Domiciliary versus centre-based rehabilitation of older community dwellers: Randomised trial with economic evaluation

Tracy Comans (2010). Domiciliary versus centre-based rehabilitation of older community dwellers: Randomised trial with economic evaluation PhD Thesis, School of Health & Rehabilitation Sciences, The University of Queensland.

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Author Tracy Comans
Thesis Title Domiciliary versus centre-based rehabilitation of older community dwellers: Randomised trial with economic evaluation
School, Centre or Institute School of Health & Rehabilitation Sciences
Institution The University of Queensland
Publication date 2010-05
Thesis type PhD Thesis
Supervisor Terry Haines
Sandy Brauer
Total pages 152
Total colour pages 4
Total black and white pages 148
Subjects 11 Medical and Health Sciences
Abstract/Summary Background Frailty and falls are interrelated syndromes affecting older people. Both negatively affect quality of life. Falls in the older population result from a complex interplay of risk factors and prevention programs for community dwelling elders often target multiple factors. These types of programs have been shown to be effective in both home and centre-based settings however there has been no direct head to head comparison of setting. Aim This thesis aims to explore the factors impacting on quality of life of older people at risk of falls and to explore the impact of setting (domiciliary or centre-based) on the efficacy and cost-effectiveness of a multidisciplinary, multiple factor, falls prevention intervention. Method A randomised controlled trial where participants received an eight week falls prevention program delivered either at home or at a centre. Initial data were explored to identify which factors were most likely to impact on the quality of life and carer strain of older people at risk of falls. Follow up data were analysed for differences in outcomes in the primary outcomes of falls rates and health related quality of life, and the secondary outcomes of measures of activity levels, physical status and depression. Measures were taken at initial assessment and two follow up points – after an eight week program and again at six months after initial assessment. Between group analyses were conducted using generalized estimating equations for normally distributed data and negative binomial regression for count data (e.g. falls). A break-even analysis was performed to test how many clients are required to be seen by a falls prevention service in order to make the service worthwhile funding from a societal viewpoint. A cost-effectiveness analysis was performed with a probabilistic sensitivity analysis to compare the cost-effectiveness of the domiciliary and centre-based services against a do-nothing alternative. Results Participants presented with a wide range of issues in addition to falling including being outside normal weight range, incontinence, and depression. Physical skills were poorer than normal for age for walking, balance, strength, reaction times and hand function. The most significant factors impacting on quality of life were having reduced participation in daily activities, depression, and having poor vision. Having poor nutrition and no longer driving also contributed to poor quality of life. The major factor contributing to increased caregiver strain was reduced participation in daily activities by the older person. For falls reduction, the centre-based service demonstrated significantly better results in preventing falls over the domiciliary based service. Participants in the centre-based arm of the trial experienced less total falls and had a greater reduction in the total number of fallers after the intervention. Quality of life, timed up and go and simple reaction time all improved in the centre-based based intervention more than the home-based intervention however these differences did not reach significance. Activity levels were similar in both groups however depression as measured by the K-10 scale improved more in clients receiving the home-based service. It is estimated that a multi-disciplinary community falls prevention team would need to see around 60 clients per year to make the service break-even using a centre-based model of care and 80 clients for a domiciliary-based model. The service the study was based on has the capability to see around 300 clients per year in a purely centre-based model or 200-250 clients per year for a home-based service. Both the domiciliary and the centre-based service are likely to be cost-effective against a do-nothing alternative for older people at high risk of falling. Conclusion This research demonstrates that delivering a similar service in different settings – domiciliary or centre-based has implications for the effectiveness of the service as measured by changes in falls rates and the economic efficiency of the service. Based on the best estimates of costs of falls currently available, these types of falls prevention services are worthwhile funding from a societal viewpoint in selected high risk groups of older people living in the community. In addition, this research informs service providers about two different cost-effective service delivery models that can be utilised to enable equitable access to falls prevention services for older people living in the community.
Keyword Rehabilitation
Falls in elderly
quality of life
Cost Effectiveness
Additional Notes Colour pages 127 and 129-131 Landscape pages 41-42, 75 and 111

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Created: Mon, 15 Nov 2010, 08:24:38 EST by Ms Tracy Comans on behalf of Library - Information Access Service