The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation

Physical activity to reduce the burden of frailty after menopause: effectiveness and adherence rate of a resource saving exercise plan

OBJECTIVE

Frailty may be increased by menopause. Physical activity has been proposed to reduce frailty, but poor adherence and cost limit effectiveness. We aimed to investigate both the effectiveness against the frailty burden and the adherence rate of a multicomponent physical activity scheme partially managed by the participating women themselves.

METHODS

Prospective controlled study consisting of a twice-weekly group physical activity scheme divided into two consecutive periods, one supervised by a health professional (12 wk) and the other supervised by the women themselves (36 wk). Group cohesion and mutual support during the patient-only period were aided by social networking via smartphones. Community-dwelling postmenopausal women were divided into a physical activity group (PAG = 126) and a usual activity control group (UAG = 126), both assessed at baseline and at the end of the study. Participants self-assigned to one of the two study arms.

RESULTS

Overall, women in the PAG were more likely to improve their frailty status (60.2% vs 42.6%, P < 0.05). The frailty reversal rate from prefrail to robust was significantly higher in the PAG than in the UAG (34.04 vs 8.00%, P < 0.05). Logistic regression confirmed that women in the PAG were more likely to improve their frailty phenotype (odds ratio [OR], 9.12; 95% confidence interval [CI], 3.45-31.52; P < 0.001). Adherence, defined by participants attending 75% of sessions, was attained by 56.35% of women at 48 wk.

CONCLUSION

A physical activity scheme implemented to improve frailty proved effective and attained acceptable adherence. Conditions in the peer-supervised 36-wk phase may increase sustainability.

Health and lifestyle advisors in support of primary care: An evaluation of an innovative pilot service in a region of high health inequality

INTRODUCTION

A health and lifestyle advisor service embedded within primary care was piloted in Kingston-upon-Hull from January 2021. We aimed to evaluate the first two years of service delivery by identifying patient demographics referred to the service, reason for referral, determine uptake and retention rates, and monitor individual lifestyle-related risk factor changes following discharge.

METHODS

Anonymised data were extracted from the SystmOne database for all patients referred to the service between January 2021 and January 2023.

RESULTS

In the initial two years of the service, 705 unique patients were referred at a mean rate of ∼29 per month. Each unique patient received a median (robust median absolute deviation; [MAD]) of 3 (Steel N, et al 2018) planned consultations prior to discharge over this period. The majority of referrals were for symptom management and health promotion purposes (95%). Of those referred, 69% attended their appointments, and 14% did not attend. The majority of referrals were white British (55%), however, the service did receive a substantial number of referrals from minority ethnic groups, with only 67% of referrals speaking English as their main language. Eighteen distinct languages were spoken. Most referrals were classified as class I obese (59.4%). Across initial and final appointments, median (robust MAD) systolic blood pressure was 130 (15) mmHg and 130 (15) mmHg, and median (robust MAD) waist circumference was 103.0 (13.3) cm and 101.0 (13.3) cm.

CONCLUSION

The evaluation highlighted the demand for this service embedded within primary care settings in Kingston-upon-Hull. Service engagement was evident, and a large proportion of those who engaged were from minority ethnic groups. A high proportion of referrals presented with obesity and/or hypertension which requires further investigation.

Health and Productivity Benefits with Early Intensified Treatment in Patients with Type 2 Diabetes: Results from Korea

The available evidence suggests positive health outcomes associated with early treatment intensification in Type 2 diabetes mellitus (T2DM). Our study estimated the productivity effects arising from improved health correlated with early intensified treatment in T2DM in Korea. Using a recently published methodology and model, we investigated the association between early intensified treatment and the probability of experiencing fewer diabetes-related complication events. Treatment strategies leading to better health outcomes are expected to be associated with social value through increased participation in paid and unpaid work activities. Therefore, we translated the lower incidence of complications into monetary terms related to productivity for the Korean population. We quantified productivity by considering (a) absenteeism, (b) presenteeism, (c) permanent loss of labor force, and (d) activity restriction. Deterministic and probabilistic sensitivity analyses in the base case parameter were performed. Approximately, 1.7 thousand (standard deviation [SD] ±580 events) micro- and macrovascular complication events could potentially be avoided by early treatment intensification. This led to a societal gain attributed to increased productivity of 23 million USD (SD ± $8.2 million). This article demonstrates the likelihood of achieving better health and productivity through early intensified treatment in diabetes.

Medical Costs Associated With Diabetes Complications in Medicare Beneficiaries Aged 65 Years or Older With Type 2 Diabetes

OBJECTIVE

To estimate medical costs associated with 17 major diabetes-related complications and treatment procedures among Medicare beneficiaries aged ≥65 years with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Claims data from 100% of Medicare beneficiaries enrolled in fee-for-service plans from 2006 to 2017 were analyzed. Records with type 2 diabetes and complications were identified using ICD-9, ICD-10, and diagnosis-related group codes. The index year was the year when a person was first identified as having diabetes with an inpatient claim or an outpatient claim plus another inpatient/outpatient claim in the 2 years following the first claim in Medicare. Included individuals were followed from index years until death, discontinuation of plan coverage, or 31 December 2017. Fixed-effects regression was used to estimate the cost in years when the complication event occurred and in subsequent years. The total cost for each complication was calculated for 2017 by multiplying the complication prevalence by the cost estimate. All costs were standardized to 2017 U.S. dollars.

RESULTS

Our study included 10,982,900 beneficiaries with type 2 diabetes. Follow-up ranged from 3 to 10 years. The three costliest complications were kidney failure treated by transplant (occurring year $79,045, subsequent years $17,303), kidney failure treated by dialysis ($54,394, $38,670), and lower-extremity amputation ($38,982, $8,084). Congestive heart failure accounted for the largest share (18%) of total complication costs.

CONCLUSIONS

Costs associated with diabetes complications were substantial. Our cost estimates provide essential information needed for conducting economic evaluation of treatment and programs to prevent and delay diabetes complications in Medicare beneficiaries.

The societal impact of early intensified treatment in patients with type 2 diabetes mellitus

Aim: The current study estimates the societal impact of early intensified treatment compared with initial monotherapy with subsequent treatment intensification in newly diagnosed adults with type 2 diabetes mellitus in Mexico. Methods: An individual patient-level simulation and a static cohort model were employed to simulate the treatment pathway and the probability of experiencing complications of diabetes. The avoided number of events was translated into avoided productivity losses, which were monetized using wages. Results: Patients on early intensified treatment experienced approximately 13,000 fewer complication events over 10 years. This was translated into a societal impact of $54 million (USD). Conclusion: Early treatment intensification is likely to be of particular benefit to health outcomes and productivity losses.

Dose-Response Association between Physical Activity and Health-Related Quality of Life in General Population: A Population-Based Pooled Study

Objective: The objective of this study was to examine the dose−response association between moderate-to-vigorous intensity physical activity (MVPA) and health-related quality of life (HRQoL) within the context of a large representative national survey from Wales, in the UK. Methods: Data for adults aged 16 years and older, living in Wales, UK, and participating in the Welsh Health Survey (WHS; 2011−2015) were employed. HRQoL was assessed using the 36-item short form (SF-36). Participants were categorized into six groups based on weekly minutes (min/week) of MVPA variable: none (no MVPA); very low (>0 to <90); low (≥90 to <150); sufficient (150 to <300); high (≥300 to <390); and very high (≥390). The association between MVPA and HRQoL was explored using multiple linear regression and generalized linear models. Results: Of the 74,578 adults in the survey cohort, 67,770 adults were included in the analyses. The results showed consistent direct curvilinear associations between MVPA and HRQoL for all SF-36 domains (p < 0.001), in both the minimally and maximally adjusted models; with the highest scores observed for those meeting the recommended physical activity guidelines (sufficient, high, and very high). The scores of the overall HRQoL and SF-36 domains demonstrated a consistent positive gradient from the very low level to the sufficient level, suggesting a dose−response relationship. Conclusions: The results showed a direct curvilinear association between MVPA and the overall HRQoL and SF-36 domains, with better scores observed for those meeting the recommended guidelines.

Cost-effectiveness of a programme to address sedentary behaviour in older adults: results from the SITLESS RCT

Background

This study details the within-trial economic evaluation and long-term economic model of SITLESS, a multi-country, three-armed randomized controlled trial comparing a combined intervention of exercise referral schemes (ERS) enhanced by self-management strategies (SMS) against ERS alone and usual care (UC).

Methods

A cost-utility analysis, conducted from the base-case perspective of the National Health Service and personal and social services, estimated the incremental cost per incremental quality-adjusted life year (QALY) and years in full capability (YFC). A secondary analysis combined the costs with a broad set of outcomes within a cost-consequence framework, from a societal perspective. A Markov-type decision-analytic model was developed to project short-term changes in physical activity to long-term outcomes and costs, over a 5- and 15-year time horizon.

Results

The results of the within-trial analysis show that SMS+ERS is highly likely to be cost-effective compared to ERS alone (ICER €4270/QALY), but not compared to UC. Participants allocated to the SMS+ERS group also showed an improvement in YFC compared to ERS alone and UC. The long-term analysis revealed that SMS+ERS is likely to be a cost-effective option compared to ERS and UC over a 5-year, but not with a 15-year horizon, being then dominated by ERS alone.

Conclusion

This research provides new evidence that SMS is a cost-effective add-on to ERS strategies. This economic evaluation informs the case for further, cost-effective, refinement of lifestyle change programmes targeted to older adults, with the aim of ultimately reducing the impact of non-communicable diseases in this population.

Healthy and unhealthy eating after a behaviour change intervention in primary care

BACKGROUND

To prevent and reduce non-communicable diseases, the Norwegian Directorate of Health encourages Healthy Life Centres (HLCs) in all municipalities.

AIMS

This study investigates whether the behaviour change interventions at HLCs positively affected participants' diet and to evaluate predictors for healthy and unhealthy eating. Our data are part of the Norwegian Healthy Life Centre Study, a 6-month, pragmatic randomised controlled trial (RCT).

METHODS

Totally, 118 participants ≥18 years old were randomised to an intervention group (n 57), or a waiting list (control group) (n 61). Eighty-six participants met at the 6 months follow-up visit. We merged the participants to one cohort for predictor analyses, using linear regressions.

FINDINGS

The RCT of the HLCs' interventions had no effect on healthy and unhealthy eating 6 months after baseline compared with controls. A short, additional healthy eating education programme produced a modest, statistically significant improvement in healthy eating compared with controls. This did not, however, reduce unhealthy eating. Higher income predicted unhealthier eating over time. Increasing body mass index and impaired physical functioning also led to an increase in unhealthy eating. Healthy eating at 6 months was predicted by self-rated health (SRH), vitality and life satisfaction, and hampered by musculo-skeletal challenges and impaired self-esteem (SE). SRH impacted improvement in healthy eating during the 6 months. The effect of interventions on healthier eating may be improved by an emphasis on developing positive self-concepts like better SRH, vitality, life satisfaction, and SE.

Evaluation of the uptake, retention and effectiveness of exercise referral schemes for the management of mental health conditions in primary care: a systematic review

BACKGROUND

Exercise is a recognised element of health-care management of mental-health conditions. In primary health care, it has been delivered through exercise referral schemes (ERS). The National Institute for Health and Care Excellence has highlighted uncertainty regarding the effectiveness of ERS in improving exercise participation and health outcomes among those referred for mental-health reasons. This review aims, therefore, to evaluate ERSs for individuals who are referred specifically for mental-health reasons.

METHODS

Studies were reviewed that assessed the effectiveness of ERSs in improving initiation of and/or adherence to exercise and/or their effectiveness in improving long-term participation in exercise and health outcomes among primary care patients who had been referred to the scheme for mental-health reasons. The data were extracted and their quality assessed. Data were analysed through a narrative synthesis approach.

RESULTS

Nine studies met the eligibility criteria. Three assessed clinical effectiveness of the schemes, eight assessed ERS uptake and/or adherence to the exercise schedule, and two assessed the impact of the ERSs on long-term exercise levels. In one study, it was found that ERSs that were based in leisure centres significantly improved long-term symptoms in those who had been referred due to their mental ill health (P<0.05). ERSs that involved face-to-face consultations and telephone calls had the highest rates of mean uptake (91.5%) and adherence (71.7%), but a difference was observed between uptake/adherence in trials (86.8%/55.3%) and in routine practice (57.9%/37.2%). ERSs that included face-to-face consultations and telephone calls increased the amount of long-term physical activity that was undertaken by people who had been referred for mental-health reasons (P=0.003).

CONCLUSIONS

Uptake and effectiveness of ERSs for mental health conditions was related to programme content and setting with more effective programmes providing both face-to-face and telephone consultations. Good uptake of yoga among those referred for mental health reasons suggests that mindful exercise options should be investigated further. Existing ERSs could be improved through application of individual tailoring and the provision of more face-to-face consultations, and social support. Further research is required to identify the types of ERSs that are most clinically effective for those with mental ill health.

Exercise Referral Instructors' Perspectives on Supporting and Motivating Participants to Uptake, Attend and Adhere to Exercise Prescription: A Qualitative Study

Exercise referral schemes are designed to support people with non-communicable diseases to increase their levels of exercise to improve health. However, uptake and attendance are low. This exploratory qualitative study aims to understand uptake and attendance from the perspectives of exercise referral instructors using semi-structured interviews. Six exercise referral instructors from one exercise referral scheme across four exercise referral sites were interviewed. Four themes emerged: (i) the role that instructors perceive they have and approaches instructors take to motivate participants to take-up, attend exercise referral and adhere to their exercise prescription; (ii) instructors' use of different techniques, which could help elicit behaviour change; (iii) instructors' perceptions of participants' views of exercise referral schemes; and (iv) barriers towards providing an exercise referral scheme. Exercise referral instructors play an important, multifaceted role in the uptake, attendance and adherence to exercise referral. On-going education and peer support for instructors may be useful. Instructors' perspectives help us to further understand how health and leisure services can design successful exercise referral schemes.

Cost-effectiveness of exercise referral schemes: a systematic review of health economic studies

Background

This systematic review aimed to provide an overview of the existing literature on cost-effectiveness of exercise referral schemes (ERSs).

Methods

A systematic search was performed in MEDLINE, EMBASE, EconLit, Web of Science and PsycINFO. Main inclusion criteria were: (1) insufficiently active people; (2) ERSs and (3) full health economic evaluations. No publication year limits were applied. The methodological quality was assessed independently by two reviewers using the Consensus Health Economic Criteria (CHEC) checklist.

Results

Fifteen eligible publications were retrieved, presenting results of 12 different studies. Compared with usual care, ERSs were found to be cost-effective in a majority of the analyses, but with modest health gains and costs per individual. These cost-effectiveness results were also sensitive to small changes in input parameters. Two studies found that ERSs combined with a pedometer/accelerometer are cost-effective, compared with usual ERS practice. Two other studies found that an ERS with phone support and an ERS with face-to-face support might be equally effective, with similar costs.

Conclusion

Although the literature demonstrated that ERSs could be cost-effective compared with usual care, these results were not robust. Based on a small number of studies, ERSs could be optimized by using tracking devices, or by providing a choice to the participants about the delivery mode. There is need for clarity on the effectiveness of and attendance to ERS, as more certainty about these key input parameters will strengthen health-economic evidence, and thus will allow to provide a clearer message to health policy-makers.

Charter to establish clinical exercise physiology as a recognised allied health profession in the UK: a call to action

The UK population is growing, ageing and becoming increasingly inactive and unfit. Personalised and targeted exercise interventions are beneficial for ageing and the management of chronic and complex conditions. Increasing the uptake of effective exercise and physical activity (PA) interventions is vital to support a healthier society and decrease healthcare costs. Current strategies for exercise and PA at a population level mostly involve self-directed exercise pathways, delivered largely via the fitness industry. Even for those who opt-in and manage to achieve the current recommendations regarding minimum PA, this generic ‘one-size-fits-all’ approach often fails to demonstrate meaningful physiological and health benefits. Personalised exercise prescription and appropriate exercise testing, monitoring and progression of interventions for individuals with chronic disease should be provided by appropriately trained and recognised exercise healthcare professionals, educated in the cognate disciplines of exercise science (eg, physiology, biomechanics, motor control, psychology). This workforce has operated for >20 years in the Australian public and private healthcare systems. Accredited exercise physiologists (AEPs) are recognised allied health professionals, with demonstrable health and economic benefits. AEPs have knowledge of the risks and benefits of distinct forms of exercise, skills in the personalised prescription and optimal delivery of exercise, and competencies to support sustained PA behavioural change, based on the established scientific evidence. In this charter, we propose a road map for the training, accreditation and promotion of a clinical exercise physiology profession in the UK.

The Active Hospital pilot: A qualitative study exploring the implementation of a Trust-wide Sport and Exercise Medicine-led physical activity intervention

BACKGROUND

In 2017 Public Health England and Sport England commissioned a Consultant-led Sport and Exercise Medicine (SEM) pilot to test the feasibility and acceptability of embedding physical activity interventions in secondary care clinical pathways. The aim of this paper is to report qualitative findings exploring the experience of healthcare professionals (HCPs) and patients involved in the Active Hospital pilot.

