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A two-year independent study of frail seniors at risk for hip fracture scored a risk reduction "grand slam" with no fractures recorded during the two-year study, says George M. Gross, PT, rehabilitation supervisor for the Elder Service Plan at the East Boston Neighborhood Health Center in Boston.
"We have a strong need for prevention and place a very high emphasis on prevention — that’s a must for us," says Gross of the capitated plan that provides comprehensive services for the most frail elderly as part of a PACE — Program of All-inclusive Care for the Elderly — demonstration site. "The nice thing about capitated programs is that you’re not restricted on how you spend your money. Physical therapy to prevent falls is not a covered service under Medicare, but we do it routinely."
The Elder Service Plan’s emphasis on primary prevention efforts by all disciplines led the rehabilitation department to conduct a review of incident reports related to falls. "We have fall prevention programs in place," notes Gross, "but even with preventive efforts, such as home safety evaluations and physical and occupational therapy evaluations of all patients, it’s impossible to eliminate or anticipate every fall. We decided that if some of our patients were going to fall despite our best efforts at primary prevention then we had to look at a program of secondary compensation to reduce the risk of injury when those falls occur."
Gross says he’d been aware of hip protector products for several years but had never been able to find much information on them. "I looked for studies in the literature and asked around at conferences and conventions, but there wasn’t much information available," he notes. "We decided to start using hip protectors for our highest-risk patients and track our own data — what we found was both compelling and gratifying."
The Elder Service Plan selected a product called HipSaver, manufactured by HipSaver in Canton, MA. The hip protector underwear has soft 1/2-inch thick polymer pads sewn into wash-and-wear poly-cotton briefs for both men and women. The pads are hand-sized and sewn right over the hips. They work by first absorbing the shock of the fall and then dispersing its impact over a larger surface area to reduce the damaging impact force of a fall on a vulnerable hip.
"At the time we began our study, we purchased six pairs of HipSaver for each of the 29 patients in the study group, at a cost of $100 per patient," says Gross. "Now, $3,000 sounds like a lot of money to an administrator — we had to justify it."
To do that, Gross and his colleagues calculated the first-year cost of a single hip fracture for an Elder Service Plan member and found it was a staggering $16,000 to $18,000 — not including downstream costs such as eventual nursing home placement or supportive home health services. "That figure meant that if we prevented a single hip fracture in the study group, we would come out far ahead."
Patients at highest risk for falls were enrolled in the study group. "We develop profiles of our fallers and have identified common risk factors for falls," says Gross. "The average age of our patients is 80 and their average number of co-morbidities is 10, but the highest correlated finding for risk of falling was prior falls."
Other predictive factors for falls identified by the Elder Service Plan include:
• dementia, which leads to poor safety awareness;
• urinary incontinence;
• gait or balance disorders;
• acute medical changes.
"A common cold or a urinary tract infection knocks our patients for loops," he says.
Yet, none of the 199 falls experienced by the 29 patients in the study group resulted in a hip fracture, compared to a 4.3% fracture rate in the less-at-risk control group not wearing HipSaver. "The control group had 350 falls and 16 hip fractures for a fracture rate of 4.3%. In other words," explains Gross, "we would expect to have 4.3 fractures for every 100 falls. That means we would have expected a minimum of eight fractures in the study group with its 199 falls — but we had none."
Going back to that $16,000 to $18,000 up-front cost for a single hip fracture, preventing eight or nine hip fractures saved the Elder Service Plan roughly $150,000 for its $3,000 investment.
"From a financial perspective — that’s a grand slam," says Gross. "From a preventive-practice perspective, it’s also a grand slam."
Yet, despite the success of the HipSaver study, Gross cautions that the hip protector pads are not a panacea. "Not every patient at risk for falls gets HipSaver," he says. "First, we try correcting as many underlying risk factors as we can. Many risk factors for falls are reversible — such as acute medical changes or medication effects. So, we still put primary prevention first."
Compliance is an issue for some patients. "The original HipSavers we used in our study were bulky," says Gross. "Some of our more body- conscious patients were reluctant to wear them."
The Elder Service Plan enlisted the help of the patients’ families, physicians, nurse practitioners, and physical therapist to try to increase compliance. "Yet, we still had patients who said they weren’t going to add more padding to my hips.’"
HipSaver now has a "slim line" product available that’s not nearly as bulky as the original product and the compliance rate has improved, says Gross. "We don’t know yet whether or not the new slimmer model is as effective as the model we tested," he notes.
For more information on HipSaver, contact the company at 7 Hubbard St., Canton, MA 02021. Telephone: (800) 358-4477. Or, visit the company’s Web site at www.hipsaver.com.