Cost-Effectiveness and Return-on-Investment of the Dynamic Work Intervention Compared With Usual Practice to Reduce Sedentary Behavior

Short-term economic evaluation of physical activity-based corporate health programs: a systematic review

OBJECTIVES

Corporate health programs (CHPs) aim to improve employees' health through health promotion strategies at the workplace. Physical activity (PA) plays a crucial role in primary prevention, leading many companies to implement PA-based CHPs. However, there is limited examination in the scientific literature on whether PA-based CHPs (PA-CHPs) lead to economic benefits. This systematic review aimed to summarize the available literature on the economic aspects of PA-CHPs.

METHODS

A systematic review was conducted to identify studies focused on PA-CHPs targeting healthy sedentary workers and reporting at least one economic outcome, such as return on investment (ROI), costs, or sick leave.

RESULTS

Of 1036 studies identified by our search strategy, 11 studies involving 60 020 participants met the inclusion criteria. The mean (±SD) cost per capita for PA-CHPs was estimated as 359€ (±238€) (95% CI, 357-361€). In 75% of the studies, the net savings generated by PA-CHPs in 12 months were reported, with an average of 1095€ (±865€) (95% CI, 496-1690€). ROI was assessed in 50% of the included studies, with an average of 3.6 (±1.41) (95% CI, 2.19-5.01).

CONCLUSIONS

In addition to promoting a healthy lifestyle, PA-CHPs have the potential to generate significant economic returns. However, the heterogeneity among the existing studies highlights the need for standardization and accurate reporting of costs in future research.

A multicomponent intervention to reduce daily sitting time in office workers: the SMART Work & Life three-arm cluster RCT

Background

Office workers spend 70-85% of their time at work sitting. High levels of sitting have been linked to poor physiological and psychological health. Evidence shows the need for fully powered randomised controlled trials, with long-term follow-up, to test the effectiveness of interventions to reduce sitting time.

Objective

Our objective was to test the clinical effectiveness and cost-effectiveness of the SMART Work & Life intervention, delivered with and without a height-adjustable workstation, compared with usual practice at 12-month follow-up.

Design

A three-arm cluster randomised controlled trial.

Setting

Councils in England.

Participants

Office workers.

Intervention

SMART Work & Life is a multicomponent intervention that includes behaviour change strategies, delivered by workplace champions. Clusters were randomised to (1) the SMART Work & Life intervention, (2) the SMART Work & Life intervention with a height-adjustable workstation (i.e. SMART Work & Life plus desk) or (3) a control group (i.e. usual practice). Outcome measures were assessed at baseline and at 3 and 12 months.

Main outcome measures

The primary outcome was device-assessed daily sitting time compared with usual practice at 12 months. Secondary outcomes included sitting, standing, stepping time, physical activity, adiposity, blood pressure, biochemical measures, musculoskeletal issues, psychosocial variables, work-related health, diet and sleep. Cost-effectiveness and process evaluation data were collected.

Results

A total of 78 clusters (756 participants) were randomised [control, 26 clusters (n = 267); SMART Work & Life only, 27 clusters (n = 249); SMART Work & Life plus desk, 25 clusters (n = 240)]. At 12 months, significant differences between groups were found in daily sitting time, with participants in the SMART Work & Life-only and SMART Work & Life plus desk arms sitting 22.2 minutes per day (97.5% confidence interval -38.8 to -5.7 minutes/day; p = 0.003) and 63.7 minutes per day (97.5% confidence interval -80.0 to -47.4 minutes/day; p < 0.001), respectively, less than the control group. Participants in the SMART Work & Life plus desk arm sat 41.7 minutes per day (95% confidence interval -56.3 to -27.0 minutes/day; p < 0.001) less than participants in the SMART Work & Life-only arm. Sitting time was largely replaced by standing time, and changes in daily behaviour were driven by changes during work hours on workdays. Behaviour changes observed at 12 months were similar to 3 months. At 12 months, small improvements were seen for stress, well-being and vigour in both intervention groups, and for pain in the lower extremity and social norms in the SMART Work & Life plus desk group. Results from the process evaluation supported these findings, with participants reporting feeling more energised, alert, focused and productive. The process evaluation also showed that participants viewed the intervention positively; however, the extent of engagement varied across clusters. The average cost of SMART Work & Life only and SMART Work & Life plus desk was £80.59 and £228.31 per participant, respectively. Within trial, SMART Work & Life only had an incremental cost-effectiveness ratio of £12,091 per quality-adjusted life-year, with SMART Work & Life plus desk being dominated. Over a lifetime, SMART Work & Life only and SMART Work & Life plus desk had incremental cost-effectiveness ratios of £4985 and £13,378 per quality-adjusted life-year, respectively.

