Original Study| Volume 23, ISSUE 5, P736-742.e6, May 2022

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Cost-Effectiveness of a Group vs Individually Delivered Exercise Program in Community-Dwelling Persons Aged ≥70 Years

Published:October 06, 2021DOI:



      Interventions aimed at reducing falls and physical inactivity could alleviate the economic burden attributable to these factors. The study aimed to analyze the cost-effectiveness of a group-delivered version of the Lifestyle-integrated Functional Exercise Program compared with an individually delivered program version.


      An economic evaluation conducted alongside the LiFE-is-LiFE randomized non-inferiority trial.


      Group and individually delivered version of a program consisting of strength and balance exercises integrated into everyday activities to prevent falls.

      Setting and participants

      309 community-dwelling older adults (aged ≥70 years) at risk of falling recruited around Heidelberg and Stuttgart (Germany).


      Cost-effectiveness of the group program was assessed over 6 months using different effect measures [quality-adjusted life years (QALYs, EQ-5D-5L), physical activity (mean number of steps/day), and falls] and cost perspectives (societal and payer’s). Incremental cost-effectiveness ratios were determined, and cost-effectiveness acceptability curves were constructed.


      From a societal perspective, mean costs, the number of falls, and the number of steps/day were somewhat higher in the group program, whereas QALYs were almost identical between the 2 interventions. From the payer’s perspective, the incremental cost-effectiveness ratio for the group compared to the individual program were €56,733 per QALY and €4755 per fall prevented. Based on the cost-effectiveness acceptability curves, the cost-effectiveness of the group program had to be rated as uncertain for both effect measures and perspectives. In contrast, it demonstrated cost-effectiveness for increasing physical activity at willingness-to-pay values per additional 1000 steps/day of €1600 (societal perspective) or €600 (payer’s perspective).

      Conclusions and Implications

      Compared to the individual program, the group program might be cost-effective for increasing physical activity in older adults but was unlikely to be cost-effective with regard to QALY or for preventing falls. The cost-effectiveness should be evaluated long-term and compared to a regular care group.


