Physical activity on prescription in primary care. Impact on physical activity level, metabolic health and health-related quality of life, and its cost-effectiveness - a short- and long-term perspective

Abstract: Non-communicable diseases (NCDs) are the leading cause of death globally and one of the major health challenges of the 21st century. In Sweden, NCDs are estimated to account for 90 % of all deaths. Strong evidence indicates a relationship between regular physical activity (PA) and positive health effects, and that PA can be used to prevent and treat diseases. In Sweden, licensed healthcare professionals offer PA on prescription (PAP) as a method of supporting patients to increase their PA level. PAP treatment includes three core components: an individualized dialogue; an individually dosed PA recommendation, including a written prescription; and a structured follow-up. PAP treatment is underutilized in Swedish health care, and further studies are needed to elucidate effective PAP treatment strategies. The Gothenburg PAP study on which this thesis is based started in 2010 at 15 health care centers (HCCs) that offered PAP to 444 patients (aged 27–85 years) who were physically inactive with metabolic risk factors, between 2010 and 2014 and followed them for 5 years. The overall aim of this thesis was to evaluate the Swedish PAP treatment regarding PA level, metabolic health, and health-related quality of life (HRQOL) for patients who were physically inactive with metabolic risk factors, and to explore factors that may predict an increased PA level. Furthermore, this thesis aimed to evaluate two different PAP treatment strategies, supported by either the HCC or a physiotherapist (PT), for patients who still had not reached a sufficient PA level after a prior 6-month period of PAP treatment. The cost-effectiveness of the two PAP strategies was also evaluated in a health economics study. A prospective observational study evaluated 6 months of PAP treatment in daily clinical care at 15 HCCs in Gothenburg. During this 6-month period, 80 % of the patients received PAP support from caregivers once or twice, 73 % increased their PA level and 42 % moved from an inadequate PA level to sufficient according to public health recommendations. Significant improvements were seen in a majority of the metabolic risk factors and HRQOL components measured, and associations were found between changes in the PA level and health outcomes (Paper I). We also identified potential predictive factors for increased PA after a 6-month PAP intervention: positively valued self-efficacy, preparedness, and physical health, and BMI < 30 kg/m2. Among patients with the lowest PA levels at baseline, 84 % had increased their PA level at the 6-month follow-up. In the patient group with 1 to 3 positively valued predictive factors included, 87–95 % had increased their PA level. (Paper II). In a randomized controlled trial, 190 patients who still had not achieved sufficient PA levels after 6 months of PAP treatment, described in Papers I and II, were randomized to continued, 2-year PAP intervention supported either by a PT or the HCC. Both long-term PAP interventions increased the PA level, metabolic health, and HRQOL with no difference between groups. Results appeared to be independent of any changes in pharmacological treatment. The study suggested that the continuous support and the duration of the intervention may be most important factors for increasing PA (Paper III). Finally, in a health economic evaluation of 3 years of PAP treatment, a costeffectiveness analysis compared the two PAP treatment strategies described in Paper III. From the societal perspective, the cost per gained quality adjusted life years (QALY) for the PT group compared to the HCC group was 147 250 SEK. The willingness to pay for a QALY needed to be > 150 000 SEK for the PT strategy to be a cost-effective choice compared to the HCC strategy indicating a moderate level of costs per QALY. Due to similar results in both groups, it was not possible to draw certain conclusions about the most cost-effective strategy; none of strategies could certainly be chosen before the other (Paper IV). In summary, this thesis shows that, in ordinary primary health care, both short- and long-term PAP treatment can be a feasible intervention to increase PA, metabolic health, and HRQOL in adult patients who are physically inactive and have at least one metabolic risk factor. These results seem to be most pronounced among patients with the lowest PA levels. Furthermore, improvement occurs in regards to metabolic risk factors, benefitting several aspects of life for the patients and reducing the cost and strain for the public health service. The identification of predictive factors for increased PA levels (positively valued self-efficacy, preparedness, and physical health, and BMI < 30 kg/m2) and the benefit of long-term PAP is essential. These findings offer clinicians an opportunity to better support patients’ behavioral changes and the individualization of PAP treatment. In optimizing the support for patients, we need educated, skilled healthcare professionals with knowledge about PAP, structured routines, and organizational support. The findings in this thesis may also create the opportunity for more widespread use of PAP as an important method of gaining health benefits for physically inactive patients.