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MartiskainenT, etal. BMJ Public Health 2023;1:e000098. doi:10.1136/bmjph-2023-000098
Effect of physical activity counselling
on the number of contacts in primary
healthcare, specialised healthcare and
the related healthcare costs among
patients with type 2 diabetes: a register-
based evaluation study
Tuula Martiskainen ,1,2 Marja- Leena Lamidi,2 Miika Linna,3,4 Mika Venojärvi,5
Heikki Tikkanen,5 Tiina Laatikainen1,2,6
Original research
To cite: MartiskainenT,
LamidiM- L, LinnaM, etal.
Effect of physical activity
counselling on the number of
contacts in primary healthcare,
specialised healthcare and the
related healthcare costs among
patients with type 2 diabetes:
a register- based evaluation
study. BMJ Public Health
2023;1:e000098. doi:10.1136/
bmjph-2023-000098
►Additional supplemental
material is published online only.
To view, please visit the journal
online (http:// dx. doi. org/ 10.
1136/ bmjph- 2023- 000098).
Received 28 March 2023
Accepted 12 September 2023
For numbered afliations see
end of article.
Correspondence to
Dr Tuula Martiskainen;
tuulama@ student. uef.
© Author(s) (or their
employer(s)) 2023. Re- use
permitted under CC BY- NC.
Published by BMJ.
ABSTRACT
Introduction This study evaluated the effect of physical
activity (PA) counselling on the number of contacts and
related costs in primary healthcare (PHC) and specialised
healthcare (SHC) among patients with type 2 diabetes
(T2D).
Methods The study was carried out in North Karelia,
Finland, among PHC clients with T2D in 2016–2018.
Altogether, 521 patients participated in the counselling.
In total, 1382 sex, age, time of diagnosis and intervention
time- matched controls were used to assess the effect
of the intervention. Information on outpatient nurse and
physician appointments in PHC and SHC was collected
from October 2016 to December 2019. The reason for
the visit was identied with the recorded main diagnosis
using both International Classication of Diseases- 10 and
International Standard Classication of Primary Care- 2
diagnoses. Unit costs of SHC visits were based on average
diagnosis- related group costs and for PHC unit costs for
appointments for physicians, nurses and physiotherapists
on the national price list.
Results The number of physician and nurse appointments
in the PHC related to T2D decreased in the intervention
group and increased in the control group with statistically
signicant differences in mean annual changes between
groups (p=0.010 and p<0.001, respectively). In PHC,
the number of physician appointments related to
musculoskeletal disorders decreased in the intervention
group and increased in the control group with a statistically
signicant difference between groups (p<0.001). In the
intervention group, T2D- related costs of appointments
per person- year in PHC decreased, while an increase was
observed in the control group (p<0.001).
Conclusions This study shows that PA counselling in
PHC offers signicant benets in the treatment of patients
with T2D by also improving the use of the resources in
healthcare. The PA counselling reduced the number of
other appointments and costs of appointments per person-
year.
INTRODUCTION
According to the WHO, diabetes will be the
seventh- leading cause of death in 2030.1 The
majority of patients with diabetes suffer from
type 2 diabetes (T2D), which is largely prevent-
able as caused strongly by obesity and physical
inactivity.2 A sedentary lifestyle, unhealthy diet
and urbanisation are strongly associated with
the prevalence of T2D in adults.3 Despite the
WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒Patients with type 2 diabetes (T2D) use a substantial
amount of healthcare services. Among primary care
contacts, nurse contacts are the most common.
⇒Previous studies have shown that reductions in body
mass index and haemoglobin A1c are correlated
with reductions in healthcare spending among pa-
tients with T2D.
WHAT THIS STUDY ADDS
⇒Physical activity (PA) counselling in primary health-
care (PHC) offers signicant benets in the treat-
ment of patients with T2D by also improving the use
of the resources in healthcare.
⇒The PA counselling reduced the number of other ap-
pointments and thus costs of the health service use.
HOW THIS STUDY MIGHT AFFECT RESEARCH,
PRACTICE OR POLICY
⇒This study carried out in ‘real- world’ setting provides
valuable additional information on the feasibility of
implementation research in PHC and how electronic
patient information systems can be used as a source
of research data.
⇒PA counselling improves the treatment outcomes
and supports patients, reduces the need for other
healthcare appointments and thus increases cost
savings and cost- effectiveness of healthcare.
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BMJ Public Health
increasing number of drugs available and various guide-
lines on the management of T2D, an expressive number
of patients continue with the disease uncontrolled.4 Many
studies have shown that proper diet and physical activity
(PA), considered as non- pharmacological treatments of
T2D, effectively improve the glycaemic control and other
metabolic outcomes in patients with T2D.5–7 People with
T2D should engage regularly with moderate or vigorous
intensity PA.7 Despite these noted benefits, adults with
T2D are less likely to engage in regular PA than the
general adult population.8 Therefore, it is important to
invest in improving lifestyles that can promote health and
maintain glycaemic control in patients with T2D.
