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Cognitive behavioral interventions (general population)

Health Care: Falls Prevention for Older Adults
Benefit-cost methods last updated December 2017.  Literature review updated February 2018.
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Cognitive behavioral interventions for falls prevention are designed to reduce the fear of falling and increase activity levels among older adults. Major components of these interventions include 1) identifying misconceptions about falls and improving self-efficacy; 2) setting realistic personal goals for increased activity levels; 3) changing the environment to reduce fall risk factors; and 4) promoting exercise to increase strength and balance.

Our analysis includes two studies, both from the Netherlands, which were modifications of the U.S.-developed Matter of Balance program. One study evaluated a group intervention held at a community center, and the other evaluated an individual program held in participants’ homes. The two interventions provided on average eight sessions of cognitive behavioral intervention for an average of 12.5 hours of instruction. Both interventions were delivered by nurses trained in geriatric care and served community-dwelling adults aged 70 & older.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $71 Benefits minus costs ($34)
Participants $9 Benefit to cost ratio $0.89
Others $11 Chance the program will produce
Indirect $168 benefits greater than the costs 42 %
Total benefits $259
Net program cost ($293)
Benefits minus cost ($34)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Health care associated with falls $71 $9 $11 $36 $127
Labor market earnings associated with falls $0 $0 $0 $279 $279
Adjustment for deadweight cost of program $0 $0 $0 ($147) ($147)
Totals $71 $9 $11 $168 $259
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $293 2016 Present value of net program costs (in 2016 dollars) ($293)
Comparison costs $0 2016 Cost range (+ or -) 50 %
Per-participant cost estimates are based on weighted average program costs in the included studies. We estimate provider hours spent on group class instruction, in-home instruction, transportation, telephone contacts, and training hours; apply the 2016 mean hourly wage estimate for Washington State reported by the Bureau of Labor Statistics (retrieved March 2018) for registered nurses; and increase wages by a factor of 1.441 to account for the cost of employee benefits. The two studies provided on average eight sessions of cognitive behavioral intervention for an average of 12.5 hours of instruction. For the group intervention, these sessions were delivered via classes at the community center. For the individual intervention, sessions were provided via home visits and telephone calls. For this intervention, we include an additional 1.5 hours of instructor travel time, per participant. We also include a cost of $19 for class materials and a per-instructor training fee of $1,036 based on estimated costs of a two-day training session as described in Dorresteijn (2016).
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

The effect size for this outcome indicates an incidence rate ratio (IRR), not a standardized mean difference effect size. An IRR less than one indicates a lower rate of the outcome in the treatment group relative to the comparison group; an IRR greater than one indicates a higher rate of the outcome. The treatment n for this outcome represents person-years.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment Age No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Falls 78 2 384 0.860 0.045 78 1.000 0.000 79 0.860 0.004

Citations Used in the Meta-Analysis

Dorresteijn, T.A., Zijlstra, G.R., Ambergen, A.W., Delbaere, K., Vlaeyen, J.W., & Kempen, G.I. (2016). Effectiveness of a home-based cognitive behavioral program to manage concerns about falls in community-dwelling, frail older people: results of a randomized controlled trial. BMC Geriatrics, 16(1), 2.

Zijlstra, G.A.R., Van, H.J.C.M., Ambergen, T., Van, R.E., Van, E.J.T.M., Tennstedt, S.L., & Kempen, G.I.J.M. (2009). Effects of a multicomponent cognitive behavioral group intervention on fear of falling and activity avoidance in community-dwelling older adults: Results of a randomized controlled trial. Journal of the American Geriatrics Society, 57(11), 2020-2028.