Papers

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Effectiveness and economic evaluation of a nurse
delivered home exercise programme to prevent falls.
1: Randomised controlled trial
M Clare Robertson, Nancy Devlin, Melinda M Gardner, A John Campbell

Abstract was effective in reducing falls and falls resulting in Department of

Medical and
moderate injuries when delivered by a research Surgical Sciences,
Objectives To assess the effectiveness of a trained physiotherapist to a group of women aged 80 years Otago Medical
district nurse individually prescribing a home based and older living in the community.7 8 School, PO Box
exercise programme to reduce falls and injuries in We have now tested in two healthcare settings the
913, Dunedin,
New Zealand
elderly people and to estimate the cost effectiveness of effectiveness and efficiency of the programme when M Clare Robertson
the programme. delivered by health professionals previously untrained research fellow
Design Randomised controlled trial with one year’s in prescribing exercise. This first paper reports on the Melinda M Gardner
follow up. effectiveness and cost effectiveness of the exercise pro-
research
physiotherapist
Setting Community health service at a New Zealand gramme in both men and women aged 75 years and A John Campbell
hospital. older when delivered from an established home health professor of geriatric
Participants 240 women and men aged 75 years and service by a trained district nurse. medicine
older. Department of
Intervention 121 participants received the exercise Economics,
University of Otago
programme (exercise group) and 119 received usual
care (control group); 90% (211 of 233) completed the Participants and methods Nancy Devlin
senior lecturer
trial. Participant recruitment Correspondence to:
Main outcome measures Number of falls, number of We identified potential participants aged 75 years and M C Robertson
injuries resulting from falls, costs of implementing the older from computerised registers at 17 general clare.robertson@
stonebow.otago.ac.nz
programme, and hospital costs as a result of falls. practices (30 doctors) in the West Auckland area, New
Results Falls were reduced by 46% (incidence rate Zealand. These patients received a letter from their BMJ 2001;322:1–6
ratio 0.54, 95% confidence interval 0.32 to 0.90). Five doctor inviting them to take part in the study. The cri-
hospital admissions were due to injuries caused by teria for exclusion were inability to walk around own
falls in the control group and none in the exercise residence, receiving physiotherapy at the time of
group. The programme cost $NZ1803 (£523) (at 1998 recruitment, or not able to understand the require-
prices) per fall prevented for delivering the ments of the trial. Recruiting took place over a six
programme and $NZ155 per fall prevented when month period in 1998.
hospital costs averted were considered.
Conclusion A home exercise programme, previously Trial design
shown to be successful when delivered by a This was a randomised controlled trial with one year’s
physiotherapist, was also effective in reducing falls follow up. The sample size calculation was based on the
when delivered by a trained nurse from within a proportion of elderly people who fell once or more in
home health service. Serious injuries and hospital a 12 month prospective community study,9 an
admissions due to falls were also reduced. The expected reduction from 0.50 to 0.30, and 20% allow-
programme was cost effective in participants aged 80 ance for dropouts. Our study was approved by the eth-
years and older compared with younger participants. ics committee of the Health Funding Authority
Northern Division.
Potential participants were informed there was an
Introduction equal chance they would receive the exercise
The frequency, serious consequences, and healthcare programme or act as a control. After written informed
costs of falls in elderly people are well documented.1–5 consent was obtained and baseline assessments
Randomised controlled trials of single and multiple (personal characteristics, health, and function) com-
interventions have shown that falls can be reduced.6 pleted at home by an independent assessor, we
The effectiveness of these programmes and their costs randomised 240 participants: 121 to the exercise pro-
in usual healthcare settings have not been reported. gramme (exercise group) and 119 to usual care
Our research group developed a home based (control group). A statistician developed the schedule
programme of strength and balance retraining, which for group allocation using random numbers, and this

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was held at another centre. Participants were then could have been employed elsewhere—could be
informed of their group allocation by telephone. included. We performed one way sensitivity analyses.

