The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation.

BACKGROUND: Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. OBJECTIVE: To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. DATA SOURCES: MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. METHODS: Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. RESULTS: Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. LIMITATIONS: We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. CONCLUSIONS: There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis.

OBJECTIVE: To assess the impact of exercise referral schemes on physical activity and health outcomes. Design Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, PsycINFO, Cochrane Library, ISI Web of Science, SPORTDiscus, and ongoing trial registries up to October 2009. We also checked study references. Study selection Design: randomised controlled trials or non-randomised controlled (cluster or individual) studies published in peer review journals. POPULATION: sedentary individuals with or without medical diagnosis. Exercise referral schemes defined as: clear referrals by primary care professionals to third party service providers to increase physical activity or exercise, physical activity or exercise programmes tailored to individuals, and initial assessment and monitoring throughout programmes. Comparators: usual care, no intervention, or alternative exercise referral schemes. RESULTS: Eight randomised controlled trials met the inclusion criteria, comparing exercise referral schemes with usual care (six trials), alternative physical activity intervention (two), and an exercise referral scheme plus a self determination theory intervention (one). Compared with usual care, follow-up data for exercise referral schemes showed an increased number of participants who achieved 90-150 minutes of physical activity of at least moderate intensity per week (pooled relative risk 1.16, 95% confidence intervals 1.03 to 1.30) and a reduced level of depression (pooled standardised mean difference -0.82, -1.28 to -0.35). Evidence of a between group difference in physical activity of moderate or vigorous intensity or in other health outcomes was inconsistent at follow-up. We did not find any difference in outcomes between exercise referral schemes and the other two comparator groups. None of the included trials separately reported outcomes in individuals with specific medical diagnoses. Substantial heterogeneity in the quality and nature of the exercise referral schemes across studies might have contributed to the inconsistency in outcome findings. Conclusions Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.

Neighbourhood deprivation and physical activity in UK older adults.

The benefits of regular physical activity for older adults are now well-established but this group remain the least active sector of the population. In this paper, the association between levels of neighbourhood deprivation and physical activity was assessed. A sample of 125 males with a mean age of 77.5 (±5.6) years, and 115 females with a mean age of age 78.6 (±8.6) underwent 7-day accelerometry, a physical performance battery, and completed a daily journeys log. Univariate associations between physical activity parameters and level of deprivation of neighbourhood were extinguished in regression models controlling for age, gender, and level of educational attainment. Age, gender, educational attainment, body mass index, physical function, and frequency of journeys from the home explained between 50% and 54% of variance in activity parameters. These results suggest the importance of strategies to help older adults maintain physical function, healthy weight, and remain active in their communities.

Television viewing and other screen-based entertainment in relation to multiple socioeconomic status indicators and area deprivation: the Scottish Health Survey 2003.

BACKGROUND: Sedentary behaviour (sitting) is detrimental to health, independently of participation in physical activity. Socioeconomic position (SEP) is known to relate strongly to physical activity participation but we know very little about how SEP relates to sedentary behaviour. This study aimed to assess the relationships between SEP, neighbourhood deprivation and an index of sedentary time. METHODS: Cross-sectional study of a representative sample of 7940 Scottish adults who participated in the 2003 Scottish Health Survey, which collected information on SEP (household income, social class and education), neighbourhood deprivation (Scottish Index of Multiple Deprivation), television and other screen-based entertainment time, and physical activity. RESULTS: The three indicators of SEP and deprivation index were independently of each other associated with daily times of television and other screen-based entertainment, even after adjustment for occupational and leisure-time physical activity, health status, smoking, alcohol drinking, car ownership and body mass index: income p = 0.002; social class p<0.001; education p<0.001, deprivation p<0.001. Also, there was a strong cumulative effect of SEP (a composite scale where 0 = lowest, 9 = highest SEP position) with those in the lowest SEP spending an additional 109 minutes each day on screen-based entertainment compared to those in the highest socioeconomic position (p<0.001 for linear trend). CONCLUSION: Adverse socioeconomic position is associated with a cumulative increase in the time spent on screen-based entertainment. Reducing inequalities would be expected to reduce exposure to sedentary behaviours, such as excessive screen-based entertainment times, and therefore reduce the risk of chronic disease.

Physical activity in older women: associations with area deprivation and with socioeconomic position over the life course: observations in the British Women's Heart and Health Study.

OBJECTIVE: To assess the association between residential area-level deprivation, individual life-course socioeconomic position and adult levels of physical activity in older British women. METHODS: A cross-sectional study of 4286 British women aged 60-79 years at baseline, who were randomly selected from general practitioner lists in 23 British towns between April 1999 and March 2001 (the British Women's Heart and Health Study). RESULTS: All three of childhood socioeconomic position, adult socioeconomic position and area of residence (in adulthood) deprivation were independently (of each other and potential confounders) associated with physical activity. There was a cumulative effect of life-course socioeconomic position on physical activity, with the proportion who undertook no moderate or vigorous activity per week increasing linearly with each additional indicator of life-course socioeconomic position (p<0.001 for linear trend). CONCLUSION: Adverse socioeconomic position across the life-course is associated with an increased cumulative risk of low physical activity in older women. Reducing socioeconomic inequalities across the life course would thus be expected to improve levels of physical activity and the associated health benefits in later life.

