Jul 16, 2009 - co-ordinated falls services has been a feature of health and social ...... individuals who are attended b
Summary: Intervention & Options Department /Agency:
Title:
Department of Health
Impact Assessment of fracture prevention interventions
Stage: Final
Version: 1.0
Date: 16 July 2009
Related Publications: Prevention Package for Older People Available to view or download at:
http://www.dh.gov Contact for enquiries: Gillian Ayling
Telephone: 0113 25 46359
What is the problem under consideration? Why is government intervention necessary? Falls represents a major public health challenge, as they lead to injury requiring high-cost unscheduled care and often result in the need for ongoing care and support. The need for universal co-ordinated falls services has been a feature of health and social care policy for many years, first articulated in the NSF for Older People. However, the incidence of falls remains too high and is forecast to rise as the population ages. Improving commissioning is a central government role. It is most efficient for evidence to be assessed and published once.
What are the policy objectives and the intended effects? In addition to existing work we wish to extend the focus to cover (i) compliance with core standards, (ii) improved response to first fracture, (iii) early intervention care pathways, and (iiii) prevention of frailty and promotion of bone health. The intended effects are to reduce the incidence of falls, and to improve outcomes for those who do fall.
What policy options have been considered? Please justify any preferred option. Do nothing Publish a set of resources which highlight the latest research into the most clinical and cost effective services and provide local health economies the tools to inform commissioning decisions on a consistent basis. The preferred option is to publish the set of guidance as the Total Benefits exceed Total Costs.
When will the policy be reviewed to establish the actual costs and benefits and the achievement of the desired effects? In calendar year 2011, but not before May 2011 (to coincide, and link, with wider review of Care Services Efficiency Delivery review of efficincy gains in the 3-years to March 2011). Ministerial Sign-off For final proposal/implementation stage Impact Assessments: I have read the Impact Assessment and I am satisfied that (a) it represents a fair and reasonable view of the expected costs, benefits and impact of the policy, and (b) the benefits justify the costs. Signed by the responsible Minister: .............................................................................................................Date:
1
Summary: Analysis & Evidence Description: Publish guiodance
Policy Option:
ANNUAL COSTS One-off (Transition)
Yrs 5
£ COSTS
Description and scale of key monetised costs by ‘main affected groups’ NHS costs and net local authority savings from care home and home care.
Average Annual Cost (excluding one-off)
£ 5m
Total Cost (PV)
£ 25m
Other key non-monetised costs by ‘main affected groups’ Objective 1 - 1 to 5 not costed, Objective 3 - first three bullet points not costed, Objective 4 -none of the bullet points costed . Costs to individuals not included ANNUAL BENEFITS
BENEFITS
One-off
Yrs 5
£ Average Annual Benefit
Description and scale of key monetised benefits by ‘main affected groups’ QALY(£50k per QALY) and Life Expectancy gains for hip fractures avoided Quality adjusted life expectancy may be 0.7 per hip fracture. Life expectancy quality adjusted for prevented fatality at age 75 is 9 QALYs. Care home cost savings to private payers
(excluding one-off)
£ 90m
Total Benefit (PV)
£ 440m
Other key non-monetised benefits by ‘main affected groups’ Reduced incidence and fear of falls leading to people retaining independence .
Key Assumptions/Sensitivities/Risks Relative risk reduction of fractures prevented, costs of services. Two rates of risk of admission to care homes tested. Risk that more then 70% of PCTs do not currently have the service Costs are shown as 2:1 ratio to benefits Price Base Year
Time Period Years
Net Benefit Range (NPV) £
NET BENEFIT (NPV Best estimate) £ 390m
What is the geographic coverage of the policy/option?
England
On what date will the policy be implemented?
From july 2009
Which organisation(s) will enforce the policy?
PCTs
What is the total annual cost of enforcement for these organisations?
£ N/A
Does enforcement comply with Hampton principles?
Yes
Will implementation go beyond minimum EU requirements?
No
What is the value of the proposed offsetting measure per year?
£ N/A
What is the value of changes in greenhouse gas emissions?
£ N/A
Will the proposal have a significant impact on competition? Micro
Annual cost (£-£) per organisation
No Small
Medium
Large
(excluding one-off)
Are any of these organisations exempt?
No
Impact on Admin Burdens Baseline (2005 Prices) Increase of £ N/A Decrease of £ N/A Key:
No
N/A
(Increase - Decrease)
Net Impact
£ N/A
Annual costs and benefits: Constant Prices
2
N/A
(Net) Present Value
Evidence Base (for summary sheets) [Use this space (with a recommended maximum of 30 pages) to set out the evidence, analysis and detailed narrative from which you have generated your policy options or proposal. Ensure that the information is organised in such a way as to explain clearly the summary information on the preceding pages of this form.]
Overview 1.1 In 2006, the Department of Health published the White Paper Our Health, Our Care, Our Sayi. The White Paper gave a strong emphasis to shifting healthcare resources to primary and community settings and also emphasised the importance of preventative healthcare in reducing the future burden of disease. 1.2 The White Paper stated: ‘We must set out a new direction for health and social care services to meet the future demographic challenges we face. We must re-orientate our health and social care services to focus together on prevention and health promotion. This means a shift in the centre of gravity of spending.’ What is “prevention”? 1.3 It is generally accepted that “prevention” includes tertiary prevention which is defined as ‘rehabilitation for people with established disease to minimise residual disabilities and complications and improve quality of life’. 1.4 However, in order to oversee the shift described in Our health, our care, our say, the White Paper also announced that ‘the accessibility and use of the evidence base for interventions that support health and well-being will be overseen through a new National Reference Group for Health and Wellbeing’. This group met for the first time in 2007 and is named Health England: the national reference group for health and wellbeing. 1.5 In their second reportii Health England proposed the following definition. ‘a clinical, social, behavioural, educational, environmental, fiscal or legislative intervention or broad partnership programme designed to reduce the risk of mental and physical illness, disability or premature death and/or to promote long-term physical, social, emotional and psychological wellbeing’. A Prevention Package for Older People 1.6 In May 2008, Secretary of State for Health announced his intention to develop a Prevention Package for Older People. Its aim is to •
raise the local focus on older people’s prevention services and to encourage older people to make full use of them;
•
in the longer term, improve health outcomes and promote greater independence and well-being in later life.
