POPULATION HEALTH MANAGEMENT Volume 17, Number 6, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/pop.2014.0002
Cost of Fall-Related Hospitalizations among Older Adults: Environmental Comparisons from the 2011 Texas Hospital Inpatient Discharge Data Samuel D. Towne Jr., PhD, MPH, CPH,1 Marcia G. Ory, PhD, MPH,1 and Matthew Lee Smith, PhD, MPH, CHES 2
Abstract
In the United States, 30% of older adults suffer a fall annually with tremendous personal and societal burden. Although estimates of national-level costs are available, most of these often cited estimates are dated, and less has been published about statewide estimates. This article documents fall-related medical costs by age, sex, and different geographic regions based on admission status of 2,937,579 hospital discharges reported in 2011, with special attention to trends over time. There were 77,086 fall-related hospitalizations in 2011, of which 78.4% represent those aged 50 and older. Among this same age group, total fall-related costs rose to $3.1 billion in 2011, from $1.9 billion in 2007. Those aged 75 and older experienced the highest cost, while average cost was lower in nonmetropolitan areas. Understanding the distribution of fall-related burden across groups and rurality allows researchers to identify social and environmental circumstances of falls and identify community resources necessary to prevent falls. (Population Health Management 2014;17:351–356)
Introduction
I
n the United States, approximately 30% of adults aged 65 and older suffer a fall annually.1 The rates of falls and fall-related injuries are even higher among the oldest old (ie, 80 years of age and older).1 As this older population continues to grow, the burden of falls will cause substantial increases in costs for individuals (eg, medical costs), their families (eg, time caring for injured individuals), and society (eg, disability, work loss2). Thus, it is critical to understand this projected burden among these older adults with the latest data available. Additionally, examining this burden by differing demographic and geographic areas allows for a greater ability to tailor this information for specific subgroups and regions.
Medical cost associated with falls
There are a variety of methods for estimating costs associated with falls. The total monetary cost associated with falls is measured as direct medical costs for treatment related to falls (eg, hospitalizations and by extension preventable hospitalizations) and indirect costs (eg, loss of productivity).1 Overall,
direct medical costs associated with fall-related health care among community-dwelling older adults accounted for approximately $6.2 billion in 1997.3(p.313) At the same time, the cost share by payer across multiple care settings (eg, inpatient hospital, emergency room, home health care, office-based services, dental, hospital outpatient services, prescription drugs) varied by insurance source. It was highest for Medicare (77.7%), followed by private insurance (12.6%), self-pay (3.8%), other sources (3.8% each), and Medicaid (2.1%).3(Table 6) In a large US study, the direct cost associated with falls (average hospitalization cost) was approximately $17,000 (2004 US$) in 1998.4(p.1320) In 2000, approximately $19 billion in cost was attributable to direct medical costs for nonfatal fall-related injuries.5(p.292) This cost is estimated to reach over $30 billion by 2020.4(p.1320),6 Nationally, the average lifetime medical cost associated with unintentional nonfatal falls among adults aged 65 and older who were treated in the emergency department and released was $1093 in 2005.7 In 2005, among adults aged 65 and older, the total lifetime medical costs of unintentional fall-related injuries was $149 million for males and $302 million for females who were treated in emergency departments and released.8(Figure 1) Among those individuals in
1 Department of Health Promotion and Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas. 2 Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, Georgia.
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the same age group who were treated and hospitalized, the total costs was $2.2 billion for males and $3.6 billion for females in 2005.8(Figure 2) Average lifetime medical cost associated with unintentional nonfatal falls among individuals aged 65 and older who were hospitalized because of injuries was $18,667 in 2005.9 In Texas, the total charges associated with falls among those aged 50 and older were almost $1.9 billion in 2007.10 Average costs associated with fall-related hospitalizations among those aged 50 and older was almost $37,000 during the same time. This was the latest cost-related data available for Texas. The study team compares results to this earlier study (2007) using the same data source and the same definition for falls and cost. Rural context
Rural areas face disparities with regard to the level of disability and disease.11,12(p.728),13 Individuals residing in rural areas typically have less access to health care services and may experience more barriers utilizing health care services.14 Rural contextual factors such as lower education and higher poverty among minority populations are an important factor in one’s health status and use of care.15 When examining statewide fall incidence rates, the inclusion of the geographic distribution can assist researchers to better understand the contextual factors related to the overall cost burden facing older adults. Objective
The study team sought to measure the latest costs associated with fall-related hospitalizations in Texas, as a model of analyses that could be conducted in other states. Additionally, analyses were conducted by age group, sex, and across different environmental settings. Herein, the rural context of costs is explored, as contextual factors may drive differences in health care utilization and costs. Methods Data and design
The study team used the latest available Texas Hospital Inpatient Discharge Public Use File (2011)16 to provide a crosssectional analysis of the current costs related to falls among Texas residents. These data are collected quarterly from all eligible hospitals in Texas. At the time of this study, 2011 was the latest full year of data available for analysis. Full details of the hospitals included in the analysis are available from the Texas Hospital Inpatient Discharge Public Use Data File codebook (< http://www.dshs.state.tx.us/thcic/DataAndReports.shtm > ). Population
The unit of analysis was the hospital discharge in Texas. The sample size included 2,937,579 hospital discharges reported in any of the 4 calendar quarters in 2011. Data from hospitals throughout the state are reported unless the hospital is located in a county with fewer than 35,000 residents or if the county has fewer than 100 licensed hospital beds in an urbanized area. Variables
The operational definition of a fall was calculated using International Classification of Diseases, Ninth Revision,
TOWNE, ORY, AND SMITH
Table 1. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Categorization for a Fall-related Hospitalization ICD-9-CM 880.0–880.9 881.0–881.9 882.0 883.0–883.9 884.0–884.9 885.0–885.9 886.0–886.9 888.0–888.9
