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Le Berre M, Forest L, Dumoulin C. Implementation of Group-Based Exercise Programs in Physiotherapy: A Rapid Scoping Review. Am J Phys Med Rehabil 2024; 103:761-768. [PMID: 38547023 DOI: 10.1097/phm.0000000000002477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
ABSTRACT This review synthesized implementation literature on group-based exercise programs in physiotherapy. MEDLINE and Embase databases were searched for English and French articles published between 2000 and 2022. Through a two-step process (titles/abstracts and full text), two independent reviewers selected studies. The independent reviewers then extracted data and assessed study quality using the Mixed Methods Appraisal Tool. A total of 31 studies involving 4555 participants were included. Data on the group-based programs were extracted using the Consensus on Exercise Reporting Template and reported narratively. Implementation outcomes were reported narratively. The most frequently reported constructs pertained to feasibility and acceptability. Overall, the implementation of group-based programs appeared to be feasible, yielding high rates of adherence and attendance (between 36% and 91%), moderate-to-high completion rates (between 46% and 100%), low-to-moderate dropout rates (between 4.5% and 35.9%), and high satisfaction (satisfaction scores generally ranging above 7/10). The present findings also indicate a high acceptability for group-based physiotherapy exercise programs among patients. This review provided an overview of the literature on the implementation of group-based exercise programs in physiotherapy. In addition, it identified the need for more evidence on fidelity and costs. Future research should address these gaps to better inform healthcare stakeholders.
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Affiliation(s)
- Mélanie Le Berre
- From the Centre de recherche de l'Institut universitaire de gériatrie de Montréal, Montreal, Canada (MLB, LF, CD); and School of Rehabilitation, Université de Montréal, Montreal, Canada (MLB, LF, CD)
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Spilsbury K, Charlwood A, Thompson C, Haunch K, Valizade D, Devi R, Jackson C, Alldred DP, Arthur A, Brown L, Edwards P, Fenton W, Gage H, Glover M, Hanratty B, Meyer J, Waton A. Relationship between staff and quality of care in care homes: StaRQ mixed methods study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-139. [PMID: 38634535 DOI: 10.3310/gwtt8143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Background Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence. Objective(s) To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers. Design Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model. Setting English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings. Participants Managers, residents, families and care home staff. Findings Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged. Limitations Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes. Conclusions Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes. Study registration This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Andy Charlwood
- Leeds University Business School, University of Leeds, Leeds, UK
| | - Carl Thompson
- School of Healthcare, University of Leeds, Leeds, UK
| | - Kirsty Haunch
- School of Healthcare, University of Leeds, Leeds, UK
| | - Danat Valizade
- Leeds University Business School, University of Leeds, Leeds, UK
| | - Reena Devi
- School of Healthcare, University of Leeds, Leeds, UK
| | | | | | - Antony Arthur
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Lucy Brown
- The Florence Nightingale Foundation, London, UK
| | | | | | - Heather Gage
- School of Biosciences and Medicine, University of Surrey, Surrey, UK
| | - Matthew Glover
- School of Biosciences and Medicine, University of Surrey, Surrey, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Julienne Meyer
- School of Health Sciences, City University of London, London, UK
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Pinheiro MB, Howard K, Oliveira JS, Kwok WS, Tiedemann A, Wang B, Taylor J, Bauman A, Sherrington C. Cost-effectiveness of physical activity programs and services for older adults: a scoping review. Age Ageing 2023; 52:7078344. [PMID: 36934340 PMCID: PMC10024893 DOI: 10.1093/ageing/afad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Evidence supporting physical activity for older adults is strongly positive. Implementation and scale-up of these interventions need to consider the value for money. This scoping review aimed to assess the volume of (i) systematic review evidence regarding economic evaluations of physical activity interventions, and (ii) of cost utility analysis (CUA) studies (trial- or model-based) of physical activity interventions for older people. METHODS We searched five databases (January 2010 to February 2022) for systematic reviews of economic evaluations, and two databases (1976 to February 2022) for CUA studies of physical activity interventions for any population of people aged 60+ years. RESULTS We found 12 potential reviews, two of which were eligible for inclusion. The remaining 10 reviews included eligible individual studies that were included in this review. All individual studies from the 12 reviews (n = 37) investigated the cost-effectiveness of structured exercise and most showed the intervention was more costly but more effective than no intervention. We identified 27 CUA studies: two investigated a physical activity promotion program and the remainder investigated structured exercise. Most interventions (86%) were more costly but more effective, and the remaining were cost-saving compared to no intervention. CONCLUSIONS There is a scarcity of reviews investigating the value for money of physical activity interventions for older adults. Most studies investigated structured exercise. Physical activity interventions were generally more effective than no intervention but more costly. As such an intervention could be cost-effective and therefore worthy of wider implementation, but there is a need for more frequent economic evaluation in this field.
