Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service

October 2012

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center 

Durham VA Medical Center

Durham, NC

John W Williams Jr., M.D., M.H.Sc., Director

Effects of Health Plan-Sponsored 

Fitness Center Benefits on Physical 

Activity, Health Outcomes, and Health 

Care Costs and Utilization: 

A Systematic Review

Investigators:

Co-Principal Investigators:

Heather A. King, Ph.D.

Jennifer M. Gierisch, Ph.D., M.P.H.

Co-Investigators:

John W. Williams Jr., M.D., M.H.Sc.

Matthew L. Maciejewski, Ph.D.

Research Associate:

Avishek Nagi, M.S.

Medical Editor:

Liz Wing, M.A.

EXECUTIVE SUMMARY
i

Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

PREFACE

Quality Enhancement Research Initiative’s (QUERI’s) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics 

of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare of Veterans. The ESP disseminates these reports throughout 

VA.

QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes and to 

support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of QUERI field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: King HA, Gierisch JM, Williams JW Jr, Maciejewski ML. Effects of 

Health Plan-Sponsored Fitness Center Benefits on Physical Activity, Health Outcomes, and 

Health Care Costs and Utilization: A Systematic Review. VA-ESP Project #09-010; 2012.

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the Durham VA Medical Center, Durham, NC, funded by the 

Department of Veterans Affairs, Veterans Health Administration, Office of Research 

and Development, Health Services Research and Development. The findings and 

conclusions in this document are those of the author(s) who are responsible for its 

contents; the findings and conclusions do not necessarily represent the views of 

the Department of Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an official position of the Department 

of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, 

grants or patents received or pending, or royalties) that con¬flict with material presented 

in the report.
1

Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

EXECUTIVE SUMMARY

BACKGROUND

Regular physical activity has many positive health benefits, including protection against chronic 

disease, improved physical and mental health and cognitive function, and better health-related 

related quality of life. Moreover, lack of physical activity is associated with higher health 

care costs and utilization. Many Americans, however, do not get the recommended levels of 

physical activity. For Veterans, Veterans Affairs (VA) health care users are less likely to meet 

physical activity recommendations and more likely to be physically inactive compared with 

Veterans who do not use VA health care. Multiple personal, social, and environmental factors 

influence participation in physical activity. Providing memberships to fitness centers may be 

a viable option to increase physical activity and the positive health outcomes associated with 

such activity. Given that most Americans have access to some form of health insurance, health 

plan promotion of and coverage for fitness center memberships has the potential to address 

multiple barriers to physical activity (e.g., cost, access) and extend fitness center access to many 

Americans. 

Our objective in this evidence synthesis was to summarize the results of diverse studies of health 

plan-sponsored fitness center memberships in an effort to understand how these benefits affect 

physical activity, clinical outcomes, health care costs and utilization, retention of plan members, 

and member satisfaction. 

Key Question 1. What are the effects of policy/benefits packages that include vouchers, rebates, 

premium reductions, or other economic incentives to encourage physical activity through fitness 

center memberships on: 

(a) Physical activity participation rates among plan members?

(b) Health outcomes demonstrated to be improved by physical activity (i.e., weight, pain, 

glucose, blood pressure, health-related quality of life)?

(c) Overall health care costs and health care utilization?

Key Question 2. What are the effects of policy/benefits packages that include vouchers, rebates, 

premium reductions, or other economic incentives to encourage physical activity through fitness 

center memberships on satisfaction with the health plan and retention of members in the health 

plan?

