Cost-Effectiveness of a Therapeutic Tai Ji Quan Fall Prevention Intervention for Older Adults at High Risk of Falling

Fuzhong Li, Peter Harmer, Elizabeth Eckstrom, Kathleen Fitzgerald, Laura Akers, Li-Shan Chou, Dawna Pidgeon, Jan Voit, Kerri Winters-Stone, Fuzhong Li, Peter Harmer, Elizabeth Eckstrom, Kathleen Fitzgerald, Laura Akers, Li-Shan Chou, Dawna Pidgeon, Jan Voit, Kerri Winters-Stone

Abstract

Background: Data on the cost-effectiveness of proven fall prevention exercise interventions are limited. We aimed to establish the cost-effectiveness of Tai Ji Quan: Moving for Better Balance (TJQMBB) compared with a conventional exercise intervention for older adults at high risk of falling.

Methods: We conducted a trial-based cost-effectiveness analysis involving 670 older adults who had a history of falling or impaired mobility. Participants received one of three interventions-TJQMBB, multimodal exercise, or stretching exercise (control)-each of which was implemented twice weekly for 24 weeks. The primary cost-effectiveness measure was the incremental cost per additional fall prevented, comparing TJQMBB and multimodal exercise to Stretching and TJQMBB to multimodal exercise, with a secondary measure of incremental cost per additional quality-adjusted life-year (QALY) gained. The intervention was conducted between February 2015 and January 2018, and cost-effectiveness was estimated from a health care system perspective over a 6-month time horizon.

Results: The total cost to deliver the TJQMBB intervention was $202,949 (an average of $906 per participant); for multimodal exercise, it was $223,849 ($1,004 per participant); and for Stretching, it was $210,468 ($903 per participant). Incremental cost-effectiveness ratios showed that the multimodal exercise was cost-effective ($850 per additional fall prevented; $27,614 per additional QALY gained) relative to Stretching; however, TJQMBB was the most economically dominant strategy (ie, having lower cost and being clinically more efficacious) compared with multimodal and stretching exercises with regard to cost per additional fall prevented and per additional QALY gained. TJQMBB had a 100% probability of being cost-effective, relative to Stretching, at a threshold of $500 per each additional fall prevented and $10,000 per additional QALY gained. Sensitivity analyses showed the robustness of the results when extreme cases, medical costs only, and missing data were considered.

Conclusions: Among community-dwelling older adults at high risk for falls, TJQMBB is a cost-effective means of reducing falls compared with conventional exercise approaches.

Trial registration: Clinicaltrials.gov (NCT02287740).

Keywords: Evidence-based interventions; Exercise; Physical activity; Quality of life.

© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America.

Figures

Figure 1.
Figure 1.
Cost-effectiveness acceptability curves showing the probability that interventions (TJQMBB, multimodal) are cost-effective compared with stretching exercise for willingness to pay thresholds for each additional fall prevented (A) and each additional QALY gained (B). TJQMBB = Tai Ji Quan: Moving for Better Balance; QALY = quality-adjusted life-year.

