Cost Effectiveness of Falls and Injury Prevention Strategies for Older Adults Living in Residential Aged Care Facilities

Developing a fall prevention intervention economic model

PURPOSE

Model-based economic evaluations require conceptualization of the model structure. Our objectives were to identify important health states, events, and patient attributes to be included in a model-based cost-effectiveness analysis of fall prevention interventions, to develop a model structure to examine cost-effectiveness of fall prevention interventions, and to assess the face validity of the model structure.

METHODS

An expert panel comprising clinicians, health service researchers, health economists, a patient partner, and policy makers completed two rounds of online surveys to gain consensus on health states, events, and patient attributes important for fall prevention interventions. The surveys were informed by a literature search on fall prevention interventions for older adults (≥65 years) including economic evaluations and clinical practice guidelines. The results of the Delphi surveys and subsequent discussions can support the face validity of a state-transition model for an economic evaluation of fall prevention interventions.

RESULTS

In total, 11 experts rated 24 health states/events and 41 patient attributes. Consensus was achieved on 14 health states/events and 26 patient characteristics. The proposed model structure incorporated 12 of the 14 selected health states/events. Panelists confirmed the face validity of the model structure during teleconferences.

CONCLUSIONS

There is a dearth of studies presenting the model conceptualization process; consequently, this study involving multiple end user partners with opportunities for input at several stages adds to the literature as another case study. This process is an example of how a fall prevention economic model was developed using a modified Delphi process and assessed for face validity.

Cost-Effectiveness of Multifactorial Interventions in Preventing Falls among Elderly Population: A Systematic Review

Objective:

To review the cost-effectiveness of multifactorial interventions to prevent falls in elderly people.

Methods:

In this systematic review, the databases including PubMed via MEDLINE, Web of Science, Embase, Scopus, Cochrane Library and Google Scholar (from 1st January 2000 to 30^th February) were used. All pre-reviewed articles related to cost-effectiveness analysis of multifactorial interventions to prevent falls in elderly were included in this paper and congresses abstracts were excluded. Descriptive statistics were used for quantitative data and content-analysis method to analyze qualitative data.

Results:

Out of the 456 articles, 19 were finally included in the study. Eighteen articles were conducted in High-Income Countries (HICs) and 16 were at the community level. Medical visits consultation and education were the most common interventions. Most studies were cost-effectiveness and using the Randomized Control Trial (RCT) methods. A fall of prevention costs ranged from $ 272 to $ 987. Incremental Cost-Effectiveness Ratio (ICER) interventions also ranged from the US $ 120,667 to the US $ 4280.9.

Conclusion:

The results show that despite the high effectiveness of multifactorial interventions to prevent elderly falls, the cost of the interventions are high and they are not very cost-effective. It would be better to design and implement multifactorial interventions with low cost and high effectiveness that are appropriate for each country.

Costs and benefits of multifactorial falls prevention in nursing homes in the Netherlands

OBJECTIVES

To investigate whether the implementation of a multifactorial falls intervention in nursing homes is cost-beneficial and alleviates the professional workload.

DESIGN

A comprehensive quantitative model was developed to calculate the impact of investments in multifactorial falls prevention in nursing homes in the Netherlands, comparing the fall incidence using intervention strategies in 1000 nursing home residents with the conditions of usual care over a five-year timeline.

SETTING AND PARTICIPANTS

We built a model combining several data sources regarding falls and injury prevalence in nursing home residents, health care costs, intervention costs and effectiveness, and demographic statistics.

MEASURES

The primary outcomes were number of falls and injuries, treatment hours and cost.

RESULTS

In the nursing home setting, a baseline scenario was calculated with 1471 falls incidents resulting in 345 injuries per year. The mean cost of injury related treatment and care was calculated 860 thousand euro per year and €4.63 million in five years. Implementing multifactorial intervention over five years, costing 702 thousand euro, resulted in savings in health care costs of €2.0 million, of which €1.6 million was saved in nursing home injury care. The benefits outweighed the costs: each euro invested was compensated by 2.86 euro benefit in total care, 2.31 benefit in nursing home care. Yearly 3050 nursing hours, 3100 paramedical care hours and 760 h of physician care were saved.

