Original Article
The high cost to health and social care of managing falls in older adults living in the community in Scotland
Scottish Medical Journal 58(4) 198–203 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013507848 scm.sagepub.com
J Craig1, A Murray2, S Mitchell3, S Clark4, L Saunders5 and L Burleigh6
Abstract Background and aims: Estimate costs for health and social care services in managing older people in the community who fall. Method and results: Analyses of predominantly national databases using cost of illness methodologies. In Scotland, 294,000 (34%) of people over 65 years and living in the community fall at least once a year. Of these 20%, almost 60,000 people contacted a medical service for assistance. There were almost 30,000 attendances at GP practices, over 36,100 calls to the Scottish Ambulance Service and 46,816 people presenting at A&E, with 16,549 admitted, 30% with a hip fracture. Mortality was high, 7% during the hospital stay, rising to over 12% at 1 year. Over 20% of patients were unable to return to their homes. Associated costs were over £470 million, with 60% incurred by social services, mainly providing long-term care. Cost per person falling was over £1720, rising to over £8600 for those seeking medical assistance. A hip fracture admission cost £39,490, compared with £21,960 for other falls-related admissions. Conclusions: Transparent, robust cost information demonstrates the substantial burden of falls for health and social care services and should be a driver for implementing evidence-based interventions to reduce falls.
Keywords Costs, falls, community, older people
Introduction Falls among older people present a serious and increasing public health challenge. Evidence shows many can be avoided,1 offering benefits to the person and carer from reduced morbidity and mortality whilst releasing resources and costs that would otherwise be incurred, particularly by health and social services. Without action, the impact of falls on the NHS and social work will grow substantially with the number of people aged over 65 years forecast to rise by a third by 2025 and those aged over 80 forecast to double in the same period.2 Moreover, a higher proportion of the population will have multimorbidity (the presence of two or more disorders),3 have poorer functional status and take polypharmacy, all significant falls risk factors. The cost of doing nothing is thus high in human and financial terms, whilst placing major strains on the services’ ability to co-ordinate care effectively and deliver compassionate and sustainable services.
Despite increasing evidence that interventions reduce the risk of falling in older age,1,4 implementation has been poor.5,6 Policy makers and healthcare professionals have been hampered in allocating scarce resources to falls prevention by the absence of data on cost of falls. Thus, they cannot evaluate if potential
1
Project Director, York Health Economics Consortium, University of York, UK 2 National Falls Programme Manager, NHS Ayrshire and Arran, Crosshouse Hospital, Kilmarnock, UK 3 Programme Manager, Rehabilitation Framework, St Andrews House, Edinburgh, UK 4 Information Services Division, Cirrus, UK 5 MECS/Telecare Team, Unit 1 St John’s Sawmill, UK 6 Consultant, NHS Greater Glasgow and Clyde, Medicine for the Elderly Mansion House Unit, Victoria Infirmary, UK Corresponding author: Joyce Craig, York Health Economics Consortium, University of York, York YO10 5NH, UK. Email: [email protected]
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programmes provide benefits which outweigh their costs, making funding decisions problematic in the face of competing needs. A systematic review of peer-reviewed articles reporting falls costs for older people living in the community noted that, in contrast to many areas of healthcare, there is a ‘glaring need’ for such data.7 Only two studies reported costs in the UK. One was limited to an ambulance service’s costs whilst the other estimated NHS and social care costs at £981 million. Updating that search identified a recent estimate that falls cost the UK NHS over £2.3 billion annually but no supporting information was provided.8 The burden of falls is thus not well established. To remedy this, the Scottish Government commissioned research into the burden of falls on its older population living in the community, together with the associated cost implication for its health and social care staff and services. The objective is to quantify the financial burden of serious falls, defined as resulting in injuries that require medical assistance, on health and care services. Research results will inform decision making on implementing care bundles to reduce falls in the community. This understanding will enable evaluation of alternative programmes and assist implementation by identifying potential resources and costs which should be released by effective preventative interventions.
Methods
Results Number of people who fall Department of Health data show that 30% of the population aged 65–79 years and 45% of those aged 80 years and over fall each year.11 Applying these assumptions to the Scottish population gives falls incidences as shown in Table 1; giving an absolute risk of 34% for those aged 65 and over. Table 2 summarises other falls-related events. Twenty per cent of people, 58,839, were estimated as experiencing serious injury following a fall. This was derived by summing those attending general practices, calling out SAS and attending A&E. To avoid double counting, for example of a referral by GP to A&E, a deduction of 9% was made (assumption). These figures were subsequently reduced by 7% to remove those residents in care homes. ISD estimated that in 2011, the number of people aged over 65 years living in the community and attending their GP for a fall-related incident was 23,480, (95% confidence intervals (CI) of 18,500–28,440). The mean GP contacts per faller were 1.27, giving a total number of GP attendances as 29,873. One quarter of attendees were aged between 65 and 80 years, with three quarters over 80 years.
