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

TABLE OF CONTENTS

EXECUTIVE SUMMARY

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 2

Data Synthesis............................................................................................................................................... 2

Rating the Body of Evidence......................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

Recommendations for Future Research......................................................................................................... 5

Conclusion..................................................................................................................................................... 6

Abbreviations Table....................................................................................................................................... 6

INTRODUCTION............................................................................................................................................... 7

Objective of this Report................................................................................................................................. 7

METHODS

Topic Development........................................................................................................................................ 8

Analytic Framework...................................................................................................................................... 8

Search Strategy.............................................................................................................................................. 9

Study Selection.............................................................................................................................................. 9

Data Abstraction .......................................................................................................................................... 11

Quality Assessment ..................................................................................................................................... 11

Data Synthesis............................................................................................................................................. 11

Rating the Body of Evidence....................................................................................................................... 11

Peer Review................................................................................................................................................. 12

RESULTS

Literature Search ......................................................................................................................................... 13

Study Characteristics................................................................................................................................... 14

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? ................................................................................................................................... 15

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?.... 17

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? ............................................................................................................................................ 17

SUMMARY AND DISCUSSION ................................................................................................................ 18

Summary of Evidence ................................................................................................................................. 18

Implication of Findings ............................................................................................................................... 18

Strengths and Limitations............................................................................................................................ 19

Recommendations for Future Research....................................................................................................... 20

Conclusions ................................................................................................................................................. 23
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

REFERENCES ................................................................................................................................................... 25

APPENDIX A. SEARCH STRATEGIES ............................................................................................. 27

APPENDIX B. EXCLUDED STUDIES................................................................................................ 28

APPENDIX C. DATA ABSTRACTION ELEMENTS.................................................................... 31

APPENDIX D. PEER REVIEW COMMENTS................................................................................. 32

APPENDIX E. GLOSSARY....................................................................................................................... 37

FIGURES

Figure 1. Analytic framework for assessing effects of health plan-sponsored fitness center benefits............8

Figure 2. Literature flow diagram....................................................................................................................13

TABLES

Table ES-1. Overview of articles evaluating effects of fitness center membership.............................................3

Table ES-2. Evidence gaps and future research ....................................................................................................6

Table 1. Summary of inclusion and exclusion criteria....................................................................................9

Table 2. Overview of articles evaluating effects of fitness center membership...........................................14

Table 3. Evidence gaps and future research ..................................................................................................20

Table 4. Comparisons of study designs used to assess effects of health plan-sponsored fitness benefits...22
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

EVIDENCE REPORT

INTRODUCTION

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.1-9 Moreover, lack of physical activity is associated with higher health care 

costs and utilization.10,11 The current U.S. guidelines recommend that adult Americans (1) engage 

in at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity 

aerobic activity each week (or an equivalent mix of moderate- and vigorous-intensity aerobic 

activity) and (2) perform strengthening activities that target all major muscle groups on at least 

2 days a week.12 However, many Americans do not get the recommended levels of physical 

activity.13 More Veterans are sufficiently active than non-Veterans. However, Veterans who use 

Veterans Affairs (VA) health care are more likely to be physically inactive (22.6% vs. 14.9%) 

and are less likely to meet physical activity recommendations (42.6% vs. 46.7%) compared with 

Veterans who do not use VA health care.14

Multiple personal, social, and environmental factors influence a person’s participation in physical 

activity.15 Consequently, multiple internal and external barriers to obtaining regular physical activity 

exist. Internal barriers include a lack of time and motivation, health problems, and emotional 

difficulties. External barriers involve weather; cultural issues; safety concerns; limited access to 

facilities, equipment, and transportation; and monetary expenses such as those associated with 

attending a fitness center. The perceived cost of engaging in physical activity is a significant barrier 

that increases the likelihood of sedentary behaviors and decreases the likelihood of participation in 

vigorous physical activity.16 Thus, reducing the cost of being physically active through providing 

full or partial 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 (84%) 

have access to some form of health insurance,17 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. 

The effects of physical activity on health care utilization and costs, various health outcomes, and 

general well-being are well established. However, the evidence base on health plan-sponsored 

benefits—specifically involving fitness center memberships—that support these outcomes has not 

been synthesized. Therefore, we conducted a systematic review of the current literature to assess 

the impact of health plan benefits, or policies that promote access to fitness centers, on physical 

activity levels, health outcomes, overall health care costs and utilization, and satisfaction with and 

retention in the health plan to inform future Veterans Health Administration (VHA) policy changes.

OBJECTIVE OF THIS REPORT

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

METHODS

TOPIC DEVELOPMENT

This review was commissioned by the VA Evidence-based Synthesis Program. The topic was 

nominated and key questions developed after a refinement process that included a preliminary 

review of published peer-reviewed literature and consultation with experts, investigators, and key 

stakeholders. The final key questions (KQs) were:

KQ 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 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?

KQ 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?

