The osteoporotic fracture prevention program in rural areas (OFRA): a protocol for a cluster-randomized health care fund driven intervention in a routine health care setting

Health-Economic Evaluation of the German Osteoporotic Fracture Prevention Program in Rural Areas (OFRA): Mobility and Falls Prevention Classes, Examination of Bone Health, and Consultation on Safety in the Living Environment

BACKGROUND

Fragility fractures are one of the leading causes of disability in older adults. Yet, evidence for effectiveness and cost-effectiveness of preventive approaches combining bone health and fall prevention is rare.

OBJECTIVE

To conduct a health-economic evaluation of the German osteoporotic fracture prevention program in rural areas (OFRA).

DESIGN

Secondary cluster-randomized intervention study based on routine data.

PARTICIPANTS

All districts in five federal states in Germany were cluster-randomized as intervention or control districts. OFRA was offered to community-living (a) women aged 75-79 years or (b) women and men aged 70-84 years with a prior fragility fracture in the intervention districts. Individuals who meet these criteria in the control districts were assigned to the control group.

INTERVENTION

OFRA comprised mobility and falls prevention classes, examination of bone health by bone density measurement, and consultation on safety in the home living environment.

MAIN MEASURES

We measured health-care costs and effectiveness in terms of time to fragility fracture or death within 1 year after initial contact, based on health insurance claims data. Implementation costs were recorded by the intervention performers. We calculated an incremental cost-effectiveness ratio (ICER) and employed the net-benefit approach to construct a cost-effectiveness acceptability curve (CEAC).

KEY RESULTS

There were 9408 individuals in the intervention group and 27,318 in the control group. Mean time to fragility fracture or death (difference: 0.82 days) and health-care costs (difference: 111.73€, p < .01) were reduced, but mean intervention costs (difference: 260.10€) increased total costs (difference: 148.37€, p < .001) in the intervention group. The ICER per fracture-free year of survival was 66,094.63€. The CEAC showed no acceptable probability of cost-effectiveness at a reasonable willingness to pay.

CONCLUSION

OFRA showed reduced rates of fragility fractures, but had high implementation costs, resulting in an unfavorable ICER. The cost-effectiveness of OFRA may improve with a longer follow-up.

Effect of an osteoporotic fracture prevention program on fracture incidence in routine care: a cluster-randomized trial

BACKGROUND

Fractures are a major health problem in aging societies. Preventive approaches combining bone health and fall prevention are rare. The osteoporotic fracture prevention program in rural areas (OFRA) is a health care fund-driven program for older people in randomly selected districts in Germany. The components of the program were falls prevention exercise classes, examination of bone health by a dual-energy X-ray absorptiometry (DXA) scan, and a consultation about "safety in the living environment." The aim of this study was to evaluate this complex preventive intervention in a routine health care setting.

METHODS

This cluster-randomized trial was performed from October 2015 to October 2018 and took place in 186 administrative districts in five federal states, 47 districts served as intervention districts, and 139, as controls. Within these districts, we included (a) all community-living women and men aged 70-85 years with prior fragility fractures and (b) all community-living women aged 75-80 years. The analysis used routine data collected by a health insurance company. The primary endpoint was all fragility fractures combined. Fracture types, mortality, and nursing home admission were explorative endpoints. Cox frailty models were used for comparative analyses with a median follow-up time of 365 days (interquartile range: 0 days).

RESULTS

Nine thousand four hundred eight individuals were approached to participate in one of the program components, 27,318 individuals served as controls. The mean age was 78.7 years. Of those approached to participate, nearly 30% joined the exercise classes. DXA measurement was reimbursed for 13.6%, and 51.8% received advice about measures to increase "safety in the living environment." The incidence of fragility fractures did not differ between the intervention and the control group (HR 0.94; 95% CI 0.80-1.11). However, femoral fractures, the most frequent fracture type, were reduced in the intervention group (HR 0.76; 95% CI 0.59-0.99). Mortality and nursing home admission did not differ between the intervention and the control group.

CONCLUSIONS

A comprehensive fracture prevention program for older people living in rural areas was implemented. The program did not affect the primary endpoint of all fragility fractures combined. It has to be considered that we used a modified intention to treat approach based on geographic randomization and information about endpoints relied exclusively on routine data of the health care insurance.

TRIAL REGISTRATION

German Clinical Trials Register DRKS-ID: 00009000.