Table 2. Number of falls-related events Scotland 2010/2011.
A literature search was undertaken on the epidemiology of falls in the UK. Data on the number of people who fall attending general practitioners’ (GP) practices, requiring ambulance service, A&E, hospitalisation and subsequent care home residence were requested from Information Services Division (ISD)9 and the Scottish Ambulance Service (SAS). Analyses were conducted for Community Health Partnerships (CHP) in Scotland and the results shared with the Falls Lead in each CHP. The Leads were asked to verify these estimates were accurate and consistent with their own records; no inconsistencies were found. Methodologies adopted are consistent with recent guidelines for evaluating falls interventions.10 This work was supported by Scottish Government who paid Joyce Craig for her input.
Number of events
Parameters Population aged 65 years and over Total people falling Of whom serious GP attendances SAS call-outs A&E attendances Admissions Of which hip fractures Mortality at 1 year Re-admissions
868,512 294,194 58,839 29,873 36,107 46,816 16,549 5085 2020 1105
34% of population 7% of population 51% of serious falls 61% of serious falls 80% of serious falls 35% of A&E attendances 31% of admissions 12% of admissions 7% of admissions
SAS: Scottish Ambulance Service.
Table 1. Population and people who fall in Scotland. Population
Scotland
People who fall
Aged 65–80 years
Aged over 80 years
Aged 65–80 years
Aged over 80 years
Total fallers
Serious injury
644,240
224,272
193,272
100,923
294,195
58,839
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Annualising data from SAS for the first half of 2011 suggested in that year falls-related incidents attended for older people living in the community were 36,107, with 28,090 (78%) conveyed to hospital. No national data were available on the number of A&E attendees resulting from a fall. The estimated number was 46,816, assuming 40% arrive other than by ambulance. This was based on data from two NHS areas and was consistent with preliminary data from a pilot A&E IT project.
Admissions and length of stay ISD data showed 35% of presenters at A&E after a fall were admitted; 16,549 people of whom over 30% (5085) had a hip fracture. About 7% were re-admitted within 1 year with a fall or hip fracture as the primary diagnosis. The length of hospital stay showed considerable variation across mainland NHS boards. Mean stay for a hip fracture or a falls event were 29 days (range 21–37 days) and 19 days (range 14–24 days) respectively. Re-admissions were assumed to have the same length of stay as initial admissions.
Mortality and discharge by place of residence Overall mortality was 7% (1081 patients) and 12% (2020) in hospital and at 1 year post-discharge respectively. Scottish Hip Fracture Audit 2008 provided discharge destination following acute care.12 At 120 days post-admission for a hip fracture, 64% of people resided at home with the balance in some form of rehabilitation or long-term care home setting or still an inpatient.
Post-discharge At discharge, all patients were assumed to have a shared assessment by a social care worker and community therapist taking 1 h at a cost of £84. For those going directly home, a package comprising a GP visit (£36) and 8 weeks of ‘low cost’ care including home care and healthcare at a unit cost of £207 per week was assumed, giving a total cost, including assessment, of £1776. Using data from the annual census of care homes conducted by ISD,13 for those discharged into a care setting but able to return home by 120 days, a care package comprising 60 days of residential care at a cost of £780 per week plus the same package of care provided to those discharged directly home was assumed at a total cost of £8406. Costs for those remaining in residential care were estimated at £2810 per month Applying a mean length of stay 27.3 months, also obtained from census
data, gave an estimated out-turn cost per resident of £76,630. This was discounted at 3.5% per annum in accordance with central guidance14 to give an equivalent cost in 2012 of £65,942.
Estimated cost of falls Table 3 details the total costs using information published by ISD15 and Personal Social Services Research Unit, University of Kent.16 Clinical events were multiplied by the unit costs, giving a total estimated cost of £471 million. Of this, £190 million (40%) of costs were NHS related; the balance, £281 million (60%), was costs to social care, primarily for residential care (£211 million). Dividing total cost by the number of falls in the community (273,430) gave an estimated cost per fall of almost £700 to the NHS rising to £1721 including social care costs. The estimated cost to manage the 20% of these which are serious, requiring medical attention was £3466, increasing to £8607 including social care costs. Cost of a hospital admission for a hip fracture, from calling an ambulance to costs arising after discharge, including any subsequent re-admissions, was estimated at £39,490, with each other falls-related admission estimated to cost £21,960.
