For individual use only. Duplication or distribution prohibited by law.

Financial Analysis

Participation in Fitness-Related Activities of an Incentive-Based Health Promotion Program and Hospital Costs: A Retrospective Longitudinal Study
Deepak Patel, MD, MSc; Estelle V. Lambert, PhD; Roseanne da Silva, BScHons, FIA; Mike Greyling, MSc; Tracy Kolbe-Alexander, BSc, PhD; Adam Noach, BSc; Jaco Conradie, BSc; Craig Nossel, MBChB, MBA; Jill Borresen, BSc, PhD; Thomas Gaziano, MD
Abstract Purpose. A retrospective, longitudinal study examined changes in participation in fitness-related activities and hospital claims over 5 years amongst members of an incentivized health promotion program offered by a private health insurer. Design. A 3-year retrospective observational analysis measuring gym visits and participation in documented fitness-related activities, probability of hospital admission, and associated costs of admission. Setting. A South African private health plan, Discovery Health and the Vitality health promotion program. Participants. 304,054 adult members of the Discovery medical plan, 192,467 of whom registered for the health promotion program and 111,587 members who were not on the program. Intervention. Members were incentivised for fitness-related activities on the basis of the frequency of gym visits. Measures. Changes in electronically documented gym visits and registered participation in fitness-related activities over 3 years and measures of association between changes in participation (years 13) and subsequent probability and costs of hospital admission (years 45). Hospital admissions and associated costs are based on claims extracted from the health insurer database. Analysis. The probability of a claim modeled by using linear logistic regression and costs of claims examined by using general linear models. Propensity scores were estimated and included age, gender, registration for chronic disease benefits, plan type, and the presence of a claim during the transition period, and these were used as covariates in the final model. Results. There was a significant decrease in the prevalence of inactive members (76% to 68%) over 5 years. Members who remained highly active (years 13) had a lower probability (p , .05) of hospital admission in years 4 to 5 (20.7%) compared with those who remained inactive (22.2%). The odds of admission were 13% lower for two additional gym visits per week (odds ratio, .87; 95% confidence interval [CI], .801.949). Conclusion. We observed an increase in fitness-related activities over time amongst members of this incentivebased health promotion program, which was associated with a lower probability of hospital admission and lower hospital costs in the subsequent 2 years. (Am J Health Promot 2011;25[5]:341348.) Key Words: Health Insurance, Wellness Program, Chronic Disease, Prevention Research. Manuscript format: research; Research purpose: modeling/relationship testing, descriptive; Study design: retrospective longitudinal, analytic; Outcome measure: financial/economic, hospital costs; Setting: private national health insurer; Health focus: fitness/physical activity; Strategy: education, skill building/behavior change, incentives; Target population age: adults; Target population circumstances: health-insured population
Deepak Patel, MD, MSc is with UCT/MRC Research Unit for Exercise Science and Sports Medicine, University of Cape Town, Cape Town South Africa; and Discovery Health, Johannesburg, South Africa. Estelle V. Lambert, PhD; and Tracy Kolbe-Alexander, BSc, PhD, are with UCT/MRC Research Unit for Exercise Science and Sports Medicine, University of Cape Town, Cape Town, South Africa. Adam Noach, BSc; Jaco Conradie, BSc; Craig Nossel, MBChB, MBA; and Jill Borresen, BSc, PhD, are with Discovery Health, Johannesburg, South Africa. Roseanne da Silva, BScHons, FIA, is with School of Statistics and Actuarial Science. Mike Greyling, MSc, is with School of Human and Community Development, University of Witwatersrand, Johannesburg, South Africa. Thomas Gaziano, MD, is with Brigham and Womens Hospital, Harvard Medical School, Boston, Massachusetts.
Send reprint requests to Estelle V. Lambert, UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, PO Box 115, Newlands, Western Cape Town, 7725 South Africa; vicki.lambert@uct.ac.za.
This manuscript was received June 3, 2010; revisions were requested November 30, 2010, and January 18, 2011; the manuscript was accepted for publication January 20, 2011. Copyright 2011 by American Journal of Health Promotion, Inc. 0890-1171/11/$5.00 + 0 DOI: 10.4278/ajhp.100603-QUAN-172

