Cochrane

# Supplementary material 17 to:
Interventions for preventing falls in older people living in the community

Gillespie LD , Robertson MC , Gillespie WJ , Sherrington C , Gates S , Clemson L , Lamb SE
https://doi.org/10.1002/14651858.CD007146.pub3

Cochrane disclaims all liability and responsibility arising from any reliance placed on this supplementary material which has been supplied by the author(s). The above associated publication’s Author Licence will apply in respect of any supplemental materials published. How to cite the supplementary material is defined in the Cochrane policy.

# Studies reporting cost-effectiveness, cost-utility, or costs of the intervention and/or healthcare resource use

Study ID (source if not primary reference), sample, efficacy analyses, type of evaluation | Intervention(s) and comparator (N in analysis) | Perspective(s), type of currency, price year, time horizon | Cost items measured | Mean (SD) intervention cost per person | Healthcare service costs | Incremental cost per fall prevented/per QALY gained
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•Buchner 1997a •Patients from a HMO, mild deficits in strength and balance, mean age 75 years •Analysis 1.1, 1.2, 2.1, 2.2 •Cost analysis | •Centre based endurance training and/or strength training, supervised for 24 to 26 weeks then self supervised (N = 75) vs no intervention (N = 30) | •HMO •US dollar •Not specified (presumed 1992) •Period 7 to 18 months after randomisation | •Hospital costs, ancillary outpatient costs (from HMO computerised records) |  | •Hospitalised control participants more likely to have hospital costs > USD 5000 (P < 0.05) |
•Campbell 1997 and 1 and 1 (2) •Women aged ≥ 80 years from 17 general practices, mean age (SD) 84.1 (3.3) years •Analysis 1.1, 1.2 •Cost-effectiveness analysis and 1 | •Specific set of muscle strengthening and balance retraining exercises individually prescribed at home (OEP) by physiotherapist, 4 home visits and monthly phone calls in year 1, phone contact only in year 2 (N = 116) vs social visits and usual care (N = 117) | •Societal •New Zealand dollar •1995 •During participation in trial (up to 2 years) | •Intervention costs (recruitment, programme delivery, overheads) •Healthcare costs resulting from falls (actual costs of hospital admissions and outpatient services, estimates of GP visits and other costs) •Total healthcare resource use (actual costs of hospital admissions and outpatient services) | In research setting: •NZD 173 (0) in year 1 •NZD 22 (0) in year 2 | •No difference between the 2 groups for healthcare costs resulting from falls or for total healthcare costs •27% of hospital admission costs during trial resulted from falls | At 1 year: •NZD 314 per fall prevented (programme implementation costs only) At 2 years: •NZD 265 per fall prevented (programme implementation costs only)
•Campbell 1999 (3) •Men and women aged ≥ 65 years currently taking psychotropic medication, mean (SD) age 74.7 (7.2) years •Analysis 11.1, 11.2 •Cost-effectiveness analysis | •Gradual withdrawal of psychotropic medication over 14 weeks (N = 48) vs continued to take psychotropic medication (N = 45) (double-blind) | •Health system •New Zealand dollar •1996 •During participation in trial (44 weeks) | •Intervention costs (recruitment, medication preparation and delivery, overheads) •Healthcare costs resulting from falls (actual costs of hospital admissions and outpatient services, emergency department, community services) •Total healthcare resource use (actual costs of hospital admissions and outpatient services, emergency department, community services) | In research setting: •NZD 258 (0) for 44 weeks | •Total hospital admission costs NZD 21,871 intervention group NZD 68,006 control group (P = 0.044) | •NZD 538 per fall prevented (programme implementation costs only)
