Family Practice Vol. 19, No. 6, 675-681
© Oxford University Press 2002
Breaking bones, breaking budgets: a clinical and economic evaluation of a prospective, randomized, practice controlled, intervention study in the prevention of accidents in primary care
a School of Care Sciences, University of Glamorgan, Pontypridd,
b Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, The Medical School and
c Health Economics Facility, University of Birmingham, Edgbaston, Birmingham,
d Department of General Practice and Primary Care, Medical Sciences, Queen Mary, University of London, London, UK.
Joyce E Kenkre, School of Care Sciences, University of Glamorgan, Pontypridd CF37 1DL, UK; E-mail: jkenkre{at}glam.ac.uk
Kenkre JE, Allan TF, Tobias RS, Parry DJ, Bryan S and Carter YH. Breaking bones, breaking budgets: a clinical and economic evaluation of a prospective, randomized, practice controlled, intervention study in the prevention of accidents in primary care. Family Practice 2002; 19: 675–681.
Received 2 October 2001; Revised 29 April 2002; Accepted 16 July 2002.
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Abstract |
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Objective. This longitudinal study was designed to assess the effect of an educational training package for primary health care teams in accident prevention for older people, with reference to the incidence of accidents and their associated economic consequence.
Methods. Nineteen general practices in the West Midlands serving a population of 138 397 were allocated randomly at the practice level either to receive training or continue normal practice. Study data was collated from the initial telephone call, reporting an accident, to the surgery, advice/treatment given at the practice and/or the community, casualty, inpatient care, written correspondence to the patient’s GP and any subsequent follow-up visits for accidents to people aged 65 years or older.
Results. One thousand, six hundred and sixty-six (8.2%) patients aged 65 years or older registered with the participating practices experienced one accident or more, costing the NHS £1.4 million. Extrapolated nationally, annual costs to the NHS for accidents to older people amount to £568 million. The educational package had no significant impact on the incidence of accidents. A paucity of general safety advice was given [48 (1.8%) occasions].
Conclusions. Budgets are being eroded and patients are suffering unnecessarily due to lack of accident prevention advice. This should be considered a priority within the primary health care team. Educational packages alone do not appear to be a cost-effective approach to accident prevention in primary care.
Keywords. Accidents, costs, older people, prevention.
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Introduction |
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The government has reiterated consistently the need to reduce unintentional accidents within the population,1,2 but deaths due to falls have risen since 1992.2 Information concerning accident data may be obtained from various sources.3,4,5 However, no complete comprehensive dataset exists on the incidence of accidents and their management within primary and secondary care.
The incidence of accidents increases with age and a previous estimate, in 1997, suggests that accidents in the home cost the country £30 billion annually.2 These costs are predicted to rise due to the foreseen increase in the proportion of older people within the population,6 which will have a significant impact on the already limited NHS resources, especially long-term care services.7
Thus, any intervention which can reduce significantly the number of accidents in the elderly population is likely to be cost-effective, not least to the NHS but also to the accident victims and their families. We report here the results from an educational intervention study concerning the prevention of accidents to older people, the accident sequelae and the financial consequence.
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Methods |
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All practices within the Birmingham and Hereford and Worcester Health Authority districts were invited to participate in a randomized practice controlled intervention study to prevent accidents in older people (Fig. 1
). Twenty-two practices were randomly selected from 31 willing to participate, the total population (161 697) was sufficient for the calculated power of the study. Minimization, a technique for correcting imbalances in a stratified randomization, was used to balance the intervention and control practices in terms of numbers of partners, list size and practice location. The practices were divided into three strata for the minimization and equal numbers of control and intervention were selected from these. Three intervention practices withdrew, following the phased three month baseline collection, due to the lack of time for training in accident prevention. Data continued to be collected for a further nine months in the remaining 19 practices (population 138 397). The population over 65 (12 439) was greater in control practices (n = 11) than in intervention (7944, n = 8).
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Annually, 34% of people over the age of 65, following an accident, are admitted to hospital.8 To ensure a probability of 80% that a change of 10% in admissions can be detected by using a 5% significance test, a sample of 322 was required in each of the intervention and control groups.
Seventeen per cent of females over 65 have accidents annually,9 therefore, to show a change of 5 percentage points in the rate, 780 females were required for each group. Males have a lower percentage of accidents annually, approximately 9%, therefore, to detect a change of 5%, 380 males are required in each group. This ensures in each case that there is an 80% chance of a 5% significance test detecting this change.
