Cost-effectiveness of Occupational Therapy in Older People: Systematic Review of Randomized Controlled Trials

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1 RESEARCH ARTICLE Cost-effectiveness of Occupational Therapy in Older People: Systematic Review of Randomized Controlled Trials Hirofumi Nagayama 1,4 *, Kounosuke Tomori 1, Kanta Ohno 2, Kayoko Takahashi 3 & Keita Yamauchi 4 1 Department of Occupational Therapy, Kanagawa University of Human Services, Kanagawa, Japan 2 Graduate Course of Health and Social Services, Kanagawa University of Human Services, Kanagawa, Japan 3 School of Allied Health, Department of Occupational Therapy, Kitasato University, Kanagawa, Japan 4 Graduate School of Health Management, Keio University, Kanagawa, Japan Abstract A systematic review of the cost-effectiveness of occupational therapy for older people was conducted. MEDLINE, CINAHL, Web of Science, PsycINFO, Cochrane Library, OT seeker and unpublished trials registers were searched. Reference lists of all potentially eligible studies were searched with no language restrictions. We included trial-based full economic evaluations that considered both costs and outcomes in occupational therapy for older people compared with standard care (i.e. other therapy) or no intervention. We reviewed each trial for methodological quality using the Cochrane risk of bias tool and assessed the quality of economic evaluations using a Drummond checklist. In the results of this review, we included five eligible studies (1 5) that were randomized controlled trials with highquality economic evaluation. Two studies were full economic evaluations of interventions for fall prevention (1 and 2); two studies were full economic evaluations of preventive occupational therapy interventions (3 and 4; one was a comparison of an occupational therapy group with a social work group); one study was a full economic evaluation of occupational therapy for individuals with dementia (5). Two of the studies (one was preventive occupational therapy [3] and the other was occupational therapy for dementia [5]) found a significant effect and confirmed the costeffectiveness of occupational therapy for older people compared with the control group. These studies found that occupational therapy for older people was clinically effective and cost-effective in comparison with standard care or other therapies. With reference to their clinical implication, these intervention studies (using a client-centred approach) suggested potentially cost-effective means to motivate clients to maintain their own health. However, this review has limitations because of the high heterogeneity of the reviewed studies on full economic evaluations of occupational therapy for older people. Future studies on the cost-effectiveness of occupational therapy in older people are strongly warranted. Copyright 2015 John Wiley & Sons, Ltd. Received 28 December 2014; Revised 26 July 2015; Accepted 27 July 2015 Keywords older people; cost-effectiveness of occupational therapy; systematic review *Correspondence Hirofumi Nagayama, Department of Occupational Therapy, Kanagawa University of Human Services, Heiseicho, Yokosuka, Kanagawa, , Japan. hirofuminagayama@gmail.com Published online 18 September 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: /oti.1408 Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd. 103

2 Cost-effectiveness of Occupational Therapy Nagayama et al. Introduction Life expectancy increased by approximately 30 years in the 20th century in the United States, Canada, Australia and New Zealand with even larger gains in Japan and some western European countries, such as Spain and Italy (Christensen et al., 2009). However, the growing population of older people, including those who need care, and increases in medical costs for older people present a major problem in developed countries (Christensen et al., 2009; Tamiya et al., 2011). In Japan, older people account for 55.6% of overall healthcare costs (Ministry of Health Labour and Welfare, 2011). In Canada, they account for approximately 44% of healthcare costs (Wister and Speechley, 2015). Tamiya et al. (2011) reported that sustaining Japan s economy and supporting an increasing number of older people present several challenges, including providing good medical care at a reasonable cost and ensuring that older people weakened by physical or mental disabilities have a good quality of life (QOL). A previous systematic review reported that occupational therapy for older adults was effective in enhancing functional ability, social participation and QOL. Voigt-Radloff et al. assessed occupational therapy randomized controlled trials (RCTs) of older people with and without diseases or disability in a series of studies published between 2004 and 2012 (2013). Occupational therapy was found to be effective in the cases of stroke (Steultjens et al., 2003; Legg et al., 2007), mobility and falling (Voigt-Radloff et al., 2013), dementia (Carlson et al., 1996; Kim et al., 2012) and maintaining activities of daily living (ADL) and improving the QOL of older people (Steultjens et al., 2004). Legg et al. (2007) reported that occupational therapy delivered to patients following a stroke, when aimed at personal ADL, increased performance scores (standardized mean difference 0.18, 95% confidence interval (CI): 0.04 to 0.32, p = 0.01) and reduced the risk of poor outcome (death, deterioration or dependency in personal ADL; odds ratio 0.67, 95% CI: 0.51 to 0.87, p = 0.003). Kim et al. (2012) reported that occupational therapy for dementia was effective in improving behavioural problems (standardized mean difference 0.32; 95% CI: 0.04 to 0.59). Steultjens et al. (2004) reported that occupational therapy for community-dwelling older people resulted in positive outcomes for functional ability (ex. ADL). There is some evidence for occupational therapy s efficacy in skills training combined with the instruction in the use of assistive devices, when combined with a home hazard assessment, in decreasing the incidence of falls in high-risk older people. There is also evidence that comprehensive occupational therapy has benefits for functional ability, social participation and QOL (Steultjens et al., 2004). There is insufficient empirical for the efficacy of counselling the primary caregivers of dementia patients regarding the patient s functional abilities (Steultjens et al., 2004). Occupational therapy effects in an older population have been reviewed previously; however, none of these reviews have addressed the economic evaluations of occupational therapy. There is significant evidence to support the role of occupational interventions in improving ADL (Walker et al., 2004; Legg et al., 2007), outdoor mobility (Logan et al., 2004) and leisure activities (Parker et al., 2001). This may reduce healthcare costs through improved independence in the older population, which may result in lower costs of informal care, delayed admission to nursing homes and lower costs of other healthcare and social services (e.g. costs for day care, home care or meals on wheels; Graff et