•Campbell 2005 •People aged ≥ 75 years with severe visual impairment, mean (SD) age 83.6 (4.8) years •Analysis 15.1, 15.2, 16.1, 16.2, 17.1, 17.2 •Cost-effectiveness analysis | •Home safety assessment and modification programme, 1 to 2 home visits by experienced occupational therapist (N = 198) vs no home safety programme (N = 193) | •Health system •New Zealand dollar •2004 •During trial period (1 year) | •Intervention costs (training; recruitment; occupational therapists’ time, transport, administration; services and equipment installed in homes; overhead costs) | •NZD 325 (292) | •Not calculated (preplanned, no significant difference in number of fall injuries in the 2 groups) | •NZD 650 per fall prevented (home safety programme implementation costs only)
•Close 1999 (4) •People aged ≥ 65 years attending emergency department with a fall, mean (SD) age 78.2 (7.5) years •Analysis 22.1, 22.2, 22.3, 23.1, 23.2, 24.1, 24.2 •Cost analysis | •Multifactorial medical and occupational therapy assessment with referral to relevant services if indicated, 1 visit to day hospital for assessments, 1 home visit by occupational therapist (N = 184) vs usual care (N = 213) | •Health system •Pounds sterling •Not specified (presumed 1995) •For 12 months after randomisation | •Medical and occupational therapy assessment (unit cost GBP 90.00), hospital admissions (unit cost GBP 220.77), outpatient visits (unit cost GBP 58.38), GP visits (unit cost GBP 17.89) | •GBP 74 (0) for medical and occupational therapist assessment | •No difference between the 2 groups for health service costs (GBP 1953 intervention groups, GBP 2549 control group) |
•Coleman 1999 •Patients from a HMO aged ≥ 65 years at high risk of hospitalisation and functional decline, mean age 77.3 years •Analysis 22.2, 23.2, 24.2 •Cost analysis | •Multifactorial at a primary care clinic, half-day clinic held every 3 to 4 months (5 physicians, N = 96) vs usual care (4 physicians, N = 73) | •Health system •US dollar •Not specified •During trial period (24 months) | •Medical care (hospitalisation, emergency, and outpatient visits, pharmacy costs) |  | •No difference between the 2 groups for pharmacy costs or total health service costs |
•Conroy 2010 (5) •Community-living, aged ≥ 70, at high risk of falling (defined using modified Falls Risk Assessment Tool questionnaire) •Analysis 22.1, 22.2, 22.3, 23.1, 23.2, 24.1, 24.2 •Cost-effectiveness analysis | •Multifactorial programme at day hospital (physiotherapy, occupational therapy, nurse, medical review, referral to specialist) (N = 172 of 183) vs falls prevention information booklet only (N = 171 of 181) | •National Health Service, personal social services •Pound sterling •2007-8 •12-month study period | •Screening, recruitment, intervention programme (multidisciplinary staff time), health services potentially relevant to falls (GP and practice nurse consultations, outpatient first visit, emergency, inpatient bed days) | •GBP 349 (316) | •Mean total healthcare costs GBP 2238 (4957) intervention group GBP 1659 (5100) control group (mean incremental cost GBP 578 (95% CI -12,593 to 17,264) | •GBP 3320 per fall prevented
•Cumming 1999 (6) •Men and women recruited primarily before discharge from selected hospital wards, mean age 77 years •Analysis 15.1, 15.2, 16.1, 16.2; 17.1, 17.2 •Cost-effectiveness analysis | •Home safety visit by experienced occupational therapist, environmental hazard assessment, facilitation for necessary modifications, 1 home visit, follow-up telephone call 2 weeks later (N = 264) vs routine care (N = 266) | •Societal •Australian dollar •1997 •1 year from trial entry | In subsample of 103 intervention group and 109 control group (last 212 recruited into trial): •Hospitalisation, other healthcare costs provided in an institutional setting (e.g. outpatients), healthcare costs provided in the home (e.g. home nursing), informal care costs (e.g. personal care provided by a relative or friend, help around the home), home modification costs, occupational therapist (intervention costs) | •AUD 223 (0) intervention group, AUD 15 control group (home modification and occupational therapist intervention costs only) | •Mean total healthcare costs AUD 10,084 intervention group, AUD 8279 control group (P = 0.26 for median costs) | •AUD 4986 per fall prevented (all N = 527 participants) •AUD 3980 per fall prevented for participants reporting a fall in previous year (N = 203 participants) •< AUD 0 per fall prevented i.e. cost saving for participants reporting a fall in previous year (sensitivity analysis, outliers removed)
