically inactive 70 to 92 year olds in the US who were monitored for six months (Li 2005). The pooled rate ratio from our meta-analysis of the five published trials (n = 1,629 participants) shows that tai chi reduced therate of falls by 40% in a combination of healthy people aged 60 and older plus older frailer


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Table 6. Effectiveness and cost effectiveness of 16 weekly tai chi classes compared with noclasses after 24 weeks

StudyCurrency

Target group


falls(95% CI

forincidence

rateratio)


personreceiving theintervention*

Incrementalcost per


intervention$NZ 2008(reportedcurrency)

ICER fordelivery of


ICER fordelivery and

totalhealthcare

use$NZ 2008(reportedcurrency)

Haas 2006 $A 2002

60 years

13%(0.46 to

0.96

0.126(126/337

86/347)

$303($A234)

$2,442($A1,889)

$2,176($A1,683)

$373($A298)

CI denotes confidence interval.ICER denotes incremental cost effectiveness ratio (incremental cost per fall prevented).$NZ denotes New Zealand dollars, $A Australian dollars.*Numbers in brackets are data used for this calculation (number of falls in control group / number incontrol group minus number of falls in intervention group / number in intervention group).Main outcomes are reported in Voukelatos 2007.Calculated from raw data in Haas 2006 (total cost of tai chi classes $A81,232/347 in intervention group =$A234).Estimated using cost for 15 weeks tai chi classes twice weekly ($A470 at 2008 prices) calculated pro rata(classes once a week for 16 weeks) from Day 2008 (exchange rate $A1 = $NZ1.249 in mid-June 2008,Purchasing Power Parity not yet available for 2008).

Table 7. Estimated impact of 16 weekly tai chi classes to 1,000 participants after 24weeks

StudyTarget group

Cost fordelivery to

1,000


Number of falls

prevented



for 1,000


Totalcost/cost

saving for

1,000participants$NZ 2008

Haas 2006 60 years

$303,000 126(630)

$274,176 *


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The evidence of effectiveness and cost effectiveness from the Central Sydney trial issummarised in Table 6. The Centre for Health Economics Research and Evaluation published aseparate report on the cost effectiveness of tai chi in this trial (Haas 2006). In Table 7 we showthe estimated impact after 24 weeks of 16 weekly classes with 1,000 participants.

The modified version of tai chi used in most of the classes in this trial was designed byDr Paul Lam especially for older people with arthritis ( www.taichiproductions.com ). Tai Chi for Arthritis has 12 movements based on the Sun style. In 2005 ACC invited Dr Lam to help designsafety measures and set up training courses for class teachers to be used throughout New Zealand.

H o m e s a f e t y a s s e s sm e n t a n d m o d i f i c a t i o n

Modifications in the home aimed at reducing home hazards and risky behaviour associated with falls are a component of many of the multifactorial falls prevention programmes.However, effectiveness of this approach was not known until trials testing home assessment andmodification alone were completed. We found three trials testing a home safety programme as asingle intervention and with the rate of falls available for pooling. Two of these trials showed asignificant reduction in the rate of falls (Campbell 2005, Cumming 1999).

A systematic review published this month (Clemson 2008) endorses the effectiveness of home safety assessment and modification programmes delivered by an experienced occupationaltherapist for preventing falls in community living older people. We would recommend targetingsubgroups at high risk of falls, as this approach was not effective in reducing falls in a general

population (Stevens 2001).

People recently discharged from hospitalIn the trial by Cumming where the majority of participants were recruited on discharge

from hospital, the subgroup who benefited most from the home safety programme were thosereporting a fall in the previous year (hazard ratio 0.75, 95% confidence interval 0.58 to 0.96). Acomprehensive economic evaluation of the home safety programme in Cummings trial confirms

that the programme is more likely to be cost effective in older people who have a history of falls(Salkeld 2000).