Discussion Evidence from Scottish national datasets has identified the burden of falls on health and social care services as being approximately 85,000 episodes each year resulting from attendances at GP practices, calls to SAS or people presenting directly at A&E. This leads to 16,549 hospital inpatient admissions annually in Scotland. Of these, 7% died before discharge and over 20% were unable to return home. Associated costs were estimated at over £470 million, with 60% falling on social services. The main limitations of this study include the use of only national datasets. These include data which are quality assured for consistency of definitions, coding, accuracy and comparability across sources.17 Consequently, no activity or costs were provided for non-quality assured data including attendances at outpatient services, fracture liaison clinics, osteoporosis services, medications, long-term social care support in the community, provision of aids and adaptations, and of community alarms and other telecare devices. Furthermore, data quality relies on consistent use of coding across health boards. Historically, falls have been under-recorded. We also acknowledge that indirect costs incurred by patients, families, unpaid carers and wider societal costs including loss in productivity from absenteeism go unaccounted for. Hence, the costs in this analysis are judged conservative estimates.
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Table 3. Estimated cost of falls and fractures in Scotland 2010/2011. Clinical event GP attendances SAS call-outs A&E attendances Hospital inpatient: Falls (non-hip fracture) Hip fracture Discharge falls: Home Residential: short term Long term Discharge fractures: Home Residential: short term Long term Re-admissions Mortality Total cost Cost of community fall Cost per serious fall Cost of hip fracture Cost of other falls admissions
Number of events
Cost per event
Total cost
Total percentage
29,873 36,107 46,816
£36 £257 £101
£1,075,410 £9,278,921 £4,728,420
0.2 2.0 1.0
11,464 5085
£7406* £14,528**
£84,897,875 £73,874,588
18.0 15.7
8042 2681 1823
£1776 £8406 £65,942
£15,806,302 £22,534,017 £120,204,650
3.3 4.8 25.5
2436 3322 1370 1105 2020
£1776 £8406 £65,942 £7406 £3703
0.9 5.9 19.2 1.9 1.6 100.0
273,430*** 54,686 [ref. 22] 5085 11,464
£1721 £8607 £39,490 £21,960
£4,326,108 £27,921,676 £90,352,482 £8,182,560 £7,479,672 £470,662,683 £470,662,683 £470,662,683 £200,809,483 £251,741,970
SAS: Scottish Ambulance Service. *Unit cost per day ¼ £397. **Unit cost per day ¼ £498. ***Adjusted to remove falls in residential homes.
Nevertheless, these costs, whilst specific to Scotland, are anticipated to generalise to other parts of the UK. For example, the cost per fall, calculated by dividing the independently derived estimated cost of £2.3 billion8 in the UK, by the estimated number of falls, was £667; a difference of under 5% from the £693 estimated from this work. The high cost of falls, in particular of hip fractures, at £39,490 per event, supports the evaluation of effective interventions to reduce the risk of fracture at either the individual or population level. The evidence base for falls risk reduction is expanding with the most recent Cochrane review in 2009 systematically reviewing 111 trials with 55,303 participants in a community setting.1 This concluded ‘assessment and individualised multifactorial intervention programmes appear effective in reducing the rate of falls in studies from different healthcare systems’. However, only eight studies provided a comprehensive economic evaluation leading the authors to further comment: ‘there was some, although limited, evidence that falls prevention strategies can be cost saving during the trial period, and may also be cost-effective over the participants remaining lifetime’.
