|An economic evaluation of community and residential aged care falls prevention strategies in NSW
|Church J, Goodall S, Norman R, Haas M
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.
This study investigated the cost-effectiveness of strategies to prevent falls and fall injuries in older people. The authors concluded that Tai Chi was most cost-effective for community-dwelling older people. Expedited cataract surgery and psychotropic medication withdrawal were cost-effective, but the evidence was limited. For older people in care homes, medication review and vitamin D supplementation were most cost-effective. The analyses and methods were appropriate and mostly well reported. The conclusions reached by the authors appear to be appropriate.
Type of economic evaluation
Cost-effectiveness analysis, cost-utility analysis
This study investigated the cost-effectiveness of strategies designed to prevent falls and fall injuries, in people aged 65 years or older. Two hypothetical cohorts of people were assessed; one with a mean age of 75 years living in the community and the other with a mean age of 85 years living in care homes for the elderly.
The interventions for those living in the community were group or home exercise, Tai Chi, psychotropic medication withdrawal, cardiac pacing, expedited cataract surgery, and multiple or multifactorial interventions. Those for people living in care homes were vitamin D supplementation, clinical medication review, and multiple or multifactorial interventions. Each intervention was compared against no intervention.
A decision-analytic Markov model was used to synthesise the evidence from published studies. The time horizon was 10 years and the authors did not state the study perspective.
A systematic literature review was undertaken, in September 2008, to identify the effectiveness data. Searches were conducted in PubMed, EMBASE, the Cochrane Library, CRD databases, and Web of Science. Randomised controlled trials, with a population mean age of 65 years or older and with 20 or more participants, were included. Two researchers used standardised methods to extract the data and an intention-to-treat analysis was conducted. A pooled measure of risk was calculated, using random-effects meta-analysis, for each intervention. A Cochrane review of falls was used for the community analysis. Other published studies and expert opinion were used for some inputs. The main clinical effectiveness estimates were the relative risk of falls, and the fall-related and any cause deaths. The annual probabilities of being low, medium, or high risk, depending on fall history and injury history, were estimated.
Monetary benefit and utility valuations:
The utility estimates were collected from members of the UK population using the European Quality of life (EQ-5D) measure. The utility decrements for events in the model were from published sources.
Measure of benefit:
The measures of benefit were quality-adjusted life-years (QALYs), hospitalisations avoided, and falls avoided. These were discounted annually at 5%.
The health care costs were estimated for each intervention. These costs were from a selection of relevant published studies, personal communications, and state health departments. They were adjusted to 2009 Australian dollars (AUD), using the average health price index for government spending on hospitals and nursing homes. The costs were discounted at 5% annually.
Analysis of uncertainty:
The variability in the results was examined in one-way sensitivity analyses, performed on each input, using 95% confidence intervals from the literature, where possible, or ±25% of the initial estimate. The sensitivity analysis results were illustrated in a tornado plot.
For the community cohort, compared with no intervention, the incremental cost per QALY ratios were AUD 2,211 for expedited cataract surgery, AUD 16,584 for psychotropic medication withdrawal, AUD 44,879 for Tai Chi, AUD 72,765 for group exercise, AUD 74,186 for multiple interventions, AUD 80,257 for cardiac pacing, AUD 96,205 for home exercise, AUD 130,139 for multifactorial active intervention, and AUD 172,009 for multifactorial referral intervention.
For the residential cohort, the incremental cost per QALY ratios were AUD 106 for vitamin D supplementation, AUD 45,287 for multiple interventions, and AUD 56,752 for multifactorial active intervention. Medication review was dominant, as it produced more QALYs at lower costs than no intervention.
The one-way sensitivity analyses showed that these results were most sensitive to the fear of falling, the effectiveness of the interventions, and the intervention costs.
The authors concluded that Tai Chi was the most cost-effective falls prevention strategy for community-dwelling older people. Expedited cataract surgery and psychotropic medication withdrawal were cost-effective, but the evidence was limited. For older people in care homes, medication review and vitamin D supplementation were the most cost-effective strategies.
The interventions were briefly described and a reference to another publication was given for further details. These interventions might be feasible for other settings.
The effectiveness estimates were from a systematic review and meta-analysis performed by the authors. This appears to have been of high quality and comprehensive, and it was clearly reported. The results of a Cochrane review that was published after this systematic review was completed, were considered. The authors stated that caution was required in interpreting their pooled estimates, due to heterogeneity between the individual trials. The measure of benefit was appropriate as it considered both morbidity and mortality.
The perspective was not stated, making it difficult to assess if all the relevant costs were included. Only health care costs were analysed. The resource quantities were summarised clearly in the report and some cost items were listed, but only the total costs for each intervention were reported. These costs appear to have been from reasonable sources and they were appropriately discounted and adjusted for inflation.
Analysis and results:
The analytic approach appears to have been appropriate and was described sufficiently, including a diagram of the Markov model. The incremental results and the sensitivity analysis (for one intervention) were clearly reported. Only one-way sensitivity analyses were undertaken. A probabilistic sensitivity analysis could have assessed the overall uncertainty in the model and strengthened the conclusions. The authors acknowledged some limitations of the analysis including the assumptions required, such as costs based on the mean duration and intensity of the interventions, and limited data from few studies or studies with small samples.
The analyses and methods were appropriate and mostly well reported. Given the scope of the study, the conclusions reached by the authors appear to be appropriate.
Church J, Goodall S, Norman R, Haas M. An economic evaluation of community and residential aged care falls prevention strategies in NSW. New South Wales Public Health Bulletin 2011; 22(3-4): 60-68
Subject indexing assigned by NLM
Accidental Falls /economics /prevention & Aged; Cataract Extraction; Cost-Benefit Analysis; Female; Humans; Male; New South Wales; Primary Prevention /economics /methods; Psychotropic Drugs /administration & Residential Facilities /statistics & Tai Ji; Vitamin D /administration & control; dosage; dosage; numerical data
Date bibliographic record published
Date abstract record published