al., 2008). It is necessary to not only investigate occupational therapy effectiveness but also investigate costeffectiveness. Health economics studies are defined as full economic evaluation studies, partial economic evaluation studies and single effectiveness studies that include more limited information relating to the description, measurement or valuation of resource use associated with interventions (Higgins and Green, 2011b). A full economic evaluation comprises a comparative analysis of alternative courses of action in terms of both costs (resource use) and consequences (outcomes and effects; Drummond et al., 2005b). Usually, full economic evaluation studies are performed alongside RCTs to examine the clinical effect or efficacy. Full economic evaluation studies aim to describe, measure and value all relevant alternative courses of action (e.g. intervention X vs. comparative condition Y), their resource inputs and consequences (Higgins and Green, 2011b). Other types of studies assessing healthcare resources do not make explicit comparisons between alternative interventions in terms of both costs (resource use) and consequences (effects; Higgins and Green, 2011b). We wanted to investigate whether occupational therapy for older 104 Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd.

3 Nagayama et al. Cost-effectiveness of Occupational Therapy people is more cost-effective than other therapies; therefore, we targeted the full economic evaluation studies. We hypothesized that occupational therapy may increase functional ability and QOL while reducing healthcare costs through improved independence in the older people when compared with other types of therapy (standard care or no intervention). Therefore, we conducted a systematic review of the literature on the cost-effectiveness of occupational therapy for older people. Methods We conducted a systematic review focused on determining the cost-effectiveness of occupational therapy for older people. A systematic review attempts to collate all empirical evidence that fits pre-specified eligibility criteria in order to answer a specific research question. We used explicit, systematic methods selected to minimize bias, thus providing more reliable findings from which conclusions can be drawn and decisions can be made (Higgins and Green, 2011b). We performed this systematic review protocol according to the guidelines of the preferred reporting items for systematic reviews and meta-analyses: PRISMA statement (Liberati et al., 2009). This systematic review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews ( uk/prospero; PROSPERO2013: CRD ). Data extraction MEDLINE, CINAHL, Web of Science, PsycINFO, Cochrane Library and OT seeker databases were searched. We also searched unpublished trials registered on the ClinicalTrials.gov and the University Hospital Medical Information Network Clinical Trials Registries. Reference lists of all potentially eligible studies were also searched. Publication data ranged up to 13 January 2014, and no language restrictions were applied. Independently extracted data using a search strategy form were developed for this review (Appendix A). The study eligibility based on study titles and abstracts were assessed. Types of studies included Study inclusion and exclusion methodologies are shown in Table I. Our review assessed peer-reviewed academic papers describing RCTs and cluster RCTs that had conducted a full economic evaluation of occupational therapy for older people. Participants were over the age of 60 years; we had no restrictions for disease and disability. Systematic literature reviews, study protocols, conference proceedings and commentary papers were omitted as well as studies that compared two types of occupational therapy, modelbased economic evaluations (lacking a comparison group), research that solely calculated cost data (cost analysis) or effect data and studies that did not calculate total cost (e.g. only intervention cost). Occupational therapy intervention Individual and group types of occupational therapy interventions, which targeted physical, sensory, psychological and cognitive function, ADL, environment, use of assistive devices and primary caregiver counselling were included. These interventions were based on the International Classification of Functioning, Disability and Health (Who, 2001), which has been employed in other occupational therapy reviews. No limit was set regarding intervention duration or follow-up period. Outcomes The primary outcomes of this review were total medical or care costs, functional status (i.e. functional independence as a measure or the fall ratio), social participation and QOL. Costs were measured by examining total medical costs incurred during both intervention and follow-up. An incremental costeffectiveness ratio was calculated when homogeneous and complete data were reported for costs and for either functional status or QOL. When dealing with reported total costs and the increment costeffectiveness ratio (ICER), we converted UK pounds using average currency conversion rates ( hmrc.gov.uk/exrate) for the final year of data collection in each study. We calculated costs in 2014 using an inflation rate of 2% per annum. Functional status and social participation were measured by the following ADL indices: the Barthel index (Mahoney and Barthel, 1965), functional independent measure (Granger et al., 1986), Frenchay activity index (Schuling et al., 1993) and assessment of motor and process skills (Fisher, 1997). QOL was measured using Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd. 105

4 Cost-effectiveness of Occupational Therapy Nagayama et al. Table I. Criteria for review inclusion and exclusion of studies Inclusion criteria Exclusion criteria Publication type Research paper Systematic review, study protocol, conference proceeding, commentary paper Study design Randomized control trial (RCT) and cluster Not RCT randomized control trial Participant age 60 (We included the studies whose 60< participants were older than 60 years) Intervention type Occupational therapy (including improved sensory-motor function, psychological function, cognitive function, activities of daily living, environment training, instruction regarding the use of assistive devices and counselling of primary caregiver) Not occupational therapy Comparison group Outcome Economic evaluation type At least one comparison group, either standard care/other intervention/no intervention (not occupational therapy) The primary outcomes of this review were functional status (i.e. functional independence measure or fall ratio), social participation or quality of life and cost. Costs were measured as total medical cost and care cost for the direct and indirect costs incurred during both intervention and follow-up. An incremental cost-effectiveness ratio was calculated when homogeneous and complete data were reported for costs and for either functional status or quality of life. Cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis No control group, two types of occupational therapy Only cost data or only effect data