The evidence base for single interventions, in particular exercise,18,19 is widely published. In 2008, Sherrington et al.’s4 meta-analysis confirmed that ‘the pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9603 participants, rate ratio (RR) ¼ 0.83, 95% confidence interval (CI) ¼ 0.75–0.91, P < 0.001’. The greatest benefit arose from programmes providing over 50 h of individualised targeted gait and balance exercises. Originating from New Zealand, the Otago Exercise Programme adheres to these recommendations and has demonstrated in meta-analysis significantly reduced fall rates (incidence RR ¼ 0.68, 95% CI ¼ 0.56–0.79).20 It is one of the few exercise interventions to prove its cost effectiveness in adults over 80 years old, alongside two other interventions; an individually customised multifactorial programme in those with four or more of the eight targeted fall risk factors and a home safety programme in those who had previously fallen.21 However, earlier papers by the New Zealand group in 2001 did not demonstrate net savings in healthcare costs despite showing a clear reduction in falls with the home-based exercise programme.22 More recently
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in Australia, the most cost-effective intervention at a population level was analysed to be Tai Chi.23 Despite the relative paucity of cost-benefit evidence, some authors have argued that given falls are the largest single risk factor for hip fracture,24 interventions to reduce these should be prioritised for evaluation. Of course, prevention of hip and other fractures should also include assessment and management of osteoporosis. Oral bisphosphonates remain the mainstay of treatment and have been shown to be cost effective for all women, regardless of quartile of life expectancy or age.25 Further research is ongoing regarding newer medicines including zoledronate and denosumab. Less easy to quantify is the impact of falls on physical and psychological functioning including the impact of early admission to long-term care facilities upon quality of life. People who fall and remain in the community also have a high incidence of post-fall syndrome; symptoms include loss of self-confidence, mobility and balance issues with the resulting social isolation associated with loneliness, depression, increased dependency and a poorer quality of life. These factors can affect quality of life more profoundly than the initial fall, with repercussions on the lives of family and friends.26 Further work is required to assess the economic implications of investing in national falls programmes and care bundle in an attempt to reduce the heavy financial burden of falls to health and social care, balanced against the current evidence of their clinical and economic effectiveness. This study should provide new and important data to enable policy makers and planners to decide where best to allocate resources. In addition, clinicians and researchers should find the data useful when evaluating falls interventions. Declaration of conflicting interests None declared.
Funding Funding was provided by the Scottish Government to JC to lead the analysis. The sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report or the decision to submit for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Ethical approval No ethical approvals were required.
Contributorship AM and SM developed the initial concept of the work, approved the project design and collaborated with project delivery. JC provided the draft project design, requested
data from various sources and undertook the data analysis. SC provided the data on NHS events and associated costs, whilst LS provided data on social care events and associated costs. LB provided the substantive draft and critically appraised the analysis. All commented on versions of the draft report and approved the version to be published.
References 1. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database 2009; Art. No.: CD007146. 2. Department of Health. Fracture prevention services: an economic evaluation of fracture plan. London: Department of Health, 2009. 3. Barnett K, Mercer S, Norbury N, et al. Epidemiology of multimorbidity and implications for healthcare, research, and medical education: a cross-sectional study. The Lancet 2012; 380: 37–43. 4. Sherrington C, Whitney JC, Lord SR, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc 2008; 56: 2234–2243. 5. Royal College of Physicians. Falling standards, broken promises. Report of the national audit of falls and bone health in older people. Available at http://www.rcplondon.ac.uk/sites/default/files/national_report.pdf (2010, accessed 11 January 2013). 6. Logan PA, Coupland CAC, Gladman JRF, et al. Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial. BMJ 2010; 340: c2102. 7. Davis JC, Robertson MC, Ashe MC, et al. International comparison of cost of falls in older adults living in the community: a systematic review. Osteopor Int 2010; 21: 1295–1306. 8. College of Optometrists/British Geriatrics Society. The Importance of Vision in Preventing Falls. Available at http://www.college-optometrists.org/en/utilities/documentsummary.cfm/docid/99A3825F-3E6C-44DA-994D4B42D C1AF5A4 (2011, accessed 11 January 2013). 9. ISD national datasets providing epidemiological, activity and costs information on health and care services in Scotland. Available at http://www.isdscotland.org/ About-ISD/ (accessed 11 January 2013). 10. Davis JC, Robertson MC, Comans T, et al. Guidelines for conducting and reporting economic evaluation of fall prevention strategies. Osteopor Int 2009; 22: 2449–2459. 11. Department of Health. Impact Assessment of fracture prevention interventions. Available at http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/documents/ digitalasset/dh_106379.pdf (2009, accessed 11 January 2013). 12. Scottish Hip Fracture Audit 2008. ISD Scotland Publications. Available at http://www.shfa.scot.nhs.uk/ (2008, accessed 11 January 2013). 13. Scottish Home Care Census 2010. Available at http:// www.isdscotland.org/Health-Topics/Health-and-SocialCommunity-Care/Care-Homes/Census/ (2010, accessed 11 January 2013).
