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Be Active:
An Economic Appraisal
April 2006
P.R. Myles
Executive Summary
This report is an economic appraisal of the physical activity referral programme ‘Be Active’. The aim is to determine whether the benefits of the ‘Be Active’ programme outweighed the costs. A cost-consequences analysis (CCA) has been carried out which provides detailed costing of the project and a descriptive account of expected health benefits. A CCA does not attempt to place a monetary value on benefits. A Primary Care Trust perspective has been adopted and costs incurred by patients or other sectors have not been The report also includes a summary of the NICE review of economic effectiveness of physical activity interventions. The total cost of running the ‘Be Active’ Project for 2006/07 is £97,972 GBP at 2006 prices. Based on previous demand, the projected number of patients for 2006/07 was calculated to be 988. Costs per patient were calculated for 2006/07 considering both a ‘best case scenario’ and a ‘worst case scenario’. If all patients completed the programme, the cost per patient was estimated to be £99.20. Assuming a dropout rate of 67%, as in the previous cohort, resulting in only 326 patients completing the programme, the cost per patient would be £301. These costs will decrease over subsequent years and approximate the NICE estimates of £272 (2006 GBP) for physical activity interventions involving intensive interviews and exercise Expected benefits of raised activity levels include reduced cardiovascular risk factors such as hypertension, prevention of obesity, promotion of mental well-being and improved muskulo-skeletal strength. Long-term benefits include decreased CHD risk over 10 years, decreased risk of Type 2 Diabetes and cancer. The NICE review of the economic effectiveness for exercise referral programmes found them to be both more effective and more costly as compared to usual care (leaflets and information on physical activity) in The NICE economic modelling found that all physical exercise interventions (brief interventions, pedometers, exercise referral, walking and cycling schemes) had a cost per quality adjusted life year (QALY) less than £30,000. NICE considers any treatment or intervention that costs less than £30,000 per QALY gained acceptable. Even if only 3% of participants maintained their new exercise levels, all the interventions would have a cost per QALY gained of less than £7,000 (NICE 2006). 33% of the previous ‘Be Active’ cohort was still engaged in physical activity at 20 weeks. Total future costs saved (discounted at 3.5%) per QALY gained always exceeded the cost of interventions per person and varied from £750- Only at annual CHD, stroke and diabetes treatment costs less than £600 per person, did any of the physical activity interventions result in a net cost to the health service. Considering ‘Be Active’ is a health referral programme for people with, or at risk of medical conditions such as hypertension, diabetes, cardiac rehabilitation, BMI of over 30, ischaemic heart disease, angina, depression, osteoarthritis or other heart diseases, it is almost certain that there would be a net saving to Even at an annual treatment cost of £50 per person, the highest cost per QALY gained was less than £500 for any physical activity intervention. A patient on antihypertensives alone can cost the PCT anything between £140-£1400 per annum depending on the type and The NICE guidance on physical activity interventions recommends that commissioners and policy makers endorse exercise referral schemes to promote physical activity if they are part of a properly designed and controlled study to determine effectiveness. Measures should include intermediate outcomes such as knowledge, attitudes and skills, as well as measures of physical activity levels. Recommendations
Based on the findings of this report it is recommended that the funding of ‘Be Active’ programme be continued for at least another two years to allow for a sufficient follow-up period for collecting data on effectiveness in terms of sustained physical activity levels and The evaluation process should be reviewed to ensure key outcomes BE ACTIVE: AN ECONOMIC APPRAISAL
1. Purpose of this report
This report is an economic appraisal of the Physical Activity Referral Programme, ‘Be Active’. The main evaluation question that the report will focus on is whether the benefits of ‘Be Active’ outweigh the costs. A Cost- Consequences Analysis (CCA) approach has been followed which provides detailed costing information for the project and lists expected benefits without attempting to value the benefits in monetary terms. For costing, a Primary Care Trust perspective has been adopted. This report therefore is intended as an aid to decision making about whether funding for the project should be The report also includes a summary of the recent NICE review of economic evidence of physical activity interventions as well as a summary of the economic modelling carried out by NICE. The report looks at how this work can be interpreted at the local level and ends with recommendations for future 2. Nature of Health Promotion initiative
