Sustainable affordability of Otago exercise in the US
A. H. Villamagna
J. W. Yoo
Received: 9 March 2017 /Accepted: 12 April 2017 / Published online: 18 May 2017
International Osteoporosis Foundation and National Osteoporosis Foundation 2017
Mori et al. analyzed the cost-effectiveness of the Otago exer-
cise program in US community-dwelling white elderly wom-
en  and found that at ages 75 and 80, the combination of
bisphosphonates and Otago exercise was more cost effective
in preventing osteoporotic fracture than either strategy alone.
In this letter, we identify areas for further consideration.
In the supplement, authors assumed 42% of women invited
to the exercise program ultimately accepted and participated
. The proportion of individuals accepting the program was
between 21 and 63% in deterministic sensitivity analyses.
However, authors did not discuss potential differences in per-
sistence rates between the trial population and the community,
as there is no data on US community acceptance and persis-
tence rates. There are likely geographic or/and seasonal vari-
ations of acceptance and persistence rates in communities
across the USA that could be considered.
In order to implement the intervention, specifically, partic-
ipation in the Otago exercise program for at least 1 year ,
affordability should also be considered. According to the
National Center for Injury Prevention and Control, the
Otago exercise service can be provided under Medicare Part
A for homebound status or Part B for non-homebound status
. We identified three financial barriers to implement the
Otago exercise in the US healthcare system: (1) necessity of
re-certification of the plan of care by physician or mid-level
practitioner every 90 days; (2) lack of reimbursement for tele-
phone calls from the physical therapist and for the weights
patients need to participate; and (3) potential patient co-
payment burdens. As the Otago exercise was previously stud-
ied in New Zealand and Canada where public insurance is
available, these barriers have not been previously considered
[3–5]. In this study , authors adopted a societal perspective,
which is more suitable to analyze cost-effectiveness.
However, US healthcare policy is more influenced by com-
mercial health insurance companies, so budget impact analy-
sis from healthcare sector perspectives would be informative
to assess affordability of Otago exercise in US healthcare sys-
tem . The second panel recommended to perform analyses
from societal and health care sector perspectives simulta-
neously . The use of an Bimpact inventory,^ which is a
structured table that contains consequences from both inside
and outside the formal health care sector, intended to clarify
the scope and boundaries of the two reference cases (societal
and health care sector) analysis was also recommended .
Finally, uncertainty remains about potential changes to the
Affordable Care Act (ACA) under the Trump administration.
President Trump and congressional Republicans have pledged
to Brepeal and replace^ the ACA . Health savings accounts
and increased state flexibility are new themes in the Trump era
and could lead to changes in the current service provision to
osteoporotic patients . Therefore, cost-effectiveness of the
Otago exercise program in this population has to be tested
again, ideally by two reference case perspectives—the societal
and health care sector perspectives.
Compliance with ethical standards
Conflicts of interest None.
A reply to these comments can be found at doi:10.1007/s00198-017-
* J. W. Yoo
University of Nevada School of Medicine, Reno, Nevada, USA
Department of Internal Medicine, University of Nevada School of
Medicine, 1701 W Charleston Blvd. #230, Las Vegas, NV 89102,
Osteoporos Int (2017) 28:2733–2734