1.7 This package will bring together existing entitlements such as flu vaccination, cancer screening, eye checks, and vascular checks. It will build on these entitlements by promoting best practice around falls and fractures and footcare as well as a review of national intermediate care guidance. 3
Introduction 2.1 This Impact Assessment assesses the impact for falls prevention and fracture care. 2.2 It describes the problems under consideration (Section 3) and why it is considered necessary for the Government to intervene (Section 4). 2.3 It then outlines the policy objectives, intended outcomes and discusses the Policy Options we considered to deliver them and the reasons for adopting the approach we have (Section 5). 2.4 In Section 6 we set out the evidence, principal costs and benefits of the approach and Section 7 then provides a high-level summary of Sections 5 and 6. 2.5 Our expectation is that improved services for people and their families will deliver improved quality of life for both patient and carer. These benefits cannot readily be monetised. 2.6 However, in order to indicate the economic costs and benefits involved, it is necessary to make some assumptions about what ‘costable’ inputs might be required. 2.7 It should be stressed that this assessment is our best estimate of the gross economic costs of achieving the objectives described in the Strategy, on the following assumptions • every locality starts from the same place • they will each will implement the Strategy in the same way and within the same timeframe. 2.8 This is different from an assessment of the amount of additional resource that might have to be found to deliver those objectives that are costed here. We know, for example, that the NHS and Local Authorities in England already invest significant sums and it is certain, although we are not able to quantify it, that a proportion of the current level of resource is already invested in falls services or could – by service reconfiguration – be made available for reinvestment in modernised, responsive services of the kind described in the guidance. Similarly, investment across health and social care economies in education and training are significant and it is probable that some of that resource is already – or could be – targeted at the needs identified here. 2.9 The nature of preventive interventions means that it can be difficult to measure their effectiveness. This is because it is difficult to isolate the effects of a particular intervention owing to the timescales and the range of factors involved; and the need for large studies because different people respond so differently. 2.10 However, evidence is emerging that many interventions may lead to reduced use of more intensive services. For example, re-enablement services may work to reduce the numbers of people who need intensive care and support after the re-enablement period. In addition, a recent report by the Commission for Social Care Inspection (CSCI) stated that “a lack of
4
preventative services means there is a short term dip in the number of people eligible for social care, soon followed by a longer-term rise.”1 2.11 Furthermore, a 2002 study2 found that almost all the self-funders in residential care had entered residential care at lower levels of need than State-funded users. This suggests that selffunders may have been more likely to enter care unnecessarily. 2.12 Nonetheless, while robust and unequivocal evidence on the cost-effectiveness of preventive interventions is limited now, the evidence-base will become richer following the final evaluation of the POPPs, due later this year, the final evaluation of the Whole Systems Demonstrators programme (looking at telecare and telehealth), due in 2010, and the results of a long-term controlled study of re-enablement, concluding in 2010.
1 2
Cutting the Cake Fairly, CSCI (2008) Self-Funded Admissions to Care Homes, Netten et al, PSSRU, 2002 5
What is the problem? 3.1 Falling is a serious and frequent occurrence in people aged 65 years and over. In a population of 45,000 people aged 65 and over, •
15,500 will fall
•
6,700 of those will fall twice or more
•
2,200 fallers will attend an A&E or minor injuries unit
•
a similar number will dial 999
•
1,100 will be injured, of which 360 will be injuries to the hip
3.2 Whatever the outcome for the individual – little or no actual injury, or injury that responds well to treatment and rehabilitation – a common factor is that people who fall often lose confidence. This may mean restricting physical activity – including physical activity associated with the activities of daily life such as shopping, cleaning and gardening – which further contributes towards the loss of capacity and bone density. There is also a strong correlation between the experience of a fall and surrendering independent life in your own home in favour of a ‘safer’ setting in residential care. 3.3 Falls are a major cause of disability and mortality in the UK. Thirty percent of those aged 65 or over who live in the community fall each year, increasing to 45 percent in those aged 80 or above3,4. Annually, between 10 and 25 percent of fallers sustain a serious injury, 400,000 fallers attend accident and emergency (A&E) departments and up to six percent of falls culminate in a fracture5,6 3.4 Recurrent falls are associated with increased mortality, increased rates of hospitalisation, curtailment of daily activities and higher rates of institutionalisation7,8,9. This is compounded further by the psychological consequences, such as loss of confidence, increased fear of falling, lower quality of life10 and post-fall anxiety syndrome11. Half of fallers will have a further fall within the next 12 months12. The rate of falls among people in institutions is almost three times that of older people living in the community, with injury rates also considerably higher. 10-20 percent of institutional falls result in an osteoporotic hip fracture13,14. 3.5 The population of people at risk of falling and of fragility fractures will steadily increase, and within this increased population increased longevity will mean that there will be more ‘older 3
Campbell AJ, Reinken J, Allan BC et al. Falls in old age: A study of frequency and related clinical factors. Age and Ageing 1981; 10: 264-270. 4 Prudham D, Evans JG. Factors associated with falls in the elderly: a community study. Age and Ageing 1981; 10: 141-6. 5 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living within the community. N Eng J Med 1988; 319: 1701-07. 6 Campbell AJ, Borrie MJ, Spears GF et al. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age and Ageing 1990; 337: 12791284. 7 Baker SP, Harvey AH. Fall injuries in the elderly. Clin Geriatric Med 1995; 1: 501-12. 8 Gryfe CI, Amies A, Ashley MJ. A longitudinal study of falls in an elderly population. Incidence and morbidity. Age and Ageing 1987; 35: 644-8. 9 Tinetti ME. Factors associated with serious injury during falls by ambulatory nursing home patients. J Am Geriatr Soc 1987; 35: 644-48. 10 Cumming RG, Salkeld G, Thomas M, Szonyi G. Prospective study of the impact of fear of falling in activities of daily living, SF-36 scores and nursing home admission. J Gerontology 2000; 55: 299-305. 11 Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall related efficacy in relationship to functioning among community living elders. J Geron 1994; 49: 140-47. 12 Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET) : a randomised controlled trial. Lancet 1999; 353: 93-97. 13 Rubenstein LZ, Powers C. Falls and mobility problems: potential quality indicators and literature review. Santa Monica, CA : RAND Corporation, 1999: 1-40. 14 Cali C, Kiel DP. An epidemiological study of fall related fractures among institutionalised older people. J Am Geriatrics Soc 1995; 43: 1336-1340. 6
old’ people who have the greatest risk. For example, there are about 10,000 centenarians now but by 2050 the Office for National Statistics forecast there will be about 250,000.
