Falls Atlas domain: falls in people aged 50 and over

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

Falls single map
Falls double map Consumer summary

 

Update with 2016 data

(Updated March 2018)

This Atlas has been updated with data from 2016.

Key messages

  • Of people aged 85 and over, 25 percent had at least one ACC claim due to a fall in 2016. 
  • 8.7 percent of people aged 85 and over were admitted to hospital for at least one night as a result of the fall in 2016.
  • The average length of stay for people aged 85 and over was 13.4 days in 2016.

Hip fracture

  • In 2016, 49 percent of all hip fractures following a fall in those aged over 50 were in those aged 85 and over. 85 and overs make up 5 percent of the total population aged 50 plus.
  • Women were twice as likely to fracture their hip than 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 where people normally live (DHB of domicile).

216,000 people aged 50 and over had an ACC claim for a fall-related injury
  • In 2016, 216,000 people aged 50 and over had one or more ACC claims for a fall-related injury accepted. 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 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. Claim rates varied 1.7-fold between DHBs.
  • One in four people aged 85 and over (20,800) had an accepted ACC claim for a fall-related injury. This equated to 56 ACC claims per day. Twenty-five percent of 85 and overs had two or more ACC claims in a year.
  • There was only a weak correlation between rates of ACC claims for falls and hospital admissions rates 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 16 times more likely to be admitted to hospital as a result.

Table 1: ACC claims, hospital attendances and hip fracture rates in 2016, by age group

Age band ACC claims, rate per 1000 (count) Hospital attendances, rate per 1000 (count) Hip fracture, rate per 1000 (count)
50–64 122 (106,000) 6.4 (5,560) 0.2 (230)
65–74 130.8 (52,700) 12.9 (5210) 1.2 (500)
75–84 171.1 (36,400) 36.4 (7,750) 5.6 (1,200)
85+ 249.1 (20,700) 102.6 (8,560) 21.8 (1,820)
Total 137.6 (216,000) 17.3 (27,090) 2.3 (3,750)
27,000 people attended hospital with a fall in 2016. Older people and women had higher admission rates.
  • In 2016, on average 17 per 1000 people aged 50 and over attended hospital after a fall, equating to approximately 27,000 people. This varied more than 1.8-fold.
  • Attendance rates increased significantly with age: those aged 85 and over had 8 times more attendances than those aged 65–74 and 16 times more attendances than those aged 50–64 years.
  • Admissions were 1.4 times higher in women. 
  • This indicator looks at how many people aged 50 and over attended or were admitted to hospital as a result of a fall, including emergency department attendances.
21,000 people admitted to hospital with a fall stayed more than a day.
  • In 2016, on average 13 per 1000 people aged 50 and over stayed more than one day in hospital after a fall 
  • This was 77 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 bed-days. Older people stayed longer than younger.
  • In 2016, on average, people aged 50 and over admitted to hospital after a fall stayed for 10 days. This ranged from 6.4 to 13 days.
  • People aged 85 and over stayed 2.7 times longer than those aged 50–64 years (average of 13.4 days compared with 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.
3,750 people were admitted with a hip fracture due to a fall in 2016; fracture rates were higher in women and older people.
  • In 2016, approximately 3750 people aged 50 and over were admitted with a hip fracture at an average rate of 2.4 per 1000. 
  • Rates increased significantly with age; 49 percent of hip fractures occurred in those aged 85 and over.
  • Women had many more fractured hips than men however these figures are not age-adjusted and in the 85 and over age group there are proportionately more women than men.
  • Hip fracture rates were higher in European/Other ethnic group than other ethnicities at all ages
  • Rates have not significantly changed since 2011.

Hip fracture rates per 1,000 population by age and ethnicity (2016)

Rate per 1000 Māori Pacific people Asian European/
Other
Total
50–64y 0.2 0.2 0.1 0.3 0.3
65–74 1.0 0.6 0.7 1.3 1.2
75–84 3.2 4.1 3.4 6.0 5.6
85y+ 12.3 11.8 12.1 22.6 22.0
Total 0.8 0.8 0.8 2.8 2.4

Time trends for those aged 85 and over

Data over the last three years for people 85-year and over shows that the upward trend in most indicators reported in 2015 appears to have levelled, the only significant difference between years was that ACC claims dropped significantly between 2014 and 2016.

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
2014 283.4 89.2 15.5 23.3
2015 283.4 87.2 14.0 23.1
2016 264.2 86.5 13.4 21.8

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

68 percent of people with a hip fracture are operated on the same or next day of admission in 2016.
  • In 2016, on average, 68 percent of people with a hip fracture and aged 50 and over were operated on the same or next day of admission. 
  • 79 percent of those aged 50–64 were operated on the same or next day, compared with 67 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] that surgery be 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. 
  • A technical error in previous versions meant that the percent of people operated within the time-frame was over-estimated. Correcting this error has reduced the mean from 76 percent in 2015 to 69 percent in 2015 in this update. Historic data has been replaced for this indicator.
21 percent of people received bisphosphonate medication on discharge following an operation for hip fracture in 2016.
  • 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 2015 and 2016. This is a significant reduction from 36 percent in 2012. 
  • In 2016, four 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 6 percent to 49 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.
  • Around 11 percent of people with a FNOF in 2016 had a fall-related admission in the year prior. Of these, 19 percent were dispensed a bisphosphonate in the year prior to their fracture.
66 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.

Table: Bisphosphonate and vitamin D dispensing by age (2016)

Percent Biphosphonate Vitamin D
50–64y 21.9 47.4
65–74 29.2 59.1
75–84 25.3 69.0
85y+ 16.1 68.8
Total 21.3 66.1

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 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.

The theme for April Falls 2018 is Live Stronger For Longer, and is aimed at supporting and promoting the New Zealand integrated approach to falls and fracture prevention. Find out more about Live Stronger For Longer here.  Visit ACC’s website to order free Live Stronger For Longer resources. More information and resources are also available on the falls pages on the Commission website.  

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.

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'.

Recommended resources

Resources for consumers

  • Consumer Information on preventing falls at home and in hospital can be found on the Commission’s website here external link and on the Live Stronger for Longer website here external link

Resources for providers

Hip fracture care

10 Topics in reducing harm from falls 

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

Evidence update

The national programme conducts an annual evidence review to make sure that the resources that have been produced (including the Falls 10 Topics) remain relevant and up to date for the sector. The evidence review to coincide with the April Falls 2018 focus, 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.

Last updated 20/06/2018