The relationship between access and quality of urban green space with population physical activity.

OBJECTIVES: This study examined the association between access to quality urban green space and levels of physical activity. STUDY DESIGN: A cross-sectional examination of the relationship between access to quality urban green space and level of recreational physical activity in 4950 middle-aged (40-70 years) respondents from the European Prospective Investigation into Cancer and Nutrition (EPIC), who resided in Norwich, UK. METHODS: Using geographic information systems (GIS), three measures of access to open green space were calculated based on distance only, distance and size of green space and distance, size and quality of green space. Multiple regression models were used to determine the relationship between the three indicators of access to open green space and level of recreational physical activity. RESULTS: There was no evidence of clear relationships between recreational activity and access to green spaces. Non-significant associations were apparent for all variables, and there was no evidence of a clear trend in regression coefficients across quartiles of access for either the distance, size adjusted, and quality and size-adjusted models. Furthermore, the neighbourhood measures of access to green spaces showed non-significant associations with recreational physical activity. CONCLUSIONS: Access to urban green spaces does not appear to be associated with population levels of recreational physical activity in our sample of middle-aged adults.

Interventions for promoting physical activity.

BACKGROUND: Little is known about the effectiveness of strategies to enable people to achieve an increase in their physical activity. OBJECTIVES: To assess the effects of interventions for promoting physical activity in adults aged 16 years and older, not living in an institution. SEARCH STRATEGY: We searched CENTRAL (Issue 4, 2001), MEDLINE, EMBASE, CINAHL, PsychLIT, BIDS ISI, SPORTDISCUS, SIGLE, SCISEARCH (from earliest date available to December 2001) and reference lists of articles. SELECTION CRITERIA: Randomised, controlled, trials comparing different interventions to encourage sedentary adults not living in an institution to become physically active. Studies required a minimum of six months follow up from the start of the intervention to the collection of final data and either used an intention to treat analysis or, failing that, had no more than 20% loss to follow up. DATA COLLECTION AND ANALYSIS: At least two reviewers independently assessed each study quality and extracted data. Study authors were contacted for additional information where necessary. Standardised mean differences and 95% confidence intervals were calculated for continuous measures of self reported physical activity and cardio-respiratory fitness. For studies with dichotomous outcomes, odds ratios and 95% confidence intervals were calculated. MAIN RESULTS: The effect of interventions on self reported physical activity (11 studies; 3940 participants) was positive and moderate, with a pooled standardised mean difference of 0.31 (95% CI 0.12 to 0.50), as was the effect on cardio-respiratory fitness (7 studies; 1406 participants) pooled SMD 0.4 (95% CI 0.09 to 0.70). The effect of interventions in achieving a predetermined threshold of physical activity (6 studies; 2313 participants) was not significant with an odds ratio of 1.30 (95% CI 0.87 to 1.95). There was significant heterogeneity in the reported effects as well as heterogeneity in characteristics of the interventions. The heterogeneity in reported effects was reduced in higher quality studies, when physical activity was self-directed with some professional guidance and when there was on-going professional support. AUTHORS' CONCLUSIONS: Our review suggests that physical activity interventions have a moderate effect on self reported physical activity and cardio-respiratory fitness, but not on achieving a predetermined level of physical activity. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of the interventions. Future studies should provide greater detail of the components of interventions.

Physical activity and older adults: a review of health benefits and the effectiveness of interventions.

The purpose of this multidisciplinary review paper is to critically review evidence from descriptive, efficacy and effectiveness studies concerned with physical activity and older people. Both levels of fitness (aerobic power, strength, flexibility and functional capability) and measures of physical activity involvement decline with age, and the extent to which this is due to a biological ageing processes or disuse (physical inactivity) is critically examined. The review will consider the evidence for a causal relationship between sedentary behaviour/physical activity programmes and cardiovascular, musculoskeletal and psycho-social health, independent living and health-related quality of life into old age. The review also considers the effectiveness of different physical activity interventions for older people and issues relating to cost-effectiveness. The implications for future policy in terms of research, health care services, and education and training are briefly discussed.

National level promotion of physical activity: results from England's ACTIVE for LIFE campaign.

STUDY OBJECTIVE: To assess the impact of a national campaign on awareness of the campaign, change in knowledge of physical activity recommendations and self reported physical activity. DESIGN: three year prospective longitudinal survey using a multi-stage, cluster random probability design to select participants. SETTING: England. PARTICIPANTS: A nationally representative sample of 3189 adults aged 16-74 years. MAIN OUTCOME MEASURES: Awareness of the advertising element of the campaign, changes in knowledge of physical activity recommendations for health and self reported physical activity. RESULTS: 38% of participants were aware of the main advertising images, assessed six to eight months after the main television advertisement. The proportion of participants knowledgeable about moderate physical activity recommendations increased by 3.0% (95% CI: 1.4%, 4.5%) between waves 1 and 2 and 3.7% (95% CI: 2.1%, 5.3%) between waves 1 and 3. The change in proportion of active people between baseline and waves 1 and 2 was -0.02 (95% CI: -2.0 to +1.7) and between waves 1 and 3 was -9.8 (-7.9 to -11.7). CONCLUSION: The proportion of participants who were knowledgeable about the new recommendations, increased significantly after the campaign. There was however, no significant difference in knowledge by awareness of the main campaign advertisement. There is no evidence that ACTIVE for LIFE improved physical activity, either overall or in any subgroup.