Fall Description Fall on or from stairs or steps Fall on or from ladders or scaffolding Fall from or out of building or other structure Fall into hole or other opening in surface Other fall from one level to another Fall on same level from slipping, tripping, or stumbling Fall on same level from collision, pushing, or shoving, by or with other person Other and unspecified fall
Clinical Modification (ICD-9-CM) diagnosis codes. Categories of falls included by ICD-9-CM categorization are provided in Table 1. The definition of falls included all admitting diagnoses (eg, primary, secondary). An analysis of hip fractures associated with falls also is included. The study team defined a hip fracture related to a fall as having an admitting diagnosis code of a fall and having a diagnosis code indicating that the location of a fracture included the hip (femur or pelvis). The primary dependent variable was the total cost of fallrelated discharges among patients receiving treatment and discharged (including those who died) from an eligible hospital within any of the 4 calendar quarters in 2011. Total costs and average cost per discharge for fall patients was calculated. The operational definition of total costs included the sum of accommodation charges (eg, general fees in excess of daily care fees), non-covered accommodation charges, ancillary charges (eg, X-rays, use of operating room), and non-covered ancillary charges. Stated another way, the definition of total costs encompassed all costs associated with a hospital stay up to and including discharge. The primary independent variable was age group. Age was included to differentiate the costs associated with falls among the patient population. Age group was categorized in 5-year increments for those younger than age 90 and then grouped for those age 90 and older. Those identified as HIV and drug/ alcohol use patients were not included, as the age categories did not match those included and could not be matched to those of all other individuals in the data (ie, coding of broader age categories prevented matching more narrow age groupings for all other discharges, as only age group is available in the public use file). Additionally, the ZIP code and gender code were suppressed for records in the public use file if an ICD-9-CM code included HIV diagnosis or drug or alcohol use. A secondary independent variable was rurality. The study team wanted to know whether there was a difference in the average fall-related costs between discharges of residents of nonmetropolitan areas versus metropolitan areas. This is not an indication of the treatment facility location, but of the location of the patient receiving care for a fall-related hospitalization. County Federal Information Processing Standard (FIPS) codes were used to separate discharges into rurality. There were a total of 91,164 observations with missing county identifiers (county codes were suppressed if
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FIG. 1. The total costs among patients admitted with a fall-related injury in Texas, 2007 and 2011.
a county had fewer than 5 discharges per quarter). Urban Influence codes (UIC) downloaded from the US Department of Agriculture’s Economic Research Service17 were used to categorize rurality. These were separated into metropolitan (UIC 1–2) and nonmetropolitan (UIC 3–12). These codes are calculated based on the ‘‘size of the largest city or town’’ in relation to metro and micropolitan areas for nonmetropolitan counties and based on population size of metro areas for metropolitan counties.17 Analysis by rurality has been shown to vary depending on the measures used in analysis.18 The study team used a measure that is common in countylevel analysis and may differ from other measures (eg, Rural Urban Commuting Area Codes). Sample size
The initial sample size identified from the data included 2,937,579 discharges. Fall-related hospitalizations were the focus of this analysis. The study team restricted the analysis to discharges that included a fall present upon admission. Inclusionary criteria included any fall-related discharge within each of the 4 quarters in 2011 in Texas hospitals. A total of 77,086 fall-related discharges were included in 2011. A total of 2484 fall-related discharges were omitted when observations with missing county FIPS codes were excluded, leaving 74,602 fall-related discharges. Omitting data for missing age further reduced the fall-related discharges to 70,747 discharges, which was the total included in this analysis. Observations that were coded as having HIV were grouped with a different age classification (broader); therefore, they were unable to be included in these analyses. Statistical analysis
In Texas, the total cost associated with falls was $3,881,264,365 in 2011. Among those aged 50–64, the total cost among fall patients was $605,323,701 (average $54,504.21). For those aged 65–74, the total cost was $648,346,253 (average $54,469.15); among those aged 75– 84, the total cost was $978,241,609 (average $50,628.38). For those aged 85 and older, the total cost was $852,183,335 (average $47,149.68). For those aged 50 and older, the total costs among fall patients were $3,084,094,898 as compared to $426,246,240 for those aged 49 and younger. This was an increase from approximately $1.9 billion from 2007 (Figure 1). In Texas, the average cost among fall patients aged 50 and older was $51,057 in 2011 versus $41,215 among those aged 49 and younger (Tables 2 and 3). In all comparisons between 2007 and 2011, total costs were higher in 2011 among all age group comparisons (among those aged 50 and older), as seen in Figure 1. When considering the cost by age and sex (Tables 2 and 3), the highest average cost among fall patients was among males aged 50 and older ($55,440). Overall, the total costs associated with a fall on admission were highest for older females (Table 2). Females aged 50 and older accounted for approximately 56% of the total costs associated with falls in 2011. Males aged 50 and older accounted for approximately 32% of the total costs associated with falls. Approximately 11% of the total costs associated with a fallrelated hospitalization was contributed by those aged 49 and younger. Overall, the average cost of a hip fracture was $62,095 among those aged 50 and older versus $71,831 for those aged 49 and younger. The average costs of fall-related hospitalizations with a hip fracture among those aged 50 and
All analysis was carried out using SAS version 9.4 (SAS Institute Inc., Cary, NC). Bivariate and univariate analyses were conducted. Results are provided highlighting descriptive analysis for the outcomes of interest on the independent variables. Results Incidence and costs of falls
Overall, the majority of patients admitted and discharged from hospitals in Texas in 2011 were younger than 50 years of age (52%) and female (61%). Among those with a fall, the vast majority were aged 50 and older (85%) and female (63%). Overall, there were 77,086 fall-related hospital incidents in 2011. The incidence of being hospitalized for falls among those aged 50 and older was 60,405 in 2011, representing the vast majority of fall-related hospitalizations.
