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

Healthcare spending for non-fatal falls among older adults, USA

BACKGROUND

The older adult (65+) population in the USA is increasing and with it the number of medically treated falls. In 2015, healthcare spending attributable to older adult falls was approximately US$50 billion. We aim to update the estimated medical expenditures attributable to older adult non-fatal falls.

METHODS

Generalised linear models using 2017, 2019 and 2021 Medicare Current Beneficiary Survey and cost supplement files were used to estimate the association of falls with healthcare expenditures while adjusting for demographic characteristics and health conditions in the model. To portion out the share of total healthcare spending attributable to falls versus not, we adjusted for demographic characteristics and health conditions, including self-reported health status and certain comorbidities associated with increased risk of falling or higher healthcare expenditure. We calculated a fall-attributable fraction of expenditure as total expenditures minus total expenditures with no falls divided by total expenditures. We applied the fall-attributable fraction of expenditure from the regression model to the 2020 total expenditures from the National Health Expenditure Data to calculate total healthcare spending attributable to older adult falls.

RESULTS

In 2020, healthcare expenditure for non-fatal falls was US$80.0 billion, with the majority paid by Medicare.

CONCLUSION

Healthcare spending for non-fatal older adult falls was substantially higher than previously reported estimates. This highlights the growing economic burden attributable to older adult falls and these findings can be used to inform policies on fall prevention efforts in the USA.

Budget impact analysis of a Lifestyle-integrated Functional Exercise (LiFE) program for older people in Germany: a Markov model based on data from the LiFE-is-LiFE trial

BACKGROUND

Fall prevention is important for healthy ageing, but the economic impact of fall prevention are scarcely investigated. A recent cost-effectiveness analysis compared a group-delivered Lifestyle-integrated Functional Exercise Program (gLiFE) with an individually-delivered program (LiFE) in community-dwelling people (aged ≥ 70 years) at risk of falling. In addition, the current study aimed to analyze the budget impact of LiFE and gLiFE, compared with standard care in Germany.

METHODS

A Markov model was developed to reflect falls and associated care needs for community-dwelling persons over 5 years. The intervention effects of LiFE and gLiFE were shown to be equivalent in a non-inferiority trial, although the costs differed. Outpatient, inpatient, and intervention costs were assessed from a payer's perspective. The effect of parameter uncertainty was assessed in sensitivity analyses.

RESULTS

The budget impact due to intervention costs was €510 million for LiFE and €186 million for gLiFE. Over five years, health care expenditures were €35,008 million for those receiving standard care, €35,416 million for those receiving LiFE, and €35,091 million for persons receiving gLiFE. Thereby, LiFE and gLiFE could prevent 2700 deaths and 648,000 falls over 5 years. Parameter uncertainties in the risk of falling, uptake of an intervention offer, and in the intervention effects had a major influence; thus cost savings for LiFE and gLiFE compared with standard care could be achieved for individuals with a high risk of falling.

CONCLUSIONS

The results revealed that cost savings for LiFE and gLiFE compared with standard care could only be achieved for individuals at high risk of falling, with gLiFE being superior to LiFE. Future research should consider benefits and aspects of fall prevention beyond falls (e.g., physical activity, social aspects, and personal preferences of participants).

TRIAL REGISTRATION

The study was preregistered under underclinicaltrials.gov (identifier: NCT03462654) on 12th March 2018; https://clinicaltrials.gov/ct2/show/NCT03462654 .

The Belgian physiotherapy reimbursement criteria for fall prevention fails in screening appropriately fall-prone community-dwelling older adults

OBJECTIVES

The incidence of falling in older adults has remained unchanged over the past decades, despite evidence-based prevention initiatives. Therefore, it is appropriate to reflect on the current screening approach for preventive initiatives. The objective of this study was to determine whether the multifactorial algorithm proposed by Lusardi et al. (2017) exhibits superior predictive validity compared to the currently employed algorithm by the Belgian National Institute for Health and Disability Insurance (NIHDI).

METHODS

The current study includes a secondary analysis of data collected from a falls-related study in the Department of Rehabilitation Sciences at Ghent University to compare the predictive validity of the two algorithms. Sensitivity, specificity, positive and negative predictive value and area under the curve (AUC) were calculated to ascertain which algorithm is more accurate.

