6 The cost-effectiveness of the Dutch In Balance fall prevention intervention | 103 BACKGROUND Falls among older adults are a growing public health concern (133, 248). Annually, approximately 30% of individuals aged 65 years and above experience at least one fall every year (236). Falls commonly lead to injuries such as bruises, hip- and upper extremity fractures, and brain- and cranial damage (24, 249). Fall-related injuries, even the less severe injuries, are associated with reduced quality of life, impaired functioning and an increased risk of subsequent falls (24, 250). Fall-related injuries of older adults led to around 100,000 emergency department visits in 2023 in the Netherlands (2). These injuries impose substantial demands on healthcare resources and lead to high healthcare costs (24, 133). Annually, healthcare costs of fall-related injuries in the Netherlands are approximately €474.4 million (24). A systematic review showed that national fall-related costs found in prevalence-based studies ranged between 0.85% and 1.5% of the total healthcare expenditures (251). Considering the limited available healthcare resources and the expected increase in fall incidents due to the aging population (252), prevention of falls is of utmost importance. Fall prevention interventions aim to prevent falls and thereby to prevent injuries, improve quality of life, and reduce costs associated with falls (24). Previous studies have shown that such interventions are effective in reducing the number of falls and improving quality of life in community-dwelling older adults (49, 253). In the Netherlands, the ‘In Balance’ intervention is a widely implemented, group-based fall prevention intervention that includes exercises based on Tai Chi and offers education on risk factors associated with falls (198). Research by Faber and colleagues in 2006 (55) demonstrated the effectiveness of the original 20-week In Balance intervention for pre-frail older adults living in nursing homes. Since then, an adapted version of the In Balance intervention with a duration of 14 weeks is implemented throughout the Netherlands that targets both non-frail and pre-frail community-dwelling older adults. We recently showed that there were no statistically significant differences in falls and fall-related injuries between this adapted In Balance program and usual care, although there were less falls and fall-related injuries in the In Balance group (254). Besides effectiveness, it is important to establish the cost-effectiveness of fall prevention interventions, for example for policy makers to optimally allocate the scarce resources available and to decide about the reimbursement of such interventions. A recent systematic review indicates that the cost-effectiveness of multifactorial fall prevention programs is uncertain with substantial variation observed in incremental cost-effectiveness ratios (ICERs) (143). Additionally, the (cost-)effectiveness of fall prevention interventions differs between subgroups based on characteristics, such as age, health status, frailty, and the frequency of falls (55, 143, 255, 256). A possibility to make fall prevention more efficient is by providing group-based
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