Fall-related hospitalization and facility costs among residents of institutions providing long-term care

AIoT-Based Ergometer for Physical Training in Frail Elderly with Cognitive Decline: A Pilot Randomized Control Trial

Purpose

Reduced physical activity is reported in the elderly, especially in institutional residents. Institutionalized older adults exhibit a high prevalence of frailty. In this work, we developed an artificial intelligence of things (AIoT)-based feedback assistive strengthening ergometer (AIFASE), for the physical strengthening of the elderly with intelligent assistance.

Methods

We conducted a 12-week intervention in a long-term care facility. In total, 16 participants (84.38 ± 6.0 years; 4 males and 12 females) were recruited with 1:1 randomization of exercise to control groups. The muscle strength of the lower extremities, timed up and go test (TUG), and Short-form Physical Performance Battery (SPPB) of the participants were measured. The AIFASE system allows the clinical staff to record the personal physical performance of the elderly and generates personalized exercise prescriptions accordingly. AIFASE also displays the current usage status of all ergometers and the users’ physiological conditions. The algorithms were developed to generate warning alerts when the training workload was too large by personal physiological detection. AIFASE automatically customized the exercise prescription according to the user’s exercise performance.

Results

After a 12-week AIFASE intervention, the intervention group exhibited significant improvements in the strength of the hip flexor, Semi-Tandem Stand, and Tandem Stand.

Conclusion

In this study, we developed an AIoT ergometer that delivered customized physical training prescriptions to improve the physical performance of long-term care facility residents. We believe that the application of AIFASE will help improve the quality of institutional care.

A Multi-Level Analyses of Charges and Cost of Fall-Related Hospitalizations Among Older Adults: Individual, Hospital, and Geospatial Variation

The growing population of older adults has attracted concern from policymakers due in part to the fact that they are at higher risk of costly and potentially injurious falls. Responding to this concern, this study investigated fall-related hospitalizations among those aged 65 and older. Hospitalizations rose from 49,299 to 58,931, with charges and costs (estimated based on charges) increasing from $2.5 billion to $3.6 billion and under $900 million to over $1.1 billion, respectively. The intraclass correlation coefficients from linear mixed-effect models (with charges and costs serving as dependent variables) indicated differences in hospitals accounted for nearly half or more of medical cost variation among older adults suffering a fall-related hospitalization. Nonmetropolitan residence, being aged 65-69 (versus older), and higher risk-of-mortality on admission indicated higher costs. Identifying trends of fall-related hospitalizations over time allows for key stakeholders to not only track the burden of falls among older adults but to also use this information to attract funding for fall prevention strategies from policy makers at various levels (e.g., locally, at the state). Further, identifying characteristics of individuals (e.g., age, race, sex) and places (e.g., rural areas) that carry a higher relative cost can serve to inform the targeted allocation of finite resources including local, state, or federal funding, but also existing evidence-based practices such as community and clinical interventions.

Cost-effectiveness of droxidopa in patients with neurogenic orthostatic hypotension: post-hoc economic analysis of Phase 3 clinical trial data

OBJECTIVE

Falls are associated with neurogenic orthostatic hypotension (nOH) and are an economic burden on the US healthcare system. Droxidopa is approved by the US FDA to treat symptomatic nOH. This study estimates the cost-effectiveness of droxidopa vs standard of care from a US payer perspective.

METHODS

A Markov model was used to predict numbers of falls and treatment responses using data from a randomized, double-blind trial of patients with Parkinson's disease and nOH who received optimized droxidopa therapy or placebo for 8 weeks. The severity of falls, utility values, and injury-related costs were derived from published studies. Model outcomes included number of falls, number of quality-adjusted life-years (QALYs), and direct costs. Incremental cost-effectiveness ratios (ICERs) were calculated. Outcomes were extrapolated over 12 months.

RESULTS

Patients receiving droxidopa had fewer falls compared with those receiving standard of care and gained 0.33 QALYs/patient. Estimated droxidopa costs were $30,112, with estimated cost savings resulting from fall avoidance of $14,574 over 12 months. Droxidopa was cost-effective vs standard of care, with ICERs of $47,001/QALY gained, $24,866 per avoided fall with moderate/major injury, and $1559 per avoided fall with no/minor injury. The main drivers were fall probabilities and fear of fall-related inputs.