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14. Scottish Medicines Consortium Guidance to Manufacturers. Available at http://www.scottishmedicines.org.uk/ Submission_Process/Submission_Guidance_and_Templates_ for_Industry/Templates-Guidance-for-Submission/TemplatesGuidance-for-Submission (2013, Accessed 9 October 2013). 15. Information Services Division. Scottish Health Care Service Costs 2010/11. Available at http://www. isdscotland.org/Health-Topics/Finance/Costs/ (2011, Accessed 11 January 2013). 16. Personal Social Services Research Unit. Unit costs of health and social care. Available at http://www.pssru. ac.uk/uc/uc2011contents.htm (2011, accessed 11 January 2013). 17. Information Services Division. Data Quality Assurance 2010/11. Available at http://www.isdscotland.org/ Products-and-Services/Data-Quality/ (2011, accessed 11 January 2013). 18. Gardner MM, Robertson MC and Campbell AJ. Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials. Br J Sports Med 2000; 34: 7–17. 19. Herbert RD, Cumming RG and Close J. Effective exercise for the prevention of falls: a systematic review and meta-analysis. JAGS 2008; 56: 2234–2243. 20. Thomas S, Mackintosh S and Halbert J. Does the ‘Otago exercise programme’ reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age Ageing 2010; 39: 681–687.
21. Davis JC, Robertson MC, Ashe MC, et al. Does a homebased strength and balance programme in people aged>or ¼80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions. Br J Sports Med 2010; 44(2): 80–89. 22. Robertson MC, Devlin N, Scuffham P, et al. Economic evaluation of a community based exercise programme to prevent falls. J Epidemiol Community Health 2001; 55: 600–606. 23. Church J, Goodall S, Norman R, et al. The costeffectiveness of falls prevention interventions for older community-dwelling Australians Australian & New Zealand. J Public Health 2012; 36: 241–248. 24. Ja¨rvinen T, Sieva¨nen H, Khan K, et al. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 2008; 336: 124. 25. Pham AN, Datta SK, Weber TJ, et al. Cost-effectiveness of oral bisphosphonates for osteoporosis at different ages and levels of life expectancy. JAGS 2011; 59: 1642–1649. 26. Summary of the Updated American Geriatrics Society/ British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. American Geriatrics Society and British Geriatrics Society. J Am Geriatr Soc 2011; 59: 148–157.
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The high cost to health and social care of managing falls in older adults living in the community in Scotland
Scottish Medical Journal 58(4) 198–203 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013507848 scm.sagepub.com
J Craig1, A Murray2, S Mitchell3, S Clark4, L Saunders5 and L Burleigh6
Abstract Background and aims: Estimate costs for health and social care services in managing older people in the community who fall. Method and results: Analyses of predominantly national databases using cost of illness methodologies. In Scotland, 294,000 (34%) of people over 65 years and living in the community fall at least once a year. Of these 20%, almost 60,000 people contacted a medical service for assistance. There were almost 30,000 attendances at GP practices, over 36,100 calls to the Scottish Ambulance Service and 46,816 people presenting at A&E, with 16,549 admitted, 30% with a hip fracture. Mortality was high, 7% during the hospital stay, rising to over 12% at 1 year. Over 20% of patients were unable to return to their homes. Associated costs were over £470 million, with 60% incurred by social services, mainly providing long-term care. Cost per person falling was over £1720, rising to over £8600 for those seeking medical assistance. A hip fracture admission cost £39,490, compared with £21,960 for other falls-related admissions. Conclusions: Transparent, robust cost information demonstrates the substantial burden of falls for health and social care services and should be a driver for implementing evidence-based interventions to reduce falls.
Keywords Costs, falls, community, older people
Introduction Falls among older people present a serious and increasing public health challenge. Evidence shows many can be avoided,1 offering benefits to the person and carer from reduced morbidity and mortality whilst releasing resources and costs that would otherwise be incurred, particularly by health and social services. Without action, the impact of falls on the NHS and social work will grow substantially with the number of people aged over 65 years forecast to rise by a third by 2025 and those aged over 80 forecast to double in the same period.2 Moreover, a higher proportion of the population will have multimorbidity (the presence of two or more disorders),3 have poorer functional status and take polypharmacy, all significant falls risk factors. The cost of doing nothing is thus high in human and financial terms, whilst placing major strains on the services’ ability to co-ordinate care effectively and deliver compassionate and sustainable services.
