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Cost-effectiveness of a national exercise referral programme for primary care patients in Wales: results of a randomised controlled trial

Rhiannon Tudor Edwards1*, Pat Linck1, Natalia Hounsome4, Larry Raisanen2, Nefyn Williams3, Laurence Moore2 and Simon Murphy2

Author Affiliations

1 Centre for Health Economics & Medicines Evaluation, Institute of Medical and Social Care Research, Bangor University, Dean Street Building, Bangor LL57 1UT, UK

2 DECIPHer, Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, UK

3 North Wales Centre for Primary Care Research, Bangor University, College of Health and Behavioural Sciences, Brigantia Building, Bangor University, Bangor LL57 2UW, UK

4 Centre for Primary Care and Public Health, Yvonne Carter Building, Queen Mary University of London, 58 Turner Street, London E1 2AB, UK

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BMC Public Health 2013, 13:1021  doi:10.1186/1471-2458-13-1021

Published: 29 October 2013



A recent HTA review concluded that there was a need for RCTs of exercise referral schemes (ERS) for people with a medical diagnosis who might benefit from exercise. Overall, there is still uncertainty as to the cost-effectiveness of ERS. Evaluation of public health interventions places challenges on conventional health economics approaches. This economic evaluation of a national public health intervention addresses this issue of where ERS may be most cost effective through subgroup analysis, particularly important at a time of financial constraint.


This economic analysis included 798 individuals aged 16 and over (55% of the randomised controlled trial (RCT) sample) with coronary heart disease risk factors and/or mild to moderate anxiety, depression or stress. Individuals were referred by health professionals in a primary care setting to a 16 week national exercise referral scheme (NERS) delivered by qualified exercise professionals in local leisure centres in Wales, UK. Health-related quality of life, health care services use, costs per participant in NERS, and willingness to pay for NERS were measured at 6 and 12 months.


The base case analysis assumed a participation cost of £385 per person per year, with a mean difference in QALYs between the two groups of 0.027. The incremental cost-effectiveness ratio was £12,111 per QALY gained. Probabilistic sensitivity analysis demonstrated an 89% probability of NERS being cost-effective at a payer threshold of £30,000 per QALY. When participant payments of £1 and £2 per session were considered, the cost per QALY fell from £12,111 (base case) to £10,926 and £9,741, respectively. Participants with a mental health risk factor alone or in combination with a risk of chronic heart disease generated a lower ICER (£10,276) compared to participants at risk of chronic heart disease only (£13,060).


Results of cost-effectiveness analyses suggest that NERS is cost saving in fully adherent participants. Though full adherence to NERS (62%) was higher for the economics sample than the main sample (44%), results still suggest that NERS can be cost-effective in Wales with respect to existing payer thresholds particularly for participants with mental health and CHD risk factors.

Trial registration

Current Controlled Trials ISRCTN47680448

Public health policy; Exercise referral; Mental health; Heart disease risk factors; Cost-effectiveness