Table 2. Average Costs by Patients’ Characteristics and Fall-related Hospitalization on Admission in Texas, 2011 Age Sex Male 50 and older Younger than 50 Female 50 and older Younger than 50 Age 50 and older Younger than 50
Fall-Related Non-Fall-Related Hospitalizations Hospitalizations
$55,440.45 $44,241.02
$55,628.92 $30,862.95
$48,878.22 $36,945.16
$48,925.59 $22,566.34
$51,056.95 $41,215.07
$51,925.16 $25,422.39
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Fall-Related Hospitalizations
Non-Fall-Related Hospitalizations
$1,111,969,135.00 $267,923,639.38
$31,524,076,763.00 $14,979,577,758.00
$1,972,089,440.20 $158,309,995.17
$34,214,788,085.00 $20,870,933,714.00
found that nonmetropolitan residents continue to have lower average costs when compared to metropolitan residents. To assess differences among older adults with the highest costs, these comparisons were further stratified among those aged 50 and older. Among those aged 50 and older, costs associated with hip fractures were $55,366 among residents of nonmetropolitan areas compared to $61,715 among residents of metropolitan areas. Table 4 identifies fall-related costs by rurality and age group. As seen previously, the relative gap in average cost is consistent across the ruralurban divide.
$3,084,094,897.80 $426,246,239.63
$65,739,639,947.00 $35,856,168,092.00
Discussion
Table 3. Total Cost of Fall-related Hospitalizations in Texas, 2011 Age Sex Male 50 and older Younger than 50 Female 50 and older Younger than 50 Age 50 and older Younger than 50
Limitations
older was $60,533 versus $41,177 for those aged 49 and younger. However, the total costs associated with a hip fracture (not necessarily related to falls) was $1,076,661,057 among those aged 50 and older, while $156,088,836 for those aged 49 and younger in 2011. This includes all costs associated with a hip fracture, not necessarily those related to falls. The total costs of fall-related hospitalizations with a hip fracture among those aged 50 and older was $852,785,273 as compared to $26,188,372 for those aged 49 and younger. Costs by rurality
The total costs associated with fall-related hospitalization are presented in Table 4. In 2011, individuals residing in nonmetropolitan areas had an average fall-related cost of $45,706, and metropolitan-residing individuals had an average of $50,863. The total costs in nonmetropolitan areas accounted for 15% of the total costs among those aged 50 and older. The study team measured the overall costs of a hip fracture in nonmetropolitan and metropolitan comparisons. To ensure that the cost comparison across rurality was comparing like injuries, the study team looked at only those discharges that were coded with a hip fracture. Here, the team found that the average cost of fall-related hospitalizations where hip fracture is present was $55,132 among those residing in nonmetropolitan areas, while $61,126 among those residing in metropolitan areas. Thus, it was
Table 4. Total Costs of Fall-related Hospitalizations in Texas (2011) by Age and Rurality Age
Nonmetropolitan
This study used data that is cross-sectional in nature; therefore, trends over multiple years were not measured. However, 2011 costs were compared to those in 2007, which allowed the study team to assess gross change over time. It should be noted that the team did not account for changes in the average medical costs from 2007 to 2011 in these comparisons. Nor did the study team account for inflation, advances in treatment, or different ‘‘standards of care’’ that may contribute to higher fall-related costs from 2007 to 2011. Despite no changes in fall-specific ICD-9-CM coding occurring during the study period, changes in incentives to use these codes may have been introduced, which could have increased fall-related costs. In addition, the study team did not provide a comprehensive analysis of all fall-related injuries parceled by type. Instead, a separate set of analyses was performed on hip fractures because of the severity of this condition, which is strongly correlated with falling.19,20,21 Furthermore, this analysis did not include national data on falls, and as such may not be generalizable to other areas. That said, this study adds to the relative gap in state-level analysis of falls in a large and diverse southern state. The data are limited in that they do not include hospitals located in a county with fewer than 35,000 residents. However, the measure of rurality is at the patient level, which allows measurement of geographic variations beyond the hospital location. Furthermore, this analysis separated rurality into 2 categories (metropolitan and nonmetropolitan), which does not take into account variations within further subcategories of rurality. Rather, a more parsimonious analysis is provided that highlights major differences between metropolitan (urban) and nonmetropolitan (rural) areas. Further studies may include more detailed analysis, providing several levels of rurality to examine the nuances of fall-related costs by rural designation.
Metropolitan
Total costs of falls (mean) 50 and older $396,003,010.03 $2,582,470,982.60 ($45,564.72) ($51,795.48) Younger than 50 $44,302,717.12 $360,673,953.02 ($40,348.56) ($40,976.36) Total costs of fall-related hip fractures (mean) 50 and older $134,317,873.28 $689,724,208.17 ($55,365.98) ($61,714.76) Younger than 50 $2,864,751.78 $22,374,133.90 ($35,367.31) ($41,899.13)
Interpretation and conclusion
The rising cost of health care is showing little signs of slowing. More so, the fall-related costs in Texas grew dramatically from 2007 to 2011. The number of adults aged 50 and older was 6.96 million in 2011, from 6.14 million in 2007, which may account for a portion of this increase.22 Although the growth in the number of patients with a fallrelated hospitalization may account for a substantial portion of these costs (approximately 51,000 fall-related hospitalization in 2007), the higher costs per discharge, on average, (eg, over $51,000 in 2011 from almost $37,000 in 2007)
COST OF FALL-RELATED HOSPITALIZATIONS AMONG OLDER ADULTS
indicates costs are rising beyond those related to the increasing incidence of falls alone.10 Here, the growth in costs of health care may be related to this increased cost burden among older adults. Not only is the cost rising, but the average cost differs substantially by level of rurality. Thus, there is a gap of over $5000 (on average) depending on whether one resides in a nonmetropolitan area or metropolitan area. These differences are of great interest to those who would seek to lower the costs of fall-related hospitalizations, especially those related to hip fractures among older adults. Further research is recommended to investigate why rurality-based differences exist. The current analyses did not assume treatment in rural areas, but that costs are different depending on patients’ residential level of rurality (location identifiers are not present for hospitals in the public use file). The majority of older rural residents have been shown to utilize the closest rural hospitals, forgoing travel to farther urban hospitals23; however, this has been shown to vary by hospital size (closest) and the severity of the injuries needing treatment.24 Thus, evidence suggests that a majority of these rural residents are seeking treatment in rural areas, given the proximity of the closest hospital. Even so, those receiving care for more severe injuries may seek treatment in facilities that are larger or in urban areas, depending on the size of their local hospitals. Thus, the study team assumes the majority of costs among rural residents are likely representative of rural provision of care. Furthermore, studies have shown that average costs of ambulatory visits were lower among adults (18–44 years of age) in rural areas when compared to urban areas.25 Further research into why rural differences in cost exist is recommended. The increase in cost to treat a fall-related hospitalization is only part of the concern, where slowing the incidence of these hospitalizations may hold the most promise to combat these escalating costs. As adults enter into older age groups, the risk of falling increases, especially among those aged 65 and older.1 Finding ways to limit preventable falls among those aged 50 and older could prevent a great portion of the total costs associated with falls across the United States. The importance of this study relies on the timeliness (latest data available at the time of submission), its focus at the state level, and identification of trends over time and geographic variations in costs. This study serves as a model state-level analysis of the major shifts in costs and incidence of fallrelated hospitalizations. Such analyses allow for a more accurate assessment of falls in a specific demographic population and geographic area that can be more directly addressed by policy makers, practitioners, and researchers. On average, fall-related costs were lower for older persons, which may be attributed to the higher likelihood of death from a fall before more medical expenses are incurred.10 Although these analyses focused on older adults, it is of note that the variation in cost between fall-related and non-fall-related hospitalizations was dramatic for those aged 49 and younger. Falls among younger adults are more likely related to high-risk behaviors or occupationally related,1 which may result in different types of falls among this population. Further analysis should focus on these younger individuals to examine the primary drivers of this difference.
