Economic Evaluation of Exercise or Cognitive and Social Enrichment Activities for Improved Cognition After Stroke.

Importance: Cognitive impairment is prevalent in survivors of stroke, affecting approximately 30% of individuals. Physical exercise and cognitive and social enrichment activities can enhance cognitive function in patients with chronic stroke, but their cost-effectiveness compared with a balance and tone program is uncertain. Objective: To conduct a cost-effectiveness and cost-utility analysis of multicomponent exercise or cognitive and social enrichment activities compared with a balance and tone program. Design, Setting, and Participants: This economic evaluation used a Canadian health care systems perspective and the Vitality study, a randomized clinical trial aimed at improving cognition after stroke with a 6-month intervention and a subsequent 6-month follow-up (ie, 12 months). The economic evaluation covered the duration of the Vitality trial, between June 6, 2014, and February 26, 2019. Participants were community-dwelling adults aged 55 years and older who experienced a stroke at least 12 months prior to study enrollment in the Vancouver metropolitan area, British Columbia, Canada. Data were analyzed from June 1, 2022, to March 31, 2023. Interventions: Participants were randomly assigned to twice-weekly classes for 1 of the 3 groups: multicomponent exercise program, cognitive and social enrichment activities program, or a balance and tone program (control). Main Outcomes and Measures: The primary measures for the economic evaluation included cost-effectiveness (incremental costs per mean change in cognitive function, evaluated using the Alzheimer Disease Assessment Scale-Cognitive-Plus), cost-utility (incremental cost per quality-adjusted life-year gained), intervention costs, and health care costs. Since cognitive benefits 6 months after intervention cessation were not observed in the primary randomized clinical trial, an economic evaluation at 12 months was not performed. Results: Among 120 participants (mean [SD] age, 71 [9] years; 74 [62%] male), 34 were randomized to the multicomponent exercise program, 34 were randomized to the social and cognitive enrichment activities program, and 52 were randomized to the balance and tone control program. At the end of the 6-month intervention, the cost per mean change in Alzheimer Disease Assessment Scale-Cognitive-Plus score demonstrated that exercise was more effective and costlier compared with the control group in terms of cognitive improvement with an incremental cost-effectiveness ratio of CAD -$8823. The cost per quality-adjusted life-year gained for both interventions was negligible, with exercise less costly (mean [SD] incremental cost, CAD -$32 [$258]) and cognitive and social enrichment more costly than the control group (mean [SD] incremental cost, CAD $1018 [$378]). The balance and tone program had the lowest delivery cost (CAD $777), and the exercise group had the lowest health care resource utilization (mean [SD] $1261 [$1188]) per person. Conclusions and Relevance: The findings of this economic evaluation suggest that exercise demonstrated potential for cost-effectiveness to improve cognitive function in older adults with chronic stroke during a 6-month intervention.

Cost-effectiveness of exercise versus multimodal interventions that include exercise to prevent falls among community-dwelling older adults: A systematic review and meta-analysis.

OBJECTIVE: To compare the cost-effectiveness of exercise as a unimodal intervention versus multimodal interventions that included exercise in conjunction with other falls prevention strategies to prevent falls among community-dwelling older adults. DESIGN: Systematic review and meta-analysis. DATA SOURCES: MEDLINE, EMBASE, NHS EED, and CINAHL (1 January 1946 to June 2022). ELIGIBILITY CRITERIA: Economic evaluations of fall prevention strategies that included exercise delivered as a unimodal intervention or a multimodal intervention that included exercise in conjunction with other falls prevention strategies among community-dwelling adults aged 60 years and over. RESULTS: Eighteen studies were included in this review: 9 unimodal, 6 multimodal, and 3 that included exercise delivered as both a unimodal and a multimodal intervention. In the cost-effectiveness analyses, 61.5 % (n = 8/13) of exercise-only unimodal interventions demonstrated cost-effectiveness, compared with 33.3 % (n = 2/6) of multimodal interventions. In the cost-utility analyses, 60 % (n = 6/10) of unimodal interventions compared with zero multimodal interventions (n = 0/4) demonstrated cost-effectiveness. Sixteen studies (25,017 participants) were included in our meta-analysis. Incremental costs were $128 [-$661, $1644] (2021 US dollars) for exercise-only unimodal interventions and $786 [-$72, $1644] for multimodal interventions. Estimated incremental quality-adjusted life-years was 0.09 [-0.37, 0.55] for exercise-only unimodal interventions and 0.00 [-0.04, 0.04] for multimodal interventions. Both exercise-only and multimodal interventions had an estimated 28 % reduction in falls versus the control, with incidence rate ratios for exercise-only unimodal interventions of 0.72 [0.62, 0.83] and for multimodal interventions of 0.72 [0.25, 2.09]. CONCLUSION: Exercise delivered as a unimodal intervention, particularly resistance training, provided the best value for money for fall prevention. Multimodal interventions that included exercise did not demonstrate additional benefits in terms of costs, quality of life, or fall prevention compared with exercise-only unimodal interventions. This finding may be due to the smaller number of multimodal interventions available. REVIEW REGISTRATION: PROSPERO CRD42022295561. REGISTRATION TITLE: Comparing the cost-effectiveness of multimodal versus unimodal interventions that include exercise to prevent falls among community-dwelling older adults: A systematic review.

Comparing the cost-effectiveness of the Otago Exercise Programme among older women and men: A secondary analysis of a randomized controlled trial.

OBJECTIVE: Using stratified analyses, we examined the cost-effectiveness of the Otago Exercise Programme (OEP), from a health care system perspective, among older women and men who have previously fallen. METHODS: This study was a secondary stratified analysis (by women and men), of a 12-month prospective economic evaluation of a randomized clinical trial (OEP compared with usual care). Three hundred and forty four community-dwelling older adults (≥70; 172 OEP (110 women; 62 men), 172 usual care (119 women; 53 men)) who sustained a fall in the past 12 months and received a baseline assessment at the Vancouver Falls Prevention Clinic, Canada were included. A gender by OEP/usual care interaction was examined for the falls incidence rate ratio (IRR). Outcome measures stratified by gender included: falls IRR, incremental cost-per fall prevented (ICER), incremental cost per quality adjusted life year (QALY, ICUR) gained, and mean total health care resource utilization costs. RESULTS: Men were frailer than women at baseline. Men incurred higher mean total healthcare costs $6794 (SD: $11906)). There was no significant gender by OEP/usual care interaction on falls IRR. The efficacy of the OEP did not vary by gender. The adjusted IRR for the OEP group demonstrated a 39% (IRR: 0.61, CI: 0.40-0.93) significant reduction in falls among men but not women (32% reduction (IRR: 0.69, CI: 0.47-1.02)). The ICER showed the OEP was effective in preventing falls and less costly for men, while it was costlier for women by $42. The ICUR showed the OEP did not impact quality of life. CONCLUSION: Future studies should explore gender factors (i.e., health seeking behaviours, gender related frailty) that may explain observed variation in the cost-effectiveness of the OEP as a secondary falls prevention strategy. TRIAL REGISTRATIONS: ClinicalTrials.gov Protocol Registration System Identifier: NCT01029171; URL: https://clinicaltrials.gov/ct2/show/NCT01029171 Identifier: NCT00323596; URL: https://clinicaltrials.gov/ct2/show/NCT00323596.