Pneumococcal carriage and disease in adults in England 2011-2019: the importance of adults as a reservoir for pneumococcus in communities.

BACKGROUND: Pneumococcal carriage in children has been extensively studied, but carriage in healthy adults and its relationship to invasive pneumococcal disease (IPD) is less understood. METHODS: Nasal wash samples from adults without close contact with young children (Liverpool, UK), 2011-2019, were cultured, and culture-negative samples tested by PCR. Pneumococcal carriage in adults 18-44 years was compared with carriage among PCV-vaccinated children 13-48 months (nasopharyngeal swabs, Thames Valley, UK) and IPD data for England for the same ages for 2014-2019. Age-group specific serotype invasiveness was calculated and used with national IPD data to estimate carriage serotype distributions for adults aged 65+ years. RESULTS: In total 98 isolates (97 carriers) were identified from 1,631 adults aged 18+ years (age and sex standardized carriage prevalence 6.4%), with only three identified solely by PCR. Despite different carriage and IPD serotype distributions between adults and children, serotype invasiveness was highly correlated (R=0.9). Serotypes 3, 37 and 8 represented a higher proportion of adult carriage than expected from direct low-level transmission from children to adults. The predicted carriage serotype distributions for 65+ years aligned more closely with the carriage serotype distribution for young adults than young children. CONCLUSIONS: The nasal wash technique is highly sensitive; additional benefit of PCR is limited. Comparison of carriage serotype distributions suggests some serotypes may be circulating preferentially within these specific young adults. Our data suggest that for some serotypes carried by adults 65+ years, other adults may be an important reservoir for transmission. Age groups such as older children should also be considered.

Motivation for physical activity and the moderating effect of cancer diagnosis: A nationally representative cross-sectional study.

The aim of this study was to investigate associations between types of motivation for physical activity and self-reported weekly aerobic moderate-to-vigorous physical activity (MVPA) in the 2012 and 2014 waves of the nationally representative Health Information National Trends Survey 4 (n = 7307). We further explored differential associations between MVPA and types of motivation for physical activity by cancer survivor status. We found that those who were more motivated by "getting enjoyment from exercise" reported 26.4% more MVPA (+49.8 min/week) than those who were less motivated by this factor, adjusting for covariates (p = 0.025). Conversely, those who were more motivated by "concern over the way you look" reported 22.1% less MVPA (-55.5 min/week) than those who were less motivated by this factor, adjusting for covariates (p = 0.002). We found no evidence for a relationship between motivation from either "pressure from others" or "feeling guilty when you skip exercising" and MVPA. We identified a significant interaction for "feeling guilty when you skip exercising" and cancer survivor status, adjusting for covariates (p = 0.034). Cancer survivors who reported being more motivated by "feeling guilty when you skip exercising" reported 36.2% less MVPA (-71.75 min/week) than those who were less motivated by this factor; there was no statistically reliable difference in those without a history of cancer. Findings are concordant with previous literature highlighting the primacy of enjoyment for physical activity adherence. There is a need for further inquiry into guilt-related motivation for physical activity among cancer survivors, as it may have a unique, negative impact in this population.

Cryoconservation of avian gonads in Canada.

Avian genetic resources have declined dramatically over the past half century as the cost of maintaining populations has exceeded the perceived benefit of keeping them. Despite the early importance of poultry in the development of cryopreservation techniques, very little avian germplasm has been conserved. Cryopreservation and recovery of avian gonads preserve the W chromosome and overcome problems of freezing and recovering semen or conserving and manipulating embryonic cells, and the use of vitrification procedures for preserving gonads minimizes cellular damage. On the basis of research demonstrating the biological possibility of cryopreserving and transplanting avian gonads, 5,125 testicles and 2,667 ovaries from 10 populations of Japanese quail, 9 populations of chickens, and 1 population of Chilean tinamou were cryopreserved and sent to the Canadian Animal Genetic Resources program for long-term storage. These gonads represent 20 of the 33 distinct avian populations currently maintained at Canadian public institutions of agricultural research.

Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial.

OBJECTIVE: To evaluate the cost effectiveness of manual physiotherapy, exercise physiotherapy, and a combination of these therapies for patients with osteoarthritis of the hip or knee. METHODS: 206 Adults who met the American College of Rheumatology criteria for hip or knee osteoarthritis were included in an economic evaluation from the perspectives of the New Zealand health system and society alongside a randomized controlled trial. Resource use was collected using the Osteoarthritis Costs and Consequences Questionnaire. Quality-adjusted life years (QALYs) were calculated using the Short Form 6D. Willingness-to-pay threshold values were based on one to three times New Zealand's gross domestic product (GDP) per capita of NZ$ 29,149 (in 2009). RESULTS: All three treatment programmes resulted in incremental QALY gains relative to usual care. From the perspective of the New Zealand health system, exercise therapy was the only treatment to result in an incremental cost utility ratio under one time GDP per capita at NZ$ 26,400 (-$34,081 to $103,899). From the societal perspective manual therapy was cost saving relative to usual care for most scenarios studied. Exercise therapy resulted in incremental cost utility ratios regarded as cost effective but was not cost saving. For most scenarios combined therapy was not as cost effective as the two therapies alone. CONCLUSIONS: In this study, exercise therapy and manual therapy were more cost effective than usual care at policy relevant values of willingness-to-pay from both the perspective of the health system and society. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

Growth of subcutaneous chicken testicular transplants.

Avian genetic resources have declined dramatically over the past half century, partly because the poultry community has been slow to adopt cryoconservation of avian germplasm. Techniques for gonadal cryopreservation and functional recovery have recently been developed but only some have been optimized. Chicks were castrated at 2 or 6 d and testicles were autotransplanted subcutaneously in one piece after disruption of the tunica membranes to optimize transplantation procedures without the complication of tissue rejection or immunosuppression. At 22 wk of age, the roosters were euthanized and growth of the testicular tissue was evaluated. Mortality with castration at 2 d was high but was much reduced with castration at 6 d. Transplantation of whole testicles subcutaneously on the back of chicks, without complete removal of the tunica membranes, yielded good growth of tissue with transplantation at 2 or 6 d of age. These results will contribute to the use of testicular cryopreservation and transplantation as an effective conservation strategy for avian germplasm. Further definition of the age of treatment will improve the overall efficiency.

Chimeric plumage coloration produced by ovarian transplantation in chickens.

Ovaries from Rhode Island Red donors were transplanted orthotopically into White Leghorn recipients. At maturation, recipients were mated with Rhode Island Red roosters to test the origin of their ovaries, using plumage coloration as a marker. A chick with chimeric plumage coloration was produced, indicating mechanisms that produce follicles with both donor and recipient ovarian contents. This study suggests that ovarian transplantation could be useful for in vivo studies of cytological and molecular mechanisms involved in avian folliculogenesis.

Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness.

OBJECTIVE: To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis (OA) of the hip or knee. DESIGN: In this 2 × 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA were randomly allocated to receive manual physiotherapy (n = 54), multi-modal exercise physiotherapy (n = 51), combined exercise and manual physiotherapy (n = 50), or no trial physiotherapy (n = 51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after 1 year. Secondary outcomes included physical performance tests. Outcome assessors were blinded to group allocation. RESULTS: Of 206 participants recruited, 193 (93.2%) were retained at follow-up. Mean (SD) baseline WOMAC score was 100.8 (53.8) on a scale of 0-240. Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2-47.8) for usual care plus manual therapy, 16.4 (-3.2 to 35.9) for usual care plus exercise therapy, and 14.5 (-5.2 to 34.1) for usual care plus combined exercise therapy and manual therapy. There was an antagonistic interaction between exercise therapy and manual therapy (P = 0.027). Physical performance test outcomes favoured the exercise therapy group. CONCLUSIONS: Manual physiotherapy provided benefits over usual care, that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

SF-6D and EQ-5D result in widely divergent incremental cost-effectiveness ratios in a clinical trial of older women: implications for health policy decisions.

