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King HA, Gierisch JM, Williams JW Jr, et al. Effects of Health Plan-Sponsored Fitness Center Benefits on Physical Activity, Health Outcomes, and Health Care Costs and Utilization: A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2012 Oct.

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Effects of Health Plan-Sponsored Fitness Center Benefits on Physical Activity, Health Outcomes, and Health Care Costs and Utilization: A Systematic Review [Internet].

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RESULTS

LITERATURE SEARCH

The flow of articles through the literature search and screening process is illustrated in Figure 2. We identified 3584 unique citations from a combined search of MEDLINE (via PubMed, n=3560), Embase (n=24), and the Cochrane database (n=0). Manual searching of included study bibliographies and review articles identified 5 additional citations for a total of 3589 citations. After applying inclusion/exclusion criteria at the title-and-abstract level, 47 full-text articles were retrieved and screened. Of these, 43 were excluded at the full-text screening stage, leaving 4 articles (representing 1 unique study) for data abstraction. Most studies were excluded at full-text review because they assessed types of physical activity promotion strategies other than fitness center memberships (e.g., worksite wellness) provided through health plan benefits. Our search of www.ClinicalTrials.gov did not suggest publication bias. There were no completed studies that were unpublished. In addition, there were no ongoing studies on this topic.

Figure 2. Literature flow diagram.

Figure 2

Literature flow diagram. * See Glossary for definition of companion articles. Note: At the request of a peer reviewer, we reconsidered one reference that was initially excluded at the title/abstract level; however, we retained our original conclusion (more...)

STUDY CHARACTERISTICS

Only one main study22 and three companion articles23-25 met inclusion criteria for this review (Table 2). All articles we identified addressed KQ 1; none addressed KQ 2 or KQ 3. The main study was a retrospective cohort study rated fair quality that used administrative and claims data to assess the effects of a health plan-sponsored fitness center membership benefit (known as the Silver Sneakers program) on health care costs and utilization among adults 65 years of age and older who were enrolled in the Group Health Cooperative of Puget Sound Medicare Advantage plan. The Group Health Cooperative is a consumer-governed, staff-model, health maintenance organization of more than 500,000 members.

Table 2. Overview of articles evaluating effects of fitness center membership.

Table 2

Overview of articles evaluating effects of fitness center membership.

Two companion articles assessed the effect of distance from the fitness center23 and history of depression24 on the uptake of fitness center benefits and frequency of use among participants. One additional companion article25 assessed the effect of this benefit on health care costs and utilization among health plan members with diabetes. All variables used in analyses (e.g., patient demographics, costs) were obtained from health plan administrative data. Relevant results are discussed in detail following the table.

KEY QUESTION 1. What are the effects of policy/benefits packages that include vouchers, rebates, premium reductions, or other economic incentives to encourage physical activity through fitness center memberships on:
(a) Physical activity participation rates among plan members?
(b) Health outcomes demonstrated to be improved by physical activity (i.e., weight, pain, glucose, blood pressure, health-related quality of life)?
(c) Overall health care costs and health care utilization?

KQ 1a. Physical Activity Participation

None of the included articles assessed physical activity as a primary outcome. The only metric of physical activity was the frequency of fitness center visits by participants in the Silver Sneakers program such as that reported in the main study22 and one companion article.25 Two additional companion articles assessed the associations between (1) the distance from the fitness center23 and (2) a history of depression24 on the uptake and frequency of use of the health plan-sponsored fitness center membership benefit.

The Silver Sneakers program assessed in all analyses allowed eligible health plan enrollees 65 years of age and older to access selected fitness centers and all activities (e.g., structured conditioning classes) and facilities (e.g., exercise equipment, pool) associated with these fitness centers. Participation in Silver Sneakers was voluntary; participants who opted to enroll contacted their local fitness centers to join. The health plan covered the full cost of memberships for each year; there were no additional costs to the member for the fitness center membership. No other details of the benefit structure or characteristics of selected fitness centers were provided in any of the included articles or through communications with study authors. Visits to the fitness center were documented by swipe cards at participating facilities; average attendance was calculated by dividing all fitness center visits over 2 years by 104 weeks.

In the main study,22 Nguyen et al. used administrative and claims data from a Medicare Advantage plan administered through a health maintenance organization to assess the effects of the fitness center benefit, Silver Sneakers, on health care costs and utilization among adults 65 years of age and older. In these analyses, Silver Sneakers participants (n = 4766) were compared with up to three age-and sex-matched controls (n = 9035) from the same health plan who did not elect to participate in the health plan-sponsored fitness center benefit. The followup interval was 2 years. Silver Sneakers participants were more likely to be male, have arthritis, use more preventive health services, and have higher total health expenditures at baseline than the age- and sex-matched controls. However, Silver Sneakers participants were less likely to have diabetes or congestive heart failure compared with controls. Main study limitations were the inability to (1) control for confounding from potential selection bias that could not be accounted for through analysis, (2) rule out concurrent exposures to other sources of physical activity that may have biased results, and (3) measure quality and type of physical activity; the number of visits to the fitness center was the only measure of physical activity.

In Year 1, Nguyen et al.22 reported that the average number of fitness center visits among Silver Sneakers participants was 75 (median 49; interquartile range [IQR] 11 to 120). In Year 2, the average number of visits declined to 55 (median 12; IQR 0 to 89). While participation dropped in Year 2, 61 percent of participants continued to visit fitness centers.

