This workbook is designed to help connect data from the Health Quality & Safety Commission'sAtlas of Healthcare Variation falls domain with local action. It has been updated with data from 2015.
We recommend you discuss the Atlas data at all levels of clinical governance –from the DHB falls prevention committee, to the Board, and in your health of older persons network.
From Atlas...
Know your
data / This workbook is designed to focus your attention on the data in eight indicators looking at the incidence of fall-related injuries, and aspects of treatment, in people aged 50 and older. The Workbook is provided in Word format so it can be customised for your DHB area.
...to Action
What's your plan? / The Atlas data provide a baseline for your planning and improvement projects. The Commission’s Reducing Harm from Falls programme’s expert advisory group has recommended an integrated approach to falls in older people with 10 Priorities identified for attention.
The Atlas data at a district level promote consideration of older people as a population group which ranges from those who are generally healthy and active to those who are very frail or debilitated.
Broadly speaking, an integrated approach to meet the needs of this diverse group encompasses:
- primary prevention of falls in older people: preventing falls in the first place, for example through promotion of general physical activity and exercise programmes to improve balance and strength; or assessment of bone health from age 50 for early prevention and treatment of osteoporosis; and ensuring safe civic and home environments
- secondary prevention for those who have had a fall with or without injury– here special attention might be given to the age group 85 and older as those who are most frail, most likely to fall and most likely to have a fall-related injury – nationally 25 percent have at least one ACC claim for a fall each year.
We'd like to acknowledge the work done by the members of the expert advisory group convened by the Commission for the specific purpose of developing the falls domain.
We hope you find the Workbook supports your team's discussion of how to build on the work you are already doing and planning to prevent falls and reduce harm from falls.
Thank you,
Reducing Harm from Fallsexpert advisory group and programme team
Health Quality Evaluation team
What's in this WorkbookHow to use the Workbook / 1
From Atlas to Action: key resources / 2
Highlights from the evidence: what works / 3
Key indicator summary for our DHB area and implications / 4
Worksheets for indicators in the Atlas of Healthcare Variation falls domain
1People 50+ with one or more ACC claim for a fall / 5
2People 50+ with one or more hospital admissions due to a fall / 6
3People 50+ admitted for more than one day due to a fall / 7
4Average bed-days for people 50+ admitted with a fall (DHB of domicile) / 8
5Hip fracture 50+ due to a fall (DHB of domicile) / 9
6Percent hip fracture 50+ operated on the same or next day of admission (DHB of service) / 10
7Percent bisphosphonate on discharge followinghip fracture (DHB of service) / 11
8Percent vitamin D on discharge followinghip fracture (DHB of service) / 12
OTHER RESOURCES
Tutorial: using the bar chart to determine statistical significance / 13
Understanding variation
The goal of the falls domain was to explore any areas of wide variation between DHBs and identify possible areas for local quality improvement. In particular we are interested in identifying ‘unwarranted’ variation, that is, variation in health service use that cannot be explained by differences in patient illness or preferences.
Resources on the health quality evaluation webpages are:
- Variation in medical practice: literature review and discussion
- Addressing unwarranted variation: literature review on methods for influencing practice
- Variation and improving services: analysing and interpreting variation.
Selected references
1Rubenstein LZ. 2006. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 35–S2:ii37–ii41.
2Gillespie LD, Robertson MC, Gillespie WJ, et al. 2012. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews (9): CD007146.
3Cameron ID, Gillespie LD, Robertson MC, et al. 2012. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews (12): CD005465.
4Carande-Kulis V, Stevens JA, Florence CS, et al. 2015. A cost–benefit analysis of three older adult fall prevention interventions. Journal of Safety Research 52: 65–70.
5Gallagher JC, Melton LJ, Riggs BL, et al. 1980. Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clinical Orthopaedics and Related Research 150: 163–71.
6Port L, Center J, Briffa NK, et al. 2003. Osteoporotic fracture: missed opportunity for intervention. Osteoporosis International 14(9): 780–4.
How to use the Workbook
We recommended that data from the Atlas of Healthcare Variation falls domain are reviewed at all levels of clinical governance.
- Theworkbook is designed to support structured discussion on each of the eight indicators looking at the incidence of fall-related injuries, and aspects of treatment, in people aged 50 and older.
- It may be appropriate that your DHB area's data is entered into the worksheets as a first step (the workbook is provided in a Word format to allow you to customise the content).
Highlights from theevidence for preventing falls and reducing harm from falls– key points relevant for community-wide planning to inform your discussion of Atlas data in the worksheet for each indicator.
Worksheetsfor each indicator:
- suggest key questions for discussion, directing attention to immediate gains with high-risk groups and longer-term gains in a population health approach
- allow you to record Atlas data in a breakdown of ethnicity, age group and gender
in some places you'll need to calculate percentage with reference to the preceding figures
- suggest comparisons using the bar chart with the national mean and a similar DHB area.