INTRODUCTION Physical inactivity and sedentary living are major lifestyle factors that contribute to the growing burden of disease globally.1 The effects of the increasing prevalence of inactivity are most evident in the increase in noncommunicable chronic diseases of lifestyle, such as hypertension, type 2 diabetes, cancer, and coronary heart disease.2 There is compelling evidence for the beneficial effects of physical activity in the primary and secondary prevention of a large number of chronic diseases. Diseases such as type 2 diabetes,3 hypertension4,5 cardiovascular disease,6 certain cancers,4 mental illnesses,7 and osteoporosis8 are directly impacted by increasing physical activity. All-cause mortality, as well as deaths as a result of cardiovascular diseases and cancers, are significantly decreased with increased levels of physical activity.9,10 Physical activity has also been shown to mitigate the effects of other risk factors. For example, overweight individuals who are fit have greater longevity than those normal-weight individuals who are unfit.11,12 Likewise, it has been shown that physically active smokers have a lower risk of dying than nonactive smokers.13 The enormous burden of diseases related to physical inactivity or sedentary living have significant direct and indirect economic consequences for the individual and for society.1416

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

341

For individual use only. Duplication or distribution prohibited by law.

People with unhealthy lifestyles may experience a lower quality of life and an increased financial burden because of out-of-pocket expenses and lost wages. However, these individuals also impose costsreferred to as external costson others. For instance, people with healthier lifestyles may indirectly subsidize those with unhealthy lifestyles through collectively funded health insurance programs.17,18 Thorpe et al.,19 showed that the increase in prevalence of chronic diseases, particularly chronic diseases of lifestyle, rather than the increase in cost per treated patient was the most important determinant of the growth in private insurance spending between 1987 and 2002 in the United States. Likewise, in South Africa, chronic diseases of lifestyle impose a considerable cost burden.20 Approximately 12% of privately insured members have a lifestyle-related chronic disease. This is in the context of a high prevalence of physical inactivity where 63.2% of men and 75.3% of women in South Africa are estimated to be inactive or insufficiently inactive.21 Hence, there is renewed interest in incentivized health promotion programs amongst health plans in an effort to change health behavior, such as physical inactivity, and thereby rein-in long-term health care costs.22 The aims of the current retrospective longitudinal investigation, conducted over 5 years, were as follows: (1) to examine if membership of the health promotion program, Vitality, was associated specifically with increased participation in fitness-related activities of the program over time, (2) to examine if such increased participation did occur, whether it was associated with reduced hospital claims experience over the period of the study, and (3) to examine if it was possible to establish a dose effect of participation against the probability of admissions and hospital claims. This incentivized health promotion program has been previously described.23,24 METHODS Design This is a 5-year observational retrospective study of members of a South African national private health insurer, Discovery Health. Persons who were already members of the health plan or who registered for the plan between January 2001 and December 2003 were included in the study. We examined the extent to which changes in engagement with fitness-related activities, as part of the health promotion program, in the first 3 years after enrollment were related to the probability of hospital admission and hospital claims in the subsequent 2 years. Sample The study sample was comprised of 304,054 adult members of the Discovery Health medical plan, including 192,467 who registered for the health promotion program (Vitality) between January 2001 and December 2003 and 111,587 members who were not registered on the program. Inclusion criteria required continuous membership of the health plan for a 5-year period and a consistent registration (either on or off the health promotion program) for the first 3 years. An additional 1646 individuals who were members of the health promotion program in year 1 but subsequently left the program were included in the analysis of transitions. All data were analyzed while unlinked to any personal identifiers. The study protocol was approved by the Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town. In keeping with previously reported studies on the current health promotion program,23,24 engagement with fitness-related activities in the first year for this study was defined, a priori, as follows: high activity with points equivalent to more than 48 gym visits per annum; medium activity with points equivalent to 24 to 48 gym visits per annum; low activity with points equivalent to four to 24 gym visits per annum,; and inactive with points equivalent to three or fewer gym visits per annum. These categories were chosen to ensure roughly equal sample sizes in the active categories, and they referred, specifically, to activities offered and recorded by the program and not to the total level of physical activity. Members participating in the health promotion program were awarded points specifically for fitness-related activities according to the total number of electronically documented gym visits at several nationally participating gym chains. Additionally, members were able to accumulate points for registered participation in sporting events, such as road or cycle races. One hundred fifty points were allocated per gym visit, whereas participants in a road race were awarded 5000 points. Gym visits, however, accounted for approximately 96% of points for fitness-related activities recorded on the program. Intervention The health promotion program is offered to members of the Discovery Health medical plan on a voluntary basis for a nominal monthly fee of approximately $15 per month per family. The program encompasses multiple health-promotion and disease-prevention interventions targeted at several health behaviors, including physical inactivity. After registering for the program, members obtain immediate benefits, one of which is subsidized access to several national fitness center chains, through a reduced joining fee. Participation in wellness activities are additionally rewarded with points that contribute to a tier status, which, in-turn, permits members to claim increasing discounts of between 20% and 40% on goods and services at various national participating stores. Approximately 50% of the total points earned on the program are from fitness-related activities. Outcomes Measures The outcome measures included changes in the level of participation or engagement in fitness-related activities over time. Fitness-related activities were either documented electronically via a bar-coded swipe card for gym visits or via registration for specific sports- or fitness-related events (such as fun runs or cycle races). Members were then grouped according to the changes in participation in fitness-related activities from years 1 to 3; the categories described in Table 1 were thus defined. The transitions between activity groups were calculated on a 3-year basis, and the claims and admissions were monitored for the subsequent 2 years from the health insurer data-

342

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

For individual use only. Duplication or distribution prohibited by law.