RESULTS

The database included a total of 94 community-dwelling older adults (mean age 76 years ±7.4, 35% male). Thirty-nine participants experienced at least one fall in the 8 month follow up. Lusardi's approach has a higher sensitivity score (89.7% compared to 10.3%) and negative predictive value (89.9% compared to 61.1%), but a lower specificity score (61.8% compared to 100%) and positive predictive value (62.2% compared to 100%) than the NIHDI approach. The AUC is 0.76 for Lusardi's approach and 0.55 for the NIHDI approach.

CONCLUSION

The use of the multifactorial algorithm proposed by Lusardi et al. may be significant and more accurate in identifying adults at risk to falls. Further research is needed particularly with a larger, more heterogenous group of older adults.

The Mediating Role of Sarcopenia in the Association between Physical Activity and Falls among Chinese Older Adults: A Cross-Sectional Study

Physical inactivity and sarcopenia are potentially modifiable risk factors for falls in older adults, but the strength of the association between physical activity (PA), sarcopenia, and falls in Chinese older adults is unclear. This study sought to investigate the potential mediation mechanism relationship in the connection between PA, sarcopenia, including its elements (muscle strength, physical performance, and skeletal muscle mass), and falls among Chinese older people. The subjects were 3592 community-dwelling Chinese aged 60 or over, selected from the China Health and Retirement Longitudinal Study (CHARLS). PA was evaluated through the International Physical Activity Questionnaire (IPAQ), and sarcopenia was determined through the Asian Working Group on Sarcopenia (AWGS) 2019 guidelines. We employed logistic regression to explore the link between physical activity, sarcopenia, and falls. Additionally, we applied Karlson, Holm and Breen's (KHB) method to estimate two different mediation models. The results demonstrated that PA lowers the risk of falls [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.48-0.61], whereas sarcopenia increases the risk of falls (OR 1.34, 95% CI 1.16-1.55). Sarcopenia mediated the association between PA and falls, explaining a total of 2.69% of the association (indirect effect = -0.02). PA also had a significant mediating effect on the association between sarcopenia and falls, explaining a total of 20.12% of the association (indirect effect = 0.06). The proportion mediated by sarcopenia was 2.69% for PA and falls (indirect effect = -0.02). Our findings suggest that PA and sarcopenia have a direct effect on falls as well as an indirect effect through each other. Enhancing PA levels and preventing sarcopenia may help prevent falls in older adults.

Fall accidents in older people: a time trend analysis of the period 2000-2020 and the estimated economic burden on the Brazilian health system in 2025

Longitudinal monitoring of indicators of accidental falls can facilitate the planning of effective care and prevention actions. This article aims to analyze temporal trends in variables related to falls among older persons in Brazil and in the state of São Paulo during the period 2000-2020 and estimate the projected economic burden on the health system in 2025. We conducted a quantitative retrospective observational study using data from the Health Information System. The Joinpoint Regression Program version 4.7.0 and SPSS version 20.0 were used to perform linear regression and calculate the Average Annual Percent Change (AAPC), adopting a 95% confidence interval. There was an increase in mean and total admissions costs due to falls at national level in both intervals of the study period. There was an increase in total admissions costs and the total number of admissions due to falls in the state of São Paulo (AAPC of 8.5% and 4.3%, respectively). Projections for the year 2025 suggest that the total number of admissions due to falls in Brazil will be around 150,000, resulting in costs of approximately R$ 260 million. There was an increase in the variables analyzed by this study, revealing the importance of fall prevention programs associated with national public policies.

Cost-effectiveness of exercise versus multimodal interventions that include exercise to prevent falls among community-dwelling older adults: A systematic review and meta-analysis

OBJECTIVE

To compare the cost-effectiveness of exercise as a unimodal intervention versus multimodal interventions that included exercise in conjunction with other falls prevention strategies to prevent falls among community-dwelling older adults.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, NHS EED, and CINAHL (1 January 1946 to June 2022).

ELIGIBILITY CRITERIA

Economic evaluations of fall prevention strategies that included exercise delivered as a unimodal intervention or a multimodal intervention that included exercise in conjunction with other falls prevention strategies among community-dwelling adults aged 60 years and over.

