Article Text

Economic evaluations of fall prevention exercise programs: a systematic review
1. Marina B Pinheiro1,2,
2. Catherine Sherrington1,2,
3. Kirsten Howard2,3,
4. Patrick Caldwell1,2,
5. Anne Tiedemann1,2,
6. Belinda Wang1,2,
7. Juliana S Oliveira1,2,
8. Andreia Santos4,
9. Fiona C Bull4,
10. Juana F Willumsen4,
11. Zoe A Michaleff5,
12. Sarah Ferguson1,2,
13. Eleesheva Mayo1,2,
14. Nicola J Fairhall1,2,
15. Adrian E Bauman2,
16. Sarah Norris2,3
1. 1 Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
2. 2 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
3. 3 Menzies Centre for Health Policy and Economics & Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
4. 4 Physical Activity Unit, Department of Health Promotion, Division of Universal Health Coverage and Healthier Populations, World Health Organization (WHO), Geneve, Switzerland
5. 5 Northern NSW Local Health District, Lismore, New South Wales, Australia
1. Correspondence to Dr Marina B Pinheiro, Institute for Musculoskeletal Health, The University of Sydney, Sydney, NSW 2006, Australia; marina.pinheiro{at}sydney.edu.au

## Abstract

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

Design Systematic review.

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

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

Figure 2

Incremental cost-effectiveness ratios (ICERs) expressed as additional cost per fall prevented from economic evaluations of fall prevention exercise programmes. *Costs are expressed as 2020 US$. Results are presented separately for model-based and trial-based analyses. Dominant interventions (ie, more effective and less costly) are shown on the zero line. Same colours and numbers indicate same study. Closed circles indicate moderate level of certainty and open circles indicate low level of certainty. Uncertainty intervals are not displayed as most studies did not report it. ##### Risk of bias and certainty of the evidence Overall, the CHEC-list scores ranged from 11 to 17 out of 19 for trial-based analyses and from 10 to 17 out of 20 for the model-based analysis (online supplemental table 9). Limitations in the economic evaluations included: limited uncertainty analyses, conclusions not supported by the findings, lack of identification of all relevant costs for both alternatives, poor description of competing alternatives and of the structural assumptions and the validation methods of the model (only relevant for model-based analysis). Online supplemental table 10 presents the findings for the additional questions on the quality of the models, and online supplemental table 11 presents the author’s conclusions and detailed reviewers’ comments on the approach to the economic evaluations of fall prevention exercise programmes. Overall, studies selected appropriate and population relevant measures of effectiveness (9 out of 11) and appropriately considered attenuation of effect post intervention (7 out of 8, n=3 models only modelled the trial duration). However, most studies failed to explore all the relevant parameters in sensitivity analyses, did not report all parameters used in the model as well as their sources and only reported results for the end of the time horizon investigated instead of presenting intermediate measures which would enhance the interpretability of the findings. Our GRADE style rating for trial-based evaluations ranged from low (n=3 studies investigating 3 interventions) to moderate level of certainty (n=6 studies investigating 6 interventions), indicating that we have limited-to-moderate confidence that the outputs from the trial-based economic evaluations are reliable for decision-making (online supplemental table 6 and material 7). The model-based studies (n=12) investigated a total of 20 interventions, and our GRADE style rating ranged from low (n=7 studies investigating 12 interventions) to moderate level of certainty (n=6 studies investigating 8 interventions), indicating that we have limited-to-moderate confidence that the outputs from the models are reliable for decision-making (online supplemental table 6 and material 8). ##### Cost-effectiveness results The included studies reported ICERs for five outcomes: QALY, fall, fall-related injuries, fall-related fractures and fall-related hospitalisation. An overview of ICERs expressed as additional cost per QALY gained is presented in figure 1. Two trial-based and eight model-based evaluations reported QALYs for a total of two comparisons as some studies investigated more than one exercise group or reported results for subgroups. The results varied, ranging from the intervention being more effective and less costly (dominant) in four comparisons to an incremental cost of US$279 802 (2020 US$) per QALY gained. When considering an arbitrary willingness-to-pay threshold of US$100 000/QALY gained,28 most results (17 out of 24) were considered to be cost-effective and 11 of these 17 results were rated as moderate quality. Overall, the studies with moderate certainty showed better cost-effectiveness (lower ICERs).

