1

Introduction

Falls in older people is a global public health concern that reduces quality of life and increases the financial burden across the globe . Overall, 28% to 35% of people ≥ 64 years old experience 1 or more falls per year Globally, falls are the second leading cause of deaths, because of unintentional injuries. The World Health Organization reports that 80% of fatalities relating to falls occur in low- to middle-income countries, whereas Western Pacific and Southeast Asian countries account for 60% of deaths due to falls . In Hong Kong, in 2019, 18% of the population is older than 65 years, and the population of older people in Hong Kong is estimated to increase to 28% by 2036 The prevalence of falls in older people in Hong Kong is 19%, with an incidence rate of 270 falls/1000 people per year

Poor balance and gait, polypharmacy, and a previous history of falls are the most common risk factors predicting falls in older people . The risk of falls in older people increases from 10% for those with no risk factor to 70% for those with more than 4 risk factors . Outdoor falls are significantly more common than indoor falls Falls in older people can result in fractures, functional impairment, decreased quality of life and even death in some cases Recurrent falls occur in 12% of fallers, often resulting in the need for long-term nursing-home care . The cost of falls and fall-related consequences are high for older people . Injuries from falling are the most expensive injuries sustained by older people, costing $75 to $100 billion USD annually across the globe . In Hong Kong, in addition to the serious physical and psychological consequences of falls, the medical expenditure for fallers is $552 million HKD higher than that for non-fallers . Therefore, preventing falls in older people is of paramount importance.

Falls prevention programs can prevent functional disability caused by accidental falls. Physical activity is a useful and potentially cost-saving treatment option for preventing falls in older people . Physical activity has the advantage of involving home-based practice and not requiring direct supervision from a therapist once the key components of treatment are learned . Physical activity reduces the actual number of falls and injuries from falls, thereby reducing the medical expenditure and impact of falls . Substantial evidence from a Cochrane review supports physical activity for reducing the risk of falls in older people . Perhaps due in part to the known benefits of regular physical activity for reducing the risk of falls, the American College of Sports Medicine recommends regular physical activity including a combination of aerobic activity and strengthening exercises for healthy ageing in older people .

In this paper, we report physical activity as physical exercise. A combination of aerobic activity, strengthening, flexibility and balance exercise can reduce the risk of chronic medical conditions including falls and fall-related injuries by 35% to 45% in older people Specific exercises for preventing falls include but are not limited to the Otago Exercise Program, dual-task training, Tai Chi and brisk walking . These exercises combine a spectrum of strengthening and balance training programs. Recommendations for physical exercises for preventing falls suggest walking, strength and balance training for 3 hr per week. These exercises need to be ongoing for the sustained benefits of the falls prevention program .

The cost benefits of exercise-based falls prevention programs are not yet completely understood because cost-effectiveness analysis is not commonly conducted as a component of randomized controlled trials (RCTs) in this area. However, understanding the cost implications of falls prevention programs is important to better understand the value associated with the health benefits of such programs. For example, if these programs are found to essentially pay for themselves or even have a positive financial impact (i.e., result in greater cost savings than they cost), this would help motivate policymakers concerned about health care costs to develop policies that would result in more older individuals participating in such programs.

Previous systematic reviews on the cost-effectiveness of falls prevention programs were restricted to studies on home-based exercise interventions or did not consider details about the falls prevention programs reviewed, including their intensity, frequency, type and duration Over the past decade, the number of economic evaluation studies on falls prevention programs for older people has increased. Therefore, an update of the literature on this topic is warranted. Given these considerations, the current systematic review aims to: (1) summarize the findings from the research literature on the cost-effectiveness of exercise-based programs for falls prevention in older people and (2) discuss the implications of the review findings for clinical practice and future research on the dosage of cost-effective exercise-based falls prevention programs for older people. Definitions of the key terminologies relevant to understanding this review are in Table 1 .

2

Methods

This systematic review is presented in accordance with the PRISMA guidelines . It was pre-registered on PROSPERO before the search was initiated. We searched relevant literature using the following databases from inception until February 2019: CINAHL, Scopus, MEDLINE via PubMed, NHS Economic Evaluation Database, and ISI Web of Science Databases–Science Citation Index and PsycINFO. Search terms were constructed as 3 themes that included:

• •
  

  older people;

  
  
• •
  

  falls prevention and;

  
  
• •
  

  economic evaluation.

Related terms under each theme were combined by using the Boolean operator OR and the 3 themes were combined using the Boolean operator AND. Search terms used for Scopus are reported in supplementary material, Appendix 1 .