Key Question 3. Do the effects of policy/benefits packages to encourage physical activity vary 

by specific characteristics of the package (premium vs. lump sum) or age, sex, and physical 

illness of participants?
2

Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

METHODS

In consultation with a master librarian, we searched MEDLINE® (via PubMed®), Embase®, and 

the Cochrane Database of Systematic Reviews for peer-reviewed publications comparing health 

plan-sponsored strategies to encourage physical activity through fitness center memberships 

with standard benefit plans from database inception through January 2012. We selected freetext terms to search titles and abstracts as well as validated search terms for both randomized 

controlled trials and relevant observational studies adapted from the Cochrane Effective Practice 

& Organization of Care Group search, version 1.9. We limited the search to articles published 

in the English language involving human subjects 18 years of age and older. An updated search 

for publications was conducted in May 2012. We also evaluated the bibliographies of included 

primary studies. As a mechanism to assess the risk of publication bias, we searched www.

ClinicalTrials.gov for completed but unpublished studies in July 2012. 

DATA SYNTHESIS

We critically analyzed studies to compare their characteristics, methods, and findings to determine 

the feasibility of completing a quantitative synthesis (i.e., meta-analysis) based on the volume of 

relevant literature, the completeness of the results reported and the conceptual homogeneity of the 

studies. As quantitative synthesis was not possible, we analyzed the results qualitatively. 

RATING THE BODY OF EVIDENCE

In addition to rating the quality of individual studies, we evaluated the overall strength of 

evidence (SOE) for each Key Question by assessing the following domains: risk of bias, 

consistency, directness, precision, strength of association (magnitude of effect), and publication 

bias. These domains were considered qualitatively, and a summary rating of high, moderate, low, 

or insufficient SOE was assigned.

PEER REVIEW

A draft version of the report was reviewed by technical experts and clinical leadership. A 

transcript of their comments can be found in the appendix, which elucidates how each comment 

was considered in the final report.

RESULTS 

We identified 3584 unique citations from a combined search of MEDLINE (via PubMed, 

n=3560), Embase (n=24), and the Cochrane database (n=0). Manual searching of included study 

bibliographies and review articles identified 5 additional citations for a total of 3589 citations. 

After applying inclusion/exclusion criteria, 4 articles (representing 1 unique study) were included 

in this review. Most studies were excluded because they assessed types of physical activity 

promotion strategies other than fitness center memberships (e.g., worksite wellness). Our search 

of www.ClinicalTrials.gov did not suggest publication bias. There were no completed studies that 

were unpublished. In addition, there were no ongoing studies on this topic.
3

Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

All articles we identified addressed KQ 1; none addressed KQ 2 or KQ 3 (Table ES-1). The main 

study was a retrospective cohort study rated fair quality that used administrative and claims 

data to assess the health care and utilization effects of a health plan-sponsored fitness center 

membership benefit (known as the Silver Sneakers program) among adults 65 years of age and 

older who were enrolled in the Group Health Cooperative of Puget Sound Medicare Advantage 

plan. Two companion articles assessed the effect of distance from the fitness center and history of 

depression on the uptake of fitness center benefits and frequency of use among participants. One 

additional companion article assessed the effect of this benefit on health care costs and utilization 

among health plan members with diabetes. The Silver Sneakers program assessed in all analyses 

allowed eligible health plan enrollees 65 years of age and older to access selected fitness centers 

and all activities (e.g., structured conditioning classes) and facilities (e.g., exercise equipment, 

pool) associated with these fitness centers. The health plan covered the full cost of memberships 

for each year; there were no additional costs to the member for the fitness center membership. 

Table ES-1. Overview of articles evaluating effects of fitness center membership 

Reference Study Details KQ Included Outcomes

Main study

Nguyen et al., 

2008

Group Health Cooperative Medicare 

Advantage enrollees ≥ age 65

Selection dates: Jan 1998–Dec 2003

Participants: 4766 benefit users

Matched controls: 9035 benefit nonusers

1a

1c

•	 Physical activity participation 

•	 Health care cost

•	 Health care utilization 

Companion articles

Berke et al., 2006 Group Health Cooperative Medicare 

Advantage enrollees ≥ age 65

Selection dates: Jan 2002–Dec 2003

Participants: 1728 benefit users

Matched controls: 4838 benefit nonusers

1a Role of distance from fitness center on: 