Healthcare organisations are encouraged to introduce
healthy lifestyle promotion in routine practice.9 Primary
healthcare (PHC) has been identified as the setting that
can offer continuous and comprehensive lifestyle promo-
tion to patients with health- risk behaviour.10 11 Imple-
menting lifestyle counselling in clinical practice has been
shown to be feasible, cost- effective12 and acceptable among
healthcare professionals and patients.13 Many transla-
tional ‘real- world’ diabetes prevention programmes have
yielded positive results, but they have been on a small-
scale. The resources needed for implementation of many
interventions in a ‘real- world’ situation are quite modest,
but can be efficient and profitable.14
Recently diagnosed patients with T2D use a substan-
tial amount of healthcare services, especially during the
first year after diagnosis. Among primary care contacts,
nurse contacts are the most common.15 Wikström et al16
found in their study that patients with T2D who had
good treatment control had less healthcare contacts
compared with those who were not within the target level
of haemoglobin A1c (HbA1c). PHC contacts provide
opportunities to positively influence and support healthy
behaviours, optimise treatment plans and promote self-
management to patients with T2D.17 Kauppila et al18
have found that previous T2D drop- outs with significant
improvement in their glycaemic control seemed to have
more frequent visits or telephone contacts with health-
care professionals than those who did not show improve-
ment in their glycaemic control. Previous drop- outs who
had poor glycaemic control may especially benefit from
frequent controls.18
The purpose of healthcare is to improve the health of
populations. However, formal medical care is only one
of many alternatives for improving health.19 Behavioural
medicine is in a unique, but underappreciated, position
to contribute to an understanding of how best to deliver
high- quality, cost effective healthcare and promote
the public’s health across a broad range of interven-
tions.20 Roux et al21 have assessed in their study the cost-
effectiveness of population- wide strategies to promote PA
in adults and followed disease incidence over a lifetime.
According to their study, all the evaluated PA interven-
tions reduced disease incidence and were cost- effective
compared with other well- accepted preventive strategies.
PA interventions offered good value for money.21
We have previously reported that PA counselling in
PHC, even with a modest increase in exercise, offers
significant benefits in the treatment of T2D and can
contribute to the glucose control of individuals with
T2D.22 However, the evidence on the effects of PA coun-
selling of patients with T2D on healthcare contacts and
related cost- effectiveness is limited. Previous studies
have shown that reductions in body mass index (BMI)
and HbA1c23 24 correlate with reductions in healthcare
spending among patients with T2D.12 All interventions
that improve the quality of care and glycaemic control
may have longer- term impact and thus increase value in
healthcare by improving health outcomes and reducing
costs.25 The aim of this study is to evaluate the effect of
PA intervention carried out as a part of PHC services of
patients with T2D on the number of contacts and costs of
appointments in PHC and specialised healthcare (SHC).
METHODS
Participants
All patients with T2D were offered the opportunity to
participate in a PA counselling programme in the Siun
sote healthcare region in North Karelia, Finland, from
October 2016 to December 2018. Especially patients with
very little PA were referred for PA counselling by nurses,
physiotherapists and physicians. The follow- up time was
from October 2016 to December 2019. Altogether, 546
patients were referred to the PA educator of whom 521
participated in the counselling. In total, 1382 sex, age,
time of diagnosis and intervention time- matched controls
extracted from patient records were used to see the effect
of the intervention. The PA counselling was provided by
PA educators flexibly according to the patients’ needs
and thus the number of counselling sessions varied. On
average, patients visited the PA educator three times.22 26
Also, the type and intensity of PA what the patients were
advised to do varied as counselling was tailored according
to patients’ needs and health status.22
Measurements and appointments
Information on all physiological laboratory measure-
ments and number of appointments was retrieved from
electronic health records (EHRs) retrospectively. For
both intervention and control group participants, height
(cm) and weight (kg) were measured and blood samples
for HbA1c collected in health services, following the
current practice in the follow- up of patients with T2D.
The turbidimetric inhibition immune analysis method
(TINIA) was used to analyse HbA1c. All samples were
analysed in the same regional laboratory. Outpatient
visits, that is, appointments to physicians, nurses and
physiotherapists in PHC and SHC, were analysed starting
from October 2016 to the start of the intervention and
3 months after the start of the intervention until the
end of the follow- up, December 2019. The reason for
the visit was identified using the recorded main diag-
nosis according to specific International Classification of
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BMJ Public Health
Diseases (ICD)- 10 diagnoses and International Standard
Classification of Primary Care (ICPC- 2). Appointments
with an ICD- 10 code E11 and ICPC- 2 code T90 were
regarded as T2D- related visits. For musculoskeletal disor-
ders (MSD) the visits with following ICD- 10 codes, which
were the most common diagnoses related to musculoskel-
etal diseases and symptoms were the following: G44.2,
G55.2, M15, M16, M17, M19.0, M24.5, M24.6, M25.2,
M25.3, M25.5, M25.6, M25.7, M40, M41, M43.0, M45,
M47, M48, M50, M51, M53, M54, M62.3, M62.4, M62.5,
M75, M79.6, M79.7, M79.8, M79.9, M80.0, M81.0, M85.8,
R25.2, R26.8, R29.8, S33.1 and S33.2; and the ICPC- 2
codes L01–L08, L10, L13–L15, L18–L20, L28, L29, L83–
L86, L89–L92, L95 and L99 were taken into account.
Healthcare costs
The unit costs of SHC visits were based on the average
diagnosis- related group (NordDRG) costs. The NordDRG
patient grouping definitions are based on the ICD 10th
revision (ICD- 10) codes and the Finnish version of the
Nordic Classification of Surgical Procedures codes for
diagnostic and treatment procedures. The cost weights
and unit cost estimates for DRG- grouped SHC visits were
obtained from the national price list for unit costs of
healthcare services in Finland.27
The primary care contact type- related unit costs in
the national price list include visit, phone call, home
care visit and e- message costs for each type of healthcare
professional (physicians, nurses, physiotherapists). In
this study, we used the unit costs for visits/appointments
for physicians and nurses. PA counselling was provided
by special PA educators and visits to them were taken into
account in the costs of the intervention. The costs of visits
to the PA educator were estimated using the unit cost of
physiotherapists.