•Dangour 2011 •People aged 65 to 67.9 years living in low-middle socioeconomic status municipalities in Santiago, Chile •Analysis 1.2, 2.2, 13.1 •Cost analysis | 2 x 2 factorial trial: •Nutritional supplement for 24 months (10 health centres, N = 865) vs remainder (10 health centres, N = 800) •Multicomponent exercise classes, 2 x 1-hour supervised classes per week for 24 months (10 health centres, N = 854) vs remainder (10 health centres, N = 811) | •Societal and health system •Chilean peso converted to US dollar •2007 •During 2-year trial | From 94 exit interviews: •Nutritional supplementation intervention From 93 exit interviews: •Physical activity intervention | •USD 91 for nutritional supplement •USD 164 for physical activity intervention |  | •Not calculated (neither intervention reduced risk of falling; cost-effectiveness of physical activity intervention reported as USD 4.84 per extra metre walked)
•Davis 2011a •Community-living women aged 65 to 75 years •Analysis 4.1 •Cost-effectiveness analysis, cost-utility analysis | •Once weekly resistance training (N = 54) vs twice weekly balance and tone classes (N = 49) •Twice weekly resistance training (N = 51) vs twice weekly balance and tone classes (N = 49) | •Health service •Canadian dollar •2008 •9 months | •Costs of delivering the interventions (staff time, room use, equipment, building overhead costs); visits to health professionals; all visits, admissions, and procedures in hospital; laboratory and diagnostic tests | •CAD 353 once weekly resistance training •CAD 706 twice weekly resistance training •CAD 706 twice weekly balance and tone classes | •Mean healthcare costs resulting from falls, mean total healthcare costs respectively: CAD 547, CAD 1379 once weekly resistance training •CAD 184, CAD 1684 twice weekly resistance training •CAD 162, CAD 1772 twice weekly balance and tone classes | •Both once and twice weekly resistance training dominated balance and tone classes in terms of both falls and QALYs (i.e. less costly, more effective)
•De Vries 2010 (7) •People aged ≥ 65 years who consulted their GP or emergency department after a fall event within the previous 3 months, risk score ≥ 8 or living in a residential home •Analysis 22.2, 22.3, 23.2, 24.2 •Cost-effectiveness analysis, cost-utility analysis | •Multifactorial risk assessment by geriatrician at a geriatric outpatient clinic, individually tailored intervention regimen (e.g. withdrawal of psychotropic medication, balance and strength exercises by a physiotherapist, home hazard reduction by an occupational therapist, referral to ophthalmologist or cardiologist) (N = 106) vs usual care (N = 111) | •Societal •Euro (The Netherlands) •2007 •During 1 year from baseline | •Healthcare costs (e.g. geriatrician consult, GP care, specialist care, therapy, medication, hospitalisation, nursing home admission), patient and family costs (e.g. informal care), costs in other sectors (e.g. medical devices, home modifications, transportation aids) |  | •Mean of total healthcare costs intervention group EUR 7740 (9129) control group EUR 6838 (8623), difference EUR 902 (95% CI -1534 to 3357) | •EUR 226 per percentage reduction in fallers •If EUR 300,000 invested, probability that the intervention would improve quality of life (utility) by 1 point was 0.30 (incremental cost per QALY gained not reported)