Limitations

The study was carried out in one sector, limiting generalisability.

Conclusions

The SMART Work & Life intervention, provided with and without a height-adjustable workstation, was successful in changing sitting time.

Future work

There is a need for longer-term follow-up, as well as follow-up within different organisations.

Trial registration

Current Controlled Trials ISRCTN11618007.

Cost and cost-effectiveness analysis of a digital diabetes prevention program: results from the PREDICTS trial

Although technology-assisted diabetes prevention programs (DPPs) have been shown to improve glycemic control and weight loss, information are limited regarding relevant costs and their cost-effectiveness. To describe a retrospective within-trial cost and cost-effectiveness analysis (CEA) to compare a digital-based DPP (d-DPP) with small group education (SGE), over a 1-year study period. The costs were summarized into direct medical costs, direct nonmedical costs (i.e., times that participants spent engaging with the interventions), and indirect costs (i.e., lost work productivity costs). The CEA was measured by the incremental cost-effectiveness ratio (ICER). Sensitivity analysis was performed using nonparametric bootstrap analysis. Over 1 year, the direct medical costs, direct nonmedical costs, and indirect costs per participant were $4,556, $1,595, and $6,942 in the d-DPP group versus $4,177, $1,350, and $9,204 in the SGE group. The CEA results showed cost savings from d-DPP relative to SGE based on a societal perspective. Using a private payer perspective for d-DPP, ICERs were $4,739 and $114 to obtain an additional unit reduction in HbA1c (%) and weight (kg), and were $19,955 for an additional unit gain of quality-adjusted life years (QALYs) compared to SGE, respectively. From a societal perspective, bootstrapping results indicated that d-DPP has a 39% and a 69% probability, at a willingness-to-pay of $50,000/QALY and $100,000/QALY, respectively, of being cost-effective. The d-DPP was cost-effective and offers the prospect of high scalability and sustainability due to its program features and delivery modes, which can be easily translated to other settings.

Cost-effectiveness analysis of sedentary behaviour interventions in offices to reduce sitting time in Australian desk-based workers: A modelling study

OBJECTIVES

Sedentary behaviour (SB) is associated with increased incidence of chronic diseases such as type 2 diabetes (T2D), cardiovascular disease, cancers, and premature mortality. SB interventions in workplaces are effective in reducing sitting time. Previous economic evaluations have not specifically used changes in sitting time to estimate the long-term impact of SB on chronic disease-related health and cost outcomes. This research evaluated the cost-effectiveness of three hypothetical SB interventions: behavioural (BI), environmental (EI) and multi-component intervention (MI), implemented in the Australian context, using a newly developed epidemiological model that estimates the impact of SB as a risk factor on long-term population health and associated cost outcomes.

METHOD

Pathway analysis was used to identify the resource items associated with implementing each of the three interventions using a limited societal perspective (included costs: health sector, individuals and industry; excluded costs: productivity). The effectiveness of the modelled interventions in reducing daily sitting time (informed by published meta-analyses) was modelled for the Australian working population aged 20-65 years. A multi-cohort Markov model was developed to simulate the 2019 Australian population and estimate the incidence, prevalence and mortality of five diseases causally related to excessive sitting time, over the life course. Monte-Carlo simulations were used to calculate each intervention's mean incremental costs and benefits (quantified as health adjusted life years HALYs) compared to a do-nothing comparator.