ANALYTIC FRAMEWORK

The standard protocol used for this review maps to the Preferred Reporting Items for Systematic 

Reviews and Meta-Analyses (PRISMA) checklist.18 Our approach was guided by the analytic 

framework shown in Figure 1.

Figure 1. Analytic framework for assessing effects of health plan-sponsored fitness center benefits

Adults with private or 

public health insurance 

Final outcomes

• Health care costs

• Health care utilization

Intervention

Health plan-sponsored 

fitness center benefits: 

• Premium reductions

• Lump sum wellness benefit

• Vouchers

• Rebates

• Other economic incentives

Intermediate outcomes

• Physical activity 

participation rates

• Weight control

• Pain control 

• Glucose levels

• Blood pressure control 

• Patient satisfaction with 

health plan

• Plan member retention

Patient-level moderators

• Age

• Sex

• Comorbidities

Policy-level moderators

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

SEARCH STRATEGY

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 free-text terms 

to search titles and abstracts as well as validated search terms for both randomized controlled 

trials19 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. The full search strategy 

is provided in Appendix A. An updated search for publications was conducted in May 2012. We 

also evaluated the bibliographies of included primary studies. All citations were imported into an 

electronic database, EndNote® Version X5 (Thomson Reuters, Philadelphia, PA) for referencing. 

As a mechanism to assess the risk of publication bias, we searched www.ClinicalTrials.gov for 

completed but unpublished studies in July 2012. 

STUDY SELECTION

Using prespecified inclusion and exclusion criteria, two reviewers assessed titles and abstracts 

for relevance to the KQs. Full-text articles identified by either reviewer as potentially relevant 

were retrieved for further review. Each article retrieved was examined by two other reviewers 

against the eligibility criteria. Disagreements on inclusion, exclusion, or major reason for 

exclusion were resolved by discussion or by a third reviewer. The criteria to screen articles for 

inclusion or exclusion at both the title-and-abstract and full-text screening stages is shown in 

Table 1. Studies excluded at the full-text review stage are listed with the reasons for exclusion in 

Appendix B.

Table 1. Summary of inclusion and exclusion criteria

Study 

characteristic Inclusion criteria Exclusion criteria

Population Adults ≥18 years of age with or without a 

chronic illness

Studies with populations <18 years of age

Intervention •	 Intervention or “exposure” must meet the 

following definition: Health plan-sponsored 

strategies (e.g., vouchers, rebates, 

premium reductions) to encourage 

physical activity through fitness center 

memberships

If the intervention includes a variety of 

fitness or exercise-related strategies in 

addition to facilitating gym memberships, 

the majority of activities (50% or more) 

should be like those typically provided 

through a gym to increase physical activity 

(e.g., yoga classes, walking clubs, trainer) 

Study excluded if exposure meets any of the 

following criteria:

•	 Studies of health plan-sponsored access 

to rehabilitation facilities

•	 Studies of access to fitness centers not 

offered through health plan-sponsored 

economic incentives 

•	 Worksite wellness programs

•	 Interventions that use a wide array of 

health promotion strategies not typically 

provided at a fitness center (e.g., health 

risk assessments, preventive health 

screenings) if the effects of fitnessrelated activities are not distinguishable 

from other components of the 

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

Study 

characteristic Inclusion criteria Exclusion criteria

Comparator •	 Standard benefits packages (health plans 

that do not offer strategies to encourage 

physical activity through fitness center 

memberships

•	 Head-to-head comparisons of different 

health plan-sponsored programs to 

encourage physical activity through fitness 

center memberships

None; study must have a control group

Outcome KQs 1 and 3: 

•	 Physical activity participation rates (e.g., 

minutes spent being physically active, 

visits to fitness center)

•	 Weight control (i.e., weight loss or 

maintenance of current weight)

•	 Pain level using validated measures

•	 Biophysical markers such as laboratory or 

physiological markers of glucose control or 

blood pressure

•	 Health-related quality of life

•	 Health care utilization of medical 

resources (e.g., in-patient admissions, 

emergency visits, primary care or specialty 

visits)

•	 Health care costs (prioritizing total health 

care costs)

KQ 2:

•	 Member satisfaction with health plan 

•	 Retention of plan members

None

Timing For longitudinal studies, outcomes must 

be measured at ≥6 months from start of 

assessment period

For longitudinal studies, outcomes reported <6 

months from start of assessment period

Setting •	 Study conducted in North America, 

Western Europe, Australia, New Zealanda

•	 Public or private health plans

Conducted in countries other than those 

specifically listed as included

Study designb •	 Original data

•	 Prospective and retrospective 

observational studies with comparator 

(sample size ≥100 subjects)

•	 Patient or cluster randomized trials (all 

sample sizes) 

•	 Interrupted time-series designs that have 

≥3 measurement points prior to and after 

the intervention is begun

Cross-sectional studies and other 

observational study designs not specifically 

listed as “included” study designs

Publications •	 English-language only

•	 Peer-reviewed article

Non-English language publication

a

Rationale is that medical systems in economically developed countries with sufficient similarities in the system and culture are 

applicable to U.S. medical care. 

b

Study designs recommended by the Cochrane Effective Practice and Organization of Care Group.

