Research article
Cost Effectiveness of Community-Based Physical Activity Interventions

https://doi.org/10.1016/j.amepre.2008.06.040Get rights and content

Background

Physical inactivity is associated with the increased risk of many chronic diseases. Such risks decrease with increases in physical activity. This study assessed the cost-effectiveness of population-wide strategies to promote physical activity in adults and followed disease incidence over a lifetime.

Methods

A lifetime cost-effectiveness analysis from a societal perspective was conducted to estimate the costs, health gains, and cost-effectiveness (dollars per quality-adjusted life year [QALY] gained, relative to no intervention) of seven public health interventions to promote physical activity in a simulated cohort of healthy U.S. adults stratified by age, gender, and physical activity level. Interventions exemplifying each of four strategies strongly recommended by the Task Force on Community Preventive Services were evaluated: community-wide campaigns, individually adapted health behavior change, community social-support interventions, and the creation of or enhanced access to physical activity information and opportunities. Each intervention was compared to a no-intervention alternative. A systematic review of disease burden by physical activity status was used to assess the relative risk of five diseases (coronary heart disease, ischemic stroke, type 2 diabetes, breast cancer, and colorectal cancer) across a spectrum of physical activity levels. Other data were obtained from clinical trials, population-based surveys, and other published literature.

Results

Cost-effectiveness ratios ranged between $14,000 and $69,000 per QALY gained, relative to no intervention. Results were sensitive to intervention-related costs and effect size.

Conclusions

All of the evaluated physical activity interventions appeared to reduce disease incidence, to be cost-effective, and—compared with other well-accepted preventive strategies—to offer good value for money. The results support using any of the seven evaluated interventions as part of public health efforts to promote physical activity.

Introduction

Physical inactivity is a global public health problem, and has been identified as a national public health priority.1, 2, 3 There is clear evidence to link physical inactivity with an increased risk of many chronic diseases, including coronary heart disease (CHD), ischemic stroke, type 2 diabetes, breast cancer, and colorectal cancer.1, 2, 3 The negative health effects of physical inactivity are paralleled by staggering economic consequences: the annual cost directly attributable to inactivity in the U.S. is an estimated $24 billion–$76 billion, or 2.4%–5.0% of national healthcare expenditures.4, 5, 6

Fortunately, modest increases in physical activity have the potential to produce substantial health benefits.7 Further, systematic reviews of population-based interventions to promote health and prevent disease have provided strong evidence that public health efforts can successfully increase physical activity.8, 9 It appears that sustained physical activity initiatives could make substantial contributions to the control of chronic diseases. However, the potential benefits of physical activity promotion have not yet been fully realized, and the majority of adults in the U.S. (54.1%) do not engage in sufficient physical activity to meet public health recommendations.10 This situation presents an important opportunity to evaluate the merits of competing physical activity promotion strategies and to develop effective public health policy. The need for decision making in an environment of uncertainty, scarcity, and competing priorities makes the use of cost-effectiveness analysis (CEA) attractive for public health planning.

These analyses attempt to answer the question How much health improvement can be gained when an intervention is compared, dollar for dollar, with an alternative? Rather than promoting cost savings, the goal of CEA is to determine how money can be spent with maximum public health benefit. Decision-analytic models have been used routinely to guide important public health policy decisions, from airbag regulation in motor vehicles and the widespread use of pneumococcal vaccine in older adults11, 12 to the improvement of cervical cancer screening practices globally.13 Models have also been used to influence clinical practice guidelines for cardiovascular disease prevention14, 15 and to promote national anti-tobacco education efforts.16 Markov models, which consider probabilistic events over time, are particularly well-suited to evaluate population-based health promotion efforts and to examine outcomes over an extended period of time.

The purpose of this study was to evaluate the cost-effectiveness (dollars per quality-adjusted life year [QALY] gained) of seven exemplar interventions to increase physical activity, relative to no intervention, as well as to follow disease incidence over a lifetime. This study is the first to integrate the best available epidemiologic and intervention data on physical activity into a CEA of the most promising public health interventions for physical activity promotion.

Section snippets

The CDC Measurement of the Value of Exercise (MOVE) Model

A comprehensive, flexible, state-transition Markov model was developed from a societal perspective to estimate the lifetime costs, health gains, and cost-effectiveness of population interventions that promote physical activity among U.S. adults. Cost-effectiveness is defined as the ratio of incremental costs (dollars) to incremental QALYs. The incremental cost is the difference between the total expected cost of the intervention and the total expected cost of no intervention. Incremental QALYs

Average Cost Effectiveness

Estimates of the population health and economic outcomes associated with each intervention are shown in Table 4. Summarized are the average costs, effectiveness, and cost-effectiveness ratios associated with a one-time application of each physical activity promotion intervention relative to no intervention. Results are cumulative over a 40-year time-horizon for the whole U.S. population, aged 25–64 years, but average per-person values are reported here. Absent any new intervention to improve

Conclusion

All of the evaluated physical activity interventions were found to be cost-effective and offered good value for money, with gains in both survival and health-related QOL, and with reasonable cost-per-QALY and cost-per-life-year ratios. These results support using any of the seven evaluated interventions as part of public health efforts to promote physical activity. Factors specific to implementing interventions within a given strategy and setting may introduce greater variability in

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