Last updated 03/04/2017

The goal of this domain was to explore any areas of wide variation between DHBs and identify possible areas for local quality improvement.

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Update with 2015 data

(Updated March 2017)

This Atlas has been updated with data from 2015.

Key messages:

  • Of people aged 85 and over, 26 percent had at least one ACC claim due to a fall in 2015.
  • 8.7 percent people aged 85 and over were admitted to hospital for at least one night as a result of a fall in 2015.
  • Their average length of stay was 14 days.

Hip fracture:

  • In 2015, of people aged 50 and over who had a hip fracture following a fall, half were aged 85 and over. Those aged 85 and over make up 5 percent of the total population aged 50 and over.
  • Women had twice as many hip fractures as men.
  • There was wide variation between DHBs in the use of medicines to promote bone health and prevent and treat osteoporosis (bisphosphonates and vitamin D) in people aged 50 and over following hip fracture. 

Key findings

Note: these indicators present data on the number of people having one or more events or claims. Reporting the number of events would give higher numbers as a person may have more than one serious fall in a year.

The following indicators show rates for the DHB in which people normally live (DHB of domicile).

217,000 people aged 50 and over had an Accident Compensation Corporation (ACC) claim for a fall-related injury

  • In 2015, 217,000 people aged 50 and over had one or more ACC claims accepted for a fall-related injury. Data are not presented on the type of injury resulting from the fall, which may range from a simple bruise through to a head injury. This indicator does not include falls that don’t result in an ACC claim being made or accepted. This may be because the injury was very minor or the person did not seek medical assistance or chose not to lodge a claim.
  • This was a significant increase from 170,000 claims in 2011. Claims varied 1.7-fold between DHBs.
  • One in four people aged 85 and over (21,100) had an accepted ACC claim for a fall-related injury. This equated to 58 ACC claims per day.
  • There appeared to be only a weak correlation between ACC claims for falls and hospital admissions for falls by DHB. This possibly reflects severity of injury: while people aged 85 and over were twice as likely as 50–64-year-olds to have an ACC claim for a fall-related injury, they were 15 times more likely to be admitted to hospital as a result.

Table 1: ACC claims, hospital admissions and hip fracture rates in 2015, by age group

Age band ACC claims, rate per 1000 (count) Hospital admissions, rate per 1000 (count) Hip fracture, rate per 1000 (count)
50–64 125 (107,118) 6.2 (5,274) 0.2 (194)
65–74 134.6 (52,677) 12.6 (4,921) 1.1 (442)
75–84 178.7 (36,459) 35.9 (7,328) 5.5 (1,115)
85+ 264.2 (21,164) 104 (8,335) 23.1 (1,847)
Total 142 (217,418) 16.9 (25,858) 2.3 (3,598)
25,800 people were admitted to hospital with a fall in 2015. Older people and women had higher admission rates
  • In 2015, on average 17 per 1000 people aged 50 and over were admitted after a fall, equating to approximately 25,800 people. Admissions varied 1.7-fold.
  • Admission rates increased significantly with age: those aged 85 and over had eight times more admissions than those aged 65–74 and 16 times more admissions than those aged 50–64 years.
  • Admissions were 1.5 times higher in women.
  • This indicator looks at how many people aged 50 and over were admitted to hospital as a result of a fall, including emergency department attendances.

20,100 people admitted to hospital with a fall stayed more than a day

  • In 2015, on average 13 per 1000 people aged 50 and over stayed more than one day in hospital after a fall.
  • This was 78 percent of all people attending hospital after a fall.
  • Older people (85 and over), European/Other ethnicity and women all had significantly higher admission rates.

On average people admitted due to a fall stayed in hospital for 10.3 bed-days. Older people stayed longer than younger.

  • In 2015, on average, people aged 50 and over admitted to hospital after a fall stayed for 10.3 days. This ranged from 5.7–13.8 days.
  • People aged 85 and over stayed three times longer than those aged 50–64 years (average of 14 days compared with 4.5 days). In part this reflects higher hip fracture rates in the 85 and over age group.
  • This indicator is a measure of resource use. Variation in average bed-days might be a proxy for the severity of injury or the result of policy differences, for example, the use of interim care schemes.