Did not calculate total cost (e.g., only intervention cost) Did not report means and standard deviations, 95% confidence intervals or standard errors of the total cost mean Cost-analysis study Model-based economic evaluations the WHO QOL-26 (Saxena and Orley, 1997), Medical Outcomes Study 36-Item Short-Form Health Survey (Ware and Sherbourne, 1992) and Euro QOL (EuroQOL, 1990). Risk of bias assessment and economic evaluation The Cochrane risk of bias assessment tool (Higgins et al., 2011a) was applied to the method of randomization, sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective outcome reporting and other potential sources of bias. After discussions to resolve disagreements, a consensus score was arrived at for each element in each trial. Studies were critically appraised using economic evaluations of healthcare programmes (for methodology, please refer to the checklist in Drummond et al., 2005a; Drummond et al., 2005b). This checklist consisted of 10 questions for critically appraising studies of economic evaluation of healthcare programmes. Cost-effectiveness analysis We examined the cost-effectiveness using permutation matrices (Figure 1; Nixon et al., 2001). In this review, for the incremental effectiveness, we determined whether there was a significant difference (p < 0.01) in the outcome (functional status or QOL) of each study. With regard to incremental cost, we decided that significant differences corresponded to an effect size of 0.40 or more and that 95% CI did not include the value of zero in the total cost of each study. Therefore, it is with cell of a, d and g when outcome is significantly high in occupational therapy group, and it is with cell of a, b and c when total cost is significantly high in occupational therapy group. For example, in the results 106 Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd.

5 Nagayama et al. Cost-effectiveness of Occupational Therapy Figure 1. Permutation matrix for possible outcomes of economic evaluations for trials of occupational therapy versus control group (Nixon et al., 2001) of inclusion study, if occupational therapy has better outcome and lower costs, it is in cell of g (a certain decision is strongly favoured). If occupational therapy has better outcome and same costs, it is in cell of d (a decision is less favoured; Nixon et al., 2001). Results Study selection We selected the studies in accordance with the criteria mentioned in Table I. A flow diagram depicting study selection is shown in Figure 2. Initially, we found 437 individual studies, all in English. We filtered this down to 45 studies, excluding 302 studies that clearly failed to meet criteria based on the titles and abstracts, as well as 64 duplicates. We then read the full text and investigated the content of the selected 45 studies, excluding 40: 12 were about employing occupational therapy as an intervention, seven did not perform the appropriate economic evaluations (three studies reported only the occupational therapy effects and four studies did not calculate total cost), eight compared two types of occupational therapy, four did not report the standard deviation of the total medical cost, three were study protocols, two were systematic reviews, two were not RCTs, one was a commentary and another included young participants (age < 60 years; Appendix B). Thus, we included five studies that were eligible for the qualitative synthesis (Hendriks et al., 2008 [1]; Irvine et al., 2010 [2]; Hay et al., 2002 [3]; Flood et al., 2005 [4]; and Graff et al., 2008 [5]). A list of the included studies attributes is shown in Tables II and III. Participants of all studies were community-dwelling older people (age 60 years). Risk of bias and quality of economic evaluation Two authors independently assessed the risk of bias for all five studies (Table IV). Most items exhibited low risks and were well designed. Blinding of participants was or at high risk of bias in four studies; this, however, is inevitable in certain behaviourally based interventions in areas such as psychotherapy, physiotherapy and occupational therapy (Polgar and Thomas, 2013). All trials reported the results of a costeffectiveness analysis or cost-utility analysis, or both, and achieved at least 50% yes scores for applicable criteria on the Drummond checklist for quality of economic evaluations (Table V). The five included studies were well-designed RCTs and high-quality economic evaluations. However, publication bias is likely because only five studies were found for this review. Study synthesis We classified three subgroups by the type of participant and type of occupational therapy intervention. Two studies were full economic evaluations of interventions for fall prevention (1 and 2); two studies were full economic evaluations of preventive occupational therapy interventions (3 and 4; one was a comparison of an occupational therapy group with a social work group), and one study was a full economic evaluation of occupational therapy for dementia patients (5). Two studies evaluated the clinical effectiveness and cost-effectiveness of occupational therapy interventions for fall prevention (Hendriks et al., 2008 [1]; Irvine et al., 2010 [2]). Participants were older people who had heightened risks of falling. The occupational Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd. 107

6 Cost-effectiveness of Occupational Therapy Nagayama et al. Figure 2. Flow diagram of study selection therapy intervention group received recommendations regarding adaptations to the home environment, assistive devices and was referred to home care; the therapy was delivered by social and community services (Table II). The control group received leaflets on fall prevention or primary care. There were no significant differences between the groups in fall rate, ADL and QOL (Table III). Hendriks et al. (1) reported the total costs incurred by the occupational therapy and control groups. In inflation-adjusted terms, total costs were 3956 and 4066, respectively, and ICER was 7571/quality-adjusted life years (QALY; occupational therapy group vs. control group; Table III). Similarly, Irvine et al. (2) reported total costs incurred by the occupational therapy and control groups, which were adjusted for inflation; the costs were 2422 and 1796, respectively, and was 3594/fall averted (occupational therapy group vs. control group; Table III). Two studies evaluated the clinical effectiveness and cost-effectiveness of a preventive occupational therapy intervention (Hay et al., 2002 [3]; Flood et al., 2005 [4]). Participants were older people living independently in the community (Table II). Hay et al. (3) reported a significantly improved QOL in the occupational therapy group compared with controls and concluded that occupational therapy was more cost-effective for older people than the control treatment (Table III). The total costs for the occupational therapy and control groups, in inflation-adjusted terms, was 3866 and 4867, respectively; the ICER was 9949/QALY (means for occupational therapy 108 Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd.