•	 Uptake of benefit

•	 Frequency of use of benefit

Nguyen et al., 

2008

Group Health Cooperative Medicare 

Advantage enrollees ≥ age 65

Selection dates: Jan 1998–Dec 2003

Participants: 4766 benefit users 

Matched controls: 9035 benefit nonusers 

1a Role of depression history on:

•	 Uptake of benefit

•	 Frequency of use of benefit, risk of 

participation lapse

Nguyen et al., 

2008

Group Health Cooperative Medicare 

Advantage enrollees ≥ age 65

Selection dates: Jan 1998–Dec 2003

Participants: 618 benefit users with diabetes

Matched controls: 1413 benefit nonusers with 

diabetes

1a

1c

•	 Physical activity participation

•	 Health care cost

•	 Health care utilization
4

Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

Key Question 1. What are the effects of policy/benefits packages that include 

vouchers, rebates, premium reductions, or other economic incentives to 

encourage physical activity through fitness center memberships on: 

(a) Physical activity participation rates among plan members?

(b) Health outcomes demonstrated to be improved by physical activity 

(i.e., weight, pain, glucose, blood pressure, health-related quality of life)?

(c) Overall health care costs and health care utilization?

KQ 1a: Physical Activity Participation

None of the included articles assessed physical activity as a primary outcome. The only metric of 

physical activity was the frequency of fitness center visits by participants in the Silver Sneakers 

program such as that reported in the main study and one companion article. Two additional 

companion articles assessed the associations between (1) the distance from the fitness center 

and (2) a history of depression on the uptake and frequency of use of the health plan-sponsored 

fitness center membership benefit. 

In Year 1 of the main study, Silver Sneakers participants averaged 75 visits (median 49; 

interquartile range [IQR] 11 to 120). In Year 2, the average number of visits declined to 55 

(median 12; IQR 0 to 89). While participation dropped in Year 2, 61 percent of participants 

continued to visit fitness centers. A separate analysis using a subset of members with diabetes 

from the main study reported similar number of average visits per year (72 visits in Year 1, 49 

visits in Year 2).

Two companion articles provided information on other factors associated with uptake and 

frequency of use. Additional analyses suggest that distance from fitness centers and history of 

depression influence the uptake of health plan-sponsored fitness center memberships. Enrollment 

in a fitness center and frequency of use are both associated with distance from gyms. While 

history of depression is not associated with participation in a fitness center benefit, health plan 

members with a history of depression made fewer visits and were at greater risk of lapses in their 

participation compared with nondepressed members.

KQ 1b: Physical Health Outcomes

No identified studies addressed KQ 1b.

KQ 1c: Health Care Costs and Utilization 

The main study and one companion article reported the effects of health plan-sponsored fitness 

center memberships on health care costs and utilization. In adjusted models for Year 1, Nguyen 

et al. reported that adjusted total health care costs were not different between Silver Sneakers 

participants and nonparticipants. By the end of Year 2, participants incurred significantly 

lower total health care costs (-$500; CI -$892 to -$106, p=0.01) likely due to fewer inpatient 

admissions and lower inpatient care costs compared with controls. There was evidence of a doseresponse by average number of health club visits. Compared with participants who attended 
5

Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

fitness centers less than one time per week, participants who averaged two to less than three or 

three or more visits per week over 2 years had lower adjusted health care costs (2 to <3 visits 

-$1252, p<0.001; ≥ 3 visits -$1309, p=0.001). 

In another article, participants in Silver Sneakers with diabetes had lower adjusted total health 

care costs compared with age- and sex-matched nonparticipants with diabetes after 1 year of 

enrollment in the fitness center program (-$1633; 95% CI -$2620 to -$646, p=0.001). This cost 

savings was likely due to fewer hospitalizations and lower adjusted inpatient costs. In Year 2, 

participants accumulated lower total health care costs, but these savings were not statistically 

significantly different from diabetic nonparticipants (-$1230; CI -$2494 to $33, p=0.06). 

