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Prescribed physical activity. A health economic analysis.

Romé, Åsa LU (2014) In Lund University, Faculty of Medicine Doctoral dissertation Series 2014:66.
Abstract (Swedish)
Popular Abstract in Swedish

Det finns övertygande bevis för att fysisk inaktivitet ökar såväl sjuklighet som dödlighet när det gäller flertalet av våra vanligaste folksjukdomar. Inaktivitet är den globalt sett fjärde största riskfaktorn och orsak till förtida död, efter högt blodtryck, tobak och högt blodsocker. Enligt WHO:s beräkningar uppgår antalet dödsfall i världen orsakat av inaktivitet till minst 3,2 miljoner per år. Regelbunden fysisk aktivitet har en odiskutabelt positiv effekt på vår fysiska och mentala hälsa. Inaktivitet innebär en ökad ekonomisk börda för samhället: 2002 i Sverige uppgick samhällets kostnader för den del av befolkningen som var otillräckligt fysiskt aktiv och inaktiv till ca sex miljarder... (More)
Popular Abstract in Swedish

Det finns övertygande bevis för att fysisk inaktivitet ökar såväl sjuklighet som dödlighet när det gäller flertalet av våra vanligaste folksjukdomar. Inaktivitet är den globalt sett fjärde största riskfaktorn och orsak till förtida död, efter högt blodtryck, tobak och högt blodsocker. Enligt WHO:s beräkningar uppgår antalet dödsfall i världen orsakat av inaktivitet till minst 3,2 miljoner per år. Regelbunden fysisk aktivitet har en odiskutabelt positiv effekt på vår fysiska och mentala hälsa. Inaktivitet innebär en ökad ekonomisk börda för samhället: 2002 i Sverige uppgick samhällets kostnader för den del av befolkningen som var otillräckligt fysiskt aktiv och inaktiv till ca sex miljarder kronor, vilket inkluderar kostnader för hälso- och sjukvården samt s.k. indirekta kostnader för produktionsbortfall p.g.a långtidssjukfrånvaro och förtida död. Hittills har vetenskapliga studier visat begränsade belägg för kostnadseffektivitet för program inom hälso- och sjukvården, program med syfte att öka den fysiska aktivitetsnivån bland inaktiva individer. Ekonomiska utvärderingar är ett viktigt redskap då t ex prioriteringar inom hälso- och sjukvården ska genomföras. (Prioriteringar måste göras eftersom våra resurser är begränsade.)

Fysisk aktivitet på recept (FaR®) är en etablerad metod i Sverige för att skriva ett recept på motion. Det är ett koncept med syfte att öka den fysiska aktiviteten hos inaktiva så att den motsvarar de nivåer av fysisk aktivitet som rekommenderas i ett hälsofrämjande perspektiv. Det 4-månaders primärvårds-program (”Fysisk aktivitet på recept / Physical activity on prescription, PAP”) som ligger till grund för denna avhandling genomfördes i sydöstra Skåne under åren 2006-2008, och har sedan utvärderats med främst hälsoekonomiska analysmetoder.

Det övergripande syftet med avhandlingen var att analysera de hälsoekonomiska konsekvenserna av programmet ”Fysisk aktivitet på recept” (FaR). Mer specifikt var syftena med de olika studierna att undersöka hur mycket FaR-programmet kostade, och om man deltagarnas fysiska aktivitetsnivå kunde ökas genom programmet [delstudie I], att undersöka den s.k. betalningsviljan för olika hälsoeffekter av att motionera, och undersöka om det finns vissa faktorer som är associerade till betalningsviljan [delstudie II], att i en 1-års uppföljning se om deltagarna fortfarande var fysiskt aktiva, samt undersöka motivationsnivån hos deltagare som fullföljde resp inte fullföljde programmet [delstudie III]. I den sista delstudien ville vi undersöka om programmet påverkade deltagarnas livskvalitet, samt undersöka om programmet är kostnadseffektivt [delstudie IV].

Studien var en randomiserad klinisk studie, där från början 528 deltagare lottades att tillhöra antingen en hög-dos eller låg-dos grupp, där man tränade olika mycket under en 4-månaders period. Hög-dos gruppen bestod av gruppträning två gånger per vecka, undervisning om nyttan av fysisk aktivitet samt ett motiverande samtal. Låg-dos gruppen fick skriftlig information om möjligheten att delta i gruppträning en gång per vecka.

