Community-based falls prevention for older persons: a case study in economic modelling of geriatric public health interventions

Background: Falls are one of the key geriatric syndromes that significantly impact geriatric health. This study aims to seek methodological solutions in developing a credible economic model of community-based falls prevention for older persons (aged 60 and over) which would inform the local commissioning decision between current, recommended, and alternative falls prevention strategies. Methods: The study involved: (1) problem conceptualisation involving stakeholder consultations and qualitative study of older persons; (2) systematic review of existing models to identify key modelling challenges/solutions; and (3) model development based on stages (1)-(2) results, model analysis, and formulating commissioning recommendations. Key methodological developments in (3) included: (i) incorporating a wide range of societal outcomes; (ii) parameterising dynamic falls-frailty feedback; (iii) incorporating intervention capacity constraints; and (iv) assessing joint equity-efficiency impacts. Base case comparisons evaluated the performance of UK guideline-recommended strategy (RC) versus usual care (UC) representing current practice. Sensitivity, subgroup, and scenario analyses were conducted. RC was then compared to 22 alternative intervention strategies based on several decisional criteria before formulating commissioning recommendations. Results: RC had 93.4% probability of being cost-effective versus UC at cost-effectiveness threshold of £20,000 per QALY gained under 40-year societal cost-utility analysis and improved equity delineated by socioeconomic status. RC is unlikely to be the optimal strategy when compared to alternative intervention strategies based on efficiency, joint efficiency-equity, or individual-level lifetime outcomes. Feasibilities of RC-level intervention capacity and environmental interventions significantly affected strategy rankings. If not feasible, then capacity-constrained form of RC supplemented by targeted risk screening of socially vulnerable subgroups by community organisations is likely the optimal strategy. Conclusion: Guideline recommendations on community-based falls prevention should be qualified by capacity implications, efficiency-equity impact, and environmental strategies. Modelling can inform economic evaluation of diverse geriatric public health interventions and integration of diverse geriatric policies, including wider welfare policies and community mobilisation.