SUMMARY: Using two instruments (SF-6D and EQ-5D) to estimate quality adjusted life years (QALYs), we conducted an economic evaluation of a 12-month randomized controlled trial with a 12-month follow-up study in older women to evaluate the value for money of two doses of resistance training compared with balance and tone classes. We found that the incremental QALYs estimated from the SF-6D were two- to threefold greater than those estimated from the EQ-5D. INTRODUCTION: Decision makers must continually choose between existing and new interventions. Hence, economic evaluations are increasingly prevalent. The impact of quality-adjusted life year (QALY) estimates using different instruments on the incremental cost-effectiveness ratios (ICERs) is not well understood in older adults. Thus, we compared ICERs, in older women, estimated by the EuroQol-5D (EQ-5D) and the Short Form-6D (SF-6D) to discuss implications on decision making. METHODS: Using both the EQ-5D and the SF-6D, we compared the incremental cost per QALY gained in a randomized controlled trial of resistance training in 155 community-dwelling women aged 65 to 75 years. The 12-month randomized controlled trial included a subsequent 12-month follow-up. Our focus, the follow-up study, included 123 of the 155 participants from the Brain Power study; 98 took part in the economic evaluation (twice-weekly balance and tone exercises, n = 28; once-weekly resistance training, n = 35; twice-weekly resistance training, n = 35). Our primary outcome measure was the incremental cost per QALY gained of once- or twice-weekly resistance training compared with balance and tone exercises. RESULTS: At cessation of the follow-up study, the incremental QALY was -0.051 (EQ-5D) and -0.144 (SF-6D) for the once-weekly resistance training group and -0.081 (EQ-5D) and -0.127 (SF-6D) for the twice-weekly resistance training group compared with balance and tone classes. CONCLUSION: The incremental QALYs estimated from the SF-6D were two- to threefold greater than those estimated from the EQ-5D. Given the large magnitude of difference, the choice of preference-based utility instrument may substantially impact health care decisions.

Production of donor-derived offspring after ovarian transplantation between Muscovy (Cairina moschata) and Pekin (Anas platyrhynchos) ducks.

Transplantation of ovarian tissue between different breeds of chickens or Japanese quail can result in normal egg production and give rise to donor-derived offspring with a high frequency. The feasibility of interspecific ovarian transplantation was evaluated by transplanting ovarian tissue from Muscovy ducks to Pekin ducks just after hatch, with subsequent treatment of the recipients with an immunosuppressant. Among the 8 mature Pekin ducks that had received ovarian tissue from Muscovy ducklings, 2 produced fertile eggs when mated with Muscovy drakes, and one of these produced only Muscovy ducks, which were derived from the transplanted Muscovy ovary. The other produced mule ducks that were hybrids of the host Pekin duck and the Muscovy drake. Further development of interspecific transplantation of ovaries may provide a simple method for the conservation and propagation of endangered birds.

Economic evaluation of dose-response resistance training in older women: a cost-effectiveness and cost-utility analysis.

SUMMARY: We estimated the incremental cost-effectiveness of a once-weekly or twice-weekly resistance training intervention compared with balance and tone classes in terms of falls prevented and quality-adjusted life years (QALYs) gained. Both resistance training interventions were more likely to save health care resource money and offer better health outcomes for falls prevention than balance and tone classes. INTRODUCTION: This study aims to estimate the incremental cost-effectiveness and cost-utility of a once-weekly or twice-weekly resistance training intervention compared with twice-weekly balance and tone classes in terms of falls prevented and QALYs gained. METHODS: Economic evaluation was conducted concurrently with a three-arm randomized controlled trial including 155 community-dwelling women aged 65 to 75 years, Mini Mental State Examination ≥24, and visual acuity 20/40 or better. Participants received the once-weekly resistance training (n = 54), the twice-weekly resistance training (n = 51) or the twice-weekly balance and tone (the comparator) classes (n = 50) for 1 year. Measurements included the number of falls for each participant, healthcare resource utilization, and associated costs over 9 months; health status was assessed using the EQ-5D and SF-6D to calculate QALYs. RESULTS: Based on the point estimates from our base case analysis, we found that both once- and twice-weekly resistance training groups were less costly (p < 0.05) and more effective than twice-weekly balance and tone classes. The incremental QALYs assessed using the SF-6D were 0.003 for both the once- and twice-weekly resistance training groups, compared with the twice-weekly balance and tone classes. The incremental QALYs assessed using the EQ-5D were 0.084 for the once-weekly and 0.179 for the twice-weekly resistance training groups, respectively, compared with the twice-weekly balance and tone classes. CONCLUSIONS: An individually tailored resistance training intervention delivered once or twice weekly provided better value for money for falls prevention than balance and tone classes.