Be Active is a health referral programme for people with, or at risk of medical conditions such as hypertension, diabetes, cardiac rehabilitation, BMI of over 30, ischaemic heart disease, angina, depression, osteoarthritis or other heart diseases. A wide range of health professionals can refer people to the programme. The programme aims are to encourage individuals to maintain increased levels of regular physical activity to reduce the risk of developing a range of medical conditions. The delivery of the programme is structured as an initial one-to-one consultations followed by 20 activity sessions over a 20- week period. A minimal charge is attached to the programme to encourage mainstreaming of physical activity once the structured programme is complete. People on benefits are entitled to a concessionary rate. 3. Programme objectives and Primary outcomes for the evaluation
The key programme objective for ‘Be Active’ (Todd, 2005) is to encourage
individuals to maintain increased levels of regular physical activity so as to reduce the risk of developing a range of medical conditions including diabetes, cardiovascular disease and mental illness. The evaluation of the project looked at changes in outcomes such as BMI, Blood pressure, peak flow and resting heart rate (See Section 4). 4. Summary of evaluation results
An evaluation has been carried out using data collected from the 1st of April to the 30th of September 2005. 105 people attended the first appointment. 5 were considered unfit to attend and 9 did not want to go through with the programme. At week 10, there were 43 people attending and at week 20, there were 33 people. Therefore, 67% of the referred people did not complete the programme. None of the changes were statistically significant but that is not surprising considering the small numbers. For a detailed evaluation report Table 1: summary of evaluation results
Outcome measure
(25-30): overweight; (30-35): obese; >35: Lifestyle advice recommended >100 In sedentary people usually 70-80 Values <350 for adults are low and exercise 5. The Economic evaluation question and methodology employed
The main evaluation question that the report will focus on is whether the benefits of ‘Be Active’ outweigh the costs. A cost-consequences analysis (CCA) will be carried out providing a comprehensive list of beneficial consequences for the given monetary costs of the project. Such an approach will provide a comprehensive description of costs incurred in monetary terms but will not attempt to value any of the benefits. The perspective of the Primary Care Trust will be adopted for this evaluation. This means that only the costs of running the project will be considered and costs incurred by participants (such as transport, lost work time etc.) will not be considered. Since actual follow-up data is available only for six months, future benefits will be modelled based on probabilities given in literature. 6. Costs of ‘Be Active’
• Total costs of project for 2006/07 = £97,972 GBP valued at 2006 prices (For detailed costing please refer to appendix) • Applying a 3% inflation rate in keeping with Amber Valley PCT policy, costs for 2007/2008 are estimated to be £100,911. • Projected number of patients who will go through the Be Active programme if mainstreamed (based on previous demand): • Assuming there are no dropouts (best case scenario), • Assuming that future cohorts experience a similar attrition rate (67%) to the previous cohort, 326 patients are expected to complete the programme in 2006/2007 and 381 patients to complete the programme in 2007/2008. In this worst case scenario, • It is however expected that with better targeting of the intervention, actual costs will approach the ‘best case scenario’ estimates. 7. Expected benefits of ‘Be Active’
