Prescribed physical activity. A health economic analysis.

Abstract: The overall aim of this thesis was to estimate health economic consequences of the four-month primary care program ”Physical Activity on Prescription (PAP)”. Inactivity means a highly increased independent risk factor for public health diseases and morbidity, and is an economic burden to society. Evidence for cost effective interventions aiming at increasing physical activity (PA) level among inactive individuals is limited, why health economic evaluations are an important tool when arranging priorities in health care sector. Promoting PA among inactive individuals within primary health care with a prescription of exercise has shown to be effective in terms of significantly increasing physical activity levels. The Swedish FaR® concept can be seen as a concept for improving physical activity behaviour to meet public health guidelines for a sufficient level of physical activity. The program has been implemented as a concept in Swedish health care, but without a common model nationwide. The present concept of the PAP-program in the south-east health care district of Region Skåne, Sweden was based on an existing program with treatment perspective. Specifically, the aims of the different studies were to analyze costs and consequences of changing PA behaviour from the 4-month PAP-program paper I, to analyze the willingness to pay (WTP) for health effects of physical activity due to the PAP-program, and examine predictors for the WTP paper II, to analyze the cost offset of changing the PA behavior and motivation after 1 year paper III, and to analyze the benefits in terms of quality of life and cost per QALY, respectively paper IV. The study was a randomized clinical trial with a 4-month intervention. In all, 528 inactive individuals were randomized to either a high-dose or a low-dose group. The high-dose group consisted in supervised group exercise sessions twice a week during 4 months on a moderate-intense level, education in physical activity, and a motivational counselling. The low-dose group received written information on the possibility to participate in supervised exercise groups once a week on a moderate-intense level in local fitness centres. Results: A cost-consequences analysis (n=242) showed intention-to-treat program average programme costs per participant for the 4 month PAP-program being SEK 6475 for the high-dose group and SEK 3038 for the low-dose group paper 1. The largest cost was the individuals’ time cost. PA level improved significantly, with no differences between the groups. In paper II, a WTP-analysis (n=128) showed no significant differences for different health improvements between a high- and a low-dose group, and that WTP for health improvements of physical activity is influenced by a higher education level, income and BMI. Paper III examined cost-minimization and motivation of the programme at a 1 year follow-up (n=178, 95 in the high-dose group and 83 in the low-dose group), with a drop-out rate of 66% in both groups together. The results of a significantly improved PA level in paper II were confirmed in this study. There were no differences in motivation among completers and non-completers of the PAP-program. The cost offset consisted in reduced health care costs and value of lost production due to reduced inactivity, and was equal to 22%. The cost-utility analysis in paper IV of the 178 individuals that returned for the 1-year follow-up showed that the PAP-program is cost-effective, and the cost per QALY, 323,750 SEK and 101,267 SEK for the high- and low-dose group, is considered moderate according to Swedish reference values. A low-dose group was more cost-effective and had larger improvements in QoL than a high-dose group. QoL improved significantly in the low-dose group and in both groups together. Conclusions: The PAP-program showed that it was possible to make inactive individuals more physically active through intervention. Significant improvements in PA behaviour were shown in a one-year follow-up analysis. The results of this program of prescribed exercise showed significant increased QoL one year after intervention in a low-dose group. The best adherence for the PAP-program was found for elderly and those with relatively good baseline health. These individuals constitute the target population for this prescription based exercise program. Identifying the target population for participation in health promoting activity groups like the PAP-program is necessary for adherence, effectiveness and cost-effectiveness of a program. The PAP-program is cost-effective as shown in a cost-utility analysis conducted in the study. The costs per QALY estimates were considered moderate regarding to Swedish comparative values. This makes the program a method worthwhile for society. The program was most cost-effective for a low-dose group. This was showed with lower costs associated with the low-dose group, and larger improvements in QoL. An increased availability of exercise would reduce the individual’s time cost for travelling, and cost for travel. The inactive individual’s preferences for improved health through exercise were influenced by a higher education level, income and BMI. The PAP-program can reduce the society´s costs for inactivity by 22% per individual, every year the individual stays active.