Effectiveness Of Exercise Referral Schemes Research Articles

Effect of exercise referral schemes and self-management strategies on healthcare service utilisation among community-dwelling older adults: secondary analyses of two randomised controlled trials.

The objective of this study is to explore whether offering an integrated self-management strategy and exercise referral scheme intervention (ERS+SMS) or a stand-alone ERS intervention is more effective in reducing healthcare service utilisation among community-dwelling older adults over time compared with a stand-alone SMS/control intervention. Secondary analyses of two randomised controlled trials (RCTs) with linkage to Danish national health registries. Three Danish municipalities: Esbjerg, Slagelse and Odense. Danish community-dwelling older adults, aged 65 years or older, were included in the study. Participants originated from two completed RCTs: the Welfare Innovation in Primary Prevention (WIPP, n=115) and the SITLESS project (SITLESS, n=333). Participants in the two trials were randomly assigned to one of three intervention groups: ERS in combination with SMS (ERS+SMS), ERS alone or an SMS/control intervention. Annual number of days with contact to general practice (GP) and days hospitalised for all causes. No statistically significant between-group difference was observed in the annual number of days with contact with GP between participants randomised to ERS+SMS (p=0.759) or ERS only (p=0.156) compared with those randomised to the SMS/control group. In addition, no statistically significant between-group differences in days hospitalised were observed when comparing the ERS+SMS (p=0.222) or ERS only (p=0.060) group to the SMS/control group. Neither the integrated intervention (ERS+SMS) nor the ERS alone intervention was more effective in reducing healthcare service utilisation during a 2-year follow-up period compared with a stand-alone SMS/control intervention. A potential stabilising effect of ERS and/or SMS interventions on the general age-related increase in healthcare service utilisation cannot be ruled out but needs further exploration in future studies along with the exploration of the effects of long-term interventions. NCT04531852 : and : NCT02629666 : .

Effects of exercise referral schemes enhanced with behavioural self-management strategies on functional capacity and self-reported disability in community-dwelling older adults. Secondary results from the SITLESS multi-country, three-armed randomized controlled trial.

Exercise referral schemes (ERS) are an effective strategy for increasing physical activity (PA) in older adults. Behavioural self-management strategies (SMS) may augment the maintenance of PA and associated benefits in this population, resulting in preservation of the functional capacity and prevention of disability over the long-term. The primary aim was to investigate the long-term (22-months) effects of ERS enhanced with SMS on functional capacity assessed by the Short Physical Performance Battery (SPPB) compared to ERS (primary comparison) and a control condition (CTRL).Secondarily, between-group effects after 4 and 16months on the SPPB and self-reported disability outcomes were investigated. 1360 physically inactive community-dwelling older adults ≥65years from four European countries were randomized into (i) 16weeks ERS enhanced with SMS (ERS-SMS), (ii) ERS alone and (iii) CTRL. In addition to SPPB, self-reported function and disability were assessed by the short-form late life function and disability index and with a six-item activity of daily living questionnaire. No long-term effects were found for the SPPB-score in ERS-SMS vs ERS (0.21 point, 95% CI [-0.04, 0.46]). Significant group × time effects were observed for the SPPB-score after 4months in favour of ERS-SMS over CTRL (0.51 point, 95% CI [0.29, 0.73]) and ERS (0.46 point, 95% CI [0.24, 0.68]). The study did demonstrate differences, in favour of ERS + SMS, but on SPPB these were small, and not sustained over time. The additional effect of SMS was inconsistent and uncertain.

The effect of exercise referral schemes and self-management strategies on use of prescription analgesics among community-dwelling older adults: registry linkage with randomised controlled trials

Background and objectiveExercise referral schemes and self-management strategies have shown positive effects on patient-reported and objectively measured outcomes, such as increased functional capacity and physical activity level. However, the impact of these interventions on analgesic use remains uncertain. We hypothesised that exercise referral schemes, either utilised alone or in combination with self-management strategies, is more effective in reducing use of prescription analgesics compared with a self-management strategy only.Subjects and methodsWe utilised data from two completed randomised controlled trials, namely The Welfare Innovation in Primary Prevention (n = 121) and The SITLESS project (n = 338), and information from the national Danish health registries, including the National Prescription Registry. The two trials have investigated the effectiveness of interventions, which include exercise referral schemes and self-management strategies, on various aspects such as physical function and levels of physical activity among community-dwelling older adults. The studies were conducted in the period 2015–2020 and comprised older adults aged 65+ years, living in three different Danish municipalities. Participants were recruited through nationally regulated preventive home-visits. To estimate changes in use of prescription analgesics over time, a linear fixed effects regression model was applied. The outcome measure was the mean total yearly defined daily dose of analgesics.ResultsAll intervention groups showed a within-group increase in overall analgesic use, though not statistically significantly different from zero. There were no differences in estimated changes in mean total yearly defined daily dose when comparing the intervention groups to the group receiving the least extensive intervention (self-management strategies/control). The findings indicated that exercise referral schemes and self-management strategies, whether administrated individually or in combination, did not result in a reduction in analgesic use over time.