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Practical application: policy
Policy makers and funding agencies are very interested in finding ways for older adults to age in place, especially considering the costly and steadily rising public funding through Medicaid for nursing care in institutionalized settings.26 Policy makers need to have access to the most recent data available in order to understand the impact of falls, especially among those aging baby boomers who may be most vulnerable. This analysis is timely in that it can be used by policy makers and researchers; however, the study team recommends that similar analyses be conducted on a regular basis (every few years) to ensure efforts are guided by the most current evidence. More funding of implementation research is needed to further understand what works in allowing one to age healthfully in place. Practical application: research
Rising costs for fall-related hospitalizations, especially among older adults, warrants the attention of researchers to find ways to lower the incidence of falls among this growing population of older adults. Assuming that falls are an inevitable part of the aging process fails to take into account the great potential of falls prevention research.27 Fall prevention programs have the potential to reduce costs associated with falls.28,29 Targeted interventions that focus on those aged 50 and older can be effective at reducing costs if they reduce the number of falls among this population. For those with limited funding, an even more targeted approach may be to focus resources on those aged 75 to 84, as this group accounted for the largest portion of the total costs as compared to any other age group in Texas in 2011. Identifying funding opportunities for programs in the community setting that are tailored to meet the needs of those in older age groups may hold the best potential for cost reduction and containment if they can find success in reducing the number of falls in older populations. Author Disclosure Statement
Drs. Towne, Ory, and Smith declared no conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no financial support for this article. References
1. World Health Organization. WHO global report on falls prevention in older age. < http://www.who.int/ageing/publications/ Falls_prevention7March.pdf > . Accessed August 21, 2013. 2. Centers for Disease Control and Prevention. Cost of fall injuries in older persons in the United States, 2005. < http:// www.cdc.gov/homeandrecreationalsafety/falls/data/costestimates.html > . Accessed October 26, 2013. 3. Carroll NV, Slattum PW, Cox FM. The cost of falls among the community-dwelling elderly. J Manag Care Pharm 2005; 11:307–316. 4. Roudsari BS, Ebel BE, Corso PS, Molinari NA, Koepsell TD. The acute medical care costs of fall-related injuries among the U.S. older adults. Injury 2005;36:1316–1322. 5. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12:290–295.
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6. Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. J Forensic Sci 1996;41: 733–746. 7. Centers for Disease Control and Prevention. Data and Statistics (WISQARS): Cost of Injury Reports. Nonfatal emergency department treated and released injuries, both sexes, ages 65 to 85 + , United States, 2005. < http://wisqars.cdc .gov:8080/costT/ > . Accessed July 17, 2013. 8. Centers for Disease Control and Prevention. Cost of fall injuries in older persons in the United States, 2005—Figures 1–2. < http://www.cdc.gov/homeandrecreationalsafety/Falls/ data/cost-estimates-figures1-2.html > . Accessed July 16, 2013. 9. Centers for Disease Control and Prevention (CDC). Data and Statistics (WISQARS): Cost of Injury Reports. Nonfatal hospitalized injuries, both sexes, ages 65 to 85 + , United States, 2005. < http://wisqars.cdc.gov:8080/costT/ > . Accessed July 17, 2013. 10. Smith ML, Ory MG, Beasley C, Johnson KN, Wernicke MM, Parrish R. Falls among older adults in Texas: profile from 2007 Hospital Discharge Data. Tex Public Health J 2010;62(1):7–13. 11. Gamm L, Hutchison L, Dabney BJ, et al. Rural healthy people 2010: A companion document to healthy people 2010. College Station, TX: Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center, 2003. 12. Norton CH, McManus MA. Background tables on demographic characteristics, health status, and health services utilization. Health Serv Res 1989;23(6):725–756. 13. Jones CA, Parker TS, Ahearn M, Mishra AK, Variyam JN. Health status and health care access of farm and rural populations. Economic Information Bulletin NO. EIB-57. < http://www.ers.usda.gov/publications/eib-economic-informationbulletin/eib57.aspx > . Accessed March 10, 2014. 14. Gamm L, Castillo G, Pittman S. Access to quality health services in rural areas—primary care. In: Gamm LD, Hutchison LL, Dabney BJ, Dorsey AM, eds. Rural healthy people 2010: A companion document to healthy people 2010. Vol. 1. College Station: Texas A&M University Press, 2003:45–50. 15. Probst JC, Moore CG, Glover SH, Samuels ME. Person and place: the compounding effects of race/ethnicity and rurality on health. Am J Public Health 2004;94:1695–1703. 16. Texas Department of State Health Services. Texas hospital inpatient discharge public use data file. Austin, TX: Texas Department of State Health Services, Center for Health Statistics, 2011. 17. United States Department of Agriculture (USDA); Economic Research Service. Urban influence codes: overview. < http://www.ers.usda.gov/data-products/urban-influencecodes.aspx#.Unw2PPmshcZ > . Accessed November 7, 2013. 18. Smith ML, Dickerson JB, Wendel ML, et al. The utility of rural and underserved designations in geospatial assessments of distance traveled to healthcare services: implica-