Key Question 2. What are the effects of policy/benefits packages that include 

vouchers, rebates, premium reductions, or other economic incentives to 

encourage physical activity through fitness center memberships on satisfaction 

with the health plan and retention of members in the health plan?

No identified studies addressed KQ 2.

Key Question 3. Do the effects of policy/benefits packages to encourage physical 

activity vary by specific characteristics of the package (premium vs. lump sum) or 

age, sex, and physical illness of participants?

No identified studies addressed KQ 3.

RECOMMENDATIONS FOR FUTURE RESEARCH

Surprisingly few studies assessed the impact of health plan-sponsored fitness membership 

benefits. Existing studies lack diversity in included populations, benefits assessed, outcomes 

collected, and study designs employed. Across included articles in this review, main limitations 

were the inability to (1) control for confounding from potential selection bias that could not be 

accounted for through analysis, (2) rule out concurrent exposures to other sources of physical 

activity that may have biased results, and (3) measure quality and type of physical activity; 

the number of visits to the fitness center was the only measure of physical activity. However, 

a strength of the included studies was that they used existing “real world” administrative and 

claims data.

A variety of study designs can be employed—each having their own strengths and weaknesses. 

Researchers must carefully weigh the tradeoffs in costs, feasibility, time, quality of evidence, 

and generalizability, which differ among the various study design options. We used a structured 

framework to identify gaps in evidence, classify why these gaps exist, and suggest types of 

studies to consider in future research (Table ES-2).
6

Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

Table ES-2. Evidence gaps and future research

Evidence Gap Reason Type of Studies to Consider

Patients

Absence of data for patients 

other than those ≥ age 65

Insufficient information •	 Multisite cluster RCTs

•	 Quasi-experimental studies

•	 Prospective cohort studies

Interventions

Silver Sneakers program was the 

only benefit assessed

Insufficient information •	 RCTs of head-to-head comparisons of different 

types of benefit structures 

•	 Quasi-experimental studies comparing different 

types of policy changes that impact benefit 

structures

Outcomes

Uncertain effects on: 

•	 Physical activity levels 

•	 Physical health outcomes 

•	 Health care costs and 

utilization 

Insufficient information •	 Multisite cluster RCTs

•	 Prospective cohort studies

•	 Nonrandomized trials (pre-post designs) 

•	 Nonrandomized controlled before-and-after studies

Uncertain effects on health plan 

member:

•	 Satisfaction

•	 Retention 

Insufficient information •	 Multisite cluster RCTs

•	 Prospective or retrospective cohort studies

•	 Nonrandomized controlled before-and-after studies

•	 Qualitative studies 

Abbreviation: RCT = randomized controlled trial

CONCLUSION

Health plan-sponsored fitness center memberships have the potential to increase levels of physical 

activity and, subsequently, improve health and economic outcomes for Veterans. However, few 

studies have assessed the impact of health plan-sponsored fitness membership benefits. The evidence 

base for these claims remains weak due to study design limitations, and insufficient due to the 

paucity of literature. The limited evidence provides support for reductions in health care costs and 

utilization when comparing health plan members who choose to participate in health plan-sponsored 

gym memberships with those who do not—but these results may not be generalizable to Veterans 

and are based on study designs that could be subject to bias. The existing literature provides 

little insight into other outcomes such as physical activity, physical health outcomes, or health 

plan member satisfaction or retention. Thus, further evidence is needed on which to base policy 

recommendations on the merits of providing health plan-sponsored fitness center memberships.

ABBREVIATIONS TABLE

CI confidence interval

ES Executive Summary

IQR interquartile range

KQ Key Question

RCT randomized controlled trial

SOE strength of evidence

VA Department of Veterans Affairs