For this assignment you will use the Quantitative and the Qualitative article that you submitted for week 4 assignment that we

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: [email protected] 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

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-

tion strategies face significant implementation challenges [21–24]. For example, a recent survey of English GPs found that only 31% routinely screened their older pa- tients for falls history; the median annual number of re- ferrals to falls prevention services per GP was just 10 [25]. Implementation quality can be suboptimal even in RCT settings. For example, the uptake rate for a UK trial of falls prevention exercise was 6% [26]; adherence to different components of multifactorial interventions is as low as 28% [27]; and 16% of participants withdraw from falls prevention exercise at trial conclusion [28]. Low im- plementation reduces the effectiveness and population

reach/impact of falls prevention [20]. Accordingly, NICE CG161 incorporated a systematic synthesis of older peo- ple’s views on the facilitators and barriers to falls preven- tion (covering the period 1990–2003), but found no study that explored their views on multifactorial pack- ages (p. 101) [2]. More recent qualitative works have likewise focused on specific components of the falls pre- vention pathway, including receptiveness to falls preven- tion advice [29], falls risk assessment [30], and exercise uptake [31, 32] and adherence [33]. This is an important evidence gap given that complexity results from the interaction of facilitators and barriers across different pathway components. A more holistic approach to quali- tative research with current or potential falls prevention service users is warranted. Health economic evaluation is a comparative analysis

of alternative healthcare strategies in terms of costs and consequences with the purpose of informing the efficient use of scarce resources under a constrained healthcare budget [34]; it can also incorporate further decisional criteria beyond cost-effectiveness, such as reduction in social inequities of health, according to stakeholder pref- erence [35–37]. One vehicle for economic evaluation is decision modelling that represents the key causal mecha- nisms of a decision problem in mathematical and statis- tical/probabilistic relationships [34]. Decision models are particularly well-suited for considering all relevant costs and effects of interventions over long time horizons, and for evaluating ‘what-if’ scenarios for the full target popu- lation of the decision-making jurisdiction [38]. One such scenario is the commissioning of implementation re- sources to change current local practice into a form ap- proaching the NICE-recommended pathway. A de novo economic model is likely required if the

existing economic models or evidence are insufficient for informing local decision-making: e.g., due to unreal- istic representation of local practice and/or shortcom- ings in characterising the key causal mechanisms. Currently, the decision model developed to inform CG161 [39] evaluates a multifactorial intervention for the national population and may not be locally generalis- able; while the locally applicable Public Health England Return on Investment tool [11] only evaluates single- component interventions. This presents a rationale for developing a de novo model evaluating the cost-

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 2 of 19

effectiveness relative to current practice (and wider deci- sional outcomes) of a strategy that locally implements the NICE-recommended pathway. Qualitative research with current and potential con-

sumers of health services can contribute to economic modelling in two important ways [40, 41]: (a) eliciting appropriate commissioning strategies; and (b) under- standing the key methodological and evaluative chal- lenges to public health economic modelling. Concerning (a), the model-evaluated commissioning

strategy should fully reflect the complex network of intervention-related casual mechanisms influencing im- plementation. Several frameworks exist to capture such complexity [40], including the Context and Implementa- tion of Complex Interventions (CICI) framework [20] which was developed as part of the INTEGRATE-HTA project to consider a comprehensive set of factors influ- encing the assessment of complex health technologies [19]. CICI distinguishes between contextual factors (e.g., socio-cultural, legal) and implementation mechanisms (e.g., professionals, organisations) that shape implemen- tation quality. Priority-setting challenges – e.g., reducing social inequities of health [35] – also arise from the im- plementation context [40]. Given the CICI framework’s lack of focus on demand-side mechanisms (e.g., motiva- tions of the older persons to engage in healthy behaviour [42]), it could be supplemented by the health needs as- sessment (HNA) framework that incorporates demand, supply and need/eligibility as distinct yet overlapping do- mains [43]. Inductive qualitative data analysis could commence with themes sourced from this combined framework, and thereafter interact with new themes emerging from the data to arrive at the final thematic framework informing the commissioning strategies [44, 45]. Concerning (b), the nature of falls being a public

health problem faced by a broad spectrum of older pop- ulations – rather than a clinical problem faced by a well- defined, narrow patient group – presents further com- plexity to model development [41]. According to a sys- tematic methodological review, the key methodological challenges to public health economic modelling include: (i) capturing non-health outcomes and societal interven- tion costs; (ii) considering dynamic complexity in health determinants and intervention need; (iii) considering theories and models of human behaviour based on psychology and sociology; and (iv) considering social de- terminants of health and issues of equity [46]. Address- ing such challenges is part of the INTEGRATE-HTA recommendations (see chapter 3) [19], and is necessary for improving the structural validity of the decision model [41]. The same inductive analysis can identify how these challenges relate to the local decision problem and hence to the decision model structure [41].