• Helps to prevent / reduce osteoporosis, reducing the risk of hip fracture • Helps to prevent hypertension • Helps control weight and lower the risk of becoming obese by 50% compared to people with sedentary lifestyle • Reduces the risk of developing lower back pain • Promotes psychological well-being, reduces stress, anxiety and • Helps prevent or control risky behaviours, especially among children and young people, like tobacco, alcohol or other substance use, • Helps build and maintain healthy bones, muscles, and joints and makes people with chronic, disabling conditions improve their stamina • Can help in the management of painful conditions, like back pain or • Cancer risk reduction: Between 30-40% of all cancer cases are preventable by ‘feasible and appropriate diets, physical activity and maintenance of appropriate body weight’ (WCRF 1997). The risk of developing colon cancer is reduced by up to 50% (WHO 2006) • Reduction in CHD risk and the risk of developing Type II Diabetes by • Helps to prevent / reduce osteoporosis, reducing the risk of hip fracture The NICE (2006) review of effectiveness of different physical activity interventions suggests that ‘exercise referral schemes can have a positive effect on physical activity levels in the short term (6-12 weeks), but are ineffective in increasing activity levels in the longer term (over 12 weeks) or over a very long timeframe (over 1 year)’. It would therefore follow that not all the long-term benefits can be reasonably attributed to the programme. 8. Summary of the NICE review of the economic evidence for exercise
referral programmes
• Exercise referral schemes were defined as schemes directing someone to a service offering an assessment, development of a tailored physical activity programme, monitoring of progress and follow- up. There are usually a number of professionals participating in the programme and referred individuals are usually directed to an exercise • The report found some evidence that exercise referral programmes are both more effective and more costly than usual care. • This conclusion was based on 4 randomised controlled trials (RCTs) and 1 review of RCTs. Only one RCT was based in the UK and the NICE report acknowledges the limited generalisability of the study results as it lacked sufficient information on effectiveness, resource use and price data. These studies considered follow-up data ranging from • Since then NICE has issued Public Health Intervention Guidance on physical activity interventions (NICE 2006): ‘Policy makers and commissioners should only endorse exercise referral schemes to promote physical activity that are part of a properly designed and controlled research study to determine effectiveness. Measures should include intermediate outcomes such as knowledge, attitudes and skills, as well as measures of physical activity levels. Individuals should only be referred to schemes that are part of such a study.’ 9. Summary of the NICE economic modelling results for the cost-
effectiveness of physical activity interventions
• NICE has summarised the average expected cost per participant for different physical activity interventions. These are summarised in the Table 2: Average costs per patient for different physical activity
interventions
Intervention
Cost per person
Source: NICE (2006), Modelling the cost effectiveness of physical activity Average costs per patient participating in the 2006/07 ‘Be Active’ programme are estimated to be in the range of £99.20 (2006 prices) in a ‘best case scenario’, to £301 (2006 prices) in a ‘worst case scenario’. • NICE also looked at the assumption that fifty percent of participants maintain any improved levels of physical activity after the intervention for a long enough period to derive the health benefits of a new activity level. The report found that all physical exercise interventions (brief interventions, pedometers, exercise referral, walking and cycling schemes) had a cost per QALY1 less than £30,000. Even if only 3% of participants maintained their new exercise levels, all the interventions would have a cost per QALY gained of less than £7,000. 33% of the previous ‘Be Active’ cohort was still engaged in physical activity at 20 • Total future costs saved (discounted at 3.5%) per QALY gained always exceeded the cost of interventions per person. The total costs saved per QALY varied from £750 to £3,150. No obvious relationship was found between type of intervention and the total costs saved per QALY • Treatment costs saved: a range of annual treatment costs were considered from £50-£5,000. The modelling demonstrated that only at annual CHD, stroke and diabetes treatment costs less than £600 per person, did any of the physical activity interventions result in a net cost to the health service. Even at an annual treatment cost of £50 per person, the highest cost per QALY gained was less than £500 for any physical activity intervention. Table 3 gives examples of some of the potential benefits from ‘Be Active’ and possible areas of cost-savings 1 QALY- Quality Adjusted Life Year is a health outcome measure used to describe benefit in an economic analysis. It incorporates both improvements in quality of life and quantity of life. A cost per QALY of less than £30,000 is considered acceptable by NICE. Table 3: Potential benefits and likely costs of health care that are avoided in the long term