•Foss 2006 (8) •Women aged > 70 years with one unoperated cataract •Analysis 12.1, 12.2, 12.3 •Cost-utility analysis | •Second eye cataract surgery, routine post surgery care (N = 116) vs first eye cataract surgery only ( N = 113) | •National Health Service, personal social services •Pound sterling •2004 •During participation in 1 year trial; participants’ expected lifetime | •Secondary healthcare (cataract operation, bed days, outpatient, emergency department, lower and upper limb fractures), primary health care (GP visits, practice/district nurse visits), personal social services (home care, day care centre, residential and nursing home care, meals on wheels, special equipment), patient and carers’ costs (home care, carer time costs) | •Cataract operation GBP 672 (0) | •Mean of total healthcare costs intervention group GBP 646 (95% CI 16 to 1276) more than control group | •Incremental cost per fall prevented not calculated as intervention did not reduce falls At 1 year: •GBP 44,263 per QALY gained (excluding carer costs) •GBP 58,667 per QALY gained (including carer costs) Over participants’ expected lifetime: •GBP 17,299 per QALY gained (discount rate 3.5% per annum)
•Harwood 2005 (9) •Women aged > 70 years with bilateral cataracts, mean (SD) age 84.1 (3.3) years •Analysis 12.1, 12.2, 12.3 •Cost-effectiveness analysis, cost-utility analysis | •Expedited (4 weeks) first eye cataract surgery, routine post surgery care (N = 148) vs control (routine, 12 months wait) (N = 140) | •National Health Service, personal social services •Pound sterling •2004 •During participation in 1 year trial; participants’ expected lifetime | •Secondary healthcare (cataract operation, bed days, outpatient, emergency department, lower and upper limb fractures), primary health care (GP visits, practice/district nurse visits), personal social services (home care, day care centre, residential and nursing home care, meals on wheels, special equipment), patient and carers’ costs (home care, carer time costs) | •Cataract operation GBP 672 (0) | •Mean of total healthcare costs intervention group GBP 2004 (95% CI 1363 to 2833) more than control group | At 1 year: •GBP 4390 per fall prevented (excluding carer costs) •GBP 3983 per fall prevented (with carer costs included) •GBP 35,704 per QALY gained (excluding carer costs) Over participants’ expected lifetime: •GBP 13,172 per QALY gained (discount rate 3.5% per annum)
•Hendriks 2008 •Patients aged ≥ 65 years who visited the emergency department or GP for the consequences of a fall •Analysis 22.2, 23.2, 24.2 •Cost analysis | •Multifactorial programme (detailed medical and occupational therapy assessment with referral to relevant services if indicated) approximately 3.5 months after baseline assessment (N = 166) vs usual care (N = 167) | •Societal •Euro (The Netherlands) •2004 •During participation in 1 year trial | For 120 of intervention group and 129 of control group: •Programme costs (time for geriatrician, nurse, occupational therapist and administration) •Health service costs (GP, specialist, hospital admission, nursing home admission, allied health care, aids and assistive devices, home care, medication) •Participant and family costs (home modifications, out-of-pocket expenses) | •EUR 385 (0) | •EUR 4857 (4470) intervention group and EUR 4991 (6835) control group for mean total healthcare costs (P = 0.856) | •Incremental ratios not calculated as intervention did not reduce falls or result in QALY gains
•Hornbrook 1994 •Patients from a HMO aged ≥ 65 years, mean (SD) age 73.4 (6.1) years •Analysis 22.1, 22.2, 23.1, 23.2, 24.1, 24.2 •Cost description | •Multifactorial including 90 minute group meetings for 4 weeks led by health behaviourist and physical therapist (environmental, behavioural and physical risk factors, 20 minutes of exercises), encouraged to walk 3 times a week, quarterly follow-up sessions (N = 1611) vs information on home safety (N = 1571) | •Study plus personal •US dollar •Not specified •During intervention | •Subsidised home safety repairs (e.g. bath tub grab bars, stair railings) in intervention group | •Project-subsidised repairs USD 78 (subsidy USD 46, participant contribution USD 32) |  |