7
Why is Government intervention necessary? 4.1 Improving commissioning is a central government role. It is most efficient for evidence to be assessed and published once. 4.2 Services needed to treat injuries sustained in avoidable injuries – including injuries sustained in falls – also represent a diversion of scarce and costly NHS resources away from other essential services needed to treat unavoidable illness. 4.3 Finally, the Single Equality Bill now before Parliament will – when it becomes law – place a new duties on public authorities in respect of older people. These include duties to positively promote equality when, or example, decisions about what services to commission or provide – or what services to not commission or provide – are fair to all groups.
8
Policy objective and intended effects 5.1
Policy objectives are to promote services that •
minimise the risk of falling
•
minimise the injury sustained in faller by promoting bone health
•
respond effectively to the needs of people injured in falls so that they regain their optimum possible level of independence as soon as possible.
5.2 The intended effects are to promote the health, wellbeing and inclusion of older people by maintaining bone health and reducing the risk – and fear – of falling; and to minimise the diversion of costly and scarce NHS resources away from treatment and aftercare towards prevention. 5.3 We have identified objectives, which are listed in priority order in terms of impact and evidence-base, although they each have a key role for different risk groups. •
Objective 1: Improve patient outcomes and improve efficiency of care after hip fractures through compliance with core standards.
•
Objective 2: Respond to a first fracture and prevent the second - through fracture liaison services in acute and primary care settings.
•
Objective 3: Early intervention to restore independence - through falls care pathways, linking acute and urgent care services to secondary prevention of further falls and injuries.
•
Objective 4: Prevent frailty, promote bone health and reduce accidents - through encouraging physical activity and healthy lifestyle and reducing unnecessary environmental hazards.
5.4 Another suggested intervention – the establishment of Fallers Clinics – has not been pursued in light of the fact that the National Institute for Health and Clinical Evidence (NICE) discontinued work on a Health Technology Assessment for Fallers Clinic in March 2009 for lack of evidence. Objective 1 5.5 The core standards against which commissioners can secure the best outcomes for patients who suffer hip fractures are set out in The Care of Patients with Fragility Fracture, published in 2007 by the British Orthopedic Association and British Geriatric Society and known as the 'Blue Book'. Progress towards compliance can be continuously monitored by participation in the National Hip Fracture Database (NHFD)15. Commissioners can ensure a focus on quality and outcomes by requiring providers to participate in and share with commissioners their comparative data from NHFD. 5.6
The standards are: 1. All patients with hip fracture should be admitted to an acute orthopedic ward within 4 hours of presentation.
15
National Hip Fracture Database http://www.nhfd.co.uk 9
2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours. 3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer. 4. All patients presenting with a fragility fracture should be managed on an orthopedic ward with routine access to acute ortho-geriatric medical support from the time of admission. 5. All patients presenting with fragility fracture should be assessed to determine their need for anti-resorptive therapy to prevent future osteoporotic fractures. 6. All patients presenting with a fragility fracture following a fall should be offered multi-disciplinary assessment and intervention to prevent future falls. Objective 2 5.7 NICE has published a Technology Appraisal Assessment on the secondary prevention of osteoporotic fractures in TA161. Objective 3 5.8 This strand has four components: • • • •
a falls care pathway a falls service & a falls co-ordinator multi-factorial interventions community-based therapeutic exercise.