Key indicator summary –complete thispage to summarise your discussion of data from the worksheets. These three indicators help focus on planning implications for the incidence of:
- fall-related injuries treated in the community
- hospital admissions for fall-related injuries
- hip fracture due to a fall.
- 10 Topics in reducing harm from fallsand other resources developed in the national falls programmeare matched to the issues and questions raised by the Atlas indicators.
- There's a tutorialat the end of this workbook on using the bar chart to determine whether or not differences against the national mean and between DHBs are statistically significant.
FEEDBACK
Please provide feedback on the Workbook and your experience of using it to .
We'd particularly like to hear about any questions prompted by the data that haven't been mentioned in the Workbook. We may include your insights in any future revisions.
Workbook: From Atlas to Action (2015 data), published March 2017page 1
From Atlas to Action: key resourcesAtlas of Healthcare Variation falls domain / The falls domain was originally developed by an expert advisory group (EAG) convened by the Health Quality & Safety Commission in 2013. In 2016 it was updated with 2014 data and now, in April 2017, it has been updated with 2015 data. The EAG includes members of the EAG for the national falls programme, Reducing Harm from Falls. The falls domain gives clinicians, patients and providers an overview of the prevalence of falls in people aged 50 and older, including those treated in the community and in hospital.
Find the falls Atlas domain here.
The falls Atlas domain presents data on eight indicators by DHB areas in an interactive map, tables and bar graph. Read the relevant commentary online while using the worksheet for each indicator: /
Webinar
From Atlas to Action – How to use the Atlas of Healthcare falls domain
with Dr Shankar Sankaran from Counties Manukau Health, falls Clinical Lead Sandy Blake and the
Health Quality & Safety Commission’s Catherine Gerard.
The webinar from Tuesday 14 April 2015 is available here and it is still relevant to help users with the April 2017 update.
/ Patient perspective: this story could have been different...
Keep the focus on the user’s perspective to plan and provide integrated services.
Find it here.
/ These short summaries of current evidence and best practice cover core issues in falls prevention for older people, and introduce the resources and videos developed in the national programme. Links to the relevant Topic are given on the worksheet for each Atlas indicator to help inform your reflection and discussion.
Highlights from the evidence: what works
A summary of findings in the falls Atlas data for 2015confirms that, for peopleaged 65 and older, falls are a major cause of injury:
- 110,300 had at least one ACC claim in 2015 due to a fall, in other words, 300ACC claims were accepted every day
- 20,580 were admitted to hospital after a fall
- 3404of these admissions were for a fall-related hip fracture.
Among those aged 85 and older, 26 percent had one or more ACC claim, and of these, 33 percent were admitted to hospital for more than one day as a result of their fall, with an average length of stay of 14 days.
However, falls are not an inevitable part of ageing –there is strong evidence for preventing falls and reducing harm from falls. Effective interventions– when implemented – reduce the impact of falls and reduce costs at individual, system and population levels.
The expert advisory group for the national falls programmeasks you to give attention to these highlights from the evidence as to what works.
Exercise to improve balance and strength is cost-effective
Acost–benefit analysispublished in early 2015 reviewed three falls prevention programmes for older people, on the basis that they demonstrated a high level of effectiveness in randomised controlled trials, had been implemented in community settings, and were appropriate for people with differing levels of falls risk. The programmes were the Otago Exercise Programme for people aged 65 and older, or 80 and older, Tai Chi: Moving for Better Balance and Stepping On. Analysis of the return on investment for these programmes '... showed that the benefits not only covered the implementation costs but also exceeded the expected direct medical costs'4– in other words, these programmes prevented falls and provided a substantial return on investment.
Home safety assessment and modificationis effective for those at higher risk of falling
The 2012 Cochrane review on preventingfalls in older people living in the communitypresents strong evidence from randomised controlledtrials in the older age group that home safetyassessment and modification programmes are effectivein reducing falls, particularlythose at a higher risk of falling,and when the programme is delivered byan occupational therapist.
Multifactorial risk assessment and individualised interventions
Health professionals can ask older people about falls and injuries, and work with them and their families to reduce the risk of falls and related injuries. Although there are common risk factors in
the age group, every older person is different and needs an individualised plan of care that addresses their particular risk factors through appropriate treatments and referrals.
Short length of stay in acute care settings makes this approach more challenging but multifactorial interventions are effective for reducing the number of falls in older people living in the community.
Key indicator summary for our DHB areaand implicationsSummary of data and responses from worksheets to inform planning:
INDICATOR
1 / ACC claims for fall-related injuries
Nationally217,000 people aged 50 and older had an ACC claim for a fall-related injury accepted in 2015. People aged 85 and over were twice as likely to have an ACC claim for a fall-related injury and were 15 times more likely to be admitted to hospital as a result.
Falls Atlas Indicator 1key points for action from the data and questions:
INDICATOR
3 / Hospital admissions for fall-related injuries
Nationally20,100people aged 50 and older were admitted to hospital for more than one day due to a fall-related injury in 2015.