BMJ: first published as 10.1136/bmj.322.7288.697 on 24 March 2001. Downloaded from http://www.bmj.com/ on 12 July 2024 by guest. Protected by copyright.
Intervention Costs of the exercise programme
A district nurse who had had no previous experience We focused on the costs of implementing the exercise
in prescribing exercise attended a one week training programme. Although there were costs associated with
course run by the physiotherapist from the research developing the programme, these costs were incurred
group. A series of site visits and regular telephone calls before the trial and were not incremental to this
were made by the supervising physiotherapist to assess programme. We did not include the research costs of
and ensure quality control. evaluating the programme.
The implementation of the exercise programme Costs for implementing the programme were
was run from a home health service based in a geriat- obtained from trial records and the financial records of
ric assessment and rehabilitation hospital. The nurse the hospital and research group, using actual costs
delivered the exercise programme in conjunction with when available. We did not include the costs of recruit-
her work as a district nurse. The intervention consisted ing the exercise instructor because existing staff in an
of a set of muscle strengthening and balance retraining organisation may deliver the exercise programme. We
exercises that progressed in difficulty, and a walking did not put a value on the time participants spent exer-
plan.7 The programme was individually prescribed cising or walking as it was assumed these activities were
during five home visits by the instructor at weeks 1, 2, 4, done in their leisure time; the opportunity cost was
and 8, with a booster visit after six months. The number taken to be zero. Half of the recruiting costs for this first
of repetitions of the exercise and the number of ankle paper were allocated to implementation of the
cuff weights (1, 2, and 3 kg; range 0 to 6 kg) used for programme because half those recruited were ran-
muscle strengthening were increased at each visit as domised to the control group and did not receive the
appropriate. Participants were expected to exercise at exercise programme. We estimated overhead costs as
least three times a week (about 30 minutes per session) 21.9% of observed resource use because this was the
and to walk at least twice a week for a year. Compliance sector average reported for all hospital and health
was monitored with postcard calendars similar to those services in New Zealand for operating costs and
used to monitor falls. For the months when no home overhead expenses in 1998-9.12
visit was scheduled the nurse telephoned participants
to maintain motivation and discuss any problems. Resource use and healthcare costs resulting from falls
Measurement of falls and injuries and health status In a previous trial of the exercise programme we found
Falls were defined as “unintentionally coming to rest that 90% of the estimated healthcare costs resulting
on the ground, floor, or other lower level.”10 Falls were from falls were for hospital inpatient and associated
monitored for one year in both groups by asking par- health service costs.13 A further 4% were for those serv-
ticipants to return preaddressed and prepaid postcard ices used as a result of serious injuries and were not
calendars for each month. The independent assessor provided by the local hospital. Estimated costs for inju-
telephoned participants to record the circumstances of ries we classified as moderate made up the remaining
the falls and any injuries or resource use as a result of 6% of total healthcare costs resulting from falls.
the falls. She remained blind to group allocation. Therefore to estimate the costs resulting from fall
Fall events were classified as resulting in “serious” injuries in this trial we restricted measurement to actual
injury if the fall resulted in a fracture, admissions to costs incurred by the hospitals admitting participants as
hospital with an injury, or stitches were required, a result of a fall. For each fall event these included costs
“moderate” injury if bruising, sprains, cuts, abrasions, for emergency room, theatre, ward, physician, radiology,
or reduction in physical function for at least three days laboratory, and blood services, pharmacy products,
resulted or if the participant sought medical help, and hospital social workers, physiotherapy, and occupational
“no” injury. The circumstances of “serious” injuries therapy. Each hospital cost item included overhead costs
were confirmed from hospital and general practice (cleaning, heating, lighting, telephone, laundry, food,
records. The investigator classifying fall events administration, orderlies, computing, and depreciation
remained blind to group allocation. The SF-12 on equipment) calculated by the accounting convention
questionnaire was used to estimate self perceived at each hospital.
health status at entry to the trial.11 Costs for hospital items were identified as being
associated with a fall by matching the date of the cost
Methods used in economic evaluation record with the date of a trial record for a fall event.
We used cost effectiveness analysis to enable compari- Cost records were included only if the department and
sons of programme efficiency with other interventions product description indicated that the item was likely
for preventing falls. We considered costs from the soci- to have been used as a result of the fall.
etal perspective because of the broad nature of the
problems caused by falls, and we reported them in New Calculation of cost effectiveness ratios
Zealand dollars according to 1998 prices, exclusive of We measured cost effectiveness as the ratio ÄC: ÄE,
government goods and services tax. The control group where ÄC (incremental cost) was the change in
was used as the comparator for the analysis. We resource use resulting from the exercise programme.14
measured cost effectiveness as the incremental cost of This was taken as the total cost of implementing the
introducing the programme per fall event prevented exercise programme because the control group did
during the trial. not receive an intervention, plus the difference in hos-
The concept of opportunity costs was kept in mind pital costs resulting from falls during the trial for the
so that all relevant costs—that is, those resources that two groups. We planned to include estimates for hospi-

