Osteoporosis International

, Volume 23, Issue 5, pp 1513–1519

The cost of fall related presentations to the ED: A prospective, in-person, patient-tracking analysis of health resource utilization

Authors

  • J. C. Woolcott
    • Faculty of Pharmaceutical SciencesUniversity of British Columbia
    • Collaboration for Outcomes Research and Evaluation
    • Centre for Health Evaluation and Outcome SciencesProvidence Health Research Institute
  • K. M. Khan
    • Centre for Hip Health and MobilityVancouver Coastal Research Institute
    • Department of Family PracticeUniversity of British Columbia
  • S. Mitrovic
    • Faculty of MedicineUniversity of British Columbia
  • A. H. Anis
    • Centre for Health Evaluation and Outcome SciencesProvidence Health Research Institute
    • School of Population and Public HealthUniversity of British Columbia
    • Faculty of Pharmaceutical SciencesUniversity of British Columbia
    • Collaboration for Outcomes Research and Evaluation
    • Centre for Health Evaluation and Outcome SciencesProvidence Health Research Institute
    • Centre for Health Evaluation and Outcome Sciences
Original Article

DOI: 10.1007/s00198-011-1764-1

Cite this article as:
Woolcott, J.C., Khan, K.M., Mitrovic, S. et al. Osteoporos Int (2012) 23: 1513. doi:10.1007/s00198-011-1764-1

Abstract

Summary

We prospectively collected data on elderly fallers to estimate the total cost of a fall requiring an Emergency Department presentation. Using data collected on 102 falls, we found the average cost per fall causing an Emergency Department presentation of $11,408. When hospitalization was required, the average cost per fall was $29,363.

Introduction

For elderly persons, falls are a major source of mortality, morbidity, and disability. Previous Canadian cost estimates of seniors' falls were based upon administrative data that has been shown to underestimate the incidence of falls. Our objective was to use a labor-intensive, direct observation patient-tracking method to accurately estimate the total cost of falls among seniors who presented to a major urban Emergency Department (ED) in Canada.

Methods

We prospectively collected data from seniors (>70 years) presenting to the Vancouver General Hospital ED after a fall. We excluded individuals who where cognitively impaired or unable to read/write English. Data were collected on the care provided including physician assessments/consultations, radiology and laboratory tests, ED/hospital time, rehabilitation facility time, and in-hospital procedures. Unit costs of health resources were taken from a fully allocated hospital cost model.

Results

Data were collected on 101 fall-related ED presentations. The most common diagnoses were fractures (n = 33) and lacerations (n = 11). The mean cost of a fall causing ED presentation was $11,408 (SD: $19,655). Thirty-eight fallers had injuries requiring hospital admission with an average total cost of $29,363 (SD: $22,661). Hip fractures cost $39,507 (SD: $17,932). Among the 62 individuals not admitted to the hospital, the average cost of their ED visit was $674 (SD: $429).

Conclusions

Among the growing population of Canadian seniors, falls have substantial costs. With the cost of a fall-related hospitalization approaching $30,000, there is an increased need for fall prevention programs.

Keywords

CostEconomic analysisFallOlder adults

Introduction

Fall-related fractures in seniors are a major source of mortality, morbidity, and disability [1, 2]. Among persons ≥65 years of age, over 85% of all injury-related hospitalizations are due to falls [3]. Two recent systematic reviews which included studies completed in the United States, Europe, New Zealand and Australia reported that the total cost per fall ranged from $10,749 to $26,676 (2009 United States Dollars) [4, 5]. The increasing population of seniors [6] means total health care costs will increase dramatically over the coming decades. There is a need for accurate estimates of this burden for planning purposes and to help determine how to allocate resources for preventive efforts.

Fall-related costs have traditionally been estimated from administrative data. Thirty-two of 33 studies reviewed recently [4, 5] relied on administrative data to estimate fall-related costs. Although administrative datasets can provide information on large cohorts of individuals, their limitations include estimation errors from coding mistakes, and misclassification of events [7, 8]. Also, many studies using administrative data use charge data as a proxy for cost. However, charges for care and procedures often differ greatly from the true cost and are not an accurate measure of economic burden [9].