A falls care pathway 5.9 A pathway, to inform local commissioning, including how to map and review current provision – where and by whom – leading to an estimate of unmet needs. A falls service and a falls co-ordinator 5.10 A falls service can triage and assess older people who have fallen or are at high risk of falling with a falls co-ordinator to ensure that hospital and community efforts to prevent falls are co-ordinated and integrated. Multi-factorial interventions 5.11 Multi-factorial targeted interventions are based on risk assessment, and are likely to include optimising medication, reducing visual disability, avoiding unnecessary environmental hazards in the context of lifestyle advice and support to prevent frailty, preserving bone health, and promoting independence. Community-based therapeutic exercise. 6.12 The most effective component of multi-factorial interventions is therapeutic exercise. The national physical activity strategy Be Active, Be Healthy: A plan for getting the nation moving16 highlights the benefits of strength training programmes for older people, which can produce
16
Be Active, Be Healthy: A plan for getting the nation moving HM Government 2009 10
significant improvements in muscle strength, leading to better functional mobility and a reduction in falls. Objective 4 5.13 This objective can be delivered locally where commissioners seek to implement a joined-up strategy to prevent frailty, promote bone health and reduce accidents through • • • •
Preventing falls in the community, home and hospital Tackling falls in hospitals and other care settings Systematic capture of information from ambulance services Effective use of Home Improvement Agencies and handyperson services
5.14 Falls and associated fractures occur regularly in a variety of settings, principally the community, home and hospital. Promoting healthy lifestyle and ‘strong bones’ among older people is a key activity, as is early intervention to restore independence when falls occur. Local falls strategies should also include • • • • •
approaches to improving balance and strength environmental issues (e.g. trip hazards in the home and other settings), and engagement with other stakeholders with responsibility for the built environment commissioning of health and social care services to include falls prevention as a key quality indicator commissioning of ambulance services to include systematic information-sharing (especially about ‘non-conveyed’ patients’) engagement with Home Improvement Agencies and ‘handyperson’ services as part f wider strategies on falls and falls prevention (within Lifetime Homes, Lifetime Neighbourhoods).
11
Evidence base Objective 1: Improve patient outcomes and improve efficiency of care after hip fractures through compliance with core standards. 6.1 The only component of this objective that has been assessed is the fracture liaison service for acute care setting Objective 2: Respond to a first fracture and prevent the second - through fracture liaison services in acute and primary care settings. 6.2 We seek to stimulate commissioners to consider building on this be commissioning fracture liaison services locally. These take two forms, which can be summarised as being to •
Follow-up people presenting with a fragility facture (Fracture liaison, working with acute care)
•
Proactively identifying people at increased risk of osteoporotic fracture (Fracture liaison, working with primary care)
Fracture liaison, working with acute care 6.3 For patients with new fragility fractures a service known as fracture liaison can target the highest risk group. Patients aged over 50, who are admitted to hospital or who attend outpatient clinics or A&E due to a low impact fracture, gained from a fall, slip or trip from a standing height or lower, are highlighted to the service, and assessed by a specialist osteoporosis nurse. Fracture liaison, working with primary care 6.4 For patients who have fractured in the past or are at risk of osteoporotic fractures, a primary care-based fracture liaison programme can undertake proactive case finding of unassessed fragility fracture and other high-risk patients across a much wider group. Fracture liaison service 6.5 The establishment of fracture liaison service, based with acute services, is for patients aged over 50 who are admitted to hospital or who attend outpatient clinics or accident and emergency departments due to a low impact fracture, gained from a fall, slip or trip. For an average PCT population ( 320,000) the service would assess about 1,200 older people with fragility fractures each year, who undergo DXA bone density measurements at the spine and hip and clinical assessment by a specialist osteoporosis nurse Of these, osteoporosis treatment is recommended in about 75% of cases. 6.6 The role of the specialist nurse is to: • investigate, using bone scans and local protocols, and start drug and other treatments, according to NICE guidance for women and local agreements for men, to reduce the risk of a future break if someone has osteoporosis. • link directly with falls services • monitor and maintain medication adherence. 6.7 The main costs are for the nurse, a consultant session, some clerical support, revenue costs for the scanning and pharmacy costs of osteoporosis treatment, usually comprised of a bisphosphonate in combination with calcium and vitamin-D. 6.8 The input of the nurse relates primarily to the first year’s membership of the cohort programme, with minimal contact thereafter (for example through letter contact and occasional telephone calls). 12
6.9 Out of a typical PCT population of around 320,000 there will, as highlighted above, be 1,200 fragility fractures of any type per year. Using the Ipswich Fracture Liaison Service data shows a likely breakdown by age and fracture type in Table 1. Table 1 Hip Forearm Humerus Lower Limb Pelvis Spine Other Not Specified Total
45‐59 12 98 23
Age Range (years) over 1 year period 60‐69 70‐79 80‐89 90+ 22 90 173 77 86 93 37 6 21 27 10 3
Total 373 318 83
67 2 3 92
50 2 3 60
33 9 9 48
14 17 6 18
4 7 3 2
167 35 23 219
11 306
8 251
6 313
5 277
1 102
30 1247
6.10 This evaluation is focussing on the 797 hip, shoulder, spine and forearm fractures per year, as there is robust research data on the impact of a fracture liaison services in these most significant fracture types - in terms of impact on quality of life and higher service cost. For the remaining fractures we would expect a fracture liaison service to have a positive impact in reducing further fractures but we have not modelled the costs or benefits. 6.11 All the 797 hip, shoulder, spine and forearm fractures will be assessed by the fracture liaison nurse, and if necessary the consultant, and 20% of hip fracture patients and 80% of humerus, forearm and spine patients are anticipated to receive bone scans. 6.12 In line with NICE guidance, only around three-quarters will receive drugs: estimated at 100% of the hip fractures (373), 50% of the wrist fractures (159), 75% of spines (17) and 75% of shoulders (62): a total of 611 out of 797. 6.13 Using a prospective study from Kanis et al the pattern of secondary fractures for a 320,000 population for each annual cohort can be identified 6.14 Factored in to the calculation is a) the percentage of each fracture type to be treated, ranging from 100% of hip fractures to only 50% of forearm fractures, b) and the relative risk reduction through a fracture liaison service of 40% (NICE TA 161). From this therefore, can be identified the number of fractures actually averted through the service over 5 years. Table 2 Hip Forearm Spine Shoulder
Full compliance 80% compliance 22 18 7 5 8 6 6 4
6.15 An assumption of only 80% medication compliance has ben included (i.e. the optimum number of avoidable fractures is 22, 7, 8 & 6 but our modelling does not assume all the possible 13
benefits will be realised because some patients will not comply fully with the medication regime instituted after the first fracture).