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tions for public health research and practice. J Environ Public Health Epub 2013 Jun 13. doi: 10.1155/2013/960157. Hayes WC, Myers ER, Morris JN, Gerhart TN, Yett HS, Lipsitz LA. Impact near the hip dominates fracture risk in elderly nursing home residents who fall. Calcif Tissue Int 1993;52:192–198. Parkkari J, Kannus P, Palvanen M, et al. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int 1999;65:183–187. Kelly DW, Kelly BD. A novel diagnostic sign of hip fracture mechanism in ground level falls: two case reports and review of the literature. J Med Case Rep 2012;6(1): 136. Texas Department of State Health Services (DSHS) Center for Health Statistics. Texas population data. < https://www .dshs.state.tx.us/chs/popdat/detailX.shtm > . Accessed February 10, 2014. Buczko W. Bypassing of local hospitals by rural Medicare beneficiaries. J Rural Health 1994;10:237–246. Adams EK, Wright GE. Hospital choice of Medicare beneficiaries in a rural market: why not the closest? J Rural Health 1991;7:134–152. Health Care in Urban and Rural Areas, Combined Years 2004–2006: Requests for Assistance on Health Initiatives: Update of Content in MEPS Chartbook No. 13: Medical Expenditure Panel Survey, AHRQ. April 2009. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/policymakers/health-initiatives/meps/ chbook13up.html (accessed November 7, 2013). Stewart KA, Grabowski DC, Lakdawalla DN. Annual expenditures for nursing home care: private and public payer price growth, 1977–2004. Med Care 2009;47:295–301. Ory MG, Smith ML, Wade A, Mounce C, Wilson A, Parrish R. Implementing and disseminating an evidence-based program to prevent falls in older adults, Texas, 2007–2009. Prev Chronic Dis 2010;7(6):A130. Shekelle P, Maglione M, Chang J, et al. Falls prevention interventions in the Medicare population. < http://www.rand .org/pubs/reprints/RP1230 > . Accessed July 10, 2013. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146.
Address correspondence to: Samuel D. Towne, PhD, MPH, CPH 1266 TAMU Department of Health Promotion and Community Health Sciences School of Rural Public Health Texas A&M Health Science Center College Station, TX 77843-1266 E-mail: [email protected]
Cost of Fall-Related Hospitalizations among Older Adults: Environmental Comparisons from the 2011 Texas Hospital Inpatient Discharge Data Samuel D. Towne Jr., PhD, MPH, CPH,1 Marcia G. Ory, PhD, MPH,1 and Matthew Lee Smith, PhD, MPH, CHES 2
Abstract
In the United States, 30% of older adults suffer a fall annually with tremendous personal and societal burden. Although estimates of national-level costs are available, most of these often cited estimates are dated, and less has been published about statewide estimates. This article documents fall-related medical costs by age, sex, and different geographic regions based on admission status of 2,937,579 hospital discharges reported in 2011, with special attention to trends over time. There were 77,086 fall-related hospitalizations in 2011, of which 78.4% represent those aged 50 and older. Among this same age group, total fall-related costs rose to $3.1 billion in 2011, from $1.9 billion in 2007. Those aged 75 and older experienced the highest cost, while average cost was lower in nonmetropolitan areas. Understanding the distribution of fall-related burden across groups and rurality allows researchers to identify social and environmental circumstances of falls and identify community resources necessary to prevent falls. (Population Health Management 2014;17:351–356)
Introduction
I
n the United States, approximately 30% of adults aged 65 and older suffer a fall annually.1 The rates of falls and fall-related injuries are even higher among the oldest old (ie, 80 years of age and older).1 As this older population continues to grow, the burden of falls will cause substantial increases in costs for individuals (eg, medical costs), their families (eg, time caring for injured individuals), and society (eg, disability, work loss2). Thus, it is critical to understand this projected burden among these older adults with the latest data available. Additionally, examining this burden by differing demographic and geographic areas allows for a greater ability to tailor this information for specific subgroups and regions.
Medical cost associated with falls
There are a variety of methods for estimating costs associated with falls. The total monetary cost associated with falls is measured as direct medical costs for treatment related to falls (eg, hospitalizations and by extension preventable hospitalizations) and indirect costs (eg, loss of productivity).1 Overall,
direct medical costs associated with fall-related health care among community-dwelling older adults accounted for approximately $6.2 billion in 1997.3(p.313) At the same time, the cost share by payer across multiple care settings (eg, inpatient hospital, emergency room, home health care, office-based services, dental, hospital outpatient services, prescription drugs) varied by insurance source. It was highest for Medicare (77.7%), followed by private insurance (12.6%), self-pay (3.8%), other sources (3.8% each), and Medicaid (2.1%).3(Table 6) In a large US study, the direct cost associated with falls (average hospitalization cost) was approximately $17,000 (2004 US$) in 1998.4(p.1320) In 2000, approximately $19 billion in cost was attributable to direct medical costs for nonfatal fall-related injuries.5(p.292) This cost is estimated to reach over $30 billion by 2020.4(p.1320),6 Nationally, the average lifetime medical cost associated with unintentional nonfatal falls among adults aged 65 and older who were treated in the emergency department and released was $1093 in 2005.7 In 2005, among adults aged 65 and older, the total lifetime medical costs of unintentional fall-related injuries was $149 million for males and $302 million for females who were treated in emergency departments and released.8(Figure 1) Among those individuals in
1 Department of Health Promotion and Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas. 2 Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, Georgia.