RESULTS

Eighteen studies were included in this review: 9 unimodal, 6 multimodal, and 3 that included exercise delivered as both a unimodal and a multimodal intervention. In the cost-effectiveness analyses, 61.5 % (n = 8/13) of exercise-only unimodal interventions demonstrated cost-effectiveness, compared with 33.3 % (n = 2/6) of multimodal interventions. In the cost-utility analyses, 60 % (n = 6/10) of unimodal interventions compared with zero multimodal interventions (n = 0/4) demonstrated cost-effectiveness. Sixteen studies (25,017 participants) were included in our meta-analysis. Incremental costs were $128 [-$661, $1644] (2021 US dollars) for exercise-only unimodal interventions and $786 [-$72, $1644] for multimodal interventions. Estimated incremental quality-adjusted life-years was 0.09 [-0.37, 0.55] for exercise-only unimodal interventions and 0.00 [-0.04, 0.04] for multimodal interventions. Both exercise-only and multimodal interventions had an estimated 28 % reduction in falls versus the control, with incidence rate ratios for exercise-only unimodal interventions of 0.72 [0.62, 0.83] and for multimodal interventions of 0.72 [0.25, 2.09].

CONCLUSION

Exercise delivered as a unimodal intervention, particularly resistance training, provided the best value for money for fall prevention. Multimodal interventions that included exercise did not demonstrate additional benefits in terms of costs, quality of life, or fall prevention compared with exercise-only unimodal interventions. This finding may be due to the smaller number of multimodal interventions available.

REVIEW REGISTRATION

PROSPERO CRD42022295561.

REGISTRATION TITLE

Comparing the cost-effectiveness of multimodal versus unimodal interventions that include exercise to prevent falls among community-dwelling older adults: A systematic review.

Strategies to implement multifactorial falls prevention interventions in community-dwelling older persons: a systematic review

BACKGROUND

One-third of the community-dwelling older persons fall annually. Guidelines recommend the use of multifactorial falls prevention interventions. However, these interventions are difficult to implement into the community. This systematic review aimed to explore strategies used to implement multifactorial falls prevention interventions into the community.

METHODS

A systematic search in PubMed (including MEDLINE), CINAHL (EBSCO), Embase, Web of Science (core collection), and Cochrane Library was performed and updated on the 25th of August, 2022. Studies reporting on the evaluation of implementation strategies for multifactorial falls prevention interventions in the community setting were included. Two reviewers independently performed the search, screening, data extraction, and synthesis process (PRISMA flow diagram). The quality of the included reports was appraised by means of a sensitivity analysis, assessing the relevance to the research question and the methodological quality (Mixed Method Appraisal Tool). Implementation strategies were reported according to Proctor et al.'s (2013) guideline for specifying and reporting implementation strategies and the Taxonomy of Behavioral Change Methods of Kok et al. (2016).

RESULTS

Twenty-three reports (eighteen studies) met the inclusion criteria, of which fourteen reports scored high and nine moderate on the sensitivity analysis. All studies combined implementation strategies, addressing different determinants. The most frequently used implementation strategies at individual level were "tailoring," "active learning," "personalize risk," "individualization," "consciousness raising," and "participation." At environmental level, the most often described strategies were "technical assistance," "use of lay health workers, peer education," "increasing stakeholder influence," and "forming coalitions." The included studies did not describe the implementation strategies in detail, and a variety of labels for implementation strategies were used. Twelve studies used implementation theories, models, and frameworks; no studies described neither the use of a determinant framework nor how the implementation strategy targeted influencing factors.

CONCLUSIONS

This review highlights gaps in the detailed description of implementation strategies and the effective use of implementation frameworks, models, and theories. The review found that studies mainly focused on implementation strategies at the level of the older person and healthcare professional, emphasizing the importance of "tailoring," "consciousness raising," and "participation" in the implementation process. Studies describing implementation strategies at the level of the organization, community, and policy/society show that "technical assistance," "actively involving stakeholders," and "forming coalitions" are important strategies.

TRIAL REGISTRATION

PROSPERO CRD42020187450.

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 fall prevention programmes for older adults

Falls are associated with a substantial increase in risk of mortality and are the second leading cause of unintentional death worldwide. A single fall can affect all aspects of an older person's life. These broad impacts can lead to worse disability outcomes and a higher likelihood of long-term nursing home admission. There is a need to identify not just effective falls prevention interventions but also cost effectiveness.

Economic evaluations of fall prevention exercise programs: a systematic review

Objective

To investigate cost-effectiveness and costs of fall prevention exercise programmes for older adults.

Design

Systematic review.