Table 1 Group Definitions for Changes in Fitness-Related Activities From Years 13 After Enrollment
Group Inactive to no change Inactive to more active Active to less active Active to no change Active to more active Not enrolled in health promotion program Definition Inactivity in years 13 Inactivity in year 1; low, medium, or high activity in year 3 Low, medium or high activity in year 1; decreased by at least one fitness category in year 3 Low, medium, or high activity in year 1; no change in year 3 Low, medium, or high activity in year 1; increased by at least one fitness category in year 3 Not enrolled in health promotion program from years 13

base. This approach to the analysis was chosen, as, typically, fitness engagement increased rapidly in the first 3 years and leveled off thereafter. Covariates such as age, gender, plan type, and registration for chronic benefits were routinely entered as part of the database. Analysis The changes in the level of participation in the program were examined descriptively by comparing the proportion of respondents in each level. Although the sample sizes were large enough to make significance tests of the change, redundant odds ratios for the change in proportion for each category were calculated along with confidence intervals to demonstrate the change. It was difficult to categorize the members who either joined or left the health promotion program after the first year. There was a justified concern that those who failed to engage in the program may voluntarily have chosen to leave and, as such, would inflate the numbers of engaged members. To counter this concern, a further analysis was performed, in which all those who left the health promotion program were assumed to occupy the lowest level of engagement for the duration of the analysis (n 5 1646). This provided a more conservative estimate of the change in engagement for the program. The second aim required an analysis of the claims experience of the members. In particular, the study aimed to compare the claims experience for the different transition categories defined in Table 1. This analysis raised both design and analytical concerns. Firstly, a key concern for the analysis was to remove, when possible, selection

effects from the results. To address this concern, a propensity model25 for the transition categories was developed. The propensity scores were estimated by using a generalized logit model26 that included the following: age, gender, registration for chronic disease benefits, plan type, and the presence of a claim during the transition period. The propensity scores were then used as covariates in the final model. Chronic disease benefits referred to members who were registered for pharmaceutical and related benefits on the basis of a pre-existing chronic condition, for example, hypertension or asthma. Plan types ranged from comprehensive, which covered most out-of-pocket medical expenses, including doctor visits, medications, procedures, and hospitalization, with a substantial medical savings account to a core or saver-type plan, which offered fewer benefits and which required the member to copay for some of the benefits, with a smaller medical savings account. The higher the health insurance premiums, the more comprehensive the plan. The claims data present additional challenges because of the highly skewed distribution of the cost data. Diagnostic tests suggest that the distribution was well approximated by a lognormal distribution with additional zero values when no hospitalization occurred. A number of authors have proposed models that encompass this structure. In particular, Duan et al.,27 propose a two-part model in which the probability of a claim is estimated by means of probit analysis and the claim value is estimated by applying normal theory to the logged claim amounts, when these are non-zero. Feuerverger28 provides a similar analysis by using a

logit model for the probability of an event. The two-stage model has the advantage that parameters for each component can be estimated separately, which reduces the computation requirements. This is particularly relevant here, given the relatively large sample size. In the present analysis, the probability of at least one claim was modeled using a Logistic Regression (LR) analysis,26 whereas the cost of treatment (for all patients who experienced at least one claim) was analyzed using a linear model for the log of the claim amount. In order to obtain means in the original scale, the estimates from the linear model were transformed back into the original scale. Duan et al.,27 found that use of a theoretically estimated transformation was superior to the smearing estimate. However Duan et al.,29 noted that this relies on the degree to which the assumptions of the error terms, normality, and homoscedasticity are met. In the present analysis, the smearing estimator was used to estimate the means in the original scale. To obtain point and interval estimates of costs per person, the probability estimates from the LR were combined with estimates from the linear model by using numerical methods. The general form of the Monte Carlo approach has been described by Besag and Clifford.30 The distribution of the average claim was estimated by drawing a large sample from the joint distribution of the probability of a claim and the value of that claim. In order to examine whether a doseresponse pattern was evident in the data, a subset was examined. Only the patients who were in the lowest category at the start of the transition

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

343

For individual use only. Duplication or distribution prohibited by law.

