Economic models of community-based falls prevention: a systematic review with subsequent commissioning and methodological recommendations

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.

Systematic review and critical methodological appraisal of community-based falls prevention economic models

“…These findings motivated the current de novo systematic review, the methods and first part of results of which were recently published in a separate article [ 52 ]. The latter identified 46 models of community-based falls prevention, applied a methodological and reporting quality checklist designed by falls prevention experts [ 53 ], narratively synthesised methodological features relevant to falls epidemiology, falls prevention intervention and evaluation methods, and generated methodological and commissioning recommendations for falls prevention modellers and commissioners.…”

“…In total, 15,730 titles and abstracts and 92 full texts were screened from which 46 decision models were identified. See the separate article for the PRISMA flow diagram and the list of studies excluded at the full-text screening stage [ 52 ].…”

“…The systematic review methods were previously described in the aforementioned article [ 52 ]. “ Systematic review methods ” section summarises the associated search methods and inclusion criteria.…”

“…The systematic review protocol is registered on the Prospective Register of Systematic Reviews (CRD42021232147). The review followed the 2021 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline [ 83 ]: see checklist in separate article [ 52 ]. The search covered the period 2003–2020, 12 academic databases and grey literature.…”

“…The current review hence updates the latter, albeit focusing on modelling studies. The search strategy was an intersection between terms for falls, older people, and economic evaluation; the separate article reports all database search strategies [ 52 ]. Two researchers independently reviewed the titles and abstracts of identified articles at the first stage and the full texts of approved articles at the second stage.…”