This study provides national estimates of the incidence and direct medical costs associated with fall related injuries among adults aged
65 in the United States. In 2000, there were 10
300 fatal and 2.6 million non‐fatal fall related injuries. Estimated direct medical costs for these injuries totaled $0.2 billion dollars for fatal and $19 billion dollars for non‐fatal falls. By comparison, largely omitting nursing home costs and looking just at the medical costs traceable directly to falls without fully capturing the costs of complications using the case crossover method, Finkelstein et al16
estimated medical costs at $12.8 billion for the same cases analyzed here. One study found that 12% of older adults who fell subsequently required long term nursing home care.20
Hip fractures are especially traumatic. Older adults who survive hip fracture often experience significant disability and loss of independence.21,22
After hospitalization, many hip fracture patients are discharged to nursing homes where up to 25% of these formerly independent older adults remain for at least a year.23
Our findings are more similar to those reported by Englander and colleagues15
who estimated the direct costs of falls in the US in 1994 was $21 billion (in year 2000 dollars). A recent study using 1997 MEPS data estimated the cost of fall related injuries among non‐institutionalized older adults was $6.9 billion (in year 2000 dollars).24
This analysis, based on a sample of 4000 seniors, used self‐reported falls data which often are underestimated.25
In addition, this study excluded hospital patients and nursing home residents who are at much higher risk of sustaining fall related injuries than are community dwelling seniors.26
International studies underscore the substantial economic burden caused by fall related injuries, regardless of the medical care system. A recent study reported that, in 1999, ED and hospital care for fall related injuries among people aged
60 cost the United Kingdom almost £1 billion (US$1.9 billion)3
A Western Australia study estimated ED treated and hospitalized fall injuries among people aged
65 cost the Australian healthcare system $86.4 million (US$66.1 million)9
Cost estimates differed by treatment settings. Of the direct medical costs for non‐fatal injuries, almost two thirds were for injuries that required hospitalization, one fifth for injuries treated in EDs, and one eighth for injuries treated in outpatient settings. Twelve billion dollars, or 61%, was for treatment of fractures. This is similar to a study that used 1999 Medicare claims data and found that 67% of injury claims were for fractures.27
These injuries accounted for 80% of hospitalization costs, 27% of ED costs, and 32% of outpatient costs.
Medical expenditures for women, who made up 58% of the older population,19
were 2–3 times higher than for men for all treatment settings. It is likely that this difference represented treatment costs for osteoporotic fractures, principally hip fractures. Osteoporosis is a metabolic disease that causes bones to become porous and susceptible to fracture and it disproportionably affects older women.28
Women sustain hip fractures at a significantly higher rate than men29,30
and treatment typically includes surgery and hospitalization, frequently followed by nursing home admission and extensive rehabilitation.31
Although we could not identify specific kinds of fractures (the type of fracture is incompletely coded for fatalities and ICD‐9 coding is not included in NEISS‐AIP), a 1995 study found that 63% of direct medical expenditures for osteoporotic fractures were for hip fractures.32
Falls are the most common mechanism of TBI33
and are the leading cause of hospital admissions for TBI.34
If a fall related head injury occurs, older adults are particularly susceptible to intracranial hemorrhage, especially if they are taking anticoagulants.35
TBI accounted for almost half of fatal falls and associated costs. Fatality rates from TBI are highest among the oldest old, those aged
To reduce these serious and often fatal injuries, it is essential that we implement fall interventions.
Injuries to internal organs were responsible for 28% of deaths and 29% of medical costs for fatal falls. The high prevalence of this type of fall related injury has not been reported previously. Additional research is needed to clarify why older adults are at risk of dying from these types of injuries and how such fatalities could be prevented.
Although the estimated economic impact is substantial, direct medical costs do not fully portray the financial burden of fall related injuries. Our data did not permit us to estimate the costs associated with lost wages and housework for the injured or their informal caregivers, or for non‐medical expenditures (for example, wheelchair ramps), insurance claims processing costs, reduced quality of life, and decreased functional capacity of many older adults who sustained fall related injuries.
This analysis has a number of limitations. We derived the incidence and cost estimates from different data sources which adds uncertainty to the total cost estimates. This was necessary because no single nationally representative data set would allow us to estimate detailed fatal and non‐fatal incidence and costs. For example, Medicare data exclude those in Medicare HMOs and therefore could not be used to estimate injury incidence. Our analysis quantified costs for 12 months post injury. However, without additional analyses we could not identify which services were responsible for the increase in costs. Finally, most of the data sources were subject to some reporting and measurement errors which increased the lack of precision around the estimates, may have introduced some additional bias, and precluded computation of standard errors.
The magnitude of this economic burden underscores the need to implement cost effective intervention strategies. A recent meta‐analysis of the intervention literature found that fall prevention programs, analyzed as a group, effectively reduced the risk of falling by 11%,37
and a systematic review reported that multicomponent interventions for community dwelling seniors reduced fall risk 27%.38
Among people at high risk (for example, those who have fallen at least once before), clinical assessment combined with individualized fall risk reduction and patient follow up was effective, lowering the risk of falling by 18%.37
- Direct medical care costs totaled $0.2 billion for fatal and $19 billion for non‐fatal fall related injuries among people aged 65.
- Medical expenditures for women, who made up 58% of the older adult population, were 2–3 times higher than for men for all medical treatment settings.
- Fractures were both the most frequent and most expensive type of non‐fatal injury.
- The economic burden of fall related injuries underscores the need for effective interventions.
Among community dwelling older adults, the risk of falling is 3–4 times higher among people with muscle weakness or gait and balance disorders.39,40
The most effective single intervention was exercise which, overall, lowered the risk of falling between 12%37
Types of effective exercises included Tai Chi,41,42
balance and gait training, and strength building.43,44,45
Because falls are frequently the result of interactions between individuals and their environments, effective multicomponent interventions generally address multiple risk factors.46
These might include risk factor screening; exercise or physical therapy to improve gait, balance and strength; medication management (which involves reducing the number of medications, especially psychoactive medications); education about fall risk factors; referrals to healthcare providers for treatment of chronic conditions; vision assessment and correction; and home hazard reduction.47,48,49,50,51
Implications for prevention
Our results show that fall related injuries among older adults, especially among older women, are associated with substantial economic costs that are borne by individuals, society, and the medical care system. Although research has identified interventions that can reduce fall related injuries, implementation remains limited. Additional efforts are needed to successfully disseminate cost effective fall prevention programs, and to promote widespread adoption at the local level. By employing effective interventions, we can appreciably decrease the incidence of fall related injuries, improve the health and quality of life of older adults, and significantly reduce healthcare costs.