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tal costs as a result of falls in ÄC only if these costs or

Table 1 Characteristics of participants at entry to trial. Values
the number of serious injuries proved to be
are numbers (percentages) unless stated otherwise

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significantly different between the two groups.
We measured ÄE (incremental effect) as the differ- Control Exercise
group group
ence between the number of falls and the number of Characteristic (n=119) (n=121)
falls resulting in moderate or serious injury in the two Mean (SD) age (years) 81.1 (4.5) 80.8 (3.8)
groups. We considered the actual number of fall events Aged >80 years 66 (55) 60 (50)
and a standardised measure, fall events per 100 person Men 39 (33) 39 (32)
years. This measure takes into account the variable fol- Living arrangements:
low up times for individuals in the trial. Two or more participants in one home 31 (26) 26 (21)
Living alone 60 (50) 66 (55)
Living in nursing home — 1 (1)
Sensitivity analysis
Fallen in previous year 45 (38) 44 (36)
We carried out one way sensitivity analyses by calculat-
Medical conditions:
ing cost effectiveness ratios. We did this with a range of Parkinson’s disease 2 (2) 2 (2)
estimates of cost items for implementing the exercise Stroke 21 (18) 13 (11)
programme to investigate robustness of the ratios to Hip fracture 2 (2) 5 (4)
different delivery scenarios. We used the 125th centile Knee or hip pain, or both 35 (29) 41 (34)
of the total, the total, and the 75th centile of the total Mean (SD) scores on SF-12*:
costs for implementation when calculating the cost Physical component 39.1 (11.7) 40.1 (10.9)
effectiveness ratios to account for the possibility of dif- Mental component 54.5 (7.9) 54.9 (8.2)
ferent cost conditions when replicating the pro- Mean (SD) No of current prescribed drugs 3.1 (2.4) 2.9 (2.3)
gramme in different settings. Training and supervision Taking psychotropic drugs 25 (21) 21 (17)

of the exercise programme could be carried out from Home assistance:

Cleaning 33 (28) 32 (26)
the same rather than a distant centre. We therefore cal-
Showering 4 (3) —
culated cost effectiveness ratios excluding travel costs
Meals on wheels 14 (12) 19 (16)
between centres and the associated accommodation
*Score ranges 0–100, lower scores indicate poorer health.
costs. We used the 125th centile of the costs for the
home visits to give an indication of costs for delivering
the programme in a more spread out community. The treatment and interaction effects. We used Student’s t
ankle cuff weights we used were manufactured cheaply test to compare means and Fisher’s exact test or c2 test
in a non-commercial environment. Participants may to compare proportions between groups.
well have been encouraged to use more weights.
Therefore in the sensitivity analyses we used four times Results
the actual cost of the weights. The home health service
could not identify any extra overhead costs as a result Trial participants and follow up
of running the exercise programme. We included this The mean (SD) age of participants was 80.9 (4.2) years,
scenario in the sensitivity analyses. For this part of our and ages ranged from 75 to 95 years. Table 1 shows the
study we also calculated cost effectiveness ratios for characteristics of participants at entry to the trial.
those aged 80 years and older by apportioning the
costs of the programme (on a pro rata basis) between
Approved by doctor and invited to participate (n=590)
the 75 to 79 year olds and those aged 80 and older, and
using the number of fall events prevented in those
aged 80 years and older. Chose not to participate (n=284): Not eligible (n=6):
Not interested (n=120) Having physiotherapy (n=5)
Health problem (n=69) Cognitive impairment (n=1)
Time horizon Already keeps active (n=22)
Moving home (n=13) Could not contact (n=60)
Assuming that participants keep exercising, the
benefits of the exercise programme would extend past
the time individuals participated in the trial, but the Randomisation
extent of this benefit and longer term compliance rates (n=240)
are uncertain. We calculated cost effectiveness ratios for
the duration of the trial only. Control group (n=119) Exercise programme (n=121)

