The European Journal of Health Economics

, Volume 16, Issue 5, pp 517–527 | Cite as

Cost-effectiveness of a multifactorial fracture prevention program for elderly people admitted to nursing homes

  • Dirk Müller
  • Lisa Borsi
  • Claudia Stracke
  • Stephanie Stock
  • Björn Stollenwerk
Original Paper

Abstract

Background

Fractures are one of the most costly consequences of falls in elderly patients in nursing homes.

Objectives

To compare the cost-effectiveness of a ‘multifactorial fracture prevention program’ provided by a multidisciplinary team with ‘no prevention’ in newly admitted nursing home residents.

Methods

We performed a cost-utility analysis using a Markov-based simulation model to establish the effectiveness of a multifaceted fall prevention program from the perspective of statutory health insurance (SHI) and long-term care insurance (LCI). The rate of falls was used to estimate the clinical and economic consequences resulting from hip and upper limb fractures. Robustness of the results was assessed using deterministic and probabilistic sensitivity analyses.

Results

Compared to no prevention a multifactorial prevention program for nursing home residents resulted in a cost-effectiveness ratio of €21,353 per quality-adjusted life-year. The total costs for SHI/LCI would result in €1.7 million per year. Results proved to be robust following deterministic and probabilistic sensitivity analyses.

Conclusion

Multifactorial fracture prevention appears to be cost-effective in preventing fractures in nursing home residents. Since the results were based on the number of falls further research is required to confirm the results.