Table 2 Demographic and Medical Plan Characteristics of Members According to Engagement With Fitness-Related Activities in Year 1
Not Enrolled In Health Promotion Program No. of members in cohort % of all members % of members enrolled in health promotion program Mean (SD) age, y* % male % any chronic benefits % comprehensive plan * SD indicates standard deviation. 111,587 36.7% 52.2 (15) 45.0% 39% 36.0%

Fitness Inactive 145,396 47.8% 75.5% 41.2 (12) 48.0% 18% 45.0%

Fitness Low-Active 14,754 4.9% 7.7% 36.6 (10) 49.0% 13% 45.0%

Fitness Medium-Active 12,568 4.1% 6.5% 38 (10.8) 53.0% 15% 44.0%

Fitness High-Active 19,749 6.5% 10.3% 39.8 (11.9) 60.0% 17% 43.0%

Total 304,054 100.0% 100.0% 44.8 (14.3) 48.0% 25% 41.0%

period and who increased their level of activity were included in the subset analysis. A logistic regression analysis, predicting the event of a claim in years 4 and 5 was performed by using the number of gym visit equivalents (i.e., 150 fitness points) as the independent variable. The same covariates included in the previous analysis were also used. RESULTS The demographic and medical plan characteristics by engagement in fitness-related activities are shown in Table 2. Irrespective of their level of participation in fitness-related activities, those members registered for the health promotion program were younger, and a lower proportion were registered for chronic benefits com-

pared with those not registered for the program. Table 3 shows the trends for gym visits and the transitions in levels of engagement in fitness-related activities measured over 5 years. The proportion of members in the study cohort using the gym had increased from 27% at the time of enrollment at the beginning of 2004 to 33.1% at the end of 2008an increase of 22% over this period. Gym visits comprised the largest pointsearning activities of the program, accounting for about 50% of all points earned (data not shown). The proportion of members classified as inactive changed from 76% to 68% from years 1 to 5, and the odds of remaining inactive were lower by 42% over this period. Similarly, the proportion of members classified as having high activity increased from 10% to 13%

(odds ratio, 1.26; 95% confidence interval [CI], 1.25 to 1.28) over the same time period. Taking the more conservative figures, on the basis of the assumption that members who leave the program during the first year were in the lowest level of engagement, only slightly reduces effect (data not shown). The probability of hospital admission and the cost of hospital claims in years 4 to 5 are shown in Figures 1 and 2, which compare groups according to changes in participation in fitnessrelated activity from years 1 to 3. Claims are expressed in South African Rand (ZAR), with 1 ZAR 5 .1447 U.S. dollars. Members in the inactive-to more active group were less likely to be admitted (p , .05) and had lower hospital claims (p , .05) than those in the inactive-tono change group. Members in the active-tono change

Table 3 Changes in the Proportion of Members Using the Gym and Levels of Engagement in Fitness-Related Activities Over 5 Years
OR (95%CI) for Transition Into the Inactive Category Fitness Variable No. of members on the study using gym % of members using gym % inactive % low-active % medium-active % high-active Year 1 51,955 27% 76% (76%) 8% (8%) 7% (7%) 10% (10%) Year 2 59,856 31.1% 72% (72%) 8% (8%) 8% (8%) 12% (12%) Year 3 61,194 31.8% 71% (71%) 9% (9%) 8% (8%) 12% (12%) Year 4 61,752 32.1% 70% (71%) 8% (8%) 10% (9%) 12% (12%) Year 5 63,654 33.1% 68% (69%) 8% (8%) 11% (10%) 13% (13%) Years 13 Years 15

0.8 1.12 1.31 1.19

(0.790.80) (1.101.15) (1.281.33) (1.181.21)

0.58 1.04 1.63 1.26

(0.570.58) (1.021.07) (1.61.65) (1.251.28)

NOTE: Data are conservative values for proportions and take into consideration members who have left the health insurance scheme (as noted in brackets). * OR indicates odds ratio; CI, confidence interval.