A total of 12 studies reported results for falls (6 trial-based and 6 model-based) for 21 comparisons (figure 2). The findings from studies investigating falls found ICERs ranging from the intervention being more effective and less costly (dominant) in five comparisons, to US$11 986 per fall prevented (figure 2). Overall, 15 out of 21 results had ICERs below US$4000 per fall prevented and 8 of these were rated as moderate quality.

Fewer studies investigated other fall-related outcomes (n=8 studies, 4 model-based and 4 trial-based, investigating 16 comparisons) and the results for these outcomes are displayed in online supplemental figure 2. The results also varied and suggest a trend of increased ICER for more serious fall-related outcomes, from fall-related injury (ICER ranging from dominant to US$1430) to fracture (ICER ranging from US$14 031 to US$125 951) and hospitalisation (ICER ranging from US$9466 to US$403 927). Most comparisons were rated as moderate quality (10 out of 16). ##### Post-hoc analyses Several post-hoc analyses were undertaken to explore the cost-effectiveness results according to relevant characteristics of the studies. Stratified by the type of exercise, the results for tai chi, multicomponent exercise and unspecified exercise programmes were below the willingness-to-pay threshold of US$100 000/QALY gained. Within the studies investigating balance/functional exercise, 9 out of 16 were below the threshold of US$100 000/QALY gained (figure 3). Overall, the studies with moderate certainty showed better cost-effectiveness (lower ICERs). For falls prevented, no specific pattern could be identified therefore it was not clear whether a specific type of exercise offered better value for money (figure 4). Figure 3 Incremental cost-effectiveness ratios (ICERs) expressed as additional cost per QALY gained from economic evaluations of fall prevention exercise programmes according to exercise type. Multi, multicomponent; NS, exercise type not specified. Results are presented separately for model- and trial-based analyses Costs are expressed as 2020 US$. Dominant interventions (ie, more effective and less costly) are shown on the zero line. Same colours and numbers indicate same study. Closed circles indicate moderate level of certainty and open circles indicate low level of certainty. Uncertainty intervals are not displayed as most studies did not report it.

Figure 4

Incremental cost-effectiveness ratios (ICERs) expressed as additional cost per fall prevented from economic evaluations of fall prevention exercise programmes according to exercise type. Multi, multicomponent; NS, exercise type not specified. Results are presented separately for model-based and trial-based analyses *Costs are expressed as 2020 US$. Dominant interventions (ie, more effective and less costly) are shown on the zero line. Same colours and numbers indicate same study. Closed circles indicate moderate level of certainty and open circles indicate low level of certainty. Uncertainty intervals are not displayed as most studies did not report it. The level of supervision of exercise programmes (supervised; unsupervised; mix of unsupervised and supervised sessions) was found to impact on results. Overall, there was a trend for unsupervised exercise to have higher ICER for QALY (5 out of 10 comparisons below US$100 000 threshold), whereas all comparisons for supervised exercise were below the US$100 000 threshold (figure 5). No specific pattern was found when fall outcome was considered (figure 6). Figure 5 Incremental cost-effectiveness ratios (ICERs) expressed as additional cost per QALY gained from economic evaluations of fall prevention exercise programmes according to level of supervision. Results are presented separately for model-based and trial-based analyses Costs are expressed as 2020 US$. Dominant interventions (ie, more effective and less costly) are shown on the zero line. Same colours and numbers indicate same study. Closed circles indicate moderate level of certainty and open circles indicate low level of certainty. Uncertainty intervals are not displayed as most studies did not report it.

