Table 11 Features and evaluation outcomes of general population, lifetime horizon decision models
Study label (n = 12)a | Target population; Analysis; Perspective | Intervention [Comparator] | Evaluation outcomesb | Methodological caveats |
|---|---|---|---|---|
Church (2012) [58] | CD adults aged 65+; CUA/CEA; Public sector | (a) General population – Group exercise; Home exercise; Tai Chi; Multi-component int.; Multifactorial int.; Multifactorial risk assessment; (b) High-risk population – Group exercise; HAM; Multifactorial int. [NR; Cross comparisons] | Ratio: (a) General – Tai Chi ICER US$38,735 per QALY vs. NR; other interventions dominated; (b) High-risk – Group exercise ICER US$44,633 per QALY vs. NR; HAM ICER US$50,696 per QALY vs. NR; Multifactorial int. dominated. Aggregate: Reports incremental cost, no. of falls avoided and QALY gain per intervention, but all interventions have same reachc (including those targeting high-risk and specific subgroups), and hence cannot compare aggregate impacts. Parameter uncertainty: DSA – int. cost and efficacy had largest impact on group exercise ICER. PSA – CEAC. Scenarios: No fear of falling had the largest impact on group exercise ICER among parameter changes. | Recurrent falls not characterised; Unclear falls risk progression;d Unclear intervention reach;e Unclear how high-risk subgroup identified; Mismatch between falls incidence and efficacy metrics |
Deverall (2018) [62] | CD adults aged 65+; CUA; Public sector, Societal | Exercise – (i) Peer-led group exercise; (ii) Home exercise; (iii) Commercial exercise [NR] | Ratio: (i) Peer-led group exercise ICER US$6323 per QALY vs. NR; (ii) Home exercise ICER US$5486 per QALY vs. NR; (iii) Commercial exercise ICER US$46,733 per QALY vs. NR. Aggregate: For base case, home exercise generated 47,100 additional QALYs at incremental cost of US$225 m relative to NR; this compares to 42,000 and 42,300 QALYs for group exercise and commercial exercise at US$426 m and US$1550 m incremental cost relative to NR, respectively. Hence, home exercise dominated group and commercial exercises. Parameter uncertainty: DSA – efficacy and utility decrement had largest impact on ICER. PSA – 95% UI; CEAC. Scenarios: Subgroup analyses showed higher ICERs for Maori and men; equity analyses showed higher ICERs can be mainly attributed to their shorter life expectancies.e | Routine data lacks individual identifiers;f Recurrent falls not characterised; Unclear falls risk progression;d No background transition in health utilities;g Includes comorbidity care costs; Mismatch between falls incidence and efficacy metrics; No tiered threshold for evaluating societal outcomes;h No scenario estimating equity-efficiency trade-off.e |
Eldridge (2005) [63] | Adults aged 65+ in community or nursing home; CUA; Public sector | Falls risk screening + multifactorial int. or exercise [UC] | Ratio: Not reported. Aggregate: Intervention reduced the number of fallers by 2.8% over one year under base case (6.5% uptake of screening). Parameter uncertainty: PSA – 40% probability intervention is cost-effective at US$41,900 (£30,000) per QALY threshold. Scenarios: 100% screening uptake would reduce number of fallers by 11.3% over one year; 100% screening uptake and 100% self-referred exercise uptake would reduce number of fallers by 15.0%; impact of uptake increase on ICER not reported. | Recurrent falls not characterised; Unclear falls risk progression;d No background transition in health utilities;g Incorporated fixed intervention costs |
Farag (2015) [64] | CD adults aged 65+ without prior fall; CUA; Public sector | Non-specific falls prevention int. with relative risk of 0.75 and per-participant cost of US$587 [NR] | Ratio: ICER of US$24,190 per QALY vs. NR Aggregate: Incremental cost and QALY gain outcomes per person can be scaled up but unclear to what extent. Parameter uncertainty: DSA – falls risk and LTC cost had largest impact on ICER. PSA – CEAC; 57% probability of being cost-effective at AUS$50,000 (US$41,809) threshold. Scenarios: e.g., variation in uptake rate had little impact on ICER | Recurrent falls not characterised; Unclear falls risk progression;d No discounting |
