NIHR Signal Exercise referral schemes increase physical activity for some

Published on 14 October 2015

This NIHR-funded systematic review found that exercise referral schemes increased physical activity in people who have no or little physical activity to begin with compared with usual care or advice. But these schemes do not appear to be cost-effective for all people. Exercise referral schemes may be more effective for people with coronary heart disease risk factors than for people with mental health conditions, for example. Most of the trials were based in the UK, making the findings directly relevant here. Prior to publication, the findings of this review informed the 2014 update to the NICE public health guideline on exercise referral schemes. The updated guideline recommends exercise referral schemes only for people who have existing health conditions or other health risk factors and are sedentary or inactive.

Exercise referral schemes increase physical activity for some

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Why was this study needed?

Over the last two decades, exercise referral schemes have been adopted by the majority of primary care organisations in the UK. Usually primary care practitioners will refer to local authority leisure facilities for the delivery of an exercise programme. These can use indoor, community or outdoor settings for a variety of activities, like walking, swimming or gym classes. The majority of schemes offer between three to seven different activities as options and the typical length of the referral period in England and Scotland is 12 weeks. In 2006, the NICE public health guideline on four commonly used methods to increase physical activity concluded that there was insufficient evidence to recommend using exercise referral schemes. A 2011 NIHR-funded systematic review found no trial-based evidence of the effectiveness of exercise referral schemes in people with existing medical conditions. For people without a medical condition the 2011 review reported considerable uncertainty about the effectiveness and cost-effectiveness of exercise referral schemes for increasing levels of activity and improving health risk factors.

This NIHR-funded systematic review and economic evaluation aimed to update the 2011 review to find out if there was recent evidence to support the use of exercise referral schemes to promote physical activity. Prior to publication, this update provided the evidence base for updating the NICE guideline on exercise referral schemes in 2014.

What did this study do?

This systematic review searched several medical databases for trials comparing exercise referral schemes with a control group who received usual care or advice. The 2011 review results found seven trials and this update review found one more - an evaluation study incorporating a randomised controlled trial and qualitative evidence. The new trial, published in 2012, was the largest so far with over 2,000 people randomised in the UK. Uptake of exercise referral was high (at 85%) amongst those allocated to the intervention. As the trial was so large, it was important to update the evidence. Four trials included people with high risk factors for medical conditions and four included people with sedentary lifestyles, giving a total of 5,190 participants. Six of these studies were conducted in the UK and all trials were rated as moderate to high quality. The overall impact of the exercise referral schemes was pooled in a meta-analysis. The qualitative evidence was summarised in a narrative review.

This review included an economic evaluation to establish the cost-effectiveness of exercise referral schemes.

What did it find?

  • People on different exercise referral schemes were 12% more likely to achieve 90 to 150 minutes of at least moderate level of exercise per week compared with usual care at 6 to 12 months (relative risk [RR] 1.12, 95% confidence interval [CI] 1.04 to 1.20).
  • On average, different exercise referral schemes increased the number of minutes per week of physical exercise by 55.10 minutes compared with the control groups who received advice only (95% CI 18.47 to 91.73 minutes).
  • Exercise referral schemes compared with usual care did not increase physical activity for people with mental health conditions but did for people with coronary heart disease risk factors (odds ratio [OR] 1.29, 95% CI 1.04 to 1.60).
  • Enrolment (initial attendance) in exercise programs was mixed, ranging from 35% to 100% in the eight trials. Continuous participation (finishing the course) varied from 21.5% to 86%. The qualitative evidence suggested that the main barriers for engaging with the exercise referral scheme included lack of car ownership, living in a rural area or deprivation.
  • Exercise referral schemes overall were estimated to cost an additional £76,000 for each added Quality Adjusted Life Year (QALY) compared to usual care. This is a measure of the value for money offered by a medical intervention. This is more than double the usual £20,000 to £30,000 guide used by NICE to assess whether something is a cost effective use of NHS resources.

What does current guidance say on this issue?

The 2014 NICE public health guideline on exercise referral schemes to promote physical activity recommends that primary care practitioners should not refer healthy people who are sedentary or inactive to exercise referral schemes. This guideline recommends that only people who have existing health conditions or other health risk factors and are sedentary or inactive should be referred to exercise schemes.

Structured exercise programmes for management or rehabilitation after recovery from specific medical conditions are not part of the exercise referral schemes.

What are the implications?

Physical activity is known to be of near universal benefit. It can reduce your risk of major illnesses, such as heart disease, stroke, type 2 diabetes and cancer and lower your risk of early death by up to 30%. This review asked if referring people for exercise programmes can help them to realise these benefits. Most of the trials in this systematic review were conducted in the UK which makes its findings highly relevant to the UK context. The details of exercise referral schemes varied across studies and the analysis could not identify which elements promoted changes to physical activity levels. Exercise referral schemes can be more or less successful for people with different medical conditions or risk factors. They may also have an impact on more than one risk factor or condition, so this should be taken into consideration when implementing these programmes. The cost effectiveness estimates of the exercise interventions depend on multiple assumptions, such as the length and cost of exercise referral schemes and the amount of health benefit gained, meaning that any estimate is uncertain. In the analysis a small increase in quality of life was gained at an additional cost of £225 per person.