Figure 6

Incremental cost-effectiveness ratios (ICERs) expressed as additional cost per fall prevented from economic evaluations of fall prevention exercise programmes according to level of supervision. Results are presented separately for model-based and trial-based analyses. *Costs are expressed as 2020 US$. Dominant interventions (ie, more effective and less costly) are shown on the zero line. Same colours and numbers indicate same study. Closed circles indicate moderate level of certainty and open circles indicate low level of certainty. Uncertainty intervals are not displayed as most studies did not report it. Lastly, when considering participants’ baseline characteristics (general population, older age (as per included study definition), female, high fall risk) no specific pattern was found for QALY (online supplemental figure 3). However, for fall prevention, higher ICERs were found for the general population, suggesting that the intervention offers better value for money for the other subgroups (online supplemental figure 4). There were six studies that reported results separately for age, fall risk and sex. When these characteristics were explored within the studies (differences between the subgroups were not tested statistically), the ICERs for older and high fall risk were always lower (indicating better cost-effectiveness) for QALY (figure 7) and fall outcomes (figure 8). Figure 7 Incremental cost-effectiveness ratios (ICERs) expressed as additional cost per quality-adjusted life year (QALY) gained from economic evaluations of fall prevention exercise programmes according to baseline characteristics explored within the study. Costs are expressed as 2020 US$. Dominant interventions (ie, more effective and less costly) are shown on the zero line. Same colours and numbers indicate same study. Closed circles indicate moderate level of certainty and open circles indicate low level of certainty. Uncertainty intervals are not displayed as most studies did not report it.

Figure 8

Incremental cost-effectiveness ratios (ICERs) expressed as additional cost per fall prevented from economic evaluations of fall prevention exercise programmes according to baseline characteristics explored within the study. *Costs are expressed as 2020 US$. Dominant interventions (ie, more effective and less costly) are shown on the zero line. Same colours and numbers indicate same study. Closed circles indicate moderate level of certainty and open circles indicate low level of certainty. Uncertainty intervals are not displayed as most studies did not report it. #### Question 2: What are the costs of developing and implementing fall prevention exercise programs for older adults living in the community? We found five studies that estimated the costs of developing and implementing fall prevention exercise programmes in the community (online supplemental table 1).50–54 The results of one study were reported in two papers.52 55 All studies were conducted in high-income countries and the geographical location is presented in online supplemental table 2. The costing studies investigated balance/functional exercise (n=2), multicomponent (n=1), tai chi (n=1). One study did not specify exercise type. The risk-of-bias ratings for the costing studies varied, ranging from 5 to 12 out of 15 (median score=6, online supplemental table 13). Overall, intervention costs were poorly reported (online supplemental table 12). The included studies (n=24) investigated a total of 34 exercise programmes and total intervention costs, and cost breakdown was only available for 14 (41%) programmes. Total costs were only reported for 17 exercise programmes (50%). The intervention cost per person per week varied, ranging from US$0.40 to US$83 (table 1). No pattern could be found for intervention costs according to type of exercise (table 1). Online supplemental table 12 provides a detailed description of total cost, cost per item, cost in the reported currency and year, as well as costs translated to 2020 US$, and cost per week for each of the exercise programmes.

Table 1

Summary of results of the intervention costs of fall prevention exercise programs for older adults living in the community

### Fall prevention exercise targeted at older adults living in aged care facilities

#### Question 1: What is the cost-effectiveness and cost-utility of fall prevention exercise programs?

##### Study characteristics

We found one trial-based10 and one model-based56 economic evaluation investigating the cost-effectiveness of fall prevention exercise programmes in aged care facilities (online supplemental table 1). The studies were conducted in high-income countries (Australia and the USA) and investigated multicomponent and tai chi exercise programmes. Both programmes were fully supervised by an instructor and conducted in groups. Both economic evaluations had a time horizon of 12 months but differed in the perspective taken, that is, health service perspective10 and societal perspective56 (table 2 and online supplemental table 4).

