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Level of need in the population

Adults :: Falls :: Level of need in the population

Demographics

Increasing life expectancy and a reduction in fertility is leading to an ageing of England's population. Medway's population is currently younger than the national average but population projections (please see 'Our People and Place') suggest that the number of people 50 years or above will increase from 88,000 in 2013 to 102,000 by 2021 and the number of people over 85 years will grow by 27% to 5,800.

This expected growth in the older population has important implications for falls prevention strategies, healthcare and social care services. There are differences in the age distributions of Medway's wards. Rainham Central, Hempstead & Wigmore and Rainham North have the largest proportions of older people with one fifth or more of their population aged 65 years and above. 51% of falls amongst Medway residents aged 50 years and above which required hospital admission in 2012 occurred at the patient's home. 9% occurred within a residential institution. Table 1 gives a breakdown of place of occurrence of these falls.

  Percentage
Home 50.7%
Residential/nursing institutions 8.9%
School, other institution and public administrative area 4.4%
Sports and athletics area 0.4%
Street and highway 5.9%
Trade and service area 2.5%
Industrial and construction area 0.1%
Farm 0.1%
Other specified places 1.2%
Unspecified place 26.0%
Table 1: Place of occurrence of falls requiring hospital admission, Medway residents aged 50+ (n = 1260), 2012 Source: Secondary Uses Service via KMHIS data warehouse

Table 1 shows that in over a quarter of cases the place of occurrence is coded as 'unspecified'. Although this proportion has decreased compared to previous years, the reliability of the data is limited.

Hospital admissions

Figure 1 shows that the falls admission rate for Medway residents (males and females combined) aged 50 years and above rose by 23% from 2007 to 2011 when a peak of 1488.2 per 100,000 was reached in before falling again from 2011–2012. A similar pattern to that seen in figure 1 applies to admission rates for falls amongst those aged over 65 years. Further surveillance of falls–related admissions will determine whether or not this decline is an enduring trend.

Figure 1: Directly standardised hospital admission rates, all falls in >50s, 2007--2012, Medway Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics .
Figure 1: Directly standardised hospital admission rates, all falls in >50s, 2007–2012, Medway Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

In 2012, neck of femur (NOF) fractures accounted for 11.4% of all falls–related admissions in Medway compared to 52.6% of admissions where no fracture took place. Falls–related admissions for hip fractures made up 24.1% of admissions for all fractures following falls in 2012. Figure 2 shows that the highest rates of falls related Medway admissions in 2012 were for non–hip fractures ('other fracture') and injuries other than fractures ('other injury'). Over the period from 2007–2012, admission rates for 'other fractures', 'other injury" and 'other diagnoses' have been consistently higher than for 'neck of femur fracture' and 'other femur fracture'. The admission rates for all primary diagnosis categories apart from 'other fracture' have declined over 2007–2012: the rate for 'other fracture' has seen an increase from 2010–2012 (although not statistically significant). Admission rates for 'other diagnoses' (i.e., diagnoses without injury or fracture) rose steeply from 2008–2011 and then declined sharply.

Figure 2: Trends in directly age--standardised rates for falls related hospital admissions, Medway residents aged 50+, by primary diagnosis code, 2007--12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.
Figure 2: Trends in directly age–standardised rates for falls related hospital admissions, Medway residents aged 50+, by primary diagnosis code, 2007–12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

Table 2 shows the change in numbers of falls related hospital admissions for each of the five diagnosis categories over the period 2007–2012.

  Fractured neck of femur Other femur fracture Other fracture Other injury Other diagnosis
2007 120 102 302 420 273
2008 131 84 304 409 270
2009 145 85 378 505 383
2010 168 79 331 461 451
2011 155 83 373 445 557
2012 144 69 384 400 263
Table 2: Numbers of falls related hospital admissions, Medway residents aged 50 years and above, by year of occurrence and primary diagnosis code, 2007–2012 Source: Secondary Uses Service via KMHIS data warehouse.

Figure 3 shows that the admission rates for hip fractures following falls rose steadily from 2007 to 2010 and then saw an overall decline from 2010–2012 which was most marked amongst females. Further surveillance of falls–related admissions will determine whether or not this decline is an enduring trend.

Figure 3: Trends in directly age--standardised hospital admission rates for fractured neck of femur following falls, Medway residents aged 50 years and above, by primary diagnosis code, 2007--12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.
Figure 3: Trends in directly age–standardised hospital admission rates for fractured neck of femur following falls, Medway residents aged 50 years and above, by primary diagnosis code, 2007–12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

Admissions for “other diagnoses” (i.e., involving no falls related injury) saw a striking increase of 51% in their total number from 273 in 2007 to 557 in 2011 (an increase in the rate of admissions of 48% from 253.5 to 489.0 per 100,000) followed by a fall of 53% in numbers of admissions from 557 in 2011 to 263 in 2012 (a decrease in the rate of admissions of 53% from 489.0 to 228.9 per 100,000). The pattern of admission rates for “other diagnoses” is shown in figure 7.

Figure 4: Trends in directly age--standardised hospital admission rates for 'other diagnoses' following falls, Medway residents aged 50 years and above, 2007--12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics.
Figure 4: Trends in directly age–standardised hospital admission rates for ‘other diagnoses’ following falls, Medway residents aged 50 years and above, 2007–12 Source: Secondary Uses Service via KMHIS data warehouse and Office for National Statistics

The International Classification of Diseases (ICD) is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. The ICD–10 is the 10th revision of the classification and is the version which is currently in use.