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        • Federal Ministry of Health
        National Health Goal - Healthy Ageing.
        Federal Ministry of Health, Berlin2012 ([in German])
        • Daskalopoulou C.
        • Stubbs B.
        • Kralj C.
        • et al.
        Physical activity and healthy ageing: A systematic review and meta-analysis of longitudinal cohort studies.
        Ageing Res Rev. 2017; 38: 6-17
        • Cunningham C.
        • O' Sullivan R.
        • Caserotti P.
        • et al.
        Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses.
        Scand J Med Sci Sports. 2020; 30: 816-827
        • Marquez D.X.
        • Aguiñaga S.
        • Vásquez P.M.
        • et al.
        A systematic review of physical activity and quality of life and well-being.
        Transl Behav Med. 2020; 10: 1098-1109
        • Dallmeyer S.
        • Wicker P.
        • Breuer C.
        How an aging society affects the economic costs of inactivity in Germany: Empirical evidence and projections.
        Eur Rev Aging Phys Act. 2017; 14: 18
        • Bergen G.
        • Stevens M.R.
        • Burns E.R.
        Falls and fall injuries among adults aged >/=65 years - United States, 2014.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 993-998
        • Schumacher J.
        • Pientka L.
        • Trampisch U.
        • et al.
        The prevalence of falls in adults aged 40 years or older in an urban, German population. Results from a telephone survey.
        Z Gerontol Geriatr. 2014; 47: 141-146
        • Hartholt K.A.
        • van Beeck E.F.
        • Polinder S.
        • et al.
        Societal consequences of falls in the older population: Injuries, healthcare costs, and long-term reduced quality of life.
        J Trauma. 2011; 71: 748-753
        • Tinetti M.E.
        • Williams C.S.
        Falls, injuries due to falls, and the risk of admission to a nursing home.
        N Engl J Med. 1997; 337: 1279-1284
        • Heinrich S.
        • Rapp K.
        • Rissmann U.
        • et al.
        Cost of falls in old age: A systematic review.
        Osteoporos Int. 2010; 21: 891-902
        • Lee J.
        The association between physical activity and risk of falling in older adults: A systematic review and meta-analysis of prospective cohort studies.
        Geriatr Nurs. 2020; 41: 747-753
        • Jefferis B.J.
        • Merom D.
        • Sartini C.
        • et al.
        Physical activity and falls in older men: The critical role of mobility limitations.
        Med Sci Sports Exerc. 2015; 47: 2119-2128
        • Lewis Z.H.
        • Markides K.S.
        • Ottenbacher K.J.
        • et al.
        The role of physical activity and physical function on the risk of falls in older Mexican Americans.
        J Aging Phys Act. 2016; 24: 342-349
        • Bauman A.
        • Merom D.
        • Bull F.C.
        • et al.
        Updating the evidence for physical activity: Summative reviews of the epidemiological evidence, prevalence, and interventions to promote “active aging.”.
        Gerontologist. 2016; 56: S268-S280
        • Lu Z.
        • Lam F.M.H.
        • Leung J.C.S.
        • et al.
        The U-shaped relationship between levels of bouted activity and fall incidence in community-dwelling older adults: A prospective cohort study.
        J Gerontol A Biol Sci Med Sci. 2020; 75: e145-e151
      1. Edlin R. McCabe C. Hulme C. Cost Effectiveness Modelling for Health Technology Assessment. A Practical Guide. ADIS, Springer, Cham, Switzerland2015
        • Davis J.C.
        • Robertson M.C.
        • Ashe M.C.
        • et al.
        Does a home-based strength and balance programme in people aged ≥80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions.
        Br J Sports Med. 2010; 44: 80-89
        • Balzer K.
        • Bremer M.
        • Schramm S.
        • et al.
        Falls prevention for the elderly.
        GMS Health Technol Assess. 2012; 8: Doc01
        • Dubas-Jakóbczyk K.
        • Kocot E.
        • Kissimova-Skarbek K.
        • et al.
        Economic evaluation of health promotion and primary prevention actions for older people—a systematic review.
        Eur J Public Health. 2017; 27: 670-679
        • Winser S.J.
        • Chan H.T.F.
        • Ho L.
        • et al.
        Dosage for cost-effective exercise-based falls prevention programs for older people: A systematic review of economic evaluations.
        Ann Phys Rehabil Med. 2020; 63: 69-80
        • Clemson L.
        • Munro J.
        • Fiatarone Singh M.A.
        Lifestyle-Integrated Functional Exercise (LiFE) Program to Prevent Falls. Trainer’s Manual.
        Sydney University Press, Sydney2014
        • Clemson L.
        • Singh M.F.
        • Bundy A.
        • et al.
        LiFE Pilot Study: A Randomised Trial of Balance and Strength Training Embedded in Daily Life Activity to Reduce Falls in Older Adults.
        Aust Occup Ther J. 2010; 57: 42-50
        • Clemson L.
        • Fiatarone Singh M.A.
        • Bundy A.
        • et al.
        Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): Randomised parallel trial.
        BMJ. 2012; 345: e4547
        • Jansen C.P.
        • Nerz C.
        • Kramer F.
        • et al.
        Comparison of a group-delivered and individually delivered lifestyle-integrated functional exercise (LiFE) program in older persons: a randomized noninferiority trial.
        BMC Geriatr. 2018; 18: 267
        • Kramer F.
        • Labudek S.
        • Jansen C.P.
        • et al.
        Development of a conceptual framework for a group-based format of the Lifestyle-integrated Functional Exercise (gLiFE) programme and its initial feasibility testing.
        Pilot Feasibility Stud. 2020; 6: 6
      2. Jansen CP, Nerz C, Labudek S, et al. Lifestyle‑integrated functional exercise to prevent falls and promote physical activity: Results from the LiFE‑is‑LiFE randomized non‑inferiority trial. Int J Behav Nutr Phys Act. 18, 115.

