National and local strategies (best practice)
Commissioners, working collaboratively across health and social care, should consider the key areas for intervention in the context of local services for falls, falls prevention and fractures (see figure 1). The four objectives, which are listed in order of priority, are:
- Objective 1: improve patient outcomes and improve efficiency of care after hip fractures through compliance with core standards
- Objective 2: respond to a first fracture and prevent the second – through fracture liaison services in acute and primary care settings
- Objective 3: early intervention to restore independence – through falls care pathways, linking acute and urgent care services to secondary prevention of further falls and injuries
- Objective 4: prevent frailty, promote bone health and reduce accidents – through encouraging physical activity and healthy lifestyles, and reducing unnecessary environmental hazards.
Download Falls and fractures: Effective interventions in health and social care from the Department of Health website.
A systematic approach to falls and fracture prevention, Source: DoH Prevention Package, 2009
The Fracture Liaison Services (FLS) Resource Pack (2010) provides a summary of all the experience accumulated nationally and internationally.
For a population of 320,000, there are likely to be savings of £56,527 for every year that the FLS is operational.
- The Quality Adjusted Life Years (QALY) value for hip fracture patients is set at £50,000.
- Quality adjusted life expectancy may be 0.7 per hip fracture.
- Life expectancy quality adjusted for prevented fatality at age 75 years is 9 QALYs.
- There will be further capacity saving in rehabilitation/NHS community team services and primary care, in addition to a very significant quality of life gain for older people who do not incur a secondary fracture. There is also a positive impact on local authority funded social care services.
The World Health Organisation supported Fracture Risk Assessment Tool i.e. FRAX®, assesses fracture risk and calculates an individual’s 10-year probability of a major osteoporotic fracture
The 2012, Cochrane Evidence Review ‘Interventions for preventing falls in older people living in the community’ review examined interventions for preventing falls in older people living in the community (Gillespie et al, 2012). It was based on 159 trials with 79,193 participants (see table 5).
|Intervention||Decreased RATE of falls||Decreased RISK of falls|
Multi component exercise group
Multi component home based exercise
Tai Chi (borderline statistical significance)
|Multifactorial interventions which include individual risk assessments||Yes||No|
|Vitamin D in people with lower vitamin D levels before treatment||Possibly||Possibly|
|Home safety assessment/modifications –-particularly when delivered by an Occupational Therapist and for those at higher risk||Yes||Yes|
Treatment for vision problems
|Pacemaker – in people with carotid sinus hypersensitivity||Yes|
1st eye cataract surgery in women
Gradual withdrawal of psychotropic medications
|Prescribing modification programme for 10 care physicians||Unknown||Yes|
Anti-slip shoe devices – in icy conditions
Cognitive behavioural interventions
|No evidence||No evidence|
*Risk increased when regular wearers of multifocal glasses were given single lens glasses; falls inside and outside were significantly reduced in those that regularly took part in outside activities however outside falls increased for those that took part in little outside activity.
A health economic evaluation of services relating to the management of men and women at high fracture risk (NOGG, 2008) estimates that comprehensive services serving a population of approximately 320,000 people will:
- Prevent 33 fragility fractures over a 5 year period
- Save money for commissioners and providers of NHS, adult social care and public health services i.e. over 5 years the set up costs will be £234,181 yielding savings (treatment and care costs from averted falls and fractures) of £290,708. This represents a net saving of £56,527 (NOS, 2012).
A range of bone protecting treatments (as appraised in NICE TA 160 and 161) can reduce a person’s chances of fracture by up to 50%. The first line bone protecting treatment - i.e. alendronate, is cheap and effective and is currently available for £14 per patient per year (NOS, 2012).
Strength and Balance Exercise
The most effective and evidence-based component of multifactorial interventions is community based therapeutic exercise programmes that are tailored to the needs of the person. However exercise classes that are ‘general’ in nature, such as chair-based exercises, do improve certain risk factors for falling e.g. muscle weakness, but they do not reduce the actual risk of a fall or fall related injury (DoH, 2009a). Conversely, evidence based strength and balance exercise programmes such as Otago and Tai Chi can help prevent 44% of falls and 0.2 fractures per 300,000 population (DoH, 2009a).
A study which looked at a series of randomised controlled trials in the USA concluded that the combined reduction in risk of falls for all exercise interventions was 10%. The only intervention that was shown to delay the onset of the first or multiple falls was Tai Chi type exercise delivered as part of a multi-factorial falls prevention programme. However if Tai Chi is delivered to people with poor balance, adaptations to the programme must be made and progress is likely to be slow; it is likely to be more effective in ‘younger’ old age.
NICE (2004) reported cost effectiveness analyses for exercise programmes for at risk individuals living in the community setting and multifactorial interventions for at risk individuals living in the community. The incremental cost effectiveness ratios (ICERs) (1) indicate that both interventions are cost effective compared to doing nothing however the results should be interpreted with caution given the large confidence interval (2) around the ICERs. A study exploring the cost and clinical effectiveness of multifactorial interventions which identified the ‘at risk’ population are likely to be cost effective compared to conventional thresholds. However the degree of uncertainty around the ICER remains.
Exercise programmes are likely to be cost effective but less cost effective than the multifactorial intervention. However it should be noted that exercise may produce other health benefits that have not been incorporated in the analysis.
Note: Although clinical and cost effectiveness data exists for falls prevention, there are no UK studies and the quality of reporting in these studies is often patchy, with some costs and benefits reported and not others. Few comparisons can be made between studies due to the differences in methodology (NICE, 2004).
(1) The incremental cost-effectiveness ratio (ICER) is an equation used commonly in health economics to provide a practical approach to decision making regarding health interventions. It is the ratio of the change in costs of a therapeutic intervention (compared to the alternative, such as doing nothing or using the best available alternative treatment) to the change in effects of the intervention.
Last updated Wednesday, 1st November 2017