The steep drop from 2011–2012 in admissions for “other diagnoses” represents a fall in actual numbers of these admissions of 294 between 2011 and 2012: admissions coded as senility account for 61% of the total drop in admissions. Table 3 shows the breakdown of the top eight diagnosis codes within the “other diagnosis” category which were most frequently used to classify falls–related hospital admissions in Medway for 2011 and 2012.

  ICD 10 description 2011 2012 % change
R54 Senility 177 39 -78%
N39 Other disorders of urinary system 47 27 -43%
M25 Other joint disorders, not elsewhere classified 42 25 -40%
J18 Pneumonia, organism unspecified 32 17 -47%
M54 Dorsalgia 25 11 -56%
R55 Syncope and collapse 14 7 -50%
I63 Cerebral infarction 7 7 0%
J22 Unspecified acute lower respiratory infection 10 6 -40%
Other Further separate diagnoses 203 124 -39%
Total 557 263 -53%
Table 3: Number of falls–related hospital admissions without an injury or fracture recorded in primary diagnosis, 2011 & 2012, Medway residents aged 50 years and above Source: Secondary Uses Service via KMHIS data warehouse.

Median length of stay for falls–related hospital admissions in people aged over 65 years (all falls) was 7 days (mean 12.1) in 2012. The median length of stay for admissions for hip fractures was 12 days (mean 16.1). Median length of stay was longest for the “other femur fracture category at 17 days (mean 24.5).

Ambulance callouts

Data on ambulance callouts was obtained from the South East Coast Ambulance Service (SECAMB). SECAMB classify callouts by problem nature and response using NHS Pathways, a clinical triage system, which replaced the Advanced Medical Priority Dispatch System (AMPDS) triage software in 2011. Callouts to Medway residents classified as either 'fall <12ft' or 'falls–assistance only' have been included in the following analyses. 2,746 emergency calls were made to SECAMB in 2012/13 based on the inclusion criteria above. Of those, 150 were removed as they were either duplicates or call–backs from a clinician. A total of 2,596 incidents were analysed. Figure 5 shows the age and gender distribution for all Medway residents who called for an ambulance following a fall in 2012/13. Patients represented by the bars labelled "unknown” represent those where age and/or sex had not been recorded.

Figure 5: All SECAMB falls--related callouts, 2012--13, Medway residents by age and sex Source: South East Coast Ambulance Service NHS Foundation Trust, July 2013.
Figure 5: All SECAMB falls–related callouts, 2012–13, Medway residents by age and sex Source: South East Coast Ambulance Service NHS Foundation Trust, July 2013

Figure 6 shows that numbers of callouts for falls increased with age of patient (median age of patient 80 years, range 4 months– 105 years). The 80–90 year age group made up a third of all incidents throughout last year. The over 50's group (target audience) accounts for 85% (2,208/2,596) of all SECAMB callouts for falls. The proportion of falls–related callouts for female patients aged 50 years and over (66%) was almost double that of males for 2012/13.

Increases in falls–related callouts occurred during the winter months of 2012/13 — these monthly differences are in–line with overall SECAMB activity during those periods.
Of the 2,596 falls–related callouts, 371 (14%) falls had occurred in a public place. The response rate was 95% (2,477/2,596) with 119 incidents being cancelled before the ambulance arrived. The conveyance rate was 39% (962/2,477) with 1,515 patients not being conveyed to hospital. Of those patients who were conveyed to hospital, the final destination for 99% (952/962) was Medway Foundation Trust.

Falls related mortality

The falls–related mortality rates provided by the Kent & Medway Public Health Observatory (KMPHO) are based on the underlying cause of death between ICD–10 codes W00 and W19, registered anytime over the five year period from 2008–2012. The Clinical Commissioning Group populations have been sourced from the Exeter database via the Primary Care Information System.
Deaths following falls across Kent CCGs are presented in figure 6 as pooled data (age standardised mortality rates) for 2008–2012 as the numbers of deaths recorded in each year were small. In total, 55 deaths were recorded in Medway for 2008–2012 for male and female patients aged 65 years and above. The reliability of the rates presented here may be affected by the small numbers of deaths due to falls.

Figure 6: Mortality rates from falls, Kent & Medway CCGs, 2008--2012, males and females aged over 65 years (D,G and S = Dartford, Gravesham and Swanley) Source: Public Health Mortality File, PCIS populations.
Figure 6: Mortality rates from falls, Kent & Medway CCGs, 2008–2012, males and females aged over 65 years (D,G and S = Dartford, Gravesham and Swanley) Source: Public Health Mortality File, PCIS populations

For males aged 65 years and above, the age standardised mortality rate for Dartford and Gravesham CCG is significantly lower than all other Kent CCGs for 2008–2012. For all other Kent CCGs, including Medway, the falls–related mortality rates are not significantly different, and although Medway CCG's rate appears to be higher than Kent & Medway as a whole, the difference is not statistically significant. For females aged 65 years and above, the age standardised mortality rate for Medway CCG for 2008–2012 is not significantly different to the other Kent CCGs and is similar to the overall rate for Kent & Medway as a whole.