Incorporating Patient Input into Value-based Community Fall Prevention for Older Adults: Evaluating Patient Preferences and Willingness to Pay

Abstract

Background: Falls are the leading cause of injury-related death and non-fatal injuries in US older adults, including hip fracture and traumatic brain injury. Current evidence-based fall prevention programs exist in community settings. However, these programs remain severely under-utilized.

Objective: The purpose of this mixed methods study is to address the question, “What are community-dwelling older adults’ (65+) preferences for features of community-based fall prevention (CFP) programs?”

Methods: Key features of CFP programs were identified through a systematic literature review and qualitative meta-synthesis of older adults’ preferences for CFP program features, and interviews with older adults, caregivers, and a falls expert (Aim 1). A national online survey was used to quantitatively prioritize preferred CFP program features using a discrete choice experiment with conditional logit models (Aim 2). Willingness to pay for a CFP program, net benefit of program participation, and predicted uptake of several examples of CFP programs were also assessed from the perspective of older adults (Aim 3).

Results: Fifty-four articles were retained in the systematic review, representing the views of 20,540 older adults (Aim 1). Three themes emerged from the qualitative meta-synthesis. The first theme was that older adults prefer CFP programs with immediate benefits, including two categories: social support; and physical & mental benefits. The second theme was that older adults prefer CFP programs that appear trustworthy and legitimate, including two categories: endorsement by others; and familiarity & learning resources. The third theme was that CFP programs should be easy to access and fit into older adults’ daily routines, including two categories: ease of access & service utilization; and self-management & tailoring.

A total of 630 participants completed the discrete choice experiment survey (Aim 2). For the results reported here, only survey participants who made trade-offs between CFP program attributes and who correctly answered attention filter questions were included in analyses (n=328). Quantitative results of the discrete choice experiment showed that cost was the most important factor in older adults’ choice between CFP programs, regardless of income (relative importance score of 77.05% in the lower income group, and 73.79% in the higher income group). For participants with lower income, program efficacy was the least important factor (relative importance score of 2.02%), while inclusion of a home safety consultation was least important for those with higher income (relative importance score of 1.14%).

Using results of conditional logit models (n=328), survey participants’ mean marginal willingness to pay for five examples of hypothetical CFP programs in Aim 3 ranged from $56.10/month (95% CI=$49.21-$62.58) to $62.45/month (95% CI=$56.35-$68.23). For participants with lower income, willingness to pay for these hypothetical programs ranged from $53.95 (95% CI=$40.40-$66.93) to $64.81 (95% CI=$53.08-$76.82), and in the higher income group ranged from $56.20 ($51.52-$61.03) to $63.12 (95% CI=$56.19-$69.82). Net benefit/month ranged from $62.45 (95% CI=$56.35-$68.23) to $-49.10 (95% CI=$-53.25-$-45.31) for older adults who participated in the five hypothetical CFP programs, and predicted uptake among these programs was driven by cost.

Conclusions and Significance: Self-management of when, where, and how older adults participated in CFP programs reaffirmed older adults’ autonomy and independence and created a sense of empowerment for active, healthy aging. Results may be used to develop, modify, or evaluate CFP programs in order to design programs that incorporate older adults’ preferences. This may help to improve older adults’ enrollment, retention, and adherence to CFP programs, which may ultimately reduce falls and improve older adults’ quality of life and health outcomes.