Economic Evaluation of Community-based Falls Prevention Interventions: a Systematic Methodological Overview of Systematic Reviews

Abstract Background: Falls impose significant health and economic burdens on older people, making their prevention a priority for care decision-makers. The volume of falls prevention economic evaluations has increased, the findings from which have been synthesised by systematic reviews (SRs) with pre-specified criteria (e.g., objectives, eligibility, data extraction). Such SRs can inform commissioning and design of future evaluations, particularly decision models; however, their findings can be biased and partial dependent on their pre-specified criteria. This study aims to conduct a systematic overview (SO) to: (1) systematically identify SRs of community-based falls prevention economic evaluations; (2) describe the methodology and findings of SRs; (3) critically appraise the methodology of SRs; and (4) suggest commissioning recommendations based on SO findings. Methods: The SO followed the PRISMA guideline and the Cochrane guideline on SO, covering the period 2003-2020. Identified SRs’ aims, search strategies and results, extracted data fields, quality assessment methods and results, and commissioning and research recommendations were synthesised. The comprehensiveness of previous SRs’ data synthesis was judged against criteria drawn from expert guideline and academic literature on falls prevention/public health economic evaluation. Outcomes of general population, lifetime decision models were re-analysed to inform commissioning recommendations. The SO protocol is registered in the Prospective Register of Systematic Reviews (CRD42021234379).Results: Seven SRs were identified, which extracted 8 to 33 data fields from 44 relevant economic evaluations. Four economic evaluation methodological/reporting quality checklists were used; three SRs narratively synthesised methodological features to varying extent and focus. SRs generally did not appraise decision modelling features, including methods for characterising dynamic complexity of falls risk and intervention need. Their commissioning recommendations were based mainly on cost-per-unit ratios (e.g., incremental cost-effectiveness ratios) and neglected aggregate impact. There is model-based evidence of multifactorial and environmental interventions, home assessment and modification and Tai Chi being cost-effective but also the risk that they exacerbate social inequities of health. Conclusions: Current SRs of falls prevention economic evaluations do not holistically inform commissioning and evaluation design. Accounting for broader decisional factors including intervention reach and capacity constraints and a broader grasp of methodological nuances of economic evaluations, particularly decision models, are needed.