Prescribed physical activity. A health economic analysis.

The overall aim of this thesis was to estimate health economic consequences of the four-month primary care program ”Physical Activity on Prescription (PAP)”. Inactivity means a highly increased independent risk factor for public health diseases and morbidity, and is an economic burden to society. Evidence for cost effective interventions aiming at increasing physical activity (PA) level among inactive individuals is limited, why health economic evaluations are an important tool when arranging priorities in health care sector. Promoting PA among inactive individuals within primary health care with a prescription of exercise has shown to be effective in terms of significantly increasing physical activity levels. The Swedish FaR® concept can be seen as a concept for improving physical activity behaviour to meet public health guidelines for a sufficient level of physical activity. The program has been implemented as a concept in Swedish health care, but without a common model nationwide. The present concept of the PAP-program in the south-east health care district of Region Skåne, Sweden was based on an existing program with treatment perspective. Specifically, the aims of the different studies were to analyze costs and consequences of changing PA behaviour from the 4-month PAP-program [paper I], to analyze the willingness to pay (WTP) for health effects of physical activity due to the PAP-program, and examine predictors for the WTP [paper II], to analyze the cost offset of changing the PA behavior and motivation after 1 year [paper III], and to analyze the benefits in terms of quality of life and cost per QALY, respectively [paper IV]. The study was a randomized clinical trial with a 4-month intervention. In all, 528 inactive individuals were randomized to either a high-dose or a low-dose group. The high-dose group consisted in supervised group exercise sessions twice a week during 4 months on a moderate-intense level, education in physical activity, and a motivational counselling. The low-dose group received written information on the possibility to participate in supervised exercise groups once a week on a moderate-intense level in local fitness centres. Results: A cost-consequences analysis (n=242) showed intention-to-treat program average programme costs per participant for the 4 month PAP-program being SEK 6475 for the high-dose group and SEK 3038 for the low-dose group [paper 1]. The largest cost was the individuals’ time cost. PA level improved significantly, with no differences between the groups. In paper II, a WTP-analysis (n=128) showed no significant differences for different health improvements between a high- and a low-dose group, and that WTP for health improvements of physical activity is influenced by a higher education level, income and BMI. Paper III examined cost-minimization and motivation of the programme at a 1 year follow-up (n=178, 95 in the high-dose group and 83 in the low-dose group), with a drop-out rate of 66% in both groups together. The results of a significantly improved PA level in paper II were confirmed in this study. There were no differences in motivation among completers and non-completers of the PAP-program. The cost offset consisted in reduced health care costs and value of lost production due to reduced inactivity, and was equal to 22%. The cost-utility analysis in paper IV of the 178 individuals that returned for the 1-year follow-up showed that the PAP-program is cost-effective, and the cost per QALY, 323,750 SEK and 101,267 SEK for the high- and low-dose group, is considered moderate according to Swedish reference values. A low-dose group was more cost-effective and had larger improvements in QoL than a high-dose group. QoL improved significantly in the low-dose group and in both groups together. Conclusions: The PAP-program showed that it was possible to make inactive individuals more physically active through intervention. Significant improvements in PA behaviour were shown in a one-year follow-up analysis. The results of this program of prescribed exercise showed significant increased QoL one year after intervention in a low-dose group. The best adherence for the PAP-program was found for elderly and those with relatively good baseline health. These individuals constitute the target population for this prescription based exercise program. Identifying the target population for participation in health promoting activity groups like the PAP-program is necessary for adherence, effectiveness and cost-effectiveness of a program. The PAP-program is cost-effective as shown in a cost-utility analysis conducted in the study. The costs per QALY estimates were considered moderate regarding to Swedish comparative values. This makes the program a method worthwhile for society. The program was most cost-effective for a low-dose group. This was showed with lower costs associated with the low-dose group, and larger improvements in QoL. An increased availability of exercise would reduce the individual’s time cost for travelling, and cost for travel. The inactive individual’s preferences for improved health through exercise were influenced by a higher education level, income and BMI. The PAP-program can reduce the society´s costs for inactivity by 22% per individual, every year the individual stays active

Physical activity on prescription (PAP): Costs and consequences of a randomized, controlled trial in primary healthcare.

