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RESEARCH Open Access
Qualitative research to inform economic modelling: a case study in older people’s views on implementing the NICE falls prevention guideline Joseph Kwon1* , Yujin Lee2 , Tracey Young1 , Hazel Squires1 and Janet Harris1
Abstract
Background: High prevalence of falls among older persons makes falls prevention a public health priority. Yet community-based falls prevention face complexity in implementation and any commissioning strategy should be subject to economic evaluation to ensure cost-effective use of healthcare resources. The study aims to capture the views of older people on implementing the National Institute for Health and Care Excellence (NICE) guideline on community-based falls prevention and explore how the qualitative data can be used to inform commissioning strategies and conceptual modelling of falls prevention economic evaluation in the local area of Sheffield.
Methods: Focus group and interview participants (n = 27) were recruited from Sheffield, England, and comprised falls prevention service users and eligible non-users of varying falls risks. Topics concerned key components of the NICE-recommended falls prevention pathway, including falls risk screening, multifactorial risk assessment and treatment uptake and adherence. Views on other topics concerning falls prevention were also invited. Framework analysis was applied for data analysis, involving data familiarisation, identifying themes, indexing, charting and mapping and interpretation. The qualitative data were mapped to three frameworks: (1) facilitators and barriers to implementing the NICE-recommended pathway and contextual factors; (2) intervention-related causal mechanisms for formulating commissioning strategies spanning context, priority setting, need, supply and demand; and (3) methodological and evaluative challenges for public health economic modelling.
Results: Two cross-component factors were identified: health motives of older persons; and professional competence. Participants highlighted the need for intersectoral approaches and prioritising the vulnerable groups. The local commissioning strategy should consider the socioeconomic, linguistic, geographical, legal and cultural contexts, priority setting challenges, supply-side mechanisms spanning provider, organisation, funding and policy (including intersectoral) and health and non-health demand motives. Methodological and evaluative challenges identified included: incorporating non-health outcomes and societal intervention costs; considering dynamic complexity; considering social determinants of health; and conducting equity analyses.
© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: jkwon6@sheffield.ac.uk 1School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England S1 4DA Full list of author information is available at the end of the article
Kwon et al. BMC Health Services Research (2021) 21:1020 https://doi.org/10.1186/s12913-021-07056-1
http://crossmark.crossref.org/dialog/?doi=10.1186/s12913-021-07056-1&domain=pdf
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http://creativecommons.org/publicdomain/zero/1.0/
mailto:jkwon6@sheffield.ac.uk
Conclusions: Holistic qualitative research can inform how commissioned falls prevention pathways can be feasible and effective. Qualitative data can inform commissioning strategies and conceptual modelling for economic evaluations of falls prevention and other geriatric interventions. This would improve the structural validity of quantitative models used to inform geriatric public health policies.
Keywords: Falls, Falls risk, Falls prevention, National Institute for health and care excellence guideline, Implementation, Qualitative research, Facilitators and barriers, Economic model, Public health
Background Falls among older people impose significant morbidity and mortality burdens [1]. Around 30% of community- dwelling persons aged 65+ fall each year [2]. Falls can re- sult in fatal or debilitating injuries such as hip fractures [3], provoke fear of further falls [4], and induce func- tional decline [5]. They also impose substantial burdens on care systems through hospitalisations and long-term care admissions [6] and on informal caregivers [7]. Falls prevention is hence a public health priority [8]. The rationale for intervention is further supported by
randomised controlled trial (RCT) findings that diverse community-based falls prevention interventions signifi- cantly reduce the number of falls and fallers [9, 10]. In England and Wales, the National Institute for Health and Care Excellence (NICE) clinical guideline 161 (CG161) is the normative reference point for local clin- ical practice [2]. This recommends that persons aged 65+ receive falls risk screening at routine visits to health and social care professionals; those screened to be at high risk would then be referred to multidisciplinary falls risk assessment and tailored treatments, including exer- cise, home assessment and modification (HAM), medica- tion modification and vision improvements [2]. These treatments may also be delivered individually as single- component interventions [11–13], either as substitutes for the multifactorial intervention or as non-mutually exclusive complements [14, 15]. These interactions be- tween screening and treatment components, the multi- factorial risk profile of falls as a geriatric syndrome [16], and the wider environmental risk factors [17, 18] intro- duce substantial complexity to falls prevention [19, 20]. Due to this complexity, community-based falls preven-