Statistical methods
The number of appointments was presented as an abso-
lute number and number per person years. Generalised
Poisson regression was used to assess the effect of inter-
vention in the number of appointments. For each patient
time, from October 2016 to the start of the intervention,
and 3 months after the start of the intervention, until
the end of the follow- up, December 2019, together with
a group (intervention or control) and their interaction,
were used as explanatory factors in the model. Interven-
tion participants were also matched with their controls.
Subanalyses were done by healthcare area (primary vs
specialised), personnel (physicians, nurses and physi-
otherapists), disease group (T2D and MSD), sex, age
group, change in BMI and HbA1c. Because of very few
physiotherapists’ appointments sex, age group, BMI and
HbA1c specific analyses were not carried out for them.
Personal regression lines were used to define decrease
(slope 0 or smaller) or increase (slope positive) in BMI
or HbA1c values. Similarly, costs of the appointments
were presented in euros per person- years. A mixed effect
model was used to assess the effect of intervention in
reducing the cost with the same explanatory factors as in
Poisson regression. The R language and environment for
statistical computing (V.4.0.3)28 were used in statistical
analyses. P values less than 0.05 were regarded as statisti-
cally significant.
Patient and public involvement
Patients and/or the public were not involved in the
designing, conducting, reporting or making dissemina-
tion plans of this research.
RESULTS
Table 1 presents the absolute number of T2D and MSD
appointments and number of T2D and MSD appoint-
ments per person- year in PHC and SHC before and after
the start of the PA intervention in the intervention and
control groups. In PHC, there were, among all patients
in total, 1468 physician appointments related to TD2 and
2411 physician appointments due to MSD during the
whole follow- up time. Physician appointments in the PHC
related to T2D decreased, and among the patients in the
control group, the number of appointments increased
with a statistically significant difference in mean annual
changes between groups (p=0.010). Also, in the PHC,
the number of physician appointments related to MSD
decreased in the intervention group and increased in
the control group after the intervention with a statisti-
cally significant difference in change between groups
(p<0.001). In the PHC, there were in total 6302 nurse
appointments during the follow- up related to TD2 and
only 210 related to MSD. In the intervention group, nurse
appointments related to T2D declined and increased
in the control group in the PHC after the intervention
with a statistically significant difference between groups
(p<0.001). The visits to the nurses related to MSD slightly
increased in the intervention group and the difference in
change compared with the control group was significant.
There were only very few physiotherapist appointments
in PHC before the intervention and the increase in the
intervention group after the start of the intervention was
due to visits to the PA counselling. A small increase was
observed in SHC, but it was similar in intervention and
control groups. In general, the number of visits to SHC
was low except MSD physician visits.
Table 2 shows the costs of appointments per person-
year, total costs of physician and nurse appointments
in PHC and SHC before and after PA intervention in
the intervention and control groups. In the interven-
tion group, T2D- related physician and nurse costs of
appointments per person- year in PHC decreased, and in
the control group increased after the intervention with
a statistically significant difference in change between
groups (p<0.001). Also, the total costs of physician and
nurse appointments per person- year in the intervention
group decreased and increased in the control group after
the intervention with a statistically significant difference
in change between groups (p<0.001). The participants of
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the intervention group visited PA counselling on average
three times during the intervention. One appointment
lasted 60 min, and its cost was €85 per visit. Hence, the
average cost of intervention appointments was €255 per
person.
When analysing the number of PHC appointments
separately for men and women, it was observed that the
change between the intervention and control groups was
significantly different in nurse appointments related to
T2D in both sexes. The number of PHC nurse appoint-
ments related to T2D decreased in the intervention
group and increased in the control group (online supple-
mental table 1).
When analysing the number of PHC appointments
separately for sex and age group, it was observed that
the change between the intervention and control groups
was significantly different in nurse appointments related
to T2D among women and men under 65 years of age
as well as among older women. The number of visits by
PHC nurses related to T2D decreased in the intervention
group and increased in the control group in women and
Table 1 Absolute number of T2D and MSD appointments (N) and number of T2D and MSD appointments per person- year (n/
py) in PHC and SHC before and after PA intervention in intervention group (IG) and control group (CG)
Healthcare
professional
Healthcare
services
Disease
group N
IG, before
n/py
IG, after
n/py
CG, before
n/py
CG, after
n/py
P value for
interaction*†
Physicians PHC T2D 1468 0.18 0.16 0.18 0.21 0.010
MSD 2411 0.48 0.45 0.25 0.27 <0.001
SHC T2D 266 0.04 0.05 0.02 0.04 0.188
MSD 1098 0.18 0.18 0.14 0.13 0.695
Nurses PHC T2D 6302 0.97 0.73 0.72 0.89 <0.001
MSD 210 0.03 0.04 0.03 0.02 0.155
SHC T2D 100 0.01 0.02 0.01 0.02 0.407
MSD 141 0.02 0.03 0.02 0.02 0.047
Physiotherapists PHC T2D 185 0.00 0.18* 0.00 0.00 0.977
MSD 14 0.00 0.01 0.00 0.00 1.000
SHC T2D 9 0.00 0.00 0.00 0.00 0.992
MSD 226 0.00 0.07 0.00 0.05 0.970
*Interaction of group and time
†Majority of these are PA counselling visits related to the intervention
MSD, musculoskeletal disorder; PA, physical activity; PHC, primary healthcare; SHC, specialised healthcare; T2D, type 2 diabetes.