7 Nagayama et al. Cost-effectiveness of Occupational Therapy Table II. Summary of included studies Country n Participants and setting Intervention Fall prevention 1: Hendriks et al. (2008) The Netherlands 333 Had visited the accident and emergency department or general practitioner for consequences of a fall, 65 years old, living in the community Medical and occupational therapy assessments that aimed to assess and address potential risk factors for falls. 2: Irvine et al. (2010) UK 364 High risk of falls for people 70 years old, living in the community Falls prevention information leaflet and day hospital-based falls prevention programme with medical and nursing assessment, occupational therapy (home hazard reduction) and physiotherapy (mobility training) Preventive occupational therapy 3: Hay et al. (2002) United States 361 Independently living older persons, >60 years old, in two governmentsubsidized apartment complexes Occupational therapy group, which focused on enabling the subjects to implement healthful lifestyle changes as part of their daily routines 4: Flood et al. (2005) UK 321 Frail older persons, >65 years old, living in own homes Occupational therapy assessment, undertaken in older person s home Comparison group Outcome Primary care The number of people sustaining a fall during 1 year of follow-up Falls prevention information leaflet Frenchay activity index EuroQol (EQ-5D) Quality-adjusted life years (QALYs) Rate of self-reported falls per year Active control group: a generalized social activity programme administered by non-professionals Passive control group: non-treatment RAND 36-item Short Form Health Survey Functional Status Questionnaire Life Satisfaction Index-Z QALYs Social work group: social work assessment, often undertaken by telephone Community Dependency Index EQ-5D QALYs Economic evaluation type Cost data and view point Duration CUA Programme costs, healthcare costs, patient and family costs. Viewpoint of society. Intervention: 3.5 months Follow-up: 12 months CEA Programme costs, screening costs, health service costs. Viewpoint of the National Health Service and personal social services Intervention and follow-up: 12 months CUA Programme costs, healthcare costs, caregiver costs. Viewpoint of society. Intervention: 9 months Follow-up: 15 months CUA Occupational therapy cost, other National Health Service and local authority costs and private costs. Viewpoint of health services and patients. Intervention and follow-up: 8 months (Continues) Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd. 109

8 Cost-effectiveness of Occupational Therapy Nagayama et al. Table II. (Continued) Cost data and view point Duration Economic evaluation type Comparison group Outcome Participants and setting Intervention Country n Intervention: 3 months CEA Total intervention cost, direct costs inside and outside the healthcare service and indirect costs outside the healthcare service. Viewpoint of society. Primary care Assessment of motor and process skills Performance Scale of the Interview of Deterioration in Daily Activities in Dementia Sense of Competence questionnaire (caregiver) Experienced occupational therapists who had been trained (80 hours) and were experienced (at least 240 hours) in delivering treatment according to the client-centred occupational therapy guidelines for patients with dementia 135 Diagnosed with mild to moderate dementia, 65 years old, living in the community The Netherlands Dementia 5: Graff et al. (2008) CEA, cost-effectiveness analysis; CUA, cost-utility analysis. group vs. active control group and no intervention group). Flood et al. (4) reported no significant differences between occupational therapy and control groups (Table III). Total costs incurred by occupational therapy and control groups were 5665 and 4964, respectively, and the ICER was 18,110/QALY (occupational therapy group vs. control group; Table III). One study evaluated the clinical effectiveness and cost-effectiveness of an occupational therapy intervention for dementia (Graff et al., 2008 [5]). Participants were community-dwelling older people diagnosed with mild to moderate dementia (Table II). In this study, improvement of patients daily functioning and caregivers sense of competence was more significant in the occupational therapy group, and researchers concluded that occupational therapy was more costeffective for older people compared with the control treatment (Table III). The total costs incurred by the occupational therapy and control groups were 10,234 and 11,658, respectively. Cost-effectiveness of occupational therapy interventions Two studies (3 and 5) showed a significant effect of occupational therapy and noted that it was more costeffective for older people than the control treatment (Table III and Figure 3). In the study conducted by Hay et al. (2002; 3), preventive occupational therapy targeted communitydwelling independent older people who received 2 hours of therapy weekly during the 9-month intervention period. This intervention protocol is called lifestyle re-design (Clark et al., 1997; Jackson et al., 1998). The programme is based on the occupational science philosophical background (Jackson et al., 1998). The central theme of the intervention protocol was becoming healthy through one s occupation (Clark et al., 1997); here, occupation is defined broadly as regularly performed activities. The intent of the treatment was to help participants better appreciate the importance of meaningful activities in their lives and to educate them in the specific knowledge regarding ways to select or perform activities so as to achieve a healthy and satisfying lifestyle (Clark et al., 1997). The therapeutic approach entailed exposing participants to didactic teaching and direct experience with a broad range of activities. Concurrent with this exposure, each participant was asked to analyse the 110 Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd.