Abbreviation: KQ = Key Question
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

DATA ABSTRACTION 

We designed the data abstraction forms to collect the data required to evaluate the eligibility 

criteria for inclusion in this review, as well as population characteristics and other data needed 

for determining outcomes and risk of bias (Appendix C). We paid particular attention to the 

details of the intervention to assure that it was offered through a health insurance plan as a health 

benefit and that it was engaged in by the participant at a fitness center. We did not evaluate 

studies on workplace wellness or health plan access to rehabilitation facilities. One researcher 

abstracted the data, and a second reviewed the completed abstraction form alongside the original 

article to check for accuracy and completeness. As with full-text review, disagreements were 

resolved by discussion or by a third reviewer. We supplemented abstraction of published data by 

contacting authors for missing information. We contacted one author who replied with additional 

information about benefits structure and costs.

QUALITY ASSESSMENT

Data necessary for assessing quality and applicability, as described in the Agency for Healthcare 

Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative Effectiveness 

Reviews,

20 also were abstracted. Per the AHRQ Methods Guide,20 threats to internal validity of 

systematic review conclusions based on observational studies were identified through assessment 

of the body of observational literature as a whole, with an examination of characteristics of 

individual studies. Study-specific issues that were considered include: potential for selection 

bias (i.e., degree of similarity between intervention and control patients); performance bias 

(i.e., differences in care provided to intervention and control patients not related to the study 

intervention); attribution and detection bias (i.e., whether outcomes were differentially detected 

between intervention and control groups); and magnitude of reported intervention effects (see 

the section on “Selecting Observational Studies for Comparing Medical Interventions” in the 

Methods Guide). Using these quality criteria, we assigned a summary quality score (good, fair, 

poor) to included studies.20 For each study, two investigators independently assigned a summary 

quality rating; disagreements were resolved by consensus or by a third investigator as before.

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 quality of the 

evidence for each KQ as described in the Methods Guide,

20 if feasible. This approach requires 

assessment of four domains: risk of bias, consistency, directness, and precision. Additional 

domains considered were strength of association (magnitude of effect) and publication bias. 

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

insufficient strength of evidence was assigned after discussion by two reviewers. 
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

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 Appendix D, which elucidates how each comment 

was considered in the final report.
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

RESULTS

LITERATURE SEARCH

The flow of articles through the literature search and screening process is illustrated in Figure 

2. 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 at the title-and-abstract level, 47 full-text articles were 

retrieved and screened. Of these, 43 were excluded at the full-text screening stage, leaving 4 

articles (representing 1 unique study) for data abstraction. Most studies were excluded at full-text 

review because they assessed types of physical activity promotion strategies other than fitness 

center memberships (e.g., worksite wellness) provided through health plan benefits. 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.

Figure 2. Literature flow diagram

Excluded = 3542 references 

Excluded at title/abstract level 

Retrieved for full-text review = 47 

references

Excluded = 43 references 

Not intervention of interest = 27

Not full publication, peer-reviewed, or primary 

data = 11

Not geographic location of interest = 3

Not study design of interest = 1

Not outcome of interest = 1

Included = 1 unique study + 3 

companion articles*

KQ 1: Physical activity and 

health

1 study + 3 companion articles

KQ 2: Satisfaction and retention

No studies

KQ 3: Subgroup effects

No studies

Search results = 3589 references

 *See Glossary for definition of companion articles.

Note: At the request of a peer reviewer, we reconsidered one reference21 that was initially excluded at the title/abstract level; 

however, we retained our original conclusion that the reference could not be included based on our inclusion/exclusion criteria.

Abbreviation: KQ = Key Question
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

STUDY CHARACTERISTICS

Only one main study22 and three companion articles23-25 met inclusion criteria for this review 

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

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

to assess the effects of a health plan-sponsored fitness center membership benefit (known as the 

Silver Sneakers program) on health care costs and utilization among adults 65 years of age and 

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

plan. The Group Health Cooperative is a consumer-governed, staff-model, health maintenance 

organization of more than 500,000 members. 

Two companion articles assessed the effect of distance from the fitness center23 and history of 

depression24 on the uptake of fitness center benefits and frequency of use among participants. 

One additional companion article25 assessed the effect of this benefit on health care costs and 

utilization among health plan members with diabetes. All variables used in analyses (e.g., patient 

demographics, costs) were obtained from health plan administrative data. Relevant results are 

discussed in detail following the table.

Table 2. Overview of articles evaluating effects of fitness center membership 

Reference Study Details KQ Included Outcomes

Main study

Nguyen et al., 

200822

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., 

200623

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., 

200824

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., 

200825

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
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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, healthrelated 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 study22 and one companion article.25 Two additional 

companion articles assessed the associations between (1) the distance from the fitness center23

and (2) a history of depression24 on the uptake and frequency of use of the health plan-sponsored 

fitness center membership benefit. 