METHODS

Qualitative data was collected by semi-structured interviews with Active Hospital pilot SEM Consultants, and staff and patients involved in three clinical pathways. Interviews with SEM Consultants explored the experience of developing and implementing the pilot. Interviews with staff and patients explored the experience of delivering and receiving Active Hospital interventions. Data were analysed thematically.

RESULTS

Interviews identified the importance of the Active Hospital pilot being Consultant-led for the following reasons; i) having trusting relationships with decision makers, ii) having sufficient influence to effect change, iii) identifying champions within the system, and iv) being adaptable to change and ensuring the programme fits within the wider strategic frameworks. HCPs emphasised the importance of the Active Hospital interventions fitting easily within existing work practices, the need for staff training and to tailor interventions for individual patient needs. The Active Hospital pilot was well received by patients, however a lack of dedicated resource and capacity to deliver the intervention was highlighted as a challenge by both patients and HCPs.

CONCLUSION

The SEM Consultants' ability to navigate the political climate of a large National Health Service (NHS) Trust with competing agendas and limited resource was valuable. The interventions were well received and a valued addition to usual clinical care. However, implementation and ongoing delivery of the pilot encountered challenges including lack of capacity within the system and delays with recruiting to the delivery teams in each pathway.

Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Background

As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain.

Objectives

To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention.

Data sources

Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews.

Design

Realist evidence synthesis and co-design for primary care service innovation.

Setting

Primary care in Wales and England.

Participants

Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers.

Methods

The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation.

Results

Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change.

Limitations

Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts.

Conclusions

We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention.

Future work

A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial.

Study registration

This study is registered as PROSPERO CRD42018103027.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

Physical activity referral scheme components: a study protocol for systematic review and meta-regression

INTRODUCTION

In its attempt to establish effective physical activity promotion methods, research on physical activity referral schemes (PARS) is attracting significant attention. Sometimes known as physical activity on prescription schemes, PARS involve a well-defined procedure whereby a primary healthcare professional introduces a participant to the topic of physical activity and employs prescription or referral forms to connect the participant to physical activity opportunities, such as local fitness offers. The planned systematic review will focus on these referral routes and scheme components and how they are integrated into various PARS models worldwide. We seek to identify the evidence-based core components that play the most important roles in the effectiveness of PARS.

METHODS AND ANALYSIS

The development and reporting of the protocol follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We plan to conduct a systematic main literature search on PubMed, Scopus, Web of Science, CINAHL, HTA, SpringerLink and other databases. We will include studies that report outcomes on physical activity, PARS uptake and adherence rates or descriptive information about PARS models. We intend for all review stages, citation screening, data extraction and risk of bias assessment to be conducted by at least two independent reviewers. As a broad spectrum of study designs, including randomised and non-randomised studies of interventions and mixed methods, will be eligible, we will use three separate tools to assess the risk of bias in individual studies. The data will be primarily synthesised narratively, following Intervention Component Analysis. If the data allow, we will perform a random-effects meta-analysis and meta-regression to investigate the impact of specific PARS components on effect sizes.

ETHICS AND DISSEMINATION

This systematic review does not require formal ethics approval. The results will be submitted to a peer-reviewed journal and international conferences to reach the scientific community.

PROSPERO REGISTRATION NUMBER

CRD42021233229.

The Mediating Role of Self-Regulation and Self-Efficacy on Physical Activity Change in Community-Dwelling Older Adults (≥65 Years): An Experimental Cross-Lagged Analysis Using Data From SITLESS

Improving the capacity for physical activity interventions to maintain behavior change is a key public health concern and an important strategy for the health and independence of older adults. Ways of ensuring effective maintenance of physical activity levels in older adults are unclear. This study includes the objective measure of moderate-to-vigorous physical activity (MVPA); self-reported self-efficacy; and self-regulation at four timepoints (baseline, intervention completion at 4 months, 12-, and 18-month follow-up) from the SITLESS study, a clinical trial conducted with a cohort of community-dwelling older adults (≥65 years) from Denmark, Germany, Spain, and the United Kingdom. A cross-lagged analysis found that self-regulation and self-efficacy may be key determinants of MVPA behavior in community-dwelling older adults. More specifically, the use of behavioral support strategies represents an important correlate of MVPA behavior, and its association with MVPA may be mediated by self-regulation and self-efficacy in older adults in the short and long term.

The match between what is prescribed and reasons for prescribing in exercise referral schemes: a mixed method study

Background

Exercise referral schemes (ERS) aim to tackle non-communicable disease (NCD) by increasing physical activity levels through prescribed exercise. However, there is a sparsity of knowledge upon what exercises are prescribed and if they are targeted towards tackling NCD.

Method

Mixed methods were employed. Quantitative data was extracted from exercise prescription cards of 50 participants and were assessed for frequency, intensity, type and time of prescribed exercise. Descriptive measures of aggregate data are expressed as median (range: minimum-maximum). Thematic analysis of semi-structured interviews generated qualitative data on exercise referral instructors’ experiences of prescribing exercise.

Results

Thirty-eight different types of exercise were prescribed. Median prescription was 4 (1–11) exercises per session, at a moderate intensity. Participants were prescribed a median of 35 (5–70) minutes of aerobic exercise per referral session. Exercise referral instructors prescribed exercise to improve activities of daily living, promote independence and autonomy of participants, rather than explicitly targeting the referral condition.

Conclusions

Knowledge that prescribed exercises are not explicitly targeted to the referral condition provides critical information in understanding the purpose of exercise prescription. Future evaluations of ERS should be mindful of this, that is, perceived outcomes might not match up to what is being prescribed within ERS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11094-z.

Patient perspectives on tablet-based technology to collect risk factor information in primary care

BACKGROUND

Primary care provides an opportunity to introduce prevention strategies and identify risk behaviours. Algorithmic information technology such as the Risk Factor Identification Tool (RFIT) can support primary care counseling. This study explores the integration of the tablet-based RFIT in primary care clinics to support exploration of patient risk factor information.

METHODS

Qualitative study to explore patients' perspectives of RFIT. RFIT was implemented in two primary care clinics in Manitoba, Canada. There were 207 patients who completed RFIT, offered to them by eight family physicians. We conducted one-on-one patient interviews with 86 patients to capture the patient's perspective. Responses were coded and categorized into five common themes.

RESULTS

RFIT had a completion rate of 86%. Clinic staff reported that very few patients declined the use of RFIT or required assistance to use the tablet. Patients reported that the tablet-based RFIT provided a user-friendly interface that enabled self-reflection while in the waiting room. Patients discussed the impact of RFIT on the patient-provider interaction, utility for the clinician, their concerns and suggested improvements for RFIT. Among the patients who used RFIT 12.1% smoked, 21.2% felt their diet could be improved, 9.3% reported high alcohol consumption, 56.4% reported less than 150 min of PA a week, and 8.2% lived in poverty.

CONCLUSION

RFIT is a user-friendly tool for the collection of patient risk behaviour information. RFIT is particularly useful for patients lacking continuity in the care they receive. Information technology can promote self-reflection while providing useful information to the primary care clinician. When combined with practical tools and resources RFIT can assist in the reduction of risk behaviours.

Associated Sociodemographic and Facility Patterning of Uptake, Attendance, and Session Count Within a Scottish Exercise Referral Scheme

BACKGROUND

Exercise referral schemes (ERS) aim to tackle noncommunicable disease via increasing levels of physical activity. Health benefits are reliant on uptake and attending ERS sessions. Hence, it is important to understand which characteristics may influence these parameters to target interventions to improve uptake and attendance to those who need it most.

METHOD

Secondary analysis of one ERS database was conducted to (1) profile participants' nonuptake of exercise referral; (2) describe any differences between nonattenders and attenders; and (3) report session count of attenders, exploring any relationship between attender demographics and session count.

RESULTS

The study showed that (1) sociodemographic profile of nonattenders was very similar to that of those who attended; (2) there was a high, early withdrawal rate of attenders wherein 68% exited the scheme at 5 exercise sessions or less; and (3) session count did not appear to differ by demographic characteristics.

CONCLUSIONS

Nonattendance and session count did not appear to differ by demographic characteristics. Attendance at ERS was low. Nonuptake and reduced attendance may limit any associated health benefits that may be achieved from ERS. Therefore, it is important to identify additional factors that may influence participants' choice to uptake and attend ERS.