Keywords

Fracture prevention Cost-effectiveness Elderly people Nursing home residents 

JEL Classification

I1 H4 

References

  1. 1.
    Järvinen, T.L., Sievänen, H., Khan, K.M., et al.: Shifting the focus in fracture prevention from osteoporosis to falls. Br. Med. J. 336(7636), 124–126 (2008)CrossRefGoogle Scholar
  2. 2.
    Gribbin, J., Hubbard, R., Smith, C., et al.: Incidence and mortality of falls amongst older people in primary care in the United Kingdom. QJM 102(7), 477–483 (2009)CrossRefPubMedGoogle Scholar
  3. 3.
    Rubenstein, L.Z., Josephson, K.R., Robbins, A.S.: Falls in the nursing home. Ann. Intern. Med. 121(6), 442–451 (1994)CrossRefPubMedGoogle Scholar
  4. 4.
    Konnopka, A., Jerusel, N., König, H.H.: The health and economic consequences of osteopenia-and osteoporosis-attributable hip fractures in Germany: estimation for 2002 and projection until 2050. Osteoporos. Int. 20(7), 1117–1129 (2009)CrossRefPubMedGoogle Scholar
  5. 5.
    Cameron I.D, Murray G.R, Gillespie L.D, et al.: Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst. Rev. 1, 1–78:CD005465 (2010). doi:10.1002/14651858.CD005465.pub2
  6. 6.
    Buchner, D.M., Larson, E.B.: Falls and fractures in patients with Alzheimer-type dementia. J. Am. Med. Assoc. 257(11), 1492–1495 (1987)CrossRefGoogle Scholar
  7. 7.
    Neyens, J.C., van Haastregt, J.C., Dijcks, B.P., et al.: Effectiveness and implementation aspects of interventions for preventing falls in elderly people in long-term care facilities: a systematic review of RCTs. J. Am. Med. Dir. Assoc. 12(6), 410–425 (2011)CrossRefPubMedGoogle Scholar
  8. 8.
    Oliver, D., Connelly, J.B., Victor, C.R., et al.: Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 334(7584), 82 (2007)CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Temple, R.J.: A regulatory authority’s opinion about surrogate endpoints. In: Nimmo, W.S., Tucker, G.T. (eds.) Clinical measurement in drug evaluation. Wiley, New York (1995)Google Scholar
  10. 10.
    Boissel, J.P., Collet, J.P., Moleur, P., Haugh, M.: Surrogate endpoints: a basis for a rationale approach. Eur. J. Clin. Pharmacol. 43(3), 235–244 (1992)CrossRefPubMedGoogle Scholar
  11. 11.
    Kannus, P., Niemi, S., Parkkari, J., et al.: Why is the age-standardized incidence of low-trauma fractures rising in many elderly populations? J. Bone Miner. Res. 17, 1363–1367 (2002)CrossRefPubMedGoogle Scholar
  12. 12.
    Kannus, P., Sievanen, H., Palvanen, M., Jarvinen, T., et al.: Prevention of falls and consequent injuries in elderly people. Lancet 366, 1885–1893 (2005)CrossRefPubMedGoogle Scholar
  13. 13.
    Rivara, F.P., Grossman, D.C., Cummings, P.: Injury prevention. Second of two parts. N. Engl. J. Med. 337(9), 613–618 (1997)CrossRefPubMedGoogle Scholar
  14. 14.
    Tinetti, M.E., Doucette, J., Claus, E., Marottoli, R.: Risk factors for serious injury during falls by older persons in the community. J. Am. Geriatr. Soc. 43(11), 1214–1221 (1995)CrossRefPubMedGoogle Scholar
  15. 15.
    Federal Statistics Office Germany (Destatis). Aktuelle Sterbetafeln, Stand 18.2.2013. https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Bevoelkerung/Sterbefaelle/Tabellen/SterbetafelFBNL.html. Accessed 06 Feb 2014
  16. 16.
    Rapp, K., Lamb, S.E., Klenk, J., et al.: Fractures after nursing home admission: incidence and potential consequences. Osteoporos. Int. 20(19), 1775–1783 (2009)CrossRefPubMedGoogle Scholar
  17. 17.
    Davis, J.C., Robertson, M.C., Comans, T., Scuffham, P.A.: Guidelines for conducting and reporting economic evaluation of fall prevention strategies. Osteoporos. Int. 22(9), 2449–2459 (2011)CrossRefPubMedGoogle Scholar
  18. 18.
    Nyman, S.R., Victor, C.R.: Older people’s recruitment, sustained participation, and adherence to falls prevention interventions in institutional settings: a supplement to the Cochrane systematic review. Age Ageing 40(4), 430–436 (2011)CrossRefPubMedGoogle Scholar
  19. 19.