        • Seidl H.
        • Bowles D.
        • Bock J.O.
        • et al.
        [FIMA–questionnaire for health-related resource use in an elderly population: development and pilot study].
        Gesundheitswesen. 2015; 77 ([in German]): 46-52
        • Bock J.O.
        • Brettschneider C.
        • Seidl H.
        • et al.
        [Calculation of standardised unit costs from a societal perspective for health economic evaluation].
        Gesundheitswesen. 2015; 77 ([in German]): 53-61
      3. Organization for Economic Cooperation and Development.
        Inflation (CPI) (indicator). 2020;
        • Rote Liste Service GmbH
        ROTE LISTE 2018: Pharmaceutical directory for Germany (including EU approvals and certain medical devices).
        Rote Liste Service GmbH, Frankfurt/Main2018 ([in German])
        • Herdman M.
        • Gudex C.
        • Lloyd A.
        • et al.
        Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L).
        Qual Life Res. 2011; 20: 1727-1736
        • Ludwig K.
        • Graf von der Schulenburg J.M.
        • Greiner W.
        German value set for the EQ-5D-5L.
        Pharmacoeconomics. 2018; 36: 663-674
        • Lamb S.E.
        • Jørstad-Stein E.C.
        • Hauer K.
        • et al.
        Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe consensus.
        J Am Geriatr Soc. 2005; 53: 1618-1622
        • StataCorp
        Stata Multiple-Imputation Reference Manual. Release 16.
        StataCorp LLC, College Station, TX2019
        • Azur M.J.
        • Stuart E.A.
        • Frangakis C.
        • et al.
        Multiple imputation by chained equations: What is it and how does it work?.
        Int J Methods Psychiatr Res. 2011; 20: 40-49
        • Hoch J.S.
        • Briggs A.H.
        • Willan A.R.
        Something old, something new, something borrowed, something blue: A framework for the marriage of health econometrics and cost-effectiveness analysis.
        Health Econ. 2002; 11: 415-430
        • Briggs A.H.
        • O'Brien B.J.
        • Blackhouse G.
        Thinking outside the box: Recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies.
        Annu Rev Public Health. 2002; 23: 377-401
        • Davis J.C.
        • Khan K.M.
        • Hsu C.L.
        • et al.
        Action Seniors! Cost-effectiveness analysis of a secondary falls prevention strategy among community-dwelling older fallers.
        J Am Geriatr Soc. 2020; 68: 1988-1997
        • Bjerk M.
        • Brovold T.
        • Davis J.C.
        • et al.
        Health-related quality of life in home care recipients after a falls prevention intervention: A 6-month follow-up.
        Eur J Public Health. 2020; 30: 64-69
        • Bjerk M.
        • Brovold T.
        • Davis J.C.
        • et al.
        Evaluating a falls prevention intervention in older home care recipients: A comparison of SF-6D and EQ-5D.
        Qual Life Res. 2019; 28: 3187-3195
        • Grochtdreis T.
        • Dams J.
        • König H.H.
        • et al.
        Health-related quality of life measured with the EQ-5D-5L: Estimation of normative index values based on a representative German population sample and value set.
        Eur J Health Econ. 2019; 20: 933-944
        • Joore M.
        • Brunenberg D.
        • Nelemans P.
        • et al.
        The impact of differences in EQ-5D and SF-6D utility scores on the acceptability of cost-utility ratios: results across five trial-based cost-utility studies.
        Value Health. 2010; 13: 222-229
        • Hollman J.H.
        • McDade E.M.
        • Petersen R.C.
        Normative spatiotemporal gait parameters in older adults.
        Gait Posture. 2011; 34: 111-118
        • Hall K.S.
        • Hyde E.T.
        • Bassett D.R.
        • et al.
        Systematic review of the prospective association of daily step counts with risk of mortality, cardiovascular disease, and dysglycemia.
        Int J Behav Nutr Phys Act. 2020; 17: 78
        • Ding D.
        • Lawson K.D.
        • Kolbe-Alexander T.L.
        • et al.
        The economic burden of physical inactivity: A global analysis of major non-communicable diseases.
        Lancet. 2016; 388: 1311-1324
        • Klenk J.
        • Kerse N.
        • Rapp K.
        • et al.
        Physical activity and different concepts of fall risk estimation in older people–Results of the ActiFE-Ulm Study.
        PLoS One. 2015; 10: e0129098
        • Wijlhuizen G.J.
        • Chorus A.M.J.
        • Hopman-Rock M.
        The FARE: A new way to express FAlls Risk among older persons including physical activity as a measure of Exposure.
        Prev Med. 2010; 50: 143-147
        • Del Din S.
        • Galna B.
        • Lord S.
        • et al.
        Falls risk in relation to activity exposure in high-risk older adults.
        J Gerontol A Biol Sci Med Sci. 2020; 75: 1198-1205
        • McPhee J.S.
        • French D.P.
        • Jackson D.
        • et al.
        Physical activity in older age: Perspectives for healthy ageing and frailty.
        Biogerontology. 2016; 17: 567-580