Despite increasing evidence that interventions reduce the risk of falling in older age,1,4 implementation has been poor.5,6 Policy makers and healthcare professionals have been hampered in allocating scarce resources to falls prevention by the absence of data on cost of falls. Thus, they cannot evaluate if potential
1
Project Director, York Health Economics Consortium, University of York, UK 2 National Falls Programme Manager, NHS Ayrshire and Arran, Crosshouse Hospital, Kilmarnock, UK 3 Programme Manager, Rehabilitation Framework, St Andrews House, Edinburgh, UK 4 Information Services Division, Cirrus, UK 5 MECS/Telecare Team, Unit 1 St John’s Sawmill, UK 6 Consultant, NHS Greater Glasgow and Clyde, Medicine for the Elderly Mansion House Unit, Victoria Infirmary, UK Corresponding author: Joyce Craig, York Health Economics Consortium, University of York, York YO10 5NH, UK. Email: [email protected]
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programmes provide benefits which outweigh their costs, making funding decisions problematic in the face of competing needs. A systematic review of peer-reviewed articles reporting falls costs for older people living in the community noted that, in contrast to many areas of healthcare, there is a ‘glaring need’ for such data.7 Only two studies reported costs in the UK. One was limited to an ambulance service’s costs whilst the other estimated NHS and social care costs at £981 million. Updating that search identified a recent estimate that falls cost the UK NHS over £2.3 billion annually but no supporting information was provided.8 The burden of falls is thus not well established. To remedy this, the Scottish Government commissioned research into the burden of falls on its older population living in the community, together with the associated cost implication for its health and social care staff and services. The objective is to quantify the financial burden of serious falls, defined as resulting in injuries that require medical assistance, on health and care services. Research results will inform decision making on implementing care bundles to reduce falls in the community. This understanding will enable evaluation of alternative programmes and assist implementation by identifying potential resources and costs which should be released by effective preventative interventions.
Methods
Results Number of people who fall Department of Health data show that 30% of the population aged 65–79 years and 45% of those aged 80 years and over fall each year.11 Applying these assumptions to the Scottish population gives falls incidences as shown in Table 1; giving an absolute risk of 34% for those aged 65 and over. Table 2 summarises other falls-related events. Twenty per cent of people, 58,839, were estimated as experiencing serious injury following a fall. This was derived by summing those attending general practices, calling out SAS and attending A&E. To avoid double counting, for example of a referral by GP to A&E, a deduction of 9% was made (assumption). These figures were subsequently reduced by 7% to remove those residents in care homes. ISD estimated that in 2011, the number of people aged over 65 years living in the community and attending their GP for a fall-related incident was 23,480, (95% confidence intervals (CI) of 18,500–28,440). The mean GP contacts per faller were 1.27, giving a total number of GP attendances as 29,873. One quarter of attendees were aged between 65 and 80 years, with three quarters over 80 years.
Table 2. Number of falls-related events Scotland 2010/2011.
A literature search was undertaken on the epidemiology of falls in the UK. Data on the number of people who fall attending general practitioners’ (GP) practices, requiring ambulance service, A&E, hospitalisation and subsequent care home residence were requested from Information Services Division (ISD)9 and the Scottish Ambulance Service (SAS). Analyses were conducted for Community Health Partnerships (CHP) in Scotland and the results shared with the Falls Lead in each CHP. The Leads were asked to verify these estimates were accurate and consistent with their own records; no inconsistencies were found. Methodologies adopted are consistent with recent guidelines for evaluating falls interventions.10 This work was supported by Scottish Government who paid Joyce Craig for her input.
Number of events
Parameters Population aged 65 years and over Total people falling Of whom serious GP attendances SAS call-outs A&E attendances Admissions Of which hip fractures Mortality at 1 year Re-admissions
868,512 294,194 58,839 29,873 36,107 46,816 16,549 5085 2020 1105
34% of population 7% of population 51% of serious falls 61% of serious falls 80% of serious falls 35% of A&E attendances 31% of admissions 12% of admissions 7% of admissions
SAS: Scottish Ambulance Service.
Table 1. Population and people who fall in Scotland. Population
Scotland
People who fall
Aged 65–80 years
Aged over 80 years
Aged 65–80 years
Aged over 80 years
Total fallers
Serious injury
644,240
224,272
193,272
100,923
294,195
58,839
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Annualising data from SAS for the first half of 2011 suggested in that year falls-related incidents attended for older people living in the community were 36,107, with 28,090 (78%) conveyed to hospital. No national data were available on the number of A&E attendees resulting from a fall. The estimated number was 46,816, assuming 40% arrive other than by ambulance. This was based on data from two NHS areas and was consistent with preliminary data from a pilot A&E IT project.