344

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

For individual use only. Duplication or distribution prohibited by law.

fitness-related activities of the program, specifically gym visits, increased over time. This was evident in an almost 22% increase in gym membership over the 5 years. This implies that, the longer members remained on the program, the greater the proportion who joined the gym. Moreover, with time, the percentage of members classified as inactive decreased (from 76% to 68%), and there was a corresponding increase in the percentage classified as medium-engagement (7% to 10%) and high-engagement (10% to 13%) in fitness-related activities. This finding of increasing engagement in fitness-related activity over time contrasts with findings in numerous previous studies, which report an initial increase in engagement with physical activity followed by a drop-off over time.31,32 For example, in a review of physical activity interventions for older adults, van Bij32 reported that, although interventions achieved high rates of participation in the short term, participation rates declined with increasing duration. In a 1998 review, Dishman33 reported that worksite interventions to increase physical activity did not yield a statistically positive effect overall. Similarly, Harland et al.,31 found that self-reported physical activity levels after 12 weeks of intervention in a primary care setting were not maintained at 1 year regardless of the intensity of the intervention. Our study did not investigate which specific aspects of the program may have contributed to this outcome. It is possible that two features of the health promotion programsubstantially reduced cost of membership to gyms and other fitness activities and rewards for participationmay have influenced the changes in physical activity behavior on the program. The Guide to Community Preventive Services34 reported that interventions that enhanced access to places for physical activity together with informational outreach activities are effective in increasing levels of physical activity and, in some cases, may be more important than the educational and social support components.35 Reducing the costs of membership in gym and other fitness facilities may lower the motivational and financial barrier to participation. It may, for instance,

Figure 1 The Probability of Hospital Admission in Years 4 and 5 on the Basis of Changes in Level of Engagement in Fitness-Related Activities in Years 1 to 3

Probabilities reported with 95% confidence intervals. The p values refer to level of significant differences between groups, as indicated by |------|. For example, persons in the inactive-tomore active group had a significantly higher probability of a hospital claims than those in the active-tono change group (p 5 .013) or the active-tomore active group (p 5 .036).

and active-tomore active groups also claimed less (p , .05) and had a lower rate of hospital admissions than those in the active-toless active group (p , .05). In addition, those members in the active-toless active group and inactivetomore active group had similar claims and probability of admissions. Members not on the health promotion program (i.e., not on the HPP) had a significantly higher probability of admissions (p , .01) and higher claims (p , .01) than both the active-tono change group and active-tomore active groups. Conversely, members not on the program claimed less and had lower probability of admission than those in the inactive-tono change group (p , .05). Claims and probability of admis-

sions in this group, were, however, not different from the inactive-tomore active group and active-toless active groups. Figure 3 illustrates the dose response relationship between the number of additional gym visits per week and the odds ratios for hospital admission. One additional gym visit per week was associated with a 7% lower odds ratio for the probability of hospital admission. DISCUSSION The first important finding of the present longitudinal study of a health insurancelinked health-promotion program is that engagement with

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

345

For individual use only. Duplication or distribution prohibited by law.

the role of a wide selection of incentives, offered continuously and over a long period, in changing physical activity behavior. The next important finding in the study is that those members who consistently maintained or increased engagement with fitness-related activities on the program over a 3-year period had the best outcomes with regard to the probability of admission and hospital costs. It is important to note that this study measured the associations between changes in participation in fitness-related activities of a health promotion program and medical costs over time, and, as such, causality cannot be established. However, the consistently unengaged group (i.e., inactive to no change) had the worst outcomes on both measures. The variable activity groups (i.e., active to less active and inactive to more active) and those members not enrolled had equivalent outcomes that were between the consistently inactive and consistently active groups Most previous studies that have explored the relationship between physical activity and health care costs have relied on a single baseline measure of physical activity.40,41 For example, Ackerman et al.,42 found that Medicare members who participated in a community-based exercise program incurred lower increases in overall health care costs than nonparticipating controls. Those who attended more than one exercise session a week incurred approximately 80% of the costs of controls. There were no differences in total costs, but primary care costs were significantly higher amongst low users (,1 visit per week) compared with controls. Similarly, Wang et al.,12,43 showed that physically active individuals incurred significantly lower health care costs than sedentary individuals (approximately $250 less), irrespective of body mass index. This held true for elderly Medicare retirees as well.12 In one longitudinal study, Tsuji et al.,44 reported that total medical costs over a 4-year period amongst Japanese men and women age 40 to 79 years who spent more than an hour walking were 15% lower (3855) compared with those who walked ,1 hour a day (4563). The present study makes an important contribution, in that we were able

Figure 2 The Cost of Hospital Admissions in Years 4 and 5 on the Basis of Changes in Levels of Engagement in Fitness-Related Activities in Years 1 to 3

Probabilities reported with 95% confidence intervals. Cost reported in ZAR; 1 ZAR 5 0.1447 U.S. dollars. The p values refer to level of significant differences between groups, as indicated by |------|. Persons in the inactive-tomore active group had significantly higher costs of admissions than those in the active-tono change group (p , .05) or the active-tomore active group (p , .05).

facilitate change from the contemplative to the action stage in the transtheoretical model of change.36 According to Sassi and Hurst,37 actions that widen choice or make certain options more accessible are generally well accepted and not viewed as paternalistic. These actions expand the range of choices available to the individual or decrease the price individuals have to pay when they choose options that were previously available at a higher price. In the program under study, subsidized gym membership was offered as an incentive to induce members not involved in any physical activity to join the gym. For members already using gyms, the subsidy assisted in maintaining an ongoing gym membership.