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the same age group who were treated and hospitalized, the total costs was $2.2 billion for males and $3.6 billion for females in 2005.8(Figure 2) Average lifetime medical cost associated with unintentional nonfatal falls among individuals aged 65 and older who were hospitalized because of injuries was $18,667 in 2005.9 In Texas, the total charges associated with falls among those aged 50 and older were almost $1.9 billion in 2007.10 Average costs associated with fall-related hospitalizations among those aged 50 and older was almost $37,000 during the same time. This was the latest cost-related data available for Texas. The study team compares results to this earlier study (2007) using the same data source and the same definition for falls and cost. Rural context
Rural areas face disparities with regard to the level of disability and disease.11,12(p.728),13 Individuals residing in rural areas typically have less access to health care services and may experience more barriers utilizing health care services.14 Rural contextual factors such as lower education and higher poverty among minority populations are an important factor in one’s health status and use of care.15 When examining statewide fall incidence rates, the inclusion of the geographic distribution can assist researchers to better understand the contextual factors related to the overall cost burden facing older adults. Objective
The study team sought to measure the latest costs associated with fall-related hospitalizations in Texas, as a model of analyses that could be conducted in other states. Additionally, analyses were conducted by age group, sex, and across different environmental settings. Herein, the rural context of costs is explored, as contextual factors may drive differences in health care utilization and costs. Methods Data and design
The study team used the latest available Texas Hospital Inpatient Discharge Public Use File (2011)16 to provide a crosssectional analysis of the current costs related to falls among Texas residents. These data are collected quarterly from all eligible hospitals in Texas. At the time of this study, 2011 was the latest full year of data available for analysis. Full details of the hospitals included in the analysis are available from the Texas Hospital Inpatient Discharge Public Use Data File codebook (< http://www.dshs.state.tx.us/thcic/DataAndReports.shtm > ). Population
The unit of analysis was the hospital discharge in Texas. The sample size included 2,937,579 hospital discharges reported in any of the 4 calendar quarters in 2011. Data from hospitals throughout the state are reported unless the hospital is located in a county with fewer than 35,000 residents or if the county has fewer than 100 licensed hospital beds in an urbanized area. Variables
The operational definition of a fall was calculated using International Classification of Diseases, Ninth Revision,
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Table 1. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Categorization for a Fall-related Hospitalization ICD-9-CM 880.0–880.9 881.0–881.9 882.0 883.0–883.9 884.0–884.9 885.0–885.9 886.0–886.9 888.0–888.9
Fall Description Fall on or from stairs or steps Fall on or from ladders or scaffolding Fall from or out of building or other structure Fall into hole or other opening in surface Other fall from one level to another Fall on same level from slipping, tripping, or stumbling Fall on same level from collision, pushing, or shoving, by or with other person Other and unspecified fall
Clinical Modification (ICD-9-CM) diagnosis codes. Categories of falls included by ICD-9-CM categorization are provided in Table 1. The definition of falls included all admitting diagnoses (eg, primary, secondary). An analysis of hip fractures associated with falls also is included. The study team defined a hip fracture related to a fall as having an admitting diagnosis code of a fall and having a diagnosis code indicating that the location of a fracture included the hip (femur or pelvis). The primary dependent variable was the total cost of fallrelated discharges among patients receiving treatment and discharged (including those who died) from an eligible hospital within any of the 4 calendar quarters in 2011. Total costs and average cost per discharge for fall patients was calculated. The operational definition of total costs included the sum of accommodation charges (eg, general fees in excess of daily care fees), non-covered accommodation charges, ancillary charges (eg, X-rays, use of operating room), and non-covered ancillary charges. Stated another way, the definition of total costs encompassed all costs associated with a hospital stay up to and including discharge. The primary independent variable was age group. Age was included to differentiate the costs associated with falls among the patient population. Age group was categorized in 5-year increments for those younger than age 90 and then grouped for those age 90 and older. Those identified as HIV and drug/ alcohol use patients were not included, as the age categories did not match those included and could not be matched to those of all other individuals in the data (ie, coding of broader age categories prevented matching more narrow age groupings for all other discharges, as only age group is available in the public use file). Additionally, the ZIP code and gender code were suppressed for records in the public use file if an ICD-9-CM code included HIV diagnosis or drug or alcohol use. A secondary independent variable was rurality. The study team wanted to know whether there was a difference in the average fall-related costs between discharges of residents of nonmetropolitan areas versus metropolitan areas. This is not an indication of the treatment facility location, but of the location of the patient receiving care for a fall-related hospitalization. County Federal Information Processing Standard (FIPS) codes were used to separate discharges into rurality. There were a total of 91,164 observations with missing county identifiers (county codes were suppressed if
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FIG. 1. The total costs among patients admitted with a fall-related injury in Texas, 2007 and 2011.