CONCLUSION AND IMPLICATIONS

Implementation of customized multifactorial interventions provided by multidisciplinary teams is cost-beneficial in reduction of falls in nursing homes. The CBA model gives valuable information about the advantageous consequences (i.e. health benefits, financial benefits and reduced workload of staff) of falls prevention in nursing homes and can provide guidance to the management in structural implementation of multifactorial falls prevention.

Increasing the uptake of vitamin D supplement use in Australian residential aged care facilities: results from the vitamin D implementation (ViDAus) study

BACKGROUND

Adequate (≥800 IU/day) vitamin D supplement use in Australian residential aged care facilities (RACFs) is variable and non-optimal. The vitamin D implementation (ViDAus) study aimed to employ a range of strategies to support the uptake of this best practice in participating facilities. The aim of this paper is to report on facility level prevalence outcomes and factors associated with vitamin D supplement use.

METHODS

This trial followed a stepped wedge cluster, non-randomised design with 41 individual facilities serving as clusters pragmatically allocated into two wedges that commenced the intervention six months apart. This multifaceted, interdisciplinary knowledge translation intervention was led by a project officer, who worked with nominated champions at participating facilities to provide education and undertake quality improvement (QI) planning. Local barriers and responsive strategies were identified to engage stakeholders and promote widespread uptake of vitamin D supplement use.

RESULTS

This study found no significant difference in the change of vitamin D supplement use between the intervention (17 facilities with approx. 1500 residents) and control group (24 facilities with approx. 1900 residents) at six months (difference in prevalence change between groups was 1.10, 95% CI - 3.8 to 6.0, p = 0.6). The average overall facility change in adequate (≥800 IU/day) vitamin D supplement use over 12 months was 3.86% (95% CI 0.6 to 7.2, p = 0.02), which achieved a facility level average prevalence of 59.6%. The variation in uptake at 12 months ranged from 25 to 88% of residents at each facility. In terms of the types of strategies employed for implementation, there were no statistical differences between facilities that achieved a clinically meaningful improvement (≥10%) or a desired prevalence of vitamin D supplement use (80% of residents) compared to those that did not.

CONCLUSIONS

This work confirms the complex nature of implementation of best practice in the RACF setting and indicates that more needs to be done to ensure best practice is translated into action. Whilst some strategies appeared to be associated with better outcomes, the statistical insignificance of these findings and the overall limited impact of the intervention suggests that the role of broader organisational and governmental support for implementation should be investigated further.

TRIAL REGISTRATION

Retrospectively registered (ANZCTR ID: ACTRN12616000782437 ).

Systematic review of unintentional injury prevention economic evaluations 2010-2019 and comparison to 1998-2009

BACKGROUND

Health economic evaluation studies (e.g., cost-effectiveness analysis) can provide insight into which injury prevention interventions maximize available resources to improve health outcomes. A previous systematic review summarized 48 unintentional injury prevention economic evaluations published during 1998-2009, providing a valuable overview of that evidence for researchers and decisionmakers. The aim of this study was to summarize the content and quality of recent (2010-2019) economic evaluations of unintentional injury prevention interventions and compare to the previous publication period (1998-2009).

METHODS

Peer-reviewed English-language journal articles describing public health unintentional injury prevention economic evaluations published January 1, 2010 to December 31, 2019 were identified using index terms in multiple databases. Injury causes, interventions, study methods, and results were summarized. Reporting on key methods elements (e.g., economic perspective, time horizon, discounting, currency year, etc.) was assessed. Reporting quality was compared between the recent and previous publication periods.

RESULTS

Sixty-eight recent economic evaluation studies were assessed. Consistent with the systematic review on this topic for the previous publication period, falls and motor vehicle traffic injury prevention were the most common study subjects. Just half of studies from the recent publication period reported all key methods elements, although this represents an improvement compared to the previous publication period (25 %).

CONCLUSION

Most economic evaluations of unintentional injury prevention interventions address just two injury causes. Better adherence to health economic evaluation reporting standards may enhance comparability across studies and increase the likelihood that this type of evidence is included in decision-making related to unintentional injury prevention.

