An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative

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Abstract

Background

The Wales National Exercise Referral Scheme (NERS) is a 16-week programme including motivational interviewing, goal setting and relapse prevention.

Method

A pragmatic randomised controlled trial with nested economic evaluation of 2160 inactive participants with coronary heart disease risk (CHD, 1559, 72%), mild to moderate depression, anxiety or stress (79, 4%) or both (522, 24%) randomised to receive (1) NERS or (2) normal care and brief written information. Outcome measures at 12 months included the 7-day physical activity recall, the hospital anxiety and depression scale.

Results

Ordinal regression identified increased physical activity among those randomised to NERS compared with those receiving normal care in all participants (OR 1.19, 95% CI 0.99 to 1.43), and among those referred for CHD only (OR 1.29, 95% CI 1.04 to 1.60). For those referred for mental health reason alone, or in combination with CHD, there were significantly lower levels of anxiety (OR −1.56, 95% CI −2.75 to −0.38) and depression (OR −1.39, 95% CI −2.60 to −0.18), but no effect on physical activity. The base-case incremental cost-effectiveness ratio was £12 111 per quality adjusted life year, falling to £9741 if participants were to contribute £2 per session.

Conclusions

NERS was effective in increasing physical activity among those referred for CHD risk only. Among mental health referrals, NERS did not influence physical activity but was associated with reduced anxiety and depression. Effects were dependent on adherence. NERS is likely to be cost effective with respect to prevailing payer thresholds.

Trial registration

Current Controlled Trials ISRCTN47680448.

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Most cited references 14

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Exercise for depression.

D Lawlor, Phillip C. Greig, Daniel G. Mead … (2008)

Depression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychotherapy, but some people may prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression. To determine the effectiveness of exercise in the treatment of depression. We searched Medline, Embase, Sports Discus, PsycINFO, the Cochrane Controlled Trials Register, and the Cochrane Database of Systematic Reviews for eligible studies in March 2007. In addition, we hand-searched several relevant journals, contacted experts in the field, searched bibliographies of retrieved articles, and performed citation searches of identified studies. We also searched www.controlled-trials.com in May 2008. Randomised controlled trials in which exercise was compared to standard treatment, no treatment or a placebo treatment in adults (aged 18 and over) with depression, as defined by trial authors. We excluded trials of post-natal depression. We calculated effect sizes for each trial using Cohen's method and a standardised mean difference (SMD) for the overall pooled effect, using a random effects model. Where trials used a number of different tools to assess depression, we included the main outcome measure only in the meta-analysis. Twenty-eight trials fulfilled our inclusion criteria, of which 25 provided data for meta-analyses. Randomisation was adequately concealed in a minority of studies, most did not use intention to treat analyses and most used self-reported symptoms as outcome measures. For the 23 trials (907 participants) comparing exercise with no treatment or a control intervention, the pooled SMD was -0.82 (95% CI -1.12, -0.51), indicating a large clinical effect. However, when we included only the three trials with adequate allocation concealment and intention to treat analysis and blinded outcome assessment, the pooled SMD was -0.42 (95% CI -0.88, 0.03) i.e. moderate, non-significant effect. The effect of exercise was not significantly different from that of cognitive therapy. There was insufficient data to determine risks and costs. Exercise seems to improve depressive symptoms in people with a diagnosis of depression, but when only methodologically robust trials are included, the effect sizes are only moderate and not statistically significant. Further, more methodologically robust trials should be performed to obtain more accurate estimates of effect sizes, and to determine risks and costs. Further systematic reviews could be performed to investigate the effect of exercise in people with dysthymia who do not fulfil diagnostic criteria for depression.

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

T Pavey, N Anokye, A. H. Taylor … (2011)

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.

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A history of physical activity, cardiovascular health and longevity: the scientific contributions of Jeremy N Morris, DSc, DPH, FRCP.

Inhan Lee, Peter Blair, R S Paffenbarger (2001)

Since Hippocrates first advised us more than 2000 years ago that exercise-though not too much of it--was good for health, the epidemiology of physical activity has developed apace with the epidemiological method itself. It was only in the mid-20th century that Professor Jeremy N Morris and his associates used quantitative analyses, which dealt with possible selection and confounding biases, to show that vigorous exercise protects against coronary heart disease (CHD). They began by demonstrating an apparent protection against CHD enjoyed by active conductors compared with sedentary drivers of London double-decker buses. In addition, postmen seemed to be protected against CHD like conductors, as opposed to less active government workers. The Morris group pursued the matter further, adapting classical infectious disease epidemiology to the new problems of chronic, non-communicable diseases. Realizing that if physical exercise were to be shown to contribute to the prevention of CHD, it would have to be accomplished through study of leisure-time activities, presumably because of a lack of variability in intensities of physical work. Accordingly, they chose typical sedentary middle-management grade men for study, obtained 5-minute logs of their activities over a 2-day period, and followed them for non-fatal and fatal diseases. In a subsequent study, Morris et al. queried such executive-grade civil servants by detailed mail-back questionnaires on their health habits and health status. They then followed these men for chronic disease occurrence, as in the earlier survey. By 1973 they had distinguished between 'moderately vigorous' and 'vigorous' exercise. In both of these civil service surveys, they demonstrated strong associations between moderately vigorous or vigorous exercise and CHD occurrence, independent of other associations, in age classes 35-64 years. In the last 30 years, with modern-day computers, a large number of epidemiological studies have been conducted in both sexes, in different ethnic groups, in broad age classes, in a variety of social groups, and on most continents of the world. These studies have extended and amplified those of the Morris group, thereby helping to solidify the cause-and-effect evidence that exercise protects against heart disease and averts premature mortality.

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Author and article information

Journal

Journal ID (nlm-ta): J Epidemiol Community Health

Journal ID (iso-abbrev): J Epidemiol Community Health

Journal ID (publisher-id): jech

Journal ID (hwp): jech

Title: Journal of Epidemiology and Community Health

Publisher: BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 0143-005X

ISSN (Electronic): 1470-2738

Publication date (Electronic): 10 May 2012

Publication date (Print): August 2012

Publication date PMC-release: 10 May 2012

Volume: 66

Issue: 8

Pages: 745-753

Affiliations

[1 ]DECIPHer, Cardiff School of Social Sciences, Cardiff University, Cardiff, Wales, UK

[2 ]Centre for Health Economics and Medicines Evaluation, Institute of Medical and Social Care Research, Bangor University, Bangor, UK

[3 ]North Wales Centre for Primary Care Research, Bangor University, North Wales Clinical School, Wrexham, UK

Author notes

Correspondence to Dr Simon Mark Murphy, DECIPHer, Cardiff School of Social Sciences, Cardiff University, Cardiff, Wales, UK; murphys7@ 123456cf.ac.ukre

Article

Publisher ID: jech-2011-200689

DOI: 10.1136/jech-2011-200689

PMC ID: 3402741

PubMed ID: 22577180

SO-VID: 027fdf0d-b901-468a-954b-e00fc2aca5be

Copyright © © 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative

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Abstract

Background

Method

Results

Conclusions

Trial registration

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Climate Change and Human Health

Most cited references 14

Exercise for depression.

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

A history of physical activity, cardiovascular health and longevity: the scientific contributions of Jeremy N Morris, DSc, DPH, FRCP.

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