Outcome measure
Average Benefit (range) due to physical activity
Health care consequences
Potential costs avoided*
in 24 weeks as observed in the previous cohort
interventions show that physical activity alone without diet control is unlikely to result in significant weight loss. It is therefore unlikely for significant reductions solely attributable to the ‘Be Active’ programme 10 patients with baseline diastolic values indicating treatment with antihypertensives, showed a drop in diastolic blood pressure. In 7 of these, diastolic blood pressure values at *See appendix for detailed costing
9. Conclusions
The evidence in the literature shows that exercise referral programmes are more effective than usual care in raising physical activity levels. The total costs per patient for the ‘Be Active’ project for 2006/07 are estimated between £99.20-£301 after applying best and worst-case scenarios. These costs approximate the ones in the NICE economic review that estimate a cost per patient of £272 for a physical activity intervention comprising intensive interviews and exercise vouchers. Total future costs saved per QALY gained were estimated at £750-£3,150 per patient. Only at annual CHD, stroke and diabetes treatment costs less than £600 per person, would any of the physical activity interventions result in a net cost to the health service. 10. Recommendations
Based on the findings of this report it is recommended that the funding of ‘Be Active’ programme be continued for at least another two years to allow for a sufficient follow-up period for collecting data on effectiveness in terms of sustained physical activity levels and Previous evaluations have collected data on weight, BMI, systolic blood pressure, diastolic blood pressure, peak flow and resting heart rate at baseline and follow-up appointments at 10 and 20 weeks. Future evaluations should include baseline and follow-up estimates of physical There should be one-year follow-up appointments to ensure adherence to new physical activity levels in the long-term. NICE also recommends a control group receiving a one time brief intervention such as advice on physical activity from a health professional but undergoing similar follow-up appointments to the test intervention group. NICE is very unequivocal in its recommendation that only exercise referral programmes part of a well-designed evaluation study should be Other suggested health outcomes: Changes in 10 year CHD risk should be estimated for individuals in the age range 30-74 years, using the Framingham scoring criteria if the following information is available at baseline and follow-up appointments: age, gender, total cholesterol (or LDL cholesterol), HDL cholesterol, smoking status, systolic blood pressure, diastolic blood pressure and diabetic status. Future evaluations could then calculate the cost per unit reduction in CHD risk. Where data collection on cholesterol levels is not feasible, average levels for the age-gender group can be substituted for individual values. However this would compromise the robustness of the measure as the only potential change would be for the blood pressure and diabetic References
[website: http://www.bnf.org/bnf/bnf/current/noframes/128041.htm, accessed on 1st March Drummond, M., et al. (1997). Methods for the economic evaluation of health care programmes (2nd ed.). Oxford, Oxford University Press Hale, J., Cohen, D., Ludbrook, A., et al. (2005). Moving from evaluation to economic evaluation: a health economics manual for programmes to improve health and wellbeing. UK Health Promotion and Health Economics Forum. http://courses.essex.ac.uk/hs/hs915/health%20economic%20evaluation%20manual.pdf, NICE (2004). Clinical Guidance 18: Hypertension-management of hypertension in adults in NICE (2006). Hypertension: management of hypertension in adults in primary care (partial NICE (2006). Rapid review of the economic evidence of physical activity interventions NICE (2006). Modelling the cost effectiveness of physical activity interventions NICE (2006). Public Health Intervention Guidance 2: Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling. Shaw, K., O’Rourke, P., Del Mar, C., et al. (2006). Psychological interventions for overweight or obesity. The Cochrane Database of Systematic Reviews 2006 (1). Todd, S. (2005). Be Active: Evaluation report. Belper, Amber Valley PCT. WCRF (1997). Food, nutrition, and the prevention of cancer: global perspective. Washington, WHO (2006). Information sheets: benefits of physical activity. WHO http://www.who.int/moveforhealth/advocacy/information_sheets/benefits/en/index.html, Wilson, P.W.F., D’Agostino, R.B., Levy, D., et al. (1998). Prediction of coronary heart disease using risk factor categories. Circulation 97:1837-1847.