Prospective data capture is the preferred method for identifying falls [10] as the proximity of researchers to the patients in this setting provides greater confidence that the definition of a “fall” is consistently applied [4, 5, 10]. This fall definition is: “an unexpected event in which the participants come to rest on the ground, floor or lower level” [10].

Thus, better estimates of the cost of falls requires more detailed information on costs that are specific to the type of fall, postfall diagnoses and care provided in specific settings [5]. These detailed estimates of the cost per fall would complement global estimates provided by larger administrative database studies.

In this prospective study, we identified elderly persons who presented to the Vancouver General Hospital (VGH) Emergency Department (ED) due to a fall between October 31, 2007 and November 1, 2008. We prospectively collected data on their health care resource utilizations to estimate the total cost of a fall requiring an ED presentation in Vancouver, British Columbia (BC), Canada.

Methods

Study design and setting

Our study was a prospective cohort study of elderly fallers. We identified and recruited elderly persons presenting to the VGH ED as a result of a fall between October 31, 2007 and November 1, 2008 who met our study inclusion criteria. Although, the VGH Emergency Department accepts patients 24 h a day, 365 days a year, we had insufficient resources to have researchers attend the ED continuously to recruit, and monitor patients. After an assessment of arrival times taken from previously completed administrative database studies completed on VGH fallers [11, 12], we spread our recruitment efforts such that we would capture day and evening shifts in proportion to the rate at which falls had presented in prior years. Thus, as 53% of senior fall presentations occurred between 8:00 am and 4:00 pm in the year leading up to our study, we allocated 53% of our data collection efforts to day shifts. This planning aimed to avoid systematic bias as much as possible.

Participants were 70 years of age or older, were able to speak and read English, and had presented to the VGH ED as result of a fall. We excluded fallers who had reported a physician diagnosis of vision impairment that precluded their ability to read the consent form or cognitive impairment as defined by a previous diagnosis of dementia, Alzheimer's disease or Mini Mental State Exam Score of less than 24. Patients who had received care for their fall prior to presenting to the VGH ED, including patients who had been referred to the ED by a general practitioner or family physician, were also excluded from the study. Patients were identified as fallers using the ProFane fall definition [10].

Patient recruitment and ethical approval

Upon presentation to the ED, demographic information and injury type are routinely reported into the ED census database. The ED census was monitored by an investigator (JCW) or research assistant to prospectively identify potential participants and, upon identification of a faller, the ED chart was inspected for exclusion criteria. Potential participants who met the inclusion criteria were subsequently approached for informed consent. This study received ethics approval from the University of British Columbia Clinical Research Ethics Review Board (approval number H06-03142).

Data collection

Health care utilization data were collected on all care received from time of presentation until discharge. Discharge refers to one of three events: discharge from the ED (for patients discharged without hospital admission), discharge from the hospital after admission through the ED post fall (for patients admitted to the hospital), or discharge from a rehabilitation facility (for patients referred for additional care for fall-related injuries after hospital admission). Data collected included all laboratory and radiology investigations (including x-ray, ultrasound, and computerized tomography), as well as reports from specialist consultations, surgical procedures and duration of hospital stay. ED length of stay (LOS) was measured in minutes recorded on case report forms and ED Census data. Hospital and rehabilitation facility length of stay were measured in days as recorded on the patient's medical records.

Health care use and cost data

A unit cost was assigned for each component of resource utilization. In estimating the component costs of resource utilization, we followed the methods accepted by the Canadian Agency for Drugs and Technologies in Health Document for the Costing Process [13]. Unit cost estimates are shown in Table 1 [1418].
Table 1

Unit costs of health resource utilizations

Item

Cost

Emergency Department care [17]

$47.15 per hour

In-hospital bed cost [17]

$619.03 per day

Rehabilitation hospital cost [17]

$473.74 per day

Physiotherapy [18]

$60.59 per consultation

Occupational therapist [18]

$60.59 per consultation

Orthopedic consultation [15]

$156.78 per consultation

Neurological consultation [15]

$169.21 per consultation

Trauma consultation [15]

$161.09 per consultation

Geriatrician consultation [15]

$170.46 per consultation

Family practice consultation [15]

$161.09 per consultation

Hospitalist consultation [15]

$89.58 per consultation

Psychiatry consultation [15]

$288.73 per consultation

Plastics consultation [15]