Table 2 Costs of appointments per person- year (n/py) in PHC and SHC before and after PA intervention in intervention group
(IG) and control group (CG)
Healthcare
professional
Healthcare
services
Disease
group N
IG, before,
€/py
IG, after,
€/py
CG, before,
€/py
CG, after,
€/py
P value for
interaction*
Physicians PHC T2D 1468 17.85 12.60 16.90 17.77 <0.001
MSD 2411 40.78 39.89 21.27 22.33 0.601
SHC T2D 266 10.63 12.55 5.94 12.22 0.013
Both
MSD
Both
1098
5243
46.90
116.16
47.48
112.51
36.72
80.83
33.49
85.81
0.756
<0.001
Nurses PHC T2D 6302 37.58 24.94 26.28 30.76 <0.001
MSD 210 1.00 1.46 0.90 0.82 0.151
SHC T2D 100 1.23 2.91 1.50 3.40 0.982
Both
MSD
Both
141
6753
3.17
42.98
3.99
33.30
3.22
31.90
2.71
37.69
0.101
<0.001
Total costs of
physicians and
nurses 159.14 145.81 112.73 123.51 <0.001
*Interaction of group and time
MSD, musculoskeletal disorder; PA, physical activity; PHC, primary healthcare; SHC, specialised healthcare; T2D, type 2 diabetes.
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BMJ Public Health
men under the age of 65 and in the older women (online
supplemental table 2).
Among those whose HbA1c level increased, the number
of physician appointments related to T2D in PHC
decreased and the number of appointments increased
in their matched controls after the intervention. The
number of physician appointments related to T2D in
SHC decreased in those participants in the intervention
group whose HbA1c level declined, and the number of
appointments increased in their matched controls after
the intervention. Regarding the visits to nurses in PHC
related to T2D, there was a decline in the intervention
participants regardless of the change in the HbA1c level.
The mean yearly change was statistically significantly
different between the groups (p<0.001) (table 3).
Among the participants in the intervention group, the
number of nurse visits related to T2D decreased in the
PHC significantly more compared with their matched
controls regardless of the change in BMI (table 4).
DISCUSSION
This study assessed the effect of PA counselling interven-
tion on the number of contacts and costs of physicians’
and nurses’ appointments related to T2D and MSD per
person- year in PHC and SHC before and after PA inter-
vention in the intervention and control groups. To our
knowledge, there is no earlier research on the effects of
the PA counselling of patients with T2D on the use of other
health services and related costs. The primary finding of
this study is that among the participants in the interven-
tion, the number of physician and nurse appointments
in the PHC related to T2D decreased (physicians—11%,
nurses—25%), while it increased in the control group
(physicians +16.6%, nurses +24%) after the intervention.
The number of physician appointments related to
MSD in PHC decreased in the intervention group. In the
intervention group, T2D- related costs of physician and
nurse appointments per person- year in PHC decreased
(−8%) and increased in the control group (+10%)
Table 3 Absolute number of appointments (N) and number of T2D and MSD appointments per person- year (n/py) in PHC
and SHC before and after the PA intervention in the intervention group (IG) and the control group (CG) by the change in HbA1c
values
Healthcare
professional
Healthcare
services
Disease
group
Change in
HbA1c N
IG, before
n/py
IG, after n/
py
CG, before
n/py
CG, after
n/py
P value for
interaction*
Physicians PHC T2D Increased 582 0.35 0.23 0.24 0.25 0.012
Decreased 695 0.20 0.19 0.26 0.26 0.969
Unknown 191 0.01 0.01 0.05 0.14 0.308
MSD Increased 853 0.51 0.52 0.26 0.36 0.275
Decreased 1004 0.54 0.45 0.30 0.29 0.271
Unknown 554 0.37 0.36 0.18 0.17 0.966
SHC T2D Increased 99 0.04 0.11 0.02 0.04 0.486
Decreased 117 0.07 0.03 0.03 0.04 0.015
Unknown 50 <0.005 <0.005 0.01 0.04 0.999
MSD Increased 344 0.17 0.18 0.15 0.14 0.276
Decreased 426 0.22 0.18 0.13 0.13 0.456
Unknown 328 0.13 0.16 0.13 0.11 0.391
Nurses PHC T2D Increased 2536 1.48 1.00 0.99 1.10 <0.001
Decreased 2909 1.32 0.92 0.99 1.03 <0.001
Unknown 858 0.08 0.10 0.21 0.58 0.002
MSD Increased 69 0.03 0.03 0.02 0.03 0.321
Decreased 90 0.03 0.05 0.03 0.02 0.046
Unknown 51 0.03 0.03 0.03 0.01 0.215
SHC T2D Increased 42 <0.005 0.05 0.01 0.02 0.310
Decreased 41 0.01 0.01 0.01 0.02 0.227
Unknown 17 <0.005 <0.005 <0.005 0.01 1.000
MSD Increased 43 0.01 0.03 0.02 0.02 0.124
Decreased 53 0.01 0.03 0.02 0.01 0.089
Unknown 45 0.02 0.02 0.02 0.01 0.417
*Interaction of group and time
HbA1c, haemoglobin A1c; MSD, musculoskeletal disorder; PA, physical activity; PHC, primary healthcare; SHC, specialised healthcare;
T2D, type 2 diabetes.
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BMJ Public Health
after the intervention. Also, total costs of physician and
nurse appointments related to either T2D or MSD per
person- year in PHC and SHC in the intervention group
decreased and increased in the control group after the
intervention.
Clinical studies have found that enhancement of the
treatment to achieve glycaemic control, and in this way
reducing or preventing complications, may be one of the
most cost- effective interventions for patients with T2D
with inadequate glycaemic control.29 A study by Johansen
et al30 observed that lifestyle interventions can maintain
glycaemic control to at least the same extent as medi-
cation. Hence, in addition to medication, the measures
supporting healthy lifestyles should always be key compo-
nents of the treatment of patients with T2D.31 Our study
found that, in addition to positive treatment effect on
HbA1c levels that have been reported earlier,22 partici-
pating in PA counselling also decreased the number of
physician and nurse appointments related to T2D in the
PHC.