3600 people were admitted with a hip fracture due to a fall in 2015; fracture rates were higher in women and older people

  • In 2015, approximately 3600 people aged 50 and over were admitted with a hip fracture at an average rate of 2.3 per 1000.
  • Rates increased significantly with age; half of hip fractures occurred in those aged 85 and over.
  • Women had many more hip fractures than men, however these figures are not age-adjusted. In the 85 and over age group there are proportionately more women than men.
  • Hip fracture rates were higher in the European/Other ethnic group than other ethnicities at all ages.
  • Rates have not significantly changed since 2011.

Hip fracture rates by age and ethnicity

Rate per 1000 Māori Pacific people Asian European/Other Total
50–64y 0.2 0.2 0.1 0.2 0.2
65–74 0.7 0.4 0.5 1.2 1.1
75–84 3.1 3.4 3.8 5.8 5.5
85y+ 10.2 9.9 15.6 23.8 23.1
Total 0.7 0.7 0.8 2.8 2.3

Time trends for those aged 85 and over

Data over the last three years for people 85 years and over shows that the upward trend in most indicators reported for 2014 appears to have leveled in 2015, although none of these differences are statistically significant.

Claims data for people aged 85 and over (rate per 1000 population)

Rate per 1000 ACC claims Hospital admit for
more than 1 day
Average length
of stay
Fracture neck
of femur
2013 257.6 77.3 14.3 21.4
2014 283.4 89.2 15.5 23.3
2015 264.2 87.2 14.0 23.1


The indicators below assign people to where they received treatment (DHB of service).

76 percent of people with a hip fracture are operated on the same or next day of admission

  • In 2014, on average, 76 percent of people with a hip fracture aged 50 and over were operated on the same day or the next day of admission. Over the four years there has been an upward trend in the number of operations within 48 hours, but this has not reached statistical significance.
  • While the numbers are too low to present by age group, all of those aged 50–64 were operated on the same or next day, compared with 75 percent of those aged 65 and over.
  • Pain is a significant factor in a hip fracture, and surgery is one of the best ways to relieve pain. In addition to prolonging pain, the postponement of surgery increases the risk of complications and the need for repeated preoperative fasting. For these reasons, it is recommended[1] surgery is performed on the same or next day following hip fracture. It is not possible to infer whether or not any delays were appropriate from these data.

21 percent of people received bisphosphonate medication on discharge following an operation for hip fracture

  • The percent of people aged 50 and over receiving a community-dispensed bisphosphonate within six months of a hip fracture admission was 21 percent in 2014 and 2015. This is a significant reduction from 33 percent in 2012.
  • In 2015, five DHBs had less than 10 patients who received a bisphosphonate on discharge following hip fracture, compared with two DHBs in 2012.
  • There was variation between DHBs, ranging from 10 percent to 43 percent. Medicines dispensed in hospital are not included in the Atlas. This means DHBs who provide zoledronic acid (aclasta) to hospital patients will not have this use included in this indicator.

68 percent of people received Vitamin D medication on discharge following an operation for hip fracture

  • The percent of people aged 50 and over receiving community-dispensed vitamin D within six months of a hip fracture admission has not changed significantly since 2012.

Biphosphonate and Vitamin D dispensing by age

Percent Biphosphonate Vitamin D
50–64y 15.2 36.4
65–74 24.0 58.3
75–84 23.6 69.3
85y+ 19.6 73.6
Total 21.1 68.2

What questions might these data raise nationally?

  • Why do some DHBs have consistently lower or higher rates than the national average?

Background

The falls domain of the Atlas of Healthcare Variation gives clinicians, patients and providers an overview on the prevalence of falls in people aged 50 and over, including those treated in the community and in hospital. Admission rates for hip fracture are shown, and indicators on how these patients are managed, by district health board (DHB).

A fall is defined as ‘any unintentional change in position where the person ends up on the floor, ground or lower level; includes falls that occur while being assisted by others.[2]

The domain complements the work of the Australian & New Zealand Hip Fracture Registry, which is being progressively implemented across New Zealand public hospitals, together with the implementation of Fracture Liaison Services as per the Ministry of Health’s expectation.  These two initiatives are among a suite of initiatives forming part of a 'whole of system' approach to falls and fracture management for New Zealand.  This is part of a cross agency collaboration between the Commission, ACC and the Ministry of Health.

