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Association Between Cardiorespiratory Fitness and Health Care Costs: The Veterans Exercise Testing Study

Published:November 28, 2017DOI:https://doi.org/10.1016/j.mayocp.2017.09.019

      Abstract

      Objective

      To determine the association between cardiorespiratory fitness (CRF) and annual health care costs in Veterans.

      Patients and Methods

      The sample included 9942 subjects (mean age, 59±11 years) undergoing a maximal exercise test for clinical reasons between January 2005 and December 2012. Cardiorespiratory fitness, expressed as a percentage of age-predicted peak metabolic equivalents (METs) achieved, was categorized in quartiles. Total and annualized health care costs, derived from the Veterans Administration Allocated Resource Center, were compared using multiple regression, controlling for demographic and clinical characteristics.

      Results

      A gradient for reduced health care costs was observed as CRF increased, with subjects in the least-fit quartile having approximately $14,662 (P<.001) higher overall costs per patient per year compared with those in the fittest quartile, after controlling for potential confounding variables. Each 1-MET higher increment in fitness was associated with a $1592 annual reduction in health care costs (5.6% lower cost per MET), and each higher quartile of fitness was associated with a $4163 annual cost reduction per patient. The effect of CRF was more pronounced among subjects without cardiovascular disease (CVD), suggesting that the results were not driven by the possibility that less-fit individuals had greater CVD. Cost savings attributable to higher fitness were greatest in overweight and obese subjects, with lower savings observed among those individuals with a body mass index less than 25 kg/m2. In a model including historical, clinical, and exercise test responses, heart failure was the strongest predictor of health care costs, followed by CRF (P<.01).

      Conclusion

      Low CRF is associated with higher health care costs. Efforts to improve CRF may not only improve health but also result in lower health care costs.

      Abbreviations and Acronyms:

      BMI (body mass index), CVD (cardiovascular disease), MET (metabolic equivalent), RVU (relative value unit), VA (Veterans Administration)
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      References