Among patients with unsatisfactory glycaemic control,
an association between visit frequency and better diabetes
control has been shown in several studies.32–34The
patients with T2D with poor glycaemic control showed
significant and clinically meaningful improvements in
HbA1c when contacted weekly by members of the health-
care system.35 The international diabetes guidelines
recommend regular and frequent visits, for example,
every 3 months, and evaluation of the therapy until stable
glycaemic control is achieved.36 37 Every effort to improve
the glycaemic control and well- being of patients with T2D
is important in order to reduce diabetic complications.38
Our study showed that a positive effect on achievement
of treatment targets can also be achieved with PA coun-
selling services,22 simultaneously reducing the need of
other contacts to health services.
Given the rising incidence of T2D, and thus the burden
on healthcare services, health economic (HE) evalua-
tions of the management of T2D are becoming increas-
ingly relevant worldwide.29According to Liebl et al,29
Table 4 Absolute number of appointments (N) and number of T2D and MSD appointments per person- year (n/py) in PHC
and SHC before and after PA intervention in the intervention group (IG) and control group (CG) by the change in BMI values
Healthcare
professional
Healthcare
services
Disease
group Change in BMI N
IG, before
n/py
IG, after
n/py
CG, before
n/py
CG, after
n/py
P value for
interaction*
Physicians PHC T2D Increased 654 0.19 0.15 0.26 0.27 0.187
Decreased 459 0.24 0.22 0.25 0.23 0.979
Unknown 355 0.09 0.06 0.09 0.17 0.003
MSD Increased 987 0.43 0.45 0.28 0.32 0.640
Decreased 794 0.62 0.49 0.31 0.35 0.054
Unknown 630 0.37 0.39 0.19 0.20 0.899
SHC T2D Increased 119 0.04 0.06 0.03 0.04 0.729
Decreased 84 0.04 0.06 0.03 0.05 0.582
Unknown 63 0.01 <0.005 0.01 0.04 0.985
MSD Increased 429 0.18 0.17 0.17 0.12 0.200
Decreased 331 0.22 0.22 0.14 0.14 0.940
Unknown 338 0.10 0.11 0.11 0.12 0.650
Nurses PHC T2D Increased 2978 1.22 0.89 1.02 1.13 <0.001
Decreased 1877 0.98 0.78 0.98 1.04 0.005
Unknown 1448 0.37 0.24 0.35 0.65 <0.001
MSD Increased 89 0.03 0.04 0.03 0.03 0.238
Decreased 67 0.04 0.05 0.03 0.03 0.558
Unknown 54 0.02 0.02 0.02 0.02 0.648
SHC T2D Increased 59 0.01 0.03 0.01 0.02 0.954
Decreased 20 <0.005 0.01 0.01 0.02 0.989
Unknown 21 <0.005 <0.005 <0.005 0.01 1.000
MSD Increased 58 0.01 0.02 0.03 0.02 0.267
Decreased 44 0.02 0.05 0.02 0.01 0.019
Unknown 39 0.01 0.01 0.01 0.02 0.716
*Interaction of group and time
BMI, body mass index; MSD, musculoskeletal disorder; PA, physical activity; PHC, primary healthcare; SHC, specialised healthcare; T2D, type 2
diabetes.
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BMJ Public Health
HE studies have shown that in T2D hospital inpatient
care, mostly due to diabetes complications, the costs are
considerably high. Instead, diabetes medication- related
and supplies- related costs are much lower.29 In turn,
Nuckols et al39 reported in their review that multifaceted
QI interventions that lower HbA1c appear to be a reason-
ably good value relative to usual care.39
Prior studies indicate that improvements in HbA1c
can be associated with declines in healthcare utilisation
and expenditures in the short term and long term.40 41
Li et al40 reported that the multicomponent interven-
tions are more effective in risk factor control and early
prevention of complications and, thus, more cost saving
compared with standard glycaemic control for persons
with T2D. Sidorov et al41 reported that a specific disease
management programme showed to be associated with
a significant reduction in healthcare costs and other
measures of healthcare use in patients with diabetes. Our
study showed a cost reduction related to the decrease
in other than intervention appointments. Our interven-
tion itself led to, on average, a cost of €255 per person,
which exceeds the 1- year cost reduction observed in costs
of appointments related to T2D or MSD. However, the
intervention cost is only realised during the intervention
period, but the reduction in costs of other appointments
can be cumulative during several years if improvements
in lifestyles and treatment balance is achieved. So, it
would be important to analyse the longer- term impact
of the intervention. Also, in our study, only T2D- related
and MSD- related visits were included in the analyses, as
they are the most common causes of healthcare contacts
among patients with T2D. Intervention might have also
influenced the need of some other services, such as
preventive, mental health, emergency and rehabilitation
services.
Huckfeldt et al42 estimated the association of effec-
tive lifestyle interventions for weight loss with long- term
healthcare use and Medicare spending. This ancillary
study used data from the Look AHEAD randomised
clinical trial, which randomised participants with T2D
to an intensive lifestyle intervention (ILI) or control
group. They found that reductions in healthcare use
and spending associated with an ILI for T2D decreased
as participants aged. We also found that the effects on
healthcare visits seemed to be bigger among elderly
women but also among men under 65 years of age. They
also stated that their ILI clinical trial was not associ-
ated with reduced total Medicare spending in the years
immediately following the intervention.42 However, from
the same trial, Espeland et al43 reported that ILI led to
reductions in annual hospitalisations, hospital days and
number of medications, resulting in cost savings for
hospitalisation and medication across an average of 10
years.43
As healthcare costs associated with chronic illnesses are
constantly increasing, it is imperative to identify inter-
ventions to reduce long- term spending without harming
patient care.42 Usually, the effect of interventions on
healthcare costs are caused via improved treatment
balance and thus reduce the need for appointments.