Summary of costs/benefits 6.16 NHS and social care direct savings combined for a 320,000 population are about £258,000 over the 5 years, with the majority of savings in the first three years. This is based principally on hip fractures averted: £10,000 PbR tariff costs saved and £2,700 social care cost saved over 2 years on average per hip fracture. 6.17 The costs for each year’s cohort of 797 is £281,000, consisting of staff costs in year 1 (in effect covered by others cohorts from year 2 onwards) and treatment costs over the 5 year period being evaluated. Staff costs of running a Fracture Liaison Service for 320,000 for 1 year are £41,000, with bone scanning in year 1 a further £29,000. The total treatment cost distributed over 5 years is £211,000 taking into account 12% mortality, 80% compliance and the availability over the next few years of generic risedronate (from 2010), ibandronate (2011) and zoledronate (2012). 6.18 There will be further capacity saving in rehabilitation/NHS community-team services and primary care, in addition to a very significant quality of life gain for older people who do not incur a secondary fracture. 6.19 Therefore, per annual patient cohort of 797 hip, shoulder, spine and forearm fractures, over a 5 year period £258,000 will be saved in NHS acute care and local authority social care costs, against an additional £281,000 revenue costs in year 1 spent by the NHS on the intervention. 6.20 In addition to the cost savings for the NHS in reducing the incidence of hip fracture, there is also the positive impact of from reduced hip fractures on local authority-funded social care services.. 6.21 The following are illustrative estimates only, and local costs and service patterns are known to vary considerably, notably based on the extent of homecare reablement services locally. 6.22 For each 10 hip fractures averted, one assumption is that there will be a local authority cost saving of: • 0.6 care home placements This is based on 10 % rate of post-hip fracture direct transfer from hospital to care home and within this group a 60% rate of local authority funded placements, compared to selffunders. The discharge to care homes is based on analysis of Hospital Episode Statistics. The duration of this placement could vary from a few months to several years. A working assumption is that each care home placement is for 2 years at £600 per week, though cost and duration of average stay varies considerably across regions and between localities. 6.23 Thus, total LA care home costs = £37,400per year over 2 years for every 10 hip fractures, or an average of £3,740 per hip fracture. • plus three home care packages This is based on 6 out of 10 hip fractures discharged from hospital back to their own home and not to a care home, requiring a home care package; and of these 1 in 2 eligibility for local authority funding. Intensity of support will vary according to need – 14
such as frailty, need for double handed packages, and home environment – and the extent to which reablement services are commissioned. 6.24 A working assumption is that for each group of 10 hip fractures would incur costs of a care package costed as follows: 3 x (4 hours per day for 6 weeks at £15 per hour, or £2,520). 6.25
This totals £7,560 (for every 10 hip fractures), or £756 per hip fracture.
6.26 The combined value of both the care home and the care package saving element is £3,740 + £756 = £4,500 per hip fracture. 6.27 The mortality rate for hip fractures is 30% at 12 months, so 3 in 10 of averted hip fractures would not incur any social care costs. Therefore the savings are reduced by 30% to £2,700 per hip fracture. 6.28 For every anticipated reduction in 2 vertebra or ankle fractures (at 1 in 2 eligibility for LA funding within the client group) a similar local authority saving in home care is anticipated: of (50% x £2,520) - or £1260 per vertebra/ankle fracture. 6.29 A working assumption is that wrist fracture social care support can be met at minimal cost, through low cast aids and adaptations for example. 6.30 Assuming that 100 PCTs (approx 70%) do not currently have these services, the total national costs may be £28m over five years. Total savings over five years may range from £29m to £32m depending on care home diversion rates. The total public sector savings may range from £26-£28 depending on the care home diversion rates.
Establishment of fracture liaison service based in primary care. 6.31 This intervention targets patients who have fractured in the past or are at risk of osetoporotic fractures. A primary-care based fracture liaison programme can undertake proactive case finding of unassessed fragility fracture and other high risk patients across a much wider group. 6.32 A 1.00 WTE primary care-based Fracture Liaison Nurse works to pre-agreed protocols under the guidance of a GP with a specialist interest in osteoporosis to provide assessment and subsequent treatment recommendations for long-term management. This enables more comprehensive case-finding, using primary care records and the FRAX risk assessment tool to identify patients at high risk of primary fractures, and systematic annual follow-up to ensure medication compliance. 6.33 For a 100,000 population, covering a Practice-based Commissioning locality area for example, this service would cost around £65,000 per year to run, with the 1.00 WTE specialist nurse and pharmacy costs for osteoporosis treatment as the main cost elements. 6.34 This equates to £195,000 per year for a 300,000 population PCT. Very few PCTs currently offer this service. Assuming that 100 PCTs do not have this service (approx 70%), the total national costs would be £20m for five years. 6.35 The impact of a primary-care based programme targetting patients who have fractured in the past or are at risk of osetoporotic fractures (women aged 65 and above, for example) has been shown to increase compliance with national guidelines on secondary prevention of osteoporotic fractures from 9% to 64%. 6.36
Using NICE costing sheet for TA160, potentially there are about 500,000 women at risk, 15
half of them might take up the service, = 250,000, 1.6% risk of fracture = 4000, 45% of which might be prevented by treatment, = 1,800. The table below gives the unit costs of treatment for the various fractures. Table 3 Unit cost of treatment for hip fractures 6,815.66 vertebral fractures 3,410.78 wrist fractures 2,381.28 6.37 Assuming that 70% of population does not have the service currently, the, NHS savings would be of the order of £6m . If 10% of care home admissions were avoided for two years, the savings could be £8m over two years. Objective 3: Early intervention to restore independence - through falls care pathways, linking acute and urgent care services to secondary prevention of further falls and injuries. 6.38 Only the therapeutic exercise component of this objective has been assessed and costed. 6.39 Capacity for community-based therapeutic exercise, with programmes tailored to: the faller who attends urgent care, the person with a fragility fracture, and the person with a hip fracture. The overall aim of these programmes is to improve strength and balance within a context of lifestyle advice and support to prevent frailty, preserve bone health, and reducing accidents. 6.40 This intervention would cost approximately £100,000 a year for a 300,000 population, including staff and accommodation costs. 6.41 Currently there are very few PCTs who provide this service. If it is assumed that 100 PCTs do not currently have this service, the costs could be £10m per year. 6.41
Based on a study in Cambridge Falls Service:
Average PCT 158 patients screened, 40 referred into group exercise of whom 70% completed the course at one month followup. Using risks of fracture of 1.6% (based on NICE TA161), 0.5 fractures are prevented, based on Skelton, exercise can help prevent 44% of falls. Just under 0.2 fractures prevented per PCT. Assuming that 100 PCTs do not currently have the service, an additional 20 fractures could be avoided with a new service.