Abstract Objectives. To analyse costs and consequences of changing physical activity behaviour due to the "Physical Activity on Prescription" (PAP) programme. Design. A randomized controlled trial with a four-month intervention, with comparison between intervention and control group. Intervention. The PAP programme, with exercise twice a week, education, and motivational counselling. Subjects. 525 sedentary individuals, 20-80 years (intervention group n = 268, control group n = 257), with lifestyle-related health problems. A total of 245 returned for the four-month assessment. Main outcome measure. Programme costs based on intention-to-treat estimations, direct and indirect costs of inactivity, and physical activity behaviour analysed with IPAQ (International Physical Activity Questionnaire), self-reported physical activity, and measures of functional capacity. Results. The intention-to-treat programme costs for the four-month programme period was SKr (Swedish Kronor) 6475 (euro [Euro] 684) for the intervention group and SKr 3038 (euro 321) for the control group. Of this, healthcare providers' costs were 24% in the intervention group, and 31% in the control group. The physical activity behaviour was significantly improved in both groups, but no differences were found between the groups. Implications. The largest share of the PAP programme costs was the participants' costs. Significant improvements were shown in physical activity behaviour in both groups, but no differences were found between the intervention and control groups. Due to many non-completers, the potential for improvements of the motivating assignment with sedentary individuals in primary healthcare is obvious. Long-term follow-up can determine the sustainability of the results, and can be used in a future cost-effectiveness analysis

Willingness to pay for health improvements of physical activity on prescription.

AIMS: To estimate the willingness to pay for health improvements among participants in the programme "Physical Activity on Prescription". The objective was also to examine predictors such as income, education level, health status, activity level and BMI, differences for long- and short-term health effects of physical activity and differences between a high- and low-intensity activity group. METHODS: Willingness to pay (WTP) data were collected alongside a randomized, controlled trial in Sweden 2007, and 128 sedentary individuals, 20-80 years old (intervention/high-intensity group n = 71, control/low-intensity group n = 57), with lifestyle-related health problems answered open-ended questions in this contingent valuation study. RESULTS: The highest mean WTP (euro59/SEK 552) was stated for an immediate health improvement, but no significant differences compared with long-term health improvements. The high-intensity group showed higher WTP-values for all health improvements, but without significant differences compared with a low-intensity group. Regression analyses show strong associations between a higher level of education and the WTP for improved well-being and improved health, and also between income and the WTP for improved well-being. There are significant correlations between the WTP and the variables BMI, income and education level, as expected from economic theories. CONCLUSIONS: The willingness to pay for the health improvements of exercise is influenced by a higher education level, income and BMI. The highest WTP for a health outcome of physical activity is for an immediate health improvement. The results of this randomized controlled trial in primary health care may be of interest to decision makers when evaluating different approaches to promoting physical activity among people who are sedentary

Costs and outcomes of an exercise referral programme - A 1-year follow-up study.

Aims: To analyse, at a one year follow up, cost offset and outcomes of changing the physical activity (PA) behaviour due to a primary care intervention. Methodology: Participants were 528 inactive individuals with life-style related health problems, 18-84 years, and randomised into a high-dose intervention group (n=270) or a low-dose intervention group (n=258). The four month lasting intervention “Physical Activity on Prescription” (PAP) contained exercise, education and motivational counselling. At the one year follow up 178 individuals (95 in the high-dose group, 83 in the low-dose group) were assessed with the IPAQ (International Physical Activity Questionnaire) short form, perceived PA and functional ability (Six Minute Walk Test). Motivation and attitudes towards PA were assessed with a questionnaire (Gard et al), and analysed based on factor analysis. Major findings: PA increased significantly, but without differences between high-dose and low-dose groups. The rate of inactive individuals decreased from 75% to 53%. Analysis of motivation showed no differences between the groups. Principal conclusion: The PAP-program significantly improved physical activity behaviour at the one year follow up, and reduced costs for inactivity by 22%. Economic incentives, i.e. expenditures and individuals own valuation of leisure time, seem to influence preferences for participation in the PAP-program. Social-cognitive factors seem important when changing PA behaviour. Prescribed exercise may work pre-motivational for changed physical activity behaviour