Admissions and length of stay ISD data showed 35% of presenters at A&E after a fall were admitted; 16,549 people of whom over 30% (5085) had a hip fracture. About 7% were re-admitted within 1 year with a fall or hip fracture as the primary diagnosis. The length of hospital stay showed considerable variation across mainland NHS boards. Mean stay for a hip fracture or a falls event were 29 days (range 21–37 days) and 19 days (range 14–24 days) respectively. Re-admissions were assumed to have the same length of stay as initial admissions.
Mortality and discharge by place of residence Overall mortality was 7% (1081 patients) and 12% (2020) in hospital and at 1 year post-discharge respectively. Scottish Hip Fracture Audit 2008 provided discharge destination following acute care.12 At 120 days post-admission for a hip fracture, 64% of people resided at home with the balance in some form of rehabilitation or long-term care home setting or still an inpatient.
Post-discharge At discharge, all patients were assumed to have a shared assessment by a social care worker and community therapist taking 1 h at a cost of £84. For those going directly home, a package comprising a GP visit (£36) and 8 weeks of ‘low cost’ care including home care and healthcare at a unit cost of £207 per week was assumed, giving a total cost, including assessment, of £1776. Using data from the annual census of care homes conducted by ISD,13 for those discharged into a care setting but able to return home by 120 days, a care package comprising 60 days of residential care at a cost of £780 per week plus the same package of care provided to those discharged directly home was assumed at a total cost of £8406. Costs for those remaining in residential care were estimated at £2810 per month Applying a mean length of stay 27.3 months, also obtained from census
data, gave an estimated out-turn cost per resident of £76,630. This was discounted at 3.5% per annum in accordance with central guidance14 to give an equivalent cost in 2012 of £65,942.
Estimated cost of falls Table 3 details the total costs using information published by ISD15 and Personal Social Services Research Unit, University of Kent.16 Clinical events were multiplied by the unit costs, giving a total estimated cost of £471 million. Of this, £190 million (40%) of costs were NHS related; the balance, £281 million (60%), was costs to social care, primarily for residential care (£211 million). Dividing total cost by the number of falls in the community (273,430) gave an estimated cost per fall of almost £700 to the NHS rising to £1721 including social care costs. The estimated cost to manage the 20% of these which are serious, requiring medical attention was £3466, increasing to £8607 including social care costs. Cost of a hospital admission for a hip fracture, from calling an ambulance to costs arising after discharge, including any subsequent re-admissions, was estimated at £39,490, with each other falls-related admission estimated to cost £21,960.
Discussion Evidence from Scottish national datasets has identified the burden of falls on health and social care services as being approximately 85,000 episodes each year resulting from attendances at GP practices, calls to SAS or people presenting directly at A&E. This leads to 16,549 hospital inpatient admissions annually in Scotland. Of these, 7% died before discharge and over 20% were unable to return home. Associated costs were estimated at over £470 million, with 60% falling on social services. The main limitations of this study include the use of only national datasets. These include data which are quality assured for consistency of definitions, coding, accuracy and comparability across sources.17 Consequently, no activity or costs were provided for non-quality assured data including attendances at outpatient services, fracture liaison clinics, osteoporosis services, medications, long-term social care support in the community, provision of aids and adaptations, and of community alarms and other telecare devices. Furthermore, data quality relies on consistent use of coding across health boards. Historically, falls have been under-recorded. We also acknowledge that indirect costs incurred by patients, families, unpaid carers and wider societal costs including loss in productivity from absenteeism go unaccounted for. Hence, the costs in this analysis are judged conservative estimates.
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Table 3. Estimated cost of falls and fractures in Scotland 2010/2011. Clinical event GP attendances SAS call-outs A&E attendances Hospital inpatient: Falls (non-hip fracture) Hip fracture Discharge falls: Home Residential: short term Long term Discharge fractures: Home Residential: short term Long term Re-admissions Mortality Total cost Cost of community fall Cost per serious fall Cost of hip fracture Cost of other falls admissions
Number of events
Cost per event
Total cost
Total percentage
29,873 36,107 46,816
£36 £257 £101
£1,075,410 £9,278,921 £4,728,420
0.2 2.0 1.0
11,464 5085
£7406* £14,528**
£84,897,875 £73,874,588
18.0 15.7
8042 2681 1823
£1776 £8406 £65,942
£15,806,302 £22,534,017 £120,204,650
3.3 4.8 25.5
2436 3322 1370 1105 2020
£1776 £8406 £65,942 £7406 £3703
0.9 5.9 19.2 1.9 1.6 100.0
273,430*** 54,686 [ref. 22] 5085 11,464
£1721 £8607 £39,490 £21,960
£4,326,108 £27,921,676 £90,352,482 £8,182,560 £7,479,672 £470,662,683 £470,662,683 £470,662,683 £200,809,483 £251,741,970
SAS: Scottish Ambulance Service. *Unit cost per day ¼ £397. **Unit cost per day ¼ £498. ***Adjusted to remove falls in residential homes.