$72.33 per consultation

Internal medicine consultation [15]

$161.09 per consultation

Cardiology consultation [15]

$166.15 per consultation

Ophthalmology consultation [15]

$89.58 per consultation

Rheumatology consultation [15]

$163.24 per consultation

Statistical analysis

Following the recommendations published by Baladi et al. [13], cost per fall estimates were calculated using the formula \( {C_j} = \sum\nolimits_{{i = 1}}^k {{\beta_i}{\chi_i}} \) for j = 1 to 100, where Cj is the cost of the fall, βi refers to the total utilization of each health resource and χi refers to the unit cost of each health resource utilization. The Canadian Consumer Price Index for Health and Personal Care was used to adjust costs to reflect 2009 Canadian dollars [19]. Given the high incidence of fractures, particularly hip/pelvic fractures, we also estimated cost per fracture by modifying the above formula.

To estimate whether our sample of recruited participants was representative of all elderly fallers who presented to the VGH Emergency Department during the year of recruitment (October 31, 2007–November 1, 2008), we compared our sample patients with data available from the VGH ED Census for all elderly fallers. Key variables we compared were age, sex, arrival method, discharge location, diagnosis and duration of time in the ED. For continuous variables (age, duration of time in ED), we completed t-tests to test our hypothesis that the study population did not differ; for categorical variables (proportion female, arrival mechanism, diagnosis, and discharge location), we completed chi-square testing.

Data were analyzed using Microsoft Access 2003 and SAS 9.1 software.

Sensitivity analysis

To assess variability in cost per fall between Canadian provinces, we repeated the analysis above using comparable unit cost data from the Alberta Health Care Insurance Plan [2022]. Like British Columbia's, Alberta's health care system is publically funded; however, there are differences between the two systems in unit costs for procedures, interventions, and hospital care.

Results

Participant demographics and characteristics of care

From November 2007 to November 2008, there were 70,251 visits to the VGH ED. Among all visits by persons ≥70 years of age (n = 7,764), 1,484 (19%) were fall-related. Five hundred and ninety-four of the fall presentations during this period were ineligible due to patients' cognitive impairment (n = 309), inability to read or speak English (n = 256), or visual impairment (n = 63). Similarly, due to multiple fallers receiving treatment in the ED at the same time, 87 individuals could not be recruited due to the fallers either receiving care before they could be approached to participate in the study or because the patients were in different areas of the ED not allowing data to be accurately collected from more than one patient at a time. One hundred and eighty-eight individuals who met the eligibility criteria were invited to participate in the study by either JCW or SM with 99 participants consenting, representing 101 falls.

Among our study participants, the average age was 82.5 years of age, 74% were female. Ninety-four percent of study participants reported having at least one chronic condition, and participants reported currently taking five (mean) prescription medications. Table 2 outlines patient demographics and the characteristics of the care in the ED of study participants. Table 2 also provides descriptive characteristics of all elderly fallers who presented to the VGH ED during the period of recruitment. There were no differences (p > 0.05) between our sample and the registry of patients who presented over the entire year in terms of age, total time in the ED, total time spent in the ED prior to being discharged to community, and total time spent in the ED prior to being admitted to hospital.
Table 2

Demographics of fallers

Characteristic/source of data

Study participants (n = 99)

Elderly fallers presenting to VGH ED (Oct. 31, 2007–Nov. 1, 2008) (n = 1484)

Salter et al. [11] (n = 58)

ProFET trial [23] (n = 397)

Mean age in years (standard deviation)

82.5 (6.2)

83.7 (7.1)*

78.5 (5.7)

78.2 (7.5)

Female n (%)

73 (74%)

1062 (71%)*

34 (63%)

269 (68%)

Arriving via ambulance n (%)

66 (66%)

1021 (69%)*

Not available

Not available

Admitted to hospital n (%)

37 (37%)

578 (39%)*

Not available

Not available

Diagnosed with a fracture n (%)

33 (33%)

464 (31%)*

Not available

Not available

Mean total time spent in the ED in minutes (SD)

479 (404.8)

453 (428.5)

Not available

Not available

Mean total time spent in the ED in minutes (SD) for hospitalized patients

808 (489.5)

773 (511.3)*

Not available

Not available

Mean total time spent in the ED in minutes (SD) for patients discharge to community

283 (151.1)

304 (203.1)*

223 (138.5)

Not available

*p > 0.05

Among our participants, the most common injuries were fractures (33/101 = 33%) and lacerations (11/101 = 11%). Fractures of the hip/pelvis (18/33 = 55%), upper body (12/33 = 36%) and face (2%). Twenty-seven participants (27%) required a surgical procedure during their ED visit prior to discharge home (n = 6) or during their in-hospital stay (n = 21).