9 Nagayama et al. Cost-effectiveness of Occupational Therapy Table III. Summary of effects and costs Study (country) Outcomes Intervention cost/participant Total cost/participant (SD) Incremental costeffectiveness ratio (ICER) Total cost/participant ( ; inflate costs to 2014 values using an inflation rate of 2% per annum) ICER ( ; inflate costs to 2014 values using an inflation rate of 2% per annum) Fall preventive 1: Hendriks et al. Number of persons sustaining a fall I: 385 I: 4857 (4470) 9293/QALY I: /QALY (2008; The Netherlands) I: 55% (22%) C: 0 C: 4991 (6835) C: 4066 C: 61% (24%) Frenchay activity index I: 25.6 (7.9) C: 24.5 (9.1) EuroQol-5D I: 0.70 (0.25) C: 0.71 (0.28) 2: Irvine et al. (2010; UK) Fall rate per parson-year I: 349 I: 2238 (4957) 3320/fall averted I: /fall averted I:2.07% C: 0 C: 1659 (5100) C: 1796 C:2.24% Preventive 3: Hay et al. HUI-adjusted follow-up* I: $548 I: $4145 (10,801) AC: $13,784/QALY I: 3866 AC: 12,857/QALY (2002; United States) I: 80.8(1.3) AC: $144 AC:$3978 (5949) C: $7820/QALY AC: 3690 C: 7294/QALY C(AC and C): 76.1(0.7) C: $0 C:$6278 (11,803) AC and C: $10,666/QALY C: 5855 AC and C: 9949/ AC and C: 5218 (9588) AC and C: 4867 QALY 4: Flood et al. (2005; UK) EuroQol-5D and life expectancy data I: 183 I: 4379 (4173) 14,000/QALY I: ,110/QALY I: 0.33 C: 82 C: 3837 (4736) C: 4964 C: 0.38 EuroQol-5D not including life expectancy data I: 0.05 C: 0.06 Dementia 5: Graff et al. (2008; the Netherlands) AMPS-process * I: 1183 I: 12,563 (4470) Not reported I: 10,234 Not reported I:1.2 (0.8) C: 0 C: 14,311 (7833) C: 11,658 C:0.0 (0.7) Competence (SCQ)* I:107.3 (13.6) C:89.4 (14.4) *Significant effects (occupational therapy vs. control) p < ADL, activities of daily living; QOL, quality of life; FAI, Frenchay activity index; AMPS, assessment of motor and process skills; SCQ, Sense of Competence Questionnaire; I, intervention group (occupational therapy); AC, active control group (social activity group); C, control group (no treatment or other therapy). Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd. 111

10 Cost-effectiveness of Occupational Therapy Nagayama et al. Table IV. Risk of bias in clinical trial 1: Hendriks et al. (2008) 2: Irvine et al. (2010) 3: Hay et al. (2002) 4: Flood et al. (2005) 5: Graff et al. (2008) Random sequence generation Low risk Low risk Low risk Low risk Low risk Allocation concealment Low risk Low risk Unclear risk Low risk Low risk Blinding of participants and researchers Unclear risk Unclear risk Low risk Unclear risk High risk Blinding of outcome assessment Low risk Low risk Low risk Low risk Low risk Incomplete outcome data Unclear risk Low risk Low risk Low risk Low risk Selective reporting Low risk Low risk Low risk Low risk Low risk Table V. Quality of economic evaluation 1: Hendriks et al. (2008) 2: Irvine et al. (2010) 3: Hay et al. (2002) 4: Flood et al. (2005) 5: Graff et al. (2008) 1. Was a well-defined question posed in answerable form? 2. Was a comprehensive description of the competing alternatives given? 3. Was the effectiveness of the programmes or services established? 4. Were all the important and relevant costs and consequences for each alternative identified? 5. Were costs and consequences measured accurately in appropriate physical units? 6. Were costs and consequences valued credibly? 7. Were costs and consequences adjusted for differential timing? 8. Was an incremental analysis of costs and consequences of alternatives performed? 9. Was allowance made for uncertainty in the estimates of costs and consequences? 10. Did the presentation and discussion of study results include all issues of concern to users? Yes Yes Yes Yes Yes Yes Yes Yes No Yes Not sure a Not sure a Yes No c Yes No b No b No b No b No b Yes Yes Yes Yes Yes Yes Yes Yes No d Yes Not applicable e Not applicable f Yes Not applicable f Not applicable f Yes Yes Yes Yes Not applicable g Yes Yes No h Yes Yes Yes Yes Yes Yes Yes a Previous randomized controlled trials suggested effectiveness, but this study was not effective. b Capital costs were not included. c No effectiveness comparing social work with occupational therapy. d No estimate made of additional costs of the time of volunteer careers. e Recruitment period was 14 months and the follow-up period was relatively short (12 months). f Study period did not exceed 1 year. g Not reported in this study. h Sensitivity analysis was not employed. effects of each activity on their health and well-being (Hay et al., 2002). All occupational therapists that performed this intervention underwent 2 weeks of preliminary training in the treatment protocol before administering treatment (Clark et al., 1997; Hay et al., 2002). In the study conducted by Graff et al. (2006, 2008) (5), occupational therapy targeted community-dwelling 112 Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd.