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. Participation in Silver Sneakers was voluntary; participants who opted to enroll 

contacted their local fitness centers to join. 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. No 

other details of the benefit structure or characteristics of selected fitness centers were provided 

in any of the included articles or through communications with study authors. Visits to the 

fitness center were documented by swipe cards at participating facilities; average attendance was 

calculated by dividing all fitness center visits over 2 years by 104 weeks.

In the main study,22 Nguyen et al. used administrative and claims data from a Medicare Advantage 

plan administered through a health maintenance organization to assess the effects of the fitness 

center benefit, Silver Sneakers, on health care costs and utilization among adults 65 years of age and 

older. In these analyses, Silver Sneakers participants (n = 4766) were compared with up to three ageand sex-matched controls (n = 9035) from the same health plan who did not elect to participate in 

the health plan-sponsored fitness center benefit. The followup interval was 2 years. Silver Sneakers 

participants were more likely to be male, have arthritis, use more preventive health services, and 

have higher total health expenditures at baseline than the age- and sex-matched controls. However, 

Silver Sneakers participants were less likely to have diabetes or congestive heart failure compared 

with controls. Main study 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. 
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

In Year 1, Nguyen et al.22 reported that the average number of fitness center visits among Silver 

Sneakers participants was 75 (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 analysis25 using a subset of members with diabetes (n = 618) from the main study22

also reported the average number of fitness center visits among participants, which was similar to 

those reported in the main study. Silver Sneakers participants averaged 72 visits in Year 1 and 49 

visits in Year 2.

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

frequency of use. In a separate analysis of 1728 Silver Sneakers participants and 4838 

nonparticipants, Berke et al.23 found that plan members who chose the fitness center benefit lived 

closer to fitness centers compared with nonparticipants (p = 0.017; adjusted model). The odds of 

participating in Silver Sneakers decreased by 1.3 percent for every kilometer farther that a plan 

member lived from a fitness center. Additionally, participants who lived closer to fitness centers 

used these facilities more frequently than those who lived farther away. Controlling for age, 

sex, socioeconomic status, distance from center, use of selected preventive services (e.g., cancer 

screenings, vaccinations), and composite measure of disease burden (i.e., RxRisk26), participants 

made an average of 4.2 visits per month (standard deviation 3.4). 

In another analysis using Silver Sneakers participant data, Nguyen et al.24 assessed the impact 

of history of depression as identified by International Classification of Diseases (ICD)-9-CM 

codes on benefit uptake and patterns of use (n = 13,801; 4766 participants and 9035 matched 

controls). This analysis found that depression in the 12 months before the start of the Silver 

Sneakers program was not associated with enrollment in the fitness membership benefit (odds 

ratio 1.03; 95% confidence interval [CI] 0.89 to 1.20, p=0.67; adjusted model). Participants 

with a depression diagnosis, however, made fewer visits per month to fitness centers compared 

with participants who were not depressed (range -0.64 to -1.5 visits). Additionally, depressed 

participants had a 19-percent higher risk of participation lapse (hazard ratio 1.19; 95% CI 1.04 to 

1.37, p=0.01; adjusted model) compared with participants who were not depressed at baseline. 

KQ 1b: Physical Health Outcomes

No identified studies addressed KQ 1b.

KQ 1c: Health Care Costs and Utilization 

The main study22 and one companion article25 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.22 reported that adjusted total health care costs were not different between Silver 

Sneakers participants and nonparticipants (+$2; 95% CI -$341 to +$344, p=0.99). However, 

participants experienced fewer inpatient admissions (-1.0%; CI -2.1% to -0.1%, p=0.5) but made 

more primary care visits (+0.40; CI 0.27 to 0.53, p<0.001) and specialty care visits (+0.22; 

CI 0.11 to 0.33, p<0.001) compared with controls. By the end of Year 2, participants incurred 

significantly lower total health care costs (-$500; CI -$892 to -$106, p=0.01). This decrease was 

likely due to fewer inpatient admissions (-2.3%; CI -3.3% to -1.2%, p<0.001) and lower inpatient 

care costs (-$270; CI -$533 to -$6, p=0.05) compared with controls. 
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

Silver Sneakers participants had significantly more primary care visits (+0.26; CI 0.13 to 0.40, 

p<0.001) and specialty care visits (+0.25; CI 0.14 to 0.36, p<0.001) for Year 2, which resulted 

in higher costs for those services (primary care: +$80, p<0.001; specialty care: +$37, p=0.14). 

There was also evidence of a dose-response by average number of health club visits. Compared 

with participants who attended 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). 

Another article25 used a subset of participants from the retrospective cohort study.22 Claims data 

for 2031 older adults with diabetes were examined to assess the impact of Silver Sneakers on 

health care utilization and costs among this group. Participants with diabetes (n = 618) were more 

likely to be male, have lower chronic illness burden, use more preventive health services, have 

more outpatient visits for arthritis, and make more primary and specialty care visits compared to 

nonparticipants with diabetes (n =1413). Level of diabetes control, age, and total health care costs 

at baseline were not significantly different between diabetic participants and nonparticipants. 