P07-04 A systematic review of key interventional elements in international exercise referral schemes

BackgroundWith the first initiatives dating back to the 1990s, the past two decades have seen a rapid increase in the use of exercise referral schemes (ERS) worldwide. Despite the accumulating evidence on their effectiveness, there are currently no international guidelines available to inform the design of such interventions. The key elements and processes employed vary both within and between countries. This systematic review aims to address this frequently overlooked topic by identifying elements that are predominant in international ERS.MethodsScientific databases (PubMed, Scopus) and grey literature sources were systematically searched. In order to collect the information relevant for understanding and visualizing all ERS models, a broad spectrum of document types was considered eligible for inclusion, i.e. randomized controlled or pragmatic trials, cohort studies, case-control studies, case series, case reports, qualitative studies, economic evaluations, mixed designs, policy documents, and official governmental reports. We extracted data on scheme components, contents, and main actors involved in scheme delivery. Cross-functional flowcharts were employed to facilitate comparison between different ERS designs: Firstly, the collected data were visualized in flowcharts indicating the pathway a patient follows from beginning to end of an individual ERS. Secondly, elements that appeared more frequently across all included ERS were identified.ResultsPreliminary results identified 18 models of ERS that were eligible for data analysis, including Green Prescription (New Zealand), Hreyfiseðill (Iceland), National Exercise Referral Scheme (Wales). Program designs ranged from short advice by a primary healthcare professional to physical activity prescription and/or further referral to affiliated health professionals. The prevailing actors involved in scheme delivery were physicians, nurses, physiotherapists, training experts, physical activity providers, and coordinators. Seven predominant elements emerged from the comparison between ERS designs: assessment, counselling, individualized physical activity recommendations, written prescription, behavior change techniques, support person, and follow-up.ConclusionsTo the best of our knowledge, this is the first study that takes a closer look at the design characteristics of ERS across the world. Our preliminary results indicate that there are seven key elements. The contribution of these elements on the effectiveness of ERS needs to be explored in future research.

Evaluation of the uptake, retention and effectiveness of exercise referral schemes for the management of mental health conditions in primary care: a systematic review

BackgroundExercise is a recognised element of health-care management of mental-health conditions. In primary health care, it has been delivered through exercise referral schemes (ERS). The National Institute for Health and Care Excellence has highlighted uncertainty regarding the effectiveness of ERS in improving exercise participation and health outcomes among those referred for mental-health reasons. This review aims, therefore, to evaluate ERSs for individuals who are referred specifically for mental-health reasons.MethodsStudies were reviewed that assessed the effectiveness of ERSs in improving initiation of and/or adherence to exercise and/or their effectiveness in improving long-term participation in exercise and health outcomes among primary care patients who had been referred to the scheme for mental-health reasons. The data were extracted and their quality assessed. Data were analysed through a narrative synthesis approach.ResultsNine studies met the eligibility criteria. Three assessed clinical effectiveness of the schemes, eight assessed ERS uptake and/or adherence to the exercise schedule, and two assessed the impact of the ERSs on long-term exercise levels. In one study, it was found that ERSs that were based in leisure centres significantly improved long-term symptoms in those who had been referred due to their mental ill health (P<0.05). ERSs that involved face-to-face consultations and telephone calls had the highest rates of mean uptake (91.5%) and adherence (71.7%), but a difference was observed between uptake/adherence in trials (86.8%/55.3%) and in routine practice (57.9%/37.2%). ERSs that included face-to-face consultations and telephone calls increased the amount of long-term physical activity that was undertaken by people who had been referred for mental-health reasons (P=0.003).ConclusionsUptake and effectiveness of ERSs for mental health conditions was related to programme content and setting with more effective programmes providing both face-to-face and telephone consultations. Good uptake of yoga among those referred for mental health reasons suggests that mindful exercise options should be investigated further. Existing ERSs could be improved through application of individual tailoring and the provision of more face-to-face consultations, and social support. Further research is required to identify the types of ERSs that are most clinically effective for those with mental ill health.

Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER RCT.

There is modest evidence that exercise referral schemes increase physical activity in inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of exercise referral schemes on long-term physical activity. To determine if adding the e-coachER intervention to exercise referral schemes is more clinically effective and cost-effective in increasing physical activity after 1 year than usual exercise referral schemes. A pragmatic, multicentre, two-arm randomised controlled trial, with a mixed-methods process evaluation and health economic analysis. Participants were allocated in a 1 : 1 ratio to either exercise referral schemes plus e-coachER (intervention) or exercise referral schemes alone (control). Patients were referred to exercise referral schemes in Plymouth, Birmingham and Glasgow. There were 450 participants aged 16-74 years, with a body mass index of 30-40 kg/m2, with hypertension, prediabetes, type 2 diabetes, lower limb osteoarthritis or a current/recent history of treatment for depression, who were also inactive, contactable via e-mail and internet users. e-coachER was designed to augment exercise referral schemes. Participants received a pedometer and fridge magnet with physical activity recording sheets, and a user guide to access the web-based support in the form of seven 'steps to health'. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in the importance of physical activity, competence, autonomy in physical activity choices and relatedness. All participants were referred to a standard exercise referral scheme. Minutes of moderate and vigorous physical activity in ≥ 10-minute bouts measured by an accelerometer over 1 week at 12 months, worn ≥ 16 hours per day for ≥ 4 days including ≥ 1 weekend day. Other accelerometer-derived physical activity measures, self-reported physical activity, exercise referral scheme attendance and EuroQol-5 Dimensions, five-level version, and Hospital Anxiety and Depression Scale scores were collected at 4 and 12 months post randomisation. Participants had a mean body mass index of 32.6 (standard deviation) 4.4 kg/m2, were referred primarily for weight loss and were mostly confident self-rated information technology users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (n = 108) compared with the control group (n = 124); 11.8 weekly minutes of moderate and vigorous physical activity (95% confidence interval -2.1 to 26.0 minutes; p = 0.10). Sixty-four per cent of intervention participants logged on at least once; they gave generally positive feedback on the web-based support. The intervention had no effect on other physical activity outcomes, exercise referral scheme attendance (78% in the control group vs. 75% in the intervention group) or EuroQol-5 Dimensions, five-level version, or Hospital Anxiety and Depression Scale scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months, but not at 12 months. At 12 months, the intervention group incurred an additional mean cost of £439 (95% confidence interval -£182 to £1060) compared with the control group, but generated more quality-adjusted life-years (mean 0.026, 95% confidence interval 0.013 to 0.040), with an incremental cost-effectiveness ratio of an additional £16,885 per quality-adjusted life-year. A significant proportion (46%) of participants were not included in the primary analysis because of study withdrawal and insufficient device wear-time, so the results must be interpreted with caution. The regression model fit for the primary outcome was poor because of the considerable proportion of participants [142/243 (58%)] who recorded no instances of ≥ 10-minute bouts of moderate and vigorous physical activity at 12 months post randomisation. The design and rigorous evaluation of cost-effective and scalable ways to increase exercise referral scheme uptake and maintenance of moderate and vigorous physical activity are needed among patients with chronic conditions. Adding e-coachER to usual exercise referral schemes had only a weak indicative effect on long-term rigorously defined, objectively assessed moderate and vigorous physical activity. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000 per quality-adjusted life-year. The intervention did improve some process outcomes as specified in our logic model. Current Controlled Trials ISRCTN15644451. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 63. See the NIHR Journals Library website for further project information.

Effect of exercise referral schemes upon health and well-being: initial observational insights using individual patient data meta-analysis from the National Referral Database

ObjectivesTo examine if exercise referral schemes (ERSs) are associated with meaningful changes in health and well-being in a large cohort of individuals throughout England, Scotland, and Wales from the National...

Examining the Effects of Exercise Referral Schemes on Changes in Physical Activity Levels.

Examining the Effects of Exercise Referral Schemes on Changes in Physical Activity Levels.

Long-Term Health Outcomes Associated With an Exercise Referral Scheme: An Observational Longitudinal Follow-Up Study.