In all, a de novo qualitative study of older people is warranted, first to holistically explore the facilitators and barriers for implementing the NICE-recommended falls prevention pathway, and second to proactively use the resulting qualitative data to inform economic modelling. The latter would improve upon the siloed approach that is widely prevalent in the literature, whereby qualitative research is conducted and interpreted separately from economic evaluation, even when both designs are in- cluded in the same project [39, 47, 48].

Aim and objectives The study aims to capture the subjective views of older people on implementing the NICE CG161 guideline on community-based falls prevention and use the qualita- tive data to inform the development of a conceptual falls prevention economic model. The latter would guide commissioning decisions in a local health economy seek- ing to implement CG161, Sheffield being one such set- ting. The research objectives are to:

1. Identify the facilitators and barriers for implementing key components of the CG161 community-based falls prevention pathway – including falls risk screening and assessment, falls risk awareness, and uptake and adherence of treatments within multifactorial inter- vention – and contextual factors influencing the pathway implementation in Sheffield.

2. Inform potential local commissioning strategies on falls prevention by understanding the causal mechanisms in context, supply, need and demand that influence implementation.

3. Identify the methodological and evaluative challenges associated with developing a public health economic model of falls prevention in the local context.

Given the aim of informing a model applicable to a local health economy, the identified qualitative themes would likely be locally specific. Hence, the main target audience (outside of Sheffield) are economic modellers and qualitative researchers (and commissioners sponsor- ing them) interested in applying the methodology used in this case study to other local health economies and public health areas. That said, the facilitators and bar- riers identified under the first objective would be gener- alisable to other urban community settings in England and Wales and hence be of interest to professionals and patient groups seeking to improve the implementation of local falls prevention.

Methods The qualitative research involved focus groups and inter- views with older persons living in the community. The

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 3 of 19

ethics approval was obtained from the Research Ethics Committee at the School of Health and Related Re- search, University of Sheffield (ref. 025248). Written consent was obtained from willing participants.

Target population and sampling The target population comprised persons aged 65+ in Sheffield, England, and persons aged 50–64 who are at high falls risk. The latter group was included to explore the rationale for earlier prevention as is currently recom- mended for inpatient settings by CG161 [2]. Purposive sampling covered multiple categories of participant char- acteristics in terms of falls risk and service use as illus- trated in Fig. 1. According to CG161, those with a history of fall(s) re-

quiring medical attention or recurrent falls in the past year and/or mobility and balance problems were defined as high-risk [2]. Low-risk individuals were sampled be- cause they are still eligible for falls risk screening and/or interested in early prevention. Recruitment continued until all participant categories

were covered and themes saturated. Specifically, two focus groups (FG1, FG2) were formed from two separate cohorts enrolled in Dance to Health, a falls prevention programme that combines evidence-based Otago and Falls Management Exercise components in dance rou- tines [49, 50]; these groups contained high and low risk service users. Two further groups (FG3, FG4) were formed from a Patient and Public Involvement group meeting regularly at the Northern General Hospital and a social group meeting at Zest Community, a local social enterprise offering leisure, health and work support ser- vices to diverse age groups; these contained high and

low risk service non-users. Two interview participants were recruited from Dance to Health and Zest Community. Focus groups were held directly before/after the regu-

lar meetings. Community organisation staff confirmed before research commencement whether their members could give informed consent. One participant declared memory problems while another a recent diagnosis of Alzheimer’s disease; but both were regular attendees of community groups and expressed confidence in partici- pating. After obtaining written consents, questionnaires were administered to collect data on demographics, falls history and fear of falling, current physical activity, and contact with falls prevention services. Focus group participants were previously acquainted

from attending the same activity and were comfortable sharing their experiences in the group. The main inter- viewer (JK) introduced himself and his PhD project aim and presented himself as someone wanting to learn from the participants. Participants were motivated to help the interviewer understand their perspective on falls and falls prevention. For interviews, around 15 min were spent for the participants and the interviewer to become acquainted in conversing (at interviewees’ homes) before the research commenced.