Understanding Leisure Centre-Based Physical Activity after Physical Activity Referral: Evidence from Scheme Participants and Completers in Northumberland UK

Physical activity referral schemes (PARS) are a popular physical activity (PA) intervention in the UK. Little is known about the type, intensity and duration of PA undertaken during and post PARS. We calculated weekly leisure centre-based moderate/vigorous PA for PARS participants (n = 448) and PARS completers (n = 746) in Northumberland, UK, between March 2019–February 2020 using administrative data. We categorised activity levels (<30 min/week, 30–149 min/week and ≥150 min/week) and used ordinal regression to examine predictors for activity category achieved. PARS participants took part in a median of 57.0 min (IQR 26.0–90.0) and PARS completers a median of 68.0 min (IQR 42.0–100.0) moderate/vigorous leisure centre-based PA per week. Being a PARS completer (OR: 2.14, 95% CI: 1.61–2.82) was a positive predictor of achieving a higher level of physical activity category compared to PARS participants. Female PARS participants were less likely (OR: 0.65, 95% CI: 0.43–0.97) to achieve ≥30 min of moderate/vigorous LCPA per week compared to male PARS participants. PARS participants achieved 38.0% and PARS completers 45.3% of the World Health Organisation recommended ≥150 min of moderate/vigorous weekly PA through leisure centre use. Strategies integrated within PARS to promote PA outside of leisure centre-based activity may help participants achieve PA guidelines.

Gender Differences in Uptake, Adherence and Experiences: A Longitudinal, Mixed-Methods Study of a Physical Activity Referral Scheme in Scotland, UK

Physical activity referral schemes (PARS) are implemented internationally to increase physical activity (PA), but evidence of effectiveness for population subgroups is equivocal. We examined gender differences for a Scottish PARS. This mixed-methods, concurrent longitudinal study had equal status quantitative and qualitative components. We conducted 348 telephone interviews across three time points (pre-scheme, 12 and 52 weeks). These included validated self-reported PA and exercise self-efficacy measures and open-ended questions about experiences. We recruited 136 participants, of whom 120 completed 12-week and 92 completed 52-week interviews. PARS uptake was 83.8% (114/136), and 12-week adherence for those who started was 43.0% (49/114). Living in less deprived areas was associated with better uptake (p = 0.021) and 12-week adherence (p = 0.020), and with male uptake (p = 0.024) in gender-stratified analysis. Female adherers significantly increased self-reported PA at 12 weeks (p = 0.005) but not 52 weeks. Males significantly increased exercise self-efficacy between baseline and 52 weeks (p = 0.009). Three qualitative themes and eight subthemes developed; gender perspectives, personal factors (health, social circumstances, transport and attendance benefits) and scheme factors (communication, social/staff support, individualisation and age appropriateness). Both genders valued the PARS. To increase uptake, adherence and PA, PARS should ensure timely, personalised communication, individualised, affordable PA and include mechanisms to re-engage those who disengage temporarily.

Using Information Technology to Assess Patient Risk Factors in Primary Care Clinics: Pragmatic Evaluation

BACKGROUND

Tobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review.

OBJECTIVE

This study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics.

METHODS

This is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation.

RESULTS

Clinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups.

CONCLUSIONS

Clinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients' context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care.

A modified Delphi study to gain consensus for a taxonomy to report and classify physical activity referral schemes (PARS)

Background

Physical Activity Referral Schemes (PARS), including exercise referral schemes, are a popular approach to health improvement, but understanding of effectiveness is limited by considerable heterogeneity in reporting and evaluation. We aimed to gain consensus for a PARS taxonomy as a comprehensive method for reporting and recording of such schemes.

Methods

We invited 62 experts from PARS policy, research and practice to complete a modified Delphi study. In round one, participants rated the need for a PARS taxonomy, the suitability of three proposed classification levels and commented on proposed elements. In round two, participants rated proposed taxonomy elements on an 11-point Likert scale. Elements scoring a median of ≥7, indicating high agreement, were included in the final taxonomy.

Results

Of those invited, 47 (75.8%) participated in round one, with high retention in round two (n = 43; 91.5%). 42 were UK-based, meaning the resultant taxonomy has been scrutinised for fit to the UK context only. The study gained consensus for a three-level taxonomy: Level 1: PARS classification (primary classification, provider, setting, conditions accepted [have or at risk of], activity type and funding). Level 2: scheme characteristics (staff structure, staff qualifications, behaviour change theories, behaviour change techniques, referral source, referrers, referral process, scheme duration, session frequency, session length, session times, session type, exit routes, action in case of non-attendance, baseline assessment, exit assessment, feedback to referrer and exclusion criteria) and Level 3: participant measures (demographics, monitoring and evaluation, and measures of change).

Conclusion

Using a modified Delphi method, this study developed UK-based consensus on a PARS classification taxonomy. We encourage PARS practitioners and public health colleagues, especially those working with similar service models internationally, to test, refine and use this taxonomy to inform policy and practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-020-01050-2.

Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER RCT

BACKGROUND

There is modest evidence that exercise referral schemes increase physical activity in inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of exercise referral schemes on long-term physical activity.

OBJECTIVES

To determine if adding the e-coachER intervention to exercise referral schemes is more clinically effective and cost-effective in increasing physical activity after 1 year than usual exercise referral schemes.

DESIGN

A pragmatic, multicentre, two-arm randomised controlled trial, with a mixed-methods process evaluation and health economic analysis. Participants were allocated in a 1 : 1 ratio to either exercise referral schemes plus e-coachER (intervention) or exercise referral schemes alone (control).

SETTING

Patients were referred to exercise referral schemes in Plymouth, Birmingham and Glasgow.

PARTICIPANTS

There were 450 participants aged 16-74 years, with a body mass index of 30-40 kg/m², with hypertension, prediabetes, type 2 diabetes, lower limb osteoarthritis or a current/recent history of treatment for depression, who were also inactive, contactable via e-mail and internet users.

INTERVENTION

e-coachER was designed to augment exercise referral schemes. Participants received a pedometer and fridge magnet with physical activity recording sheets, and a user guide to access the web-based support in the form of seven 'steps to health'. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in the importance of physical activity, competence, autonomy in physical activity choices and relatedness. All participants were referred to a standard exercise referral scheme.

PRIMARY OUTCOME MEASURE

Minutes of moderate and vigorous physical activity in ≥ 10-minute bouts measured by an accelerometer over 1 week at 12 months, worn ≥ 16 hours per day for ≥ 4 days including ≥ 1 weekend day.

SECONDARY OUTCOMES

Other accelerometer-derived physical activity measures, self-reported physical activity, exercise referral scheme attendance and EuroQol-5 Dimensions, five-level version, and Hospital Anxiety and Depression Scale scores were collected at 4 and 12 months post randomisation.

RESULTS

Participants had a mean body mass index of 32.6 (standard deviation) 4.4 kg/m², were referred primarily for weight loss and were mostly confident self-rated information technology users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (n = 108) compared with the control group (n = 124); 11.8 weekly minutes of moderate and vigorous physical activity (95% confidence interval -2.1 to 26.0 minutes; p = 0.10). Sixty-four per cent of intervention participants logged on at least once; they gave generally positive feedback on the web-based support. The intervention had no effect on other physical activity outcomes, exercise referral scheme attendance (78% in the control group vs. 75% in the intervention group) or EuroQol-5 Dimensions, five-level version, or Hospital Anxiety and Depression Scale scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months, but not at 12 months. At 12 months, the intervention group incurred an additional mean cost of £439 (95% confidence interval -£182 to £1060) compared with the control group, but generated more quality-adjusted life-years (mean 0.026, 95% confidence interval 0.013 to 0.040), with an incremental cost-effectiveness ratio of an additional £16,885 per quality-adjusted life-year.

LIMITATIONS

A significant proportion (46%) of participants were not included in the primary analysis because of study withdrawal and insufficient device wear-time, so the results must be interpreted with caution. The regression model fit for the primary outcome was poor because of the considerable proportion of participants [142/243 (58%)] who recorded no instances of ≥ 10-minute bouts of moderate and vigorous physical activity at 12 months post randomisation.

FUTURE WORK

The design and rigorous evaluation of cost-effective and scalable ways to increase exercise referral scheme uptake and maintenance of moderate and vigorous physical activity are needed among patients with chronic conditions.

CONCLUSIONS

Adding e-coachER to usual exercise referral schemes had only a weak indicative effect on long-term rigorously defined, objectively assessed moderate and vigorous physical activity. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000 per quality-adjusted life-year. The intervention did improve some process outcomes as specified in our logic model.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15644451.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 63. See the NIHR Journals Library website for further project information.