More than a third of participants required admission to hospital (38/99 = 38%). Among participants who were hospitalized, the average length of stay in hospital was 19 days (SD: 17 range 2–69). Of hospitalized participants, 23/38 or 61% were discharged to a rehabilitation facility, where the mean length of stay was 39 days (SD: 20).

Cost of care

The total cost of care for the 101 falls was $1,152,252. The mean cost of a fall resulting in an ED presentation was $11,408 (SD: $19,655). For fallers admitted to the hospital, costs incurred during their in-hospital stay were responsible for 70% of the total cost. Among those admitted to the hospital, the average total cost was $29,363 (SD: $22,661). An extrapolation to the total number of fall-related ED visits at VGH ED (n = 1,484) yields an estimated total cost of ED care for falls of $16.9 million for the 12 months from October 31, 2007 through to and including November 1, 2008.

Table 3 provides costs specific to health care resources consumed in the ED. The total cost of ED care for the 101 falls sustained by participants was $98,213, (mean cost of ED care per fall of $972, SD: $591, range: $56–$2519). Among falls that did not require admission to hospital (63/101 = 62%), the mean cost of ED care was $674 (SD: $429). Among the 33 participants whose falls caused a fracture, their total costs of care were $777,356 with an average cost of care of $23,556 (SD: $25,955).
Table 3

Costs of ED care

Variable

Mean

Range

Standard deviation

Total cost of x-rays in ED (n = 101)

$83

$0–498

$68

Total cost of blood work in ED (n = 101)

$45

$0–148

$42

Cost of specialist consultations (n = 49)

$156

$72–170

$18

Total cost of ED care (n = 101)

$972

$56–2519

$591

Total cost of ED for d/c to community (n = 63)

$673

$56–1719

$429

Total cost of ED care for hospitalized (n = 38)

$1,490

$461–2519

$462

Subgroup analysis of fallers suffering a hip fracture

As noted above, hip fractures were identified as the most common fracture. As well, hip fracture was the most common reason for hospitalization (18/38 = 47%). Among fallers who had suffered a hip fracture, their length of stay in hospital was, on average, 24 days (SD: 17). All those with a hip fracture required surgery and 10 (56%) were required to stay in a rehabilitation hospital. The mean cost for a fall-related hip fractures were $39,507 (SD: $17,932). Fig. 1 shows the component costs of our base case model and subgroups.
https://static-content.springer.com/image/art%3A10.1007%2Fs00198-011-1764-1/MediaObjects/198_2011_1764_Fig1_HTML.gif
Fig. 1

The total estimated cost per fall from our base case model and subgroups

Sensitivity analysis

Following a similar costing methodology using unit cost data from Alberta, we estimated the mean cost of fall resulting in an ED visit to cost $11,959. For seniors hospitalized as result of their fall, the mean cost of in-hospital procedures, consultation, x-rays and laboratory tests was $31,856. The estimated mean cost of a fracture was $25,403, while the cost of a hip fracture was $42,231.

Discussion

Over a 12-month period, we prospectively collected data on 101 falls resulting in an Emergency Department visit. Using the costing methodologies recommended by the Canadian Agency for Drug and Technology in Health [13], we found the mean cost per fall to exceed $11,000. Similar to previously completed cohort studies in a population of fallers presenting to the ED, almost 40% of fallers were hospitalized due to the injuries suffered as result of a fall [23]. Our findings are the first Canadian estimates of the costs of a fall-related ED visit and they are consistent with other international estimates [4, 5].

Before discussing the implications of these findings, it is important that we address the question ‘are these 101 fallers representative of elderly fallers in a major urban center or might there be a substantial sampling bias?’ We attempted to ‘sample’ fallers over the year by targeting data collection in the appropriate day/night shift proportion that accurately reflected when fallers attended the ED the year before. Our recruitment rate when we were in attendance (‘open for business’) was 54%, which is comparable with other studies in this setting [23, 24].