In our study, we have been able to assess only the short-
term effects of PA counselling provided in PHC settings
on achieving treatment targets22 and on health service
use and costs. There is a need for longer- term analyses,
taking also into account the possible decline in the onset
of complications among patients attending lifestyle
counselling.
In our study, the physician appointments in the PHC
decreased most among those with increased HbA1c
levels, but the number of nurse appointments related
to T2D in PHC decreased irrespective to the change in
HbA1c or BMI. The visits to the PA counsellor might have
also provided the patients with other types of support that
may have normally been handled by nurses.42 However,
aiming at better control is supported by the results by
Wagner et al24 who compared healthcare utilisation and
costs over a 5- year period between two cohorts of diabetic
patients: a group whose glycaemic control improved and a
group in whom it did not improve. Their study suggested
that a sustained reduction in HbA1c levels among adult
diabetic patients is associated with significant cost savings
within 1–2 years of improvement.
The start of exercise training may see numerous acute
and chronic health issues arise in individuals with T2D,
especially if they have been very inactive. Of primary
concern are exercise- related hypoglycaemia and hyper-
glycaemia.44 Increase in exercise might have also caused
changes in other risk factors like blood pressure and thus
caused a need for changes in medication and visits to the
physician. In our study, we did not observe any remarkable
increase in T2D- related SHC visits. Musculoskeletal injury
is the most common exercise- related complication.45 46
Unaccustomed exercise demands, especially during the
initial weeks of a physical conditioning regimen, often
result in muscle soreness, musculoskeletal injury and
attrition.47 48 In this study, a decrease was observed in
MSD- related physician appointments in PHC and no
change in SHC. It can be concluded that there was no
increase in musculoskeletal injuries or other severe prob-
lems in the intervention group with the started exercise.
Instead, the intervention participants benefited from the
intervention in terms of their musculoskeletal health and
had fewer physician appointments. A small increase in
nurse appointments in SHC might be due to less severe
acute symptoms related to the start of the exercise.
The study was conducted in a ‘real- world’ setting,
and the results can be generalised to normal operation
of healthcare. This can be considered as one of the
strengths of this study. In the absence of a traditional study
design, the study participation did not influence patient
behaviour. All data needed for the study were collected
from EHRs. The absence of the traditional study design
and data extraction retrospectively from the existing
EHRs resulted in the measurement data remaining partly
incomplete. The measurement and laboratory data are
based on the actual activities of the healthcare and thus
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8MartiskainenT, etal. BMJ Public Health 2023;1:e000098. doi:10.1136/bmjph-2023-000098
BMJ Public Health
the data are missing for patients who did not visit in
healthcare or regular laboratory check- ups. The infor-
mation on appointments in the health services was also
achieved from the EHRs, giving reliable and objective
information on contacts. However, the number of phys-
iotherapist visits is most likely underestimated as they less
often record ICD- 10 or ICPC- 2 codes for the appoint-
ments compared with physicians and nurses for whom it
is mandatory. In addition, the registry does not, however,
include information from private service providers and
thus might somewhat underestimate the number of visits.
However, it is unlikely that the share of use of public and
private services would have changed during the follow- up
period of this study.
CONCLUSIONS
It can be concluded that PA counselling reduced the
number of physicians’ and nurses’ appointments in SHC
and PHC and thus the costs of treatment. This study
shows that PA counselling provided with reasonably low
cost in PHC offers significant benefits in the treatment of
patients with T2D and improves the use of resources in
healthcare.
Author afliations
1Joint municipal authority for North Karelia social and health services (Siun sote),
Joensuu, Finland
2Institute of Public Health and Clinical Nutrition, University of Eastern Finland,
Joensuu, Finland
3Department of Health and Social Management, University of Eastern Finland -
Kuopio Campus, Kuopio, Finland
4Institute of Healthcare Engineering, Management and Architecture, Aalto
University, Helsinki, Finland
5Institute of Biomedicine/Sports and Exercise Medicine, University of Eastern
Finland, Kuopio, Finland
6Department of Public Health and Social Welfare, Finnish Institute for Health and
Welfare, Helsinki, Finland
Contributors TMM and TL planned the study design. TMM and TL were
responsible for acquisition of data. M- LL compiled the data for analyses. M- LL
and TMM carried out the statistical analyses. ML provided the cost data and
estimates for the contacts in health services and expertise in related analyses
and interpretation of results. TMM, TL, M- LL, ML, MV and HT participated in the
interpretation of the data, and TMM drafted the manuscript. All authors contributed
to the critical revision of the work and approved the nal version of the manuscript.
TMM is responsible for the overall content as guarantor.
Funding This study was partly funded by the Research Committee of the Kuopio
University Hospital Catchment Area for the State Research Funding (project QCARE,
Joensuu, Finland), the Strategic Research Council at the Academy of Finland
(project IMPRO, 312703, 336325, 336329) and the Effective Life- style Counselling
for Social and Health Care Cross- Functionally (VESOTE) project.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Ethics approval This study involves human participants and the study was carried
out totally as a register- based evaluation study, which, in accordance, with Finnish
legislation (Act on secondary use of social and health data 26.4.2019/552; https://
www.nlex.//laki/ajantasa/2019/20190552), does not require ethics approval nor
informed consent from the patients. Permission to use register data was achieved
from the Joint Municipal Authority for North Karelia social and health services (Siun
sote) (permission number: 930/13.00.01.01/2017).The study was carried out totally
as a register- based evaluation study, which, in accordance, with Finnish legislation
(Act on secondary use of social and health data 26.4.2019/552; https://www.nlex.