Engagement in fitness activities in the current study may also have been influenced by rewards (variable discount on purchases based tier status) that were offered for participation. There is accumulating evidence on the role of incentives in increasing participation in health promotion programs. However, the literature on the role of incentives and rewards in influencing physical activity behavior specifically is sparse. Most studies typically report findings with limited, well-defined incentives that are offered for a short period.31,38,39 The present study suggests that a comprehensive, incentivebased health promotion program was associated with increased participation in physical activity over time. We found no comparable studies that examined

346

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

For individual use only. Duplication or distribution prohibited by law.

demonstrated a dose-response relationship. The results of this study need to be substantiated by prospective, randomized, controlled trials that investigate the role of incentivized health promotion programs in changing complex health behavior, such as physical inactivity. The outcomes of this study suggest that physical activity interventions, such as subsidized gym memberships, as part of a comprehensive, incentivized, health promotion program may be an important addition to other public-health strategies to increase physical activity and mitigate long-term health care costs. SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known on this topic? There is compelling evidence for the beneficial effects of physical activity in the prevention of chronic, noncommunicable diseases; the argument for physical activity reducing health care expenditure is less clear, although it is supported by both prospective and cross-sectional studies. Physical activity is a complex behavior that requires considerable effort to change. There is limited evidence demonstrating that interventions that enhance access to and lower the motivational and financial barriers to physical activity may be effective. What does this article add? This study found an association between membership of a health insurancelinked, incentivized, health promotion program and increased participation in fitnessrelated activities over 5 years. These changes were associated with lower associated hospital claims and probability of admissions. What are the implications for health promotion practice or research? The outcomes of this study suggest that interventions, such as subsidized gym membership or financial incentives for participation, as part of a comprehensive, incentivized health promotion program offered by health care providers may be a useful strategy to increase physical activity and mitigate longterm health care costs.

Figure 3 Odds Ratios and 95% Confidence Intervals for the Probability of Hospital Admissions per Number of Additional Gym Visits per Week

to relate changes in engagement with the physical activity components of the program to subsequent changes in hospital costs. Martinson et al.,45 reported similar results in a prospective cohort study of 2393 adults age 50 years and older who were on a health plan. They found that individuals who increased their physical activity from #1 to 3 days per week over a 3-year period incurred lower health care costs (2$2202; p , .01) than individuals who remained consistently inactive in that period. Additionally, we were able to demonstrate a dose-response relationship between engagement in fitnessrelated activity and health-related outcomes. For example, for each additional weekly gym visit, the odds ratio for the probability of hospital admission was reduced by approximately 6%. A limitation of the present study is that, althoughthe frequency of gym visits was independently recorded, the duration, intensity, and type of activities undertaken at the gym were not recorded. The study also did not include activities undertaken outside the program. However, the primary objective of the study was to ascertain

the extent to which membership of and engagement with the health promotion program, and not general level of fitness, was related to health care costs. The study also did not establish which of the various incentives and rewards may have motivated the changes in physical activity behavior. Future qualitative research will elucidate this point. The strength of the current study, on the other hand, is that engagement with fitness-related activities was independently recorded in this large, incentivized, health-insured, cohort over time. Moreover, hospital costs were also independently obtained from the health plan administrator. The current study is important in that it shows that documented engagement in fitness-related activity increases with continued membership of an incentives and rewards-based health promotion program. This increase in engagement was associated with a decrease in the probability of hospital admission as well as a decrease in overall inpatient health care costs. This association showed a temporal sequence. Moreover, the study

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

347

For individual use only. Duplication or distribution prohibited by law.