Data sources

Medline, Embase, Web of Science, Scopus, National Institute for Health Research Economic Evaluation Database, Health Technology Assessment database, Tufts Cost-Effectiveness Analysis Registry, Research Papers in Economics and EconLit (inception to May 2022).

Eligibility criteria for study selection

Economic evaluations (trial-based or model-based) and costing studies investigating fall prevention exercise programmes versus no intervention or usual care for older adults living in the community or care facilities, and reporting incremental cost-effectiveness ratio (ICER) for fall-related outcomes or quality-adjusted life years (QALY, expressed as cost/QALY) and/or intervention costs.

Results

31 studies were included. For community-dwelling older adults (21 economic evaluations, 6 costing studies), results ranged from more effective and less costly (dominant) interventions up to an ICER of US$279 802/QALY gained and US$11 986/fall prevented (US$ in 2020). Assuming an arbitrary willingness-to-pay threshold (US$100 000/QALY), most results (17/24) were considered cost-effective (moderate certainty). The greatest value for money (lower ICER/QALY gained and fall prevented) appeared to accrue for older adults and those with high fall risk, but unsupervised exercise appeared to offer poor value for money (higher ICER/QALY). For care facilities (two economic evaluations, two costing studies), ICERs ranged from dominant (low certainty) to US$35/fall prevented (moderate certainty). Overall, intervention costs varied and were poorly reported.

Conclusions

Most economic evaluations investigated fall prevention exercise programmes for older adults living in the community. There is moderate certainty evidence that fall prevention exercise programmes are likely to be cost-effective. The evidence for older adults living in care facilities is more limited but promising.

PROSPERO registration number

PROSPERO 2020 CRD42020178023.

Economic evaluation of the e-Health StandingTall balance exercise programme for fall prevention in people aged 70 years and over

BACKGROUND

globally, falls and fall-related injuries are the leading cause of injury-related morbidity and mortality in older people. In our ageing society healthcare costs are increasing, therefore programmes that reduce falls and are considered value for money are needed.

OBJECTIVE

to complete an economic evaluation of an e-Health balance exercise programme that reduced falls and injurious falls in community-dwelling older people compared to usual care from a health and community-care funder perspective.

DESIGN

a within-trial economic evaluation of an assessor-blinded randomised controlled trial with 2 years of follow-up.

SETTING

StandingTall was delivered via tablet-computer at home to older community-dwelling people in Sydney, Australia.

PARTICIPANTS

five hundred and three individuals aged 70+ years who were independent in activities of daily living, without cognitive impairment, progressive neurological disease or any other unstable or acute medical condition precluding exercise.

MAIN OUTCOME MEASURES

cost-effectiveness was measured as the incremental cost per fall and per injurious fall prevented. Cost-utility was measured as the incremental cost per quality-adjusted life year (QALY) gained.

MAIN RESULTS

the total average cost per patient for programme delivery and care resource cost was $8,321 (standard deviation [SD] 18,958) for intervention participants and $6,829 (SD 15,019) for control participants. The incremental cost per fall prevented was $4,785 and per injurious fall prevented was $6,585. The incremental cost per QALY gained was $58,039 (EQ5D-5L) and $110,698 (AQoL-6D).

CONCLUSION

this evaluation found that StandingTall has the potential to be cost-effective in specific subpopulations of older people, but not necessarily the whole older population.

TRIAL REGISTRATION

ACTRN12615000138583.

Economic evaluation of community-based falls prevention interventions for older populations: a systematic methodological overview of systematic reviews

Background

Falls impose significant health and economic burdens on older people. The volume of falls prevention economic evaluations has increased, the findings from which have been synthesised by systematic reviews (SRs). Such SRs can inform commissioning and design of future evaluations; however, their findings can be misleading and incomplete, dependent on their pre-specified criteria. This study aims to conduct a systematic overview (SO) to: (1) systematically identify SRs of community-based falls prevention economic evaluations; (2) describe the methodology and findings of SRs; (3) critically appraise the methodology of SRs; and (4) suggest commissioning recommendations based on SO findings.