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 (-3.0%, p=0.07) and lower adjusted inpatient costs (-$1021; CI -$1688 

to $367, p=0.002). However, in Year 1 diabetic participants had more primary care visits (0.77; 

CI 0.34 to 1.2, p<0.001) and primary care costs ($129; CI $32 to $266, p=0.009). 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.
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

SUMMARY AND DISCUSSION

Health plan-sponsored fitness center memberships have the potential to reach many Americans 

and may be an effective strategy to increase physical activity and its associated health benefits. 

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

benefits—we identified only one main study and three companion articles that assessed the 

impact of such benefits. Overall, the data are insufficient to grade the strength of the evidence for 

health plan-sponsored access to fitness centers through member benefits. 

The four included articles provided limited data on rates of physical activity (KQ 1a) and health 

care costs and utilization (KQ 1c). There were no data on physical health outcomes of interest 

(i.e., weight, pain, glucose, blood pressure, health related quality of life) (KQ 1b) and none on 

satisfaction with health plans or retention of plan members (KQ 2). No studies assessed whether 

effects of health plan benefits varied by characteristics of the participants (KQ 3). Further, only 

one type of plan was assessed in all analyses; thus, no included studies assessed whether effects 

of health plan-sponsored fitness center memberships varied by benefit type (KQ 3). Data were 

of limited applicability; all analyses were conducted exclusively in patients 65 years of age and 

older and were from one geographic location in the United States. 

SUMMARY OF EVIDENCE

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

of physical activity provided was descriptive information on frequency of fitness center visits. 

Overall, health plan members who opted to participate in the health plan-sponsored fitness center 

memberships made few visits to facilities. In the main study,22 members averaged 1.44 visits 

per week in Year 1 and 1.06 visits per week in Year 2. These averages were similar to those 

reported in a subset of members with diabetes.25 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.23 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.24

We found some limited evidence to support the effects of health plan-sponsored fitness center 

memberships on health care costs and utilization. While participants in the Silver Sneakers 

program made more primary and specialty care visits, overall health care costs were significantly 

lower.22 These saving were likely due to fewer inpatient admissions. Similar patterns of health 

care use and costs were seen among health plan members with diabetes.25

IMPLICATION OF FINDINGS

The clearest finding of this evidence synthesis is that the existing knowledge base does not provide 

enough data to make evidence-driven policy recommendations about the health and economic 

effects of health plan-sponsored fitness center membership benefits. The limited evidence available 

suggests that, if offered, health plan members will use fitness center memberships. However, 

internal and external barriers to optimal rates of use of such benefits remain. 
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

Overall, health plan members who opted into the Silver Sneakers program tended to have fewer 

chronic illnesses. These findings complement a recent study that found health plans offering 

coverage for fitness center memberships attract and retain enrollees with better self-reported 

health.27 Together, these finding suggest that adding fitness center memberships to health plan 

benefits facilitates favorable selection of healthier enrollees, which in turn may lower health care 

costs by adding and retaining less costly individuals to the risk pool. However, health systems such 

as the VA have a higher proportion of individuals with chronic diseases (e.g., obesity, diabetes, 

arthritis). If the VA is able to engage these populations to use fitness center memberships, the 

cost savings could be significant, particularly for Veterans whose average weekly attendance is 

more than 1 visit.22 The results of the study by Nguyen et al.25 suggest that there may be an earlier 

and greater return on investment for populations who are at higher risk. Specifically, diabetic 

participants in the Silver Sneakers program had greater reductions in total health care expenditures 

than the general population of participants analyzed in Nguyen et al. (-$1230 vs. $500).22,25

Other findings suggest that a participant’s distance from the fitness center also plays a role in 

benefit uptake and, after enrollment, frequency of use.23 Thus, health insurers who have a large 

proportion of rural enrollees who travel greater distances to fitness centers may have lower 

uptake of these benefits. Such health insurers may want to structure fitness center benefits that 

pay per visit instead of per membership or that automatically discontinue monthly fitness center 

memberships following lapses in use. This has implications for the VA patient population. Many 

Veterans travel long distances to access VA facilities. Thus, the VA would have to engage local 

and community-based facilities (e.g., commercial) closer to Veterans’ homes in order to optimize 

benefit uptake and frequency of use. Also, health plans that have older enrollees with more 

physical limitations due to chronic health conditions may choose to selectively coordinate with 

fitness centers that offer appropriate exercise options (e.g., pool-based activities, low-impact 

aerobics classes). Despite these issues, evidence suggest that health plan members who elect to 

join fitness center programs incurred lower overall health care costs, even among members with 

chronic illnesses.22,25 Health insurers evaluating whether to implement such programs should 

look for ways to enhance more frequent use of fitness centers over time, such as an attendance 

requirement for continued access, in the design structure of the benefit. 