NICE public health advisory committee considered the cost effectiveness evidence and even in the best case scenario, the estimated incremental cost effectiveness ratio was £31,009 per QALY gained. Despite this, experts noted that some specific schemes may be cost effective, or may only be cost effective for the subgroups for which the recommendation applied. They concluded that cheaper schemes, costing less than £150 per person, might be cost-effective at a threshold of £20,000–£30,000 per QALY if they remained effective. They also noted that if exercise referral schemes collected more detailed data, this would allow commissioners to make a more informed decision on future investment.

Citation

Campbell F, Holmes M, Everson-Hock E, et al. A systematic review and economic evaluation of exercise referral schemes in primary care: a short report. Health Technol Assess. 2015;19(60):1-110.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (Project number 13/45/01).

Bibliography

Anokye NK, Trueman P, Green C, et al. The cost-effectiveness of exercise referral schemes. BMC Public Health. 2011;11:954.

NICE. Exercise referral schemes to promote physical activity. PH54. London: National Institute for Health and Care Excellence; 2014.

NICE. Four commonly used methods to increase physical activity. PH2. London: National Institute for Health and Care Excellence; 2006.

NICE. Walking and cycling. PH41. London: National Institute for Health and Care Excellence; 2012.

NICE. Physical activity: brief advice for adults in primary care. PH44. London: National Institute for Health and Care Excellence; 2013.

Pavey TG, Anokye N, Taylor AH, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess. 2011;15(44):i-xii, 1-254.

Why was this study needed?

Over the last two decades, exercise referral schemes have been adopted by the majority of primary care organisations in the UK. Usually primary care practitioners will refer to local authority leisure facilities for the delivery of an exercise programme. These can use indoor, community or outdoor settings for a variety of activities, like walking, swimming or gym classes. The majority of schemes offer between three to seven different activities as options and the typical length of the referral period in England and Scotland is 12 weeks. In 2006, the NICE public health guideline on four commonly used methods to increase physical activity concluded that there was insufficient evidence to recommend using exercise referral schemes. A 2011 NIHR-funded systematic review found no trial-based evidence of the effectiveness of exercise referral schemes in people with existing medical conditions. For people without a medical condition the 2011 review reported considerable uncertainty about the effectiveness and cost-effectiveness of exercise referral schemes for increasing levels of activity and improving health risk factors.

This NIHR-funded systematic review and economic evaluation aimed to update the 2011 review to find out if there was recent evidence to support the use of exercise referral schemes to promote physical activity. Prior to publication, this update provided the evidence base for updating the NICE guideline on exercise referral schemes in 2014.

What did this study do?

This systematic review searched several medical databases for trials comparing exercise referral schemes with a control group who received usual care or advice. The 2011 review results found seven trials and this update review found one more - an evaluation study incorporating a randomised controlled trial and qualitative evidence. The new trial, published in 2012, was the largest so far with over 2,000 people randomised in the UK. Uptake of exercise referral was high (at 85%) amongst those allocated to the intervention. As the trial was so large, it was important to update the evidence. Four trials included people with high risk factors for medical conditions and four included people with sedentary lifestyles, giving a total of 5,190 participants. Six of these studies were conducted in the UK and all trials were rated as moderate to high quality. The overall impact of the exercise referral schemes was pooled in a meta-analysis. The qualitative evidence was summarised in a narrative review.

This review included an economic evaluation to establish the cost-effectiveness of exercise referral schemes.

What did it find?

  • People on different exercise referral schemes were 12% more likely to achieve 90 to 150 minutes of at least moderate level of exercise per week compared with usual care at 6 to 12 months (relative risk [RR] 1.12, 95% confidence interval [CI] 1.04 to 1.20).
  • On average, different exercise referral schemes increased the number of minutes per week of physical exercise by 55.10 minutes compared with the control groups who received advice only (95% CI 18.47 to 91.73 minutes).
  • Exercise referral schemes compared with usual care did not increase physical activity for people with mental health conditions but did for people with coronary heart disease risk factors (odds ratio [OR] 1.29, 95% CI 1.04 to 1.60).
  • Enrolment (initial attendance) in exercise programs was mixed, ranging from 35% to 100% in the eight trials. Continuous participation (finishing the course) varied from 21.5% to 86%. The qualitative evidence suggested that the main barriers for engaging with the exercise referral scheme included lack of car ownership, living in a rural area or deprivation.
  • Exercise referral schemes overall were estimated to cost an additional £76,000 for each added Quality Adjusted Life Year (QALY) compared to usual care. This is a measure of the value for money offered by a medical intervention. This is more than double the usual £20,000 to £30,000 guide used by NICE to assess whether something is a cost effective use of NHS resources.

What does current guidance say on this issue?