Methods

The SO followed the PRISMA guideline and the Cochrane guideline on SO, covering 12 databases and grey literature for the period 2003–2020. Eligible studies were SRs with 50% or more included studies that were economic evaluations of community-based falls prevention (against any comparator) for older persons (aged 60 +) or high-risk individuals aged 50–59. Identified SRs’ aims, search strategies and results, extracted data fields, quality assessment methods/results, and commissioning and research recommendations were synthesised. The comprehensiveness of previous SRs’ data synthesis was judged against criteria drawn from literature on falls prevention/public health economic evaluation. Outcomes of general population, lifetime decision models were re-analysed to inform commissioning recommendations. The SO protocol is registered in the Prospective Register of Systematic Reviews (CRD42021234379).

Results

Seven SRs were identified, which extracted 8 to 33 data fields from 44 economic evaluations. Four economic evaluation methodological/reporting quality checklists were used; three SRs narratively synthesised methodological features to varying extent and focus. SRs generally did not appraise decision modelling features, including methods for characterising dynamic complexity of falls risk and intervention need. Their commissioning recommendations were based mainly on cost-per-unit ratios (e.g., incremental cost-effectiveness ratios) and neglected aggregate impact. There is model-based evidence of multifactorial and environmental interventions, home assessment and modification and Tai Chi being cost-effective but also the risk that they exacerbate social inequities of health.

Conclusions

Current SRs of falls prevention economic evaluations do not holistically inform commissioning and evaluation. Accounting for broader decisional factors and methodological nuances of economic evaluations, particularly decision models, is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07764-2.

Economic models of community-based falls prevention: a systematic review with subsequent commissioning and methodological recommendations

BACKGROUND

Falls impose significant health and economic burdens among older populations, making their prevention a priority. Health economic models can inform whether the falls prevention intervention represents a cost-effective use of resources and/or meet additional objectives such as reducing social inequities of health. This study aims to conduct a systematic review (SR) of community-based falls prevention economic models to: (i) systematically identify such models; (ii) synthesise and critically appraise modelling methods/results; and (iii) formulate methodological and commissioning recommendations.

METHODS

The SR followed PRISMA 2021 guideline, covering the period 2003-2020, 12 academic databases and grey literature. A study was included if it: targeted community-dwelling persons aged 60 and over and/or aged 50-59 at high falls risk; evaluated intervention(s) designed to reduce falls or fall-related injuries; against any comparator(s); reported outcomes of economic evaluation; used decision modelling; and had English full text. Extracted data fields were grouped by: (A) model and evaluation overview; (B) falls epidemiology features; (C) falls prevention intervention features; and (D) evaluation methods and outcomes. A checklist for falls prevention economic evaluations was used to assess reporting/methodological quality. Extracted fields were narratively synthesised and critically appraised to inform methodological and commissioning recommendations. The SR protocol is registered in the Prospective Register of Systematic Reviews (CRD42021232147).

RESULTS

Forty-six models were identified. The most prevalent issue according to the checklist was non-incorporation of all-cause care costs. Based on general population, lifetime models conducting cost-utility analyses, seven interventions produced favourable ICERs relative to no intervention under the cost-effectiveness threshold of US$41,900 (£30,000) per QALY gained; of these, results for (1) combined multifactorial and environmental intervention, (2) physical activity promotion for women, and (3) targeted vitamin D supplementation were from validated models. Decision-makers should explore the transferability and reaches of interventions in their local settings. There was some evidence that exercise and home modification exacerbate existing social inequities of health. Sixteen methodological recommendations were formulated.

CONCLUSION

There is significant methodological heterogeneity across falls prevention models. This SR's appraisals of modelling methods should facilitate the conceptualisation of future falls prevention models. Its synthesis of evaluation outcomes, though limited to published evidence, could inform commissioning.

Nurse-led home modification interventions for community-dwelling older adults with dementia and their impact on falls prevention

This quasi-experimental study aimed to investigate the effects of nurse-led home modification interventions on the family members of home-dwelling older adults with dementia. The sample consisted of 42 older adults diagnosed with dementia and their family members. A number of validated tools were used. Three home visits were undertaken, a training package with family members was instigated, and the patients were followed up for a 6-month period. It was determined that there was a decrease in falls in the first 3-month period (p=0.002). The number of falls in the second 3-month period was lower in the older adults who had their homes modified (p=0.000). Family-centred, nurse-led home-modification interventions can be effective in the prevention and reducing of falls in older adults with dementia.

Early supported discharge for older adults admitted to hospital with medical complaints: a protocol for a systematic review

INTRODUCTION

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints.