Exercise referral schemes (ERSs) support inactive adults, who have chronic health conditions, to become physically active. Uncertainty exists regarding the effectiveness of ERSs, with few studies evaluating their long-term impact. The aims of this study were to evaluate the long-term impact (12 mo) of participation in an ERS on self-reported physical activity (PA) and a range of health-related outcomes. Data were analyzed for participants of a 24-week ERS who attended a week 52 follow-up between July 2015 and 2017. PA and health-related outcomes collected at weeks 1, 24, and 52 were analyzed using the Friedman test and Wilcoxon signed-ranks test. A total of 273 participants attended the week 52 follow-up. Self-reported PA significantly increased by a median of 636 MET minutes at week 52. There were also significant improvements in body mass index, systolic blood pressure, mental well-being, and health-related quality of life. For every 8 participants referred to this 24-week ERS, 1 participant went on to show long-term improvements in at least 1 health indicator. The evidence base requires further long-term evaluations to confirm these findings across a range of ERS providers. Changes in self-reported PA would be supported by the inclusion of device-based measurment of PA.

Multicentred randomised controlled trial of an augmented exercise referral scheme using web-based behavioural support in individuals with metabolic, musculoskeletal and mental health conditions: protocol for the e-coachER trial

IntroductionPhysical activity is recommended for improving health among people with common chronic conditions such as obesity, diabetes, hypertension, osteoarthritis and low mood. One approach to promote physical activity is via...

The effects of exercise referral schemes in the United Kingdom in those with cardiovascular, mental health, and musculoskeletal disorders: a preliminary systematic review

BackgroundExercise referral schemes within clinical populations may offer benefits for inactive and sedentary individuals, and improve and aid treatment of specific health disorders. This systematic review aims to provide an overview, and examine the impact, of exercise referral schemes in patients with cardiovascular, mental health, and musculoskeletal disorders. This review focuses on populations within the United Kingdom (UK) only, with an aim to inform national exercise referral policies and guidelines.MethodData was collected from specific sources using validated methodology through PRISMA. Systematic searches were performed using Locate, PubMed, Scopus and Pro Quest: Public Health databases. Thirteen studies met inclusion criteria set for each sub group. This included that all studies aimed to prevent, observe, or decrease ill-health relating to the disorder, participants over the age of sixteen, and health disorders and outcomes were reviewed. All studies were conducted in the UK only.ResultsIn the 13 articles, a variety of modes and types of exercise were utilised. One-to-one supervised exercise sessions based in a gym environment were most frequently employed. Results showed that longer length schemes (20+ weeks) produced better health outcomes, and had higher adherence to physical activity prescribed, than those of shorter length (8–12 weeks). In patients referred with cardiovascular disorders, cardiovascular-related measures showed significant decreases including blood pressure. Schemes increased physical activity levels over the length of scheme for all disorders.ConclusionLonger length schemes (20+ weeks) improved adherence to physical activity prescribed over the course of the scheme, and could support longer term exercise adherence upon completion, however additional research on larger samples should examine this further. An implication is that schemes currently recommended in guidelines do not tailor programmes to support long term adherence to exercise, which must be addressed. There is currently a lack of research examining programmes tailored to suit the individual’s health conditions thus further research might allow providers to tailor delivery and build upon policy recommendations in the UK.

Effects of Exercise Referral Schemes on Physical Activity Levels

Exercise referral schemes are clinical exercise interventions used in non-clinical settings throughout the UK, and are intended to improve physical activity (PA) levels and health conditions of medically referred individuals. At present, the literature reviewing the impact of exercise referral schemes on PA levels, well-being, and quality of life is inconsistent. PURPOSE: To determine if exercise referral schemes positively influence PA levels in a large cohort of of individuals throughout England. METHODS: Data were obtained from 7412 participants (Female N= 4965 [49.96, +/- 14.37y., Male N=2447 [53.15, +/- 14.75 y.) referred from hospitals (N=605), medical centres (N=406), outreach (N=353) and GP surgeries (N= 6048) to fourteen exercise referral schemes located across England. The participants’ self-reported MET/minutes per week were calculated at the start and end of the scheme to determine whether the clinical exercise intervention had any impact on participants’ PA levels. Scheme lengths were either 6 (N=1749) or 12 weeks (N= 5663) in duration and situated in leisure environments. PA programmes consisted of both aerobic and resistance training tailored to the individual. A paired samples t-test was conducted to determine if a statistically significant difference existed between pre- and post scheme PA levels. RESULTS: METS/minutes per week were combined for both the 6- and 12-week groups. There was a statistically significant increase of 290.9 MET/mins per week from pre- to post-scheme for the participants (Pre= 856.1, +/- 1278 MET/min/week, 95% CI [827, 885) to Post= 1147 +/- 1801 MET/min/week; t(7411) = -34.18, p<0.001, 95% CI [1475, 1509), with a pairwise correlation of 0.367. CONCLUSIONS: This is one of the larger samples to study PA levels in UK adults after completion of an exercise referral scheme. The results showed a significant pre-post increase in MET/min/week, although sustainability of this change is not known. Long-term follow up of participants, including a comparison group and deeper analysis of other health behaviors, is to be conducted to support the initial findings.