Pragmatic evaluation of a coproduced physical activity referral scheme: a UK quasi-experimental study

OBJECTIVES

UK exercise referral schemes (ERSs) have been criticised for focusing too much on exercise prescription and not enough on sustainable physical activity (PA) behaviour change. Previously, a theoretically grounded intervention (coproduced PA referral scheme, Co-PARS) was coproduced to support long-term PA behaviour change in individuals with health conditions. The purpose of this study was to investigate the effectiveness of Co-PARS compared with a usual care ERS and no treatment for increasing cardiorespiratory fitness.

DESIGN

A three-arm quasi-experimental trial.

SETTING

Two leisure centres providing (1) Co-PARS, (2) usual exercise referral care and one no-treatment control.

PARTICIPANTS

68 adults with lifestyle-related health conditions (eg, cardiovascular, diabetes, depression) were recruited to co-PARS, usual care or no treatment.

INTERVENTION

16-weeks of PA behaviour change support delivered at 4, 8, 12 and 18 weeks, in addition to the usual care 12-week leisure centre access.

OUTCOME MEASURES

Cardiorespiratory fitness, vascular health, PA and mental well-being were measured at baseline, 12 weeks and 6 months (PA and mental well-being only). Fitness centre engagement (co-PARS and usual care) and behaviour change consultation attendance (co-PARS) were assessed. Following an intention-to-treat approach, repeated-measures linear mixed models were used to explore intervention effects.

RESULTS

Significant improvements in cardiorespiratory fitness (p=0.002) and vascular health (p=0.002) were found in co-PARS compared with usual care and no-treatment at 12 weeks. No significant changes in PA or well-being at 12 weeks or 6 months were noted. Intervention engagement was higher in co-PARS than usual care, though this was not statistically significant.

CONCLUSION

A coproduced PA behaviour change intervention led to promising improvements in cardiorespiratory and vascular health at 12 weeks, despite no effect for PA levels at 12 weeks or 6 months.

TRIAL REGISTRATION NUMBER

NCT03490747.

Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART)

BACKGROUND

There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM).

METHODS

In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed.

RESULTS

At least 296 participants and approximately 75 peer supporters will be enrolled.

DISCUSSION

Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes.

TRIAL REGISTRATION

The ClinicalTrials.gov registration number is NCT03689530.

The Northumberland Exercise Referral Scheme as a Universal Community Weight Management Programme: A Mixed Methods Exploration of Outcomes, Expectations and Experiences across a Social Gradient

Exercise referral schemes (ERS) are internationally recognised, yet little attention has been paid to discrete referral groups or the influence of wider social determinants of health. The primary quantitative element of this mixed methods study used a mixed effects linear model to examine associations of sociodemographic predictors, obesity class and profession of referrer on weight and physical activity (PA) variables for weight-related referrals (n = 3624) to an established 24-week ERS. Chained equations modelling imputed missing data. The embedded qualitative element (n = 7) used individual semi-structured interviews to explore participant weight-related expectations and experiences. Age, gender and profession of referrer influenced weight loss. PA increased and was influenced by age and gender. The weight gap between the most and least obese narrowed over time but the PA gap between most and least widened. Age, employment and obesity class were most predictive of missing data but would unlikely alter overall conclusions. Qualitative themes were weight-loss support, personal circumstances and strategies, and weight expectations versus wellbeing rewards. This ERS worked, did not widen existing obesity inequalities, but demonstrated evidence of PA inequalities for those living with deprivation. To improve equity of experience, we recommend further stakeholder dialogue around referral experience and ongoing support needs.

Functionality of Physical Activity Referral Schemes (PARS): A Systematic Review

Background: Physical activity (PA) is vital to maintaining good health. However, WHO estimates that 60% of the world's population are inadequately active. To enhance PA, Physical Activity Referral Schemes (PARS) have been established by some countries.

Objective: This study examined the functionality of the PARS process across different countries.

Methods: This systematic review was performed and reported in accordance with the PRISMA guidelines. Sixteen electronic databases were searched from January 1990 to May 2020. PARS studies, published in English language and in peer-reviewed journals, that reported adherence, outcomes, disease conditions, interventions, facilitators and barriers, were included in this review.

Results: Twenty-seven studies conducted across eight countries met the inclusion criteria. Most patients were referred for sedentary/inactivity reasons and supervised group-based activities was the most used intervention. Participants' average adherence rate was 77.5%. Adherence was either facilitated or hindered by type of support provided during and after intervention period. Inclusion of PA allied health specialist in the intervention enhanced positive health outcomes.

Conclusion: PARS is a key driver and motivator for individuals to undertake and adhere to PA interventions. Utilization of guidelines on evidence-based interventional PA for different types of diseases, effective use of common group supervised activities and the involvement of PA specialists may aid PA adherence and foster positive health outcomes.

Patterning in Patient Referral to and Uptake of a National Exercise Referral Scheme (NERS) in Wales From 2008 to 2017: A Data Linkage Study

Exercise referral schemes have shown small but positive impacts in randomized controlled trials (RCTs). Less is known about the long-term reach of scaled up schemes following a RCT. A RCT of the National Exercise Referral Scheme (NERS) in Wales was completed in 2010, and the scheme scaled up across Wales. In this study, using a retrospective data linkage design, anonymized NERS data were linked to routine health records for referrals between 2008 and 2017. Rates of referral and uptake were modelled across years and a multilevel logistic regression model examined predictors of uptake. In total, 83,598 patients have been referred to the scheme and 67.31% of eligible patients took up NERS. Older adults and referrals for a musculoskeletal or level four condition were more likely to take up NERS. Males, mental health referrals, non-GP referrals and those in the most deprived groupings were less likely to take up NERS. Trends revealed an overall decrease over time in referrals and uptake rates among the most deprived grouping relative to those in the least deprived group. Findings indicate a widening of inequality in referral and uptake following positive RCT findings, both in terms of patient socioeconomic status and referrals for mental health.

What approaches to social prescribing work, for whom, and in what circumstances? A realist review

The use of non-medical referral, community referral or social prescribing interventions has been proposed as a cost-effective alternative to help those with long-term conditions manage their illness and improve health and well-being. However, the evidence base for social prescribing currently lags considerably behind practice. In this paper, we explore what is known about whether different methods of social prescribing referral and supported uptake do (or do not) work. Supported by an Expert Advisory Group, we conducted a realist review in two phases. The first identified evidence specifically relating to social prescribing in order to develop programme theories in the form of 'if-then' statements, articulating how social prescribing models are expected to work. In the second phase, we aimed to clarify these processes and include broader evidence to better explain the proposed mechanisms. The first phase resulted in 109 studies contributing to the synthesis, and the second phase 34. We generated 40 statements relating to organising principles of how the referral takes place (Enrolment), is accepted (Engagement), and completing an activity (Adherence). Six of these statements were prioritised using web-based nominal group technique by our Expert Group. Studies indicate that patients are more likely to enrol if they believe the social prescription will be of benefit, the referral is presented in an acceptable way that matches their needs and expectations, and concerns elicited and addressed appropriately by the referrer. Patients are more likely to engage if the activity is both accessible and transit to the first session supported. Adherence to activity programmes can be impacted through having an activity leader who is skilled and knowledgeable or through changes in the patient's conditions or symptoms. However, the evidence base is not sufficiently developed methodologically for us to make any general inferences about effectiveness of particular models or approaches.

Cost-Effectiveness of Diet and Exercise for Overweight and Obese Patients With Knee Osteoarthritis

OBJECTIVE

The Intensive Diet and Exercise for Arthritis (IDEA) trial showed that an intensive diet and exercise (D+E) program led to a mean 10.6-kg weight reduction and 51% pain reduction in patients with knee osteoarthritis (OA). The aim of the current study was to investigate the cost-effectiveness of adding this D+E program to treatment in overweight and obese (body mass index >27 kg/m² ) patients with knee OA.

METHODS

We used the Osteoarthritis Policy Model to estimate quality-adjusted life-years (QALYs) and lifetime costs for overweight and obese patients with knee OA, with and without the D+E program. We evaluated cost-effectiveness with the incremental cost-effectiveness ratio (ICER), a ratio of the differences in lifetime cost and QALYs between treatment strategies. We considered 3 cost-effectiveness thresholds: $50,000/QALY, $100,000/QALY, and $200,000/QALY. Analyses were conducted from health care sector and societal perspectives and used a lifetime horizon. Costs and QALYs were discounted at 3% per year. D+E characteristics were derived from the IDEA trial. Deterministic and probabilistic sensitivity analyses (PSAs) were used to evaluate parameter uncertainty and the effect of extending the duration of the D+E program.

RESULTS

In the base case, D+E led to 0.054 QALYs gained per person and cost $1,845 from the health care sector perspective and $1,624 from the societal perspective. This resulted in ICERs of $34,100/QALY and $30,000/QALY. In the health care sector perspective PSA, D+E had 58% and 100% likelihoods of being cost-effective with thresholds of $50,000/QALY and $100,000/QALY, respectively.