Guidelines for conducting and reporting economic evaluation of fall prevention strategies.

UNLABELLED: Falls in older people result in substantial health burden. Compelling evidence indicates that falls can be prevented. We developed comprehensive guidelines for economic evaluations of fall prevention interventions to facilitate publication of high-quality economic evaluations of the effective strategies and aid decision making. INTRODUCTION: The importance of economics applied to falls and fall prevention in older people has largely been overlooked. The use of different methodologies to assess the costs and health benefits of the interventions and their comparators and the inconsistent reporting in the studies limits the usefulness of these economic evaluations for decision making. We developed guidelines to encourage and facilitate completion of high-quality economic evaluations of effective fall prevention strategies. METHODS: We used a generic checklist for economic evaluations as a platform to develop comprehensive guidelines for conducting and reporting economic evaluations of fall prevention strategies. We considered the many challenges involved, particularly in identifying, measuring, and valuing the relevant cost items. RESULTS: We recommend researchers include cost outcomes and report incremental cost-effectiveness ratios in terms of falls prevented and quality adjusted life years in all clinical trials of fall prevention interventions. Studies should include the following cost categories: (1) implementing the intervention, (2) delivering the comparator group intervention, (3) total health care costs, (4) costs of fall-related health care resource use, and (5) personal and informal carer opportunity costs. CONCLUSIONS: This paper provides a timely benchmark to promote comparability and consistency for conducting and reporting economic evaluations of fall prevention strategies.

International comparison of cost of falls in older adults living in the community: a systematic review.

SUMMARY: Our objective was to determine international estimates of the economic burden of falls in older people living in the community. Our systematic review emphasized the need for a consensus on methodology for cost of falls studies to enable more accurate comparisons and subgroup-specific estimates among different countries. INTRODUCTION: The purpose of this study was to determine international estimates of the economic burden of falls in older people living in the community. METHODS: This is a systematic review of peer-reviewed journal articles reporting estimates for the cost of falls in people aged > or =60 years living in the community. We searched for papers published between 1945 and December 2008 in MEDLINE, PUBMED, EMBASE, CINAHL, Cochrane Collaboration, and NHS EED databases that identified cost of falls in older adults. We extracted the cost of falls in the reported currency and converted them to US dollars at 2008 prices, cost items measured, perspective, time horizon, and sensitivity analysis. We assessed the quality of the studies using a selection of questions from Drummond's checklist. RESULTS: Seventeen studies met our inclusion criteria. Studies varied with respect to viewpoint of the analysis, definition of falls, identification of important and relevant cost items, and time horizon. Only two studies reported a sensitivity analysis and only four studies identified the viewpoint of their economic analysis. In the USA, non-fatal and fatal falls cost US $23.3 billion (2008 prices) annually and US $1.6 billion in the UK. CONCLUSIONS: The economic cost of falls is likely greater than policy makers appreciate. The mean cost of falls was dependent on the denominator used and ranged from US $3,476 per faller to US $10,749 per injurious fall and US $26,483 per fall requiring hospitalization. A consensus on methodology for cost of falls studies would enable more accurate comparisons and subgroup-specific estimates among different countries.