The criteria for selecting studies for this review were structured by using the PICOS (Patient problem, Intervention, Comparison, Outcome measure and Study design) framework and are reported in supplementary material, Appendix 2 . Studies were included if they:

• •
  

  were RCTs;

  
  
• •
  

  evaluated the cost-effectiveness of exercise-based falls prevention programs and;

  
  
• •
  

  involved people ≥ 60 years old.

The reference lists of the included studies were also manually searched. Reports were excluded if they were:

• •
  

  study protocols, systematic reviews and conference abstracts or;

  
  
• •
  

  non-English publications.

The outcome measures for this systematic review included the incremental cost-effectiveness ratio (ICER), the cost per quality-adjusted life year (QALY), the incremental cost per fall, and the benefit-to-cost ratio and cost-utility analysis.

All identified studies were subject to a 4-step screening process. Duplicates were removed and titles were screened by 1 reviewer (CF). The abstract and full-text screening was then conducted by 2 reviewers (LH and LC). Discrepancies were resolved by discussion until consensus was reached or with a third reviewer (SW) if needed. The following data were extracted for all included studies: author, publication year, country of origin, sample size, type of intervention including duration and frequency and follow-up period of treatment, economic analysis, perspective (societal, healthcare), cost data, economic outcome measure, currency, discounting, study perspective (healthcare or societal) and author’s conclusion. Because most studies of cost-effectiveness do not report detailed information on the study methodology and instead refer to a previous publication, we retrieved the information relevant to the methods from referred studies published elsewhere. Authors of the included studies were contacted to obtain additional information. Two reviewers (LF and PK) were involved in data extraction; discrepancies in the contents of data extraction were resolved by discussion or with a third reviewer (SW) if needed.

The methodological quality of the included studies was assessed with the Physiotherapy Evidence Database (PEDro) scale . The PEDro includes 11 “yes” or “no” questions, each “yes” response scoring 1 point. Scores ≥ 60% were considered good methodological quality and < 60% poor methodological quality . The quality of economic evaluation was assessed with the Quality of Health Economic Studies (QHES) scale . The QHES includes 16 questions relating to the evaluation of cost-effectiveness. Each question is scored as “yes” or “no”, with each “yes” response counting toward the total score. Scores ≥ 75% were considered high quality and < 75% poor quality Two reviewers (TL and LF) independently evaluated study quality with both scales, and any disagreements were resolved by discussion or with a third reviewer (SW) if needed and for a final determination. For consistency, all study currencies were converted and reported in US dollars by using a conventional currency converter ( https://www.oanda.com/currency/converter/ ) [12.12.2018].

3

Results

The flow of data search is reported in Fig. 1 . The search yielded 5964 relevant citations, and 12 studies met our inclusion criteria and were included in this systematic review. The included studies involved 3668 participants, with an average of 306 participants per study (range 68 to 1090 ). Table 2 summarizes the key data extracted from the studies. The countries of origin were Canada, Australia, the United States, the United Kingdom, . The Netherlands, Finland, and New Zealand . Except for 3 studies, all remaining studies followed up study participants for ≥ 12 months.

Flow of studies screened.

3.1

Methodological quality

The methodological quality of studies according to the PEDro and quality of economic evaluation according to the QHES are reported in Tables 3 and 4 , respectively. The methodological quality was good for 5 studies and poor for 7 . Eight studies were rated as having good-quality economic evaluation. Owing to the study design, none of the studies blinded participants and therapists.

Table 3

Summary of methodological quality of the included studies according to the PEDro scale.

PEDro Scale	Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8	Item 9	Item 10	Item 11	Total Score/10
Davis et al., 2011(a)	Y	Y	N	N	N	N	Y	Y	N	Y	Y	5
Davis et al., 2011(b)	Y	Y	N	N	N	N	Y	Y	N	N	Y	4
Hendriks et al., 2008	Y	Y	Y	N	N	N	Y	N	Y	Y	Y	6
Iliffe et al., 2014	Y	Y	Y	Y	N	N	N	N	Y	Y	Y	6
Irvine et al., 2010	Y	Y	Y	N	N	N	N	Y	N	Y	Y	5
Isaranuwatchai et al., 2017	Y	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8
Markle-Reid et al., 2010	Y	Y	Y	Y	N	N	Y	N	N	Y	Y	6
McLean et al., 2015	Y	Y	N	N	N	N	N	N	Y	N	N	2
Rizzo et al., 1996	Y	Y	N	N	N	N	N	Y	N	N	N	2
Robertson et al., 2001(a)	Y	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8
Robertson et al., 2001 (b)	Y	Y	N	N	N	N	N	Y	Y	Y	Y	5
Timonen et al., 2008	Y	Y	N	Y	N	N	Y	N	N	Y	Y	4

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