Promoting physical activity: issues in primary health care.

In the past few years, alliances between primary care and leisure services have become a popular strategy for exercise promotion in the England. 'GP Referral Schemes' typically involve referral to a local leisure centre by a General Practitioner (GP), whereupon patients are inducted into a 10-12 week exercise programme at a reduced fee. Referred patients are usually white, middle aged and apparently healthy women, with the main reason for referral being overweight. The schemes are characterised by their lack of formal evaluation, making conclusions about effectiveness impossible. In the US, physicians advice to exercise has been the focus of interventions to date. Two controlled trials, one randomised, have provided some evidence that exercise behaviour can be changed, at least in the short term. The ability to recruit sufficient numbers of patients, who have potentially the most to gain from increased physical activity, is the biggest barrier to primary care based interventions. One contributing factor to this problem, may be doctors and nurses' knowledge about the benefits of physical activity.

Cost-effectiveness of a primary care based physical activity intervention in 45-74 year old men and women: a randomised controlled trial.

OBJECTIVE: To assess the cost-effectiveness of a primary care based intervention aimed at increasing levels of physical activity in inactive people aged 45-74. METHODS: A total of 714 inactive people aged 45-74, taken from two west London general practices, were randomised into two groups. Intervention subjects were invited to a consultation with an exercise development officer, and offered a personalised 10 week programme to increase their level of regular physical activity, combining leisure centre and home based activities. Control subjects were sent information on local leisure centres. All subjects were followed up at eight months. RESULTS: There was a net 10.6% (95% confidence interval 4.5 to 16.9%) reduction in the proportion of people classified as sedentary in the intervention group compared with the control group, eight months after the intervention. The intervention group also reported an increase in the mean number of episodes of physical activity per week, as compared with the control group (an additional 1.52 episodes (95% confidence interval 1.14 to 1.95)). The cost of moving a person out of the sedentary group was shown to be less than 650 Pounds. The cost of moving someone to the now commonly recommended level was estimated at almost 2500 Pounds. CONCLUSIONS: Moderate physical activity can be successfully encouraged in previously sedentary men and women aged 45-74 through a primary care based intervention. The process of recruitment was the most important variable cost. A high uptake rate would maximise cost-effectiveness, and sensitivity analysis suggests that unit costs could be halved with a more effective recruitment strategy.

Obesity management by life-style strategies.

This chapter discusses lifestyle management strategies for obesity in adults and is based on an assumption that treatment, resulting in appropriate and sustained weight loss, is of benefit to individuals. It examines dietary management strategies including the use of very low calorie diets, moderate energy restriction and individual and group approaches in commercial and non-commercial environments. It explores the role of physical activity in the treatment of obesity in particular focusing on the associated health benefits and the increasing evidence of the importance of physical activity in weight maintenance. It discusses the effect of behavioural interventions on achieving and maintaining weight loss and briefly offers suggestions for the organisation of lifestyle interventions.

A systematic review of physical activity promotion strategies.

We have reviewed randomised controlled trials of physical activity promotion to provide recent and reliable information on the effectiveness of physical activity promotion. Computerised databases and references of references were searched. Experts were contacted and asked for information about existing work. Studies assessed were randomised controlled trials of healthy, free living, adult subjects, where exercise behaviour was the dependent variable. Eleven trials were identified. No United Kingdom based studies were found. Interventions that encourage walking and do not require attendance at a facility are most likely to lead to sustainable increases in overall physical activity. Brisk walking has the greatest potential for increasing overall activity levels of a sedentary population and meeting current public health recommendations. The small number of trials limits the strength of any conclusions and highlights the need for more research.

Randomised controlled trials of physical activity promotion in free living populations: a review.

OBJECTIVES: To review evidence on the effectiveness of trials of physical activity promotion in healthy, free living adults. To identify the more effective intervention programmes. METHODS: Computerised databases and references were searched. Experts were contacted and asked for information about existing work. INCLUSION CRITERIA: Randomised controlled trials of healthy, free living adult subjects, where exercise behaviour was the dependent variable were included. CONCLUSIONS: Ten trials were identified. The small number of trials limits the strength of any conclusions and highlights the need for more research. No UK based studies were found. Previously sedentary adults can increase activity levels and sustain them. Promotion of these changes requires personal instruction, continued support, and exercise of moderate intensity which does not depend on attendance at a facility. The exercise should be easily included into an existing lifestyle and should be enjoyable. Walking is the exercise most likely to fulfil these criteria.