Does a home-based strength and balance programme in people aged > or =80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions.

OBJECTIVES: To investigate the value for money of strategies to prevent falls in older adults living in the community. DESIGN: Systematic review of peer reviewed journal articles reporting an economic evaluation of a falls prevention intervention as part of a randomised controlled trial or a controlled trial, or using an analytical model. MEDLINE, PUBMED, EMBASE and NHS EED databases were searched to identify cost-effectiveness, cost-utility and cost-benefit studies from 1945 through July 2008. MAIN OUTCOME MEASURES: The primary outcome measure was incremental cost-effectiveness, cost-utility and cost-benefit ratios in the reported currency and in pounds sterling at 2008 prices. The quality of the studies was assessed using two instruments: (1) an economic evaluation checklist developed by Drummond and colleagues and (2) the Quality of Health Economic Studies instrument. RESULTS: Nine studies meeting our inclusion criteria included eight cost-effectiveness analyses, one cost-utility and one cost-benefit analysis. Three effective falls prevention strategies were cost saving in a subgroup of PARTICIPANTS: (1) an individually customised multifactorial programme in those with four or more of the eight targeted fall risk factors, (2) the home-based Otago Exercise Programme in people > or =80 years and (3) a home safety programme in the subgroup with a previous fall. These three findings were from six studies that scored > or =75% on the Quality of Health Economic Studies instrument. CONCLUSIONS: Best value for money came from effective single factor interventions such as the Otago Exercise Programme which was cost saving in adults 80 years and older. This programme has broad applicability thus warranting warrants health policy decision-makers' close scrutiny.

Reducing hazard related falls in people 75 years and older with significant visual impairment: how did a successful program work?

BACKGROUND: In a randomized controlled trial testing a home safety program designed to prevent falls in older people with severe visual impairment, it was shown that the program, delivered by an experienced occupational therapist, significantly reduced the numbers of falls both at home and away from home. OBJECTIVES: To investigate whether the success of the home safety assessment and modification intervention in reducing falls resulted directly from modification of home hazards or from behavioral modifications, or both. METHODS: Participants were 391 community living women and men aged 75 years and older with visual acuity 6/24 meters or worse; 92% (361 of 391) completed one year of follow up. Main outcome measures were type and number of hazards and risky behavior identified in the home and garden of those receiving the home safety program, compliance with home safety recommendations reported at six months, location of all falls for all study participants during the trial, and environmental hazards associated with each fall. RESULTS: The numbers of falls at home related to an environmental hazard and those with no hazard involved were both reduced by the home safety program (n = 100 participants) compared with the group receiving social visits (n = 96) (incidence rate ratios = 0.40 (95% confidence interval, 0.21 to 0.74) and 0.43 (0.21 to 0.90), respectively). CONCLUSIONS: The overall reduction in falls by the home safety program must result from some mechanism in addition to the removal or modification of hazards or provision of new equipment.

Interventions for preventing falls in elderly people.

BACKGROUND: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention. OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group specialised register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field. SELECTION CRITERIA: Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate. MAIN RESULTS: Sixty two trials involving 21,668 people were included. Interventions likely to be beneficial: Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness: Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants). Interventions unlikely to be beneficial: Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants). REVIEWER'S CONCLUSIONS: Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

Interventions for preventing falls in elderly people.