LIMITATIONS

A limitation of the current study is the reliance on falls data from a randomized controlled trial where the placebo group served as the proxy for standard of care. Data from a larger patient population, reflecting 'real-life' patient use and/or comparison with other agents used to treat nOH, would have been a useful complement, but these data were not available.

CONCLUSION

Using Markov modeling, droxidopa appears to be a cost-effective option compared with standard of care in US clinical practice for the treatment of nOH.

What happens to patients when they fracture their hip during a skilled nursing facility stay?

OBJECTIVES

To characterize outcomes of patients experiencing a fall and subsequent hip fracture while in a nursing home receiving skilled nursing facility (SNF) services.

DESIGN

Observational study.

PARTICIPANTS

Short-stay fee-for-service Medicare beneficiaries who experienced their first hip fracture during an SNF stay.

MEASUREMENTS

Outcomes measured in the 90 days after the hip fracture hospitalization included community discharge (with a stay in the community <30 days), successful community discharge (in the community ≥30 days), death, and institutionalization.

RESULTS

Between 1999 and 2007, 27,305 hip fractures occurred among short-stay nursing home patients receiving SNF care. After surgical repair of the hip fracture, 83.9% of these patients were discharged from the hospital back to an SNF, with most (99%) returning to the facility where the hip fracture occurred. In the first 90 days after hospitalization, 24.1% of patients died, 7.3% were discharged to the community but remained fewer than 30 days, 14.0% achieved successful community discharge, and 54.6% were still in a health care institution with almost 46.4% having transitioned to long-term care.

CONCLUSION

SNF care aims to maximize the short-stay patient's independence and facilitate a safe community transition. However, experiencing a fall and hip fracture during the SNF stay was a sentinel event that limited the achievement of this goal. There is an urgent need to ensure the integration of fall prevention into the patient's plan of care. Further, falls among SNF patients may serve as indicator of quality, which consumers and payers can use to make informed health care decisions.

Cost per fall: a potentially misleading indicator of burden of disease in health and residential care settings

RATIONALE

Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person.

METHOD

Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study.

RESULTS

The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year).

CONCLUSIONS

This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use.

Factors associated with falls among older adults living in institutions

Background

Falls have enormous impact in older adults. Yet, there is insufficient evidence regarding the effectiveness of preventive interventions in this setting. The objectives were to measure the frequency of falls and associated factors among older people living institutions.

Methods

Data were obtained from a survey on a probabilistic sample of residents aged ≥65 years, drawn in 1998-99 from institutions of Madrid (Spain). Residents, their caregivers, and facility physicians were interviewed. Fall rates were computed based on the number of physician-reported falls in the preceding 30 days. Adjusted rate ratios were computed using negative binomial regression models, including age, sex, cognitive status, functional dependence, number of diseases, and polypharmacy.

Results

The final sample comprised 733 residents. The fall rate was 2.4 falls per person-year (95% confidence interval [CI], 2.04-2.82). The strongest risk factor was number of diseases, with an adjusted rate ratio (RR) of 1.32 (95% CI, 1.17-1.50) for each additional diagnosis. Other variables associated with falls were: urinary incontinence (RR = 2.56 [95% CI, 1.32-4.94]); antidepressant use (RR = 2.32 [95% CI, 1.22-4.40]); arrhythmias (RR = 2.00 [95% CI, 1.05-3.81]); and polypharmacy (RR = 1.07 [95% CI, 0.95-1.21], for each additional medication). The attributable fraction for number of diseases (with reference to those with ≤ 1 condition) was 84% (95% CI, 45-95%).

Conclusions

Number of diseases was the main risk factor for falls in this population of institutionalized older adults. Other variables associated with falls, probably more amenable to preventive action, were urinary incontinence, antidepressants, arrhythmias, and polypharmacy.