References

1. World Health Report 2003: Shaping the Future. New York, NY: World Health Organization; 2003. 2. Booth FW, Laye MJ, Lees SJ, et al. Reduced physical activity and risk of chronic disease: the biology behind the consequences. Eur J Appl Physiol. 2008;102(4):381390. 3. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393403. 4. Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a metaanalysis of randomized, controlled trials. Ann Intern Med. 2002;136(7):493503. 5. Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc. 2001;33(6 suppl):S484S492. 6. Sesso HD, Paffenbarger RS Jr, Lee IM. Physical activity and coronary heart disease in men: the Harvard alumni health study. Circulation. 2000;102(9):975980. 7. Strohle A, Hofler M, Pfister H, et al. Physical activity and prevalence and incidence of mental disorders in adolescents and young adults. Psychol Med. 2007;37(11):16571666. 8. Vuori IM. Dose-response of physical activity and low back pain, osteoarthritis, and osteoporosis. Med Sci Sports Exerc. 2001;33(6 suppl):S551S586. 9. van Dam RM, Li T, Spiegelman D, et al. Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ. 2008;337:a1440. 10. Kujala UM, Kaprio J, Sarna S, Koskenvuo M. Relationship of leisure-time physical activity and mortality: the Finnish twin cohort. JAMA. 1998;279(6):440444. 11. Sui X, LaMonte MJ, Laditka JN, et al. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA. 2007;298(21):25072516. 12. Wang F, McDonald T, Reffitt B, Edington DW. BMI, physical activity, and health care utilization/costs among Medicare retirees. Obes Res. 2005;13(8):14501457. 13. Hedblad B, Ogren M, Isacsson SO, Janzon L. Reduced cardiovascular mortality risk in male smokers who are physically active: results from a 25-year follow-up of the prospective population study men born in 1914. Arch Intern Med. 1997;157(8):893899. 14. Keeler EB, Manning WG, Newhouse JP, et al. The external costs of a sedentary lifestyle. Am J Public Health. 1989;79(8):975981. 15. Abegunde DO, Mathers CD, Adam T, et al. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet. 2007;370(9603):19291938.

16. Adeyi OSR. Public Policy and the Challenge of Chronic Noncommunicable Diseases. The World Bank; 2007. 17. Sari N. Physical inactivity and its impact on healthcare utilization. Health Econ. 2009;18(8):885901. 18. Sturm R. The economics of physical activity: societal trends and rationales for interventions. Am J Prev Med. 2004;27(3 suppl):126135. 19. Thorpe KE, Florence CS, Howard DH, Joski P. The rising prevalence of treated disease: effects on private health insurance spending. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5. 20. The Analysis of REF Shadow Returns 2008. Hatfield, Pretoria: Council for Medical Schemes; 2009. 21. Joubert J, Norman R, Lambert EV, et al. Estimating the burden of disease attributable to physical inactivity in South Africa in 2000. S Afr Med J. 2007;97(8 Pt 2):725731. 22. Schult TM, McGovern PM, Dowd B, Pronk NP. The future of health promotion/ disease prevention programs: the incentives and barriers faced by stakeholders. J Occup Environ Med. 2006;48(6):541548. 23. Lambert EV, da SR, Fatti L, et al. Fitnessrelated activities and medical claims related to hospital admissions: South Africa, 2006. Prev Chronic Dis. 2009;6(4):A120. 24. Patel DN, Lambert EV, Da Silva R, et al. The association between medical costs and participation in the Vitality health promotion program among 948,974 members of a South African health insurance company. Am J Health Promot. 2010;24(3):199204. 25. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational, studies for causal effects. Biometrika. 1983;70(1):4155. 26. Agresti A. Categorical Data Analysis. New York, NY: J. Wiley; 1990. 27. Duan N, Manning WG, Morris CN, Newhouse JP. A comparison of alternative models for the demand for medical care. J Bus Econ Stat. 1984;1(2):115126. 28. Feuerverger A. On some methods of analysis for weather experiments. Biometrika. 1979;66(3):655658. 29. Duan N, Manning WG, Morris CN, Newhouse JP. Choosing between the Sample-Selection Model and the Multi-Part Model, J Bus Econ Stat. 1984;2(3):283289. 30. Besag J, Clifford P. Generalised Monte Carlo significance tests. Biometrika. 1989;76(4):633642. 31. Harland J, White M, Drinkwater C, et al. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ. 1999;319(7213):828832. 32. van der Bij AK, Laurant MG, Wensing M. Effectiveness of physical activity