a county had fewer than 5 discharges per quarter). Urban Influence codes (UIC) downloaded from the US Department of Agriculture’s Economic Research Service17 were used to categorize rurality. These were separated into metropolitan (UIC 1–2) and nonmetropolitan (UIC 3–12). These codes are calculated based on the ‘‘size of the largest city or town’’ in relation to metro and micropolitan areas for nonmetropolitan counties and based on population size of metro areas for metropolitan counties.17 Analysis by rurality has been shown to vary depending on the measures used in analysis.18 The study team used a measure that is common in countylevel analysis and may differ from other measures (eg, Rural Urban Commuting Area Codes). Sample size
The initial sample size identified from the data included 2,937,579 discharges. Fall-related hospitalizations were the focus of this analysis. The study team restricted the analysis to discharges that included a fall present upon admission. Inclusionary criteria included any fall-related discharge within each of the 4 quarters in 2011 in Texas hospitals. A total of 77,086 fall-related discharges were included in 2011. A total of 2484 fall-related discharges were omitted when observations with missing county FIPS codes were excluded, leaving 74,602 fall-related discharges. Omitting data for missing age further reduced the fall-related discharges to 70,747 discharges, which was the total included in this analysis. Observations that were coded as having HIV were grouped with a different age classification (broader); therefore, they were unable to be included in these analyses. Statistical analysis
In Texas, the total cost associated with falls was $3,881,264,365 in 2011. Among those aged 50–64, the total cost among fall patients was $605,323,701 (average $54,504.21). For those aged 65–74, the total cost was $648,346,253 (average $54,469.15); among those aged 75– 84, the total cost was $978,241,609 (average $50,628.38). For those aged 85 and older, the total cost was $852,183,335 (average $47,149.68). For those aged 50 and older, the total costs among fall patients were $3,084,094,898 as compared to $426,246,240 for those aged 49 and younger. This was an increase from approximately $1.9 billion from 2007 (Figure 1). In Texas, the average cost among fall patients aged 50 and older was $51,057 in 2011 versus $41,215 among those aged 49 and younger (Tables 2 and 3). In all comparisons between 2007 and 2011, total costs were higher in 2011 among all age group comparisons (among those aged 50 and older), as seen in Figure 1. When considering the cost by age and sex (Tables 2 and 3), the highest average cost among fall patients was among males aged 50 and older ($55,440). Overall, the total costs associated with a fall on admission were highest for older females (Table 2). Females aged 50 and older accounted for approximately 56% of the total costs associated with falls in 2011. Males aged 50 and older accounted for approximately 32% of the total costs associated with falls. Approximately 11% of the total costs associated with a fallrelated hospitalization was contributed by those aged 49 and younger. Overall, the average cost of a hip fracture was $62,095 among those aged 50 and older versus $71,831 for those aged 49 and younger. The average costs of fall-related hospitalizations with a hip fracture among those aged 50 and
All analysis was carried out using SAS version 9.4 (SAS Institute Inc., Cary, NC). Bivariate and univariate analyses were conducted. Results are provided highlighting descriptive analysis for the outcomes of interest on the independent variables. Results Incidence and costs of falls
Overall, the majority of patients admitted and discharged from hospitals in Texas in 2011 were younger than 50 years of age (52%) and female (61%). Among those with a fall, the vast majority were aged 50 and older (85%) and female (63%). Overall, there were 77,086 fall-related hospital incidents in 2011. The incidence of being hospitalized for falls among those aged 50 and older was 60,405 in 2011, representing the vast majority of fall-related hospitalizations.
Table 2. Average Costs by Patients’ Characteristics and Fall-related Hospitalization on Admission in Texas, 2011 Age Sex Male 50 and older Younger than 50 Female 50 and older Younger than 50 Age 50 and older Younger than 50
Fall-Related Non-Fall-Related Hospitalizations Hospitalizations
$55,440.45 $44,241.02
$55,628.92 $30,862.95
$48,878.22 $36,945.16
$48,925.59 $22,566.34
$51,056.95 $41,215.07
$51,925.16 $25,422.39
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Fall-Related Hospitalizations
Non-Fall-Related Hospitalizations
$1,111,969,135.00 $267,923,639.38
$31,524,076,763.00 $14,979,577,758.00
$1,972,089,440.20 $158,309,995.17
$34,214,788,085.00 $20,870,933,714.00
found that nonmetropolitan residents continue to have lower average costs when compared to metropolitan residents. To assess differences among older adults with the highest costs, these comparisons were further stratified among those aged 50 and older. Among those aged 50 and older, costs associated with hip fractures were $55,366 among residents of nonmetropolitan areas compared to $61,715 among residents of metropolitan areas. Table 4 identifies fall-related costs by rurality and age group. As seen previously, the relative gap in average cost is consistent across the ruralurban divide.
$3,084,094,897.80 $426,246,239.63
$65,739,639,947.00 $35,856,168,092.00
Discussion
Table 3. Total Cost of Fall-related Hospitalizations in Texas, 2011 Age Sex Male 50 and older Younger than 50 Female 50 and older Younger than 50 Age 50 and older Younger than 50
Limitations
older was $60,533 versus $41,177 for those aged 49 and younger. However, the total costs associated with a hip fracture (not necessarily related to falls) was $1,076,661,057 among those aged 50 and older, while $156,088,836 for those aged 49 and younger in 2011. This includes all costs associated with a hip fracture, not necessarily those related to falls. The total costs of fall-related hospitalizations with a hip fracture among those aged 50 and older was $852,785,273 as compared to $26,188,372 for those aged 49 and younger. Costs by rurality
The total costs associated with fall-related hospitalization are presented in Table 4. In 2011, individuals residing in nonmetropolitan areas had an average fall-related cost of $45,706, and metropolitan-residing individuals had an average of $50,863. The total costs in nonmetropolitan areas accounted for 15% of the total costs among those aged 50 and older. The study team measured the overall costs of a hip fracture in nonmetropolitan and metropolitan comparisons. To ensure that the cost comparison across rurality was comparing like injuries, the study team looked at only those discharges that were coded with a hip fracture. Here, the team found that the average cost of fall-related hospitalizations where hip fracture is present was $55,132 among those residing in nonmetropolitan areas, while $61,126 among those residing in metropolitan areas. Thus, it was
Table 4. Total Costs of Fall-related Hospitalizations in Texas (2011) by Age and Rurality Age
Nonmetropolitan
This study used data that is cross-sectional in nature; therefore, trends over multiple years were not measured. However, 2011 costs were compared to those in 2007, which allowed the study team to assess gross change over time. It should be noted that the team did not account for changes in the average medical costs from 2007 to 2011 in these comparisons. Nor did the study team account for inflation, advances in treatment, or different ‘‘standards of care’’ that may contribute to higher fall-related costs from 2007 to 2011. Despite no changes in fall-specific ICD-9-CM coding occurring during the study period, changes in incentives to use these codes may have been introduced, which could have increased fall-related costs. In addition, the study team did not provide a comprehensive analysis of all fall-related injuries parceled by type. Instead, a separate set of analyses was performed on hip fractures because of the severity of this condition, which is strongly correlated with falling.19,20,21 Furthermore, this analysis did not include national data on falls, and as such may not be generalizable to other areas. That said, this study adds to the relative gap in state-level analysis of falls in a large and diverse southern state. The data are limited in that they do not include hospitals located in a county with fewer than 35,000 residents. However, the measure of rurality is at the patient level, which allows measurement of geographic variations beyond the hospital location. Furthermore, this analysis separated rurality into 2 categories (metropolitan and nonmetropolitan), which does not take into account variations within further subcategories of rurality. Rather, a more parsimonious analysis is provided that highlights major differences between metropolitan (urban) and nonmetropolitan (rural) areas. Further studies may include more detailed analysis, providing several levels of rurality to examine the nuances of fall-related costs by rural designation.