11 Nagayama et al. Cost-effectiveness of Occupational Therapy Figure 3. Permutation matrix for possible outcomes of economic evaluations for trials of occupational therapy versus control group dementia patients who received ten 1-hour-long sessions during the 3-month intervention period. In the first four sessions, which focused on diagnostics and goal definition, patients and primary caregivers learned to choose and prioritize meaningful activities that they wanted to improve (Graff et al., 2006). To do so, both patients and primary caregivers used the Canadian occupational performance measure (Mary et al., 1998). The occupational therapist evaluated the possibilities of modifying patients homes and environments and observed patients abilities to perform relevant daily activities and use compensatory and environmental strategies. Compensatory strategies are used to adapt ADLs to the disabilities of patients, and environmental strategies are employed to adapt the patients environments to their cognitive disabilities (Graff et al., 2006). Occupational therapists performing these interventions had been trained for 80 hours prior to beginning the therapy; they also had at least 240 hours of experience in delivering treatment according to the client-centred occupational therapy guideline for patients with dementia. Discussion Summary of the main results This systematic review assessed the cost-effectiveness of occupational therapy interventions for older people. We included five studies, either well-designed RCTs or high-quality economic evaluations. Two studies (3 and 5) showed a significant effect and concluded that occupational therapy was cost-effective for older people compared with control treatments (Table III and Figure 3). Cost-effectiveness of occupational therapy intervention Two studies (3 and 5) showed that occupational therapy is cost-effective. Occupational therapy intervention in these studies conducted client-centred goal setting on a meaningful occupation; additionally, therapists were thoroughly educated in the intervention protocol. From this result in the present systematic review, we hypothesized that client-centred occupational therapy improves problemsolving skills and can motivate clients to maintain their own health. Van Haastregt et al. (2000) conducted a review of preventive home visits and found that tailoring interventions to the needs of the participants may be an important aspect of intervention effectiveness. These intervention methods can potentially promote health self-care and reduce medical costs, which require further study. Comparison with previous systematic reviews We compared the results of previous systematic reviews on the clinical effects of occupational therapy for older people. With regard to findings on fall prevention (Peeters et al., 2007), there is strong evidence that certain exercise programmes may help prevent falls. Both individual home-based and group exercise classes reduce the rate and risk of falling, as do home safety interventions. With regard to preventive occupational therapy, Steultjens et al. (2004) and Voigt-Radloff et al. (2013) concluded that both comprehensive and specific occupational therapy interventions, including skills training and instruction in assistive devices, had positive outcomes on functional abilities in later years. By means Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd. 113

12 Cost-effectiveness of Occupational Therapy Nagayama et al. of a careful analysis of ADL, the occupational therapist adapts skills or activities to the individual demands to improve ADL performance. Their intervention also reflects the client-centred problem-solving attitude of occupational therapy (Steultjens et al., 2004). With regard to systematic reviews and meta-analyses of occupational therapy for patients with dementia, Kim et al. (2012) concluded that an occupational therapy intervention based on sensory stimulation was effective in improving behavioural problems. Our systematic review found that occupational therapy improved patients daily functioning, caregivers sense of competence and decreased total cost (i.e. was cost-effective). Further research is required to clarify the suitability of occupational therapy in patients with dementia. The present systematic review is the first to assess the cost-effectiveness of occupational therapy in older people. This systematic review revealed slightly different results compared with the previous systematic review because this review measured cost-effectiveness, and the previous review did not. However, the intervention mentioned in the previous systematic review indicated that there is potential for cost-effective intervention. Future studies are required to study the cost-effectiveness of occupational therapy in older people. Limitations and future directions Our review had several limitations. The first is the high heterogeneity of the studies that included full economic evaluations of occupational therapy for older people. The research we examined occurred in different countries, with different perspectives, different compared variables, different patient groups, different types of occupational therapy, different durations of therapy and different intervals between end of therapy and final assessment. This is because there are few studies regarding cost-effectiveness analysis of occupational therapy for older people. Greater numbers of occupational therapy RCTs with full economic evaluations would be beneficial to the field. The second limitation was the risk of biases within the studies extracted in this review; in four of five studies, risks associated with blinding of participants and researchers was or high. However, it is inherently difficult to blind both therapist and patient during therapy. Another potential confound is publication bias. In addition to the studies extracted for this review, studies that obtained negative results regarding the cost-effectiveness of occupational therapy for older people may not have been published. The third limitation pertained to our review method: a single person screened the titles found in the initial search. Although it may have been more appropriate to have several screeners, we doubt that this limitation had any significant influence on our results because of our rigorous inclusion criteria. We excluded studies that did not report the total costs of standard deviations, 95% CI or standard errors. We could have included and summarized these excluded studies; however, we believe that the conclusion of this review would not have been changed by doing so. This is the case because in these studies, real cost data were not calculated (only simulation data). We only sought to include studies that assessed the cost-effectiveness of occupational therapy for older people using real cost data. The results of this review indicate a future direction for the study of occupational therapy in older people. First, a full economic evaluation study (cost-effectiveness analysis or cost-utility analysis) should be designed, in conjunction with an effect study. In our field, there are few full economic evaluation studies (in this review, we excluded seven partial economic evaluation studies). Second, as an outcome measure in economic evaluation, QOL may be used to measure the effects of occupational therapy. QOL-based outcomes, particularly QALY, are recommended in global economic evaluation (in this review, three of five studies qualify [1, 3 and 4]). We may derive a value for occupational therapy as compared with other health technologies by using QALY. It is necessary to advance the study of occupational therapy in older people using a healthcare economist. Conclusion This systematic review explored the cost-effectiveness of several occupational therapy interventions for older people. Two studies (3 and 5) found that occupational therapy for older people was clinically effective and cost-effective in comparison with standard care or other therapies. In studies 3 and 5, client-centred goal setting and focusing on a meaningful occupation were revealed as clinical implications. The interventions in these studies suggested that these methods can motivate clients to maintain their own health and that they are potentially cost-effective. Except for these results, there are few studies, and the evidence is weak. Future studies on the cost-effectiveness of occupational therapy in older people are strongly warranted. 114 Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd.