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Affiliation(s)
| | - Kirsten Howard
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, Menzies Centre for Health Policy and Economics, The University of Sydney, Sydney, Australia
| | - Juliana S Oliveira
- Sydney Local Health District, Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Wing S Kwok
- Sydney Local Health District, Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Anne Tiedemann
- Sydney Local Health District, Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Belinda Wang
- Sydney Local Health District, Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Jennifer Taylor
- Sydney Local Health District, Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Adrian Bauman
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Catherine Sherrington
- Sydney Local Health District, Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
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Cost-effectiveness of exercise versus multimodal interventions that include exercise to prevent falls among community-dwelling older adults: A systematic review and meta-analysis. Maturitas 2023; 169:16-31. [PMID: 36630860 DOI: 10.1016/j.maturitas.2022.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023]
Abstract
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.
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Benedetto V, Hill J, Harrison J. Cost effectiveness of fall prevention programmes for older adults. Br J Community Nurs 2022; 27:530-533. [PMID: 36327206 DOI: 10.12968/bjcn.2022.27.11.530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Valerio Benedetto
- Research Associate, Synthesis, Economic Evaluation and Decision Science (SEEDS) Group, University of Central Lancashire
| | - James Hill
- Senior Fellow, Synthesis, Economic Evaluation and Decision Science (SEEDS) Group, University of Central Lancashire
| | - Joanna Harrison
- Associate, Synthesis, Economic Evaluation and Decision Science (SEEDS) Group, University of Central Lancashire
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Pinheiro MB, Sherrington C, Howard K, Caldwell P, Tiedemann A, Wang B, S Oliveira J, Santos A, Bull FC, Willumsen JF, Michaleff ZA, Ferguson S, Mayo E, Fairhall NJ, Bauman AE, Norris S. Economic evaluations of fall prevention exercise programs: a systematic review. Br J Sports Med 2022; 56:1353-1365. [DOI: 10.1136/bjsports-2022-105747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/04/2022]
Abstract
ObjectiveTo investigate cost-effectiveness and costs of fall prevention exercise programmes for older adults.DesignSystematic review.Data sourcesMedline, 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 selectionEconomic 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.Results31 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.ConclusionsMost 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 numberPROSPERO 2020 CRD42020178023.
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Kwon J, Squires H, Franklin M, Young T. Systematic review and critical methodological appraisal of community-based falls prevention economic models. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:33. [PMID: 35842721 PMCID: PMC9287934 DOI: 10.1186/s12962-022-00367-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 07/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research. METHODS The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results. RESULTS 46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made. CONCLUSION Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.
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Affiliation(s)
- Joseph Kwon
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Hazel Squires
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Matthew Franklin
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
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Ambrens M, van Schooten KS, Lung T, Clemson L, Close JCT, Howard K, Lord SR, Zijlstra GAR, Tiedemann A, Valenzuela T, Vandelanotte C, Chow J, McInerney G, Miles L, Woodbury A, Delbaere K. Economic evaluation of the e-Health StandingTall balance exercise programme for fall prevention in people aged 70 years and over. Age Ageing 2022; 51:6604744. [PMID: 35679193 DOI: 10.1093/ageing/afac130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Meghan Ambrens
- School of Health, Medicine and Applied Science, Appleton Institute, CQUniversity, Melbourne, VIC, Australia.,Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia
| | - Kimberley S van Schooten
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia.,School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Thomas Lung
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia.,Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lindy Clemson
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Excellence in Population Ageing Research, The University of Sydney, Sydney, NSW, Australia
| | - Jacqueline C T Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Menzies Centre for Health Policy and Economics, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Stephen R Lord
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia.,School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - G A Rixt Zijlstra
- Care and Public Health Research Institute, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Anne Tiedemann
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Trinidad Valenzuela
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney NSW 2141, Australia.,Exercise Science Laboratory, School of Kinesiology, Faculty of Medicine, Universidad Finis Terrae, Santiago, Chile
| | | | - Jessica Chow
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia
| | - Garth McInerney
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia
| | - Lillian Miles
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia
| | - Ashley Woodbury
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia
| | - Kim Delbaere
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, NSW, Australia.,School of Population Health, University of New South Wales, Sydney, NSW, Australia
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Kwon J, Squires H, Franklin M, Lee Y, Young T. Economic evaluation of community-based falls prevention interventions for older populations: a systematic methodological overview of systematic reviews. BMC Health Serv Res 2022; 22:401. [PMID: 35346185 PMCID: PMC8962024 DOI: 10.1186/s12913-022-07764-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/08/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Kwon J, Squires H, Franklin M, Lee Y, Young T. Economic models of community-based falls prevention: a systematic review with subsequent commissioning and methodological recommendations. BMC Health Serv Res 2022; 22:316. [PMID: 35255898 PMCID: PMC8902781 DOI: 10.1186/s12913-022-07647-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/14/2022] [Indexed: 11/21/2022] Open
Abstract
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. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07647-6.