People with severe visual impairment Older people with visual impairment are at double the risk of falling compared with their

normally sighted peers. A home safety programme modified for use in people with severe visualimpairment was tested in the VIP trial (Campbell 2005). It was delivered by experiencedoccupational therapists during one or two home visits. The occupational therapists facilitated

provision of any equipment such as grab rails, mobility aids and improvements in lighting. After one year falls were reduced by 41%. This trial was carried out in Auckland and Dunedin, NewZealand with participants recruited through low vision clinics and the Royal New ZealandFoundation of the Blind. The cost effectiveness of the home safety programme in people withvisual impairment was also established (Campbell 2005).


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reason this intervention works in reducing falls. Raising awareness regarding safety in the publicenvironment and mobility training may also have a part to play.

Dr Lindy Clemson, a senior researcher in the field of occupational therapy from MonashUniversity, Melbourne, Australia provided us with the following points, and some notesregarding best practice for environmental fall prevention home visits by an occupational therapist(see also Peterson & Clemson 2008).

1. The occupational therapy approach is very different from the pre-determined hazard listwith a safety brochure provided. It is clear from the literature that this will not make asignificant difference to the number of falls sustained.

2. An occupational therapy home visit where reducing falls risk is the focus, differs from

other occupational therapy visits where improving access and making things easier toaccomplish are the expected outcomes.

Take into account the person-environment fit. Ladder safety or alternatives to climbing andcommunity safety may be an appropriate focus for an active person, whereas tripping hazards andsafe reaching are likely more important for a frailer and more sedentary lifestyle.

Understand the perceptions of the older person of their experience of falls and their beliefs

about causes of falls . Challenge the individual to appraise their risk and to explore understandingof potential causes of falls. We need to listen to what people are saying and be observant of whatthey are doing.

Use a problem solving approach. Audit the home collaboratively with the client to address behavioural and environmental concerns and develop priorities.

Understand the meaning of home, activities and roles, and sense of control . These providethe context for working to make changes in the environment or to working with the person tochange habits that might be risky behaviours. We know these factors will directly influencewhether or not people will follow through with recommendations and decisions.

Consider risk taking behaviours and encourage protective adaptations. Use situational cuesand target the behaviour to be changed. Solutions are very often aimed at changing habitual

behaviours.

Have up-to-date knowledge on options for important hazards that are frequently involvedin falls . For example, be knowledgeable about slip resistant products, strategies to fix loose floor coverings and new home safety products.

Use environmental re-design strategies. For example, remove or re-locating furniture to reduceclutter and allow turning space.


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Table 8. Effectiveness and cost effectiveness at one year for delivering a home safetyassessment and modification programme compared with no home safety programme fromtwo clinical trials and one analytic model

StudyCurrency

Target group


falls(95% CI

forincidence

rateratio)

Number of falls prevented

per personreceiving theintervention*

Incrementalcost per


intervention$NZ 2008(reported

currency)

ICER fordelivery of


ICER fordelivery andhealthcare

costs$NZ 2008(reportedcurrency)

Campbell 2005$NZ 2004 75 years

visual acuity6/24 or worse

41%(0.42 to

0.83)

0.535(271/193 172/198)

$369($NZ325)

$738($NZ650)

Salkeld 2000 $A 1998 65 yearsrecently

discharged fromhospital

14%(0.71 to

1.03)

0.362(324/266 226/264)

$7,075($A4,986)

65 yearsrecently

discharged fromhospital, fall in previous year

25%(0.58 to

0.96)

0.913(193/103

99/103)

$5,648($A3,980)

Smith &Widiatmoko

1998 $A 1996

75 years

NA NA $251 ($172) $2,504($A1,721)

CI denotes confidence interval.ICER denotes incremental cost effectiveness ratio (incremental cost per fall prevented).$NZ denotes New Zealand dollars, $A Australian dollars.

NA denotes these data are not available (not reported).*Numbers in brackets are raw data used for this calculation (number of falls in control group/number in controlgroup minus number of falls in intervention group/number in intervention group).