Examining the social cognitive predictors of adherence to an exercise referral scheme

In order to enhance the effectiveness of exercise referral schemes (ERS), further understanding is required of the important predictors of successful adherence to inform future interventions. The present study aimed to explain ERS adherence through examining social cognitive factors in the early stages of the scheme. A prospective cross-sectional design was employed with adults referred to an 8-week ERS completing self-report measures across multiple social cognitive variables at baseline (N = 124) and mid-scheme (N = 58). Findings demonstrated that baseline social cognitive factors were not significantly related to overall ERS adherence. However, when measured at mid-scheme, goal-setting, scheduling self-efficacy, barrier self-efficacy and social support from family were significant correlates of adherence, with changes in social cognitive factors from baseline to mid-scheme combining to explain 22% of the variance in ERS adherence. Our findings provide evidence for early improvements in social cognitive constructs explaining total ERS adherence, thus highlighting their importance in the initial stages of an ERS.

Impact of primary care exercise referral schemes on the health of patients with obesity

Primary care exercise referral schemes (ERSs) are a potentially useful setting to promote physical activity (PA). It is not established, however, whether interventions to increase PA, such as ERSs, have differing health outcomes according to the participants’ body mass index (BMI). This paper summarizes evidence for the impact of primary care ERSs on the health of people with obesity and reports findings of a reanalysis of the EMPOWER study, providing the first data to report differential outcomes of ERSs by BMI category. Our literature review revealed a paucity of published data. A 2011 Health Technology Assessment review and 2015 update were identified, but normal-weight participants were neither excluded nor were results stratified by weight in the included studies. A study of the effect of exercise referral in overweight women reported a significantly greater increase in PA levels in the ERS group than the control group at 3 months. Reanalysis of the EMPOWER study data showed a significant improvement in PA at 3 months in both obese and overweight/normal BMI groups, with the effect size attenuated to 6 months. There was no significant difference from baseline to 6 months in blood pressure for either BMI category. At 6 months, there was a significant decrease in weight from baseline for the obese category. Comparison of crude mean differences between BMI groups revealed a significant mean difference in PA at 3 months favoring the overweight/normal BMI group, but not at 6 months. There were no further significant differences in unadjusted or adjusted mean differences for other outcomes at follow-up. We report some evidence of a differential impact of ERS on PA by BMI category. However, the effect of ERSs in primary care for patients with obesity remains unclear due to the small number of published studies that have reported outcomes by BMI category. Further research is needed.

Can adding web-based support to UK primary care exercise referral schemes improve patients’ physical activity levels? Intervention development for the e-coachER study.

Can adding web-based support to UK primary care exercise referral schemes improve patients’ physical activity levels? Intervention development for the e-coachER study.

Long-term engagement with a practice-based exercise referral scheme: Patients’ perceptions of effectiveness

Objectives Limited and contradictory evidence exists on the long-term effectiveness of exercise referral schemes (ERS) for physical activity promotion and its impact on perceived health status. The intention of this study was to investigate patients’ views of a physical activity intervention on their self-assessed health status.Methods A longitudinal qualitative study design was employed with 12 patients aged 55 – 74, attending a primary care physical activity intervention. Semi-structured interviews took place on three occasions over a 12 month period in a Primary Care Health Centre. Transcripts of recorded interviews were coded and thematically analysed using grounded theory techniques.Results The majority of patients believed that their engagement with the Scheme and resultant long-term increase in physical activity behaviour, helped to improve their health status. This was evident through improved perceptions of medical conditions, through stabilisation or reductions in medication and visits to medical services.Conclusion The findings show the value of a long-term physical activity intervention in a Primary Care setting, through increases in physical activity levels and patients self-assessed health status. These findings can serve as guide for future service commissioners of ERS.

A systematic review and economic evaluation of exercise referral schemes in primary care: a short report.