Virtual slides

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Ensuring vitamin D supplementation in nursing home patients--a quality improvement project

Randomized controlled trials have shown that adequate vitamin D supplementation in nursing home (NH) residents reduces the rates of falls and fractures. In our NH, review of medication administration records of all patients (n = 101) revealed that only 34.6% of the patients were currently prescribed adequate doses of vitamin D, revealing a need for intervention. We designed a Quality Improvement (QI) project with the objective of improving the vitamin D prescription rate in our NH. We used the Plan-Do-Study-Act (PDSA) approach to implement this QI project. Patients not currently prescribed an adequate dose of vitamin D were identified and started on a daily dose of 800 IU of vitamin D. Additionally, patients who were experiencing falls while on an adequate dose of vitamin D for 3 months were examined for the possibility of vitamin D deficiency and were started on 50,000 IU of vitamin D per week for 12 weeks if they were found to be vitamin D-deficient based on blood levels of 25-hydroxy-vitamin D below 30 ng/mL. We found that with several PDSA cycles over a period of 5 months, the prescription rate for vitamin D was increased to 86%, surpassing our initial goal of 80%. In conclusion, we found that a multidisciplinary QI program utilizing multiple PDSA cycles was effective in reaching target prescription rates for vitamin D supplementation in a population of NH patients.

Mining geriatric assessment data for in-patient fall prediction models and high-risk subgroups

Background

Hospital in-patient falls constitute a prominent problem in terms of costs and consequences. Geriatric institutions are most often affected, and common screening tools cannot predict in-patient falls consistently. Our objectives are to derive comprehensible fall risk classification models from a large data set of geriatric in-patients' assessment data and to evaluate their predictive performance (aim#1), and to identify high-risk subgroups from the data (aim#2).

Methods

A data set of n = 5,176 single in-patient episodes covering 1.5 years of admissions to a geriatric hospital were extracted from the hospital's data base and matched with fall incident reports (n = 493). A classification tree model was induced using the C4.5 algorithm as well as a logistic regression model, and their predictive performance was evaluated. Furthermore, high-risk subgroups were identified from extracted classification rules with a support of more than 100 instances.

Results

The classification tree model showed an overall classification accuracy of 66%, with a sensitivity of 55.4%, a specificity of 67.1%, positive and negative predictive values of 15% resp. 93.5%. Five high-risk groups were identified, defined by high age, low Barthel index, cognitive impairment, multi-medication and co-morbidity.

Conclusions

Our results show that a little more than half of the fallers may be identified correctly by our model, but the positive predictive value is too low to be applicable. Non-fallers, on the other hand, may be sorted out with the model quite well. The high-risk subgroups and the risk factors identified (age, low ADL score, cognitive impairment, institutionalization, polypharmacy and co-morbidity) reflect domain knowledge and may be used to screen certain subgroups of patients with a high risk of falling. Classification models derived from a large data set using data mining methods can compete with current dedicated fall risk screening tools, yet lack diagnostic precision. High-risk subgroups may be identified automatically from existing geriatric assessment data, especially when combined with domain knowledge in a hybrid classification model. Further work is necessary to validate our approach in a controlled prospective setting.

Comparative effectiveness of implementing evidence-based education and best practices in nursing homes: effects on falls, quality-of-life and societal costs

OBJECTIVES

The aim was to conduct a comparative effectiveness research study to estimate the effects on falls, negative affect and behavior, and the associated societal costs of implementing evidence-based education and best practice programs in nursing homes (NHs).

DESIGN

A quasi-experimental design, a variant of a cluster randomized trial of implementation research examining transfer of research findings into practice, was used to compare outcomes among three groups of residents in 15 nursing homes per group.

METHODS

Forty-five NHs participated in one of three conditions: (1) standard training, (2) training and implementation modules provided to facility staff, or (3) staff training and implementation modules augmented by surveyor training. After application of exclusion and matching criteria, nursing homes were selected at random within three regions of New York State. Outcomes were assessed using medical records and the Minimum Data Set (MDS).

RESULTS

The main finding was of a significant reduction of between 5 and 12 annual falls in a typical nursing home. While both intervention groups resulted in fall reduction, the larger and significant reduction occurred in the group without surveyor training. A significant reduction in negative affect associated with training staff and surveyors was observed. Net cost savings from fall prevention was estimated.