Health economic benefits from optimized meal services to older adults-a literature-based synthesis

Malnutrition among older adults causes health problems and economic costs. Prevention of malnutrition through meal service can reduce such costs. This study estimates potential health economic benefits to be generated through meal service to home-dwelling older adults. The study contains three components: (1) systems analysis describing the relationship between meal service, nutritional status, health risk, and health-related costs, focusing on older adults, (2) a series of literature reviews to quantify the identified elements in each stage-subject combination: (i) meal service impact on nutrition status of older adults, (ii) associations between nutrition status and health risks, (iii) health care resource needs associated with these health risks, and (3) a model synthesis of literature findings to estimate the expected economic benefit of improved health status derived from meal service enrollment, using Denmark as an example. Expected economic benefits in terms of saved direct and indirect health care costs and improved quality-of-life was estimated at an amount of €307 per year per individual enrolled, of which direct health care cost savings constituted €75, while value of improved quality-of-life and reduced mortality constituted the rest. The average health economic benefit from enrolling older adults into meal service is likely to decrease with the number of subscribers. Findings like these are important to take into consideration, when making policy decisions regarding size of the meal service capacity, although it should be noted that the presented estimates are based on a number of assumptions of which some are subject to uncertainty.

Hip protectors are cost-effective in the prevention of hip fractures in patients with high fracture risk

Cost-effective preventive interventions are necessary for tackling the increasing number of hip fractures, which are frequently occuring as a serious consequence of osteoporosis. Several interventions have been available for preventing and treating osteoporosis. The aim of this study was to systematically review and critically appraise studies that assessed cost-effectiveness of hip protectors for the prevention of hip fractures and to investigate the effects of age, gender and residence situation on cost-effectiveness. A systematic review was conducted in order to identify economic evaluation studies examining the hip protector solely or compared to no treatment according to the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Synthesis of results was performed to observe trends between the studies. Methodological quality of the studies was assessed by the use of the Quality of Health Economic Studies (QHES) instrument. A total of 15 economic evaluation studies were included for analysis. The methodological quality was high in most studies (13/15). The hip protector was solely evaluated in three studies and within 12 other studies compared with no intervention. All studies that investigated the cost-effectiveness in long-term care facilities revealed that hip protector use is a cost-effective strategy for the prevention of hip fractures in elderly. Cost-effectiveness was also observed in two studies that provided hip protectors in a geriatric hospital ward. Four studies included both community-dwelling residents and residents living in a long-term care facility in their study. These studies showed more variability regarding cost-effectiveness. One study did not report information regarding the residence situation of their cohort, but also observed cost-effectiveness. In conclusion, this review suggests that hip protectors are a cost-effective approach in the prevention of hip fractures in populations with high risk of hip fractures especially in long-term care facilities and a geriatric ward in a hospital.

Process outcomes of a multifaceted, interdisciplinary knowledge translation intervention in aged care: results from the vitamin D implementation (ViDAus) study

BACKGROUND

Vitamin D supplement use is recommended best practice in residential aged care facilities (RACFs) for the prevention of falls, however has experienced delays in uptake. Following successful international efforts at implementing this evidence into practice, the ViDAus study sought to replicate this success for the Australian context. The aim of this paper is to report on the process outcomes of implementing this intervention.

METHODS

Forty-one RACFs were engaged in a multifaceted, interdisciplinary knowledge translation intervention. This focused on raising awareness to improve knowledge on vitamin D, and supporting facilities to identify barriers and implement locally devised strategies to improve the uptake of evidence based practice (EBP).

RESULTS

Staff members of participating facilities (n = 509 including nursing, care and allied health staff) were well engaged and accepting of the intervention, though engagement of servicing general practitioners (GPs) (n = 497) and pharmacists (n = 9) was poor. Facilities each identified between three and eight strategies focused on raising awareness, identifying residents to target for vitamin D and creating referral pathways depending upon their own locally identified barriers and capacity. There was variable success at implementing these over the 12-month intervention period. Whilst this study successfully raised awareness among staff, residents and their family members, barriers were identified that hindered engagement of GPs.