Statistical analysis
We analysed data on an intention to treat basis with Withdrew from exercise only (n=13):
Health problem (n=11)
Stata Release 6 and SPSS 6.1.1. No deviations occurred Too busy (n=2)
from random allocation—all those who were allocated
to the exercise group received at least one home visit,
Withdrew from trial (n=21): Withdrew from trial (n=8):
and no participants in the control group received the Died (n=6) Died (n=1)
programme. The mean (SD) time between baseline Fall injury (n=3) Health problem (n=5)
Health problem (n=6) Too busy (n=1)
assessment and the first home visit was 11.5 (6.1) days. Too busy (n=5) Decline in cognitive function (n=1)
Moved away (n=1)
We compared the numbers of falls in the two
groups using negative binomial regression models.15
These models estimate the number of occurrences of Assessments at 1 year (n=97) Assessments at 1 year (n=109)
Completed trial (falls monitored Completed trial (falls monitored
an event when the event has Poisson variation with for 1 year) (n=98) for 1 year) (n=113)
overdispersion, and they allow for variable follow up
times for participants and investigation of the Flow of participants through trial

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The figure shows the flow of participants through confidence interval 3% to 19%). Those who died or
the trial. We have not reported the results of withdrew were more likely to have had a fall in the year

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assessments repeated after one year. More participants before the trial and took more drugs at entry to the
from the exercise group than the control group trial (mean (SD) number 4.3 (2.4) v 2.8 (2.3), P = 0.002).
completed the trial (113 v 98, difference 11%, 95% Overall, 43% (49 of 113) of participants who com-
pleted the trial carried out their prescribed exercise
programme three or more times a week, 72% (n = 81)
Table 2 Incidence of fall events and follow up times
carried it out at least twice a week, and 71% (n = 80)
Control Exercise walked at least twice a week during the year’s follow up.
group group
(n=119) (n=121)
Falls and fall related injuries
No of falls 109 80*
Table 2 shows the actual and standardised numbers of
Falls per 100 person years 100.6 68.5
falls and the numbers of falls resulting in injuries dur-
No of injurious falls: 49 42
Serious 9 2†
ing the trial. We found a 46% reduction in the number
Moderate 40 40 of falls during the trial for the exercise group
Injurious falls per 100 person years 45.2 36.0 compared with the control group (incidence rate ratio
No (%) of falls for which medical care sought 26 (24) 18 (23) from negative binomial regression model 0.54, 95%
Mean (SD) follow up time (months) 10.9 (2.7) 11.6 (1.9)‡ confidence interval 0.32 to 0.90). The number of falls
Total follow up time (person years) 108.33 116.79 was reduced in those aged 80 years and older (81 v 43
*Incidence rate ratio 0.54 (95% confidence interval 0.32 to 0.90), P=0.019. falls for control and exercise groups, respectively;
†Fisher’s exact test, P=0.033. P = 0.007), and there was no difference in participants
‡Student’s t test, P=0.028.
aged 75 to 79 years. One participant did fall while
exercising according to instructions.
Table 3 Incremental costs of implementing exercise programme Fewer participants in the exercise than control
Total cost group had a serious injury resulting from a fall during
Cost item Resource use Unit cost ($NZ) ($NZ) the trial (2 v 9, relative risk 4.6, 95% confidence interval