Appendix 1: Detailed costing procedure

1. ACE inhibitor (recommended first line antihypertensive in hypertensive patients younger than 55 yrs, NICE CG18 update) Most commonly used ACE inhibitors in AVPCT: Ramipiril, Enalapril and Lisinopril Cost per patient over six months
(Source: courtesy Hazel Baxter, Pharmacy Services, AVPCT) 2. Calcium Channel blockers (recommended first line antihypertensive in hypertensive patients older than 55 years, or black patients of any age, NICE CG18 update) Most commonly used CCB in AVPCT is Felodipine Cost per patient over six months
tablets £6.70 Felodipine 5mg modified-release tablets £8.93 Felodipine 10mg modified-release tablets £12.01
(Source: courtesy Hazel Baxter, Pharmacy Services, AVPCT)
Note:The NICE CG18 guideline update on antihypertensives is still in draft
form and is out for consultation. The costing given in this appraisal is
based on the recommendations in the update in anticipation that these will
be eventually adopted. At present AVPCT prescribing practice is based on
the previous NICE CG18 (2004). Under this, thiazides are the first line
antihypertensives (unless contraindicated or there is a specific reason to
prescribe another drug group). Specific agents (in order of choice) used
would be:
• Bendroflumethiazide 2.5mg
[Information courtesy: Helen Hulme, Pharmacy Services, AVPCT] A single six month prescription of Bendroflumethiazide 2.5mg daily would cost: Unit cost= 20 pack of 2.5 mg=£0.74 Duration of prescription=6*30=180 days approximately Cost over six months for one patient= 180/20*0.74= £6.66 (Source of cost: BNF 50) 3. Detailed costing for ‘Be Active’ Funding costs for mainstreaming ‘Be Active’ GBP (£) valued at 2006 prices: Instructors x 3 x 30 hrs pw (includes on costs and pay award) Operational Manager x 1 x 15 hrs pw (includes on costs) Printing/Stationery: Referral pads, vouchers, information Note: It is likely that equipment costs in subsequent years will go down and have been roughly estimated by project staff to be £400-£600 valued at 2006 Be Sizewise: An Economic Appraisal Be Sizewise:
An Economic Appraisal
April 2006
P. R. Myles

Be Sizewise: An Economic Appraisal Executive Summary
• This report is intended as an aid to decision making about whether continued funding should be provided for the Health Referral Project • A Cost-consequences analysis has been carried out which provides detailed costing information for the project and lists expected benefits without attempting to value the benefits in monetary terms. For costing, a Primary Care Trust perspective has been adopted which means any costs incurred by the patient or other sectors have not been • A review of the literature found that ‘Be Sizewise’ is designed in keeping with current evidence of what works best in weight • The results of the pilot project showed that 84.3% of the pilot project cohort achieved weight loss and sustained this over a period of 6 months. This amounted to an average reduction in BMI of 4.26kg/m2. • Based on the pilot project results and literature review, likely benefits of ‘Be Sizewise’ include: reduction in 10year CHD risk, fall in blood pressure and reduction in cancer and diabetes related morbidity and mortality. However, these benefits are based on assumptions of weight • The cost per patient for ‘Be Sizewise’ has been estimated at £318.50 in 2006/07 and £258.60 in 2007/08 based on project costs and projected • Benefits in terms of potential costs saved are likely to accrue from costs associated with diagnosis, treatment, in patient care, GP consultations, GP prescriptions and specialist clinics. Be Sizewise: An Economic Appraisal • Lifestyle interventions, such as diet and exercise are comparable to drug treatments for obese individuals with risk factors such as impaired glucose tolerance (IGT), both in terms of effectiveness and cost. Recommendations
• Based on the literature review and pilot project, it is recommended that the project funding be continued for at least another two years to allow for a sufficient follow-up period for collecting data on effectiveness in terms of sustained weight loss or weight maintenance and behaviour The evaluation process should be reviewed to ensure robust Be Sizewise: An Economic Appraisal BE SIZEWISE: AN ECONOMIC APPRAISAL
1. Purpose of this report
This report is an economic appraisal of the Health Referral Programme, ‘Be Sizewise’. The main evaluation question that the report will focus on is whether the benefits of ‘Be Sizewise’ outweigh the costs. A Cost- Consequences Analysis (CCA) approach has been followed which provides detailed costing information for the project and lists expected benefits without attempting to value the benefits in monetary terms. For costing, a Primary Care Trust perspective has been adopted. This report therefore is intended as an aid to decision making about whether funding for the project should be 2. Nature of Health Promotion initiative