CONCLUSIONS

The intervention was overall feasible to implement and perceived as appropriate by GPs, pharmacists, facility staff, residents and family members. More facilitation, higher-level organisational support and strategies to improve RACF access to GPs however were identified as important improvements for the implementation of vitamin D supplement use.

TRIAL REGISTRATION

Retrospectively registered (ANZCTR ID: ACTRN12616000782437 ) on 15 June 2016.

Colecalciferol Initiation Post Minimal Trauma Fracture

Purpose: The purpose of this study was to determine the proportion of patients admitted to a major tertiary teaching hospital in Australia aged 50 years and older with a confirmed neck of femur or vertebral minimal trauma fracture, who are commenced on colecalciferol supplementation by discharge, and to describe the doses prescribed. Methods: A subanalysis of a retrospective audit of electronic medical files for patients admitted with a minimal trauma fracture of the hip or vertebra between January 1, 2016, and June 30, 2016, was conducted. Results: A total of 406 patients were screened and 64 patients were included in the audit. In this subanalysis of these 64 patients eligible for inclusion, 38 were not on any vitamin or mineral supplementation at admission. Of these, 26 patients (68.4%) had their serum colecalciferol levels measured, and 21 patients (55.2%) overall were initiated on colecalciferol. Conclusion: Over half of patients with a minimal trauma fracture were commenced on colecalciferol therapy, but a noteworthy proportion of patients remain untreated. Patients with colecalciferol levels are more likely to be initiated on therapy compared with those of whom levels were not taken during admission. This is a missed opportunity for intervention that may place patients at a higher risk of subsequent fracture; therefore, effective strategies should be implemented to address this treatment gap in the future.

Drugs in fall versus non-fall accidents with major trauma - A population-based clinical and medico-legal autopsy study

BACKGROUND

The main aim of the present population-based study was to compare drugs in fall versus non-fall accidents causing major trauma, including both clinical and medico-legal autopsy data.

METHODS

All individuals with accidents resulting in major trauma, a new injury severity score (NISS)>15 or lethal outcome was identified at hospital and/or the Department of Forensic Medicine between 2011 and 2013. Modified Downton Fall Risk Index ranged from 0 to 7, and was based on specific pharmaceuticals (max 5 points), previous fall (1 point) and cognitive impairment (1 point).

RESULTS

One hundred and four individuals with major traumatic accidents were identified, 38 (36.5%) died. The median modified Downton Fall Risk Index was 2 for fall accidents and 0 for non-fall accidents (p < 0.001). Modified Downton Fall Risk Index was an age-independent factor associated with fall accident (p < 0.001). The medico-legal autopsy rate for in-hospital patients was 50% (6/12) for fatal fall accidents in comparison with 92.3% (12/13) for fatal non-fall accidents (p = 0.03). In individuals undergoing medico-legal autopsy, the proportion of individuals with any detected drug was 77% in fall accidents compared to 39% in non-fall accidents (p = 0.036). The presence of sedatives (p = 0.002) and bensodiazepines (p = 0.023) were higher for fall accidents compared to non-fall accidents.

CONCLUSION

This population-based study on accidents with major trauma showed that drugs had high impact on fall accidents with major trauma. It seems warranted from a public health perspective to study if implementation of medication review guidelines at hospital managing polypharmacy issues may prevent fall accident recidivism.

Economic Evaluations of Falls Prevention Programs for Older Adults: A Systematic Review

OBJECTIVES

To provide a comprehensive overview of economic evaluations of falls prevention programs and to evaluate the methodology and quality of these studies.

DESIGN

Systematic review of economic evaluations on falls prevention programs.

SETTING

Studies (N=31) of community-dwelling older adults (n=25), of older adults living in residential care facilities (n=3), and of both populations (n=3) published before May 2017.

PARTICIPANTS

Adults aged 60 and older.

MEASUREMENTS

Information on study characteristics and health economics was collected. Study quality was appraised using the 20-item Consensus on Health Economic Criteria.

