背景:运动转诊计划(ERS)已在西方国家实施,以刺激成人体育锻炼的增加,但其有效性和成本效益的证据是模棱两可的。ERS的吸收和依从性差可能会对有效性和成本效益产生负面影响,如果是由社会人口因素形成的,也可能导致或扩大健康不平等。ERS递送的不同模式具有降低成本并增强摄取和粘附性的潜力。这项研究的主要目的是研究不同的ERS交付计划对计划采纳和依从性的影响。次要目的是检查社会人口因素对计划吸收和遵守的影响,以及交付方式对交付方案核心部分的预期资源和相应成本的影响。
方法:这是一项具有成本分析的观察性队列研究。分析了一家大型英国ERS(患者人数=28,917)的为期三年(2019-2021年)的常规监测数据。在此期间,相继实施了三个不同的交付方案:标准(所有会议都在指定的地点面对面交付),混合(会议最初是面对面的,然后切换到远程交付,以应对新冠肺炎大流行),和修改(面对面的会议,远程,或者两者的结合,根据新冠肺炎风险和个人偏好逐案确定)。进行了多层次二元逻辑和线性回归,以检查交付计划和社会人口统计学特征对吸收和依从性的影响。成本数据来自区域一级协调员,并通过国家一级NERS管理人员提供的NERS审计,并使用描述性统计数据进行汇总。
结果:交付方案对方案的接受没有影响。与标准方案(平均参加23.1次练习)的人相比,修改后的方案的人依从性较高(平均出席25.7次),而混合方案的人依从性较低(平均出席19.4次)。年纪大了,或者来自贫困程度较低的地区,增加摄取和坚持的可能性。女性增加了摄取的机会,但与较低的依从性有关。从二级保健转介到该计划的患者比从初级保健转介到预防目的的患者更有可能接受该计划,然而,他们参加锻炼的人数较低。该计划典型的16周周期面对面交付的每人估计费用为65.42英镑。该计划的实际交付周期相同(在大流行背景之外)估计每人花费201.71英镑。
结论:这项研究提供了有关交付计划对ERS吸收和依从性影响的新证据,并加强了有关社会经济因素影响的现有证据。研究结果将ERS提供者的注意力引向特定的患者亚组,如果要解决不平等,需要额外的干预来支持吸收和坚持。在提供者可能正在考虑替代交付方案的时候,这些发现挑战了预期,即实施虚拟交付必然会导致成本节约。
BACKGROUND: Exercise Referral Schemes (ERSs) have been implemented across Western nations to stimulate an increase in adult physical activity but evidence of their effectiveness and cost-effectiveness is equivocal. Poor ERS
uptake and adherence can have a negative impact on effectiveness and cost-effectiveness and, if patterned by socio-demographic factors, can also introduce or widen health inequalities. Different modes of ERS delivery have the potential to reduce costs and enhance
uptake and adherence. The primary aim of this study was to examine the effect of different programmes of ERS delivery on scheme uptake and adherence. Secondary aims were to examine the effect of socio-demographic factors on scheme
uptake and adherence, and the impact of delivery mode on the expected resource and corresponding costs of delivering core parts of the programme.
METHODS: This was an observational cohort study with cost analysis. Routine monitoring data covering a three-year period (2019-2021) from one large UK ERS (number of patients = 28,917) were analysed. During this period three different programmes of delivery were operated in succession: standard (all sessions delivered face-to-face at a designated physical location), hybrid (sessions initially delivered face-to-face and then switched to remote delivery in response to the Covid-19 pandemic), and modified (sessions delivered face-to-face, remotely, or a combination of the two, as determined on a case-by-case basis according to Covid-19 risk and personal preferences). Multi-level binary logistic and linear regression were performed to examine the effect of programme of delivery and socio-demographic characteristics on uptake and adherence. Cost data were sourced from regional-level coordinators and through NERS audits supplied by national-level NERS managers and summarised using descriptive statistics.
RESULTS: There was no effect of programme of delivery on scheme
uptake. In comparison to those on the standard programme (who attended a mean of 23.1 exercise sessions) those on the modified programme had higher adherence (mean attendance of 25.7 sessions) while those on the hybrid programme had lower adherence (mean attendance of 19.4 sessions). Being older, or coming from an area of lower deprivation, increased the likelihood of uptake and adherence. Being female increased the chance of
uptake but was associated with lower adherence. Patients referred to the programme from secondary care were more likely to take up the programme than those referred from primary care for prevention purposes, however their attendance at exercise sessions was lower. The estimated cost per person for face-to-face delivery of a typical 16-week cycle of the scheme was £65.42. The same cycle of the scheme delivered virtually (outside of a pandemic context) was estimated to cost £201.71 per person.
CONCLUSIONS: This study contributes new evidence concerning the effect of programme of delivery on ERS uptake and adherence and strengthens existing evidence concerning the effect of socio-economic factors. The findings direct the attention of ERS providers towards specific patient sub-groups who, if inequalities are to be addressed, require additional intervention to support uptake and adherence. At a time when providers may be considering alternative programmes of delivery, these findings challenge expectations that implementing virtual delivery will necessarily lead to cost savings.