Table 2

Summary of results of the trial and model-based economic evaluations investigating fall prevention exercise programs in older adults living in aged care facilities

##### Risk of bias and certainty of the evidence

The risk-of-bias rating of the economic evaluations was 9 out of 20 for the model-based evaluation and 17 out of 19 for the trial-based economic evaluation (online supplemental table 9). Online supplemental tables 10 and 11 presents detailed information about the quality of the economic evaluations.

Our GRADE style rating found a moderate level of certainty for the trial-based evaluation (online supplemental material 7), indicating moderate confidence that the outputs are reliable for decision-making. A low level of certainty was found for the model-based analysis indicating that we have limited confidence that the outputs from this model are reliable for decision-making (online supplemental material 8).

##### Cost-effectiveness results

Both studies investigated fall-related outcomes (fall and injurious fall). The trial-based evaluation that investigated the multicomponent exercise programme found ICERs of US$35/fall prevented and US$56/injurious fall avoided. The study that modelled the tai chi programme found that the intervention was less costly and more effective (dominant) (table 2).

#### Question 2: What are the costs of developing and implementing fall prevention exercise programs for older adults living in aged care facilities?

In addition to the two economic evaluations,10 56 we also found two costing studies,57 58 which were also conducted in a high-income country (the USA) and investigated multicomponent exercise programmes. The CHEC-list Score for the costing studies was low and rated as 4 and 6 out of 15 (online supplemental table 13).

All four studies included in this review reported intervention costs, but none of them reported the total costs as well as the breakdown of the cost items contributing to the total cost (online supplemental table 12). Only two studies reported intervention cost per person per week or provided enough data to allow its calculation and they reported a cost of US$3 and US$9 per person per week to run the exercise in the aged care facility (table 3).

Table 3

Summary of results of the intervention costs of fall prevention exercise programs for older adults living in care facilities

## Discussion

There are a considerable number of economic evaluations of fall prevention exercise programmes for people living in the community (n=20, reported in 21 articles), but none were conducted in low-income or middle-income countries. Overall, there was heterogeneity in the economic analyses investigated, making direct comparisons difficult. The results varied, with ICER estimates ranging from dominant (more effective and less costly) to as high as US$279 802 per QALY gained and US$11 986 per fall prevented. A considerable proportion of the interventions (17 out of 24, 71%) had an ICER below a willingness-to-pay threshold of US$100 000 per QALY gained. The level of certainty varied between low and moderate, but there was a considerable number of studies with moderate level of certainty (n=11). These results suggest that fall prevention exercise programmes probably offer good value for money depending on one’s willingness to pay, particularly for ‘older’ old people (aged 80+ years) and those with high fall risk. There was a trend for more favourable results for supervised exercise. In contrast, there are few economic evaluations (n=2) investigating fall prevention exercise programmes for older adults living in aged care facilities. The results of these economic evaluations are promising, with relatively low ICERs for fall avoided (dominant and US$35/fall avoided) and moderate level of certainty for the trial-based analysis. None of the included studies conducted in care facilities investigated QALYs. The overall evidence in this setting is less clear, and more high-quality trial-based and model-based analyses are needed. The intervention costs varied across the included economic analyses and are similar to costs found in previous reports of fall prevention exercise.59

### Implications for clinicians and policy-makers

Although our results suggest that exercise programmes may offer better value for money for specific subgroups (‘older’ old people, people with higher fall risk) and this information could inform budget allocation, we argue that fall prevention exercise should be offered to all older adults given its proven benefits for fall reduction.7 Although a trend was found for multicomponent and tai chi exercises and supervised programmes to offer better value for money than balance and functional exercise and unsupervised programmes, these results should be interpreted with caution. Therefore, policy-makers and managers considering funding exercise programmes should choose the exercise type and supervision level according to their context and budget.