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Table 9. Estimated impact after one year from delivering a home safety assessmentand modification programme to 1,000 participants

StudyTarget group

Cost fordelivery to

1,000participants

$NZ 2008

Totalnumber of

fallspreventedfor 1,000

participants

Total cost of falls

prevented * for 1,000


Totalcost/cost

saving * for1,000


Campbell 2005 75 years, visual

acuity 6/24 or worse$369,000 535 $357,610 $11,390

Salkeld 2000 (1) 65 years recentlydischarged from

hospital

362 $2,561,150

65 years recentlydischarged fromhospital, fall in previous year

913 $5,156,624

Salkeld 2000 (2) 65 years recentlydischarged from

hospital

$369,000 362 $241,972 $127,208

65 years recently

discharged fromhospital, fall in previous year

$369,000 913 $610,277 $241,277

$NZ denotes New Zealand dollars.*Negative values indicate cost savings.Estimated using average cost of a fall $NZ668.43 (at 2008 prices, societal perspective) fromRobertson 2001a.Calculated using cost per fall prevented reported in Salkeld 2000 (includes all healthcare use for one year).Cost of delivery assumed the same as in VIP trial (Campbell 2005).


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Ca t a r a c t s u rg er yAs noted above, older people with visual impairment are at double the risk of falling

compared with their normally sighted peers. Three trials have tested an intervention aimed atreducing falls by improving vision. Two trials tested whether expedited cataract removal wouldreduce falls in women over 70 who had been referred to a hospital ophthalmology department(Harwood 2005; Foss 2006). Patients on the waiting list were randomised to expedited surgery(approximately four weeks) or to remain on the waiting list (12 months wait). The rate of fallswas significantly reduced following first eye cataract surgery compared with those on the waitinglist (Harwood 2005), but not following second eye surgery (Foss 2006). However, pooling of therate ratios from the two trials showed a significant 33% reduction in falls.

A comprehensive economic evaluation of the cost effectiveness of first eye cataractsurgery in the trial has been reported (Sach 2007) and Table 10 summarises the evidence oneffectiveness and cost effectiveness of this intervention. We have modelled the impact of thisintervention using the reported data, and the cost of eye cataract surgery in New Zealand in a

private health setting (Table 11).This trial also reported a cost utility analysis and extended the time period of the analysis

from the trial duration to the participants remaining lifetime. The cost-utility ratios from the National Health Service perspective, and from the personal social services perspective for oneyear, were above the current accepted willingness to pay value of UK30,000. However, whenthe costs and QALYs were modelled over the participants expected lifetime, the incremental cost

per QALY was within this limit at UK13,172 (at 2005 prices). The authors also provided costeffectiveness acceptability curves.

The QALY provides a generic measure to enable comparison of cost effectiveness acrossdifferent types of health services and treatments. However there are limitations in using QALYsfor economic evaluations of complex interventions for older people since these interventionsresult in multiple benefits not captured by health related quality of life measures (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 islarger for self reported fear of falling than for falls or a fracture (Iglesias 2008).

A s s es s m e n t a n d m u l t i f a c t o r i a l in t e r v e n t i o nThere is strong evidence that multifactorial interventions are effective in reducing falls in

older people in the community, and good evidence for their effectiveness in residential carefacilities and hospitals. Multifactorial programmes address the individuals risk factors for fallsand this is always the approach taken by a clinician treating an individual patient.

The first intervention tested in a randomised controlled trial that was successful inreducing falls was a multifactorial programme addressing individual risk factors for fallsdelivered at home by a nurse and physiotherapist (Tinetti 1994). Participants were aged 70 or over and had one or more of eight specified risk factors for falling. The intervention was costsaving in those with four or more of the eight risk factors at baseline (Rizzo 1996).

Th id f ff i d ff i f hi i l i i d i


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Table 10. Effectiveness and cost effectiveness of expedited first eye cataract surgerycompared with no surgery after one year

StudyCurrency

Targetgroup


falls(95% CI

forincidence

rate

ratio)


person receivingthe

intervention*

Incrementalcost per


intervention$NZ 2008

ICER fordelivery of

interventionand all

healthcarecosts

$NZ 2008(reported

currency)

ICER fordelivery and all

healthcarecosts plus carer

costs$NZ 2008(reportedcurrency)

Sach 2007 UK 2005

Women >70years

34%(0.45 to

0.96)

0.456(1.3900.934)

$3,700 $11,901(UK4,390)

$10,801(UK3,983)

$NZ denotes New Zealand dollars, UK pounds sterling.*Numbers in brackets are raw data used for this calculation (reported mean number of falls per person incontrol group minus mean number of falls per person in intervention group).