The educational training package included a staff video, community video, trainer’s guide, trainer’s cards and transparencies. Training topics included introduction to the problem, membership of the team, accident prevention advice, after effects, assessing the individual, assessing the home, assessing external factors, teamwork and the development of practice protocols. Training sessions were limited to three hours.
Study data were collated from the initial telephone call, reporting an accident, to the surgery, advice/treatment given at the practice and/or the community, casualty, inpatient care, written correspondence to the patient’s GP and any subsequent follow-up visits.
The costs of the treatment for accident-related injuries comprised two components: inpatient and non-inpatient activity. Inpatient activity costs were based on mean values for the relevant health resource groups (HRGs) with adjustments to reflect variations in length of stay.10 Non-inpatient activity was costed using national published sources.11 All costs were inflated to a common 1998 price base and are expressed in UK pounds sterling.
Statistical analysis was carried out in SPSS v8, Stata v5.0 and Excel97. Chi-squared tests were used to compare frequencies, binomial tests for proportions and random effects analysis of variance (ANOVA) was used to investigate differences between practices and hospitals, on the mean length of stay (LOS) and age of the patients following an accident.
The mean costs of the intervention group were compared with the control group by using a t-test. Uncertainty in the parameter values was expressed using the 95% confidence interval around the mean. Given the often skewed nature of cost distributions, the Bootstrap–t was used to check the validity of the parametric method.12,13 Bootstrapping is a method for re-sampling from one’s data to obtain a non-parametric estimate of error from which a confidence interval may be calculated. The results indicated that for these cost data the t-test was suitable.
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Results |
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Information was collected on 1666 patients, aged 65 years and over, who had experienced an accident during the study period from all participating practices. One thousand one hundred and eighty-one (71%) were female, with 1051 (63%) known to be aged 75 years or older. Four hundred and forty-three (27%) patients lived alone, but this information was not available for 659 (40%) patients, despite data collection occurring in primary care. The demographic data is given in Table 1
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There were no overall significant reductions in the rate of accidents in the intervention practices compared with the controls. Since the intervention and controls were not significantly different a random effects analysis on this outcome was not considered necessary. There were significant differences that were evident during the baseline period and which continued during the active phase of the study. Prior to the study commencing, an average of 4.1% of over 65s had experienced an accident per practice in control practices and an average of 3.0% per practice in intervention practices. During the active phase of the study period these were 4.7% for control practices and 4.0% for intervention practices (Figs 2 and 3
). There was a significantly larger increase in the percentage of accidents in the intervention practices compared with controls (test of proportions Z = 3.71, P < 0.001).
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Overall, intervention practices (559, 34%) had approximately half as many patients experiencing an accident as control practices (1107, 66%) (test of proportions Z = 4.85, P < 0.001). This represents 7% (1 in 14) of the study population in the intervention and 8.9% (1 in 11) in the control practices. The overall odds ratio of having an accident in a control practice was 1.29 compared with intervention practices (95% CI 1.16–1.43).
The majority 1477 (89%) had only one accident during the study period (Table 2). Falls were the most frequently recorded cause for their initial accident (1124, 67%), with 1357 falls being reported overall.
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A total of 1901 injury sites were recorded, the most frequent sites were arm/hands (510, 27%), legs (340, 18%) and head (290, 15%). The most frequently reported injuries were cuts and lacerations (361, 22%); tenderness and swelling (350, 21%) and fractures (319, 19%). Most fractures (267, 84%) were as a result of a fall, with no significant difference between intervention and control practices.
Contacts and sequences
There were 655 contacts, following the patients’ initial accident, for the 559 intervention patients and 1310 contacts for the 1107 control patients. The vast majority of intervention 447 (80%) and 812 (73%) control patients only had the one contact, with or from the health profession, following their accident.
In the intervention practices, 398 (71%) people made their first contact with the casualty department, 55 (10%) with the practice nurse, 49 (9%) first visited the GP and 33 (9%) first spoke with the receptionist. Of the 398 people who went to casualty, only 67 (17%) letters from the hospital were received by the patient’s GP. Of the 88 people who had accidents within residential homes, only 7 (8%) were seen by their GP or at casualty.
