1. NICE Physical Activity Collaborating Centre 2006 National Institute for Health and Clinical Excellence (NICE) Public Health Guidance: Physical Activity

2. NICE Physical Activity Collaborating Centre 2006 Outline l Introduction to NICE l Brief overview of what counts as evidence l Review Process l Intervention Guidance l Implementation Advice l Audit Criteria l Questions / Discussion

3. NICE Physical Activity Collaborating Centre 2006 NICE Independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill-health. Bring together knowledge and evidence on ways of promoting good health and treating ill-health

4. NICE Physical Activity Collaborating Centre 2006 What does NICE do? Guidance Public Health HealthTechnologies Clinical Practice

5. NICE Physical Activity Collaborating Centre 2006 Types of NICE Public Health Guidance Intervention Guidance Recommendations on clear types of activity (“interventions”), provided by local organisations, that help to reduce the risk of developing a disease or promote or maintain a healthy lifestyle.  Brief interventions  Pedometers  Exercise Referral  Walking and cycling schemes Programme Guidance Broader strategic activities for the promotion of good health and the prevention of ill-health. This guidance may focus on a topic or a particular setting:  a topic, such as smoking,  on a particular population, such as young people,  on a particular setting, for example, the workplace.

6. NICE Physical Activity Collaborating Centre 2006 NICE Guidance focuses on.. Effectiveness Cost-effectiveness - QALY To do or not to do… and what are the best ways to do it?

7. NICE Physical Activity Collaborating Centre 2006 What counts as evidence? The message is clear: practitioners should be ensuring that people receive care based on the best possible evidence What works? Challenge: what counts as evidence? Evidence-basedpractice Evidence-basedguidelines Evidence-basedpolicy Evidence-baseddecision-making

8. NICE Physical Activity Collaborating Centre 2006 Evidence-based public health policy & practice public health policies and practices are interventions into people’s lives, therefore it is reasonable to require the same documentation of effects as one expects from clinical interventions aimed at individuals

9. NICE Physical Activity Collaborating Centre 2006 What counts as evidence? Evidence has been interpreted in relation to notions of proof and rationality – subject to rigorous scrutiny Assumption in evidence-based medicine – that research evidence, quantitative nature would provide watertight answers Hierarchy of evidence – research evidence tends to be more highly valued Relative neglect of other forms of evidence

10. NICE Physical Activity Collaborating Centre 2006

11. NICE Physical Activity Intervention Guidance Effectiveness of : 1. Brief interventions in primary care 2. Exercise referral 3. Pedometers 4. Community-based walking and cycling schemes

12. NICE Physical Activity Collaborating Centre 2006 Rapid Review Process  Define the intervention  Identify search terms / conduct search (‘hits’)  Preliminary screen ‘In and out’ (using title/abstract)  Data extraction (using standardized form)  Study quality appraisal  Summary report on findings  NICE PHIAC meeting – draft guidance / public consultation  NICE publishes Final Guidance

13. NICE Physical Activity Collaborating Centre 2006 Effectiveness – Public Health Interventions? Hierarchy of Evidence 1.Meta-analyses, systematic review of RCTs or RCTs 2.Systematic reviews of, or individual, non-RCTs, case-control studies, cohort studies, CBA, ITS, correlation studies 3.Non-analytic studies (for example, case reports, case series studies 4.Expert opinion, formal consensus

14. NICE Physical Activity Collaborating Centre 2006 NICE Parameters for Rapid Review Study year and type l …. include search for interventions and evaluations and also cohort, qualitative and survey studies for corroborative evidence. l ….if sufficient high quality, up to date evidence is found for a specific question, older studies and/or those using weaker designs will not be examined. l Only English language papers will be included. l Adults (>16 years) l Minimum time period of 6 weeks between baseline and repeat measures for interventions [review assessed outcomes at 6-12 week; >12-52 weeks; >1 year]

15. NICE Physical Activity Collaborating Centre 2006 NICE guidance - what counts as evidence? Evidence used – depends on the extent to which it answers questions in the scope Typical review: An evidence briefing (review of reviews) A systematic review (of primary data) Existing (published) primary research New primary research

16. NICE Physical Activity Collaborating Centre 2006 In / Out Criteria l Aim of the study is to examine the effectiveness of …….? l Does the study have a control or comparison group? l Are the study’s participants all adults (16+ only)? l Is the intervention plus follow-up a minimum of 6 weeks or more? l Is the main outcome a physical activity behaviour or physical fitness measure? l For the purpose of this review do you think that this study should be (please circle): Included Excluded Not sure

17. NICE Physical Activity Collaborating Centre 2006 Brief interventions in primary care Definition: Any brief intervention involving verbal advice, encouragement, negotiation or discussion with the overall aim of increasing physical activity delivered in a primary care setting by a health or exercise professional, with or without written or other support or follow up

18. NICE Physical Activity Collaborating Centre 2006 Brief interventions in primary care Search Terms: Brief interventions, counselling, therapy AND primary care, general practice, physical activity, exercise, fitness AND controlled trial 1749 hits from databases 50 relevant 12 studies met criteria for data extraction

19. NICE Physical Activity Collaborating Centre 2006 Brief interventions in primary care Low quality scores due to: ♦ Not randomised ♦ Outcome assessment was not independent and blind ♦ Use of unvalidated PA measures ♦ No ‘intention–to-treat’ analysis ♦ No adjustment for baseline physical activity

20. NICE Physical Activity Collaborating Centre 2006 Brief interventions in primary care Results showed: ♦ Moderate increases in PA ♦ in ST (3 studies), ♦ longer term (4 studies) ♦ very long term (3 studies) ♦ Written ‘prescriptions’ may be useful adjunct ♦ Follow up may be necessary for LT change

21. NICE Physical Activity Collaborating Centre 2006 Pedometers Definition: any intervention using pedometers as a tool to increase physical activity; used alone or in combination; were purchased by individual or provided (with or without advice) by health care team or another professional/agency.

22. NICE Physical Activity Collaborating Centre 2006 Pedometers Search Terms: Pedometers, Step counters 475 hits from databases 64 relevant 4 studies met criteria for data extraction

23. NICE Physical Activity Collaborating Centre 2006 Pedometers Main reasons for exclusions: ♦ no control or comparison group ♦ pedometers were used as a monitoring tool ♦ not an intervention study ♦ no follow-up period of at least 6- weeks

24. NICE Physical Activity Collaborating Centre 2006 Pedometers Results showed: ♦ At 12 weeks: equivocal ♦ 12-52 weeks: equivocal ♦ >1 year: no studies ♦ Suggest that appropriate programme / support is required in addition to the pedometer ♦ Overall lack of evidence

25. NICE Physical Activity Collaborating Centre 2006 Exercise referral Definition: A scheme involving referral by an appropriate professional to a service where there is a formalised process of assessment of need, the development of tailored programme and monitoring of progress

26. NICE Physical Activity Collaborating Centre 2006 Exercise referral 5220 hits from databases 139 relevant 4 studies met criteria for data extraction Search Terms: Exercise, physical activity AND referral, primary health care, prescription AND study, intervention, trial, control, controlled, comparison, comparator

27. NICE Physical Activity Collaborating Centre 2006 Exercise referral Low quality scores due to: ♦ No ‘intention–to-treat’ analysis ♦ No adjustment for baseline physical activity Main reasons for exclusions: ♦ Not an intervention study ♦ Not an exercise referral scheme according to our definition ♦ No control or comparison group ♦ Not adult population group (<16 years)

28. NICE Physical Activity Collaborating Centre 2006 Exercise referral Results showed: ♦ Moderate increases in PA in ST (2 studies) ♦ Equivocal evidence of effectiveness in the longer term (4 studies) and very long term (3 studies) ♦ Overall insufficient evidence and further research needed

29. NICE Physical Activity Collaborating Centre 2006 Community-based walking and cycling schemes Definition: Projects and groups with the aim of increasing participation in walking and cycling through involvement in organised (led) walks/rides. Can include referral by a member of the primary care team of an individual as well as ‘self referral’ to such schemes, brought about by community workers, promotional flyers, media coverage, etc

30. NICE Physical Activity Collaborating Centre 2006 Community-based walking and cycling schemes Search Terms: walk, walking, bike, bicycling, bike riding, led walks, health walks, groups walks, pedal backs the years, rides, riding AND community intervention, project, programme, program, trial 16, 599 hits from databases 254 relevant 0 studies met criteria Cycling Walking 4 studies met criteria Grey literature

31. NICE Physical Activity Collaborating Centre 2006 Community-based w alking schemes Low quality scores due to: ♦ high loss to follow-up ♦ use of unvalidated measure of physical activity ♦ lack of use of intention to treat analysis ♦ lack of adjustment for baseline physical activity levels Main reasons for exclusions: ♦ Not led walks/rides ♦ Not intervention studies ♦ No pre-measures

32. NICE Physical Activity Collaborating Centre 2006 Community-based w alking schemes Results showed: ♦ 1 high quality RCT showed no effect ♦ 1 lower quality controlled study showed no effect ♦ 1 high quality RCT showed +ve effect ♦ 1 lower quality RCT found +ve effect ♦ Overall evidence is equivocal

33. NICE Physical Activity Collaborating Centre 2006 Community-based cycl ing schemes ♦ Database searches resulted in no evidence (Note: organised rides only) Grey literature: ♦ Lack of pre-measures ♦ 1 lower quality controlled study showed no effect

34. NICE Physical Activity Collaborating Centre 2006 Economic Analysis ♦ Additional review process ♦ Undertaken by Matrix Consultancy ♦ Separate report available ♦ Summary findings: ♦ Limited evidence for brief interventions ♦ No evidence for walking and cycling ♦ Some evidence for exercise referral ♦ No evidence for pedometers

35. NICE Physical Activity Collaborating Centre 2006 Guidance Development Process Synopsis (executive summary & evidence tables), full reviews, supplementary reviews & economic modelling submitted to Public Health Interventions Advisory Committee (PHIAC) PHIAC produces draft recommendations Draft recommendations published for consultation Responses to consultation published PHIAC amends recommendations Final guidance published on website

36. NICE Physical Activity Collaborating Centre 2006 How PHIAC formulated recommendations ♦ Whether there was sufficient evidence (in terms of quantity, quality and applicability) to form a judgement ♦ Whether, on balance, the evidence demonstrates that the intervention is effective or ineffective, or whether it is equivocal ♦ Where there is an effect, the typical effect size

37. NICE Physical Activity Collaborating Centre 2006 Brief Interventions in Primary Care: Recommendations Recommendation 1 - Primary care practitioners should: ♦ Take the opportunity, whenever possible, to identify inactive adults and advise them to aim for 30 minutes of moderate activity on 5 days of the week (or more) ♦ Use their judgment to determine when this would be inappropriate ♦ Use a validated tool to identify inactive individuals Brief interventions 1

38. NICE Physical Activity Collaborating Centre 2006 Brief Interventions in Primary Care: Recommendations Recommendation 2 - Primary care practitioners should: ♦ Take into account individual’s needs, preferences and circumstances when providing physical activity advice ♦ Agree goals with individuals ♦ Provide written information about the benefits of activity and the local opportunities to be active ♦ Follow up at appropriate intervals 3-to-6 month period Brief interventions 2

39. NICE Physical Activity Collaborating Centre 2006 Brief Interventions in Primary Care: Recommendations Recommendation 3 – Local policy makers, commissioners and managers together with primary care practitioners should: ♦ Monitor the effectiveness of local strategies and systems to promote physical activity ♦ Consider whether or not opportunistic advice is helping to increase the physical activity levels of people from disadvantaged groups, including those with disabilities ♦ Assess how effective professionals from a range of disciplines are at raising LT p.a. among these groups Brief interventions 3

40. NICE Physical Activity Collaborating Centre 2006 Brief Interventions in Primary Care: Recommendations Recommendation 4 – Local policy makers, commissioners and managers together with primary care practitioners should: ♦ Pay particular attention to the cultural needs of hard to reach and disadvantaged communities, including BME groups when developing service infrastructures to promote physical activity Brief interventions 4

41. NICE Physical Activity Collaborating Centre 2006 Exercise Referral PHIAC determined there was insufficient evidence to recommend the use of exercise referral schemes to promote physical activity other than as part of research studies where their effectiveness can be evaluated

42. NICE Physical Activity Collaborating Centre 2006 Exercise Referral: Recommendation Recommendation 5 – Practitioners, policy makers and commissioners should: ♦ Only endorse exercise referral schemes to promote p.a. that are part of a properly designed and controlled research study to determine effectiveness ♦ Measure intermediate outcomes such as knowledge, attitudes and skills, as well as measures of p.a. ♦ Only refer individuals to schemes that are part of such a study

43. NICE Physical Activity Collaborating Centre 2006 Pedometers, walking and cycling schemes PHIAC determined there was insufficient evidence to recommend the use of pedometers and walking and cycling schemes to promote physical activity other than as part of research studies where their effectiveness can be evaluated … …professionals should continue to promote walking and cycling as a means of incorporating p.a. into people’s daily lives

44. NICE Physical Activity Collaborating Centre 2006 Pedometers, walking and cycling schemes: Recommendation Recommendation 6 : Practitioners, policy makers and commissioners should: ♦ Only endorse pedometers and walking and cycling schemes to promote p.a. that are part of a properly designed and controlled research study to determine effectiveness ♦ Measure intermediate outcomes such as knowledge, attitudes and skills, as well as measures of p.a.

45. NICE Physical Activity Collaborating Centre 2006 In summary… ♦ SUPPORTED: ♦ Brief interventions in Primary Care ♦ EVALUATE: ♦ Exercise referral ♦ Walking schemes ♦ Pedometers ♦ NICE Implementation Advice

46. NICE Physical Activity Collaborating Centre 2006 D13: ‘effective programmes to improve health and reduce health inequalities, conforming to nationally agreed best practice, particularly as defined in NICE guidance and agreed national guidance on public health’

47. NICE Physical Activity Collaborating Centre 2006 Responsibility for implementing this guidance rests with those responsible for commissioning and delivering public health services

48. NICE Physical Activity Collaborating Centre 2006 Key areas for implementation ♦ Training ♦ Communication ♦ Monitoring local strategies and systems ♦ Evaluation of existing and new pedometer, exercise referral, walking and cycling schemes

49. NICE Physical Activity Collaborating Centre 2006 http://www.nice.org.uk/page.aspx?o=PHI002&c=publichealth

50. Forthcoming Programme Guidance: Physical activity and the Environment To produce guidance for the Highways Agency, local authorities, the NHS, the independent sector and others, on the promotion and creation of built or natural physical environments that are conducive to and support increased levels of physical activity among local communities, to meet the physical activity recommendations of the Chief Medical Officer of England

51. Questions What are the implications for practitioners?