RESULTS

When implemented at the national level, the interventions were estimated to reach 1,018 organisations with 1,619,239 employees. The estimated incremental cost of SB interventions was A$159M (BI), A$688M (EI) and A$438M (MI) over a year. Incremental health-adjusted life years (HALYs) gained by BI, EI and MI were 604, 919 and 349, respectively. The mean ICER for BI was A$251,863 per HALY gained, A$737,307 for EI and A$1,250,426 for MI. Only BI had any probability (2%) of being cost-effective at a willingness-to-pay threshold of A$50,000 per HALY gained from a societal perspective.

CONCLUSION

SB interventions are not cost-effective when a reduction in sitting time is the outcome measure of interest. The cost-effectiveness results are heavily driven by the cost of the sit-stand desks and the small HALYs gained from reducing sitting time. Future research should focus on capturing non-health-benefits of these interventions, such as productivity, work satisfaction, and other health benefits: metabolic, physical, and musculoskeletal outcomes. Importantly, the health benefits of simultaneously reducing sitting time and increasing standing time for such interventions should be captured with the joint effects of these risk factors appropriately considered.

The Cost-Effectiveness of the SMART Work & Life Intervention for Reducing Sitting Time

Sedentary behaviours continue to increase and are associated with heightened risks of morbidity and mortality. We assessed the cost-effectiveness of SMART Work & Life (SWAL), an intervention designed to reduce sitting time inside and outside of work, both with (SWAL-desk) and without (SWAL-only) a height-adjustable workstation compared to usual practice (control) for UK office workers. Health outcomes were assessed in quality-adjusted life-years (QALY) and costs in pound sterling (2019-2020). Discounted costs and QALYs were estimated using regression methods with multiply imputed data from the SMART Work & Life trial. Absenteeism, productivity and wellbeing measures were also evaluated. The average cost of SWAL-desk was £228.31 and SWAL-only £80.59 per office worker. Within the trial, SWAL-only was more effective and costly compared to control (incremental cost-effectiveness ratio (ICER): £12,091 per QALY) while SWAL-desk was dominated (least effective and most costly). However, over a lifetime horizon, both SWAL-only and SWAL-desk were more effective and more costly than control. Comparing SWAL-only to control generated an ICER of £4985 per QALY. SWAL-desk was more effective and costly than SWAL-only, generating an ICER of £13,378 per QALY. Findings were sensitive to various worker, intervention, and extrapolation-related factors. Based on a lifetime horizon, SWAL interventions appear cost-effective for office-workers conditional on worker characteristics, intervention cost and longer-term maintenance in sitting time reductions.

Evidence base of economic evaluations of workplace-based interventions reducing occupational sitting time: an integrative review

OBJECTIVE

To review the evidence on the economic evaluations of workplace-based interventions that are designed to reduce prolonged periods of occupational sitting.

DESIGN

An integrative review.

DATA SOURCES

The search was conducted in 11 databases, including PubMed, Scopus, PsychINFO, NHS-EED, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest, Cochrane library, Sportdiscus, Research Paper in Economics (RePeC), the International Health Economic Association (IHEA) and EconLit. The databases were searched for articles published from inception to January 2022. Subsequent citation searches were also conducted in Google Scholar. The items of the Consensus Health Economic Criteria (CHEC) checklist were used for quality appraisal of the included studies.

RESULTS

This review included five randomised control trails, including 757 office-based workers in high-income countries. The median quality appraisal score based on the CHEC items was 14 points (a range of 9-18). The mean duration of interventions was 33 weeks (a range of 4-52 weeks). Overall, the studies reported economic benefit when implemented to reduce occupational sitting time but no effect on absenteeism. From the societal perspective, the interventions (eg, the use of a sit-stand desk) were cost-effective.

CONCLUSION

The economic impact of workplace interventions implemented to reduce occupational sitting time is evident; however, the existing evidence is limited, which precludes strong conclusions. Cost-effectiveness is not often evaluated in the studies exploring workplace interventions that address occupational sitting time. Workplace interventions are still in the development and testing phase; thus, the challenge for future studies is to include economic evaluation of interventions addressing sedentary behaviour in workplaces.

PROSPERO REGISTRATION NUMBER

CRD42021226275.