    Berry, S.D., Samelson, E.J., Ngo, L.: Subsequent fracture in nursing home residents with a hip fracture: a competing risk approach. J. Am. Geriatr. Soc. 56, 1887–1892 (2008)CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Rapp, K., Becker, C., Lamb, S.E., et al.: Hip fractures in institutionalized elderly people: incidence rates and excess mortality. J. Bone Miner. Res. 23(11), 1825–1831 (2008)CrossRefPubMedGoogle Scholar
  21. 21.
    Seger, W., Sittaro, N.A., Lohse, R., Rabba, J.: Comparison of survival under domestic or institutional care: the Hannover morbidity and mortality long-term care study. Deutsche Med. Wochenschr. 136, 1465–1471 (2011)CrossRefGoogle Scholar
  22. 22.
    Alagic, V., Staudinger, B.: Quality of Life in German Nursing Homes-Results of a Survey using the EQ5D Questionnaire. Gesundheitswesen 73(12), 795–802 (2011)CrossRefPubMedGoogle Scholar
  23. 23.
    Peasgood, T., Herrmann, K., Kanis, J.A., Brazier, J.E.: An updated systematic review of health state utility Values for osteoporosis related conditions. Osteoporos. Int. 20, 853–868 (2009)CrossRefPubMedGoogle Scholar
  24. 24.
    Heinrich, S., Rapp, K., Rissmann, U.: Service use and costs of incident femoral fractures in nursing home residents in Germany: the Bavarian Fall and Fracture Prevention project. J. Am. Med. Dir. Soc. 12(6), 459–466 (2011)CrossRefGoogle Scholar
  25. 25.
    Institute for the Hospital Remuneration System. In-hospital costs according to GDRG 2010/2012 Report Browser. http://www.g-drg.de/cms/G-DRG-System_2012/Abschlussbericht_zur_Weiterentwicklung_des_G-DRG-Systems_und_Report_Browser (year 2010; diagnoses based on ICD-10 Version 2010; procedures based on OPS Version 2010). Accessed 06 Feb 2014
  26. 26.
  27. 27.
    Ersatzkasse West. Reimbursement list for occupational therapy. http://www.vdek.com/vertragspartner/sonstige-vertragspartner/heilmittelerbringer/zulassung/verguetungslisten-west/ergo_west.pdf. Accessed 06 Feb 2014
  28. 28.
    Institute for Quality and Efficiency in Health Care (IQWiG). General methods for evaluating the relation between costs and benefits. https://www.iqwig.de/download/General_Methods_for_the_Assessment_of_the_Relation_of_Benefits_to_Costs.pdf. Accessed 06 Feb 2014
  29. 29.
  30. 30.
    Rölke Pharma GmbH. SAFEHIP® AirX. http://www.roelkepharma.de/shop_safehip-airx-kompakt.php. Accessed 06 Feb 2014
  31. 31.
    Publisher of German Practitioners. Group education and written information on hip protectors. http://www.aerzteverlag.de/default.asp?docid=107. Accessed 06 Feb 2014
  32. 32.
    Medical fee schedule (GOÄ). Labour costs for education (GOÄ B III 20). http://www.e-bis.de/goae/defaultFrame.htm. Accessed 06 Feb 2014
  33. 33.
    Association of SHI Physicians. Occupational therapy: counseling and environmental check. http://www.kvberlin.de/20praxis/50verordnung/20heilmittel/heilmittel_verguetung/verguetung_ergo.pdf. Accessed 06 Feb 2014
  34. 34.
    Association of SHI Physicians. Physiotherapy (offered as group exercise). http://www.kvberlin.de/20praxis/50verordnung/20heilmittel/heilmittel_verguetung/verguetung_physio.pdf. Accessed 06 Feb 2014
  35. 35.
    Association of SHI Physicians. Geriartric Assessment by physician (EBM Nr. 03240, point value 370). http://www.kbv.de/ebm2012/EBMGesamt.htm. Accessed 06 Feb 2014
  36. 36.
    Verband der Ersatzkassen (VDEK). Vergütungsvereinbarung gemäß § 125 SGB V für die Abrechnung physiotherapeutischer Leistungen, Massagen und medizinischer Bäder. http://www.vdek.com/content/vdeksite/vertragspartner/heilmittel/rahmenvertrag/_jcr_content/par/download_6/file.res/verguetungsvereinbarung_west_2012.pdf. Accessed 06 Feb 2014
  37. 37.
    Kassenärztliche Vereinigung Berlin. Vergütungsliste Ergotherapie. http://www.kvberlin.de/20praxis/50verordnung/20heilmittel/hm_verguetung/verguetung_ergo.pdf(2011). Accessed 06 Feb 2014
  38. 38.
    Frybeck, D.G., Chinnis, J.O., Ulvila, J.W.: Bayesian cost effectiveness analysis. an example using the GUSTO trial. Int. J. Technol. Assess. Health Care 17, 83–97 (2001)CrossRefGoogle Scholar