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Affiliation(s)
- Joseph Kwon
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England.
| | - Hazel Squires
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England
| | - Matthew Franklin
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England
| | - Yujin Lee
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, England
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England
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11
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Health economic evaluation of exercise interventions in people over 60 years old: A systematic review. Exp Gerontol 2022; 161:111713. [DOI: 10.1016/j.exger.2022.111713] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022]
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Edmunds K, Scuffham P, Newton RU, Galvão DA, Tuffaha H. Exercise in preventing falls for men with prostate cancer: a modelled cost-utility analysis. Support Care Cancer 2022; 30:5037-5046. [PMID: 35201385 PMCID: PMC9046330 DOI: 10.1007/s00520-022-06900-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 02/08/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Men who receive androgen deprivation therapy (ADT) for prostate cancer (PCa) are a vulnerable falls population due to the side effects of treatment. The purpose of this paper is to determine the cost-effectiveness of exercise in preventing falls and fractures for this high-risk population in Australia. METHODS A decision analytic model was constructed to evaluate the cost utility of an exercise intervention compared to usual care from a health system perspective. The intervention comprised two 1-h sessions of supervised exercise per week over 1 year for men with non-metastatic PCa receiving curative radiation therapy and ADT. A Markov model simulated the transition between five health states: (1) at risk of falling; (2) at recurrent risk of falling; (3) fracture (minor or major); (4) non-fracture injury (minor or major); and (5) death. Model inputs including transition probabilities and utility scores were obtained from published meta-analyses, and costs were drawn from Australian data sources (e.g. Medical Benefits Schedule). The model time horizon was 3 years, and costs and effects were discounted at 5% annual rate. Costs and quality-adjusted life years (QALYs) were aggregated and compared between the intervention and control to calculate incremental net monetary benefit (iNMB). Uncertainty in the results was explored using deterministic and probabilistic sensitivity analyses (PSA). RESULTS At a willingness-to-pay of AU$50,000 per QALY, the exercise intervention dominated, as it was less costly and more effective than usual care. The iNMB was $3010 per patient. The PSA showed a 58% probability the intervention was cost-effective. CONCLUSION This is the first modelled economic evaluation of exercise for men with PCa. Our results suggest supervised exercise is cost-effective in reducing the risks of falls and fractures in this population.
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Affiliation(s)
- Kim Edmunds
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, QLD, 4072, Australia.
| | - Paul Scuffham
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Australia
| | - Daniel A Galvão
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Australia
| | - Haitham Tuffaha
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, QLD, 4072, Australia
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Kwon J, Lee Y, Young T, Squires H, Harris J. Qualitative research to inform economic modelling: a case study in older people's views on implementing the NICE falls prevention guideline. BMC Health Serv Res 2021; 21:1020. [PMID: 34583685 PMCID: PMC8479997 DOI: 10.1186/s12913-021-07056-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background High prevalence of falls among older persons makes falls prevention a public health priority. Yet community-based falls prevention face complexity in implementation and any commissioning strategy should be subject to economic evaluation to ensure cost-effective use of healthcare resources. The study aims to capture the views of older people on implementing the National Institute for Health and Care Excellence (NICE) guideline on community-based falls prevention and explore how the qualitative data can be used to inform commissioning strategies and conceptual modelling of falls prevention economic evaluation in the local area of Sheffield. Methods Focus group and interview participants (n = 27) were recruited from Sheffield, England, and comprised falls prevention service users and eligible non-users of varying falls risks. Topics concerned key components of the NICE-recommended falls prevention pathway, including falls risk screening, multifactorial risk assessment and treatment uptake and adherence. Views on other topics concerning falls prevention were also invited. Framework analysis was applied for data analysis, involving data familiarisation, identifying themes, indexing, charting and mapping and interpretation. The qualitative data were mapped to three frameworks: (1) facilitators and barriers to implementing the NICE-recommended pathway and contextual factors; (2) intervention-related causal mechanisms for formulating commissioning strategies spanning context, priority setting, need, supply and demand; and (3) methodological and evaluative challenges for public health economic modelling. Results Two cross-component factors were identified: health motives of older persons; and professional competence. Participants highlighted the need for intersectoral approaches and prioritising the vulnerable groups. The local commissioning strategy should consider the socioeconomic, linguistic, geographical, legal and cultural contexts, priority setting challenges, supply-side mechanisms spanning provider, organisation, funding and policy (including intersectoral) and health and non-health demand motives. Methodological and evaluative challenges identified included: incorporating non-health outcomes and societal intervention costs; considering dynamic complexity; considering social determinants of health; and conducting equity analyses. Conclusions Holistic qualitative research can inform how commissioned falls prevention pathways can be feasible and effective. Qualitative data can inform commissioning strategies and conceptual modelling for economic evaluations of falls prevention and other geriatric interventions. This would improve the structural validity of quantitative models used to inform geriatric public health policies. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07056-1.