In the control practices, 783 (71%) people made their first contact with the casualty department, 101 (9%) with the practice receptionist, and 70 (6%) with the practice nurse. Of the 783 people who went to casualty, only 122 (16%) letters from the hospital were received by the patient’s GP. Of the 93 (8%) people who had accidents within residential homes, only 6 (1%) were seen by their GP or at casualty.
Hospital admissions
There were 558 patients admitted during the study period. The number of patients admitted from each practice ranged from 8 to 82 and the variation across practices was significantly different (
2 = 223.59, d.f. = 18, P < 0.001). The average percentage of admissions for study subjects was not significantly different for both intervention and control practices (2.9% and 2.6% respectively, Z = 1.26, P = 0.206).
There were significant differences in the mean number of LOS days between practices (F18,536 = 1.982, P = 0.009), ranging from 9 to 26 days. However, when analysed by intervention and control groups there was no significant difference either at baseline or during the study. The average age of admission for intervention and control practices was 81 and 80 years respectively.
The following analyses took into account practice variation. In no case was there a significant difference between intervention and control. Significant differences (F12,524 = 2.012, P = 0.021) were apparent in the mean number of days (4–26) that patients stayed in the different hospital trusts within the West Midlands region (Table 3). The age of those that were admitted (F12,527 = 2.176, P = 0.021) to the different trusts was also significantly different, ranging from 73 to 86 years.
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The LOS and age varied significantly (LOS F37,499 = 2.783, P < 0.001, age F37,502 = 1.993, P = 0.001) for the ‘reason for admission’. Fractures of the femur were the most common reason for admission, with patients’ average age of 82 years and LOS average 25 days (SD = 24.64) in hospital. The mean age of patients undergoing fixation and or manipulation of a fracture was 81 years. Ninety-five patients (also, mean age 81 years) required hip replacement with an average LOS of 24 days. There was significant variation in the LOS (F10,302 = 3.354, P < 0.001) and age (F10,303 = 2.731, P = 0.003) between patients with the different operation types.
Advice
Following their accident, 678 patients received advice from a health professional. Intervention and control practices gave a similar amount of advice as each other (Table 4). However, if the first contact was with the hospital, patients were 1.5 times more likely to have had no advice given than if they had seen the PHCT. General safety advice was given on 48 (1.8%) occasions: 23 occasions were during the pre-active phase of the study and 25 during the active phase.
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Similar advice was given across practices. However, under 75s were approximately twice as likely to be told to ring the surgery if their symptoms, due to their accident, recurred than those older than 75 years.
On debriefing the practices, accident prevention was considered an important issue but of a low priority. The majority had not held any practice meeting on the subject and only one had developed a practice protocol.
Cost implications
The total cost of the training including development of the video (£35 000), researcher time, departmental training time, primary health care team (PHCT) training time was £38 100.
There was no statistically significant difference (P = 0.61) in the mean NHS cost per registered elderly patient in the intervention group versus the control group (Table 5). The total cost for the study population, based upon all relevant resources used, was £1 428 087.
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Discussion |
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This study raises many important issues, despite no demonstrable change being shown in the incidence of accidents between the control or intervention practices. This may, in part, be due to the reduced power of the study by the withdrawal of the three practices. However, it may also reflect the difficulty of changing behaviour with this type of intervention. It was apparent, from the minimal advice given to patients, that the health professionals had not changed their practice from reactive care to the institution of preventative measures. GPs feel that they ‘cannot be all things to all people’, nor should they be. Strategies need to be created that address and achieve a change in the pattern of care, so that older people receive effective advice on the prevention of accidents. The elderly would welcome health promotion activity, provided that it is given in easily accessible forms.14
Traditionally, primary care health visitors’ roles included health promotion. However, study patients were more likely to see a practice nurse, for follow-up care after an accident, than a health visitor. Thus, demonstrating the changing roles of primary care health professionals, since the practice nurse appears to be establishing her role within health promotion.15
Prevalence
Following the initial accident, the main injuries sustained were cuts and lacerations, bruises, tenderness and swelling. A similar study reported that over half the injuries sustained were contusions, swellings or sprains, but most were not reported to the medical services.16
Sixty-seven per cent (1124) of patients presenting, following an accident, had experienced a fall. A similar percentage of falls has been recorded in a longitudinal study of falls in an elderly population.17 However, in this current study, 69% (1149) of those who fell were 75 years or older. This is a higher percentage of falls than in previous studies, which reported fall prevalence of 28% in people aged over 65,18 40% in those aged 75 years or older,19 rising to 50% in those over 80 years of age.20
This current investigation established that 84% (267) of fractures were caused by a fall. Similar results were obtained by a comparable study of elderly patients, with falls being the predisposing factor for 87% of all fractures.21 It has been suggested previously that rapid assessment of patients attending A&E departments for certain risk factors might reduce the number of hospital admissions.22
Contacts and sequences
This study established that 1061 (64%) patients, following their first recorded accident, attended their local A&E department. This is markedly different from a postal survey16 which found that only 5–6% patients reported to an A&E department. An investigation of unnecessary or inappropriate attendance at the A&E department found that 23% could have been cared for in primary care.23 Previous studies have reported that elderly patients’ attendance at A&E departments were due to social isolation.24 Nevertheless, records of home circumstances are not made in secondary care and few in primary care. Knowing this information would help in the future management of care. This issue of appropriate attendance, however, was not addressed within this study but should be considered for future strategy in care provision.
