NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Cover of The Clinical Effectiveness and Cost-Effectiveness of Exercise Referral Schemes: A Systematic Review and Economic Evaluation

The Clinical Effectiveness and Cost-Effectiveness of Exercise Referral Schemes: A Systematic Review and Economic Evaluation

Health Technology Assessment, No. 15.44

, , , , , , , , , , , , and .

Author Information

,1,* ,2 ,3 ,4 ,1 ,5 ,5 ,1 ,1 ,6 ,7 ,8 and 1.

1 Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK
2 Health Economics Research Group, Brunel University, Uxbridge, UK
3 School of Sport and Health Sciences, University of Exeter, Exeter, UK
4 York Health Economics Consortium, University of York, York, UK
5 Centre for Sport, Exercise and Health, Bristol University, Bristol, UK
6 BHF Health Promotion Research Group, Department of Public Health, University of Oxford, Oxford, UK
7 SPARColl, Strathclyde University, Glasgow, UK
8 Chief Medical Officer, Fitness Industry Association, London, UK
* Corresponding author



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.

Data sources:

MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked.


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.


Suggested citation:

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).

Declared competing interests of authors: JS is Chief Medical Officer of the Fitness Industry Association (FIA). The FIA meets his receipted expenses. The post attracts neither a salary nor fees.

The research reported in this issue of the journal was commissioned by the HTA programme as project number 08/72/01. The contractual start date was in September 2009. The draft report began editorial review in December 2010 and was accepted for publication in March 2011. As the funder, by devising a commissioning brief, the HTA programme specified the research question and study design. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.

The views expressed in this publication are those of the authors and not necessarily those of the HTA programme or the Department of Health.

© 2011, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK97780
PubReader format: click here to try


  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (4.8M)

Related information

Related citations in PubMed

See reviews...See all...

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...