Discussion topics The main discussion topics were structured around the sequential steps of the proactive prevention pathway rec- ommended by CG161 [2], namely: (i) falls risk screening/ assessment by professionals; (ii) participant suggestions on raising falls risk awareness in the community; (iii) initial uptake of different treatments; and (iv) long-term

Fig. 1 Categories for study participant characteristics

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 4 of 19

adherence to treatments. The pathway is proactive in that it is initiated by professional referral of high-risk individ- uals after falls risk screening. If mentioned by participants, two further pathways were discussed: the reactive pathway – where older persons are referred to falls prevention by professionals after medical attention for a fall, which is also recommended by CG161 (see recommendations 1.1.2.1, 1.1.3.2 and 1.1.6.1) [2]; and the self-referred path- way – where older persons enrol in falls prevention with- out professional referral. A simplified graphical summary of the proactive

pathway, as shown in Fig. 2, was used to explain the main topics to participants. Four treatment types – exercise, HAM, medication change and vision im- provement – were explained while emphasising that other types exist, such as chiropody. It was also highlighted that a reactive pathway after a serious fall is commonly used, and that a self-referred pathway is recommended by experts [51]. Further contextual fac- tors influencing falls risk and prevention (e.g., safety of pedestrian walks in Winter) were actively explored as they emerged during discussion.

Data collection Recorded audio data were transcribed and anonymised. The questionnaire data were similarly transferred to an Excel spreadsheet and anonymised. Both data were stored securely in the University designated folder.

Data analysis A framework analysis was employed for the analysis of obtained data [44, 45]. The approach involved five stages: (a) familiarisation – which involves repeated lis- tening to audio and reading of transcripts for immersion in the data; (b) identifying a thematic framework – which is based on an a priori set of issues related to the research objectives and themes emerging from the data; (c) indexing – which systematically applies the thematic

framework to the transcripts; (d) charting – which ‘lifts’ the data from the transcripts and rearranges them (e.g., in a tabular format) according to the thematic frame- work; and (e) mapping and interpretation – which seeks associations and develops policy-related strategies from the charted data based on a priori issues and emerging themes. Stages (a) to (c) were conducted independently by two authors (JK and YL). All authors contributed to stages (d) and (e). From stage (b) onwards, three frameworks related to

the research objectives were constructed using a priori concepts and themes emerging from the data:

(I) Framework to understand the facilitators and barriers to components of the NICE CG161 falls prevention pathway and cross-component and con- textual factors.

(II) Framework to inform potential commissioning strategies by accounting for causal mechanisms in context, priority setting, need/eligibility, supply and demand.

(III)Framework to understand the key methodological challenges to public health economic model development.

Framework (I): facilitators and barriers and cross- component and contextual factors This framework closely followed the structure of the dis- cussion topics and charted the main themes identified from the data. Facilitators and barriers for the pathway implementation that emerged from the data were ar- ranged by a priori thematic categories corresponding to the NICE CG161 pathway components – i.e., (i) falls risk screening/assessment by professionals; (ii) raising falls risk awareness; (iii) initial uptake of treatments; and (iv) long-term adherence to treatments. Cross-component factors – i.e., facilitators and barriers influencing mul- tiple pathway components – were highlighted.

Fig. 2 Graphical summary of the recommended falls prevention guideline used to introduce the discussion topics to focus group and interview participants

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 5 of 19

Additional contextual factors influencing the pathway implementation were noted as they emerged from the data.

Framework (II): potential commissioning strategies This framework rearranged the main themes under Frame- work (I) into a format that guides commissioning strategies (actual or model-evaluated). An a priori CICI-HNA frame- work was constructed that combined the thematic categor- ies within the CICI [20] and the HNA frameworks [43]. This is illustrated in Fig. A in Supplementary Material with accompanying descriptions. In brief, the CICI framework distinguished between implementation context (e.g., socio- economic, legal) and mechanisms (e.g., provider, funding) [20]. The HNA framework distinguished between supply, demand and need/eligibility [43]: supply corresponded to the CICI implementation mechanisms; demand encom- passed personal and external factors influencing uptake/ad- herence decisions (e.g., health-related motives for healthy behaviour [42], community marketing, self-efficacy promo- tions [52, 53]); need/eligibility was determined by normative clinical and public health guidelines and intervention stud- ies that demonstrated a group’s ability to benefit from an intervention [43]. Further thematic categories that emerged from the data were noted (e.g., priority setting challenges that contextualised commissioning [35]). The mapped themes informed commissioning strategies by highlighting which CICI-HNA factors were modifiable – i.e., lie within the decision space which is defined by the stakeholders in- volved, decision time horizon and budget/capacity con- straints – and to what extent.

Framework (III): challenges for public health economic modelling The thematic categories of key methodological chal- lenges for public health economic modelling were taken from a systematic methodological review [46]: (i) captur- ing non-health outcomes and societal intervention costs; (ii) considering dynamic complexity in health determi- nants and intervention need; (iii) considering theories and models of human behaviour based on psychology and sociology; and (iv) considering social determinants of health and issues of equity. Additional challenges as- sociated with economic modelling and evaluation were also identified from the emerging data.