BACKGROUND: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention. OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group specialised register (January 2001), Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2001), MEDLINE (1966 to February 2001), EMBASE (1988 to 2001 Week 14), CINAHL (1982 to March 2001), The National Research Register, Issue 1, 2001, Current Controlled Trials (www.controlled-trials.com accessed 25 May 2001), and reference lists of articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate. MAIN RESULTS: Interventions likely to be beneficial: ~bullet~A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98). ~bullet~A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). ~bullet~Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (1 trial, 530 participants, RR 0.64, 95% CI 0.49 to 0.84). A reduction in falls was seen both inside and outside the home. ~bullet~Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74). ~bullet~Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes, both for unselected community dwelling older people (data pooled from 3 trials, 1973 participants, pooled RR 0.73, 95%CI 0.63 to 0.86), and for older people with a history of falling, or selected because of known risk factors (data pooled from 2 trials, 713 participants, pooled RR 0.79, 95%CI 0.67 to 0.94). Interventions of unknown effectiveness: ~bullet~Group-delivered exercise interventions (9 trials, 2177 participants). ~bullet~Nutritional supplementation (1 trial, 50 participants). ~bullet~Vitamin D supplementation, with or without calcium (3 trials, 679 participants). ~bullet~Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants). ~bullet~Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants). ~bullet~Fall prevention programmes in institutional settings. ~bullet~Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants). ~bullet~Home hazard modification for older people without a history of falling (1 trial, 530 participants). ~bullet~ Hormone replacement therapy (1 trial, 116 participants). Interventions unlikely to be beneficial: ~bullet~Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants). REVIEWER'S CONCLUSIONS: Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

Economic evaluation of a community based exercise programme to prevent falls.

OBJECTIVE: To assess the incremental costs and cost effectiveness of implementing a home based muscle strengthening and balance retraining programme that reduced falls and injuries in older women. DESIGN: An economic evaluation carried out within a randomised controlled trial with two years of follow up. Participants were individually prescribed an exercise programme (exercise group, n=116) or received usual care and social visits (control group, n=117). SETTING: 17 general practices in Dunedin, New Zealand. PARTICIPANTS: Women aged 80 years and older living in the community and invited by their general practitioner to take part. MAIN OUTCOME MEASURES: Number of falls and injuries related to falls, costs of implementing the intervention, healthcare service costs resulting from falls and total healthcare service costs during the trial. Cost effectiveness was measured as the incremental cost of implementing the exercise programme per fall event prevented. MAIN RESULTS: 27% of total hospital costs during the trial were related to falls. However, there were no significant differences in health service costs between the two groups. Implementing the exercise programme for one and two years respectively cost $314 and $265 (1995 New Zealand dollars) per fall prevented, and $457 and $426 per fall resulting in a moderate or serious injury prevented. CONCLUSIONS: The costs resulting from falls make up a substantial proportion of the hospital costs for older people. Despite a reduction in falls as a result of this home exercise programme there was no significant reduction in healthcare costs. However, the results reported will provide information on the cost effectiveness of the programme for those making decisions on falls prevention strategies.

Practical implementation of an exercise-based falls prevention programme.

Muscle weakness and impaired balance are risk factors underlying many falls and fall injuries experienced by older people. Fall prevention strategies have included exercise programmes that lower the risk of falling by improving strength and balance. We have developed an individually tailored, home-based, strength and balance retraining programme, which has proven successful in reducing falls and moderate fall injuries in people aged 80 years and older. Here we describe a simple assessment of strength and balance and the content and delivery of a falls prevention exercise programme.

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial.

OBJECTIVES: To assess the effectiveness of a trained district nurse individually prescribing a home based exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme. DESIGN: Randomised controlled trial with one year's follow up. SETTING: Community health service at a New Zealand hospital. PARTICIPANTS: 240 women and men aged 75 years and older. INTERVENTION: 121 participants received the exercise programme (exercise group) and 119 received usual care (control group); 90% (211 of 233) completed the trial. MAIN OUTCOME MEASURES: Number of falls, number of injuries resulting from falls, costs of implementing the programme, and hospital costs as a result of falls. RESULTS: Falls were reduced by 46% (incidence rate ratio 0.54, 95% confidence interval 0.32 to 0.90). Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. The programme cost $NZ1803 (523 pound sterling) (at 1998 prices) per fall prevented for delivering the programme and $NZ155 per fall prevented when hospital costs averted were considered. CONCLUSION: A home exercise programme, previously shown to be successful when delivered by a physiotherapist, was also effective in reducing falls when delivered by a trained nurse from within a home health service. Serious injuries and hospital admissions due to falls were also reduced. The programme was cost effective in participants aged 80 years and older compared with younger participants.