It is estimated that only 39% of men and 29% of women in England achieve the levels of physical activity that are recommended to protect health and prevent disease. One approach to addressing this problem has been the development of exercise referral schemes (ERSs), in which health professionals refer patients to external exercise providers. These schemes have been widely rolled out across the UK despite concerns that they may not produce sustained changes in levels of physical activity and, therefore, may not be cost-effective interventions. The evidence to determine clinical effectiveness and cost-effectiveness was evaluated in 2009. This review seeks to update this earlier work by incorporating new evidence and re-examining the cost-effectiveness. To assess the clinical effectiveness and cost-effectiveness of ERSs compared with usual care. Exhaustive searches of relevant electronic databases and journals were undertaken to identify new studies evaluating ERSs using a randomised controlled trial (RCT) design. RCTs that incorporated a qualitative evaluation of the intervention were identified in order to explore the barriers and facilitators to the uptake of and adherence to ERSs. Data were extracted using a previously designed tool and study quality assessed for potential bias. Where data could be pooled, meta-analyses were carried out. Qualitative analysis was also undertaken using a thematic approach. The cost-effectiveness was evaluated using a Markov structure which estimated the likelihood of becoming physically active and the subsequent risk reduction on coronary heart disease (CHD), stroke and type 2 diabetes mellitus. The model adopts a lifetime horizon, and a NHS and Personal Social Services perspective was taken with discounting at 1.5% for both costs and benefits. The search identified one new RCT and one new qualitative study. The new data were pooled with existing data from the 2011 review by Pavey et al. [Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2011;15(44)] to give a total of eight studies with 5190 participants. The proportion of individuals achieving 90-150 minutes of at least moderate-intensity activity per week at 6-12 months' follow-up was greater for ERSs than usual care (relative risk 1.12; 95% confidence interval 1.04 to 1.20). Older patients and those referred for CHD risk factors appeared to be more likely than others to increase their levels of physical activity. Qualitative evidence suggests that interventions enabling the development of social support networks are beneficial in promoting uptake and adherence. Exercise referral gained 0.003 quality-adjusted life-years (QALYs) at an additional cost of £225 per person. The estimated mean incremental cost-effectiveness ratio (ICER) in the probabilistic sensitivity analysis was £76,276. In the univariate sensitivity analysis the results were very sensitive (ICERs ranged from < £30,000 to > £100,000) to changes in the effect of ERSs on physical activity uptake and the duration of the protective effects and the direct health-related quality-of-life gains attributable to physical activity. Exercise referral schemes result in a small improvement in the number of people who increase their levels of physical activity. The cost-effectiveness analysis indicates that the ICER for ERSs compared with usual care is around £76,000 per QALY, although the cost-effectiveness of ERSs is subject to considerable uncertainty. This study is registered as PROSPERO CRD42013005200. National Institute for Health Research Health Technology Assessment programme.

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

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. 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. 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. 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. 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. 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. 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. The National Institute for Health Research Health Technology Assessment programme.

The cost-effectiveness of exercise referral schemes

BackgroundExercise referral schemes (ERS) aim to identify inactive adults in the primary care setting. The primary care professional 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 patient. This paper examines the cost-effectiveness of ERS in promoting physical activity compared with usual care in primary care setting.MethodsA decision analytic model was developed to estimate the cost-effectiveness of ERS from a UK NHS perspective. The costs and outcomes of ERS were modelled over the patient's lifetime. Data were derived from a systematic review of the literature on the clinical and cost-effectiveness of ERS, and on parameter inputs in the modelling framework. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses investigated the impact of varying ERS cost and effectiveness assumptions. Sub-group analyses explored the cost-effectiveness of ERS in sedentary people with an underlying condition.ResultsCompared with usual care, the mean incremental lifetime cost per patient for ERS was £169 and the mean incremental QALY was 0.008, generating a base-case incremental cost-effectiveness ratio (ICER) for ERS at £20,876 per QALY in sedentary individuals without a diagnosed medical condition. There was a 51% probability that ERS was cost-effective at £20,000 per QALY and 88% probability that ERS was cost-effective at £30,000 per QALY. In sub-group analyses, cost per QALY for ERS in sedentary obese individuals was £14,618, and in sedentary hypertensives and sedentary individuals with depression the estimated cost per QALY was £12,834 and £8,414 respectively. Incremental lifetime costs and benefits associated with ERS were small, reflecting the preventative public health context of the intervention, with this resulting in estimates of cost-effectiveness that are sensitive to variations in the relative risk of becoming physically active and cost of ERS.ConclusionsERS is associated with modest increase in lifetime costs and benefits. The cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness and cost of ERS and is subject to some significant uncertainty mainly due to limitations in the clinical effectiveness evidence base.

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,...