        • Myers J.
        • McAuley P.
        • Lavie C.J.
        • Despres J.P.
        • Arena R.
        • Kokkinos P.
        Physical activity and cardiorespiratory fitness as major markers of cardiovascular risk: their independent and interwoven importance to health status.
        Prog Cardiovasc Dis. 2015; 57: 306-314
        • Booth F.W.
        • Roberts C.K.
        • Laye M.J.
        Lack of exercise is a major cause of chronic diseases.
        Compr Physiol. 2012; 2: 1143-1211
        • Ding D.
        • Lawson K.D.
        • Kolbe-Alexander T.L.
        • et al.
        • Lancet Physical Activity Series 2 Executive Committee
        The economic burden of physical inactivity: a global analysis of major non-communicable diseases.
        Lancet. 2016; 388: 1311-1324
        • Cahalin L.P.
        • Myers J.
        • Kaminsky L.
        • et al.
        Current trends in reducing cardiovascular risk factors in the United States: focus on worksite health and wellness.
        Prog Cardiovasc Dis. 2014; 56: 476-483
        • Barr V.J.
        • Robinson S.
        • Marin-Link B.
        • et al.
        The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model.
        Hosp Q. 2003; 7: 73-82
        • Carlson S.A.
        • Fulton J.E.
        • Pratt M.
        • Yang Z.
        • Adams E.K.
        Inadequate physical activity and health care expenditures in the United States.
        Prog Cardiovasc Dis. 2015; 57: 315-323
        • Burton W.N.
        • Chen C.Y.
        • Li X.
        • Schultz A.B.
        • Abrahamsson H.
        The association of self-reported employee physical activity with metabolic syndrome, health care costs, absenteeism, and presenteeism.
        J Occup Environ Med. 2014; 56: 919-926
        • Anderson L.H.
        • Martinson B.C.
        • Crain A.L.
        • et al.
        Health care changes associated with physical inactivity, overweight, and obesity.
        Prev Chronic Dis. 2005; 2: A09
        • Rosenberg D.
        • Cook A.
        • Gell N.
        • Lozano P.
        • Grothaus L.
        • Arterburn D.
        Relationships between sitting time and health indicators, costs, and utilization in older adults.
        Prev Med Rep. 2015; 2: 247-249
        • Kodama S.
        • Saito K.
        • Tanaka S.
        • et al.
        Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis.
        JAMA. 2009; 301: 2024-2035
        • Després J.P.
        Physical activity, sedentary behaviours, and cardiovascular health: when will cardiorespiratory fitness become a vital sign?.
        Can J Cardiol. 2016; 32: 505-513
        • Ross R.
        • Blair S.N.
        • Arena R.
        • et al.
        • American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health
        • Council on Clinical Cardiology
        • Council on Epidemiology and Prevention; Council on Cardiovascular and Stroke Nursing
        • Council on Functional Genomics and Translational Biology
        • Stroke Council
        Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign. An American Heart Association Scientific Statement from the Committee on Physical Activity and the Council on Lifestyle and cardiometabolic Health.
        Circulation. 2016; 134: e653-e699
        • Kokkinos P.F.
        • Faselis C.
        • Myers J.
        • et al.
        Cardiorespiratory fitness and incidence of major adverse cardiovascular events in US veterans: a cohort study.
        Mayo Clin Proc. 2017; 92: 39-48
        • Nauman J.
        • Nes B.M.
        • Lavie C.J.
        Prediction of cardiovascular mortality by estimated cardiorespiratory fitness independent of traditional risk factors: the HUNT study.
        Mayo Clin Proc. 2017; 92: 218-227
        • Jimenez-Pavon D.
        • Artero E.G.
        • Lee D.C.
        • et al.
        Cardiorespiratory fitness and risk of sudden cardiac death in men and women in the United States.
        Mayo Clin Proc. 2016; 91: 849-857
        • Kokkinos P.
        • Myers J.
        Physical activity: clinical outcomes and applications.
        Circulation. 2010; 122: 1637-1648
        • Kaminsky L.A.
        • Arena R.
        • Beckie T.M.
        • et al.
        • American Heart Association Advocacy Coordinating Committee, Council on Clinical Cardiology, and Council on Nutrition, Physical Activity and Metabolism
        The importance of cardiorespiratory fitness in the United States: the need for a national registry. A Policy Statement from the American Heart Association.
        Circulation. 2013; 127: 652-662
        • Defina L.F.
        • Haskell W.L.
        • Willis B.L.
        • et al.
        Physical activity versus cardiorespiratory fitness: two (partly) distinct components of cardiovascular health?.
        Prog Cardiovasc Dis. 2015; 57: 324-329
        • EU Working Group “Sport and Health”
        EU Physical Activity Guidelines.
        (Available at:) (Accessed November 1, 2017)
        • Haskell WL
        • Lee IM
        • Pate RR
        • et al.
        • American College of Sports Medicine
        • American Heart Association
        Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.
        Circulation. 2007; 116: 1081-1093
        • Helmerhorst H.J.
        • Brage S.
        • Warren J.
        • Besson H.
        • Ekelund U.
        A systematic review of reliability and objective criterion-related validity of physical activity questionnaires.
        Int J Behav Nutr Phys Act. 2012; 9: 103
        • Ainsworth B.
        • Cahalin L.
        • Buman M.
        • Ross R.
        The current state of physical activity assessment tools.
        Prog Cardiovasc Dis. 2015; 57: 387-395
        • Page W.F.
        • Mahan C.M.
        • Kang H.K.
        Vital status ascertainment through the files of the Department of Veterans Affairs and the Social Security Administration.
        Ann Epidemiol. 1996; 6: 102-109
        • Shue P.
        • Froelicher V.F.
        EXTRA: an expert system for exercise test reporting.
        J Non-Invasive Testing. 1998; II-4: 21-27
        • Myers J.
        • Buchanan N.
        • Walsh D.
        • et al.
        Comparison of the ramp versus standard exercise protocols.
        J Am Coll Cardiol. 1991; 17: 1334-1342
        • Glass S.
        • Dwyer G.B.
        ACSM's Metabolic Equations Handbook.
        Lippincott, Williams & Wilkins, Philadelphia2007
        • Morris C.K.
        • Myers J.
        • Froelicher V.F.
        • Kawaguchi T.
        • Ueshima K.
        • Hideg A.
        Nomogram based on metabolic equivalents and age for assessing aerobic capacity in men.
        J Am Coll Cardiol. 1993; 22: 175-182
        • Berra K.
        • Rippe J.
        • Manson J.E.
        Making physical activity counseling a priority in clinical practice: the time for action is now.
        JAMA. 2015; 314: 2617-2618
        • Leigh J.P.
        • Hubert H.B.
        • Romano P.S.
        Lifestyle risk factors predict healthcare costs in an aging cohort.
        Am J Prev Med. 2005; 29: 379-387
        • Jones T.F.
        • Eatton C.B.
        Cost-benefit analysis of walking to prevent coronary heart disease.
        Arch Fam Med. 1994; 3: 705-710
        • Romley J.A.
        • Axeen S.
        • Lakdawalla D.N.
        • Chernew M.E.
        • Bhattacharya J.
        • Goldman D.P.
        The relationship between commercial health care prices and Medicare spending and utilization.
        Health Serv Res. 2015; 50: 883-896
        • Archer D.
        • Marmor T.
        Medicare and commercial health insurance: the fundamental difference.
        Health Affairs Blog. February 15, 2012;
        • Fonarow G.C.
        • Calitz C.
        • Arena R.
        • et al.
        • American Heart Association
        Workplace wellness recognition for optimizing workplace health: a presidential advisory from the American Heart Association.
        Circulation. 2015; 131: e480-e497
        • Mitchell T.L.
        • Gibbons L.W.
        • Devers S.M.
        • Earnest C.P.
        Effects of cardiorespiratory fitness on healthcare utilization.
        Med Sci Sports Exerc. 2004; 36: 2088-2092
        • Weiss J.P.
        • Froelicher V.F.
        • Myers J.N.
        • Heidenreich P.A.
        Health care costs and exercise capacity.
        Chest. 2004; 126: 608-613
        • Bachman J.M.
        • DeFina L.F.
        • Franzini L.
        • et al.
        Cardiorespiratory fitness in middle age and health care costs in later life.
        J Am Coll Cardiol. 2015; 66: 1876-1885
      1. What is driving U.S. health care spending? America's unsustainable health care cost growth. A report from the Robert Wood Johnson Foundation, 2012. Available at: https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf401339. Accessed October 29, 2017.

        • Organization for Economic Cooperation and Development (OECD)
        Healthcare costs unsustainable in advanced economies without reform.
        (Available at:) (Accessed March 14, 2017)
        • Social Security Advisory Board
        The unsustainable cost of health care.
        (Available at:) (Accessed March 15, 2017)
        • Tremblay M.S.
        • Colley R.C.
        • Saunders T.J.
        • Healy G.N.
        • Owen N.
        Physiological and health implications of a sedentary lifestyle.
        Appl Physiol Nutr Metab. 2010; 35: 725-740
        • Forman D.
        • Arena R.
        • Boxer R.
        • et al.
        • American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Stroke Council
        Prioritizing functional capacity as a principal endpoint for therapies oriented to older adults with cardiovascular disease: a scientific statement for healthcare professionals from the American Heart Association.
        Circulation. 2017; 136: e894-e918