costing & cost-effectiveness in falls prevention -...
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Costing & cost-effectiveness in
falls preventionNSW Falls Prevention Network Forum
May 27, 2011
Wendy Watson
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Source: Watson, Yang & Mitchell (unpublished data)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.