STRENGTHS AND LIMITATIONS

Our study has a number of strengths, including a protocol-driven review, a comprehensive 

search, and careful quality assessment. We also allowed inclusion of a wide array of 

observational and experimental studies and sought to collect both patient-level outcomes (e.g., 

physical activity levels, biophysical markers) and system-level outcomes (e.g., health care 

costs, health plan member retention rates). However, limitations to our evidence review exist. 

The greatest limitation of this review is the lack of relevant studies—and particularly no data 

relevant to KQ 2 and KQ 3. We limited our search to English-language articles and only included 

citations from North America, Western Europe, Australia, and New Zealand. We maintained 

this search limitation because we lacked translation resources and, more importantly, wanted to 

prioritize studies that were applicable to the U.S. medical system and populations, specifically 

Veterans. It was the opinion of the investigators and our stakeholders that the resources needed to 

translate non-English articles had a low potential likelihood of identifying relevant data. To the 
20

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

extent that studies applicable to the United States were published in languages other than English 

or were conducted outside these countries, we may have failed to include relevant studies. 

Also, the single included study and its associated companion articles all used retrospective 

observational designs, which has important implications for the strength of associations explored 

in these studies. Some key limitations were the limited ability to control for residual confounding 

due to nonrandomized design, no measure of overall physical activity outside of fitness center 

visits, and no data on the type and quality of physical activity conducted during fitness center 

visits. In addition, it is crucial to assess fitness center membership prior to and separate from the 

rollout of fitness center benefits in order to assess whether the benefit is reaching new or lapsed 

gym users or supplanting memberships of existing fitness center users. In other words—is the 

benefit enhancing access for people who are not physically active without the benefit but who 

would become physically active with the benefit? One strength of the included studies, however, 

was their use of existing “real world” administrative and claims data.

RECOMMENDATIONS FOR FUTURE RESEARCH

Offering partial or full gym membership discounts is a common practice. For example, according 

to the Employer Health Benefits 2012 Annual Survey from the Kaiser Family Foundation 

and Health Research and Educational Trust,28 65 percent of all large firms (i.e., 200 or more 

workers) offer gym membership discounts or onsite exercise facilities—highlighting the need 

for evaluation and identification of best practices related to this increasingly offered benefit. 

However, results of our review confirm that the current body of literature is weak and insufficient 

to identify whether these programs improve outcomes and, if so, what are the best practices 

associated with implementing them. Thus, additional studies are needed to assess the potential 

merits, costs, and challenges of health plan-sponsored fitness center benefits in order to better 

inform VA policy. We used the framework recommended Robinson et al.29 to identify gaps in 

evidence and classify why these gaps exist (Table 3). 

Table 3. 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
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Effects of Health Plan-Sponsored Fitness Center Benefits Evidence-based Synthesis Program

Evidence Gap Reason Type of Studies to Consider

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

Potential Study Designs for Future Research

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

and study designs employed. There are numerous possibilities regarding future research in 

this area. In particular, a variety of study designs can be employed—each having their own 

strengths and weaknesses. Three broad types of possible study designs and specific examples 

are introduced in Table 4, including (1) experimental (e.g., cluster randomized controlled 

trial), (2) quasi-experimental (e.g., interrupted time series design), and (3) observational (e.g., 

prospective cohort study, retrospective cohort study using administrative data). 

A cluster randomized controlled trial is a form of randomized controlled trial where groups 

of subjects or sites (e.g., VA medical centers) are the unit of randomization to treatment or 

control rather than individual participants. An interrupted time series design involves multiple 

measurements prior to and following an event (e.g., policy change to add fitness center 

membership benefits), which allows for evaluation of temporal trends but does not include 

randomization to study conditions. In an observational prospective cohort study, a defined group 

of individuals is followed over time before outcomes and exposures are measured. Retrospective 

cohort studies examine past exposures and outcomes. Table 4 gives an overview of the major 

strengths and limitations of these selected study design alternatives tailored to future research 

on health plan-sponsored fitness center memberships. We considered a variety of domains 

such as level of control over benefit structure, measurement/assessment, internal validity, 

generalizability, and feasibility (e.g., time, cost). 
22

ed Fitness Center Benefits Evidence-based Synthesis Program

 designs used to assess effects of health plan-sponsored fitness benefits

Major Strengths Major Limitations

ion to treatment (i.e., the fitness benefit) or control minimizes 

e of unaccounted, unmeasured factors (i.e., confounding 

nd reduces selection bias.

control exists over measurement, such as included 

as well as length of followup and timing. 

ater strength of evidence and confidence in results/causality.

 greatest level of control over structure of the intervention 

).

 possibility of comparing different benefit structures using 

ve comparators (i.e., comparative effectiveness trials).

•	 Threats to validity are still possible if randomization is not successful; results 

also may be undermined if significant and/or differential dropouts occur.

•	 Design is potentially time-consuming, with a longer lag time in generating findings 

compared to retrospective cohort studies using existing administrative data. 

•	 Design has potentially higher costs than retrospective cohort studies using 

existing administrative data. 

•	 External validity/generalizability is potentially limited if there is a highly 

selected population, setting, and tightly controlled implementation with resources/staff not available in “real world” settings. 