Nevertheless, these costs, whilst specific to Scotland, are anticipated to generalise to other parts of the UK. For example, the cost per fall, calculated by dividing the independently derived estimated cost of £2.3 billion8 in the UK, by the estimated number of falls, was £667; a difference of under 5% from the £693 estimated from this work. The high cost of falls, in particular of hip fractures, at £39,490 per event, supports the evaluation of effective interventions to reduce the risk of fracture at either the individual or population level. The evidence base for falls risk reduction is expanding with the most recent Cochrane review in 2009 systematically reviewing 111 trials with 55,303 participants in a community setting.1 This concluded ‘assessment and individualised multifactorial intervention programmes appear effective in reducing the rate of falls in studies from different healthcare systems’. However, only eight studies provided a comprehensive economic evaluation leading the authors to further comment: ‘there was some, although limited, evidence that falls prevention strategies can be cost saving during the trial period, and may also be cost-effective over the participants remaining lifetime’.
The evidence base for single interventions, in particular exercise,18,19 is widely published. In 2008, Sherrington et al.’s4 meta-analysis confirmed that ‘the pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9603 participants, rate ratio (RR) ¼ 0.83, 95% confidence interval (CI) ¼ 0.75–0.91, P < 0.001’. The greatest benefit arose from programmes providing over 50 h of individualised targeted gait and balance exercises. Originating from New Zealand, the Otago Exercise Programme adheres to these recommendations and has demonstrated in meta-analysis significantly reduced fall rates (incidence RR ¼ 0.68, 95% CI ¼ 0.56–0.79).20 It is one of the few exercise interventions to prove its cost effectiveness in adults over 80 years old, alongside two other interventions; an individually customised multifactorial programme in those with four or more of the eight targeted fall risk factors and a home safety programme in those who had previously fallen.21 However, earlier papers by the New Zealand group in 2001 did not demonstrate net savings in healthcare costs despite showing a clear reduction in falls with the home-based exercise programme.22 More recently
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Scottish Medical Journal 58(4)
in Australia, the most cost-effective intervention at a population level was analysed to be Tai Chi.23 Despite the relative paucity of cost-benefit evidence, some authors have argued that given falls are the largest single risk factor for hip fracture,24 interventions to reduce these should be prioritised for evaluation. Of course, prevention of hip and other fractures should also include assessment and management of osteoporosis. Oral bisphosphonates remain the mainstay of treatment and have been shown to be cost effective for all women, regardless of quartile of life expectancy or age.25 Further research is ongoing regarding newer medicines including zoledronate and denosumab. Less easy to quantify is the impact of falls on physical and psychological functioning including the impact of early admission to long-term care facilities upon quality of life. People who fall and remain in the community also have a high incidence of post-fall syndrome; symptoms include loss of self-confidence, mobility and balance issues with the resulting social isolation associated with loneliness, depression, increased dependency and a poorer quality of life. These factors can affect quality of life more profoundly than the initial fall, with repercussions on the lives of family and friends.26 Further work is required to assess the economic implications of investing in national falls programmes and care bundle in an attempt to reduce the heavy financial burden of falls to health and social care, balanced against the current evidence of their clinical and economic effectiveness. This study should provide new and important data to enable policy makers and planners to decide where best to allocate resources. In addition, clinicians and researchers should find the data useful when evaluating falls interventions. Declaration of conflicting interests None declared.
Funding Funding was provided by the Scottish Government to JC to lead the analysis. The sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report or the decision to submit for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Ethical approval No ethical approvals were required.
Contributorship AM and SM developed the initial concept of the work, approved the project design and collaborated with project delivery. JC provided the draft project design, requested
data from various sources and undertook the data analysis. SC provided the data on NHS events and associated costs, whilst LS provided data on social care events and associated costs. LB provided the substantive draft and critically appraised the analysis. All commented on versions of the draft report and approved the version to be published.
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