Metropolitan
Total costs of falls (mean) 50 and older $396,003,010.03 $2,582,470,982.60 ($45,564.72) ($51,795.48) Younger than 50 $44,302,717.12 $360,673,953.02 ($40,348.56) ($40,976.36) Total costs of fall-related hip fractures (mean) 50 and older $134,317,873.28 $689,724,208.17 ($55,365.98) ($61,714.76) Younger than 50 $2,864,751.78 $22,374,133.90 ($35,367.31) ($41,899.13)
Interpretation and conclusion
The rising cost of health care is showing little signs of slowing. More so, the fall-related costs in Texas grew dramatically from 2007 to 2011. The number of adults aged 50 and older was 6.96 million in 2011, from 6.14 million in 2007, which may account for a portion of this increase.22 Although the growth in the number of patients with a fallrelated hospitalization may account for a substantial portion of these costs (approximately 51,000 fall-related hospitalization in 2007), the higher costs per discharge, on average, (eg, over $51,000 in 2011 from almost $37,000 in 2007)
COST OF FALL-RELATED HOSPITALIZATIONS AMONG OLDER ADULTS
indicates costs are rising beyond those related to the increasing incidence of falls alone.10 Here, the growth in costs of health care may be related to this increased cost burden among older adults. Not only is the cost rising, but the average cost differs substantially by level of rurality. Thus, there is a gap of over $5000 (on average) depending on whether one resides in a nonmetropolitan area or metropolitan area. These differences are of great interest to those who would seek to lower the costs of fall-related hospitalizations, especially those related to hip fractures among older adults. Further research is recommended to investigate why rurality-based differences exist. The current analyses did not assume treatment in rural areas, but that costs are different depending on patients’ residential level of rurality (location identifiers are not present for hospitals in the public use file). The majority of older rural residents have been shown to utilize the closest rural hospitals, forgoing travel to farther urban hospitals23; however, this has been shown to vary by hospital size (closest) and the severity of the injuries needing treatment.24 Thus, evidence suggests that a majority of these rural residents are seeking treatment in rural areas, given the proximity of the closest hospital. Even so, those receiving care for more severe injuries may seek treatment in facilities that are larger or in urban areas, depending on the size of their local hospitals. Thus, the study team assumes the majority of costs among rural residents are likely representative of rural provision of care. Furthermore, studies have shown that average costs of ambulatory visits were lower among adults (18–44 years of age) in rural areas when compared to urban areas.25 Further research into why rural differences in cost exist is recommended. The increase in cost to treat a fall-related hospitalization is only part of the concern, where slowing the incidence of these hospitalizations may hold the most promise to combat these escalating costs. As adults enter into older age groups, the risk of falling increases, especially among those aged 65 and older.1 Finding ways to limit preventable falls among those aged 50 and older could prevent a great portion of the total costs associated with falls across the United States. The importance of this study relies on the timeliness (latest data available at the time of submission), its focus at the state level, and identification of trends over time and geographic variations in costs. This study serves as a model state-level analysis of the major shifts in costs and incidence of fallrelated hospitalizations. Such analyses allow for a more accurate assessment of falls in a specific demographic population and geographic area that can be more directly addressed by policy makers, practitioners, and researchers. On average, fall-related costs were lower for older persons, which may be attributed to the higher likelihood of death from a fall before more medical expenses are incurred.10 Although these analyses focused on older adults, it is of note that the variation in cost between fall-related and non-fall-related hospitalizations was dramatic for those aged 49 and younger. Falls among younger adults are more likely related to high-risk behaviors or occupationally related,1 which may result in different types of falls among this population. Further analysis should focus on these younger individuals to examine the primary drivers of this difference.
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Practical application: policy
Policy makers and funding agencies are very interested in finding ways for older adults to age in place, especially considering the costly and steadily rising public funding through Medicaid for nursing care in institutionalized settings.26 Policy makers need to have access to the most recent data available in order to understand the impact of falls, especially among those aging baby boomers who may be most vulnerable. This analysis is timely in that it can be used by policy makers and researchers; however, the study team recommends that similar analyses be conducted on a regular basis (every few years) to ensure efforts are guided by the most current evidence. More funding of implementation research is needed to further understand what works in allowing one to age healthfully in place. Practical application: research
Rising costs for fall-related hospitalizations, especially among older adults, warrants the attention of researchers to find ways to lower the incidence of falls among this growing population of older adults. Assuming that falls are an inevitable part of the aging process fails to take into account the great potential of falls prevention research.27 Fall prevention programs have the potential to reduce costs associated with falls.28,29 Targeted interventions that focus on those aged 50 and older can be effective at reducing costs if they reduce the number of falls among this population. For those with limited funding, an even more targeted approach may be to focus resources on those aged 75 to 84, as this group accounted for the largest portion of the total costs as compared to any other age group in Texas in 2011. Identifying funding opportunities for programs in the community setting that are tailored to meet the needs of those in older age groups may hold the best potential for cost reduction and containment if they can find success in reducing the number of falls in older populations. Author Disclosure Statement
Drs. Towne, Ory, and Smith declared no conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no financial support for this article. References
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Address correspondence to: Samuel D. Towne, PhD, MPH, CPH 1266 TAMU Department of Health Promotion and Community Health Sciences School of Rural Public Health Texas A&M Health Science Center College Station, TX 77843-1266 E-mail: [email protected]
