Costing & cost-effectiveness in

falls preventionNSW Falls Prevention Network Forum

May 27, 2011

Wendy Watson

(w.watson@unsw.edu.au)

NSW Injury Risk Management Research Centre, UNSW

Surveillance, Monitoring &

Costing

Defining the magnitude of the

problem & monitoring the impact of

interventions

The public health approach

1. Defining the problem

2. Identifying risk factors

3. Developing & trialling

interventions

4. Implementing

programs

5. Evaluating programs

Surveillance,

monitoring &

costing

Falls & medically treated fall injuries,

65 years & older, NSW

Sources: NSW Population Health Survey & 2009 Baseline Falls Prevention

Survey

26.8 25.6

8.67.0

0

5

10

15

20

25

30

1999 2003 2006 2009

Pro

po

rtio

n o

f p

op

ula

tio

n

Year

Falls

Medically treated injuries

Fall-related admission rates65 years & older, NSW

Source: Watson & Mitchell (2011, in press)

1799.2

2036.7

0

250

500

750

1000

1250

1500

1750

2000

2250

1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Ag

e-s

tan

da

rdis

ed

ra

te

Year

Average annual change = + 1.7%

Cost of older persons’ fall-related

injuries, NSW, 2006/07

Medical treatments $34 million (6%)

Pharmaceuticals $9 million (1.5%)

Allied Health, $19 million (3.5%)

Ambulance$22 million (4%)

Community nursing, $9 million (1.5%) Domiciliary services,

$13.5 million (2.5%)

Hospital inpatient $263 million (47%)

ED & Outpatient $61 million (11%)

Residential aged care$128 million (23%)

Total cost: $558.5 million

Source: Watson, Clapperton & Mitchell, 2010

Current vs earlier projections:

admissions

16,300

34,400

28,250

73,500

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

2011 2021 2031 2041 2051

Pro

po

rtio

n o

f p

op

ula

tio

n

Year

Moller (2003): separations

Watson et al (unpub): Incident admissions

Current vs earlier projections:

bed-days

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

211,600 454,100

481,896

1,294,441

Ho

sp

ita

l b

ed

-da

ys

YearMoller (2003)

Watson et al (unpub)

Projected cost of hospital inpatient care,

65 years & older, NSW (2006/07 $AUD)

0

100

200

300

400

500

600

700

800

Es

tim

ate

d c

os

t ($

mil

lio

ns

)

Year

85 +

75-84

65-74

Historical

Projected

$268.2 million

$773.4 million

Source: Watson, Yang & Mitchell (unpublished data)

Adequate physical activity

Females, 45 years & older, NSW

Source: NSW Population Health Surveys, 1999-2009.

0

10

20

30

40

50

60

2002 2003 2004 2005 2006 2007 2008 2009

Pro

po

rtio

n o

f p

op

ula

tio

n

Year

45-54 years

55-64 years

65-74 years

75 years +

%

Fall-related hip fractures

552.7

432.1

0

100

200

300

400

500

600

Ag

e-s

tan

da

rdis

ed

ra

te

Year

Average annual change = - 2.1%

Source: Watson WL & Mitchell RJ. (in press, 2011)

Summary

• Over the past decade:

– Rate of self-reported falls has remained relatively

stable

– Falls hospitalisations number & rate continued to

increase significantly

• Projections suggest:

– Major impact on hospital services even if falls

hospitalisation rate contained at 2008 level

• Trends which may ameliorate these impacts:

– Proportion of older women undertaking adequate

exercise increasing significantly (except 75 years +)

– Rate of hip fracture decreasing significantly

Economic evaluation

Cost-effectiveness modelling, priority-setting & resourcing

The public health approach

1. Defining the problem

2. Identifying risk factors

3. Developing & trialling

interventions

4. Implementing

programs

5. Evaluating programs

Surveillance,

monitoring &

costing

Cost-effectiveness modelling, priority-setting & resourcing

Cost of

injury

data

Population modelling of C-E, NSW

Intervention Efficacy Church et al (2011) Day et al (2009) Priority

General population

• Tai chi +++ Most cost-effective of

general interventions

Maybe C-E if cost

per participant

can be reduced

High risk groups

(recent falls history)

• OT delivered

home hazard

assessment &

modification

++ Included in active

multi-factorial

intervention (not

cost-effective)

Most cost-

effective of all

interventions

modelled

• Multi-factorial

risk management*

++ Not cost-effective Good clinical

practice but not

for widespread

implementation

* A study by Wu et al (2010) modelled a “falls rehabilitation program” (multi-factorial

risk assessment with a supervised exercise program) for the U.S. Medicare

population and found it to be cost-effective.