Assessment
One hundred and eighty-nine (11%) older people had more than one accident and only 5 (3%) were seen by an occupational therapist and 4 (2%) by social services. The NHS Community Care Act of 199025 formalized the requirement for local authorities to be involved in assessment of an individual in need. Social services have the ultimate responsibility for the assessment. However, if the patients are not referred for assessment, or the carer is not aware that, following an initial assessment, a review can be requested, then appropriate facilities and provision of care may not be provided.26
General Medical Services Statistics record that approximately 58% of population within the study area were 65 years or older and female.27 However, the majority reporting a first accident (1181, 71%) and a subsequent accident (156, 72%) were female. This represents 10% of the study population, considerably less than the recognized annual rate of 17%.9 Similarly, approximately 6% of men had accidents in this study, compared with 9% nationally.
The 1991 census showed that, in the West Midlands, there were 795 256 people 65 years or older, with only 14 705 (1.8%) from minority ethnic groups.28 There was a low percentage of ethnic minority people within this sample (6, 0.4%) who experienced an accident. This is an issue that must be re-investigated as greater proportions of these many diverse populations grow older.
Implications for length of stay
There was a significant difference found in LOS between the trusts within the West Midlands region. Even though a patient may have sustained a fractured neck of femur, hospitalization may not occur. Recently, there has been a reduction in hospital beds, resulting in elderly patients being cared for more in the community. Fractures of the femur were the most common reason for admission to hospital, with 24 days being the average LOS and this is much higher than recorded in the USA.29
Cost implications
The total cost of £1.4 million for caring for patients aged 65 or older, following an accident, is likely to influence PCGs/PCTs/LHGs’ future outlook on accident prevention. When this is extrapolated to the whole of the NHS (England and Wales), the total cost nationally would be approximately £568 million annually. The government spends £1.6 billion annually on the treatment of accidents for the whole population (52 million).2 The costs, estimated from this study, equate approximately to a third of this budget but the over 65s only represent 15.8% of the population. The true cost of any accident must be considered, not only in terms of monetary cost but also to the patients’ and carers’ quality of life.
Limitations in the collection of accident information
It is important to acknowledge that there were numerous problems that limited the collection of information regarding accidents within A&E departments and primary care. The information systems varied considerably and there was no consistent compatible method of data collection between the hospitals. The caring philosophy within A&E departments addresses the presenting problem only and not the mechanism of injury. This resulted in the retrieval of incomplete datasets from the medical records.
Communication between A&E departments and community staff was varied. Many of the community members were not based at the practice and fundamental clarification was needed to identify PHCT members. On numerous occasions, incident details were not communicated to the general practice or to the supporting health visitor. One hospital did not communicate A&E attendances during a four month period, yet had not informed the primary care health professionals of this problem. This lack of communication with primary care staff could result in inappropriate or no care being given to the patient following discharge, with detrimental consequences.
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Acknowledgments |
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The authors wish to acknowledge project funding from NHSE West Midlands Regional Office and the Department of Health for their sponsorship through the Royal Society for the Prevention of Accidents (RoSPA). Special thanks to colleagues at RoSPA for their invaluable help throughout the project. Also, the authors are especially grateful to Verity Allan, Melanie Cohen, Pauline Morgan, Pat Ogan, Kim Waldron and to all members of the primary health care teams who participated in the study.
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References |
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