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Affiliation(s)
- Joseph Kwon
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA.
| | - Yujin Lee
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, England, CV4 7AL
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA
| | - Hazel Squires
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA
| | - Janet Harris
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA
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Scheckel B, Stock S, Müller D. Cost-effectiveness of group-based exercise to prevent falls in elderly community-dwelling people. BMC Geriatr 2021; 21:440. [PMID: 34311698 PMCID: PMC8314607 DOI: 10.1186/s12877-021-02329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical studies indicate that strength-balance training for active fall prevention can prevent fractures in older people. The present modelling study evaluates the cost-effectiveness of fall prevention exercise (FPE) provided to independently living older people compared to no intervention in Germany. METHOD We designed a Markov model to evaluate the cost-effectiveness of a group-based FPE-program provided to independently living people ≥75 years from the perspective of the German statutory health insurance (SHI). Input data was obtained from public databases, clinical trials and official statistics. The incremental cost-effectiveness ratio (ICER) was presented as costs per avoided hip fracture. Additionally, we performed deterministic and probabilistic sensitivity analyses and, estimated monetary consequences for the SHI in a budget impact analysis (BIA). RESULTS For women, the costs per hip fracture avoided amounted to €52,864 (men: €169,805). Results of deterministic and probabilistic sensitivity analyses confirmed the robustness of the results. According to the BIA, for the reimbursement of FPE additional costs of €3.0 million (women) and €7.8 million (men) are expected for the SHI. CONCLUSIONS Group-based FPE appears to be no cost-effective option to prevent fall-related hip fractures in independently living elderly. To allow a more comprehensive statement on the cost effectiveness of FPE fracture types other than hip should be increasingly evaluated in clinical trials.
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Affiliation(s)
- Benjamin Scheckel
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Str. 176-178, 50935, Cologne, Germany.
| | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Str. 176-178, 50935, Cologne, Germany
| | - Dirk Müller
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Str. 176-178, 50935, Cologne, Germany
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15
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Mahalingam M, Peterson C, Bergen G. Systematic review of unintentional injury prevention economic evaluations 2010-2019 and comparison to 1998-2009. ACCIDENT; ANALYSIS AND PREVENTION 2020; 146:105688. [PMID: 32911130 PMCID: PMC7554223 DOI: 10.1016/j.aap.2020.105688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/02/2020] [Accepted: 07/09/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Mallika Mahalingam
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway, Atlanta, GA, 30341, United States.
| | - Cora Peterson
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway, Atlanta, GA, 30341, United States
| | - Gwen Bergen
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway, Atlanta, GA, 30341, United States
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Winser SJ, Chan HTF, Ho L, Chung LS, Ching LT, Felix TKL, Kannan P. Dosage for cost-effective exercise-based falls prevention programs for older people: A systematic review of economic evaluations. Ann Phys Rehabil Med 2020; 63:69-80. [DOI: 10.1016/j.rehab.2019.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 01/23/2023]
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Romera-Liebana L, Orfila F, Segura JM, Real J, Fabra ML, Möller M, Lancho S, Ramirez A, Marti N, Cullell M, Bastida N, Martinez D, Giné M, Cendrós P, Bistuer A, Perez E, Fabregat MA, Foz G. Effects of a Primary Care-Based Multifactorial Intervention on Physical and Cognitive Function in Frail, Elderly Individuals: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2019; 73:1688-1674. [PMID: 29346524 PMCID: PMC6248206 DOI: 10.1093/gerona/glx259] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 01/10/2023] Open
Abstract
Background Detecting and managing frailty at early stages can prevent disability and other adverse outcomes. The study aim was to evaluate whether a multifactorial intervention program could modify physical and cognitive frailty parameters in elderly individuals. Methods We conducted a multicenter, randomized, single-blind, parallel-group trial in community-living prefrail/frail elderly individuals in Barcelona. A total of 352 patients, aged ≥65 years old with positive frailty screening, was randomized into two groups to receive a 12-week multidisciplinary intervention or usual care, with concealed allocation. The intervention consisted of: exercise training, intake of hyperproteic nutritional shakes, memory training, and medication review. Main outcome assessments with multivariate analysis were conducted at 3 and 18 months. Results A total of 347 participants (98.6%) completed the study, mean age 77.3 years, 89 prefrail subjects (25.3%), and 75.3% female (n = 265). Eighteen-month assessments were performed in 76% of the sample. After 3 and 18 months, adjusted means difference between-groups showed significant improvements for the intervention group in all comparisons: Short Physical Performance Battery score improved 1.58 and 1.36 points (p < .001), handgrip strength 2.84 and 2.49 kg (p < .001), functional reach 4.3 and 4.52 cm (p < .001), and number of prescriptions decreased 1.39 and 1.09 (p < .001), respectively. Neurocognitive battery also showed significant improvements across all dimensions at 3 and 18 months. Conclusions A physical, nutritional, neurocognitive, and pharmacological multifaceted intervention was effective in reversing frailty measures both at short-term and 18 months. Lasting benefits of a multi-intervention program among frail elderly individuals encourage its prioritization.