Objective 4: Prevent frailty, promote bone health and reduce accidents - through encouraging physical activity and healthy lifestyle and reducing unnecessary environmental hazards. 6.42
Only assessment and osteoporosis medication for care home residents has been costed.
Organising appropriate assessment and osteoporosis medication for all ambulatory care home residents. 6.43 Interventions include: prescription of high strength vitamin D and calcium supplements to all care home residents; teaching to all care staff on falls risk factors, preventative measures, 16
osteoporosis and when to refer to the falls specialist for assessment; a comprehensive geriatric assessment of all recurrent fallers. 6.44
Costs of this intervention comprise pharmacy and specialist NHS staff time.
6.45
There are estimated to be 320,000 care home residents over 65 17.
6.46 Prescription of high strength vitamin D and calcium supplements would be £60 per resident per year; 6.47 Staff time, covering teaching to all care staff and a comprehensive geriatric assessment of all recurrent fallers, would be a further £20,000 per PCT. 6.48 Very few PCTs currently offer this service. Therefore the costs are estimated as £9 m for 100 PCTs assuming 50% compliance by clients. 6.49 In institutions, the rate of falls is almost three times that of community dwelling elderly, with injury rates also considerably higher. 10-20% of institutional falls result in an osteoporotic hip fracture 18 6.50 Using the 320k care home residents x 70% of PCTs and assuming 50% compliance and twice the risk of fracture as that of the community population, and the same risk reduction as community intervention about 1,600 fractures are avoided. Assuming the same distribution of factures as in the community, the savings are estimated as £8m.
17
SR1 and PSSRU estimate – personal correspondence Rubenstein LZ, Powers C. Falls and mobility problems: potential quality indicators and literature review. Santa Monica, CA : RAND Corporation, 1999: 1-40. 18. Cali C, Kiel DP. An epidemiological study of fall related fractures among institutionalised older people. J Am Geriatrics Soc 1995; 43: 1336-1340.
18 18 .
17
Summary of Options and Costs Options considered Issue policy guidance 7.1 Assuming 100 PCTs do not have these services currently – approx 70%. Table 4
Service FLS primary therepeuctic care homes Total
Costs £m £28 £20 £10 £9 £67
Savings central estimate £m £29 £14
Net cost £m -£1 £6 £10 £2 £17
£8 £50
Savings public sector £25 £11 £0 £8 £43
Saving private £4 £3
£7
7.2 Total costs over 5 years are estimated to be about £70m. Financial savings both from hospital care avoided and care home and home care avoided may deliver £50m savings. 7.3 These include savings to NHS , local government and private clients. This gives a net total cost of £17 over 5 years which equates to about net cost £3m per year. 7.4 Benefits for example in terms of quality adjusted life year (QALY) would be in addition to these savings. However, there appear to be no studies which directly measure the QALY gains. An alternative has been explored for hip fractures An health technology report ( Stevenson et al (2005), looked at osteoporosis risks. The Health State Utility Values used in their economic modelling was 0.83 in year 1 and 0.925 in 2nd year and thereafter. Using life expectancy tables for people aged 75 plus, the QALY loss based on sex weighted cohort mortality rates for those experiencing a hip fracture are estimate to be 0.75 discounted (at 1.5% per annum) quality adjusted life expectancy (QALE) compared with the general population In addition, there is the 30% mortality ie 3 out of 10 people with fracture who would lose about 9 QALE. . Using data obtained from Hospital Episode Statistics (HES) for the year 2005-2006, over 80% of finished consultant episodes with the diagnosis of a fractured neck of femur were over the age of 75, and 95% of all hip fractures were over the age of 60. Therefore, the QALE may be an under-estimate. Further, since the general population will include those experiencing hip fractures QALE may be an under-estimate. However if the life expectancy of those who fall is in shorter for other reasons, then the QALE may be an over-estimate. 7.5 The table below summaries the number of hip fractures. For the FLS, the hip fractures prevented have been directly estimated. For the other three areas, an assumption that hip fractures account for 30% of all fractures (based on Table 1 above) has been made. This gives a total of 2,660 hip fractures avoided. Table 5 HIPS FLS Primary Care homes Exercise TOTAL
National 1,800 370 480 10 2,660
7.6 Using a value of £50k for the approx 2,660 fractures avoided and the above QALY gains of 0.75 for 70% for whom fracture avoided and 9 for 30% for whom death was avoided . These 18
would imply benefits of £435m. In addition there are £7m savings to private payers of care home care avoided. Given the opportunity cost of a QALY to the NHS may be half the value of a QALY (ie £25k), the net NHS costs have been doubled. The Net Present Value is £390m,
19
Specific impact tests Health Impact 8.1 In screening for whether a full Health Impact Assessment is required we have considered whether the impact is likely to be ‘significant’ across within at least two of the three domains. The definition of ‘significant’ is that it refers to he whole population, to a major sub group of the population, or to the degree of severity of the impact. 8.3. Our judgement is that the target population is only that small proportion of the whole population that is at risk of falling, and so is not significant. 8.4 We also considered whether promoting the benefits are ‘significant’ in terms of the impact on people affected and their carers across at least two of the domains. 8.5
The domains are •
wider determinants of health (Income, Crime, Environment, Transport, Housing, Education, Employment, Agriculture, Social cohesion)
•
lifestyle related variables (Physical activity, Diet, Smoking, drugs, or alcohol use, Sexual behaviour, Accidents and stress at home or work
•
demand for heath and social care services (Primary care, Community services, Hospital care, Need for medicines, Accident or emergency attendances, Social services, Health protection and preparedness response).