•	 Design may pose a measurement burden for participants.

 allows assessment of temporal trends in variables of interest 

after the event (i.e., policy change to include fitness center 

ps). 

entially lower cost than RCTs and prospective designs if 

ng data sources. 

•	 This design has a lack of control over unaccounted, unmeasured factors (i.e., 

confounding variables). 

•	 Design is potentially less feasible; it would need to identify an event and have 

access to relevant data before and after a policy change.

•	 Design may require a large sample size.•	 There is no control over structure of benefit unless policymakers consult with 

researcher.

control exists over measurement, such as measure diversity 

d type), as well as length of followup and timing. 

ater “real-world” applicability compared to tightly controlled 

 trials. 

ater strength of evidence than with other observational 

h as case-control and retrospective cohort designs because 

ce of event can be assessed. 

•	 Time and cost investment is likely substantial because of the need for a large 

sample size and multiple assessments.

•	 There is a significant measurement burden for participants.•	 This design is potentially less feasible and must identify the setting prior to 

benefit and enrollment, which may pose a significant logistical barrier.

•	 There is a greater risk of bias, lower quality, and lower strength of evidence 

compared to RCTs.

•	 There is no control over the structure of benefit.

 is convenient if datasets are available and accessible (e.g., 

). 

osts required are potentially less than other designs. 

 uses a similar method to existing studies, making it possible 

eplicate prior findings. 

•	 Design is limited by the information available and existing variables (e.g., 

type, quality, timing, followup).

•	 Relevant data must be available and affordable; a large sample size is 

necessary to create a cohort of interest and define an adequate control group.

•	 Compared to other designs, risk of bias is highest and quality and strength of 

evidence are lowest.

•	 There is no control over the structure of benefit. 

olled trial
23

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

When weighing which study designs to use, researchers should always start with what is the 

best design to answer the research question at hand. However, researchers must also carefully 

weigh the tradeoffs in costs, feasibility, time, quality of evidence, and generalizability, which 

differ among the various study design options. Previous research on health plan-sponsored access 

to fitness memberships has exclusively used retrospective observational designs. Compared 

with prospective or experimental designs, retrospective observational designs allow for rapid 

generation of findings if existing data can be used. However, they offer the lowest strength of 

evidence when compared with the other designs described above and do not allow for control 

over the benefit structure. Moreover, retrospective observational designs may offer only limited 

information on complex behaviors like physical activity. The existing literature is limited in this 

regard and only provides descriptive information on the number of gym visits. Future studies 

should assess the quality of the physical activity (e.g., moderate vs. vigorous) and the time spent 

engaging in the activity.

Prospective cohort and quasi-experimental designs, such as interrupted time series designs, 

provide greater strength of evidence through establishing temporality of events compared with 

retrospective designs, as well as offering control over the type and quality of measures collected. 

These designs also come at higher costs, are more time consuming, may pose significant 

measurement burden on participants, and are impractical for rare events such as shifts in policies. 

In addition, these designs do not allow for control over the structure of the benefits. Also for 

interrupted time series designs, it can be difficult to disentangle the effects of the benefit from 

natural temporal trends without establishing a contemporaneous control group, and use of 

existing datasets may limit the quality and type of variables assessed. 

When assessing the impact of providing memberships to fitness centers through health plansponsored benefits, RCTs offer the greatest strength of evidence. These designs also allow for 

control over the intervention tested (i.e., the benefit structure). Moreover, randomized designs 

can allow for direct comparisons of different benefit structures through comparative effectiveness 

trials (head-to-head comparisons). Also, RCTs can allow testing of different incentive strategies 

(e.g., cash rewards, premium discounts, loss of benefit based on attendance) to encourage 

continued use of fitness centers. Measurement of complex outcomes like physical activity can 

be built into the design of trials through the use of objective and automatic physical activity 

monitoring (e.g., pedometers with wireless data upload). However, randomized trials also 

tend to be costly and time consuming. In addition, the evidence generated may have limited 

generalizability if the study was conducted in a tightly controlled research environment with 

highly selected populations. Efficiencies can be built into theses design such as using cluster 

randomized designs and using existing data sources such as VA electronic medical records.

CONCLUSIONS

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 
24

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

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 plansponsored fitness center memberships. 
25

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

REFERENCES

1. Bauman AE. Updating the evidence that physical activity is good for health: an 

epidemiological review 2000-2003. J Sci Med Sport. 2004;7(1 Suppl):6-19.

2. Vogel T, Brechat PH, Lepretre PM, et al. Health benefits of physical activity in older 

patients: a review. Int J Clin Pract. 2009;63(2):303-20.

3. Tseng CN, Gau BS, Lou MF. The effectiveness of exercise on improving cognitive 

function in older people: a systematic review. J Nurs Res. 2011;19(2):119-31.

4. Bize R, Johnson JA, Plotnikoff RC. Physical activity level and health-related quality of 

life in the general adult population: a systematic review. Prev Med. 2007;45(6):401-15.