METHODS

A systematic review of randomised controlled trials and quasi randomised controlled trials will be carried out in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies will be included if they provide an ESD intervention to older adults admitted to hospital for medical complaints compared with continuing inpatient care. MEDLINE, CINAHL, CENTRAL and EMBASE databases will be searched. The primary outcome measure will be length of hospital stay, secondary outcomes will include functional abilities, falls, quality of life, carer and patient satisfaction, unplanned emergency department re-presentation, unscheduled hospital readmission, nursing home admission or mortality. Titles and abstracts of studies will be screened independently by two authors. The Cochrane Risk of Bias Tool will be used independently by two reviewers to assess the methodological quality of the included studies. GRADE will be used to assess the quality of the body of evidence. A pooled meta-analysis will be conducted using RevMan software V.5.4.1, depending on the uniformity of the data.

ETHICS AND DISSEMINATION

The authors will present the findings of the review to a patient and public involvement stakeholder panel of older people that has been established at the Ageing Research Centre in the University of Limerick. Formal ethical approval is not required for the review as all data collected will be secondary data and will be analysed anonymously.

PROSPERO REGISTRATION NUMBER

CRD42021223112.

Falls prevention at GP practices: a description of daily practice

BACKGROUND

General practitioners (GPs) can be considered the designated professionals to identify high fall risk and to guide older people to fall preventive care. Currently it is not exactly known how GPs treat this risk. This study aims to investigate GPs' daily practice regarding fall preventive care for frail older patients.

METHODS

Sixty-five GPs from 32 Dutch practices participated in this study for a period of 12 months. When a GP entered specific International Classification of Primary Care-codes related to frailty and/or high fall risk in their Electronic Health Records, a pop-up appeared asking "Is this patient frail?". If the GP confirmed this, the GP completed a short questionnaire about patient's fall history and fear of falling (FOF), and the fall preventive care provided.

RESULTS

The GPs completed questionnaires regarding 1394 frail older patients aged ≥75. Of 20% of these patients, the GPs did not know whether they had experienced a fall or not. The GPs did not know whether a FOF existed in even more patients (29%). Of the patients with a fall history and/or a FOF (N = 726), 37% (N = 271) received fall preventive care. Two main reasons for not offering fall preventive care to these patients were: I) the patient finds treatment too intensive or too much of a hassle (37%), and II) the GP identified a high fall risk but the patient did not acknowledge this (14%). When patients were treated for high fall risk, the GP and the physiotherapist were the most frequently involved health care providers. The involved health care providers most often treated mobility limitations, cardiovascular risk factors, and FOF.

CONCLUSIONS

The results from this study show that GPs were frequently not aware of their frail patient's fall history and/or FOF and that the majority of the frail older patients with a fall history and/or FOF did not receive fall preventive care. Developing systematic screening strategies for the primary care setting enhancing the identification of high fall risk and the provision of fall preventive care may improve patients' quality of life and reduce health care costs.

The (cost-)effectiveness of an implemented fall prevention intervention on falls and fall-related injuries among community-dwelling older adults with an increased risk of falls: protocol for the in balance randomized controlled trial

Background

Falls and fall-related injuries among older adults are a serious threat to the quality of life and result in high healthcare and societal costs. Despite evidence that falls can be prevented by fall prevention programmes, practical barriers may challenge the implementation of these programmes. In this study, we will investigate the effectiveness and cost-effectiveness of In Balance, a fourteen-week, low-cost group fall prevention intervention, that is widely implemented in community-dwelling older adults with an increased fall risk in the Netherlands. Moreover, we will be the first to include cost-effectiveness for this intervention. Based on previous evidence of the In Balance intervention in pre-frail older adults, we expect this intervention to be (cost-)effective after implementation-related adjustments on the target population and duration of the intervention.

Methods

This study is a single-blinded, multicenter randomized controlled trial. The target sample will consist of 256 community-dwelling non-frail and pre-frail adults of 65 years or older with an increased risk of falls. The intervention group receives the In Balance intervention as it is currently widely implemented in Dutch healthcare, which includes an educational component and physical exercises. The physical exercises are based on Tai Chi principles and focus on balance and strength. The control group receives general written physical activity recommendations. Primary outcomes are the number of falls and fall-related injuries over 12 months follow-up. Secondary outcomes consist of physical performance measures, physical activity, confidence, health status, quality of life, process evaluation and societal costs. Mixed model analyses will be conducted for both primary and secondary outcomes and will be stratified for non-frail and pre-frail adults.