8.6 The services described are interventions for a small cohort of people who are at risk of falling. Our judgement is that there will be a small effect so far as domain 2 is concerned (promote more physical activity, reduce accidents) and – in domain 3 – a slight reduction in A&E attendances, and a modest increase in medicines for bone metabolism) but that, overall, the scale of change envisaged does not warrant a full Health Impact Assessment. Single Equality Assessment 8.7 The need for care and support to prevent falls and fractures is based on an assessment of individual – rather than group identity needs – in all cases. After assessing the likely impact, our conclusion is that the guidance unlikely to have an adverse or negative impact on any group or community. Rather, it has the potential to have a positive impact by reducing and removing barriers and inequalities that currently exist.
20
Specific Impact Tests: Checklist Use the table below to demonstrate how broadly you have considered the potential impacts of your policy options. Ensure that the results of any tests that impact on the cost-benefit analysis are contained within the main evidence base; other results may be annexed.
Type of testing undertaken
Results in Evidence Base?
Results annexed?
Competition Assessment
No
No
Small Firms Impact Test
No
No
Legal Aid
No
No
Sustainable Development
No
No
Carbon Assessment
No
No
Other Environment
No
No
Health Impact Assessment
Yes
No
Race Equality
Yes
No
Disability Equality
Yes
No
Gender Equality
Yes
No
Human Rights
Yes
No
Rural Proofing
No
No
21
Annexes Annex 1: Resources Ali A, Morris RO, Skelton DA, Masud T. Falls Services in the UK – A Survey of UK Geriatricians. 5th National Conference on Falls and Postural Stability. Manchester, 2004. Appell HJ. Muscular atrophy following immobilisation. A review. Sports Med. 1990; 10, 42-58 Brooke-Wavell K; Athersmith LE; Jones PR; Masud T. (1998) Brisk walking and postural stability: A cross-sectional study in postmenopausal women. Gerontology 44(5), 288-92 Campbell AJ, Robertson MC. Implementation of multifactorial interventions for fall and fracture prevention. Age Ageing. 2006 Sep;35 Suppl 2:ii60-ii64. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Brit Med J 2004; 328: 680-7. Close JCT, McMurdo MET. Falls and bone health services for older people. Age Ageing 2003;32:494496. Close JCT, Lord SR, Menz HB, Sherrington C. What is the role of falls? Best Practice & Research Clinical Rheumatology 2005;19(6):913-935. Craig A, Dinan S, Smith A, Taylor A, Webborn N. NHS: Exercise Referral Systems: A National Quality Assurance Framework. Department of Health. The Stationary Office, 2000. Day L, Fildes B, Gordon I, et al. Randomised factorial trial of falls prevention among older people living in their own homes. Brit Med J 2002; 325: 128-32 Department of Health. National Service Framework for Older People: Modern Standards and Service Models. London, Her Majesty’s Stationary Office, 2001. Department of Health. A Recipe for Health – Not a Single Ingredient. London, Her Majesty’s Stationary Office, 2007. Dinan SD. Exercise for vulnerable older patients. In: (Eds) Young A, Harries M. Physical Activity for Patients: An exercise prescription. London: Royal College of Physicians, 2001. Dinan S, Lenihan P, Tenn T, Iliffe S Is the promotion of physical activity in vulnerable, older people feasible and effective in general practice? 2006; 56(531): 791-3. Ebrahim S, Thompson PW, Baskaran V, Evans K. Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis. Age Ageing 1997; 26: 253-260. FRAX ® WHO Fracture Risk Assessment Tools, accessible at http://www.shef.ac.uk/FRAX/index.htm Gillespie LD, et al. Interventions for preventing falls in elderly people. The Cochrane Database of Systematic Reviews 2005, Issue 5. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2009, Issue 2. Art.No.: CD007146. DOI: 10.1002/14651858.CD007146.pub2. Gregg EW, Pereira MA, Caspersen CJ. Physical activity, falls, and fractures among older adults: a review of the epidemiologic evidence. J Am Geriatr Soc 2000; 48:883-93. Halter M, Close J, Elrick A, Brain G, Swift C. Falls in older population: A pilot study to assess those individuals who are attended by the London Ambulance Service as a result of a fall but are not conveyed to an Accident and Emergency Department. London Ambulance Service NHS Trust, 2000. 22