5. Glenister D. Exercise and mental health: a review. J R Soc Health. 1996;116(1):7-13.

6. Gerber M, Puhse U. Review article: do exercise and fitness protect against stress-induced 

health complaints? A review of the literature. Scand J Public Health. 2009;37(8):801-19.

7. Penedo FJ, Dahn JR. Exercise and well-being: a review of mental and physical health 

benefits associated with physical activity. Curr Opin Psychiatry. 2005;18(2):189-93.

8. Bucksch J, Schlicht W. Health-enhancing physical activity and the preventionof chronic 

diseases--an epidemiological review. Soz Praventivmed. 2006;51(5):281-301.

9. Taylor AH, Cable NT, Faulkner G, et al. Physical activity and older adults: a review of 

health benefits and the effectiveness of interventions. J Sports Sci. 2004;22(8):703-25.

10. Franklin BA. Physical activity to combat chronic diseases and escalating health care 

costs: the unfilled prescription. Curr Sports Med Rep. 2008;7(3):122-5.

11. Colditz GA. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31(11 

Suppl):S663-7.

12. Department of Health and Human Services. Centers for Disease Control and Prevention. 

2008 Physical Activity Guidelines for Americans. Available at: http://www.cdc.gov/

physicalactivity/everyone/guidelines/adults.html. Accessed August 1, 2012.

13. Department of Health and Human Services. Centers for Disease Control and Prevention.

2007 U.S. Physical Activity Statistics. Available at: http://apps.nccd.cdc.gov/PASurveillance/

StateSumResultV.asp?CI=&Year=2007&State=0#data Accessed August 1, 2012.

14. Littman AJ, Forsberg CW, Koepsell TD. Physical activity in a national sample of 

veterans. Med Sci Sports Exerc. 2009;41(5):1006-13.

15. Cerin E, Leslie E, Sugiyama T, et al. Perceived barriers to leisure-time physical activity in 

adults: an ecological perspective. J Phys Act Health. 2010;7(4):451-9.

16. Salmon J, Owen N, Crawford D, et al. Physical activity and sedentary behavior: 

a population-based study of barriers, enjoyment, and preference. Health Psychol. 

2003;22(2):178-88.
26

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

17. U.S. Census Bureau. Health Insurance Highlights 2010. Available at: http://www.census.

gov/hhes/www/hlthins/data/incpovhlth/2010/highlights.html. Accessed August 1, 2012.

18. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews 

and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-12.

19. Wilczynski NL, McKibbon KA, Haynes RB. Response to Glanville et al.: How to 

identify randomized controlled trials in MEDLINE: ten years on. J Med Libr Assoc. 

2007;95(2):117-8; author reply 119-20.

20. Agency for Healthcare Research and Quality. Methods Guide for Effectiveness and 

Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and 

Quality. Available at: http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviewsand-reports/?pageaction=displayproduct&mp=1&productID=318. Accessed August 1, 2012.

21. Fody-Urias BM, Fillit H, Hill J. The effect of a fitness program on health status and 

health care consumption in Medicare MCOs. Manag Care Interface. 2001;14(9):58-64.

22. Nguyen HQ, Ackermann RT, Maciejewski M, et al. Managed-Medicare health 

club benefit and reduced health care costs among older adults. Prev Chronic Dis. 

2008;5(1):A14.

23. Berke EM, Ackermann RT, Lin EH, et al. Distance as a barrier to using a fitness-program 

benefit for managed medicare enrollees. J Aging Phys Act. 2006;14(3):313-323.

24. Nguyen HQ, Koepsell T, Unutzer J, et al. Depression and use of a health plan-sponsored 

physical activity program by older adults. Am J Prev Med. 2008;35(2):111-7.

25. Nguyen HQ, Maciejewski ML, Gao S, et al. Health care use and costs associated with 

use of a health club membership benefit in older adults with diabetes. Diabetes Care. 

2008;31(8):1562-7.

26. Putnam KG, Buist DS, Fishman P, et al. Chronic disease score as a predictor of 

hospitalization. Epidemiology. 2002;13(3):340-6.

27. Cooper AL, Trivedi AN. Fitness memberships and favorable selection in Medicare 

Advantage plans. N Engl J Med. 2012;366(2):150-7.

28. The Kaiser Family Foundation and Health Research Educational Trust. Employer Health 

Benefits 2012 Annual Survey. Available at: http://ehbs.kff.org/. Accessed September 27, 

2012.

29. Robinson KA, Saldanha IJ, Mckoy NA. Frameworks for Determining Research Gaps 

During Systematic Reviews. Methods Future Research Needs Report No. 2. (Prepared by 

the Johns Hopkins University Evidence-based Practice Center under Contract No. HHSA

290-2007-10061-I.) AHRQ Publication No. 11-EHC043-EF. Rockville, MD: Agency for 

Healthcare Research and Quality. June 2011. Available at: www.effectivehealthcare.ahrq.

gov/reports/final.cfm. Accessed May 22, 2012.