Honkanen (2006) [70] | Adults aged 65+ living in community at baseline; CUA/ROI; Public sector | Hip protector [NR] | Ratio: Women, baseline age 65 – intervention dominated by NR; Women, age 70 – intervention dominated by NR; Women, age 75 – ICER of US$27,006 per QALY; Women, age 80 – intervention dominates NR; Women, age 85 – intervention dominates NR; Men, age 65 – intervention dominated by NR; Men, age 70 – intervention dominated by NR; Men, age 75 – intervention dominated by NR; Men, age 80 – ICER of US$184,609 per QALY; Men, age 85 – intervention dominates NR. Aggregate: Prevented fractures, incremental cost and QALY gain outcomes per person can be scaled up but unclear to what extent. Parameter uncertainty: DSA – base case results robust. PSA – 68% probability of being cost-effective at US$50,000 (US$710042021 price) threshold for women age 75; 61% for men age 85. Scenarios: Intervention is less cost-effective for functionally dependent subgroup – e.g., intervention no longer dominant for women age 80 and 85, though still cost-effective at US$71,004 threshold (point estimates not reported) | Unclear falls risk progression;d Includes comorbidity care costs. |
Johansson (2008) [73] | CD adults aged 65+ (n = 5500); CUA; Societal | Multifactorial and environmental int.i [UC] | Ratio: Intervention dominates comparator Aggregate: Total int. cost of US$895,137; total costs savings of US$904,986; total QALY gain of 35.16 Parameter uncertainty: No DSA. PSA – scatter plot Scenarios: Scenarios that made intervention no longer dominant – doubled fracture risk; lower fracture cost; inclusion of net consumption care cost;j higher discount rate; no health/cost consequences of fracture beyond 1st year; 25% rise in int. cost | Unclear falls risk progression;d Includes comorbidity care costs (net consumption); Quasi-experimental study for effectiveness evidence; No tiered threshold for evaluating societal outcomes;h Internal and external validities assessed |
Nshimyu-mukiza (2013) [80] | Women aged 65+ (subgroup within women aged 40+); CUA/CEA; Public sector | Fracture risk screening + Physical activity (PA), Vitamin D & calcium and/or Osteoporosis screening & treatment [NR; Cross comparisons] | Ratio: No screening + PA dominates NR; BMD/CAROC screening + PA + Vit D & calcium produces ICER of US$57,279 relative to No screening + PA and dominates all other strategies. Aggregate: Incremental cost and QALY gain per person can be scaled up (total population reported). Parameter uncertainty: No DSA. PSA – CEAC; 75% probability that BMD/CAROC +PA + Vit D & calcium is cost-effective to No screening + PA under threshold of CAD$50,000 (US$517892021 price). Scenarios: Rankings of strategies under CUA and CEA robust under variations in single or multiple parameters. | Incorporates incoming cohorts; No background transition in health utilities;g Structural and external validities assessed |
OMAS (2008) [81] | CD adults aged 65+; CEA/ROI; Public sector | (i) Exercise; (ii) HAM; (iii) Vit D & calcium; (iv) Gait stabiliser; (v) Psychotropics withdrawal.k [NR] | Ratio: All interventions dominate NR for men and women Aggregate: Reports net cost saving per person which can be scaled up to total for each intervention subgroup at regional level Parameter uncertainty: No analysis Scenarios: No analysis | Recurrent falls not characterised; Unclear falls risk progression;d Mismatch between intervention need and falls risk;k Parameter uncertainty not assessed |
