An individually tailored exercise programme delivered at home can prevent falls. The programme can be delivered safely by a district nurse and is suitable for both men and women. Academic researchers are sometimes perceived as being remote from the day to day realities of delivering health care, and the results of research do not always reach those who could benefit.16
Our trial is an example of effective collaboration between researchers, public health professionals, and administrators, resulting in health benefits to elderly people in the community.
Subgroup analysis showed that the programme was effective in those aged 80 years and older but not in those aged 75 to 79 years. Although our trial was not designed to test this, the finding is consistent with our previous finding that falls were not reduced by the exercise programme in a sample of women and men aged 65 years and older who were taking psychotropic drugs.17
The programme may be more effective in frailer, elderly people than younger, fitter people because the exercises increase strength and balance above the critical threshold necessary for stability.
As with all age groups only a proportion will be prepared to join an exercise programme, but as shown by the characteristics at trial entry, the participants represented a general population of this age group. Follow up was good, although more people withdrew from the control than exercise group. This may have biased the results against effectiveness because those who withdrew were at a higher risk of falling.
The exercise group had the same number of moderate injuries but fewer serious injuries as a result of a fall than the control group. Injuries resulting in hospital admissions are costly, and reducing injuries such as fractures and lacerations in our trial resulted in cost savings.
We used hospital admission costs as a result of a fall injury as our estimate of the consequences of the exercise programme. We found the same number of moderate injuries resulting from falls in both groups. We also knew from an earlier study that the remaining medical and personal costs resulting from falls account for only 10% of the total healthcare costs for falls.
We estimated the cost of implementing the exercise programme to serve as a guide for the cost of replicating the programme in the future. Costs may well differ in a different setting or be influenced by the reporting expectations of those who fund the programme, by the efficiency and experience level of the instructor, and by the age group enrolled. For example, some of the costs of implementing the programme would not be incurred if the programme was run in one urban area (see table for the same centre scenario).
Comparison with other interventions for preventing falls
Implementing this single intervention proved as or more effective in reducing falls than other successful community based programmes reported in the literature.18–21
Withdrawing psychotropic drugs reduced the risk of falls by 66%, but there were difficulties in recruiting participants to the trial and a high dropout rate.16
Other community based interventions have not proved successful in reducing falls.22–25
Little information is available at present for comparing the efficiency of the exercise programme with other interventions aimed at preventing falls. We found only two publications reporting the cost effectiveness of implementing an intervention for preventing falls in the community.26,27
The exercise programme in our trial was more cost effective than a home based, targeted, multifactorial intervention (total intervention implementation costs per fall prevented $US2668 (at 1993 prices; around $NZ6141) versus $NZ1803, although this figure did include “developmental” costs for the programme). A home assessment and modification programme, successful in reducing falls in those with a history of a fall in the previous year, cost an average of $A4986 (at 1997 prices; $NZ1.00=$A0.89 in 1997) per fall prevented. This cost effectiveness ratio incorporated all healthcare resource use during the trial.27
Some other studies have shown reduced healthcare use or cost savings occurred as a result of a programme to prevent falls.19,28
Benefits may result from early identification of health problems, earlier referrals, or physically fitter people spending a shorter time in hospital.
In our previous trials, the exercise programme was delivered by a physiotherapist.7,17
We conclude that a trained district nurse is also an appropriate person to implement the programme. Implementation of the programme worked well when run from an established home health service and required the minimum of input from other staff. We recommend that nurses are trained and supervised by a suitably qualified physiotherapist. Although supervision in the same centre would be less time consuming and less costly, long distance supervision combining site visits and telephone contact worked well. This trial studied one trained nurse in one health service delivering a home based exercise programme. Our second pragmatic trial studies practice nurses trained to deliver the programme from general practices.29