A separate analysis25 using a subset of members with diabetes (n = 618) from the main study22 also reported the average number of fitness center visits among participants, which was similar to those reported in the main study. Silver Sneakers participants averaged 72 visits in Year 1 and 49 visits in Year 2.

Two companion articles provided information on other factors associated with uptake and frequency of use. In a separate analysis of 1728 Silver Sneakers participants and 4838 nonparticipants, Berke et al.23 found that plan members who chose the fitness center benefit lived closer to fitness centers compared with nonparticipants (p = 0.017; adjusted model). The odds of participating in Silver Sneakers decreased by 1.3 percent for every kilometer farther that a plan member lived from a fitness center. Additionally, participants who lived closer to fitness centers used these facilities more frequently than those who lived farther away. Controlling for age, sex, socioeconomic status, distance from center, use of selected preventive services (e.g., cancer screenings, vaccinations), and composite measure of disease burden (i.e., RxRisk26), participants made an average of 4.2 visits per month (standard deviation 3.4).

In another analysis using Silver Sneakers participant data, Nguyen et al.24 assessed the impact of history of depression as identified by International Classification of Diseases (ICD)-9-CM codes on benefit uptake and patterns of use (n = 13,801; 4766 participants and 9035 matched controls). This analysis found that depression in the 12 months before the start of the Silver Sneakers program was not associated with enrollment in the fitness membership benefit (odds ratio 1.03; 95% confidence interval [CI] 0.89 to 1.20, p=0.67; adjusted model). Participants with a depression diagnosis, however, made fewer visits per month to fitness centers compared with participants who were not depressed (range -0.64 to -1.5 visits). Additionally, depressed participants had a 19-percent higher risk of participation lapse (hazard ratio 1.19; 95% CI 1.04 to 1.37, p=0.01; adjusted model) compared with participants who were not depressed at baseline.

KQ 1b. Physical Health Outcomes

No identified studies addressed KQ 1b.

KQ 1c. Health Care Costs and Utilization

The main study22 and one companion article25 reported the effects of health plan-sponsored fitness center memberships on health care costs and utilization. In adjusted models for Year 1, Nguyen et al.22 reported that adjusted total health care costs were not different between Silver Sneakers participants and nonparticipants (+$2; 95% CI -$341 to +$344, p=0.99). However, participants experienced fewer inpatient admissions (-1.0%; CI -2.1% to -0.1%, p=0.5) but made more primary care visits (+0.40; CI 0.27 to 0.53, p<0.001) and specialty care visits (+0.22; CI 0.11 to 0.33, p<0.001) compared with controls. By the end of Year 2, participants incurred significantly lower total health care costs (-$500; CI -$892 to -$106, p=0.01). This decrease was likely due to fewer inpatient admissions (-2.3%; CI -3.3% to -1.2%, p<0.001) and lower inpatient care costs (-$270; CI -$533 to -$6, p=0.05) compared with controls.

Silver Sneakers participants had significantly more primary care visits (+0.26; CI 0.13 to 0.40, p<0.001) and specialty care visits (+0.25; CI 0.14 to 0.36, p<0.001) for Year 2, which resulted in higher costs for those services (primary care: +$80, p<0.001; specialty care: +$37, p=0.14). There was also evidence of a dose-response by average number of health club visits. Compared with participants who attended fitness centers less than one time per week, participants who averaged two to less than three or three or more visits per week over 2 years had lower adjusted health care costs (2 to < 3 visits -$1252, p<0.001; ≥ 3 visits -$1309, p=0.001).

Another article25 used a subset of participants from the retrospective cohort study.22 Claims data for 2031 older adults with diabetes were examined to assess the impact of Silver Sneakers on health care utilization and costs among this group. Participants with diabetes (n = 618) were more likely to be male, have lower chronic illness burden, use more preventive health services, have more outpatient visits for arthritis, and make more primary and specialty care visits compared to nonparticipants with diabetes (n =1413). Level of diabetes control, age, and total health care costs at baseline were not significantly different between diabetic participants and nonparticipants.

Participants in Silver Sneakers with diabetes had lower adjusted total health care costs compared with age- and sex-matched nonparticipants with diabetes after 1 year of enrollment in the fitness center program ($1633; 95% CI -$2620 to -$646, p=0.001). This cost savings was likely due to fewer hospitalizations (-3.0%, p=0.07) and lower adjusted inpatient costs (-$1021; CI -$1688 to $367, p=0.002). However, in Year 1 diabetic participants had more primary care visits (0.77; CI 0.34 to 1.2, p<0.001) and primary care costs ($129; CI $32 to $266, p=0.009). In Year 2, participants accumulated lower total health care costs, but these savings were not statistically significantly different from diabetic nonparticipants (-$1230; CI -$2494 to $33, p=0.06).

KEY QUESTION 2. What are the effects of policy/benefits packages that include vouchers, rebates, premium reductions, or other economic incentives to encourage physical activity through fitness center memberships on satisfaction with the health plan and retention of members in the health plan?

No identified studies addressed KQ 2.

KEY QUESTION 3. Do the effects of policy/benefits packages to encourage physical activity vary by specific characteristics of the package (premium vs. lump sum) or age, sex, and physical illness of participants?

No identified studies addressed KQ 3.

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