13 Nagayama et al. Cost-effectiveness of Occupational Therapy Conflict of interest No potential conflicts of interest were disclosed. Acknowledgements We would like to show our greatest appreciation to all professors and all students of the Graduate School of Health Management, Keio University, who provided helpful comments and suggestions. Finally, we would like to thank Grant-in-Aid for Young Scientists (B), grant number , for a grant that made it possible to complete this study. Author contributions Study plan and design: H. N., K. T., K. O., K. T., K. Y. Data extraction: H. N., K. T. Assessment of data: H. N., K. T. Drafting of the manuscript: H. N., K. T., K. O. Final revision of the manuscript for important intellectual content: H. N., K. T., K. O., K. T., K. Y. Statistical analysis: H. N. Supervision: K. Y. REFERENCES CarlsonM,FanchiangS-P,ZemkeR,ClarkF(1996).Ametaanalysis of the effectiveness of occupational therapy for older persons. The American Journal of Occupational Therapy 50(2): doi: /ajot Christensen K, Doblhammer G, Rau R, Vaupel JW (2009). Ageing populations: the challenges ahead. Lancet 374 (9696): doi: /s (09) Clark F, Azen SP, Zemke R, Jackson J, Carlson M, Mandel D, Hay J, Josephson K, Cherry B, Hessel C, Palmer J, Lipson L (1997). Occupational therapy for independent-living older adults. A randomized controlled trial. JAMA: The Journal of the American Medical Association 278(16): Drummond M, Manca A, Sculpher M (2005a). Increasing the generalizability of economic evaluations: recommendations for the design, analysis, and reporting of studies. International Journal of Technology Assessment in Health Care 21(2): Drummond MF, Sculpher MJ, Torrance GW, O brien B, Stoddart GL (2005b). Methods for the Economic Evaluation of Health Care Programmes (3rd ed.). Oxford New York: Oxford: Oxford University Press. EuroQol G (1990). EuroQol a new facility for the measurement of health-related quality of life. Health Policy (Amsterdam, Netherlands) 16(3): Fisher AG (1997). Assessment of Motor and Process Skills. Colorado: Three Star Press Fort Collins. Flood C, Mugford M, Stewart S, Harvey I, Poland F, Lloyd-Smith W (2005). Occupational therapy compared with social work assessment for older people. An economic evaluation alongside the CAMELOT randomised controlled trial. Age and ageing 34(1): doi: /ageing/afh232. Graff MJ, Adang EM, Vernooij-Dassen MJ, Dekker J, Jonsson L, Thijssen M, Hoefnagels WH, Rikkert MG (2008). Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study. BMJ 336(7636): doi: /bmj be. Graff MJ, Vernooij-Dassen MJ, Thijssen M, Dekker J, Hoefnagels WH, Rikkert MG (2006). Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. BMJ 333(7580): doi: /bmj be. Granger CV, Hamilton BB, Sherwin FS (1986). Guide for the use of the uniform data set for medical rehabilitation. Uniform data system for medical rehabilitation project office, Buffalo General Hospital, New York. Hay J, Labree L, Luo R, Clark F, Carlson M, Mandel D, Zemke R, Jackson J, Azen SP (2002). Cost-effectiveness of preventive occupational therapy for independentliving older adults. Journal of the American Geriatrics Society 50(8): Hendriks MR, Evers SM, Bleijlevens MH, Van Haastregt JC, Crebolder HF, Van Eijk JT (2008). Cost-effectiveness of a multidisciplinary fall prevention program in community-dwelling elderly people: a randomized controlled trial (ISRCTN ). International journal of technology assessment in health care 24(2): doi: /s Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods G, Cochrane Statistical Methods G (2011a). The Cochrane collaboration s tool for assessing risk of bias in randomised trials. BMJ 343 d5928. doi: /bmj.d5928. Higgins JPT, Green S (eds) (2011b). Cochrane Handbook for Systematic Reviews of Interventions Version [up dated March 2011]. Oxford: The Cochrane Collaboration. Irvine L, Conroy SP, Sach T, Gladman JR, Harwood RH, Kendrick D, Coupland C, Drummond A, Barton G, Masud T (2010). Cost-effectiveness of a day hospital falls prevention programme for screened communitydwelling older people at high risk of falls. Age and ageing 39(6): doi: /ageing/afq1089. Jackson J, Carlson M, Mandel D, Zemke R, Clark F (1998). Occupation in lifestyle redesign: the well elderly study occupational therapy program. The American journal Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd. 115