We have selected an arbitrary willingness-to-pay threshold of US100 000 per QALY gained to facilitate the interpretation of findings. Although this threshold has been commonly referenced in the US literature,28 whether an intervention is cost-effective or not depends on the decision-maker’s willingness to pay. Decision-makers considering implementing a fall prevention exercise programme should also take into account the additional benefits of physical activity for overall health60 that were not included in the economic evaluations, low risk as well as the ease of implementation of the intervention (ie, no sophisticated equipment required and no need for the highly specialised workforce). The overview of the intervention costs presented in this review should be interpreted in the context of the duration of the exercise programme, level of supervision and number of participants. Policy-makers and governments considering the implementation of a fall prevention exercise programme can use this information to inform their budget and implementation planning. The intervention cost information can also be used as an input for future model-based analyses. None of the included studies were conducted in low-income and middle-income countries. However, most of the model-based analyses used effectiveness measures from meta-analyses that included some studies conducted in low and middle-income countries. Considering the ease of implementation of falls prevention exercise programmes, we would expect to find similar cost-effectiveness ratio in countries with lower income levels. This needs to be tested in future studies. ### Strengths and limitations This is the largest systematic review of economic evaluations and costing studies of fall prevention exercise programmes and the first to include both community and aged care settings. This was also the first review to attempt to explore the results according to participant and programme characteristics, to summarise intervention costs, to conduct an in-depth appraisal of the risk of bias of the studies and to apply GRADE style rating to assess the certainty of the evidence. Our results are aligned with previous reviews that concluded that fall prevention programmes for older people living in the community are likely to offer good value for money,13 29 although it was often unclear the methods and criteria used to judge an intervention as cost-effective in these previous reviews. The following limitations should be considered when interpreting the results of this study. Although we used a comprehensive search strategy and searched specialised databases, we only searched electronic databases and performed hand search of peer-reviewed systematic reviews. It is possible that we may have missed economic evaluations of fall prevention exercise programmes that were not available in these sources. As anticipated, we were unable to pool the results by conducting a meta-analysis. There are often inherent challenges in comparing and combining the results of economic evaluations as they commonly have several differences, such as context and health service of the country, perspective, time horizon, cost items considered, methods for capturing costs and for calculating ICERs. We attempted to facilitate comparability between studies by reporting results in 2020 US and by displaying the results in figures. However, such approach has limitations as it does not consider the underlying heterogeneity between the studies. Additionally, uncertainty intervals were not displayed in the figures as these were rarely reported in the included studies. Therefore, caution is needed when interpreting the results of the figures and they should be analysed in combination with the detailed information provided for each study in the online supplemental tables and materials. There may be a risk of publication bias. There is presently no clear method to assess publication bias in reviews of economic evaluations as economic evaluation protocols are commonly not registered and trial-based economic evaluations should only be performed for interventions that are effective.

Several studies only reported results for natural outcomes (ie, fall-related outcomes). These results are useful when comparing interventions with the same outcome measure. However, natural outcomes do not allow us to examine whether the intervention represents value for money relative to other disparate healthcare programmes. A willingness-to-pay threshold for fall-related outcomes is currently not available in the literature, which makes the interpretation of results more challenging. Previous non-exercise fall prevention strategies, such as home safety programmes and multifactorial interventions have demonstrated similar results to the ones found in this review.13 29

Although we found that supervised programmes seem to offer better value for money than unsupervised programmes, these results should be interpreted with caution as social interactions in supervised programmes may contribute to the results of exercise interventions. However, as social interaction is a key component of supervised exercise it is not possible to disentangle the proportion of the effect observed that is due to the exercise programme itself or social interactions associated with the programme.

### Recommendations for future research

Future economic evaluations of fall prevention exercise programmes should describe both alternatives in details, including the type of exercise, frequency, duration, as well as provide a detailed description of the control intervention as the content of the control intervention will influence the interpretation of results. Additionally, studies should report disaggregated values, that is, total costs per group, incremental costs and incremental outcomes, instead of only presenting ICERs, as the additional information would enhance the interpretation of findings. Studies should also express the uncertainty in the results by reporting uncertainty intervals and acceptability curves.

