The effect of exercise referral schemes upon health and wellbeing: Initial observational insights using individual patient data meta-analysis from The National Referral database
Authors: Wade Matthew , Mann Steven , Copeland Robert J. , Steele James 
Published: January 2019

Background: Physical activity is widely considered to be effective in the prevention, management, and treatment of many chronic health disorders. Yet, population physical activity levels are relatively low and have changed little in recent years. Sufficient physical activity levels for health and wellbeing often do not arise as result of typical activities of daily living. As such, specific exercise has been argued to be necessary for many, and one approach to providing this has been through exercise referral schemes (ERS). Schemes are aimed at increasing physical activity levels in sedentary individuals with chronic disease, however, evidence is currently lacking as to whether ERSs are effective as currently implemented. Thus, it is of interest to consider broadly whether meaningful changes in health and wellbeing outcomes are observed in people undergoing and ERS. Purpose: To examine if ERSs are associated with meaningful changes in health and wellbeing in a large cohort of individuals throughout England, Scotland and Wales from The National Referral Database. Method: Data were obtained from 23731 participants from 13 different ERSs. Average age was 51±15 years and, 68% of participants were female. Health and wellbeing outcomes were examined including body mass index, blood pressure, resting heart rate, short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS), World Health Organization Well-Being Index (WHO-5), Exercise Related Quality of Life scale (ERQoL), and Exercise Self-Efficacy Scale (ESES). Two stage individual patient data random effects meta-analysis was performed on the change scores, (i.e. post- minus pre-ERS scores) and interval estimates were compared to null intervals for meaningfulness. Results: Estimates and 95%CIs revealed that statistically significant changes occurred when compared to point nulls of zero for body mass index (-0.55 kg.m2 [-0.69 to -0.41]), systolic blood pressure (-2.95 mmHg [-3.97 to -1.92]), SWEMWBS (2.99 pts [1.61 to 4.36]), WHO-5 (8.78 pts [6.84 to 10.63]), ERQoL (15.26 pts [4.71 to 25.82]), ESES (2.58 pts [1.76 to 3.40]), but not resting heart rate (0.22 fc [-1.57 to 1.12]), diastolic blood pressure (-0.93 mmHg [-1.51 to -0.35]). However, comparisons of estimates and intervals against null intervals for meaningfulness of changes suggested that the majority of outcomes may not improve meaningfully. Conclusion: The analyses performed here were with the intention of considering broadly; do we observe a meaningful effect in people who are undergoing ERSs? With respect to this broad question the present results demonstrate that, although many health and wellbeing outcome changes are statistically significant when compared to point null estimates (i.e. they differ from a change of zero) our analysis revealed there may be a general lack of meaningful change over time in participants undergoing ERSs, though results varied widely across different schemes. These findings suggest the need to consider the implementation of ERSs more critically in order to discern how best to maximize their effectiveness such that it reflects the efficacy often evidence in the literature.