Results Participant characteristics Twenty-seven persons participated in research across four focus groups (FG1–4) and two interviews (INT1–2) between October 2019 and January 2020. Table 1 sum- marises their characteristics. Regarding current access to falls prevention, 11 re-

ported having spoken to a professional about falls risk.

Nevertheless, 21 reported recent use of services with some falls prevention properties [9], suggesting that the main falls prevention pathway under current practice is self-referral by older persons. Of the 21 users, 13 re- ported accessing multiple interventions. The most widely accessed services were physiotherapy and falls education.

Framework (I): facilitators and barriers and cross- component and contextual factors Table 2 summarises the identified facilitators and bar- riers to implementation by pathway component. The themes are numbered to facilitate re-mapping to later frameworks. Table A in Supplementary Material shows the direct transcript quotes for each theme. Figure B in Supplementary Material graphically illustrates how themes were mapped from qualitative data to Frame- work (I) and subsequently re-mapped to Frameworks (II) and (III).

Falls risk screening and assessment by professionals Factors influencing falls risk screening and assessment by professionals could be divided into three groups: (A) professional competence; (B) system-wide approaches and resources; and (C) motivation and awareness of older persons. Participants were aware of the importance of professional competence in conducting the falls risk screening, particularly incompetence as barriers. For ex- ample, one participant had noticed the narrow scope of professional risk assessment:

(FG1) “I’d think it was important if somebody went to a health professional, the health professional would check on a whole lot of background information apart from immediate health thing – you know, what is your living, housing situation.” (Theme [1–6])

Nevertheless, participants were also aware of the impact of system-level approaches and resources beyond indi- vidual professional competence and made suggestions on improvement. One such suggestion was to adopt a proactive, data-based approach to risk screening akin to mass vaccination:

(FG1) “And with regards to hooking people in, when flu jab time comes up, we all get a text or a message or we get told that we need a flu jab. So, follow that lead, really. I’m sure there’s a record showing age groups and then tell them ‘Look, this service is available. Come on in!’” (Theme [1, 2])

Moreover, a few comments suggested that older person’s motivation to maintain health would facilitate profes- sional efforts to discuss falls risk and prevention:

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Table 1 Summary of participant characteristics Field Variable N (%)

Demographics Sex Female 20 (74)

Male 7 (26)

Age < 60 5 (19)

60–64 1 (4)

65–69 5 (19)

70–74 5 (19)

75–79 7 (26)

80–84 2 (7)

85–89 1 (4)

> = 90 1 (4)

Fall history and fear of falling Experienced fall in previous year Yes 14 (52)

No 13 (48)

Number of falls in previous year 0 13 (48)

1 6 (22)

2 4 (15)

3+ 4 (15)

Whether fall(s) required medical attentiona (% among fallers) Yes 8 (57)

No 6 (43)

Fall resulted in fracture (% among fallers) Yes 3 (21)

How worried are you about falling while walking or balancing? 1 Never 4 (15)

2 Hardly 5 (19)

3 Sometimes 11 (41)

4 Often 4 (15)

5 All the time 3 (11)

Current physical activity level Currently engaged in some exercise group/activityb Yes 19 (70)

No 8 (30)

History of falls risk screening Whether spoken to a GP or other professionals about risk of falling in previous year Yes 11 (41)

No 16 (59)

If yes, where was it? (% among Yes for previous question) GP 5 (45)

Social care 0 (0)

Falls clinic 3 (27)

A&E 0 (0)

Hospital 2 (18)

Other 1 (9)

Falls prevention service use in past year Type of falls prevention service usec Physiotherapy 12

Occupational therapy 1

HAM 4

Medication change 0

Vision surgery 5

Vit D supplement 6

Assistive device 7

Footwear change 6

Falls education 12

Acronym: HAM home assessment and modification a At least GP visit b Suggested options were Chairobics, Pilates, dancing, swimming and group walks with additional space for participants to state other exercise/physical activity types c The list of services was taken from …

strength and balance were collected to measure changes in physical outcomes, and participants completed questionnaires and interviews to assess program acceptability. Ninety-eight participants (mean age=64, 71% women) registered for the program; 77 (85%) completed baseline and follow-up meas- urements. Positive ongoing feedback was received, and attend- ance was good. On average across all sites, there was significant improvement in participant leg strength (time to complete 5 repetition sit-to-stand: 14 s to 11 s, p<0.01), bal- ance (timed single-leg stance: 5.6 s to 7.8 s, p<0.01) and gait speed (timed 4 meter walk: 0.51 m/s to 0.94 m/s, p<0.01), and a significant decrease in BMI (p<0.01). Participants reported both the exercise and yarning comp

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