Kwon Joseph, Squires Hazel, Young Tracey
Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK.
Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK.
Age Ageing. 2025 Aug 1;54(8). doi: 10.1093/ageing/afaf212.
Three pathways exist for community-based falls prevention: reactive (R), after a fall requiring medical attention; proactive (P), after professional referral of high-risk individuals; and self-referred (SR), voluntary intervention enrolment. The UK guidelines recommend scale-up of all three ['recommended care' (RC)], but scale-up of none ['usual care' (UC)], one (R, P, SR) or two (R+P, R+SR, P+SR) are potential options. This study aims to compare the options in terms of efficiency and equity.
Cost-utility analysis from the societal perspective over a 40-year horizon identified the optimal strategy based on efficiency alone. Probabilistic sensitivity analysis accounted for parameter uncertainty. Efficiency and equity were jointly evaluated by distributional cost-effectiveness analysis. Alternative scenarios assessed changes in frailty, cognitive impairment, intervention demand and GP access.
Public sector cost-effectiveness threshold would need to exceed £30 000 per quality-adjusted life year (QALY) gained for RC to have the highest probability of being cost-effective. R and R+SR were cost-effective, with costs per QALY gained of £2365 (R versus UC) and £5516 (R+SR versus R). RC was cost-ineffective, incurring £34 258 per QALY gained versus R+SR. Other strategies were dominated. However, if decision-makers had the same relative health inequality aversion level as the English general public, RC was optimal in terms of efficiency and equity at threshold of £30 000 per QALY gained. Scenarios of worse geriatric health favoured RC.
Both efficiency and relative health inequality need to be considered for the UK guideline-recommended falls prevention to be optimal versus other permutations of community-based strategies.
基于社区的跌倒预防存在三种途径：反应性（R），在跌倒需要医疗护理之后；主动性（P），在高危个体经专业转诊之后；以及自我转诊（SR），自愿参与干预。英国指南建议扩大所有这三种途径的规模（“推荐护理”（RC）），但不扩大规模（“常规护理”（UC））、仅扩大一种途径（R、P、SR）或两种途径（R+P、R+SR、P+SR）也是可能的选择。本研究旨在比较这些选择在效率和公平性方面的差异。
从社会角度进行为期40年的成本效用分析，仅基于效率确定最优策略。概率敏感性分析考虑了参数不确定性。通过分布成本效益分析联合评估效率和公平性。替代情景评估了身体虚弱、认知障碍、干预需求和全科医生可及性的变化。
公共部门的成本效益阈值需要超过每获得一个质量调整生命年（QALY）30000英镑，RC才最有可能具有成本效益。R和R+SR具有成本效益，每获得一个QALY的成本分别为2365英镑（R与UC相比）和5516英镑（R+SR与R相比）。RC不具有成本效益，每获得一个QALY的成本为34258英镑，与R+SR相比。其他策略处于劣势。然而，如果决策者与英国普通公众具有相同的相对健康不平等厌恶水平，那么在每获得一个QALY的阈值为30000英镑时，RC在效率和公平性方面是最优的。老年健康状况较差的情景更有利于RC。
要使英国指南推荐的跌倒预防相对于其他基于社区的策略组合达到最优，需要同时考虑效率和相对健康不平等。