Hauer, K., Rost, B., Rutschle, K., et al. Exercise training for rehabilitation and secondary prevention of falls in geriatric patients with a history of injurious falls. J.Am.Geriatr.Soc. 2001; 49, 10-20. Ivers RQ, Cumming RG, Mitchell P, et al. Risk factors for fractures of the wrist, shoulder and ankle: the Blue Mountains Eye Study. Osteoporos Int 2002; 13:513-8. Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fujiwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom D, Melton III LJ, Pols H, Reeve J, Silman A, Tenenhouse A. A meta-analysis of previous fracture and subsequent fracture risk. Bone 2004; 35: 375-382. Law MR, Wald NJ, Meade TW. Strategies for prevention of osteoporosis and hip fracture. Brit Med J 1991; 303:453-9. Lord SR, McLean D, Strathers G. Physiological factors associated with injurious falls in older people living in the community. Gerontol 1992;38:338-46. Lord SR, Castell S, Corcoran J, et al. The effect of group exercise on physical functioning and falls in frail older people living in retirement villages: a randomized, controlled trial. J Am Geriatr Soc 2003; 51: 1685-92. Lundin-Olsson L, Nyberg L, Gustafson Y. “Stops walking when talking” as a predictor of falls in elderly people. Lancet 1997; 349:617 NICE 21 Falls Guideline. Falls: the assessment and prevention of falls in older people. National Institute of Clinical Evidence, London. 2004. McClure R, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Population-based interventions for the prevention of fall-related injuries in older people. The Cochrane Database of Systematic Reviews 2005, Issue 1. McMurdo ME, Rennie LM. Improvements in quadriceps strength with regular seated exercise in the institutionalized elderly. Arch.Phys.Med.Rehabil. 1994; 75, 600-603. Omnabele-Pearson G, Skelton DA. Exercise and Bone Health. In: Lanham-New S, O'Neill T, Morris R, Skelton D, Sutcliffe A (eds). Managing Osteoporosis. Oxford: Clinical Publishing, 2007; pp 151–168 Pereira MA, Kriska AM, Day RD. A randomised walking trial in postmenopausal women: Effects on physical activity and health 10 years later. Arch Int Med 1998; 158: 1695-1701. Perrin PP, Gauchard GC, Perrot C, Jeandel C. Effects of physical and sporting activities on balance control in elderly people. Brit. J. Sports Med 1999; 33:121-126 Rutherford OM. Bone density and physical activity. Proceed Nutr Soc 1997; 56: 967-975 Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(12):2234-43. Sinaki M. Postmenopausal spinal osteoporosis: physical therapy and rehabilitation principles. Mayo Clin Proc 1982; 57:699-703. Skelton DA, Greig CA, Davies JM, Young A. Strength, power and related functional ability of healthy people aged 65-89 years. Age Ageing 1994; 23:371-377 Skelton DA, Young A, Greig CA, Malbut KE. Effects of resistance training on strength, power and selected functional abilities of women aged 75 and over. Journal American Geriatric Society 1995; 43:1081-1087 Skelton DA, McLaughlin AW. Training Functional ability in old age. Physiotherapy 1996; 82, 159-167.
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Skelton DA, Dinan SM. Exercise for falls management: Rationale for an exercise programme to reduce postural instability. Physiotherapy: Theory and Practice. 1999; 15: 105-120. Skelton DA. Effects of physical activity on postural stability. Age Ageing 2001; 30(Suppl 4), 33-39 Skelton DA, Kennedy J, Rutherford OM. Asymmetry in Muscle Strength And Explosive Power Amongst Community Dwelling Frequent Fallers And Non-Fallers Aged Over 65. Age Ageing 2002; 31:119-125 Skelton DA, Beyer N. Exercise and Injury Prevention in Older People. Scandinavian Journal of Medicine and Sports Science. 2003; 13: 1-9 Skelton DA, Todd C. What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? How should interventions to prevent falls be implemented?. WHO, Denmark. 2004. Skelton DA, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005 34;6:636639 Tinetti M, Speechley M, Ginter S Risk factors for falls among elderly persons living in the community. N Eng J Med 1988; 319:1701-1707 Tinetti ME, Lui WL, Claus EB. Predictors and prognosis of inability to get up after falls among older persons. J Am Med Assoc 1993; 269:65-70 Voukelatos A, Cumming RG, Lord SR, Rissel C. A randomized, controlled trial of tai chi for the prevention of falls: the Central Sydney tai chi trial. J Am Geriatr Soc. 2007 Aug;55(8):1185-91. Whipple, R. H., Wolfson, L. I., & Amerman, P. M. (1987). The relationship of knee and ankle weakness to falls in nursing home residents: an isokinetic study. J.Am.Geriatr.Soc. 35 , 13-20. Wolf SL, Barnhart HX, Kutner NG, McNeeley E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of tai chi and computerised balance training. J Am Geriat Soc 1996;44:489-97. Wolf SL, Sattin RW et al. Intense Tai Chi exercise training and fall occurrences in older, transitionally frail adults: A randomized, controlled trial. J Am Ger Soc 2003;51(12):1693-1701 Yardley L, Smith H. A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. Gerontologist 2003; 42: 17-23. Young, A. & Dinan, S. M. (2000). Active in later life. In ABC of sports medicine. pp. 51-55. British Medical Journal Books, Cambridge, UK.
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References for Part 1
i
Department of Health. Our health, our care, our say; a new direction for community services. London: Department of Health, 2006. ii
Health England (2009a) Report No 2: Prevention and Preventative Spending; available at: http://healthengland.org/publications/HealthEnglandReportNo2.pdf
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