•Kemmler 2010 •Women aged ≥ 65 living independently •Analysis 4.1, 4.2 •Cost analysis | •Multicomponent exercise, two 60-minute classes and two 20-minute home training sessions weekly for 18 months (N = 115) vs control (low-intensity exercise classes 60 minutes once weekly for 10 weeks followed by 10 weeks of rest) (N = 112) •All participants received calcium (1500 m/d) and cholecalciferol (500 IU/d) supplements | •Health system •Euro (Germany) •Not specified •During participation in 18 month trial | •Total healthcare costs (no details provided) |  | •EUR 2255 (2596) exercise group and EUR 2780 (3318) control group for mean total healthcare costs (P = 0.20) |
•Liu-Ambrose 2008 (10) •Women and men aged ≥ 70 years recruited from 2 referral based falls clinics •Analysis 1.1, 1.2 •Cost-effectiveness analysis | •Specific set of muscle strengthening and balance retraining exercises individually prescribed at home (OEP) by trained physiotherapist for 1 year (N = 36) vs guideline care (N = 38) •All participants received falls risk assessment, comprehensive geriatric assessment and treatment | •Health system •Canadian dollar •Not specified •12 months | •Cost of delivering the intervention •Cost of the falls clinic | •CAD 14,285 |  | •CAD 247 per fall prevented (comparable to incremental cost-effectiveness ratios in New Zealand studies of the Otago Exercise Programme)
•Markle-Reid 2010 •Community-living aged ≥ 75, newly referred to and eligible for home support services; reported a fall in previous year, fear of falling or unsteady on feet •Analysis 22.1, 22.2, 23.1, 23.2, 24.1, 24.2 •Cost analysis | •Multifactorial individually tailored home visits (case manager, registered nurse, occupational therapist, physiotherapist, registered dietitian) once per month for 6 months in addition to standard home care services (N = 49) vs control (standard home care services) (N = 43) | •Societal •Canadian dollar •2006 •6 months | •Primary care; emergency department and specialists; hospital days; 7 types of other health and social professionals; medications; laboratory services using the Health and Social Services Utilization Inventory |  | •Mean total direct healthcare costs CAD 5126 intervention group, CAD 4800 control group at 6 months (P = 0.330) | •Not calculated (intervention did not reduce falls)
•Robertson 2001a •Men and women aged ≥ 75 years from 17 general practices, mean (SD) age 80.9 (4.2) years •Analysis 1.1, 1.2, 1.3 •Cost-effectiveness analysis | •Specific set of muscle strengthening and balance retraining exercises individually prescribed at home (OEP) by trained district nurse, supervised by physiotherapist, 5 home visits and monthly phone calls for 1 year (N = 121) vs usual care (N = 119) | •Health system •New Zealand dollar •1998 •During participation in 1-year trial | •Intervention costs (training, recruitment, programme delivery, supervision of exercise instructor, overheads) •Hospital admission costs resulting from fall injuries during trial (actual costs of hospital admissions) | In community health service setting: •NZD 432 (0) for 1 year | •5 hospital admissions due to fall injuries in control group, none in exercise group (cost savings of NZD 47,818) | •NZD 1803 per fall prevented (programme implementation costs only) •NZD 155 per fall prevented (programme implementation costs and hospital admission cost savings)
•Tinetti 1994 (11) •Men and women aged ≥ 70 years with ≥ 1 risk factor for falling (postural hypotension; use of sedatives; ≥ 4 medications; impairment in arm or leg strength or range of motion, balance, gait, transfer skills; environmental hazards), mean (SD) age 77.9 (5.3) years •Analysis 22.1, 22.2, 22.3, 23.1, 23.2, 24.1, 24.2 •Cost-effectiveness analysis | •Multifactorial targeted intervention for 3 months after the baseline assessment, extended if health problems had interfered with ability to exercise (behavioural instructions, exercise programmes, adjustment to medications, home safety) delivered by physician and at home by nurse and physiotherapist (8 physicians, N = 148) vs home visits by social work student (8 