Main outcomes are reported in Harwood 2005.Cost of pre-surgery visit to private ophthalmologist, cataract surgery including hospital and anaesthetistcosts, 2 follow up visits (personal communication Marinoto Clinic, October 2008).

Table 11. Estimated impact after one year from expedited first cataract surgery for1,000 participants

StudyTarget group

Cost fordelivery to

1,000participants

$NZ 2008

Totalnumber of

fallspreventedfor 1,000

participants

Total cost of falls

prevented * for 1,000


Totalcost/cost

saving * for1,000


Sach 2007 Women >70 years

456 $5,426,856

456 $4,925,256$3,700,000 456 $304,804|| $3,395,196

$NZ denotes New Zealand dollars.*Negative values indicate cost savings.


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Table 12. Effectiveness and cost effectiveness of individualised multifactorialintervention compared with no intervention after one year

StudyCurrency

Target group


falls(95% CI

forincidence

rate

ratio)


person receivingthe

intervention*

Incrementalcost per



ICER fordelivery of


ICER fordeliveryand total

healthcareuse

$NZ 2008(reportedcurrency)

Rizzo 1996 $US 1993

70 years, 1of 8 targeted

risk factors for falls

31%(0.52 to

0.90)

0.499(164/14494/147)

$1,870($US905)

$3,670($US1,772)


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Mul t ip l e i n t e rven t ionsMultifaceted group learning

A programme that may well provide a possible multiple intervention option for ACC andthe Ministry of Health to promote is Stepping On (Clemson 2004). In a 14 month randomisedcontrolled trial in Sydney, Australia, small group learning (2-hour weekly sessions for sevenweeks) led to a significant 31% reduction in falls in community living people who had had a fallin the previous 12 months (Table 14). Falls prevention programmes in New Zealand often takethe form of group learning sessions run by community organisations. An ad hoc approach maynot be effective, therefore not cost effective in preventing falls, so that these organisations shouldconsider using the Stepping On programme instead.

The emphasis of this programme is on behaviour change to avoid falls. The programmeincludes sessions on fall risk appraisal, exercise, home hazards, strategies to get around the localcommunity, safe footwear, vision as a risk factor for falls, vitamin D, hip protectors, medicationmanagement, mastering safe mobility, and a home visit to follow through the falls preventionstrategies and activities, and to assist with home adaptations and modifications if required. A

booster session was held after three months.We estimated the cost of delivering this intervention in 2008 New Zealand dollars since

no cost data were reported from this trial (Table 15). A manual has been published that providesall the information an experienced occupational therapist would require to run the sessions. Theestimated impact of the programme after one year if 1,000 participants with a previous fall wererecruited, is shown in Table 16.

Another successful multiple intervention, this one with a focus on home safety, was acomprehensive geriatric assessment (all participants) followed by a home safety visit(intervention participants only) (Nikolaus 2003). The subgroup who reported having had two or more falls in the previous year showed the greatest benefit.

Population approach

Despite methodological limitations of the evaluation studies reviewed (five controlled butnot randomised trials), the consistency of findings in a Cochrane systematic review led to theconclusion that a population based approach to the prevention of fall related injury is effectiveand can form the basis of public health practice (McClure 2005).

Two controlled studies also provide good evidence that a concerted population approachto falls prevention will result in a reduction in healthcare use and costs. The results of a cost

benefit study of the Stay on Your Feet programme in Queensland, Australia is summarised inTable 17 (Kempton 2000, Beard 2006). The cost benefit evaluation compared hospital records

(admissions) between a matched sample and the intervention areas.The programme activities were community based and aime

Documents

ACC Optim Report[1]