title: A systematic review and economic evaluation of exercise referral schemes in primary care: a short report.
abstract: BACKGROUND
  It is estimated that only 39% of men and 29% of women in England achieve the levels of physical activity that are recommended to protect health and prevent disease. One approach to addressing this problem has been the development of exercise referral schemes (ERSs), in which health professionals refer patients to external exercise providers. These schemes have been widely rolled out across the UK despite concerns that they may not produce sustained changes in levels of physical activity and, therefore, may not be cost-effective interventions. The evidence to determine clinical effectiveness and cost-effectiveness was evaluated in 2009. This review seeks to update this earlier work by incorporating new evidence and re-examining the cost-effectiveness.
  
  
  OBJECTIVE
  To assess the clinical effectiveness and cost-effectiveness of ERSs compared with usual care.
  
  
  METHODS
  Exhaustive searches of relevant electronic databases and journals were undertaken to identify new studies evaluating ERSs using a randomised controlled trial (RCT) design. RCTs that incorporated a qualitative evaluation of the intervention were identified in order to explore the barriers and facilitators to the uptake of and adherence to ERSs. Data were extracted using a previously designed tool and study quality assessed for potential bias. Where data could be pooled, meta-analyses were carried out. Qualitative analysis was also undertaken using a thematic approach. The cost-effectiveness was evaluated using a Markov structure which estimated the likelihood of becoming physically active and the subsequent risk reduction on coronary heart disease (CHD), stroke and type 2 diabetes mellitus. The model adopts a lifetime horizon, and a NHS and Personal Social Services perspective was taken with discounting at 1.5% for both costs and benefits.
  
  
  RESULTS
  The search identified one new RCT and one new qualitative study. The new data were pooled with existing data from the 2011 review by Pavey et al. [Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2011;15(44)] to give a total of eight studies with 5190 participants. The proportion of individuals achieving 90-150 minutes of at least moderate-intensity activity per week at 6-12 months' follow-up was greater for ERSs than usual care (relative risk 1.12; 95% confidence interval 1.04 to 1.20). Older patients and those referred for CHD risk factors appeared to be more likely than others to increase their levels of physical activity. Qualitative evidence suggests that interventions enabling the development of social support networks are beneficial in promoting uptake and adherence. Exercise referral gained 0.003 quality-adjusted life-years (QALYs) at an additional cost of £225 per person. The estimated mean incremental cost-effectiveness ratio (ICER) in the probabilistic sensitivity analysis was £76,276. In the univariate sensitivity analysis the results were very sensitive (ICERs ranged from < £30,000 to > £100,000) to changes in the effect of ERSs on physical activity uptake and the duration of the protective effects and the direct health-related quality-of-life gains attributable to physical activity.
  
  
  CONCLUSIONS
  Exercise referral schemes result in a small improvement in the number of people who increase their levels of physical activity. The cost-effectiveness analysis indicates that the ICER for ERSs compared with usual care is around £76,000 per QALY, although the cost-effectiveness of ERSs is subject to considerable uncertainty.
  
  
  BACKGROUND
  This study is registered as PROSPERO CRD42013005200.
  
  
  BACKGROUND
  National Institute for Health Research Health Technology Assessment programme.
authors.affiliation: Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Campbell
authors.affiliation: Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Mike
authors.initials: M
authors.lastname: Holmes
authors.affiliation: Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Emma
authors.initials: E
authors.lastname: Everson-Hock
authors.affiliation: Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Davis
authors.affiliation: Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Buckley Woods
authors.affiliation: Health Economics Research Group (HERG), Brunel University, Uxbridge, UK.
authors.forename: Nana
authors.initials: N
authors.lastname: Anokye
authors.affiliation: Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Tappenden
authors.affiliation: Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Eva
authors.initials: E
authors.lastname: Kaltenthaler
mesh_terms: D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D003924:Diabetes Mellitus, Type 2 / Q000517:prevention & control*; D004739:England; D015444:Exercise; D006801:Humans; D008390:Markov Chains; D017059:Models, Econometric; D011320:Primary Health Care / Q000458:organization & administration*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D012017:Referral and Consultation / Q000191:economics*; D013222:State Medicine