physicians, N = 140) | •Health system •US dollar •1993 •The year following study enrolment | •Intervention costs (developmental and training costs, recruitment costs, overheads, equipment, and staff related costs) •Health services (hospitalisation and emergency department, outpatient, home care, skilled nursing facilities) | •USD 905 (range 588 to 1346) | •Mean total healthcare costs USD 8310 intervention group and USD 10,439 control group | Using mean costs: •USD 1772 per fall prevented (intervention costs only) •< USD 0 per fall prevented, i.e. cost saving (total healthcare costs) •< USD 0 per ‘medical’ fall prevented, i.e. cost saving (total healthcare costs)
•Van Rossum 1993 •General population aged 75 to 84 years, 73% aged 75 to 79 years •No data available for pooling •Cost analysis | •Multifactorial home visits 4 times a year for 3 years, extra visits if necessary by public health nurses lasting 45 to 60 minutes (N = 292) vs no home visits (N = 288) | •Health system •Dutch guilder •Not specified •During 3 year trial period | •Health services (community care services, hospital, long term institutional care, home visits) | •Total 393,981 Dutch guilders for intervention group home visits | •Total health service costs were 4% per person less for control (mean 19,321 guilders) than intervention group (mean 20,080 guilders) |
•Voukelatos 2007 (12) •Healthy community-living people aged ≥ 60 years, mean (SD) age 69 (6.5) years •Analysis 1.1, 1.2, 3.1, 3.2 •Cost-effectiveness analysis | •Tai Chi classes 1 hour weekly for 16 weeks (N = 347) vs no intervention (N = 337) | •Public health system (NSW Health) •Australian dollar •Not specified (presumed 2001) •During 24 week trial period | •Intervention costs (cost of venues, advertising, instructors) •Health service use related to falls from health care use diary and hospital records, valued at standard costs (GP, specialist, tests, hospitalisations, medications) | •AUD 245 (0) intervention group plus charge AUD 44 per participant | •Mean total healthcare costs higher for Tai Chi group (AUD 55) than control group (AUD 17) (P < 0.0001) | •AUD 1683 per fall prevented (includes cost offset by charging AUD 44 per instruction course)
•Weber 2008 •Community living patients of the Geisinger Health System, rural Pennsylvania aged ≥ 70 years, ≥ 4 prescription medications, ≥ 1 psychoactive medications •No data available for pooling •Cost analysis | •Standardised medication review by clinical pharmacist or geriatrician, recommendations to the primary physician via an electronic medical record system (15 clinic sites, N = 413) vs usual care (3 clinic sites, N = 207) | •Geisinger Health System •US dollar •Not specified (presumed 2003) •From date of electronic message (intervention) or 30 January 2003 (comparator) to end of 15 month study | •Health services (outpatient, inpatient, emergency department, total costs calculated from the Geisinger Health Plan insurance database) |  | •No significant trends in health service costs |
•Wyman 2005 (13) •Women aged ≥ 70 years, mean (SD) 78.8 (5.6) years •Analysis 22.1, 22.2, 23.1, 23.2, 24.1, 24.2 •Cost description | •Multifactorial home-based programme for 12 weeks followed by 16 weeks of computerised telephone support (risk factor assessment, tailored counselling, education, exercise, walking programme, referrals as needed) delivered by nurses (N = 137) vs health education (N = 135) | •Health system •US dollar •Not specified •From end of 28 week intervention period, end point not reported | •Health service costs associated with falls (clinic visit, emergency department, ambulance, hospital inpatient, outpatient physical therapy, rehabilitation centre, home care) |  | •Mean cost of an injurious fall USD 6606 (range 63 to 85,984), median USD 658 (costs not broken down by group) |

See also 14
GP: general practitioner
HMO: health maintenance organisation
OEP: Otago Exercise Programme
QALY: quality adjusted life year

## References

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