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Affiliation(s)
- Laura Romera-Liebana
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain.,Universitat Autonoma de Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primaria Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Francesc Orfila
- Institut Universitari d'Investigació en Atenció Primaria Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Institut Catala De La Salut, Gerencia Barcelona Ciutat, Spain
| | - Josep Maria Segura
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primaria Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Jordi Real
- Unitat de Suport a la Recerca Barcelona, Institut Universitari d'Investigacio en Atenció Primaria Jordi Gol (IDIAP Jordi Gol), Spain.,Epidemiologia i Salut Pública, Universitat Internacional de Catalunya, Barcelona, Spain.,CIBERDEM, Badalona, Spain
| | - Maria Lluïsa Fabra
- Rehabilitation Unit, Drassanes Health Centre, Institut Català de la Salut, Barcelona, Spain
| | - Mercedes Möller
- Rehabilitation Unit, Drassanes Health Centre, Institut Català de la Salut, Barcelona, Spain
| | - Santiago Lancho
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain
| | - Anna Ramirez
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain
| | - Nuria Marti
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain
| | - Montserrat Cullell
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain
| | - Nuria Bastida
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain
| | - Dolors Martinez
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain
| | - Maria Giné
- Blanquerna Universitat Ramon Llull Facultat de Psicologia Ciencies de l'Educacio i de l'Esport, Barcelona, Spain
| | | | - Anna Bistuer
- Rehabilitation Unit, Drassanes Health Centre, Institut Català de la Salut, Barcelona, Spain
| | - Elena Perez
- Institut Català d'Assistencia i Serveis Socials (ICASS), Barcelona, Spain
| | | | - Gonçal Foz
- Primary healthcare centre Raval Nord, Institut Català de la Salut, Barcelona, Spain
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Li F, Harmer P, Eckstrom E, Fitzgerald K, Akers L, Chou LS, Pidgeon D, Voit J, Winters-Stone K. Cost-Effectiveness of a Therapeutic Tai Ji Quan Fall Prevention Intervention for Older Adults at High Risk of Falling. J Gerontol A Biol Sci Med Sci 2019; 74:1504-1510. [PMID: 30629121 PMCID: PMC6696718 DOI: 10.1093/gerona/glz008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Indexed: 01/01/2023] Open
Abstract
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).
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Affiliation(s)
| | - Peter Harmer
- Department of Exercise and Health Science, Willamette University, Salem, Oregon
| | - Elizabeth Eckstrom
- Division of General Internal Medicine & Geriatrics, Oregon Health and Science University, Portland
| | | | | | - Li-Shan Chou
- Department of Human Physiology, University of Oregon, Eugene
| | - Dawna Pidgeon
- Department of Rehabilitation, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jan Voit
- Voit Better Balance, Mercer Island, Washington
| | - Kerri Winters-Stone
- Knight Cancer Institute and School of Nursing, Oregon Health and Science University, Portland
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Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019; 1:CD012424. [PMID: 31789289 PMCID: PMC6360922 DOI: 10.1002/14651858.cd012424.pub2] [Citation(s) in RCA: 433] [Impact Index Per Article: 86.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND At least one-third of community-dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have been found to prevent falls in these people. An up-to-date synthesis of the evidence is important given the major long-term consequences associated with falls and fall-related injuries OBJECTIVES: To assess the effects (benefits and harms) of exercise interventions for preventing falls in older people living in the community. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers up to 2 May 2018, together with reference checking and contact with study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We excluded trials focused on particular conditions, such as stroke. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. MAIN RESULTS We included 108 RCTs with 23,407 participants living in the community in 25 countries. There were nine cluster-RCTs. On average, participants were 76 years old and 77% were women. Most trials had unclear or high risk of bias for one or more items. Results from four trials focusing on people who had been recently discharged from hospital and from comparisons of different exercises are not described here.Exercise (all types) versus control Eighty-one trials (19,684 participants) compared exercise (all types) with control intervention (one not thought to reduce falls). Exercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.71 to 0.83; 12,981 participants, 59 studies; high-certainty evidence). Based on an illustrative risk of 850 falls in 1000 people followed over one year (data based on control group risk data from the 59 studies), this equates to 195 (95% CI 144 to 246) fewer falls in the exercise group. Exercise also reduces the number of people experiencing one or more falls by 15% (risk ratio (RR) 0.85, 95% CI 0.81 to 0.89; 13,518 participants, 63 studies; high-certainty evidence). Based on an illustrative risk of 480 fallers in 1000 people followed over one year (data based on control group risk data from the 63 studies), this equates to 72 (95% CI 52 to 91) fewer fallers in the exercise group. Subgroup analyses showed no evidence of a difference in effect on both falls outcomes according to whether trials selected participants at increased risk of falling or not.The findings for other outcomes are less certain, reflecting in part the relatively low number of studies and participants. Exercise may reduce the number of people experiencing one or more fall-related fractures (RR 0.73, 95% CI 0.56 to 0.95; 4047 participants, 10 studies; low-certainty evidence) and the number of people experiencing one or more falls requiring medical attention (RR 0.61, 95% CI 0.47 to 0.79; 1019 participants, 5 studies; low-certainty evidence). The effect of exercise on the number of people who experience one or more falls requiring hospital admission is unclear (RR 0.78, 95% CI 0.51 to 1.18; 1705 participants, 2 studies, very low-certainty evidence). Exercise may make little important difference to health-related quality of life: conversion of the pooled result (standardised mean difference (SMD) -0.03, 95% CI -0.10 to 0.04; 3172 participants, 15 studies; low-certainty evidence) to the EQ-5D and SF-36 scores showed the respective 95% CIs were much smaller than minimally important differences for both scales.Adverse events were reported to some degree in 27 trials (6019 participants) but were monitored closely in both exercise and control groups in only one trial. Fourteen trials reported no adverse events. Aside from two serious adverse events (one pelvic stress fracture and one inguinal hernia surgery) reported in one trial, the remainder were non-serious adverse events, primarily of a musculoskeletal nature. There was a median of three events (range 1 to 26) in the exercise groups.Different exercise types versus controlDifferent forms of exercise had different impacts on falls (test for subgroup differences, rate of falls: P = 0.004, I² = 71%). Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies; high-certainty evidence) and the number of people experiencing one or more falls by 13% (RR 0.87, 95% CI 0.82 to 0.91; 8288 participants, 37 studies; high-certainty evidence). Multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88; 1374 participants, 11 studies; moderate-certainty evidence) and the number of people experiencing one or more falls by 22% (RR 0.78, 95% CI 0.64 to 0.96; 1623 participants, 17 studies; moderate-certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99; 2655 participants, 7 studies; low-certainty evidence) as well as reducing the number of people who experience falls by 20% (RR 0.80, 95% CI 0.70 to 0.91; 2677 participants, 8 studies; high-certainty evidence). We are uncertain of the effects of programmes that are primarily resistance training, or dance or walking programmes on the rate of falls and the number of people who experience falls. No trials compared flexibility or endurance exercise versus control. AUTHORS' CONCLUSIONS Exercise programmes reduce the rate of falls and the number of people experiencing falls in older people living in the community (high-certainty evidence). The effects of such exercise programmes are uncertain for other non-falls outcomes. Where reported, adverse events were predominantly non-serious.Exercise programmes that reduce falls primarily involve balance and functional exercises, while programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises plus resistance exercises). Tai Chi may also prevent falls but we are uncertain of the effect of resistance exercise (without balance and functional exercises), dance, or walking on the rate of falls.