Modelling the potential health and economic benefits of reducing population sitting time in Australia

BACKGROUND

Strong evidence indicates that excessive time spent sitting (sedentary behaviour) is detrimentally associated with multiple chronic diseases. Sedentary behaviour is prevalent among adults in Australia and has increased during the COVID-19 pandemic. Estimating the potential health benefits and healthcare cost saving associated with reductions in population sitting time could be useful for the development of public health initiatives.

METHODS

A sedentary behaviour model was developed and incorporated into an existing proportional, multi-state, life table Markov model (ACE-Obesity Policy model). This model simulates the 2019 Australian population (age 18 years and above) and estimates the incidence, prevalence and mortality of five diseases associated with sedentary behaviour (type 2 diabetes, stroke, endometrial, breast and colorectal cancer). Key model inputs included population sitting time estimates from the Australian National Health Survey 2014-2015, healthcare cost data from the Australian Institute of Health and Welfare (2015) and relative risk estimates assessed by conducting literature reviews and meta-analyses. Scenario analyses estimated the potential change in disease incidence as a result of changes in population sitting time. This, in turn, resulted in estimated improvements in long term health outcomes (Health-adjusted life years (HALYs)) and healthcare cost-savings.

RESULTS

According to the model, if all Australian adults sat no more than 4 h per day, the total HALYs gained would be approximately 17,211 with health care cost savings of approximately A$185 million over one year. Under a more feasible scenario, where sitting time was reduced in adults who sit 4 or more hours per day by approximately 36 min per person per day (based on the results of the Stand Up Victoria randomised controlled trial), potential HALYs gained were estimated to be 3,670 and healthcare cost saving could reach A$39 million over one year.

CONCLUSIONS

Excessive sedentary time results in considerable population health burden in Australia. This paper describes the development of the first Australian sedentary behaviour model that can be used to predict the long term consequences of interventions targeted at reducing sedentary behaviour through reductions in sitting time. These estimates may be used by decision makers when prioritising healthcare resources and investing in preventative public health initiatives.

Economics of sedentary behaviour: A systematic review of cost of illness, cost-effectiveness, and return on investment studies

AIMS

METHODS: RESULTS: We identified nine articles (conducted in Australia (n = 5), Europe (n = 3) and China (n = 1)); three reported healthcare costs associated with excessive sedentary time, whilst six were economic evaluations of interventions targeting sedentary behaviour. Healthcare costs associated with excessive sedentary time as reported in cost of illness studies were substantial; however, none explored non-health sector costs. In contrast, all full economics evaluations adopted a societal perspective; however, costs included differed depending on the intervention context. One sedentary behaviour intervention in children was cost-saving. The five interventions targeting occupational sitting time of adults in office workplaces were cost-effective. Physical environmental changes such as sit-stand desks, active workstations etc., were the key cost driver.

CONCLUSIONS

Sedentary behaviour is likely associated with excess healthcare costs, although future research should also explore costs across other sectors. Cost-effectiveness evidence of sedentary behaviour reduction interventions in workplaces is limited but consistent. Key gaps relate to the economic credentials of interventions targeting children, and modelling of long-term health benefits of interventions.

Factors impacting workplace investment in sit-stand workstations from the perspective of purchasing decision-makers

This explanatory sequential mixed-method study explored the factors associated with the investment (or not) in sit-stand workstations (SSWs) and alternative initiatives to reduce prolonged sitting at work from the perspective of furniture purchasing decision-makers in Australian workplaces. Participants (n = 270) from >200 organisations across 19 industry sectors completed an online survey. Seven interviews were conducted in a sub-sample of participants from organisations without SSWs. The majority (80%) of workplaces reported having invested in SSWs. Workplaces without SSWs, opposed to those with SSWs, were more likely to be private (79.6% vs. 43.5%), of small/medium size (70.4% vs. 35.6%) and without a wellness program (57.4% vs. 22.2%) (all p < 0.05). Financial implications were the main reason for not investing in SSWs. Exercise and stretch breaks were alternative initiatives to reducing sedentary behaviour at work. Better evidence on the return on investment is needed to support purchasing decisions on SSWs.