Discussion

This trial will provide insight into the clinical and societal impact of an implemented Dutch fall prevention intervention and will have major benefits for older adults, society and health insurance companies. In addition, results of this study will inform healthcare professionals and policy makers about timely and (cost-)effective prevention of falls in older adults.

Trial registration

Netherlands Trial Register: NL9248 (registered February 13, 2021).

Older Adults' Experiences With the Visual Physio-Feedback Technology and Peer-Led Combined Group and Home-Based Exercises

This study aimed to explore older adults' experience with an in-home Physio-feEdback and Exercise pRogram and explore whether the Physio-feEdback and Exercise pRogram intervention influenced their physical activity adherence. A qualitative study approach was employed, and data were collected using exercise logs, observations, focus groups, and open-ended questions after the program completion. Nineteen participants who engaged in an 8-week Physio-feEdback and Exercise pRogram intervention participated in this study. Thematic analysis was used. Three major concepts of the self-determination theory, including competence, relatedness, and autonomy, were used as guidelines for coding. Results reveal three themes, including: (a) competence-alignment of body and mind and increased awareness about fall risk, (b) relatedness-relationship with peer coach and having fun with friends, and (c) autonomy-integration of exercise into daily activities for staying physically and socially active. Individuals' need for competence and autonomy can be supported by giving physio-feedback, cognitive reframing, and peer-led exercise, which can enhance physical activity and prevent falls.

Implementation and Evaluation of a Fall Risk Screening Strategy Among Frail Older Adults for the Primary Care Setting: A Study Protocol

BACKGROUND

Falls are an increasing problem among older people. There are several evidence-based interventions available to prevent falls. However, these are not always well implemented in the primary care setting. General practitioners (GPs) are often the first point of contact for health issues, making them the designated professionals for providing falls prevention. Because GPs are often unaware which patients have a high fall risk and patients themselves do not always know they have a high fall risk, this study aims to evaluate the implementation of a targeted fall risk screening strategy among independently living, frail older people in the primary care setting.

MATERIALS AND METHODS

The targeted fall risk screening strategy used in this study consists of tools for screening high fall risk and for identifying the underlying cause(s) of the high fall risk, an accredited training course in falls prevention for professionals, and service provision by certified physio- and exercise therapists who are able to offer evidence-based falls prevention interventions. This targeted fall risk screening strategy will be implemented in the primary care setting and evaluated at the level of the GP practice and at the level of the patient by using the RE-AIM model of Glasgow et al. In a pre-posttest design, data will be collected of the total number of frail older people who are screened, referred and enrolled for fall-preventive care. Furthermore, barriers and facilitators of the implementation of the fall risk screening strategy will be identified by conducting focus groups and interviews with the care providers and frail older patients. Additionally, the influence of the falls prevention interventions on frail older patients will be evaluated by using a pre-posttest design with a 12-month follow-up period during which data are collected regarding patients' stability, mobility, strength, balance, self-efficacy, health status, and daily activities.

STUDY REGISTRATION

This study is approved by the Medical Ethics Committee Brabant, the Netherlands (NL61582.028.17/ P1732) and registered at the Netherlands Trial Register, NL7917.

Personal preferences of participation in fall prevention programmes: a descriptive study

BACKGROUND

Participation in fall prevention programmes is associated with lower risk of injurious falls among older adults. However participation rates in fall prevention interventions are low. The limited participation in fall prevention might increase with a preference based approach. Therefore, the aims of this study are to a) determine the personal preferences of older adults regarding fall prevention and b) explore the association between personal preferences and participation.

METHODS

We assessed the personal preferences of older adults and the association between their preferences, chosen programme and participation level. Nine different programmes, with a focus on those best matching their personal preferences, were offered to participants. Twelve weeks after the start of the programme, participation was assessed by questionnaire. Logistic regression was performed to test the association between preferences and participation and an ANOVA was performed to assess differences between the number of preferences included in the chosen programme and participation level.

RESULTS

Of the 134 participants, 49% preferred to exercise at home versus 43% elsewhere, 46% preferred to exercise alone versus 44% in a group and 41% indicated a programme must be free of charge while 51% were willing to pay. The combination of an external location, in a group and for a fee was preferred by 27%, whereas 26% preferred at home, alone and only for free. The presence of preferences or the extent to which the programme matched earlier preferences was not associated with participation.