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Affiliation(s)
- Catherine Sherrington
- The University of SydneyInstitute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and HealthPO Box 179Missenden RoadSydneyNSWAustralia2050
| | - Nicola J Fairhall
- The University of SydneyInstitute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and HealthPO Box 179Missenden RoadSydneyNSWAustralia2050
| | - Geraldine K Wallbank
- The University of SydneyInstitute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and HealthPO Box 179Missenden RoadSydneyNSWAustralia2050
| | - Anne Tiedemann
- The University of SydneyInstitute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and HealthPO Box 179Missenden RoadSydneyNSWAustralia2050
| | - Zoe A Michaleff
- The University of SydneyInstitute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and HealthPO Box 179Missenden RoadSydneyNSWAustralia2050
| | - Kirsten Howard
- The University of SydneySchool of Public HealthSydneyNSWAustralia2006
| | - Lindy Clemson
- The University of SydneyFaculty of Health SciencesEast St. LidcombeLidcombeNSWAustralia1825
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Sarah E Lamb
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
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Olij BF, Ophuis RH, Polinder S, van Beeck EF, Burdorf A, Panneman MJM, Sterke CS. Economic Evaluations of Falls Prevention Programs for Older Adults: A Systematic Review. J Am Geriatr Soc 2018; 66:2197-2204. [PMID: 30325013 DOI: 10.1111/jgs.15578] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Branko F Olij
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Robbin H Ophuis
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Ed F van Beeck
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Alex Burdorf
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | | | - Carolyn Shanty Sterke
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, the Netherlands.,Aafje, Rotterdam, the Netherlands
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Huter K, Dubas-Jakóbczyk K, Kocot E, Kissimova-Skarbek K, Rothgang H. Economic evaluation of health promotion interventions for older people: do applied economic studies meet the methodological challenges? COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:14. [PMID: 29686540 PMCID: PMC5902889 DOI: 10.1186/s12962-018-0100-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 04/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the light of demographic developments health promotion interventions for older people are gaining importance. In addition to methodological challenges arising from the economic evaluation of health promotion interventions in general, there are specific methodological problems for the particular target group of older people. There are especially four main methodological challenges that are discussed in the literature. They concern measurement and valuation of informal caregiving, accounting for productivity costs, effects of unrelated cost in added life years and the inclusion of 'beyond-health' benefits. This paper focuses on the question whether and to what extent specific methodological requirements are actually met in applied health economic evaluations. METHODS Following a systematic review of pertinent health economic evaluations, the included studies are analysed on the basis of four assessment criteria that are derived from methodological debates on the economic evaluation of health promotion interventions in general and economic evaluations targeting older people in particular. RESULTS Of the 37 studies included in the systematic review, only very few include cost and outcome categories discussed as being of specific relevance to the assessment of health promotion interventions for older people. The few studies that consider these aspects use very heterogeneous methods, thus there is no common methodological standard. CONCLUSION There is a strong need for the development of guidelines to achieve better comparability and to include cost categories and outcomes that are relevant for older people. Disregarding these methodological obstacles could implicitly lead to discrimination against the elderly in terms of health promotion and disease prevention and, hence, an age-based rationing of public health care.
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Affiliation(s)
- Kai Huter
- 1SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- 2High-profile Area of Health Sciences, University of Bremen, Bremen, Germany
| | - Katarzyna Dubas-Jakóbczyk
- 3Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Ewa Kocot
- 3Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Katarzyna Kissimova-Skarbek
- 3Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Heinz Rothgang
- 1SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- 2High-profile Area of Health Sciences, University of Bremen, Bremen, Germany
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Deverall E, Kvizhinadze G, Pega F, Blakely T, Wilson N. Exercise programmes to prevent falls among older adults: modelling health gain, cost-utility and equity impacts. Inj Prev 2018; 25:258-263. [PMID: 29363590 DOI: 10.1136/injuryprev-2016-042309] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 11/10/2017] [Accepted: 01/03/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Some falls prevention interventions for the older population appear cost-effective, but there is uncertainty about others. Therefore, we aimed to model three types of exercise programme each running for 25 years among 65+ year olds: (i) a peer-led group-based one; (ii) a home-based one and (iii) a commercial one. METHODS An established Markov model for studying falls prevention in New Zealand (NZ) was adapted to estimate incremental cost-effectiveness ratios (ICERs) in cost per quality-adjusted life-years (QALYs) gained. Detailed NZ experimental, epidemiological and cost data were used for the base year 2011. A health system perspective was taken and a discount rate of 3% applied. Intervention effectiveness estimates came from a Cochrane Review. RESULTS The intervention generating the greatest health gain and costing the least was the home-based exercise programme intervention. Lifetime health gains were estimated at 47 100 QALYs (95%uncertainty interval (UI) 22 300 to 74 400). Cost-effectiveness was high (ICER: US$4640 per QALY gained; (95% UI US$996 to 10 500)), and probably more so than a home safety assessment and modification intervention using the same basic model (ICER: US$6060). The peer-led group-based exercise programme was estimated to generate 42 000 QALYs with an ICER of US$9490. The commercially provided group programme was more expensive and less cost-effective (ICER: US$34 500). Further analyses by sex, age group and ethnicity (Indigenous Māori and non-Māori) for the peer-led group-intervention showed similar health gains and cost-effectiveness. CONCLUSIONS Implementing any of these three types of exercise programme for falls prevention in older people could produce considerable health gain, but with the home-based version being likely to be the most cost-effective.