Resultaten av en kostnads-konsekvens analys [delstudie I] visar att vid en fyra-månaders uppföljning (n=245) är den genomsnittliga kostnaden per deltagare för programmet SEK 6475 för en hög-dos grupp, och SEK 3038 för en låg-dos grupp, och att den största delen av kostnaderna bärs av individen själv. Deltagarnas fysiska aktivitetsnivå ökade signifikant, men utan skillnader mellan grupperna. Studien av betalningsviljan [delstudie II], som genomfördes på de 128 första deltagarna som fullföljde 4-månaders programmet, visade ingen signifikant skillnad i betalningsvilja för olika hälsoförbättringar av FaR mellan de båda grupperna, men att betalningsviljan är associerad till en högre utbildningsnivå, inkomst och BMI. En kostnadsanalys i delstudie III (n=178, bortfall 66%) visar att samhällets kostnader pga minskad inaktivitet minskar med 22%, pga minskade kostnader för hälso- och sjukvården och minskade kostnader för produktionsbortfall. Den signifikanta ökningen av fysisk aktivitetsnivå som sågs vid 4 månader kunde bekräftas i 1-års uppföljningen. En s.k. kostnads-nytto analys [delstudie IV] av de 178 individer som kom till 1-års uppföljningen visar att FaR-programmet är kostnadseffektivt, och att kostnaden per QALY, SEK 323 750 (hög-dos gruppen) och SEK 101 267 (låg-dos gruppen) anses moderat i förhållande till andra metoder inom sjukvården. En låg-dos grupp är mer kostnadseffektiv och har större livskvalitetsförbättringar än en hög-dos grupp.

Konklusioner: FaR-programmet kunde få inaktiva individer att öka sin fysiska aktivitetsnivå signifikant. Deras livskvalitet ökade också signifikant, i en låg-dos gruppen. Bäst följsamhet för programmet fanns hos äldre och hos de individer som skattade sin hälsa till relativt god när de startade i programmet. Dessa individer kan sägas utgöra målgruppen för FaR-programmet eftersom de uppnår bäst resultat. Att identifiera rätt målgrupp är nödvändigt för att uppnå följsamhet, effektivitet och kostnadseffektivitet av ett program som detta. FaR-programmet är kostnadseffektivt, visat i en kostnadsnyttoanalys, och gör programmet lönsamt i ett samhällsperspektiv. Programmet är mest kostnadseffektivt för en låg-dos grupp. En ökad tillgänglighet när det gäller träning hade kunnat öka marginalnyttan genom en ökad följsamhet i programmet. (Less)
Abstract
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®... (More)
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. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Karlberg, Ingvar, Göteborg University
organization
publishing date
type
Thesis
publication status
published
subject
keywords
physical activity, inactivity, costs, cost-effectiveness, quality of life, exercise referral, QALY, willingness to pay.
in
Lund University, Faculty of Medicine Doctoral dissertation Series
volume
2014:66
pages
152 pages
publisher
Physiotherapy
defense location
Health Sciences Center, Baravägen 3, Lund
defense date
2014-05-22 13:00
ISSN
1652-8220
ISBN
978-91-87651-93-9
language
English
LU publication?
yes
id
a39c6bc7-62e6-4e51-97c4-40083f13aa5c (old id 4438623)
date added to LUP
2014-05-21 08:15:38
date last changed
2016-09-19 08:44:48
@phdthesis{a39c6bc7-62e6-4e51-97c4-40083f13aa5c,
  abstract     = {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. <br/><br>
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. <br/><br>
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].<br/><br>
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. <br/><br>
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. <br/><br>
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.},
  author       = {Romé, Åsa},
  isbn         = {978-91-87651-93-9},
  issn         = {1652-8220},
  keyword      = {physical activity,inactivity,costs,cost-effectiveness,quality of life,exercise referral,QALY,willingness to pay.},
  language     = {eng},
  pages        = {152},
  publisher    = {Physiotherapy},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral dissertation Series},
  title        = {Prescribed physical activity. A health economic analysis.},
  volume       = {2014:66},
  year         = {2014},
}