//laki/ajantasa/2019/20190552), does not require ethics approval nor informed
consent from the patients. Data management and analyses have been carried out in
accordance with relevant guidelines and regulations in Finland.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available. The health records data
analysed in the current study are condential and according to the Personal Data
Act in Finland cannot be made publicly available to protect the privacy of the
patients.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer- reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
TuulaMartiskainen http://orcid.org/0000-0002-5508-5545
REFERENCES
1 WHO. Global status report on noncommunicable diseases 2010,
. 2011Available: https://apps.who.int/iris/bitstream/handle/10665/
44579/9789240686458_eng.pdf?sequence=1&isAllowed=y
[Accessed 8 Mar 2023].
2 Colberg SR, Sigal RJ, Fernhall B, etal. Exercise and type 2 diabetes:
the American college of sports medicine and the American diabetes
association: joint position statement. Diabetes Care 2010;33:2692–6.
3 Ogurtsova K, da Rocha Fernandes JD, Huang Y, etal. IDF diabetes
atlas: global estimates for the prevalence of diabetes for 2015 and
2040. Diabetes Res Clin Pract 2017;128:40–50.
4 Lopez Stewart G, Tambascia M, Rosas Guzmán J, etal. Control
of type 2 diabetes mellitus among general practitioners in private
practice in nine countries of Latin America. Rev Panam Salud
Publica 2007;22:12–20.
5 Franz MJ, MacLeod J. Success of nutrition- therapy interventions
in persons with type 2 diabetes: challenges and future directions.
Diabetes Metab Syndr Obes 2018;11:265–70.
6 Gregg EW, Chen H, Wagenknecht LE, etal. Association of an
intensive lifestyle intervention with remission of type 2 diabetes.
JAMA 2012;308:2489–96.
7 Colberg SR, Sigal RJ, Yardley JE, etal. Physical activity/exercise and
diabetes: a position statement of the American diabetes Association.
Diabetes Care 2016;39:2065–79.
8 Di Loreto C, Fanelli C, Lucidi P, etal. Validation of a counseling
strategy to promote the adoption and the maintenance of physical
activity by type 2 diabetic subjects. Diabetes Care 2003;26:404–8.
9 World Health Organization. Action Plan for Implementation
of the European Strategy for the Prevention and Control of
Noncommunicable Diseases 2012–2016. Geneva: WHO, 2012.
10 Rubio- Valera M, Pons- Vigués M, Martínez- Andrés M, etal. Barriers
and Facilitators for the implementation of primary prevention and
health promotion activities in primary care: a synthesis through
meta- ethnography. PLoS One 2014;9:e89554.
11 World Health Organization. Primary health care, now more than ever.
In: The Worlds Health Report. Geneva: WHO, 2008.
12 Garrett S, Elley CR, Rose SB, etal. Are physical activity interventions
in primary care and the community cost- effective? A systematic
review of the evidence. Br J Gen Pract 2011;61:e125–33.
13 Dawes D, Ashe M, Campbell K, etal. Preventing diabetes in
primary care: a feasibility cluster randomized trial. Can J Diabetes
2015;39:111–6.
14 Dunbar JA, Hernan AL, Janus ED, etal. Challenges of diabetes
prevention in the real world: results and lessons from the Melbourne
diabetes prevention study. BMJ Open Diabetes Res Care
2015;3:e000131.
1602. Protected by copyright. on October 25, 2023 at University Hospital Medical Libraryhttp://bmjpublichealth.bmj.com/bmjph: first published as 10.1136/bmjph-2023-000098 on 24 October 2023. Downloaded from
MartiskainenT, etal. BMJ Public Health 2023;1:e000098. doi:10.1136/bmjph-2023-000098 9
BMJ Public Health
15 Sabale U, Bodegård J, Sundström J, etal. Healthcare utilization
and costs following newly diagnosed Type- 2 diabetes in Sweden: a
follow- up of 38,956 patients in a clinical practice setting. Prim Care
Diabetes 2015;9:330–7.
16 Wikström K, Lamidi M- L, Rautiainen P, etal. The effect of the integration
of health services on health care usage among patients with type 2
diabetes in North Karelia, Finland. BMC Health Serv Res 2021;21:65.
17 Hodgson S, Morgan- Harrisskitt J, Hounkpatin H, etal. Primary care
service utilisation and outcomes in type 2 diabetes: a longitudinal
cohort analysis. BMJ Open 2022;12:e054654.
18 Kauppila T, Eriksson JG, Honkasalo M, etal. Relationship between
number of contacts between previous dropouts with type 2 diabetes
and health care professionals on glycaemic control: a cohort study in
public primary health care. Prim Care Diabetes 2019;13:468–73.
19 Kaplan RM, Gold M, Duffy SQ, etal. Economic analysis in behavioral
health: toward application of standardized methodologies. Health
Psychol 2019;38:672–9.
20 Wilson DK, Lorig K, Klein WMP, etal. Efcacy and cost- effectiveness
of behavioral interventions in nonclinical settings for improving
health outcomes. Health Psychol 2019;38:689–700.
21 Roux L, Pratt M, Tengs TO, etal. Cost effectiveness of
community- based physical activity interventions. Am J Prev Med
2008;35:578–88.