interventions for older adults: a review. Am J Prev Med. 2002;22(2):120133. 33. Dishman RK, Oldenburg B, ONeal H, Shephard RJ. Worksite physical activity interventions. Am J Prev Med. 1998;15(4):344361. 34. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity: a systematic review. Am J Prev Med. 2002;22(4 suppl):73107. 35. Yancey AK, McCarthy WJ, Harrison GG, et al. Challenges in improving fitness: results of a community-based, randomised, controlled lifestyle change intervention. J Womens Health. 2006;15(4):412429. 36. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):3848. 37. Sassi F, Hurst J. The prevention of lifestylerelated chronic diseases: an economic framework. Organisation for Economic Co-operation and Development, 2008. Available at: http://www.oecd.org/ dataoecd/57/14/40324263.pdf. Accessed July 19, 2010. 38. Finkelstein EA, Brown DS, Brown DR, Buchner DM. A randomized study of financial incentives to increase physical activity among sedentary older adults. Prev Med. 2008;47(2):182187. 39. Herman CW, Musich S, Lu C, et al. Effectiveness of an incentive-based online physical activity intervention on employee health status. J Occup Environ Med. 2006;48(9):889895. 40. Pronk NP, Goodman MJ, OConnor PJ, Martinson BC. Relationship between modifiable health risks and short-term health care charges. JAMA. 1999;282(23):22352239. 41. Sevick MA, Dunn AL, Morrow MS, Marcus BH, Chen GJ, Blair SN. Cost-effectiveness of lifestyle and structured exercise interventions in sedentary adults: results of project ACTIVE. Am J Prev Med. 2000;19(1):18. 42. Ackermann RT, Cheadle A, Sandhu N, et al. Community exercise program use and changes in healthcare costs for older adults. Am J Prev Med. 2003;25(3): 232237. 43. Wang F, McDonald T, Champagne LJ, Edington DW. Relationship of body mass index and physical activity to health care costs among employees. J Occup Environ Med. 2004;46(5):428436. 44. Tsuji I, Takahashi K, Nishino Y, et al. Impact of walking upon medical care expenditure in Japan: the Ohsaki Cohort Study. Int J Epidemiol. 2003;32(5): 809814. 45. Martinson BC, Crain AL, Pronk NP, et al. Changes in physical activity and short-term changes in health care charges: a prospective cohort study of older adults. Prev Med. 2003;37(4):319326.

348

American Journal of Health Promotion

May/June 2011, Vol. 25, No. 5

f
Online subscriptions now available

The Wisdom of Practice and the Rigor of Research

Definition of Health Promotion
Health Promotion is the art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health, and supporting them in changing their lifestyle to move toward a state of optimal health. Optimal health is a dynamic balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of learning experiences that enhance awareness, increase motivation, and build skills and, most important, through the creation of opportunities that open access to environments that make positive health practices the easiest choice.

DIMENSIONS OF OPTIMAL HEALTH

(ODonnell, American Journal of Health Promotion, 2009, 24,1,iv) Editor in Chief Michael P. ODonnell, PhD, MBA, MPH Associate Editors in Chief Margaret Schneider, PhD Jennie Jacobs Kronenfeld, PhD Shirley A. Musich, PhD Kerry J. Redican, MPH, PhD, CHES
SECTION EDITORS Interventions Fitness Barry A. Franklin, PhD Medical Self-Care Lucy N. Marion, PhD, RN Nutrition Karen Glanz, PhD, MPH Smoking Control Michael P. Eriksen, ScD Weight Control Kelly D. Brownell, PhD Stress Management Cary Cooper, CBE Mind-Body Health Kenneth R. Pelletier, PhD, MD (hc) Social Health Kenneth R. McLeroy, PhD Spiritual Health Larry S. Chapman, MPH Strategies Behavior Change James F. Prochaska, PhD Culture Change Daniel Stokols, PhD Population Health David R. Anderson, PhD, LP Applications Underserved Populations Antronette K. (Toni) Yancey, MD, MPH Health Promoting Community Design Bradley J. Cardinal, PhD The Art of Health Promotion Larry S. Chapman, MPH Research Database Leslie Spenser, PhD Financial Analysis Ron Z. Goetzel, PhD Measurement Issues Shawna L. Mercer, MSc, PhD

The American Journal of Health Promotion provides a forum for that rare commodity practical and intellectual exchange between researchers and practitioners.
Kenneth E. Warner, PhD Dean and Avedis Donabedian Distinguished University Professor of Public Health School of Public Health, University of Michigan

The contents of the American Journal of Health Promotion are timely, relevant, and most important, written and reviewed by the most respected researchers in our field.
David R. Anderson, PhD, LP Senior Vice President & Chief Health Officer, StayWell Health Management

ANNUAL SUBSCRIPTION RATES:

INDIVIDUAL
Print + Online U.S. Canada and Mexico Other Countries

Subscribe today...
(Available 1/1/11. Good through 12/31/11)

INSTITUTION
Print Online Print + Online

$139 $148 $157

$184 $193 $202

$359 $359 $359

$359 $368 $377

Call 800-783-9913 (U.S. only) or 818-760-8520

Check out our new online format:

http://www.HealthPromotionJournal.com/online.htm