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Affiliation(s)
- Eamonn Deverall
- Public Health Registrar, University of Otago, Wellington, New Zealand
| | - Giorgi Kvizhinadze
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, New Zealand
| | - Frank Pega
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, New Zealand
| | - Tony Blakely
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nick Wilson
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, New Zealand
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23
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Padilla Colón CJ, Molina-Vicenty IL, Frontera-Rodríguez M, García-Ferré A, Rivera BP, Cintrón-Vélez G, Frontera-Rodríguez S. Muscle and Bone Mass Loss in the Elderly Population: Advances in diagnosis and treatment. JOURNAL OF BIOMEDICINE (SYDNEY, NSW) 2018; 3:40-49. [PMID: 30505650 PMCID: PMC6261527 DOI: 10.7150/jbm.23390] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aging is the result of different functional changes leading to a substantial reduction of all human capabilities. A variety of anatomical and physiological changes occur with advancing age. These changes are more evident in the elderly population. There are various methods to measure muscle and bone mass loss, but the dual X-ray absorptiometry (DXA) is considered one of the most efficient. The elderly population (65 years and older) has been increasing throughout the years. Loss of muscle mass (sarcopenia) and loss bone mass (osteopenia or osteoporosis) with advancing age, when untreated, represent a major public health problem for the elderly population and may result in loss of independence in later life. Untreated age-related sarcopenia and osteopenia/osteoporosis increase the risk for falls and fractures, making older individuals more susceptible to the development of mobility limitations or severe disabilities that ultimately affect their capacity for independence. In this review, we will discuss the muscle and bone mass loss in the elderly population and advances in diagnosis and treatment.
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Affiliation(s)
- Carlos J. Padilla Colón
- Department of Education, Physical Education and Health Programs, San Juan, PR, USA
- Research and Development Service (151), VA Caribbean Healthcare System, San Juan PR, USA
| | - Irma L. Molina-Vicenty
- Research and Development Service (151), VA Caribbean Healthcare System, San Juan PR, USA
- Department of Biology, University of Puerto Rico, Rio Piedras Campus, San Juan, PR, USA
- Department of Radiological Sciences, University of Puerto Rico, Medical Sciences Campus, San Juan, PR, USA
| | - María Frontera-Rodríguez
- Research and Development Service (151), VA Caribbean Healthcare System, San Juan PR, USA
- Department of Biology, University of Puerto Rico, Rio Piedras Campus, San Juan, PR, USA
| | - Alejandra García-Ferré
- Research and Development Service (151), VA Caribbean Healthcare System, San Juan PR, USA
- Department of Biology, University of Puerto Rico, Rio Piedras Campus, San Juan, PR, USA
| | | | - Gerardo Cintrón-Vélez
- Research and Development Service (151), VA Caribbean Healthcare System, San Juan PR, USA
- Department of Biology, University of Puerto Rico, Rio Piedras Campus, San Juan, PR, USA
| | - Sebastián Frontera-Rodríguez
- Research and Development Service (151), VA Caribbean Healthcare System, San Juan PR, USA
- Department of Biology, University of Puerto Rico, Rio Piedras Campus, San Juan, PR, USA
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Isaranuwatchai W, Perdrizet J, Markle-Reid M, Hoch JS. Cost-effectiveness analysis of a multifactorial fall prevention intervention in older home care clients at risk for falling. BMC Geriatr 2017; 17:199. [PMID: 28863774 PMCID: PMC5580442 DOI: 10.1186/s12877-017-0599-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 08/24/2017] [Indexed: 11/17/2022] Open
Abstract
Background Falls among older adults can cause serious morbidity and pose economic burdens on society. Older age is a known risk factor for falls and age has been shown to influence the effectiveness of fall prevention programs. To our knowledge, no studies have explicitly investigated whether cost-effectiveness of a multifactorial fall prevention intervention (the intervention) is influenced by age. This economic evaluation explores: 1) the cost-effectiveness of a multifactorial fall prevention intervention compared to usual care for community-dwelling adults ≥ 75 years at risk of falling in Canada; and 2) the influence of age on the cost-effectiveness of the intervention. Methods Net benefit regression was used to examine the cost-effectiveness of the intervention with willingness-to-pay values ranging from $0–$50,000. Effects were measured as change in the number of falls, from baseline to 6-month follow-up. Costs were measured using a societal perspective. The cost-effectiveness analysis was conducted for both the total sample and by age subgroups (75–84 and 85+ years). Results For the total sample, the intervention was not economically attractive. However, the intervention was cost-effective at higher willingness-to-pay (WTP) (≥ $25,000) for adults 75–84 years and at lower WTP (< $5,000) for adults 85+ years. Conclusions The cost-effectiveness of the intervention depends on age and decision makers' WTP to prevent falls. Understanding the influence of age on the cost-effectiveness of an intervention may help to target resources to those who benefit most. Trial registration Retrospectively registered. Clinicaltrials.gov identifier: NCT00463658 (18 April 2007).
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Affiliation(s)
- Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON, M5T 3M6, Canada.
| | - Johnna Perdrizet
- Centre for Excellence in Economic Analysis Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Maureen Markle-Reid
- School of Nursing; Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main St. W, Hamilton, ON, L8N 3Z5, Canada
| | - Jeffrey S Hoch
- Centre for Excellence in Economic Analysis Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON, M5T 3M6, Canada.,Division of Health Policy and Management, Department of Public Health Sciences, University of California, Davis, 2103 Stockton Blvd. Sacramento, California, 95817, USA
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