CONCLUSION

Adding D+E to usual care for overweight and obese patients with knee OA is cost-effective and should be implemented in clinical practice.

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

Background

Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs).

Methods

The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs.

Results

The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs.

Conclusion

The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.

Bayesian strategy selection identifies optimal solutions to complex problems using an example from GP prescribing

Complex health problems require multi-strategy, multi-target interventions. We present a method that uses machine learning techniques to choose optimal interventions from a set of possible interventions within a case study aiming to increase General Practitioner (GP) discussions of physical activity (PA) with their patients. Interventions were developed based on a causal loop diagram with 26 GPs across 13 clinics in Geelong, Australia. GPs prioritised eight from more than 80 potential interventions to increase GP discussion of PA with patients. Following a 2-week baseline, a multi-arm bandit algorithm was used to assign optimal strategies to GP clinics with the target outcome being GP PA discussion rates. The algorithm was updated weekly and the process iterated until the more promising strategies emerged (a duration of seven weeks). The top three performing strategies were continued for 3 weeks to improve the power of the hypothesis test of effectiveness for each strategy compared to baseline. GPs recorded a total of 11,176 conversations about PA. GPs identified 15 factors affecting GP PA discussion rates with patients including GP skills and awareness, fragmentation of care and fear of adverse outcomes. The two most effective strategies were correctly identified within seven weeks of the algorithm-based assignment of strategies. These were clinic reception staff providing PA information to patients at check in and PA screening questionnaires completed in the waiting room. This study demonstrates an efficient way to test and identify optimal strategies from multiple possible solutions.

Effectiveness of physical activity promotion and exercise referral in primary care: protocol for a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Physical inactivity is the fourth leading risk factor for global mortality. Reducing sedentary behaviour and increasing physical activity are efficacious for improving many physical and mental health conditions including cardiovascular disease, type 2 diabetes and depression. Reducing sedentary behaviour and increasing physical activity can also be effective at reducing obesity; however, sedentary behaviour and reduced physical activity are also associated with mortality independently. Despite this, most adults in the UK do not currently meet the UK Chief Medical Officers' guidelines for weekly physical activity. As most adults visit their general practitioner at least once a year, the primary care consultation provides a unique opportunity to deliver exercise referral or physical activity promotion interventions. This is a protocol for a systematic review of randomised controlled trials for the effectiveness of physical activity promotion and referral in primary care.

METHODS

A comprehensive literature search of Embase, MEDLINE (Ovid), Web of Science (Core Collection), Scopus, CINAHL, PsycINFO, and The Cochrane Library (CENTRAL) will be conducted for studies with a minimum follow-up of 12 months that report physical activity as an outcome measure (by either self-report or objective measures) including an intention to treat analysis. The authors will screen papers, first by title and abstract and then by full text, independently assess studies for inclusion, appraise risk of bias and extract data. The quality of the evidence will be assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluations) approach. The primary outcome will be participation in physical activity at 12 months. Pooled effects will be calculated using random effects models. Results will be submitted for publication in a peer-reviewed journal and for presentation at UK national primary care conferences.

DISCUSSION

This systematic review and meta-analyses will summarise the evidence for the effectiveness of physical activity promotion and referral as interventions for improving physical activity, as well as whether studies using objective measures of physical activity have similar effects to those studies using self-report measures. This knowledge has importance for primary care clinicians, patients and, given the focus of the recent NHS long-term plan on preventive medicine, those making policy decisions.

SYSTEMATIC REVIEW REGISTRATION

The protocol is registered with PROSPERO the international prospective register of systematic reviews, ID CRD42019130831.

Insufficient Reporting of Factors Associated With Exercise Referral Scheme Uptake, Attendance, and Adherence: A Systematic Review of Reviews

BACKGROUND

Exercise referral schemes (ERS) are prescribed programs to tackle physical inactivity and associated noncommunicable disease. Inconsistencies in reporting, recording, and delivering ERS make it challenging to identify what works, why, and for whom.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided this narrative review of reviews. Electronic databases were searched for systematic reviews of ERS. Inclusion criteria and quality assessed through A Measurement Tool to Assess Systematic Reviews (AMSTAR). Data on uptake, attendance, and adherence were extracted.

RESULTS

Eleven reviews met inclusion criteria. AMSTAR quality was medium. Uptake ranged between 35% and 81%. Groups more likely to take up ERS included (1) females and (2) older adults. Attendance ranged from 12% to 49%. Men were more likely to attend ERS. Effect of medical diagnosis upon uptake and attendance was inconsistent. Exercises prescribed were unreported; therefore, adherence to exercise prescriptions was unreported. The influence of theoretically informed approaches on uptake, attendance, and adherence was generally lacking; however, self-determination, peer support, and supervision were reported as influencing attendance.

CONCLUSIONS

There was insufficient reporting across studies about uptake, attendance, and adherence. Complex interventions such as ERS require consistent definitions, recording, and reporting of these key facets, but this is not evident from the existing literature.

Do Older People with Diabetes Meet the Recommended Weekly Physical Activity Targets? An Analysis of Objective Physical Activity Data

Appropriate management of diabetes mellitus (DM) includes following a healthy lifestyle, in which reaching physical activity (PA) recommendations is an important factor. Despite this, it remains unclear whether people with DM meet the recommended PA targets. We therefore aimed to investigate the proportion of older adults with DM (type 1 and 2) engaging in the recommended amount of PA per week in a cross-sectional study. PA levels were objectively measured using the GT1M ActiGraph accelerometer for seven consecutive days, and the cut-off of 150 min of moderate-to-vigorous PA (MVPA) was used. To assess the relationship between not meeting the recommendation for, and the significant factors associated with PA level (MVPA < 150 min/week), a multivariable logistic regression analysis was applied. 197 diabetic participants (mean age = 66.8 years; 46.7% males) spent only 74.5 ± 94.4 min/weekly in MVPA, and only 39 (=19.8%) reached the cut-off for sufficient PA levels. Significant correlates of not meeting the recommendation for PA levels were female sex, depressive symptoms, and age. In conclusion, only one-fifth of diabetic people reached the recommended amount of PA, suggesting that more intervention is needed to increase PA levels in this population.

Systematic review of the methods used in economic evaluations of targeted physical activity and sedentary behaviour interventions

The burden of noncommunicable diseases (NCD) on health systems worldwide is substantial. Physical inactivity and sedentary behaviour are major risk factors for NCD. Previous attempts to understand the value for money of preventative interventions targeting physically inactive individuals have proved to be challenging due to key methodological challenges associated with the conduct of economic evaluations in public health. A systematic review was carried out across six databases (Medline, SPORTSDiscus, EconLit, PsychINFO, NHS EED, HTA) along with supplementary searches. The review examines how economic evaluations published between 2009-March 2017 have addressed methodological challenges with the aim of bringing to light examples of good practice for future studies. Fifteen economic evaluations from four high-income countries were retrieved; there is a dearth of studies targeting sedentary behaviour as an independent risk factor from physical activity. Comparability of studies from the healthcare and societal perspectives were limited due to analysts' choice in cost categories, valuation technique and time horizon differing substantially. The scarcity of and inconsistencies across economic evaluations for these two behaviours have exposed a mismatch between calls for more preventative action to tackle NCD and the lack of information available on how resources may be optimally allocated in practice. Consequently, this paper offers a table of recommendations on how future studies can be improved.

A pedometer-based walking intervention in 45- to 75-year-olds, with and without practice nurse support: the PACE-UP three-arm cluster RCT

BACKGROUND

Guidelines recommend walking to increase moderate to vigorous physical activity (MVPA) for health benefits.

OBJECTIVES

To assess the effectiveness, cost-effectiveness and acceptability of a pedometer-based walking intervention in inactive adults, delivered postally or through dedicated practice nurse physical activity (PA) consultations.

DESIGN

Parallel three-arm trial, cluster randomised by household.

SETTING

Seven London-based general practices.

PARTICIPANTS

A total of 11,015 people without PA contraindications, aged 45-75 years, randomly selected from practices, were invited. A total of 6399 people were non-responders, and 548 people self-reporting achieving PA guidelines were excluded. A total of 1023 people from 922 households were randomised to usual care (n = 338), postal intervention (n = 339) or nurse support (n = 346). The recruitment rate was 10% (1023/10,467). A total of 956 participants (93%) provided outcome data.

INTERVENTIONS

Intervention groups received pedometers, 12-week walking programmes advising participants to gradually add '3000 steps in 30 minutes' most days weekly and PA diaries. The nurse group was offered three dedicated PA consultations.