Be Sizewise is a health referral programme for people with a BMI of over 35 in Amber Valley. A wide range of health professionals can refer people to the programme. The programme aims are weight management and long-term behaviour change. There are three components to the programme: good health and nutrition, behavioural change and physical activity. The programme design is in keeping with current evidence on what works best in weight management and weight loss programmes. A Cochrane systematic review on interventions for overweight and obesity found that a combination of behaviour therapy, diet and exercise resulted in a significantly higher weight loss as compared to any of the components delivered singly (Shaw et al. 2006). The delivery of the programme is structured as an initial one-to-one consultations followed by 10 group sessions over 3 months. Follow-up 3. Weight management goals for the Programme
• Minimum goal- stabilise current weight • Ideal goal- 5% weight loss over 3 months • Programme ideal- 10% weight loss over a six month period Be Sizewise: An Economic Appraisal 4. Summary of evaluation results
A total of 52 people joined the pilot project and 34 people completed the 3- month programme. 32 people attended the follow-up appointment at 6 months and 6 people attended the follow-up appointment at 12 months. There was an average reduction in BMI of 4.26kg/m2. There was a 34.6% attrition rate over the 3-month period. This suggests the need for a detailed examination of the characteristics of non-responders and possibly, a review of the current targeting strategy. Table 1 summarises the key findings. Table 1: Results of evaluation
Change in Weight
At 3 months
At 6 months
5. The Economic evaluation question and methodology employed
The main evaluation question that the report will focus on is whether the benefits of ‘Be Sizewise’ outweigh the costs. A cost-consequences analysis (CCA) will be carried out providing a comprehensive list of beneficial consequences for the given monetary costs of the project. Such an approach will provide a comprehensive description of costs incurred in monetary terms but will not attempt to value any of the benefits. The perspective of the Primary Care Trust will be adopted for this evaluation. This means that only the costs of running the project will be considered and costs incurred by participants (such as transport, lost work time etc.) will not be considered. Since actual follow-up data is available only for six months, future benefits will be modelled based on probabilities given in literature. Be Sizewise: An Economic Appraisal 6. Costs of Be Sizewise
• Total costs of pilot project (June 2004-Dec. 2004, run on a part-time basis) = £25,397 (GBP valued at 2004 prices) • Funding costs for mainstreaming ‘Be Sizewise’ GBP (£) valued at 2006 prices: £55,736pa (detailed costing in appendix) • Applying a 3% inflation rate in keeping with Amber Valley PCT policy, costs for 2007/2008 are estimated to be £57,408. • Projected number of patients who will go through the Be Sizewise programme if mainstreamed (based on pilot project demand): 7. Expected benefits of Be Sizewise
Weight reduction and behavioural change. A systematic review of diet, physical activity and behavioural interventions for weight loss found an average decrease in weight of 1.7 kg over one year with such interventions Long term benefits due to weight reduction: • In the Framingham Heart Study, the risk of death within a 26-year period increased by 1% for each extra pound (0.45 kg) gain in weight between the ages 30–42 years, and by 2% between the ages 50–62 • Reduction in cardiovascular disease risk (this includes both coronary heart disease and stroke): This is by reduction in blood pressure and total cholesterol. For every 10% weight loss in a person initially weighing 100 kg there would be an expected 10 mm Hg fall in systolic Be Sizewise: An Economic Appraisal and diastolic blood pressure. A weight loss in the range of 4%-8% of body weight was found to be associated with a decrease in blood pressure in the range of 3mm Hg systolic and diastolic blood pressure. There is evidence that even if the fall in blood pressure levels does not indicate complete withdrawal of antihypertensive therapy, it may decrease dosage requirements of the medication (Mulrow et al. 2006). Similarly, there would be an expected 10% fall in total cholesterol and a 15% fall in low-density lipoproteins (Jung 1997). • Diabetes risk reduction: the risk of Type 2 Diabetes rises progressively from a BMI of over 21kg/m2 (James and Rigby 2004). A 10% weight loss in a person initially weighing 100 kg would result in a 50% fall in • Cancer risk reduction: Between 30-40% of all cancer cases are preventable by ‘feasible and appropriate diets, physical activity and maintenance of appropriate body weight’ (WCRF 1997). 8. Valuing the benefits
As mentioned in the introduction, no direct attempt will be made to value the benefits in monetary terms. The purpose of this section is to provide a descriptive account of the nature and extent of cost savings. It is difficult to value the impact of lifestyle interventions for weight reduction, on hypertension, hypercholesterolemia and subsequent cardiovascular disease. This is because it is difficult to estimate the long-term effects of short–term weight loss (Avenell et al. 2004). Lifestyle interventions, such as diet and exercise are comparable to drug treatments for obese individuals with risk factors such as impaired glucose tolerance (IGT), both in terms of effectiveness and cost (Avenell et al. 2004). There is evidence that a reduction in BMI in the range of 1-2kg/m2 over a year, would result in a significantly lower diabetes incidence over 3-6 years (Norris et al. 2006a). Costs associated with diabetes could be due to diagnosis, treatment, in patient care, GP consultations, GP prescriptions,