22 Martiskainen TM, Lamidi M- L, Venojärvi M, etal. Effectiveness of
physical activity counselling provided for people with type 2 diabetes
mellitus in primary healthcare in North Karelia, Finland: a register-
based evaluation study. BMJ Open 2022;12:e058546.
23 Cawley J, Meyerhoefer C, Biener A, etal. Savings in medical
expenditures associated with reductions in body mass index among
US adults with obesity, by diabetes status. Pharmacoeconomics
2015;33:707–22.
24 Wagner EH, Sandhu N, Newton KM, etal. Effect of improved glycemic
control on health care costs and utilization. JAMA 2001;285:182–9.
25 Porter ME. What is value in health care N Engl J Med
2010;363:2477–81.
26 Martiskainen T, Lamidi M- L, Venojärvi M, etal. Factors affecting
the effectiveness of the physical activity counselling intervention
implemented in primary health care in adults with type 2 diabetes.
BMC Endocr Disord 2023;23:166.
27 Mäklin S, Kokko P, THL Helsinki. Working paper 21/2020; 2021. Unit
costs of health and social care in Finland in 2017,
28 R Core Team. R. Vienna, Austria; R: A language and environment
for statistical computing. R foundation for statistical computing, .
2020Available: https://www.R-project.org [Accessed 5 Aug 2022].
29 Liebl A, Khunti K, Orozco- Beltran D, etal. Health economic
evaluation of type 2 diabetes mellitus: a clinical practice focused
review. Clin Med Insights Endocrinol Diabetes 2015;8:13–9.
30 Johansen MY, MacDonald CS, Hansen KB, etal. Effect of an
intensive lifestyle intervention on glycemic control in patients with
type 2 diabetes: A RCT. JAMA 2017;318:637–46.
31 Sjöström M, Oja P, Hagströmer M, etal. Health- enhancing physical
activity across European Union countries: the eurobarometer study.
J Public Health 2006;14:291–300.
32 Rhee MK, Slocum W, Ziemer DC, etal. Patient adherence improves
glycemic control. Diabetes Educ 2005;31:240–50.
33 Fenton JJ, Von Korff M, Lin EHB, etal. Quality of preventive care for
diabetes: effects of visit frequency and competing demands. Ann
Fam Med 2006;4:32–9.
34 Al OM. Diabetes care and control: the effect of frequent visits to
diabetes care center. Ann Saudi Med 2014;34:229–34.
35 Piette JD, Weinberger M, Kraemer FB, etal. Impact of automated
calls with nurse follow- up on diabetes treatment outcomes in a
department of veterans affairs health care system: a randomized
controlled trial. Diabetes Care 2001;24:202–8.
36 Inzucchi SE, Bergenstal RM, Buse JB, etal. Management of
Hyperglycaemia in type 2 diabetes, 2015: a patient- centred
approach. update to a position statement of the American diabetes
association and the European association for the study of diabetes.
Diabetologia 2015;58:429–42.
37 American diabetes association professional practice committee.
Glycemic targets: standards of medical care in diabetes—2022.
Diabetes Care 2022;45:S83–96.
38 Berecki- Gisolf J, Collie A, McClure RJ. Determinants of physical
therapy use by compensated workers with musculoskeletal
disorders. J Occup Rehabil 2013;23:63–73.
39 Nuckols TK, Keeler E, Anderson LJ, etal. Economic evaluation of
quality improvement interventions designed to improve glycemic
control in diabetes: a systematic review and weighted regression
analysis. Diabetes Care 2018;41:985–93.
40 Li R, Zhang P, Barker LE, etal. Cost- effectiveness of interventions to
prevent and control diabetes mellitus: a systematic review. Diabetes
Care 2010;33:1872–94.
41 Sidorov J, Shull R, Tomcavage J, etal. Does diabetes disease
management save money and improve outcomes? A report
of simultaneous short- term Savings and quality improvement
associated with a health maintenance organization- sponsored
disease management program among patients fulfilling health
employer data and information set criteria. Diabetes Care
2002;25:684–9.
42 Huckfeldt PJ, Frenier C, Pajewski NM, etal. Associations of
intensive lifestyle intervention in type 2 diabetes with health care
use, spending, and disability: an ancillary study of the look AHEAD
study. JAMA Netw Open 2020;3:e2025488.
43 Espeland MA, Glick HA, Bertoni A, etal. Impact of an intensive
lifestyle intervention on use and cost of medical services among
overweight and obese adults with type 2 diabetes: the action for
health in diabetes. Diabetes Care 2014;37:2548–56.
44 Kanaley JA, Colberg SR, Corcoran MH, etal. Exercise/physical
activity in individuals with type 2 diabetes: a consensus statement
from the American college of sports medicine. Med Sci Sports Exerc
2022;54:353–68.
45 Hootman JM, Macera CA, Ainsworth BE, etal. Association
among physical activity level, cardiorespiratory fitness,
and risk of musculoskeletal injury. Am J Epidemiol
2001;154:251–8.
46 Hootman JM, Macera CA, Ainsworth BE, etal. Epidemiology of
musculoskeletal injuries among sedentary and physically active
adults. Med Sci Sports Exerc 2002;34:838–44.
47 Pollock ML, Gaesser GA, Butcher JD, etal. Position stand: the
recommended quantity and quality of exercise for developing
and maintaining cardiorespiratory and muscular tness, and
exibility in healthy adults. Medicine & Science in Sports & Exercise
1998;30:975–91.
48 Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness:
treatment strategies and performance factors. Sports Med
2003;33:145–64.
1602. Protected by copyright. on October 25, 2023 at University Hospital Medical Libraryhttp://bmjpublichealth.bmj.com/bmjph: first published as 10.1136/bmjph-2023-000098 on 24 October 2023. Downloaded from
