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Pavey TG, Anokye N, Taylor AH, et al. The Clinical Effectiveness and Cost-Effectiveness of Exercise Referral Schemes: A Systematic Review and Economic Evaluation. Southampton (UK): NIHR Journals Library; 2011 Dec. (Health Technology Assessment, No. 15.44.)

7Discussion

Statement of principal findings

Systematic review of exercise referral scheme effectiveness

In total seven27,28,50,61,6870 RCTs (3030 participants) met the review inclusion criteria. Five RCTs compared ERS with usual care (e.g. PA advice),27,28,50,61,70 two RCTS compared an alternative PA-promoting strategy (i.e. walking programme or PA counselling)61,69 with usual care and one RCT compared an alternative form of ERS (i.e. ERS plus SDT intervention) with usual care.68 Although these trials were all judged to meet our definition of ERS (i.e. a referral from a primary health-care professional to an individualised exercise programme designed to meet the needs of the participant) there was considerable heterogeneity in the nature of the exercise/PA intervention across studies. Studies recruited predominantly sedentary middle-aged adults who had evidence of at least one lifestyle risk factor and five of the studies also included individuals with a medical diagnosis (e.g. hypertension, depression). ERS usually took place at a leisure centre and involved 10–12 weeks of exercise intervention and where there was follow-up it took place at 6 and/or 12 months post randomisation. Studies were judged to have a moderate or low overall risk of bias.

The most consistently reported outcome was self-reported PA. In ITT analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved 90–150 minutes of at least moderate-intensity PA per week at 6–12 months' follow-up (pooled RR 1.11, 95% CI 0.99 to 1.25). There was no difference in PA between ERS versus alternative PA promotion interventions or ERS versus ERS plus SDT at 6–12 months' follow-up. We found no evidence to support differences across subgroups (e.g. age, gender) in terms of the impact of ERS on PA. There was no consistent evidence for a difference between ERS and any of the comparator groups in the duration of moderate/vigorous intensity and total PA, physical fitness, blood pressure, serum lipids, glycaemic control, obesity indices (body weight, BMI, percentage fat), respiratory function, psychological well-being (perception of self-worth, or symptoms of depression or anxiety) or HRQoL. None of the included trials separately reported outcomes in individuals with medical diagnoses.

Systematic review of predictors of uptake and adherence to exercise referral schemes

We found considerable variation across studies in the level of uptake (i.e. attendance at the first induction visit) and adherence to ERS (i.e. completion of the programme) across the 19 included studies (14 observational studies and five RCTs).Uptake levels were higher, on average, in RCTs than in observational studies, although there was no clear difference in adherence between the two. In bivariate and multivariate analyses, women and older people were more likely to take up ERS. In addition, although older people were also more likely to adhere, women were less likely to adhere than men. Very few studies reported associations between ERS uptake or adherence and participant psychosocial factors or programme-level predictors. However, most qualitative studies found a perception of a range of several short-term physical and psychosocial benefits associated with ERS. As the interviews largely involved females, less is known about these perceptions in males. Less favourable aspects of ERS involved limited involvement from the referrer (e.g. GP), and selected experiences at the exercise facility. However, there were also many positive comments on how the ERS served to initiate an exercise programme. Few qualitative studies attempted to identify if and how an ERS contributes to a sustainable physically active lifestyle beyond the usual 10- to 12-week facility-based programme.

Systematic review of exercise referral scheme cost-effectiveness

Four economic evaluations that assessed the cost-effectiveness of ERS were identified: three trial-based economic evaluations50,61,70 and a model-based analysis.76 Given the limitations (inclusion of studies providing an effectiveness estimate not meeting our definition of ERS; non-UK; lack of cost per QALY estimates) in these previous analyses we undertook a de novo model-based economic evaluation. Indicative incremental cost per QALY estimates for ERS for various scenarios have been provided. Compared with usual care, the base-case ICER for ERS was £20,876/QALY in sedentary individuals with at least one lifestyle risk factor and £14,618/QALY in sedentary obese individuals, £12,834/QALY in sedentary hypertensives and £8414/QALY for sedentary individuals with depression. These ICERs were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. Allowing for short-term gains in QoL associated with ERS resulted in small reductions (£1500–£3000/QALY) in the ICER compared with the base case, although these findings were sensitive to the duration of any short-term benefits.