References

    1. Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged ≥65 years – United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65:993–998. doi:10.15585/mmwr.mm6537a2
    1. Burns ER, Stevens JA, Lee R. The direct costs of fatal and non-fatal falls among older adults – United States. J Safety Res.. 2016;58:99–103. doi:10.1016/j.jsr.2016.05.001
    1. Centers for Disease Control and Prevention. Older Adults Falls: Important Factors About Falls Accessed December 8, 2018.
    1. Burns E, Kakara R. Deaths from falls among persons aged ≥65 years – United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2018;67:509–514. doi:10.15585/mmwr.mm6718a1
    1. Hoffman GJ, Hays RD, Shapiro MF, Wallace SP, Ettner SL. The costs of fall-related injuries among older adults: annual per-faller, service component, and patient out-of-pocket costs. Health Serv Res. 2017;52:1794–1816. doi:10.1111/1475-6773.12554
    1. Davis JC, Robertson MC, Ashe MC, Liu-Ambrose T, Khan KM, Marra CA. International comparison of cost of falls in older adults living in the community: a systematic review. Osteoporos Int. 2010;21:1295–1306. doi:10.1007/s00198-009-1162-0
    1. Florence CS, Bergen G, Atherly A, Burns E, Stevens J, Drake C. Medical costs of fatal and nonfatal falls in older adults. J Am Geriatr Soc. 2018;66:693–698. doi:10.1111/jgs.15304
    1. Houry DFC, Baldwin G, Stevens J, McClure R. The CDC Injury Center’s response to the growing public health problem of falls among older adults. Am J Lifestyle Med. 2016;10;74–77. doi:10.1177/1559827615600137
    1. Gillespie LD, Robertson MC, Gillespie WJ, et al. . Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146. doi:10.1002/14651858.CD007146.pub3
    1. US Preventative Services Task Force , Grossman DC, Curry SJ, Owens DK, et al. . Interventions to prevent falls in community-dwelling older adults – US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:1696–1704. doi:10.1001/jama.2018.3097
    1. Sherrington C, Michaleff ZA, Nicola Fairhall N, et al. . Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51:1750–1758. doi:10.1136/bjsports-2016-096547
    1. Davis JC, Robertson MC, Ashe MC, Liu-Ambrose T, Khan KM, Marra CA. Does a home-based strength and balance programme in people aged > or =80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions. Br J Sports Med. 2010;44:80–89. doi:10.1136/bjsm.2008.060988
    1. Olij BF, Ophuis RH, Polinder S, et al. . Economic evaluations of falls prevention programs for older adults: a systematic review. J Am Geriatr Soc. 2018;66:2197–2204. doi:10.1111/jgs.15578
    1. Church J, Goodall S, Norman R, Haas M. The cost-effectiveness of falls prevention interventions for older community-dwelling Australians. Aust N Z J Public Health. 2012;36:241–248. doi:10.1111/j.1753-6405.2011.00811.x
    1. Deverall E, Kvizhinadze G, Pega F, et al. . Exercise programmes to prevent falls among older adults: modelling health gain, cost-utility and equity impacts. Inj Prev. 2018. [Epub ahead of print]. doi:10.1136/injuryprev-2016-042309
    1. Li F, Eckstrom E, Harmer P, Fitzgerald K, Voit J, Cameron KA. Exercise and fall prevention: narrowing the research-to-practice gap and enhancing integration of clinical and community practice. J Am Geriatr Soc. 2016;64:425–431. doi:10.1111/jgs.13925
    1. Li F, Harmer P, Fitzgerald K, et al. . Effectiveness of a therapeutic Tai Ji Quan intervention vs a multimodal exercise intervention to prevent falls among older adults at high risk of falling: a randomized clinical trial. JAMA Intern Med. 2018;178:1301–1310. doi:10.1001/jamainternmed.2018.3915
    1. Stevens JA, Burns ER.. A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults. 3rd ed.Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2015.
    1. Sanders GD, Neumann PJ, Basu A, et al. . Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316:1093–1103. doi:10.1001/jama.2016.12195
    1. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148. doi:10.1111/j.1532-5415.1991.tb01616.x
    1. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896–903. doi:10.1093/ptj/80.9.896
    1. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198. doi:10.1016/0022-3956(75)90026-6
    1. Li F. Transforming traditional Tai Ji Quan techniques into integrative movement therapy – Tai Ji Quan: moving for better balance. J Sport Health Sci. 2013;3:9–15. doi:10.1016/j.jshs.2013.11.002
    1. Lord SR, Castell S, Corcoran J, et al. . The effect of group exercise on physical functioning and falls in frail older people living in retirement villages: a randomized, controlled trial. J Am Geriatr Soc. 2003;51: 1685–1692. doi:10.1046/j.1532-5415.2003.51551.x
    1. Li F, Harmer P, Fisher KJ, et al. . Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60:187–194. doi:10.1093/gerona/60.2.187
    1. The EuroQol Group : The EuroQol – a new facility for the measurement of health-related quality of life. Health Policy. 1990;16:199–208. doi:10.1016/0168-8510(90)90421-9
    1. Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Med Care. 2005;43:203–220. doi:10.1136/bmj.322.7288.697
    1. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness – the curious resilience of the $50,000-per-QALY threshold. N Engl J Med. 2014;371:796–797. doi:10.1056/NEJMp1405158
    1. Patil R, Kolu P, Raitanen J, et al. . 101 cost-effectiveness of vitamin D and exercise in preventing injurious falls among older women. Injury Prev. 2016;22:A38. doi:10.1136/injuryprev-2016-042156.101
    1. Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: randomized controlled trial. BMJ. 2001;322:1–6. doi:10.1097/00005650-200503000-00003
    1. Frick KD, Kung JY, Parrish JM, Narrett MJ. Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. J Am Geriatr Soc. 2010;58:136–141. doi:10.1111/j.1532-5415.2009.02575.x
    1. Farag I, Sherrington C, Hayes A, et al. . Economic evaluation of a falls prevention exercise program among people with Parkinson’s disease. Mov Disord. 2016;31:53–61. doi:10.1002/mds.26420
    1. Li F, Harmer P. Economic evaluation of a Tai Ji Quan intervention to reduce falls in people with Parkinson disease, Oregon, 2008–2011. Prev Chronic Dis. 2015;12:140413. doi:10.5888/pcd12.140413
    1. McLean K, Day L, Dalton A. Economic evaluation of a group-based exercise program for falls prevention among the older community-dwelling population. BMC Geriatr. 2015;15:33. doi:10.1186/s12877-015-0028-x
    1. Li F, Harmer P, Fitzgerald K. Implementing an evidence-based fall prevention intervention in community senior centers. Am J Public Health. 2016;106:2026–2031. doi:10.2105/AJPH.2016.303386
    1. Carande-Kulis V, Stevens JA, Florence CS, Beattie BL, Arias I. A cost-benefit analysis of three older adult fall prevention interventions. J Safety Res. 2015;52:65–70. doi:10.1016/j.jsr.2014.12.007
    1. Shankar KN, Liu SW, Ganz DA. Trends and characteristics of emergency department visits for fall-related injuries in older adults, 2003–2010. West J Emerg Med. 2017;18:785–793. doi:10.5811/westjem.2017.5.33615
    1. DeGrauw X, Annest JL, Stevens JA, Xu L, Coronado V. Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older, United States, 2006–2011. J Safety Res. 2016;56:105–109. doi:10.1016/j.jsr.2015.11.002
    1. Li F, Harmer P, Stock R, et al. . Implementing an evidence-based fall prevention program in an outpatient clinical setting. J Am Geriatr Soc. 2013;61:2142–2149. doi:10.1111/jgs.12509
    1. Fink D, Houston K. Implementing an evidence-based Tai Ji Quan program in a multicultural setting: a pilot dissemination project. J Sport Health Sci. 2014;3:27–31. doi:10.1016/j.jshs.2013.10.003
    1. Leung J. Implementing tai ji quan: moving for better balance in real-world settings: success and challenges. J Sport Health Sci. 2014;3:34–35. doi:10.1016/j.jshs.2013.12.001
    1. Ory MG, Smith ML, Jiang L, et al. . Fall prevention in community settings: results from implementing tai chi: moving for better balance in three states. Front Public Health. 2015;2:258. doi:10.3389/fpubh.2014.00258

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel