Candace Rutt, Ph.D. Quantification of Health Benefits for Cycling and Walking: The Health Economic Assessment Tool

Often Urban Environments Favor Motorized Transportation…..

….and Hinder Walking and Cycling

However, there are Places that are Conducive to Active Transportation

Why Assess Health Consequences?

Source: American Public Health Association, “The Hidden Health Costs of Transportation” Report prepared by Urban Design 4Health, Inc. February 10,2010, pg.2

Chronic Disease and Risk Factors 7 out of 10 deaths in the U.S. are from chronic diseases such as heart disease, cancer and stroke 7 out of 10 deaths in the U.S. are from chronic diseases such as heart disease, cancer and stroke These chronic diseases are primarily related to four risk behaviors These chronic diseases are primarily related to four risk behaviors - lack of physical activity - poor nutrition - tobacco use - excessive alcohol consumption Source:

Behaviors & Environment 70% Medical Care, 10% Genetics 20% Prevention, 4% Medical Services 96% $2.2 Trillion Current Health Care Spending Factors Influencing Health National Health Expenditures SOURCE: Centers for Disease Control and Prevention, Blue Sky Initiative, University of California at San Francisco, Institute of the Future, 2000

“Get more exercise”... Source: Wernham, A. Health Impact Project.

Source of slide: Meehan, L.A from the Nashville Area Metropolitan Planning Organization. Incorporating Health in Regional Transportation Planning. Healthy Communities and Transportation Webinar, American Public Health Association, January 18, Transportation, Land Use and Obesity

Perfect win-win option Reduce inactivity Reduce congestion Improve road safety Improve air quality and noise Reduce energy consumption and CO 2 More livable communities Why Walking and Cycling?

Why Guidance on Economic Assessment? Economic evaluation is a standard tool of transport planners so it can help the health sector to speak “their” language Economic evaluation is a standard tool of transport planners so it can help the health sector to speak “their” language Public health benefits are likely to be great, esp. if inactive persons can be reached Public health benefits are likely to be great, esp. if inactive persons can be reached Need for a transparent robust methodology Need for a transparent robust methodology

HEAT Developed by the WHO with international experts Developed by the WHO with international experts Economic tool to estimate reductions in mortality due to cycling (transportation) and walking (recreaction and transportation) Economic tool to estimate reductions in mortality due to cycling (transportation) and walking (recreaction and transportation) Very conservative and does not include morbidity Very conservative and does not include morbidity Currently for adults only Currently for adults only

HEAT Can be used for planning new infrascructure, evaluate current or future levels of walking and cycling or even for Health Impact Assessments Can be used for planning new infrascructure, evaluate current or future levels of walking and cycling or even for Health Impact Assessments

HEAT Data imputs for the model: Data imputs for the model: –Average amount of time spent walking or cycling  Number of people walking and cycling and average distance of trips

HEAT How to get the need inputs How to get the need inputs –Route user surveys –Travel surveys –Destination based surveys –Traffic counts –Pedometers

Copenhagen Study – Effect Estimate for Transport Cycling 6,954 regular cycle commuters 6,954 regular cycle commuters N = 30,640 N = 30,640 Followed for 14.5 years Followed for 14.5 years Mean journey time of 3 hours per week Mean journey time of 3 hours per week RR = 0.72 ( ) RR = 0.72 ( ) Adjusted for age, sex, educational status, leisure time physical activity, body mass index, blood lipid levels, smoking and blood pressure Adjusted for age, sex, educational status, leisure time physical activity, body mass index, blood lipid levels, smoking and blood pressure

Effect Estimate for Walking 9 studies were found that accounted for OTHER types of leisure-time PA 9 studies were found that accounted for OTHER types of leisure-time PA A meta-analysis weighted by sample size found a RR of.78 ( ) for walking 29 minutes a day 7 days a week A meta-analysis weighted by sample size found a RR of.78 ( ) for walking 29 minutes a day 7 days a week Model is still being modified Model is still being modified

HEAT Outputs of the model Outputs of the model –Number of lives saved –Annual benefit in SVL which is $5.8 million per person in the U.S.

Uses in Other Countries Austria: USD: $570 million per year Austria: USD: $570 million per year Pilsen, Czech Republic: $1.2 million if 2% of population took up regular cycling Pilsen, Czech Republic: $1.2 million if 2% of population took up regular cycling UK/Scotland: $1.5-3 billion per year if modal share goal of 13% reached UK/Scotland: $1.5-3 billion per year if modal share goal of 13% reached New Zealand: adding cycling and pedestrian facilities to the Auckland Harbour Bridge for a savings of $900,000 per 1000 regular bike commuters New Zealand: adding cycling and pedestrian facilities to the Auckland Harbour Bridge for a savings of $900,000 per 1000 regular bike commuters

Challenges to Adapting to U.S. US Is much larger and heterogeneous US Is much larger and heterogeneous Travel data only collected nationally every 5 years Travel data only collected nationally every 5 years Very few local regions collect transport related data Very few local regions collect transport related data Hard to find good data on bike lanes and sidewalks Hard to find good data on bike lanes and sidewalks

U.S. Uses Paper by Götschi (2012) examined cycling in Portland Paper by Götschi (2012) examined cycling in Portland –By 2040, investments in the range of $138 to $605 million will result in health care cost savings of $388 to $594 million, fuel savings of $143to $218 million, and savings in value of statistical lives of $7 to $12 billion. –The cost-benefit ratios for healthcare and fuel savings are between 3.8 and 1.2 to 1

Nonmotorized Transportation Pilot Project FHWA allocated $100 million dollars to 4 pilot communities FHWA allocated $100 million dollars to 4 pilot communities – –Marin County, CA – –Minneapolis, MN – –Columbia, MO – –Sheboygan County, WI The communities were selected by congress with input from bike and pedestrain advocates as well as communnity leaders. The communities were selected by congress with input from bike and pedestrain advocates as well as communnity leaders. Several factors were used to pick the communities including demographics, level of readiness and level of urbanization. Several factors were used to pick the communities including demographics, level of readiness and level of urbanization.

Nonmotorized Transportation Pilot Project As of 2013 the communities spent $88.5 million dollars with 78.9 million for infrastructure, 7.5 million in outreach education and marketing and 1.3 million in bicycle parking. They were also able to leverage 59 million dollars in other Federal State local and private funds.

Increases in Walking and Cycling 85.1 million Vehicle Miles Traveled were averted million Vehicle Miles Traveled were averted. Walking mode share increased 15.8% and cycling mode share increased 44%. Walking mode share increased 15.8% and cycling mode share increased 44%. At individual project sites trip counts increased 56% for pedestrian trips and 115% for cycling trips. At individual project sites trip counts increased 56% for pedestrian trips and 115% for cycling trips. ¼ mile network cycling access was expanded to 240,00 people, 160,00 housing units and 102,000 jobs. ¼ mile network cycling access was expanded to 240,00 people, 160,00 housing units and 102,000 jobs. Over 70% of projects connected to activity centers. Over 70% of projects connected to activity centers.

Economic Savings The number of lives saved per year is expected to be 9 for Minneapolis, 2 for Colombia, 8 for Marin County, and 0 for Sheboygan County. The investments in Minneapolis are projected to return $21,642,000 per year, Columbia will save $5,396,000, and Marin County will save $18,776,000. With the small decrease in cycling in Sheboygan County, they are expected to lose $153,000.

Discussion Criticism of HEAT- cycling is that it uses a RR from Copenhagen Criticism of HEAT- cycling is that it uses a RR from Copenhagen However, similar RR were also found in Shanghai However, similar RR were also found in Shanghai

Discussion Other outputs could be used: Other outputs could be used: –QALY –DALY –Morbidity by disease (cost of illness)

Next Steps Adding morbidity into both models Adding morbidity into both models Modifying input and output parameters Modifying input and output parameters Inform and train potential users Inform and train potential users Examine injury and exposure to air pollution Examine injury and exposure to air pollution Develop a model for children Develop a model for children

WHO Guidance and Tool Download the guidance document and user guide from

HEAT Tool - Minneapolis Q1: Your data: amount of cycling from a single point in time, or before and after an intervention Q1: Your data: amount of cycling from a single point in time, or before and after an intervention –Single point in time –Before and after Q2: Enter your pre-intervention cycling data Q2: Enter your pre-intervention cycling data –Duration –Distance –Trips Q6.1: Trips: average number of trips per person, or total number of trips?: Q6.1: Trips: average number of trips per person, or total number of trips?: –Average per adult –Total number of trips observed

HEAT Tool- Minneapolis Q6.3: Total number of trips Q6.3: Total number of trips –Enter the number of trips observed per day: –11,241 trips –What proportion of these trips are cycling trips? –100% percent Q6.4: Do you know the number of people who take cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return journeys out of all trips observed? Q6.4: Do you know the number of people who take cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return journeys out of all trips observed? –Enter the number of individuals cycling –Estimate this based on return journeys

HEAT Tool - Minneapolis Q6.5: How many individuals contributed to the cycling trips entered? Q6.5: How many individuals contributed to the cycling trips entered? –Study population – 294,729 –How many days per year do people cycle? –365 days per year –The default is 124 days per year but this was based on modeling the VOLPE and DOT used to calculate daily averages Q6.7: Enter the average trip duration or distance Q6.7: Enter the average trip duration or distance –Duration –Distance

HEAT Tool - Minneapolis Q6.9: Average trip length Q6.9: Average trip length –Average trip length –2.26 miles –This is the national average of cycling trip length NHTS data Q7: How many people benefit? Q7: How many people benefit? –Persons –294,729 –In some cases this figure will be the number of cyclers in your study area, city or country or cycling data may be based on a representative sample of a larger population. In this case, you may wish to apply the findings to the whole population.

HEAT Tool - Minneapolis Q2: Enter your post-intervention cycling data Q2: Enter your post-intervention cycling data – Duration –Distance –Trips Q6.1: Trips: average number of trips per person, or total number of trips? Q6.1: Trips: average number of trips per person, or total number of trips? –Average per adult –Total number of trips observed Q6.3: Total number of trips Q6.3: Total number of trips –Enter the number of trips observed per day: –17,986 Trips –What proportion of these trips are cycling trips? –100 percent

HEAT Tool - Minneapolis Q6.4: Do you know the number of people who take cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return journeys out of all trips observed? Q6.4: Do you know the number of people who take cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return journeys out of all trips observed? –Enter the number of individuals cycling –Estimate this based on return journeys Q6.5: How many individuals contributed to the cycling trips entered? Q6.5: How many individuals contributed to the cycling trips entered? –Study population –326,085 –How many days per year do people cycle? –365 days per year

HEAT Tool - Minneapolis Q6.7: Enter the average trip duration or distance Q6.7: Enter the average trip duration or distance –Duration –Distance Q6.9: Average trip length Q6.9: Average trip length –Average trip length: –2.26 Miles Q7: How many people benefit? Q7: How many people benefit? –Number of cyclists: –326,085 persons

HEAT Tool - Minneapolis Q9: Proportion of cycling data attributable to your intervention Q9: Proportion of cycling data attributable to your intervention –Estimate the proportion of cycling which you would like to attribute to the intervention. –It is prudent to assume that not all the cycling, or increase in cycling is due to the intervention. –Please enter a proportion between 0-100% –60 percent Q10: Time needed to reach full level of cycling Q10: Time needed to reach full level of cycling –Please select the time period before maximum uptake is achieved: –5 years –This is the default value

HEAT Tool - Minneapolis Q11: Mortality rate Q11: Mortality rate –It is recommended to use the local crude mortality rate for the population aged years. –HEAT is not appropriate for populations consisting mainly of children, very young adults, or older people, –793.8 deaths per 100,000 population Q12: Value of statistical life Q12: Value of statistical life –The value of a statistical life is derived with a methodology called “willingness to pay” to avoid death in relation to the years this person can expect to live according to the statistical life expectancy. –5,800,000 dollars

HEAT Tool - Minneapolis Q13: Time period over which benefits are calculated Q13: Time period over which benefits are calculated –Please select the time period over which you wish average benefits to be calculated –25 years Q14: Costs to include a benefit–cost ratio in the HEAT calculation Q14: Costs to include a benefit–cost ratio in the HEAT calculation –Yes – No Q16: Discount rate to apply to future benefits Q16: Discount rate to apply to future benefits –Please enter the rate by which you wish to discount future financial savings –5 percent

HEAT Tool - Results There are an additional 31,356 individuals regularly cycling compared to baseline There are an additional 31,356 individuals regularly cycling compared to baseline The number of deaths averted per year is 9.15 The number of deaths averted per year is 9.15 The average annual benefit is $21,642,000 The average annual benefit is $21,642,000 The benefits accumulated over 25 years in $541,051,000 The benefits accumulated over 25 years in $541,051,000

Additional Resources Report to the U.S. Congress on the Outcomes of the Nonmotorized Transportation Pilot Program SAFETEA- LU Section 1807: trian/ntpp/2012_report/final_report_april_2012.pdfQu antification of health benefits of cyling and walking Transport, Health and Environment Pan European Programme (THE PEP) HEPA Europe (European network for promotion of health-enhancing physical activity)

Multidisciplinary Team Core Group: Nick Cavill, Harry Rutter, Sonja Kahlmeier, Hywell Dinsdale, Francesca Racioppi, Pekka Oja Contributors: Lars Bo Andersen, Finn Berggren, Hana Bruhova-Foltynova, Fiona Bull, Andy Cope, Maria Hagströmer / Michael Sjöström, Eva Gleissenberger / Robert Thaler, Brian Martin, Irina Mincheva Kovacheva, Hanns Moshammer, Bhash Naidoo, Kjartan Saelensminde, Peter Schantz, Thomas Schmid, Heini Sommer, Jan Sørensen, Sylvia Titze, Ardine de Wit / Wanda Wendel Vos, Mulugeta Yilma

Contact Candace Rutt