CONCLUSION

Despite the fact that preferences can vary greatly among older adults, local programmes should be available for at least the two largest subgroups. This includes a programme at home, offered individually and for free. In addition, local healthcare providers should cooperate to increase the accessibility of currently available group programmes.

Economic Evaluation of Exercise-Based Fall Prevention Programs for People with Parkinson's Disease: A Systematic Review

Objectives: Falls are common in Parkinson's disease (PD). Exercise interventions can prevent falls. This review aims to (1) explore the existing evidence regarding the cost-effectiveness of exercise-based fall prevention programs for people with PD and (2) discuss the implications of the review findings for future research and clinical practice. Design: Databases AMED Allied and Complementary Medicine, CINAHL, CRD, EBSCO, EMBASE, MEDLINE, PubMed, Scopus, and Web of Science were searched from their inception until June 2019. Randomized and nonrandomized trials that included an economic evaluation of fall prevention programs for people with PD were considered. Quality of the economic evaluation was assessed using the Consensus on Health Economic Criteria list (CHEC-list), and the methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) and Cochrane risk of bias tool. Results: Nine hundred and sixty-five studies were screened to include three studies involving 556 participants. Quality of economic evaluation assessed using CHEC-list was high. The methodological quality was high for two studies and low for one study. Tested interventions included Tai Ji Quan, physiotherapist-led, supervised, weekly and monthly balance, and strengthening exercises. The duration of the interventions ranged from 10 weeks to 6 months, while the intervention frequency ranged from two sessions per week to one session per month. Treatment sessions lasted for 60 min in all three studies. One high economic and methodological quality study comparing Tai Ji Quan with resistance and stretching exercises reported least cost resource use among Tai Ji Quan group (USD 80,441) and greater incremental number of falls prevented. All three tested interventions had an 80% probability of being cost-effective with the corresponding country-specific threshold incremental cost-effectiveness ratio values. Conclusions: The findings provide some evidence for exercise-based intervention as a cost-effective treatment option for preventing falls in PD; however, due to the limited number of available studies, heterogeneity of the interventions, and diversity of assessment settings, a firm conclusion cannot be established. Additional studies evaluating the cost-effectiveness of fall prevention programs involving larger samples and using different treatment parameters in various settings are warranted.

Cost-Effectiveness of a Therapeutic Tai Ji Quan Fall Prevention Intervention for Older Adults at High Risk of Falling

BACKGROUND

Data on the cost-effectiveness of proven fall prevention exercise interventions are limited. We aimed to establish the cost-effectiveness of Tai Ji Quan: Moving for Better Balance (TJQMBB) compared with a conventional exercise intervention for older adults at high risk of falling.

METHODS

We conducted a trial-based cost-effectiveness analysis involving 670 older adults who had a history of falling or impaired mobility. Participants received one of three interventions-TJQMBB, multimodal exercise, or stretching exercise (control)-each of which was implemented twice weekly for 24 weeks. The primary cost-effectiveness measure was the incremental cost per additional fall prevented, comparing TJQMBB and multimodal exercise to Stretching and TJQMBB to multimodal exercise, with a secondary measure of incremental cost per additional quality-adjusted life-year (QALY) gained. The intervention was conducted between February 2015 and January 2018, and cost-effectiveness was estimated from a health care system perspective over a 6-month time horizon.

RESULTS

The total cost to deliver the TJQMBB intervention was $202,949 (an average of $906 per participant); for multimodal exercise, it was $223,849 ($1,004 per participant); and for Stretching, it was $210,468 ($903 per participant). Incremental cost-effectiveness ratios showed that the multimodal exercise was cost-effective ($850 per additional fall prevented; $27,614 per additional QALY gained) relative to Stretching; however, TJQMBB was the most economically dominant strategy (ie, having lower cost and being clinically more efficacious) compared with multimodal and stretching exercises with regard to cost per additional fall prevented and per additional QALY gained. TJQMBB had a 100% probability of being cost-effective, relative to Stretching, at a threshold of $500 per each additional fall prevented and $10,000 per additional QALY gained. Sensitivity analyses showed the robustness of the results when extreme cases, medical costs only, and missing data were considered.

CONCLUSIONS

Among community-dwelling older adults at high risk for falls, TJQMBB is a cost-effective means of reducing falls compared with conventional exercise approaches.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT02287740).