Uptake of an exercise class and use of bone density measurement after advice by the health insurance fund: results from the osteoporotic fracture prevention program in rural areas (OFRA)

BACKGROUND

OFRA is a large health insurance fund-driven program which aims to reduce the risk of falls and fractures in older people living in rural areas. The programme offered specific mobility and falls prevention classes and bone density measurement by a DXA scan free of charge to more than 10,000 people, and was promoted by staff of the health insurance fund either by a visit at home, or a phone call, or a visit at home and a subsequent phone call. The aim of this study was to analyse the uptake of an exercise class and the use of a DXA scan after advice.

METHODS

Telephone interviews were conducted in a randomly selected subgroup of 780 persons 9 months after first contact. Rates of uptake of an exercise class or use of a DXA scan were calculated. Predictors of uptake and use were analysed applying logistic regression models.

RESULTS

The rate of uptake after advice for specific mobility and fall prevention class was 29.6%. For DXA scan, the rate of use after advice was 16.7%. Rates of uptake and use increased if the first contact by a visit at home or a phone call was followed by an additional subsequent phone call.

CONCLUSION

A direct motivational approach in older people by a health insurance fund is feasible and results in relevant participation and utilization rates in exercise classes and DXA scans.

Long-term evaluation of the implementation of a large fall and fracture prevention program in long-term care facilities

Background

Falls and fractures are extremely frequent in long-term care facilities (LTCFs). Therefore, a fall and fracture prevention program was started in nearly 1000 LTCFs in Bavaria/Germany between 2007 and 2010. The components of the program were exercise classes, the documentation of falls, environmental adaptations, medication reviews, the recommendation to use hip protectors and education of staff. The present study aimed to provide a comprehensive evaluation of the implementation process of the program regarding results of the implementation phase and the follow-up of 3–9 years after start of implementation.

Methods

Data from numerous sources were used, including data from published studies, statistical data, health insurance claims data and unpublished data from an online questionnaire. To incorporate different aspects, time periods and results, the RE-AIM framework was applied.

Results

The program was adopted by 942 of the 1150 eligible LTCFs and reached about 62,000 residents. During the implementation phase exercise classes and recommendation about environmental adaptations were offered in nearly all LTCFs. 13.5% of the residents participated in exercise classes. Hip protectors were available for 9.2% of all residents. In the first implementation wave, femoral fracture rate was significantly reduced by 18% in the first year. At follow-up nearly 90% of all LTCFs still offered exercise classes, which were attended by about 11% of residents. However, only 10% of the exercise classes completely fulfilled the requirements of an effective strength and balance training. Individual advice about environmental adaptations was provided in 74.3% of the LTCFs and nearly all LTCFs claimed to offer hip protectors to their residents. A long-term effect of the program on femoral fractures could not be detected.

Conclusions

The program did not affect the femoral fracture rate in the long run. Possible reasons could be a high turn-over of the staff, a reduced fidelity of training components or a shift in daily priorities among the staff.

[The osteoporotic fracture prevention program in rural areas (OFRA): analysis of 1092 mobility courses in rural areas]

BACKGROUND

Specific training reduces the risk of falls and fall-related injuries in older persons. The availability of specific exercise programs in Germany, especially in rural areas is scarce. Therefore, a healthcare fund driven program osteoporotic fracture prevention program in rural areas (OFRA) (German name: "Trittsicher durchs Leben") was implemented in rural areas in 47 counties of 5 federal states. The most important components of the program are the "Trittsicher" mobility course and falls prevention classes organized by members of the German Association of Rural Women and executed by exercise instructors of the German Gymnastics Association or physiotherapists. Since the start of the program in October 2015 more than 2300 classes have been carried out.

AIM

The study analyzed the structural characteristics of the first 1092 "Trittsicher" mobility courses and the characteristics of the 12,246 participants.

METHOD

The analysis is based on data of a standardized course documentation sheet and information from an internal database of a health insurance company. Additionally, the distance between the location of the course and place of residence was determined for a subgroup of the participants.

RESULTS

The classes were conducted in communal and confessional rooms, in sports associations, kindergartens and restaurants. The majority of the 12,246 participants were female (89.1%), the median age was 75 years. The average size of the classes was 11.2 participants per course. More than half of the participants attended all six sessions. Half of the participants of the courses had to travel less than 1.7 km between the place of residence and the location of the courses.

CONCLUSION

"Trittsicher" mobility courses are a new specific offer to improve mobility and reduce the risk of falling. They contribute to a better care of older people in rural areas.