Falls Atlas Indicator 3key points for action from the data and questions:
INDICATOR
5 / Hip fracture due to a fall
Nationally3,600people aged 50 and older had a fall-related hip fracture in 2015.
Falls Atlas Indicator 5key points for action from the data and questions:
Implications from the data for our DHB area
Given the ageing population, and the points noted above, implications for planning and providing an integrated approach in our DHB areaare as follows:describe
Workbook: From Atlas to Action (2015 data), published March 2017page 1
INDICATOR / Worksheet: People 50+ with one or more ACC claim for a fallOur data: what questions should we ask?
In 2015, in our DHB area, there were number people 50+ with one or more ACC claims.
/ Nationally, 26 percent of those aged 85 and older have at least one ACC claim for a fall each year. What is the data in the age group table below telling us?
- Not all fall-related injuries are captured in this data set (ie,not reported by patients, not medically treated or not claimed for, or more than one claim).What assumptions can we make about the rate of falls with injury? What can we do to elicit better falls histories?
- Given the high incidence of falls with injury, what is being done community-wide to reduce falls in the frail elderly? Are there established programmes and referral pathways?
- What screening and interventionsare undertaken routinely to reduce injury related to falling, eg, assessment of bone health for detection and treatment of osteoporosis?
Our data: breakdown and comparisons
- Compared to the national mean of 142 per 1000, our rate of number is statistically significantly lower/no different/significantly higher.
- Compared to the rate of number per 1000 in name, a similar DHB area, our rate is statistically significantly lower/no different/significantly higher.
By ethnicity in our DHB area in 2015, people 50+ with one or more ACC claim for a fall were
Ethnicity (2015) / National mean / Our DHB area
Rate per 1000 / Count / Rate per 1000
Māori / 96.7
Pacific / 103.7
Asian / 86.1
All other ethnicities / 154.3
By age group in our DHB area in 2015, people 50+ with one or more ACC claim for a fall were
Age group (2015) / National mean / Our DHB area
Rate per 1000 / Count / Rate per 1000
50–64 years / 125
65–74 years / 135
75–84 years / 179
85+ years / 264
By gender in our DHB area in 2015, people 50+ with one or more ACC claim for a fall were
Gender (2015) / National mean / Our DHB area
Rate per 1000 / Count / Rate per 1000
Female / 156.5
Male / 125.7
RESOURCES
Ask, assess, act project and resources Topic 2 Which older person is at risk of falling? Ask, assess, act pdf
Topic 3 Falls risk assessment and care planning: what really matters? pdf Topic 5 After a fall: what should happen?pdf
Workbook: From Atlas to Action (2015 data), published March 2017page 1
INDICATOR / People 50+ with one or more hospital admissions due to a fallIndicator 3 (admissions for more than one day) has been selected for attention in this Workbook as a useful subset of all hospital admissions. Indicator 2 includes admissions to emergency departments, which may be influenced by factors such as availability of or access to after-hours primary care.
Workbook: From Atlas to Action (2015 data), published March 2017page 1
INDICATOR / Worksheet: People 50+ admitted for more than one day due to a fallOur data: what questions should we ask?
In 2015 in our DHB area there were number people 50+ admitted for more than one day due to a fall.
/
- This indicator only looks at one fall-related admission per person in a year. Do we know how many people had more than one admission for a fall-related injury in a year?
- Older people admitted due to a fall are by definition at risk of falling, and should have their risk factors assessed and addressed in an individualised care plan. Is this reflected in the report on our quality and safety markers for falls?
- Do we know how well we addressed these patients' risk factors – either asan inpatient or follow-up with GP and/or other services? For instance, medicineuse could be reviewed in hospital, whereas optimising an older person's vision may be a post-discharge referral.
Our data: breakdown and comparisons
- Compared to the national mean of 13.1 per 1000, our rate of number is statistically significantly lower/no different/significantly higher.
- Compared to the rate of number per 1000 in name, a similar DHB area, our rate is statistically significantly lower/no different/significantly higher.
By ethnicity in our DHB area in 2015, people 50+ admitted for more than one day due to a fall were
Ethnicity (2015) / National mean / Our DHB area
Rate per 1000 / Count / Rate per 1000
Māori / 7.6
Pacific / 7.9
Asian / 5.6
All other ethnicities / 14.7
By age group in our DHB area in 2015, people 50+ admitted for more than one day due to a fall were
Age group (2015) / National mean / Our DHB area
Rate per 1000 / Count / Rate per 1000
50–64 years / 4.1
65–74 years / 9.4
75–84 years / 29
85+ years / 87.2
By gender in our DHB area in 2015, people 50+ admitted for more than one day due to a fall were
Gender (2015) / National mean / Our DHB area
Rate per 1000 / Count / Rate per 1000
Female / 15.6
Male / 10.4
RESOURCES
Ask, assess, act project and resources Topic 2 Which older person is at risk of falling? Ask, assess, actpdf
Topic 3 Falls risk assessment and care planning: what really matters?pdf Topic 5 After a fall: what should happen? pdf