Population modelling of C-E, NSW

Intervention Efficacy Church et al (2011) Day et al (2009) Priority

Specific populations

• Expedited

cataract

surgery

+ Cost-effective Limited potential

to impact falls

rates

• Psychotropic

medication

withdrawal

+ Cost-effective High relative C-E

but issues with

implementation

need to be

addressed

Residential aged care

• Medication

review

+ Highly cost-effective

• Vitamin D +++ Cost-effective

Resourcing - Return On Investment

• CEAs do not inform policy-makers of the size a

program needs to be, and therefore the

threshold of investment required, to be cost-

saving

• Need to establish potential ROI for community-

based falls prevention programs

• To be efficient, it is important to know the:

– number of clients that a program needs to service to

break-even

– ideal type of client the program should target

Examples of “break-even” analyses

• Comans et al (2009)

– A break-even analysis of a community rehabilitation

falls prevention service (ANZJPH)

• Program: 2 variations of multi-disciplinary falls

prevention service (group-based & individual

home-based)

• Miller et al (2011)

– Assessing the cost and potential returns of evidence-

based programs for seniors (Evaluation & the Health

Professions)

• Program: “A Matter of Balance/Volunteer Lay

Leader Model”

Conducting a ”break-even” analysis

• Step 1: Review literature & estimate potential

benefits of the intervention

• Step 2: Develop a cost model to estimate:

– Fixed costs of program

– Variable costs (per additional client)

– Savings (medical costs averted)

• Step 3: Determine the required effect size to

achieve a specified ROI

– Number of Falls Needed to be Averted (NFNA)

– Number of clients needed to achieve the NFNA

• Step 4: Establish the threshold of funding

required

Relevant data for cost savings

Place of residence bylevel of care

Average cost ($)Male Female Persons

Community

Hospital admissions 19,478 21,081 20,563 ED attendances 4,119 2,607 3,169

Non-hospital treatments 327 549 462 Total Community 4,147 5,290 4,722

Residential Aged CareHospital admissions 11,808 10,999 11,196

ED attendances 2,826 1,762 1,985 Non-hospital treatments 241 175 196

Total Residential Aged Care 1,864 2,025 1,979

All NSWHospital admissions 18,100 18,609 18,454 ED attendances 3,789 2,241 2,721

Non-hospital treatments 280 424 369TOTAL NSW 3,366 4,211 3,906

Source: Watson, Clapperton & Mitchell, 2010http://www.health.nsw.gov.au/pubs/2010/pdf/Incidence_Cost_of_Falls.pdf

Summary• Strong evidence for effective interventions to

prevent falls in older people

• CEAs have identified interventions that are likely

to be cost-effective

• The next step requires the translation of these

interventions into community-based/population

level programs

• The use of break-even analysis in this process

can assist in:

– informing intervention priorities in this area,

– providing an estimate of the threshold of investment

– ensuring that finite resources are efficiently allocated.

Conclusion

• Population level planning a priority

• Need for coordinated implementation of high

intensity prevention programs

– Population health resources directed at reducing

generic distal risk factors(generating a “low risk”

population)

– Clinical resources directed at reducing proximal risk

factors (the “high risk” groups)

• NSW Health Plan for Prevention of Falls and Harm from

Falls among Older People: 2011-2015

References:

• Church J, Goodall S, Norman R, Haas M. An economic evaluation of community and

residential aged care falls prevention strategies in NSW. NSW Public Health Bulletin. in

press;22(3-4).

• Comans T, Brauer S, Haines T. A break even analysis of a community rehabilitation falls

prevention service. Australian and New Zealand Journal of Public Health. 2009;33(3):240-5.

• Day L, Hoareau M, Finch C, Harrison J, Segal L, Bolton T, et al. Modelling the impact, costs

and benefits of falls prevention to support policy-makers and program planners. Melbourne:

Monash University Accident Research Centre2009. Report No. 286.

• Hall, S.C. Phillips L. Dubois N. Follett and N. Pancaningtyas (2010). Preventing Falls,

Promoting Health, Engaging Community: Evaluation Report of the Greater Southern Area

Health Service Physical Activity Leaders Network Tai Chi Program. Canberra, ANU Medical

School.

• McClure RJ, Hughes K, Ren C, McKenzie K, Dietrich U, Vardon P, et al. The population

approach to falls injury prevention in older people: findings of a two community trial. BMC

Public Health. 2010;10(1):79.

• Miller TR, Dickerson JB, Smith ML, Ory MG. Assessing Costs and Potential Returns of

Evidence-Based Programs for Seniors. Evaluation & the Health Professions. 2010.

• Watson W, Mitchell R. Conflicting trends in fall-related injury hospitalisations among older

people: Variations by injury type. Osteoporosis International. 2011 (in press) (Online FirstTM

16/12/2010).

• Watson W, Clapperton A, Mitchell R. The incidence and cost of falls injury among older

people in New South Wales, 2006/07. Sydney: NSW Department of Health. 2010.

• Wu S, Keeler EB, Rubenstein LZ, Maglione MA, Shekelle PG. A Cost-Effectiveness

Analysis of a Proposed National Falls Prevention Program.

Clinics in Geriatric Medicine. 2010;26(4):751-66.