Training course* 1.0 to 20.7). Nine falls resulted in fractures (five
Exercise nurse: required hospital admission) and three in lacerations
Time (hours) 40 17.73 709
requiring sutures. The same numbers of moderate
Travel to Dunedin 1 return flight, shuttles 696.25 696
injuries occurred in the two groups.
Accommodation (nights)† 4 125.00 500
Economic evaluation
Physiotherapist (hours) 37.5 19.17 180
Materials Folder 28.21 28 Costs of implementing the exercise programme
Transport in Dunedin Visits to 15 clients 0.62 per km 28 Table 3 shows the values for the cost items for
Recruitment, programme prescription, and follow up implementing the exercise programme. The pro-
Exercise nurse time (hours) 1239 Average 18.43 22 833 gramme cost $NZ52 229 ($NZ432 per person) to
Exercise nurse transport (km) 6250 0.62 3875 deliver to the 121 participants for one year.
Doctors’ time‡ 30 doctors, 0.25 hours each 40.39 606
General practice staff time‡ 17 practices, 0.75 hours 13.11 111 Resource use resulting from falls
each
Overall, 44 of 189 (23%) falls resulted in the use of
Typing lists and letters (hours)‡ 51 15.64 399
Pager (months) 18 27.00 486
healthcare services (table 2). Medical care was sought
Postage (stamps) 580 0.40 232
for more falls in the control than exercise group, but
Stationery and photocopying Paper, envelopes 0.10 275 the difference was not significant. The five people
Telephone calls 1619 0.10 162 admitted to hospital were all from the control group
Ankle cuff weights 177, courier Average 21.27 3764 and were aged over 80 years. The actual cost of these
Instruction booklets 121 folders, paper 7.50 908 admissions and therefore the hospital cost averted by
Supervision of programme the exercise programme was $NZ47 818.
Physiotherapist:
Cost effectiveness measures
Time (hours) 43.5 19.17 834
The incremental cost per fall prevented was $NZ1803
Travel to Auckland 3 return flights, shuttles Average 545.67 1637
Accommodation (nights)† 5 Average 137.40 687
(table 4). Estimates for the cost per fall with an injury
Telephone calls 44 Average 3.34 147
prevented ranged from $NZ5603 to $NZ9437 for the
Exercise nurse: different cost scenarios. When we included cost savings
from hospital admissions in the calculation of cost
Time (hours) 210 17.73 3720
effectiveness ratios, the estimates of the ratios were
Telephone calls 26 Average 3.96 103
considerably lower (some indicated cost savings) than
Overhead costs§ 21.85% of resource 9378
use for those calculated using the exercise programme
Total cost 52 299 costs alone.
Average cost per participant for 1 432 The exercise programme was considerably more
year programme cost effective for those aged 80 years and older than for
Average exchange rate in 1998, $NZ1.00=32p. the total sample. Estimates for cost effectiveness ratios
*Costs for training course were divided equally among the four nurses at course (three nurses were from
trial reported in accompanying paper). for implementing the exercise programme in this age
†Includes food allowance. group were $NZ682 per fall prevented and $NZ1852
‡Half these costs were used because control group participants were also recruited.Time spent by doctors per injurious fall prevented. When hospital costs
was valued using weighted average price in 1998 for consultation “person over 65 without card”; item used
in calculation of consumers price index. averted and costs for implementation were both used
§Office accommodation, financial and administration services, depreciation on equipment. in the calculations of the cost effectiveness ratios, the