Strengths and limitations of the assessment

Exercise referral scheme clinical effectiveness

We undertook a comprehensive and systematic review of the literature for the clinical effectiveness of ERS. This systematic review was restricted to controlled trials, to provide a high level of evidence for ERS clinical effectiveness. Unlike some previous systematic reviews in this field,35,39,41 we carefully selected ERS studies on the basis that there was clear evidence of referral by a primary-care health professional to third-party exercise provider. A central tenet of the ERS intervention is the referral process itself and that is potentially a key motivator and driver for individuals to take up and adhere to exercise interventions.22 Qualitative studies in the present review also highlighted the importance of the GP in promoting a more active lifestyle. Although this resulted in the exclusion of a number of primary care-based exercise intervention studies [e.g. Elley (‘green prescription’),29,78 Lamb et al.,58 Harland et al.,43 Munro et al.82], we believe this focus to be consistent with the decision problem of this report.

Predictors of exercise referral scheme uptake and adherence

We extended the scope of this report to undertake a review of quantitative and qualitative literature so as to better understand the potential predictors and drivers of ERS uptake and adherence. Although this review incorporated trial, observational and qualitative evidence, it was not fully systematic in that it was limited to studies primarily identified by our electronic searches for effectiveness studies. Furthermore, we did not incorporate formal methods of qualitative synthesis such as meta-ethnography.

Exercise referral scheme cost-effectiveness

A particular strength of our cost-effectiveness analysis was the further development of the economic model used in the NICE evaluation of primary care-based exercise interventions.76 These further developments included the incorporation of epidemiological data linking PA and the future risk of clinical outcomes (i.e. CHD, stroke, diabetes) in specific medical diagnoses groups (i.e. obesity, hypertension, depression), consideration of short-term gains in HRQoL associated with increased PA, and PSA. Additionally, model effectiveness estimates were based on meta-analysis, in contrast to the previous NICE modelling analysis, which selected effectiveness estimates from specific individual trials.

Two principal limitations of our economic analysis were the dearth of information for a number of key model inputs (detailed in the next section) and the fact that differences in QALYs were often very small, leading to instability of the ICERs. Furthermore, for the purposes of generating a cost per QALY for medical diagnostic groups, we assumed the same benefit in terms of PA gains in those populations as sedentary ‘at-risk’ individuals.

Uncertainties

Exercise referral scheme clinical effectiveness

Although we have identified seven RCTs that recruited some 1400 ERS participants, because of limitations and gaps in this evidence base there remain at least four key uncertainties regarding the clinical effectiveness of ERS. These include (1) the impact of ERS in people with a medical diagnosis; (2) whether ERS consistently affects prognostic outcomes such as blood pressure and serum lipids; (3) whether the small increases in self-reported PA are clinically significant; and (4) whether these small short-term gains in activity are maintained in the longer term.

Exercise referral scheme cost-effectiveness

Evidence on the cost-effectiveness of ERS needs to be interpreted with some caution. Although the ICERs are relatively favourable, these are derived from findings that show small differences in costs and effects, with effectiveness data that suggest that ERS has a modest effect on QALY gains (typically < 0.01 in our analyses). Sensitivity analyses show that the cost per QALY associated with ERS can change markedly with plausible changes in model input values, which means that robust evidence on whether or not ERS are likely to be cost-effective cannot currently be provided. The cost-effective ratios reported should be treated with caution until more robust effectiveness data become available.

Interventions which involve complex behaviour change components are not well suited to decision-analytic models. Individual-level simulation models that can detect changes in individual behaviours over time may better address questions over the cost-effectiveness of ERS interventions. However, there will be a trade-off between developing a simple model (as in this review) which can be populated and acknowledges its limitations versus a more complex model that may be a better representation of reality but can be only partially populated and may result in greater uncertainty. In both cases, the fundamental issue that needs to be addressed is improvements in the source data on the effectiveness of ERS.

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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.
Pavey TG, Anokye N, Taylor AH, et al.
Southampton (UK): NIHR Journals Library; 2011 Dec.

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