Estimating the Economic Burden Related to Older Adult Falls by State: Author Q&A with Dr. Yara Haddad

Yara Haddad, PharmD, MPH, BCGP

At JPHMP, our mission is to advance and disseminate impactful, practice-based evidence to inform initiatives and policies to improve population health. The public health researchers, academics, policy makers, and practitioners who contribute content to the journal support this mission and strive to improve public health for all communities through their research.

We spoke with Dr. Yara Haddad about her new article “Estimating the Economic Burden Related to Older Adult Falls by State,” published in the Journal of Public Health Management and Practice.

JPHMP Direct: In your article, you discuss the burden of older adult falls. Could you start by giving an overview of what is currently known about the estimates of incidence and costs of older adult falls in the United States?

Dr. Yara Haddad: Older adult falls are common and can cause serious health issues. When not fatal, falls often result in brain injury, hip fracture, and loss of independence. In the United States, 1 in 4 older adults falls each year. Age-adjusted fall death rates have increased more than 30% between 2007 and 2016, and more than half of all states had a significant rise in fall death rates. Injuries caused by a fall account for approximately 80% of all injury-related hospitalizations in older adults every year. At an estimated average cost of $30,000 per fall-related hospitalization, these fall injuries often result in substantial medical cost.

A recent study by the Centers for Disease Control and Prevention (CDC) estimated that US healthcare spending on older adult falls at $50 billion annually, with 75 percent of these dollars shouldered by publicly funded healthcare programs (Medicare and Medicaid).

JPHMP Direct: What are some of the limitations of the current methods of estimating the economic burden of older adult falls?

Dr. Yara Haddad: While a number of studies report the national economic burden of older adult falls, there are no studies that estimate the state-specific economic burden.

National estimates use various data sources including hospital discharge data, Medicare data, and Medical Expenditure Panel Survey data. These estimates vary widely due to differences in the methods used to identify a fall, use of multiple and varying databases to extract information, and the differences in study design. The differences make it difficult to compare estimates across the methods.

Our study highlights two methods states can use to estimate and interpret their state-specific spending on older adult falls. State specific cost information is valuable in that it can inform efforts to efficiently allocate state resources and implement cost-effective prevention strategies. 

JPHMP Direct: In your article, you discuss two methods of estimating the cost of older adult falls, namely partial attributable fraction and count applied to cost. Could you give us a brief overview of the methods applied in these two approaches?

Dr. Yara Haddad: The first method, partial attributable fraction, offers detail on older adult falls spending by payer type: Medicare, Medicaid, and private insurance. It is calculated by applying the national attributable fraction for older adult falls to the total state health expenditure accounts in 2014. The second method, count applied to cost, allows states to use their own counts for residents hospitalized or admitted to emergency departments (ED) to calculate lifetime costs due to fall injuries requiring medical treatment. While both methods rely on nationally calculated costs, they are applied to state-specific total health expenditures and state-reported counts of medically treated injuries to estimate the economic burden of older adult falls.

JPHMP Direct: The Healthcare Cost and Utilization Project data (HCUP) databases include charges incurred per hospitalization (SID) or emergency department visit (SEDD). Why would you not use the specific charges that are associated with each fall encounter as a way to calculate specific costs for older adult falls per state?

Dr. Yara Haddad: The State Emergency Department Databases (SEDD), and the State Inpatient Databases (SID), contain data on the total charge billed for a service. In most cases, these charges do not reflect the actual cost in conducting the service or the amount hospitals were reimbursed for the service. The files available for the SID and SEDD contain cost to charge ratios that can be used to estimate actual cost, but these are hospital specific, making it difficult to estimate state level direct medical costs.

The Web-based Injury Statistics Query and Reporting System (WISQARS) cost of injury reports used in this study provides an estimate of the lifetime medical cost for an older adult fall-related ED visit or hospitalization including hospital readmission charges, rehabilitation costs, and follow-up visits beyond 18 months for serious injuries. This provides a more comprehensive estimate in comparison to the cost to charge ratios in HCUP.

JPHMP Direct: If state officials are interested in calculating medical costs for adult falls, what would be the best approach for them to use?

Dr. Yara Haddad: States and local governments can use one of the two methods, depending on data availability and needs.

The partial attributable fraction method can offer states details on spending estimates on older adult falls by payer type, specifically the publicly funded healthcare programs Medicare and Medicaid. A limitation of this method is that the attributable fraction is based on national data and is not unique to their state.

The count applied to cost method allows states to use the state’s own counts for residents hospitalized or admitted to emergency departments to obtain an estimate of lifetime costs due to fall injuries. The count applied to cost method can also be used to track cost estimates across years to assess the economic impact of implemented prevention strategies that reduce hospitalizations or emergency department visits for an older adult fall. A limitation of this method is that it does not capture as comprehensive a list of costs as the partial attributable fraction and you cannot calculate cost by payer type.

JPHMP Direct: Were there any surprising findings from your study?

Dr. Yara Haddad: While not unexpected, it is useful to point out that the lifetime cost estimates calculated using the count applied to cost method were typically lower than the annual cost estimates calculated using the partial attributable fraction. The reason is likely because 90% of fall-related medical costs incur within three months after a fall. Therefore, the majority of costs captured by the count applied to cost method are also likely to be captured by the partial attributable faction method. In addition, the partial attributable fraction method includes a wider range of medical costs (eg, outpatient hospital services, prescriptions, durable medical equipment, physician and clinical services).

JPHMP Direct: Can you provide an overview of some of the limitations of your study?

Dr. Yara Haddad: For partial attributable fraction, we assumed fall prevalence and proportion of spending by payer type on older adult falls is similar for all states, after adjusting for differences in the proportion of older adults per state. For the count applied to cost method, we assumed the cost of treatment for any hospitalized or ED-treated fall injury is similar in all states. While these are notable limitations, we view both methods as valuable resources for states and local governments who wish to evaluate the economic burden of older adult falls in their communities.

JPHMP Direct: What can states do to reduce the medical costs of older adult falls?

Dr. Yara Haddad: Preventing falls can reduce medical costs and there are many effective fall prevention programs and interventions that can be implemented at the state and local level. The Centers for Disease Control and Prevention provides guidance to states on effective fall prevention interventions and how to implement them. CDC provides tools and resources for clinical fall prevention through its STEADI initiative ( States can track falls and healthcare costs to help prioritize state-driven fall prevention efforts. These data can determine the need, location, and impact that state-driven fall prevention efforts have on health outcomes and healthcare costs.

Read our other author Q&As:

About the Author

Dr. Haddad is a consultant geriatric pharmacist in the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention in Atlanta. She supports the Home Recreation and Transportation Safety Branch. She received a doctor of pharmacy degree from the University of Maryland School of Pharmacy and a master’s degree in public health prevention science from Emory University Rollins School of Public Health. Her areas of concentration are geriatric care, older adult fall and injury prevention, and effects of medications on older adult safety.

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