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Subgroup analysis showed that the programme

Table 4 Cost effectiveness ratios and sensitivity analysis:
was effective in those aged 80 years and older but not
incremental cost per fall event prevented in exercise group

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compared with control group
in those aged 75 to 79 years. Although our trial was not
designed to test this, the finding is consistent with our
Exercise Including
programme hospital costs
previous finding that falls were not reduced by the
Cost scenario costs only ($NZ) averted* ($NZ) exercise programme in a sample of women and men
Cost per fall prevented: aged 65 years and older who were taking psychotropic
Total cost of programme 1803 155 drugs.17 The programme may be more effective in
125th centile total cost of programme 2254 605 frailer, elderly people than younger, fitter people
75th centile total cost of programme 1353 (296) because the exercises increase strength and balance
Training, supervision in same centre 1639 (10) above the critical threshold necessary for stability.
125th centile cost of home visits 2084 435
As with all age groups only a proportion will be
× 4 ankle cuff weights 2278 629
prepared to join an exercise programme, but as shown
No extra overhead costs 1480 (169)
by the characteristics at trial entry, the participants rep-
Aged >80 years† 682 (576)
resented a general population of this age group. Follow
Adjusted cost per fall prevented‡:
Total cost of programme 1629 140
up was good, although more people withdrew from the
125th centile total cost of programme 2037 547 control than exercise group. This may have biased the
75th centile total cost of programme 1222 (268) results against effectiveness because those who
Training, supervision in same centre 1481 (9) withdrew were at a higher risk of falling.
125th centile cost of home visits 1883 393 The exercise group had the same number of mod-
× 4 ankle cuff weights 2058 568 erate injuries but fewer serious injuries as a result of a
No extra overhead costs 1337 (153) fall than the control group. Injuries resulting in hospi-
Aged >80 years† 422 (356) tal admissions are costly, and reducing injuries such as
Cost per injurious fall prevented: fractures and lacerations in our trial resulted in cost
Total cost of programme 7471 640 savings.
125th centile total cost of programme 9339 2508
We used hospital admission costs as a result of a fall
75th centile total cost of programme 5603 (1228)
injury as our estimate of the consequences of the exer-
Training, supervision in same centre 6791 (41)
cise programme. We found the same number of mod-
125th centile cost of home visits 8634 1802
× 4 ankle cuff weights 9437 2606
erate injuries resulting from falls in both groups. We
No extra overhead costs 6132 (700)
also knew from an earlier study that the remaining
Aged >80 years† 1852 (1563) medical and personal costs resulting from falls account
Adjusted cost per injurious fall prevented‡: for only 10% of the total healthcare costs for falls.
Total cost of programme 5685 487 We estimated the cost of implementing the exercise
125th centile total cost of programme 7106 1908 programme to serve as a guide for the cost of replicat-
75th centile total cost of programme 4263 (934) ing the programme in the future. Costs may well differ
Training, supervision in same centre 5167 (31) in a different setting or be influenced by the reporting
125th centile cost of home visits 6569 1371 expectations of those who fund the programme, by the
× 4 ankle cuff weights 7180 1983 efficiency and experience level of the instructor, and by
No extra overhead costs 4665 (532) the age group enrolled. For example, some of the costs
Aged >80 years† 1195 (1009)
of implementing the programme would not be
Negative values, shown in brackets, indicate cost savings. incurred if the programme was run in one urban area
Average exchange rate in 1998 New Zealand $NZ1.00 =32p.
*Estimates of ratios incorporate both incremental cost of implementing (see table 4 for the same centre scenario).
programme and hospital costs averted owing to fewer falls resulting in hospital
admissions in exercise group compared with control group.
Comparison with other interventions for
†Calculated using total cost of programme divided pro rata between
participants aged >80 years (n=60) and less than 80 years (n=61) in exercise preventing falls
group and fall events prevented in those aged >80 years.
‡Calculated using fall events per 100 person years to adjust for variable follow Effectiveness
up times for individuals in trial. Implementing this single intervention proved as or
more effective in reducing falls than other successful
net cost of the programme for those aged 80 years and
community based programmes reported in the
older resulted in cost savings of $NZ576 per fall event
literature.18–21 Withdrawing psychotropic drugs
prevented and $NZ1563 per injurious fall event
reduced the risk of falls by 66%, but there were difficul-
prevented.
ties in recruiting participants to the trial and a high
dropout rate.16 Other community based interventions
Discussion have not proved successful in reducing falls.22–25
An individually tailored exercise programme delivered
at home can prevent falls. The programme can be Economic efficiency
delivered safely by a district nurse and is suitable for Little information is available at present for comparing
both men and women. Academic researchers are the efficiency of the exercise programme with other
sometimes perceived as being remote from the day to interventions aimed at preventing falls. We found only
day realities of delivering health care, and the results of two publications reporting the cost effectiveness of
research do not always reach those who could benefit.16 implementing an intervention for preventing falls in
Our trial is an example of effective collaboration the community.26 27 The exercise programme in our
between researchers, public health professionals, and trial was more cost effective than a home based,
administrators, resulting in health benefits to elderly targeted, multifactorial intervention (total intervention
people in the community. implementation costs per fall prevented $US2668 (at

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Funding: This project was funded by the Health Funding

What is already known on this topic Authority Northern Division, New Zealand. MCR and MMG
were part funded by Accident Rehabilitation and Compensation