14 Cost-effectiveness of Occupational Therapy Nagayama et al. of occupational therapy: official publication of the American Occupational Therapy Association 52(5): Kim SY, Yoo EY, Jung MY, Park SH, Park JH (2012). A systematic review of the effects of occupational therapy for persons with dementia: a meta-analysis of randomized controlled trials. NeuroRehabilitation 31(2): doi: /nre Legg L, Drummond A, Leonardi-Bee J, Gladman JR, Corr S, Donkervoort M, Edmans J, Gilbertson L, Jongbloed L, Logan P, Sackley C, Walker M, Langhorne P (2007). Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials. BMJ 335 (7626): 922. doi: /bmj Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. PLoS Medicine 6(7)(e ). doi: / journal.pmed Logan PA, Gladman JR, Avery A, Walker MF, Dyas J, Groom L (2004). Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke. BMJ 329(7479): doi: /bmj f. Mahoney FI, Barthel DW (1965). Functional evaluation: the Barthel index. Maryland State Medical Journal 14: Mary L, Sue B, Anne C, Mary A, Mccoll HP, Nancy P (1998). Canadian Occupational Performance Measurement (COPM) 3rd edn.. Ontario: CAOT Publications ACE. Ministry of Health Labour and Welfare (2011). The general condition of the 2011 national medical expenditure. Retrieved 4 Dec, 2013 from Nixon J, Khan KS, Kleijnen J (2001). Summarising economic evaluations in systematic reviews: a new approach. BMJ 322(7302): doi: / bmj Parker CJ, Gladman JR, Drummond AE, Dewey ME, Lincoln NB, Barer D, Logan PA, Radford KA (2001). A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke. TOTAL study group. Trial of occupational therapy and leisure. Clinical Rehabilitation 15(1): Peeters GM, De Vries OJ, Elders PJ, Pluijm SM, Bouter LM, Lips P (2007). Prevention of fall incidents in patients with a high risk of falling: design of a randomised controlled trial with an economic evaluation of the effect of multidisciplinary transmural care. BMC Geriatrics 7: 15. doi: / Polgar S, Thomas SA (2013). Introduction to Research in the Health Sciences (6th ed.). London: Elsevier Health Sciences. Saxena S, Orley J (1997). Quality of life assessment: the World Health Organization perspective. European Psychiatry 12: Schuling J, De Haan R, Limburg M, Groenier KH (1993). The Frenchay activities index. Assessment of functional status in stroke patients. Stroke; A Journal of Cerebral Circulation 24(8): Steultjens EM, Dekker J, Bouter LM, Jellema S, Bakker EB, Van Den Ende CH (2004). Occupational therapy for community dwelling elderly people: a systematic review. Age and Ageing 33(5): doi: /ageing/ afh174. Steultjens EM, Dekker J, Bouter LM, Van De Nes JC, Cup EH, Van Den Ende CH (2003). Occupational therapy for stroke patients: a systematic review. Stroke; A Journal of Cerebral Circulation 34(3): doi: /01.str Tamiya N, Noguchi H, Nishi A, Reich MR, Ikegami N, Hashimoto H, Shibuya K, Kawachi I, Campbell JC (2011). Population ageing and wellbeing: lessons from Japan s long-term care insurance policy. Lancet 378(9797): doi: /s (11) Van Haastregt JC, Diederiks JP, Van Rossum E, De Witte LP, Crebolder HF (2000). Effects of preventive home visits to elderly people living in the community: systematic review. Bmj 320(7237): doi: /bmj. d5928. Voigt-Radloff S, Ruf G, Vogel A, Van Nes F, Hull M (2013). Occupational therapy for elderly: evidence mapping of randomised controlled trials from Zeitschrift für Gerontologie und Geriatrie. doi: /s Walker MF, Leonardi-Bee J, Bath P, Langhorne P, Dewey M, Corr S, Drummond A, Gilbertson L, Gladman JR, Jongbloed L, Logan P, Parker C (2004). Individual patient data meta-analysis of randomized controlled trials of community occupational therapy for stroke patients. Stroke; A Journal of Cerebral Circulation 35(9): doi: /01.str fb. Ware JE, Jr, Sherbourne CD (1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care: 30(6): Who (2001). International Classification of Functioning, Disability and Health. Geneva, Switzerland: World Health Organisation. Wister AV, Speechley M (2015). Inherent tensions between population aging and healthcare systems: what might the Canadian healthcare system look like in twenty years? Journal of Population Ageing. doi: /s Occup. Ther. Int. 23 (2016) John Wiley & Sons, Ltd.