  39. 39.
    Stinnett, A.A., Mullahy, J.: Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med. Decision Mak. 18(2 Suppl):S68–S80 (1998)CrossRefGoogle Scholar
  40. 40.
    Mauskopf, J.A., Sullivan, S.D., Annemans, L.: Principles of good practice for budget impact analysis: report of the ISPOR task force on good research practices—budget impact analysis. Value Health 10(5), 336–347 (2007)CrossRefPubMedGoogle Scholar
  41. 41.
    Wagner A. Assessment of the medical service for the long-term care insurance funds. http://www.mds-ev.org/media/pdf/Pflegebegutachtunge_2009.pdf. Accessed 06 Feb 2014
  42. 42.
    Bundesministerium für Familie, Senioren, Frauen und Jugend (BMFSFJ). Erster Bericht des Bundesministeriums […] über die Situation der Heime und die Betreuung der Bewohnerinnen und Bewohner. (2006) http://www.bmfsfj.de/doku/Publikationen/heimbericht/root.html. Accessed 06 Feb 2014
  43. 43.
    Wright, J.C., Weinstein, M.C.: Gains in life expectancy from medical interventions—standardizing data on outcomes. N. Engl. J. Med. 339(6), 380–386 (1998)CrossRefPubMedGoogle Scholar
  44. 44.
    Jensen, J., Lundin-Olsson, L., Nyberg, L., Gustafson, Y.: Fall and injury prevention in older people living in residential care facilities. A cluster randomized trial. Ann. Int. Med. 136(10), 733–741 (2002)CrossRefPubMedGoogle Scholar
  45. 45.
    Becker, C., Kron, M., Lindemann, U., et al.: Effectiveness of a multifaceted intervention on falls in nursing home residents. J. Am. Geriatr. Soc. 51(3), 306–313 (2003)CrossRefPubMedGoogle Scholar
  46. 46.
    Schwartz, A.V., Nevitt, M.C., Brown Jr, B.W., Kelsey, J.L.: Increased falling as a risk factor for fracture among older women: the study of osteoporotic fractures. Am. J. Epidemiol. 161(2), 180–185 (2005)CrossRefPubMedGoogle Scholar
  47. 47.
    Bouxsein, M.L., Delmas, P.D.: Considerations for development of surrogate endpoints for antifracture efficacy of new treatments in osteoporosis: a perspective. J. Bone Miner. Res. 23(8), 1155–1167 (2008)CrossRefPubMedCentralPubMedGoogle Scholar
  48. 48.
    Dargent-Molina, P., Favier, F., Grandjean, H., et al.: Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet 348(9021), 145–149 (1996)CrossRefPubMedGoogle Scholar
  49. 49.
    Young, Y., Myers, A.H., Provenzano, G.: Factors associated with time to first hip fracture. J. Aging Health 13(4), 511–526 (2001)CrossRefPubMedGoogle Scholar
  50. 50.
    Robertson, M.C., Campbell, A.J., Gardner, M.M., Devlin, N.: Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J. Am. Geriatr. Soc. 50(5), 905–911 (2002)CrossRefPubMedGoogle Scholar
  51. 51.
    Goz, V., Koehler, S.M., Egorova, N.N., et al.: Kyphoplasty and vertebroplasty: trends in use in ambulatory and inpatient settings. Spine J. 11(8), 737–744 (2011)CrossRefPubMedGoogle Scholar
  52. 52.
    Heinrich, S., Rapp, K., Stuhldreher, N., et al.: Cost-effectiveness of a multifactorial fall prevention program in nursing homes. Osteoporos. Int. 24(4), 1215–1223 (2013)CrossRefPubMedGoogle Scholar
  53. 53.
    Kerse, N., Butler, M., Robinson, E., Todd, M.: Fall prevention in residential care: a cluster, randomized, controlled trial. J. Am. Geriatr. Soc. 52(4), 524–531 (2004)CrossRefPubMedGoogle Scholar
  54. 54.
    Chen, J.S., Sambrook, P.N., Simpson, J.M., et al.: Risk factors for hip fracture among institutionalized older people. Age Ageing 38(4), 429–434 (2009)CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Dirk Müller
    • 1
  • Lisa Borsi
    • 1
  • Claudia Stracke
    • 1
  • Stephanie Stock
    • 1
  • Björn Stollenwerk
    • 2
  1. 1.Cologne Institute for Health Economics and Clinical EpidemiologyThe University Hospital of Cologne (AöR)CologneGermany
  2. 2.Helmholtz Zentrum München (GmbH), German Research Center for Environmental HealthInstitute of Health Economics and Health Care Management (IGM)MunichGermany

Personalised recommendations