Service use and costs of incident femoral fractures in nursing home residents in Germany: the Bavarian Fall and Fracture Prevention Project (BF2P2).

OBJECTIVES: Hip fractures are one of the most costly consequences of falls in the elderly. Despite their increased risk of falls and fractures, nursing home residents are often neglected in service utilization and costing studies. The purpose of this study was to determine service use, initial and long-term direct costs of incident femoral fractures in nursing home residents 65 years or older in Germany. DESIGN: An incidence-based, bottom-up cost-of-illness study aiming at measuring fracture-related direct costs from a payer perspective was conducted. SETTING: Nursing homes PARTICIPANTS: The retrospective dataset included all insurants of a sickness fund (Allgemeine Ortskrankenkasse Bavaria), who were 65 years or older, resided in a nursing home, and had a level of care of at least one in the statutory long-term care insurance (n = 60,091). MEASUREMENTS: Incident femoral fractures (ICD-10, S72) in 2006 were followed until the end of 2008, incorporating service use and costs of inpatient care (up to 12 months after the initial hospitalization episode), nursing home care (until death or the end of 2008), and ambulatory care (pharmaceuticals, nonphysician providers, and medical supply within 3 months after the initial hospitalization episode). Additional costs for nursing home and ambulatory care were determined with a before/after design. Costs beyond the year 2006 were discounted with a rate of 5%. Sensitivity analyses on key parameters were performed. RESULTS: Overall mean direct costs of 9488 USD (SD ± 4453 USD, 2006) occurred for incident femoral fractures (n = 1525). This included inpatient care (90.2%), additional costs for nursing home care (7.1%), and ambulatory care (2.7%). Eighty-seven percent of the costs occurred for the initial hospitalization episode and 13% for long-term costs. After the index admission, 12.1% were admitted to a rehabilitation facility, 4.1% were rehospitalized within a year, and in 17.7% the level of care increased within 90 days after the end of the initial hospital episode. The share of residents with incident femoral fractures rehospitalized was significantly higher and costs for nonphysician providers were significantly lower for male residents. CONCLUSION: Residents with femoral fractures used a wide range of health services. Our study underestimates the true costs to society in Germany. Efforts should be directed to economic evaluations of fall-prevention programs aiming at reducing fall-related fractures including femoral fractures.

Effectiveness of a multifactorial intervention to reduce physical restraints in nursing home residents.

OBJECTIVES: To evaluate the effectiveness of a multifactorial intervention to reduce the use of physical restraints in residents of nursing homes. DESIGN: Cluster-randomized controlled trial. SETTING: Forty-five nursing homes in Germany. PARTICIPANTS: Three hundred thirty-three residents who were being restrained at the start of the intervention. INTERVENTION: Persons responsible for the intervention in the nursing homes attended a 6-hour training course that included education about the reasons restraints are used, the adverse effects, and alternatives to their use. Technical aids, such as hip protectors and sensor mats, were provided. The training was designed to give the change agents tools for problem-solving to prevent behavioral symptoms and injuries from falls without using physical restraints. MEASUREMENTS: The main outcome was the complete cessation of physical restraint use on 3 consecutive days 3 months after the start of the intervention. Secondary outcomes were partial reductions in restraint use, percentage of fallers, number of psychoactive drugs, and occurrence of behavioral symptoms. RESULTS: The probability of being unrestrained in the intervention group (IG) was more than twice that in the control group (CG) at the end of the study (odds ratio=2.16, 95% confidence interval=1.05-4.46). A partial reduction of restraint use was also about twice as often achieved in the IG as in the CG. No negative effect was observed regarding medication or behavioral symptoms. The percentage of fallers was higher in the IG. CONCLUSION: The intervention reduced restraint use without a significant increase in falling, behavioral symptoms, or medication.

Effect of a statewide fall prevention program on incidence of femoral fractures in residents of long-term care facilities.

OBJECTIVES: To evaluate the effect of a statewide dissemination of a modified evidence-based fall prevention program on incidence of femoral fractures in nursing homes. DESIGN: Observational study of a staged implementation of a successful fall prevention program. SETTING: One thousand three hundred fifty-nine nursing homes in two federal states in the south of Germany. PARTICIPANTS: Nine thousand seventy-seven residents in the intervention homes and 43,583 residents in control homes from the same and a different federal state. INTERVENTION: Staff education on fall prevention, advice on environmental adaptations, and progressive strength and balance training over at least 1 year. MEASUREMENTS: Incident femoral fractures. RESULTS: One thousand five hundred eighteen femoral fractures occurred in the total study population during the intervention period. The crude incidence rate of femoral fractures was 39.5/1,000 person-years in residents from the intervention homes and 40.9 and 39.7/1,000 person-years in residents from two sets of control homes. In a multivariate model, there was no evidence of an effect of the fall prevention program on incidence of femoral fracture when compared with control homes from the same federal state (adjusted hazard ratio (AHR)=0.96, 95% confidence interval (CI)=0.83-1.11) or from a different federal state (AHR=1.00, 95% CI=0.86-1.16). CONCLUSION: The statewide dissemination of a multifactorial fall prevention program did not appear to reduce the burden of femoral fractures in residents of nursing homes.

Accidental falls among community-dwelling older adults: improving the identification process of persons at risk by nursing staff.

Elderly persons living in the community are a heterogeneous population. Among them, the screening of persons at risk of falling is still a matter of debate. The aim of this analysis was to improve the identification process of elderly persons living in the community at risk for falling by nursing staff of community- based services. A secondary analysis was performed with the data from a prospective non-randomized interventional trial. The study included 268 community-dwelling older adults (mean age of 82 years, 81.3% female) from Ulm and Neu-Ulm with a followup period of 12 months. Fall risk indicators were extracted from the nursing assessment and analysis with crude odds ratios revealed the following risk indicators for falls: assistance when transferring, bathing and climbing a flight of stairs as well as fall history. Afterwards, fall risk indicators were selected by backward elimination in a multiple logistic regression. Variable selection identified a positive fall history and the need for assistance when bathing as important risk indicators. These two risk indicators could be used as a screening tool, which would be easy to perform by nursing staff in their daily work. This screening test defined as more than one fall in the last 12 months or bathing assistance, the first ADL to be affected in the disablement process, has a sensitivity of 85.3% and a specificity of 42.1%.

An algorithm to screen long-term care residents at risk for accidental falls.

BACKGROUND AND AIMS: The process applied to identify fall risks in frail elderly persons remains a matter of debate. We intended to develop a fall screening instrument for clinically defined subgroups of long-term care residents, to be administered by nursing staff. METHODS: Fall risk indicators were selected by multiple logistic regression in three pre-defined subgroups. The first consisted of residents who were not able to transfer, defined as a change from sit-to-stand position, without physical assistance (NAT). The second subgroup comprised residents who were able to transfer, but who had had a recent fall during the last 6 months (AT-F). Residents who were able to transfer but had had no recent fall (AT-NF) were in the third subgroup. The prospective observational study included 472 long-stay residents (mean age 84 years, 79% female) from three community nursing homes, with a follow-up period of 12 months. RESULTS: Fall incidence was highest in the AT-F subgroup: 6066 per 1000 resident years. The risk indicators identified included a positive fall history and restraint use in the NAT group, transfer assistance in the AT-F group, and urinary incontinence and visual impairment in the AT-NF group. CONCLUSIONS: The identification of different risk indicators in the subgroups indicates that specific strategies may be more appropriate to improve the effectiveness of fall prevention in long-term care, than the application of one strategy to all residents. The identification of incontinence, visual impairment, and restraints as risk indicators stresses the need for intervention studies which specifically address these items.