The Health Quality & Safety Commission's national programme, Reducing Harm from Falls, aims to reduce harm from falls in older people. The programme has worked from an evidence-base to promote practices and interventions that reduce the risk of falling, rate of falls and severity of injury, and also promote the best possible outcomes for those who have suffered harm related to a fall.

In 2013, falls in older people was the first focus of the Commission’s national patient safety campaign (Open for better care) with an emphasis on reducing harm from falls for older patients in hospital setting.

In 2015, April Falls activities supported the Open for better care patient safety campaign and promoted an integrated approach to falls in older people across health and social services. The falls domain of the Atlas is a critical foundation, because knowing your local and regional falls data is a key component of understanding how well services are integrated.

In 2017, the programme reinforces the need for a sustained focus on falls prevention through its 'Stand up to falls' April Falls theme. Significant achievements have been reported with a reduced number of in-hospital serious harm falls resulting in a fractured hip. However, we have a duty to remain vigilant in this high harm area to sustain the gains, and continue to improve outcomes for those in our care.

In your DHB area: know your data – what’s your plan?

The national programme, Reducing Harm from Falls, has recommended 10 priorities in an integrated approach to falls in older people and has provided an updated workbook 'From Atlas to Action' to help guide you in better understanding your local data and developing a plan to address any gaps identified in the priorities. 

Click here for the workbook 'From Atlas to Action'.

Data sources and method

Data for this Atlas domain were drawn from hospital inpatient (National Minimum Dataset) and outpatient (National Non-Admitted Patients Collection) collections, ACC, DHB Shared Services and the Pharmaceutical Collection.

The Pharmaceutical Collection contains claim and payment information from community pharmacists for subsidised dispensing. This collection does not allow for analysis of the patients’ condition or the effectiveness of the dose provided, so it was not possible to assess the appropriateness or otherwise of prescribing. Unsubsidised dispensing is not included in the analysis; nor does it indicate if people took the medicine.

The data are not age-standardised, although users can stratify it to see the impact of age on falls rates. You can view the Atlas comparing the age profile of the selected DHB with the national average here.

The methodology is provided here.

  • How do DHBs with similar populations compare? How much might these results be explained by differences in ethnic and gender composition?
  • Is there a correlation between availability of an orthogeriatric service and the prescription of bisphosphonates and vitamin D on discharge?
  • Is there a correlation between the availability of Fracture Liaison Service and the prescription of bisphosphonates and vitamin D on discharge?

A note about zoledronic acid

The expert advisory group convened by the Commission to develop this Atlas identified differences between DHBs as to whether they provide zoledronic acid (aclasta) to hip fracture patients in hospital or in the community. There can be a significant cost to patients to receive zoledronic acid in the community.

Read the Medsafe guideline on the use of zoledronic acid.

Recommended resources

Resources for consumers

  • Consumer Information on preventing falls at home and in hospital is here

Resources for providers

Hip fracture care

10 Topics in reducing harm from falls 

A set of evidence-based learning resources provides update on current best practice, covering issues in primary and secondary prevention of falls that will be raised in discussions about the Atlas data, eg:

Evidence Update

The national programme conducts an annual evidence review to make sure the resources produced (including the Falls 10 Topics) remain relevant and up to date for the sector. The ‘Just In’ Evidence review coincides with the April Falls 2017 focus, and can be found here.

 


References

  1. Morris JN, Belleville-Taylor P, Fries BE et al. 2011. interRAI Long-Term Care Facilities (LTCF) Assessment Form and User’s manual. Version 9.1, Australian Edition. Washington DC: interRAI. URL: http://catalog.interrai.org/LTCF-long-term-care-facilities-manual-australian external link
  2. Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group. 2014. Australian and New Zealand Guideline for Hip Fracture Care: Improving Outcomes in Hip Fracture Management of Adults. Sydney: Australian and New Zealand Hip Fracture Registry Steering Group.
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