Diabetes clinics, specialist diabetes nurses or long-term residential and Be Sizewise: An Economic Appraisal nursing care (Diabetes UK, 2001). The Be Sizewise pilot project cohort had an average reduction in BMI of 4.26kg/m2. Table 2 summarises likely benefits of Be Sizewise in terms of potential healthcare costs avoided in the long term. Be Sizewise: An Economic Appraisal Table 2: Potential costs to health care that are avoided in the long term
Expected health benefits in the medium term (6 months) -Fall in Total cholesterol by 0.25 mmol/l -Fall in diastolic blood pressure of 3.6 mmHg -Fall in systolic blood pressure of 6.1mmHg -Fall in systolic and diastolic blood pressures by 3mmHg -In women, reduced risk of death, CVD death, cancer and Difficult to cost as literature does not provide probabilities -In men, reduced risk of diabetes related death Be Sizewise: An Economic Appraisal 9. Conclusions
The literature review shows that ‘Be Sizewise’ is designed in keeping with current evidence of what works best in weight management and weight loss programmes. Based on the pilot project results and literature review, likely benefits of Be Sizewise include: reduction in 10year CHD risk, fall in blood pressure and reduction in cancer and diabetes related morbidity and mortality. However, these benefits are based on assumptions of weight The cost per patient for Be Sizewise has been estimated at £318.50 in 2006/07 and £258.60 in 2007/08 based on project costs and projected number of patients. Benefits in terms of potential costs saved are likely to accrue from costs associated with diagnosis, treatment, in patient care, GP consultations, GP prescriptions and specialist clinics. Lifestyle interventions, such as diet and exercise are comparable to drug treatments for obese individuals with risk factors such as impaired glucose tolerance (IGT), both in terms of effectiveness and cost. 10. Recommendations
• Based on the literature review and pilot project, it is recommended that the project funding be continued and a detailed evaluation be carried out with data collected over a twelve-month period. Current referral forms have been designed to collect baseline information on BMI, blood pressure, smoking and medication and similar forms should be • Documented changes in medication use should be used for more precise costing in future economic evaluations. • Additional outcome measures recommended for future evaluations: Changes in 10 year CHD risk should be estimated for individuals in the age range 30-74 years, using the Framingham scoring criteria if the following information is available at baseline and follow-up Be Sizewise: An Economic Appraisal appointments: age, gender, total cholesterol (or LDL cholesterol), HDL cholesterol, smoking status, systolic blood pressure, diastolic blood pressure and diabetic status (Refer Wilson 1998 for methodological details). Future evaluations could then include the cost per unit reduction in CHD risk. Where data collection on cholesterol levels is not feasible, average levels for the age-gender group can be substituted for individual values. However this would compromise the robustness of the measure as the only potential change would be for the blood pressure and diabetic status variables. Evaluators must also be aware that no evidence was found in the literature on whether any benefits related to CHD risk would be lost if weight loss was not sustained which is why a minimum follow-up period of one year should be Be Sizewise: An Economic Appraisal References
Avenell, A., Broom, J., Brown, T.J. (2004). Systematic review of the long term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment 8 (21).
[website: http://www.bnf.org/bnf/bnf/current/noframes/128041.htm, accessed on 1st March Diabetes UK (2001). Diabetes Factsheet No. 3: Cost and complications [website: http://www.diabetes.org.uk/infocentre/fact/fact3.htm , accessed on 26th Feb. 2006] Drummond, M., et al. (1997). Methods for the economic evaluation of health care programmes (2nd ed.). Oxford, Oxford University Press Hale, J., Cohen, D., Ludbrook, A., et al. (2005). Moving from evaluation to economic evaluation: a health economics manual for programmes to improve health and wellbeing. UK Health Promotion and Health Economics Forum. http://courses.essex.ac.uk/hs/hs915/health%20economic%20evaluation%20manual.pdf, Harvey, E.L., Glenny, A.M., Kirk, S.F.L., et al. (2006). Improving health professionals’ management and the organisation of care for overweight and obese people. The Cochrane Database of Systematic Reviews 2006 (1). James, P. and Rigby, N. (2004). The challenge to movers and shakers: broad strategies to prevent obesity and diabetes. Diabetes Voice 49 (2).