The 2014 NICE public health guideline on exercise referral schemes to promote physical activity recommends that primary care practitioners should not refer healthy people who are sedentary or inactive to exercise referral schemes. This guideline recommends that only people who have existing health conditions or other health risk factors and are sedentary or inactive should be referred to exercise schemes.

Structured exercise programmes for management or rehabilitation after recovery from specific medical conditions are not part of the exercise referral schemes.

What are the implications?

Physical activity is known to be of near universal benefit. It can reduce your risk of major illnesses, such as heart disease, stroke, type 2 diabetes and cancer and lower your risk of early death by up to 30%. This review asked if referring people for exercise programmes can help them to realise these benefits. Most of the trials in this systematic review were conducted in the UK which makes its findings highly relevant to the UK context. The details of exercise referral schemes varied across studies and the analysis could not identify which elements promoted changes to physical activity levels. Exercise referral schemes can be more or less successful for people with different medical conditions or risk factors. They may also have an impact on more than one risk factor or condition, so this should be taken into consideration when implementing these programmes. The cost effectiveness estimates of the exercise interventions depend on multiple assumptions, such as the length and cost of exercise referral schemes and the amount of health benefit gained, meaning that any estimate is uncertain. In the analysis a small increase in quality of life was gained at an additional cost of £225 per person.

NICE public health advisory committee considered the cost effectiveness evidence and even in the best case scenario, the estimated incremental cost effectiveness ratio was £31,009 per QALY gained. Despite this, experts noted that some specific schemes may be cost effective, or may only be cost effective for the subgroups for which the recommendation applied. They concluded that cheaper schemes, costing less than £150 per person, might be cost-effective at a threshold of £20,000–£30,000 per QALY if they remained effective. They also noted that if exercise referral schemes collected more detailed data, this would allow commissioners to make a more informed decision on future investment.

Citation

Campbell F, Holmes M, Everson-Hock E, et al. A systematic review and economic evaluation of exercise referral schemes in primary care: a short report. Health Technol Assess. 2015;19(60):1-110.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (Project number 13/45/01).

Bibliography

Anokye NK, Trueman P, Green C, et al. The cost-effectiveness of exercise referral schemes. BMC Public Health. 2011;11:954.

NICE. Exercise referral schemes to promote physical activity. PH54. London: National Institute for Health and Care Excellence; 2014.

NICE. Four commonly used methods to increase physical activity. PH2. London: National Institute for Health and Care Excellence; 2006.

NICE. Walking and cycling. PH41. London: National Institute for Health and Care Excellence; 2012.

NICE. Physical activity: brief advice for adults in primary care. PH44. London: National Institute for Health and Care Excellence; 2013.

Pavey TG, Anokye N, Taylor AH, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess. 2011;15(44):i-xii, 1-254.

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

Published on 30 July 2015

Campbell, F.,Holmes, M.,Everson-Hock, E.,Davis, S.,Buckley Woods, H.,Anokye, N.,Tappenden, P.,Kaltenthaler, E.

Health Technol Assess Volume 19 , 2015

BACKGROUND: 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. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of ERSs compared with usual care. DESIGN: 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. RESULTS: 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 pound225 per person. The estimated mean incremental cost-effectiveness ratio (ICER) in the probabilistic sensitivity analysis was pound76,276. In the univariate sensitivity analysis the results were very sensitive (ICERs ranged from < pound30,000 to > pound100,000) 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. CONCLUSIONS: 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 pound76,000 per QALY, although the cost-effectiveness of ERSs is subject to considerable uncertainty. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005200. FUNDING: National Institute for Health Research Health Technology Assessment programme.

Exercise referral schemes aim to increase physical activity levels as there is considerable evidence supporting the health benefits of regular exercise. Exercise referral schemes are complex interventions consisting of several components. They typically include assessment by a GP or other health professional to determine if people are sedentary or inactive; a referral to a qualified physical activity professional or service; a personal assessment to determine what programme of exercise should be recommended for their individual needs; and an opportunity to participate in an exercise programme. Some schemes can also include a progress review after completion.

Physical activity, exercise and physical fitness are terms that describe different concepts which can be confusing. Physical activity is best defined as any bodily movement that uses energy. Exercise is a type of physical activity that is usually planned, structured and repetitive. Exercise aims to improve or maintain physical fitness. Physical fitness is usually measurable and is related to health gain or skill development.

Expert commentary

The limited focus on a few health outcome measures means much of the effectiveness on a wider range of health outcomes is missed, and in particular the health impacts associated with multi-morbidities which make up the majority of referrals in exercise referral schemes. More importantly basing measures of physical activity on fixed parameters (i.e. 90 - 150 min moderate activity levels per week) overlooks the much more important measure of total increases in physical activity across all levels. This, we know, has a non-linear relationship with health and also accrues the greatest health benefits for those who are the least active -even if they don’t achieve the fixed benchmarks.

Malcolm Ward, Principal Health Promotion Specialist, Public Health Wales