RESULTS

Economic evaluations of falls prevention through exercise (n = 9), home assessment (n = 6), medication adjustment (n = 4), multifactorial programs (n = 11), and various other programs (n = 13) were identified. Approximately two-thirds of all reported incremental cost-effectiveness ratios (ICERs) with quality-adjusted life-years (QALYs) as outcome were below the willingness-to-pay threshold of $50,000 per QALY. All studies on home assessment and medication adjustment programs reported favorable ICERs, whereas the results of studies on exercise and multifactorial programs were inconsistent. The overall methodological quality of the studies was good, although there was variation between studies.

CONCLUSION

The majority of the reported ICERs indicated that falls prevention programs were cost-effective, but methodological differences between studies hampered direct comparison of the cost-effectiveness of program types. The results imply that investing in falls prevention programs for adults aged 60 and older is cost-effective. Home assessment programs (ICERs < $40,000/QALY) were the most cost-effective type of program for community-dwelling older adults, and medication adjustment programs (ICERs < $13,000/QALY) were the most cost-effective type of program for older adults living in a residential care facility. J Am Geriatr Soc 66:2197-2204, 2018.

Proportionality in Public Health Regulation: The Case of Dietary Supplements

The idea that the degree of infringement public health interventions have on individual rights should be proportional to the degree of expected benefits has emerged as an influential principle in public health ethics and policy. While proportionality makes sense in theory, it may be difficult to implement in practice, due to the inherent conflict between individual rights and the common good underlying the principle. To apply the proportionality principle to a decision of policy, one must still find a reasonable way of balancing these competing values in light of the available options and empirical evidence. In this article, I consider how the proportionality principle applies to the regulation of dietary supplements and examine some critiques of the current oversight system. I argue that it may be difficult maintain proportional oversight because the risks of dietary supplements vary considerably. Strengthening the regulations may therefore promote an appropriate level of regulation in some cases but lead to overregulation in others.

Preventing vitamin D deficiency (VDD): a systematic review of economic evaluations

Background

Vitamin D deficiency (VDD) is a public health concern worldwide. If untreated, it can lead to reduced quality of life and escalated costs brought about by ill-health. Preventive programmes to improve population vitamin D status exist but little is known about their cost-effectiveness. This information is vital so that decision-makers adopt efficient strategies and optimise use of public resources.

Aims

Systematically review and critically appraise economic evaluations of population strategies to prevent VDD.

Methods

The databases reviewed were MEDLINE, EMBASE, Econlit, NHS EED, CEA, and RepEc. All full economic evaluations of VDD prevention strategies were included. Interventions considered were food fortification, supplementation and public health campaigns. Data extracted included type of evaluation, population, setting, measure of benefit and main results.

Results

Of the 2492 records screened, 14 studies were included. The majority of studies focused on supplementation within at-risk groups with the primary objective of either preventing fractures or falls in older adults. There was insufficient economic evidence to draw conclusions about the cost-effectiveness of population strategies. No study was identified that offered a direct comparison of the two main alternative population strategies: food fortification vs. supplementation.

Conclusions

Whilst there is a growing body of evidence on the cost-effectiveness of micro nutrient programmes, there is a paucity of data on vitamin D fortification and how fortification programmes compare to population supplementation programmes. We highlight research gaps, and offer suggestions of what is required to undertake population-based cost-effectiveness analysis.

Prevalence of vitamin D supplement use in Australian residential aged care facilities in November 2014

Objective

We sought to establish the prevalence and predictors of adequate vitamin D supplement use, as per current falls prevention guidelines in Australian aged care homes. De-identified medication chart data from November 2014 were collected from pharmacists. The proportion of residents prescribed vitamin D and associations between adequate vitamin D supplementation and state, calcium use and osteoporosis medication use were assessed.

Results

The prevalence of adequate vitamin D supplement use (≥800 IU) was 47.1% of residents (95% CI 41.4, 52.8%). There was no significant difference between states (p = 0.3), however there was large variation between individual facilities (15.9–85.0%). Residents were more likely to be prescribed an adequate dose of vitamin D if they were prescribed a calcium supplement (p = 0.0001) or an osteoporosis medication (p = 0.03).