Pega (2016) [82] | CD adults aged 65+; CUA; Public sector | HAM [NR] | Ratio: HAM produces ICER of US$7155 per QALY vs. NR. Aggregate: For base case, total int. cost was US$115.2 m, total net cost vs. NR US$87.4 m and total QALY gain 34,000. Parameter uncertainty: DSA – impact on ICER not assessed, fatal falls risk and falls risk most impactful for incremental cost and QALY, respectively. PSA – 95% UI for base case ICER between below zero to US$15,901 per QALY. Scenarios: For secondary prevention scenario,l ICER was US$1591 per QALY, total int. cost US$14.2 m, total net cost vs. NR, US$4.9 m, and total QALY gain 20,100. Subgroup analyses showed higher ICERs for Maori and men; equity analyses showed higher ICERs can be mainly attributed to their shorter life expectancies.e | Routine data lacks individual identifier;f Recurrent falls not characterised; Unclear falls risk progression;d No background transition in health utilities;g Includes comorbidity care costs; Mismatch between falls incidence and efficacy metrics; Unrealistic efficacy duration; Joint parameter uncertainty not assessed; No scenario estimating equity-efficiency trade-off.e |
RCN (2005) [34] | CD adults aged 60+; CUA; Public sector | Exercise; Multifactorial intervention [NR] | Ratio: Multifactorial intervention for high-risk group dominates NR; Exercise for high-risk group produces ICER of US$18,425 per QALY relative to NR. Aggregate: Not reported. Parameter uncertainty: No DSA. PSA – scatter plot Scenarios: No analysis | Recurrent falls not characterised; Unclear falls risk progression;d Unclear intervention reach.c |
Wilson [92] | CD adults aged 65+; CUA; Public sector | HAM [NR] | Ratio: HAM produces ICER of US$4358 per QALY vs. NR. Aggregate: For base case, total int. cost was US$7.7 m, total net cost vs. NR US$6.7 m and total QALY gain 2800. Parameter uncertainty: DSA – efficacy had largest impact on base case ICER. PSA – 95% UI for base case ICER between below zero to US$12,165 per QALY. Scenarios: For secondary prevention scenario,l ICER was US$557 per QALY, total int. cost US$687,151, total net cost vs. NR, US$72,626, and total QALY gain 1420. For primary prevention scenario,m ICER was US$7633 per QALY, total int. cost US$7.0 m, total net cost US$6.6 m and total QALY gain 1520. Subgroup analyses showed higher ICER for Maori; equity analyses showed higher ICER can be mainly attributed to Maori’s shorter life expectancy.e | Routine data lacks individual identifiers;f Recurrent falls not characterised; Unclear falls risk progression;d No background transition in health utilities;g Includes comorbidity care costs; Unclear intervention reach;c Mismatch between falls incidence and efficacy metrics; Unrealistic efficacy duration; Joint parameter uncertainty not assessed; No scenario estimating equity-efficiency trade-off.e |
Zarca (2014) [94] | Adults aged 65+ without previous hip fracture; CUA/CEA; Public sector | Vitamin D – (i) Universal supplementation; (ii) Supplement then screen for calibration; (iii) Screen then supplement [NR; Cross comparisons] | Ratio: Universal supplementation was dominated by other strategies; Supplement then screen strategy produces ICER of US$7758 per QALY vs. NR; Screen then supplement strategy produces ICER of US$7307 per QALY vs. Supplement then screen and US$7605 per QALY vs. NR. Aggregate: Difficult to compare strategies without data on intervention reach.c Possible that Screen then supplement strategy has smallest reach. Estimating total cost of Screen then supplement to be US$111.7 m for 800,000 persons. Parameter uncertainty: DSA – int. cost had largest impact on ICER of Screen then supplement vs. NR. PSA – 100% probability of Screen then supplement being most cost-effective strategy at threshold of €20,000 (US$297292021 price). Scenarios: Results robust to discount rates rising from 3 to 6%. | Hospitalisation cost only; Unclear intervention reach;c Structural, external and internal validities assessed |