MAIN OUTCOME MEASURES

The primary and main secondary outcomes were changes from baseline to 12 months in average daily step counts and time in MVPA (in ≥ 10-minute bouts), respectively, from 7-day accelerometry. Individual resource-use data informed the within-trial economic evaluation and the Markov model for simulating long-term cost-effectiveness. Qualitative evaluations assessed nurse and participant views. A 3-year follow-up was conducted.

RESULTS

Baseline average daily step count was 7479 [standard deviation (SD) 2671], average minutes per week in MVPA bouts was 94 minutes (SD 102 minutes) for those randomised. PA increased significantly at 12 months in both intervention groups compared with the control group, with no difference between interventions; additional steps per day were 642 steps [95% confidence interval (CI) 329 to 955 steps] for the postal group and 677 steps (95% CI 365 to 989 steps) for nurse support, and additional MVPA in bouts (minutes per week) was 33 minutes per week (95% CI 17 to 49 minutes per week) for the postal group and 35 minutes per week (95% CI 19 to 51 minutes per week) for nurse support. Intervention groups showed no increase in adverse events. Incremental cost per step was 19p and £3.61 per minute in a ≥ 10-minute MVPA bout for nurse support, whereas the postal group took more steps and cost less than the control group. The postal group had a 50% chance of being cost-effective at a £20,000 per quality-adjusted life-year (QALY) threshold within 1 year and had both lower costs [-£11M (95% CI -£12M to -£10M) per 100,000 population] and more QALYs [759 QALYs gained (95% CI 400 to 1247 QALYs)] than the nurse support and control groups in the long term. Participants and nurses found the interventions acceptable and enjoyable. Three-year follow-up data showed persistent intervention effects (nurse support plus postal vs. control) on steps per day [648 steps (95% CI 272 to 1024 steps)] and MVPA bouts [26 minutes per week (95% CI 8 to 44 minutes per week)].

LIMITATIONS

The 10% recruitment level, with lower levels in Asian and socioeconomically deprived participants, limits the generalisability of the findings. Assessors were unmasked to the group.

CONCLUSIONS

A primary care pedometer-based walking intervention in 45- to 75-year-olds increased 12-month step counts by around one-tenth, and time in MVPA bouts by around one-third, with similar effects for the nurse support and postal groups, and persistent 3-year effects. The postal intervention provides cost-effective, long-term quality-of-life benefits. A primary care pedometer intervention delivered by post could help address the public health physical inactivity challenge.

FUTURE WORK

Exploring different recruitment strategies to increase uptake. Integrating the Pedometer And Consultation Evaluation-UP (PACE-UP) trial with evolving PA monitoring technologies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98538934.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 37. See the NIHR Journals Library website for further project information.

Long-Term Health Outcomes Associated With an Exercise Referral Scheme: An Observational Longitudinal Follow-Up Study

BACKGROUND

Exercise referral schemes (ERSs) support inactive adults, who have chronic health conditions, to become physically active. Uncertainty exists regarding the effectiveness of ERSs, with few studies evaluating their long-term impact. The aims of this study were to evaluate the long-term impact (12 mo) of participation in an ERS on self-reported physical activity (PA) and a range of health-related outcomes.

METHODS

Data were analyzed for participants of a 24-week ERS who attended a week 52 follow-up between July 2015 and 2017. PA and health-related outcomes collected at weeks 1, 24, and 52 were analyzed using the Friedman test and Wilcoxon signed-ranks test.

RESULTS

A total of 273 participants attended the week 52 follow-up. Self-reported PA significantly increased by a median of 636 MET minutes at week 52. There were also significant improvements in body mass index, systolic blood pressure, mental well-being, and health-related quality of life.

CONCLUSIONS

For every 8 participants referred to this 24-week ERS, 1 participant went on to show long-term improvements in at least 1 health indicator. The evidence base requires further long-term evaluations to confirm these findings across a range of ERS providers. Changes in self-reported PA would be supported by the inclusion of device-based measurment of PA.

Factors influencing patient uptake of an exercise referral scheme: a qualitative study

Exercise referral schemes aim to increase physical activity amongst inactive individuals with or at risk of long-term health conditions. Yet many patients referred to these schemes (by health professionals) fail to take up the exercise opportunities on offer. Understanding factors influencing uptake to exercise referral schemes may help improve future attendance. Using the Socio-Ecological Model as a framework, this qualitative study aimed to explore factors influencing uptake to an exercise referral scheme based in the North West of England. Semi-structured interviews were conducted with referred patients (n = 38) about their reasons for referral, interactions with referring health professionals, events following referral and ideas to improve future uptake. Data were analysed thematically and mapped onto the constructs of the Socio-Ecological Model. Factors reported to influence uptake included intrapersonal (past PA experiences, motivation, competing priorities), interpersonal (scheme explanations, support) and organizational influences (scheme promotion, communication between service, cost). Whilst several intrapersonal-level factors influenced patient decisions to uptake the exercise referral scheme, modifiable interpersonal and organizational factors were identified as potential targets for intervention. Recommendations are made for improving awareness of exercise referral schemes and for enhancing communication between referring practitioners, patients and referral scheme staff.

Discontinuously supervised aerobic training vs. physical activity promotion in the self-management of type 2 diabetes in older Italian patients: design and methods of the 'TRIPL-A' randomized controlled trial

Background

Physical activity (PA) has health benefits for people with type 2 diabetes (T2D). Indeed, regular PA is considered an important part of any T2D management plan, yet most patients adopt a sedentary lifestyle.

Exercise referral schemes (ERS) have the potential to effectively promote physical activity among T2D patients, and their effectiveness may be enhanced when they are supported by computer-based technologies.

The ‘TRIPL-A’ study (i.e., a TRIal to promote PhysicaL Activity among patients in the young-old age affected by T2D) aims to assess if realizing an innovative ERS, based on a strong partnership among general practitioners, specialist physicians, exercise specialists, and patients, and supported by a web-based application (WBA), can effectively lead sedentary older T2D patients to adopt an active lifestyle.

Methods

A randomized controlled design will be used, and an ERS, supported by a WBA, will be implemented. 300 physically inactive T2D patients (aged 65–74 years) will be assigned to either an intervention or control arm. Control arm patients will only receive behavioral counseling on physical activity and diet, while intervention arm patients will also undergo an 18-month (3 day/week), discontinuously supervised aerobic exercise training program. The trial will be divided into six three-month periods: during first, third and fifth period, an exercise specialist will supervise the training sessions and, using the WBA, prescribe exercise progression and monitor exercise adherence. Patients will exercise on their own in the other periods.

Patients’ sedentary behaviors (primary outcome), PA level, fitness status, metabolic profile, psychological well-being, quality of life, and use of health care services (secondary outcomes) will be assessed at baseline and at 6, 12, and 18 months from baseline.

Repeated measure ANCOVAs will be used to compare the intervention and control arm with respect to each study outcome measure.

Discussion

Primary and secondary outcome results will allow us to evaluate the effectiveness of an ERS, specifically designed for the management of T2D clinical conditions and supported by a WBA, in promoting PA within Italian primary care settings.

Trial registration

This trial is retrospectively registered under the Australian New Zealand Clinical Trials Registry (reference number: ACTRN12618001164280; registered 13 July 2018).

Can Interpersonal Behavior Influence the Persistence and Adherence to Physical Exercise Practice in Adults? A Systematic Review

Objective: Motivation seems to be a fundamental indicator of long-term physical exercise adherence. Self-Determination Theory (SDT) argues that social environment plays a central role in the satisfaction of basic psychological needs, which might directly affect the quality of one's motivation. Individuals who appear to be more self-determined tend to persist longer at certain behaviors. Therefore, this body of work intends to analyze the relationship between motivational variables and behavioral outcomes in the exercise context, having as theoretical background the Self-Determination Theory. Methods: This systematic review was conducted through an electronic search on Web of Science, PubMed, SPORTDiscus, and PsycINFO. Data such as instruments, main predictors and results were collected from studies published between 1985 and 2018. A total of 35 empirical studies were considered for a detailed analysis. Results: Results showed the relevance of autonomy support performed by exercise professionals, as well as the major contribution that these behaviors have toward the satisfaction of basic psychological needs, besides the inherent benefits of developing more autonomous regulations. According to the literature, few studies have analyzed interpersonal thwarting behavior and the way this relates to basic psychological needs' frustration. Nether less, there seems to be a negative relationship between less self-determined regulations and exercise practice. Conclusion: Despite the existence of numerous cross-sectional studies that demonstrate positive correlations between SDT and behavioral outcomes in the exercise context, longitudinal research that analyzes all six dimensions of interpersonal behaviors and their relationship with persistence and adherence to exercise proves to be crucial. However, according to this review, interventions based on SDT appear to be fundamental when it comes to promote the maintenance of a long-term exercise practice.