Importantly, we compared our sample of 101 patients with other samples of ‘senior emergency department fallers’ in three ways. To preview the bottom line, the data for our sample, fell within one confidence interval of the data for the three comparison groups. Specifically, we compared the sample against (a) all senior fallers who presented to the VGH ED in 2008, (b) a sample of 58 consecutive fallers recruited at the VGH ED in 2003, [11] and (c) a highly cited large RCT that recruited senior fallers in the UK [23]. We saw no statistical differences between our recruited population and the global population of elderly fallers to the VGH ED in 2008/2009. Also, when we compare the available variables of Salter et al. [11] and Close et al. [23] to our recruited population, we see no noticeable differences in age, gender, arrival method, admission rates, and time spent in the ED.

We also note that the average costs in our Canadian province, British Columbia, were comparable to those reported in the neighboring province, Alberta, which has an essentially similar health delivery system.

Although our study focused only on the direct medical costs of falling, the nonmedical costs of falls—including costs due to long-term care admissions, household changes, modifications to lifestyle and activities for both elderly persons who have fallen and their caregivers—are likely substantial and would significantly increase the total costs of a falls [25].

For those falls that resulted in a hip fracture (17.8%), their associated direct medical cost was $39,507. Using administrative data on hip fractures among seniors >85 years of age in Ontario, Wiktorowicz et al. [26] estimated the 1-year cost of a hip fracture. Their estimate, which included both direct and indirect costs, was $28,977 [26]. Our estimate included only the costs of in-hospital and rehabilitation care and did not account for any indirect costs or costs of care after discharge from hospital or rehabilitation facility. By excluding the indirect costs and only estimating the cost of in-hospital care, we believe ours to be a conservative estimate of the cost of fall-related hip fractures. These hip fracture data are independent of any potential ‘sampling bias’ and have important implications for governments anticipating the economic burden of hip fractures. We appreciate that costs of medical conditions vary in different countries so our data will not generalize outside of Canada. Nevertheless, the finding that the prospectively collected, validated costs were 36% greater than the widely quoted ‘cost’ in our country may be of interest to health economists and policy makers in other countries where hip fracture is a major cost driver.

Our study has several strengths. The major one is in the collaboration among health economists, clinical researchers, and ED staff. This allowed us (JCW/SM) to personally track patients through the ED to accurately capture costs prospectively and in real-time for each participant. This meant we captured the individual care received by each senior faller including investigations, procedures, consultations, and length of stay. As a result, rather than extrapolating the care and costs of care from Case Mix Group data or Resource Intensity Weight data, we were able to microcost according to the care received by each participant. This costing approach used the VGH fully allocated cost model that is designed specifically for use in this type of detailed costing estimates [17].

In addition to these strengths on the economics element, our clinical partnership meant we used the accepted fall definition [10]—again, in real time so we were not relying on coding/chart review. This improves our confidence in the case finding compared with studies that used diagnoses as coded in administrative datasets.

There are some limitations to our study that would result in conservative estimates of cost to the health care system. Participants were followed until discharge from the ED, hospital, or rehabilitation facility and no subsequent costs incurred were included in our estimates. If posthospital costs had been included, as they were in the study by Tiedemann et al. [25], our cost per fall estimates would have been larger. Also, we did not recruit nonEnglish speaking or cognitively impaired individuals who may have different fall-related health resource utilizations and costs from our sample population.

The incidence of falls is high among elderly persons yet there has been little microcosting of these events. Using a bottom-up rather than top-down costing approach, we have identified key cost areas and have provided new data as to the costs of falls in seniors between the time of Emergency Department presentation and their first discharge from clinical care. This study highlights the substantial burden falls puts on our health care system and the need to increase efforts designed to prevent falls in seniors.

Acknowledgements

This research was funded by the Michael Smith Foundation for Health Services Research (JCW, KK, CAM and Canadian Institutes for Health Research (JCW, KK, CAM). CAM is the holder of a Government of Canada Research Chair in Pharmaceutical Outcomes.

Conflicts of interest

None.

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2011