Mulrow, C.D., Chiquette, E., Angel, L., et al. (2006). Dieting to reduce body weight for controlling hypertension. The Cochrane Database of Systematic Reviews 2006 (1). NICE (2004). Clinical Guidance 18: Hypertension-management of hypertension in adults in NICE (2006). NICE guidance: Statins for the prevention of cardiovascular events. NICE (2006). Hypertension: management of hypertension in adults in primary care (partial Be Sizewise: An Economic Appraisal Norris, S.L., Zhang, X., Avenell, A., et al. (2006a). Long term non-pharmacological weight loss interventions for adults with prediabetes. The Cochrane Database of Systematic Reviews Norris, S.L., Zhang, X., Avenell, A., et al. (2006b). Long term non-pharmacological weight loss interventions for adults with type 2 diabetes mellitus. The Cochrane Database of Systematic RCP (1998). Clinical management of overweight and obese patients: with particular reference to the use of drugs. London, Royal College of Physicians of London. Shaw, K., O’Rourke, P., Del Mar, C., et al. (2006). Psychological interventions for overweight or obesity. The Cochrane Database of Systematic Reviews 2006 (1). Smith, S.C., et al. (2004). Principles for National and Regional guidelines on cardiovascular prevention: A scientific statement from the World Heart and Stroke Forum. Circulation 109:
Southern Derbyshire Health Community Consensus (2005). Guidelines for Primary Prevention of CHD. Southern Derbyshire. Todd, S. (2005). Be Sizewise: Evaluation report. Belper, Amber Valley PCT. WCRF (1997). Food, nutrition, and the prevention of cancer: global perspective. Washington, Wilson, P.W.F., D’Agostino, R.B., Levy, D., et al. (1998). Prediction of coronary heart disease using risk factor categories. Circulation 97:1837-1847.
Be Sizewise: An Economic Appraisal APPENDIX 1: DETAILED COSTING PROCEDURE
1. Simvastatin (statin- lipid lowering drug, AVPCT prescribing guideline) 40 mg daily dose over 6 months per patient 6*30=180 tablet approx. would cost 180/28*4.87=£31.31 2. ACE inhibitors (recommended first line antihypertensive in hypertensive patients younger than 55 yrs, NICE CG18 update) Most commonly used ACE inhibitors in AVPCT: Ramipiril, Enalapril and Cost per patient per month
Cost per patient over six months
(Source: courtesy Hazel Baxter, Pharmacy Services, AVPCT) 3. Calcium Channel blockers (recommended first line antihypertensive in hypertensive patients older than 55 years, or black patients of any age, NICE Most commonly used CCB in AVPCT is Felodipine. Cost per patient per month
Cost per patient over six months
Felodipine 2.5mg modified-release tablets £6.70 Felodipine 5mg modified-release tablets £8.93 Felodipine 10mg modified-release tablets (Source: courtesy Hazel Baxter, Pharmacy Services, AVPCT) Be Sizewise: An Economic Appraisal Note:The NICE CG18 guideline update on antihypertensives is still in draft
form and is out for consultation. The costing given in this appraisal is based on the recommendations in the update in anticipation that these will be eventually adopted. At present AVPCT prescribing practice is based on the previous NICE CG18 (2004). Under this, thiazides are the first line antihypertensives (unless contraindicated or there is a specific reason to prescribe another drug group). Specific agents (in order of choice) used would [Information courtesy: Helen Hulme, Pharmacy Services, AVPCT] A single six month prescription of Bendroflumethiazide 2.5mg daily would Duration of prescription=6*30=180 days approximately Cost over six months for one patient= 180/20*0.74= £6.66 4. Detailed costing of Be Sizewise Project for 2006/07 Funding costs for mainstreaming ‘Be Sizewise’ GBP (£) valued at 2006 prices: 1 x full-time weight management advisor (37.5hrs)- £24,198pa 1 x part-time operational management (15hrs pw)- £ 9,211pa Be Sizewise: An Economic Appraisal Venue costs (8 groups x 46 weeks=368 sessions)- £ 3,312pa

Source: http://www.activehealthforum.org.uk/sites/default/files/Evaluating%20the%20Cost%20Effectiveness%20of%20Exercise%20Referral_0.pdf