Future modelled economic evaluations should identify all relevant costs for both alternatives, clearly report the parameters used as well as their sources and report uncertainty intervals for the results. Additionally, extensive sensitivity and scenario analyses should be performed to test the robustness of the findings and to enhance interpretation of results. Farag et al’s study could be used as an example.42 In this model-based analysis, different intervention costs, uptake levels and programme effectiveness were modelled in sensitivity analyses and, therefore, the results offer clear guidance to policy-makers considering implementing a fall prevention programme. In addition to reporting the results for the end of the time horizon, authors should also report intermediate results in a stepped manner so the impact of each of the steps of the model can be tested. Examples of intermediate results include results limited to trial-based data, results after application of utility weights, and extension of time horizon.

Future studies should consider using standardised methods for identifying and measuring costs and health benefits to enhance comparability of results. Additionally, they should present a detailed breakdown of the elements and costs involved in developing and implementing a fall prevention programme, such as training, staff and equipment to allow implementation. Unit costs should also be presented for each of these items. Actual intervention costs should be reported instead of costs based on recommendations for future applications, which could be explored in a scenario analysis.

Most of the trial-based economic evaluations included in this review only included fall-related healthcare utilisation. Future studies should consider including total healthcare utilisation as exercise may have additional consequences that are not captured by the fall-related healthcare utilisation measure. For instance, exercise may result in other general health benefits and therefore reduce other service utilisation that is not related to a fall. On the other hand, exercise may have unintended consequences and may increase the incidence of adverse events requiring medical attention that are not related to falls, such as musculoskeletal complaints. Therefore, capturing healthcare utilisation more broadly would offer a more comprehensive picture of the cost-effectiveness of the intervention.

Future primary studies investigating the effectiveness of fall prevention exercise programmes should consider including a trial-based economic evaluation, particularly those conducted in low-and-middle-income countries. Studies should also consider including a generic outcome measure such as QALY to enhance comparability with other interventions. We strongly recommended that future primary studies and reviews follow standard economic evaluation best-practice recommendations17–19 and reporting guidelines, such as the Consolidated Health Economic Evaluation Reporting Standards statement.61

## Conclusions

This review found a considerable number of economic evaluations (n=20, 11 of moderate certainty) investigating the value for money of fall prevention exercise programmes for older adults living in the community. The results of the economic evaluations varied, which probably reflects the heterogeneity between studies, with differences in the perspective taken, time horizon, healthcare systems between countries, which in turn influences the cost consideration. However, for many of the studies, there is an indication of significant potential for cost-effectiveness of fall prevention exercise programmes. The intervention appeared to be more cost effective for ‘older’ old people (eg, 80+) and those with high fall risk. The evidence for older adults living in aged care facilities is limited but promising. The intervention costs varied, and no clear association was found between costs and type of exercise, location and level of supervision. The intervention costs summarised in this report should be interpreted considering exercise type, duration, level of supervision and number of participants. This information can be used for planning the implementation of future programmes or future models investigating the value for money of such programmes.

Not applicable.

## Footnotes

• Twitter @mabpinheiro, @CathieSherr, @AnneTiedemann1, @JulianaSOlive11

• Contributors MBP, CS, KH, AT, AS, FCB, JFW, ZM, NJF, AEB and SN developed the concept and protocol. MBP designed the search strategy, screened studies, extracted data, assessed the methodological quality of studies, conducted data synthesis and drafted and revised the paper. PC, JSO, SF and EM screened studies, extracted data, conducted data synthesis and developed the figures. NJF and ZM screened studies, assessed the methodological quality of studies and revised the paper. MBP, CS, KH, AT, AS, FCB, JFW, AEB and SN analysed and interpreted the data. All authors revised the draft paper and approved the final manuscript.

• Funding This work was prepared for and funded by the Physical Activity Unit, Department of Health Promotion, Division of Universal Health Coverage and Healthier Populations, WHO.

• Competing interests None declared.

• Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

• Provenance and peer review Not commissioned; externally peer reviewed.

• Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.