CONCLUSIONS

A low cost intervention targeting dissemination of evidence-based best practices in nursing homes can result in the potential for fall reduction, and cost savings.

Methodological issues in fall prevention research involving older adults in long-term care facilities

The purpose of this study was to conduct a systematic review of the current fall prevention literature, examining methodological issues resulting from variations in fall definitions, methods of data collection, and standards for reporting fall rates in studies involving older adults in long-term care settings. This systematic review used the five stages of Whittemore and Knafl's review methodology to extract data from the databases, summarize, and synthesize the findings of the 10 studies included. The Critical Appraisal Skill Program checklist for randomized controlled trials criteria was used to appraise the methodological quality of the studies. Inconsistencies in fall definitions, methods of data collection, and standards for reporting fall rates were apparent across the studies reviewed. Standardized approaches to defining falls, collecting data, and reporting fall rates are necessary to interpret, make comparisons among, and disseminate the findings of studies.

Preventing falls and fractures in long-term care

The prevalence of falls and associated injuries increases with age and dependency. The highest occurs among individuals living in long-term care institutions. Preventing falls results in reduced physical and psychological morbidity as well as having cost-saving implications. This review explores both uni- and multifactorial approaches to reducing fall rates and risk in individuals in long-term care, as well as highlighting the differences in this group from community-dwelling individuals.

In home or at home? How collective decision making in a new care facility enhances social interaction and wellbeing amongst older adults

Benevolent, long-term care can threaten older adults' sense of autonomy in a residential home environment. Increasing reliance on a hotel style of living has been seen to erode social identity, life satisfaction and even survival or lifespan. Drawing on evidence from both gerontological and social psychological literature, this paper examines the links between the empowerment of residents and their subsequent quality of life in the context of a move into a new care facility in a medium-sized town in South-West England. A longitudinal experiment was conducted during which 27 residents on one floor of a new facility were involved in decisions surrounding its décor, while those on another floor were not. The residents' attitudes and behaviour were monitored at three points over five months (four weeks pre-move, four weeks post-move, and four months post-move). Consistent with the social identity literature, members of the empowered group reported increased identification with staff and fellow residents in the new home, displayed enhanced citizenship, reported improved wellbeing, and made more use of the communal space. Moreover the staff found the empowered residents to be more engaged with their environment and the people around them, to be generally happier and to have better health. These patterns were observed one month after the move and remained four months later. Some implications for theory and practice are discussed.

Cost of falls in old age: a systematic review

SUMMARY

The purpose of this study was to review the evidence of the economic burden of falls in old age. This review showed that falls are a relevant economic burden. Efforts should be directed to fall-prevention programmes.

INTRODUCTION

Falls are a common mechanism of injury and a leading cause of costs of injury in the elderly. The purpose of this study was to review for the first time the evidence of the economic burden caused by falls in old age.

METHODS

A systematic review was conducted in the databases of PubMed, of the Centre for Reviews and Dissemination and in the Cochrane Database of Systematic Reviews until June 2009. Studies were assessed for inclusion, classified and synthesised. Costs per inhabitant, the share of fall-related costs in total health care expenditures and in gross domestic products (GDP) were calculated. If appropriate, cost data were inflated to the year 2006 and converted to US Dollar (USD PPP).

RESULTS

A total of 32 studies were included. National fall-related costs of prevalence-based studies were between 0.85% and 1.5% of the total health care expenditures, 0.07% to 0.20% of the GDP and ranged from 113 to 547 USD PPP per inhabitant. Direct costs occurred especially in higher age groups, in females, in hospitals and long-term care facilities and for fractures. Mean costs per fall victim, per fall and per fall-related hospitalisation ranged from 2,044 to 25,955; 1,059 to 10,913 and 5,654 to 42,840 USD PPP and depended on fall severity. A more detailed comparison is restricted by the limited number of studies.

CONCLUSION

Falls are a relevant economic burden to society. Efforts should be directed to economic evaluations of fall-prevention programmes aiming at reducing fall-related fractures, which contribute substantially to fall-related costs.