The Cost of Integrating a Physical Activity Counselor in the Primary Health Care Team
=====================================================================================

* William E. Hogg
* Xue Zhao
* Douglas Angus
* Michelle Fortier
* Jianwei Zhong
* Tracey O'Sullivan
* Ronald J. Sigal
* Chris Blanchard

## Abstract

*Objective:* This article assesses direct costs of integrating a physical activity counselor (PAC) into primary health care teams to improve physical activity levels of inactive patients.

*Methods:* A monthly cost analysis was conducted using data from 120 inactive patients, aged 18 to 69 years, who were recruited from a community-based family medicine practice. Relevant cost items for the intensive counseling group included (1) office expenses; (2) equipment purchases; (3) operating costs; (4) costs of training the PAC; and (5) labor costs. Physical and human capital were amortized over a 5-year horizon at a discount rate of 5%.

*Results:* Integrating a PAC into the primary health care team incurred an estimated one-time cost of CA$91.43 per participant per month. Results were very sensitive to the number of patients counseled.

*Conclusions:* The costs associated with the intervention are lower than many other intervention studies attempting to improve population physical activity levels. Demonstrating this competitive cost base should encourage additional research to assess the effectiveness of integrating a PAC into primary health care teams to promote active living among patients who do not meet recommended physical activity levels.

*   Cost Analysis
*   Counseling
*   Health Care Team
*   Motor Activity
*   Primary Health Care

Consistent with the World Health Organization's recognition of physical inactivity as one of the leading risk factors for morbidity and mortality,1,2 research shows that physical activity has many benefits and can prevent and improve chronic disease.3–8 One potential and promising way of increasing physical activity may be to incorporate physical activity counselors (PACs) into primary care settings.

Physical activity (PA) promotion programs have received little attention in economic feasibility analyses, especially in Canadian settings. Current literature revealed only a few cost-consequence analyses, cost-effectiveness analyses, or cost analyses evaluating PA promotion projects.1,9 Nevertheless, Katzmarzyk et al10 have estimated that for every 10% increase in PA participation in Canada, there is a cost offset of $150 million annually in direct health care expenses. In consequence, the economic evaluation of PA promotion programs has strong policy implications for Canada, which has a Medicare system through which medically necessary physician services are paid through a tax-supported public system. Recent efforts to reform primary care services have featured a transition to teams where the government pays the salaries of allied health professionals from a wide variety of disciplines to work with family physicians in practices usually owned by the physicians.

The purpose of this study was to conduct a pilot study assessing the monthly program costs of integrating a PAC into a primary care team. The setting for this pilot project was a single community-based primary care practice in Ottawa, Ontario, serving approximately 10,000 predominantly Francophone patients, 75% of whom (n = 7,500) are seen annually. Patients recruited for the project were 18 to 69 years of age; reported they do not meet the guideline of at least 150 minutes per week of PA; indicated during recruitment that they were somewhat motivated to change; and were free of unstable or uncontrolled medical conditions. Pregnant women were excluded.

The project was a 2-arm stratified, randomized controlled trial completed in 2005. In one arm, patients received brief PA counseling from their physician or nurse practitioner. In the second arm, patients received brief PA counseling from their provider as well as intensive counseling from a PAC. The PAC in our project held an undergraduate university degree in exercise science as well as a certification from the Canadian Society for Exercise Physiology. Ethics approval for the project was granted by the University of Ottawa, Montfort Hospital, and Ottawa Hospital Research Institute ethics boards.

There were 61 subjects randomized into the intervention group to receive the counseling from the PAC, and 59 were provided brief counseling only. The methods are published elsewhere in detail, including a study flow diagram.11

We proposed a cost study only because it is important to know the cost to determine if this approach is feasible. The relevant cost items for the intervention were classified under 5 headings: (1) office expenses; (2) equipment purchases; (3) operating costs; (4) costs of training the PAC; and (5) labor costs. Before the onset of the trial, the PAC received 2 months of training to develop an autonomic, supportive style and to learn and practice motivational interviewing techniques.11

In our cost analysis, we assumed the discount rate to be 5%, and the costs were amortized over 5 years. By varying the discount rate, we estimated the amortized costs for both physical capital (equipment purchases) and human capital (PAC training). Project costs are detailed in Table 1.

View this table:
[Table 1.](http://www.jabfm.org/content/25/2/250/T1)

Table 1. Incremental Cost Components At the End of the 3-Month Intervention

Our results are consistent with some of the reports from the literature based on nominal price comparison.12–15 At the end of the 3-month intensive counseling intervention, the direct health cost per participant was $274.28 and the average cost per month was $91.43. Average cost per patient dropped sharply as the number of patients counseled increased, reflecting an approximation of unused PAC capacity. We estimated that the counselor could counsel up to 90 patients during the same intervention. The cost of integrating a PAC into the primary health care system was relatively inexpensive compared with other PA promotion projects reported in the literature,12–15 so it is reasonable to proceed now with studies to determine if co-locating a PAC in the primary care setting is effective in increasing the activity of inactive members of the practice.

## Notes

*   This article was externally peer reviewed.

*   *Funding:* Funding for this research was provided by the Ontario Ministry of Health and Long-Term Care Primary Health Care Transition Fund.

*   *Conflict of interest:* none declared.

*   *Disclaimer:* The views expressed in this article are the views of the authors and do not necessarily reflect those of the Ontario Ministry of Health and Long-Term Care.

*   Received for publication May 1, 2011.
*   Revision received November 28, 2011.
*   Accepted for publication December 5, 2011.

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