BMJ: first published as 10.1136/bmj.322.7288.697 on 24 March 2001. Downloaded from http://www.bmj.com/ on 12 July 2024 by guest. Protected by copyright.
Falls are the costliest type of injury among elderly Insurance Corporation of New Zealand. MMG was also part
people, and the healthcare costs increase with funded by a Trustbank Otago Community Trust medical
frequency of falls and severity of injuries research fellowship.
Competing interests: None declared.
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12 Crown Company Monitoring Advisory Unit. Hospital and health services
cost effectiveness ratio incorporated all healthcare performance reporting measures. Quarter ended 30 Sep 1999.
resource use during the trial.27 13 Robertson MC, Devlin N, Scuffham P, Gardner MM, Buchner DM, Camp-
bell AJ. Economic evaluation of a community based exercise programme
Some other studies have shown reduced healthcare to prevent falls. J Epidemiol Community Health 2001 (in press.)
use or cost savings occurred as a result of a programme 14 Drummond MF, O’Brien B, Stoddart GL, Torrance GW. Methods for the
to prevent falls.19 28 Benefits may result from early iden- economic evaluation of health care programmes, 2nd ed. New York: Oxford
University Press, 1997.
tification of health problems, earlier referrals, or physi- 15 StataCorp. Stata statistical software: release 6.0. College Station, TX: Stata,
cally fitter people spending a shorter time in hospital. 1999.
16 Morris M, Hutchinson J. Practice makes perfect: developing public health
practice. J Epidemiol Community Health 1999;53:683-4.
Conclusions 17 Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM.
In our previous trials, the exercise programme was Psychotropic medication withdrawal and a home-based exercise
program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc
delivered by a physiotherapist.7 17 We conclude that a 1999;47:850-3.
trained district nurse is also an appropriate person to 18 Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al.
A multifactorial intervention to reduce the risk of falling among elderly
implement the programme. Implementation of the people living in the community. N Engl J Med 1994;331:821-7.
programme worked well when run from an established 19 Buchner DM, Cress ME, de Lateur BJ, Esselman PC, Margherita AJ, Price
R, et al. The effect of strength and endurance training on gait, balance, fall
home health service and required the minimum of risk, and health services use in community-living older adults. J Gerontol
input from other staff. We recommend that nurses are Med Sci 1997;52A:218-24M.
20 Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T, et al.
trained and supervised by a suitably qualified Reducing frailty and falls in older persons: an investigation of Tai Chi and
physiotherapist. Although supervision in the same computerized balance training. J Am Geriatr Soc 1996;44:489-97.
21 Cumming RG, Thomas M, Szonyi G, Salkeld G, O’Neill E, Westbury C, et
centre would be less time consuming and less costly, al. Home visits by an occupational therapist for assessment and modifica-
long distance supervision combining site visits and tion of environmental hazards: a randomized trial of falls prevention.
J Am Geriatr Soc 1999;47:1397-402.
telephone contact worked well. This trial studied one 22 Lord SR, Ward JA, Williams P, Strudwick M. The effect of a 12-month
trained nurse in one health service delivering a home exercise trial on balance, strength, and falls in older women: a
randomized controlled trial. J Am Geriatr Soc 1995;43:1198-206.
based exercise programme. Our second pragmatic trial 23 McMurdo ME, Mole PA, Paterson CR. Controlled trial of weight bearing
studies practice nurses trained to deliver the pro- exercise in older women in relation to bone density and falls. BMJ
gramme from general practices.29 1997;314:569.
24 MacRae PG, Feltner ME, Reinsch S. A 1-year exercise program for older
women: effects on falls, injuries, and physical performance. J Aging Physi-
We thank the participants; the West Auckland doctors and their cal Activity 1994;2:127-42.
receptionists; Gaye McKay, exercise instructor; Tania Roebuck, 25 Reinsch S, MacRae P, Lachenbruch PA, Tobis JS. Attempts to prevent falls
independent assessor; Lenore Armstrong, research nurse; Beth and injury: a prospective community study. Gerontologist 1992;32:450-6.
Cozens, manager, home health services; Margaret Devlin, Safe 26 Rizzo JA, Baker DI, McAvay G, Tinetti ME. The cost-effectiveness of a
Waitakere; Toni Gibbins, clinical analyst; Peter Herbison, statisti- multifactorial targeted prevention program for falls among community
elderly persons. Med Care 1996;34:954-69.
cian; Molly Kavet, clinical information analyst; Professor Murray 27 Salkeld G, Cumming RG, O’Neill E, Thomas M, Szonyi G, Westbury C.
Tilyard and the General Practice Research Unit; Sheila Williams, The cost effectiveness of a home hazard reduction program to reduce
statistician; and Gail Woollacott, locality manager. falls among older persons. Aust NZ J Public Health 2000;24:265-71.
Contributors: All authors contributed to the study or proto- 28 Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL, Osterweil D.
col design, or both, interpreted the data, and wrote the paper. The value of assessing falls in an elderly population. A randomized clini-
cal trial. Ann Intern Med 1990;113:308-16.
AJC directed the project. MCR managed the project and the 29 Robertson MC, Gardner MM, Devlin N, McGee R, Campbell AJ.
data gathering, analysed and interpreted the data, and wrote the Effectiveness and economic evaluation of a nurse delivered home
paper. MMG trained and supervised the exercise instructor. ND exercise programme to prevent falls. 2: Controlled trial in multiple
and Dr Paul Scuffham advised on the economic evaluation. AJC centres. BMJ 2001;322:701-4.
and MCR will act as guarantors for the paper. (19 December 2000)

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