Cost-effectiveness of exercise referral schemes enhanced by self-management strategies to battle sedentary behaviour in older adults: protocol for an economic evaluation alongside the SITLESS three-armed pragmatic randomised controlled trial

INTRODUCTION

Promoting physical activity (PA) and reducing sedentary behaviour (SB) may exert beneficial effects on the older adult population, improving behavioural, functional, health and psychosocial outcomes in addition to reducing health, social care and personal costs. This paper describes the planned economic evaluation of SITLESS, a multicountry three-armed pragmatic randomised controlled trial (RCT) which aims to assess the short-term and long-term effectiveness and cost-effectiveness of a complex intervention on SB and PA in community-dwelling older adults, based on exercise referral schemes enhanced by a group intervention providing self-management strategies to encourage lifestyle change.

METHODS AND ANALYSIS

A within-trial economic evaluation and long-term model from both a National Health Service/personal social services perspective and a broader societal perspective will be undertaken alongside the SITLESS multinational RCT. Healthcare costs (hospitalisations, accident and emergency visits, appointment with health professionals) and social care costs (eg, community care) will be included in the economic evaluation. For the cost-utility analysis, quality-adjusted life-years will be measured using the EQ-5D-5L and capability well-being measured using the ICEpop CAPability measure for Older people (ICECAP-O) questionnaire. Other effectiveness outcomes (health related, behavioural, functional) will be incorporated into a cost-effectiveness analysis and cost-consequence analysis.The multinational nature of this RCT implies a hierarchical structure of the data and unobserved heterogeneity between clusters that needs to be adequately modelled with appropriate statistical and econometric techniques. In addition, a long-term population health economic model will be developed and will synthesise and extrapolate within-trial data with additional data extracted from the literature linking PA and SB outcomes with longer term health states.Methods guidance for population health economic evaluation will be adopted including the use of a long-time horizon, 1.5% discount rate for costs and benefits, cost consequence analysis framework and a multisector perspective.

ETHICS AND DISSEMINATION

The study design was approved by the ethics and research committee of each intervention site: the Ethics and Research Committee of Ramon Llull University (reference number: 1314001P) (Fundació Blanquerna, Spain), the Regional Committees on Health Research Ethics for Southern Denmark (reference number: S-20150186) (University of Southern Denmark, Denmark), Office for Research Ethics Committees in Northern Ireland (ORECNI reference number: 16/NI/0185) (Queen's University of Belfast) and the Ethical Review Board of Ulm University (reference number: 354/15) (Ulm, Germany). Participation is voluntary and all participants will be asked to sign informed consent before the start of the study.This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement number 634 270. This article reflects only the authors' view and the Commission is not responsible for any use that may be made of the information it contains.The findings of the study will be disseminated to different target groups (academia, policymakers, end users) through different means following the national ethical guidelines and the dissemination regulation of the Horizon 2020 funding agency.Use of the EuroQol was registered with the EuroQol Group in 2016.Use of the ICECAP-O was registered with the University of Birmingham in March 2017.

TRIAL REGISTRATION NUMBER

NCT02629666; Pre-results.

Multicentred randomised controlled trial of an augmented exercise referral scheme using web-based behavioural support in individuals with metabolic, musculoskeletal and mental health conditions: protocol for the e-coachER trial

INTRODUCTION

Physical activity is recommended for improving health among people with common chronic conditions such as obesity, diabetes, hypertension, osteoarthritis and low mood. One approach to promote physical activity is via primary care exercise referral schemes (ERS). However, there is limited support for the effectiveness of ERS for increasing long-term physical activity and additional interventions are needed to help patients overcome barriers to ERS uptake and adherence.This study aims to determine whether augmenting usual ERS with web-based behavioural support, based on the LifeGuide platform, will increase long-term physical activity for patients with chronic physical and mental health conditions, and is cost-effective.

METHODS AND ANALYSIS

A multicentre parallel two-group randomised controlled trial with 1:1 individual allocation to usual ERS alone (control) or usual ERS plus web-based behavioural support (intervention) with parallel economic and mixed methods process evaluations. Participants are low active adults with obesity, diabetes, hypertension, osteoarthritis or a history of depression, referred to an ERS from primary care in the UK.The primary outcome measure is the number of minutes of moderate-to-vigorous physical activity (MVPA) in ≥10 min bouts measured by accelerometer over 1 week at 12 months.We plan to recruit 413 participants, with 88% power at a two-sided alpha of 5%, assuming 20% attrition, to demonstrate a between-group difference of 36-39 min of MVPA per week at 12 months. An improvement of this magnitude represents an important change in physical activity, particularly for inactive participants with chronic conditions.

ETHICS AND DISSEMINATION

Approved by North West Preston NHS Research Ethics Committee (15/NW/0347). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals.Results will be disseminated to ERS services, primary healthcare providers and trial participants.

TRIAL REGISTRATION NUMBER

ISRCTN15644451; Pre-results.

Equity of a government subsidised exercise referral scheme: A population study

BACKGROUND

Health inequities could increase if utilisation of physical activity interventions is lower among socioeconomically disadvantaged groups. We examined associations between area level socioeconomic disadvantage and utilisation of Australian government-subsidised, general practitioner (GP)-referred, accredited exercise physiologist (AEPs) services.

METHODS

We conducted a cross-sectional analysis of Australian Medical Benefits Scheme (MBS) data (N = 228,771 AEP services) for the 2015-2016 financial year and aggregated publicly available data from several sources. Spearman's correlations examined associations between utilisation of AEP services and area-level socioeconomic disadvantage, indicated by Index of Relative Socioeconomic Disadvantage (IRSD) decile scores. Lower IRSD scores indicate greater levels of socioeconomic disadvantage.

RESULTS

Significant correlations between IRSD score and study variables were as follows: Out-of-pocket expenses/service (rs = 0.52); number of patients/AEP provider (rs = -0.42); number of patients/1000 population (rs = -0.24); AEP services/1000 population (rs = -0.18); average services/patient (rs = 0.24); and AEP provider/1000 population (rs = 0.14).

CONCLUSION

Patients living in areas of greater disadvantage utilised government-subsidised, GP-referred AEP services at a higher rate and paid lower out-of-pocket fees than those living in more affluent areas. Thus, AEP services are equitably distributed, from a utilisation perspective, and acceptable to patients living in areas of disadvantage. However, the higher caseloads and lower fees that characterise AEP services in areas of greater disadvantage may result in shorter consultation times. Further research on exercise referral schemes is warranted, particularly whether socioeconomic disadvantage is associated with adherence to exercise sessions and health outcomes.

Physical activity promotion for patients transitioning to dialysis using the "Exercise is Medicine" framework: a multi-center randomized pragmatic trial (EIM-CKD trial) protocol

BACKGROUND

Patients on dialysis are physically inactive, with most reporting activity levels below the fifth percentile of healthy age-matched groups. Several small studies have reported efficacy of diverse exercise interventions among persons with CKD and those on dialysis. However, no single intervention has been widely adopted in real-world practice, despite a clear need in this vulnerable population with high rates of mortality, frailty, and skilled nursing hospitalizations.

METHODS/DESIGN

We describe a pragmatic clinical trial for an exercise intervention among patients transitioning to dialysis. We will use an existing framework - Exercise is Medicine (EIM) - developed by the American College of Sports Medicine. After undertaking formative qualitative research to tailor the EIM framework to the advanced CKD population (eGFR < 30 ml/min/1.73m2), we will randomize 96 patients from two regions-Atlanta and Bay Area-in two intervention arms with incremental levels of clinical-community integration: physical activity assessment during Nephrology clinical visit, brief counseling at pre-dialysis education, and physical activity wearable (group 1) versus group 1 intervention components plus a referral to a free, EIM practitioner-led group exercise program over 16 weeks (group 2; 8 week core intervention; 8-week follow up). We will assess efficacy by comparing between group differences in minutes/week of objectively measured moderate intensity physical activity. To evaluate implementation, we will use questionnaires for assessing barriers to referral, participation and retention along the path of the intervention. Further we will have a plan for dissemination of the intervention by partnering with relevant stakeholders.

DISCUSSION

The overall goal is to inform the development of a practical, cost-conscious intervention "package" that addresses barriers and challenges to physical activity commonly faced by patients with advanced CKD and can be disseminated amongst interested practices.

TRIAL REGISTRATION

ClinicalTrials.gov identifier (Dated:10/17/2017): NCT03311763 .