HEALTH ECONOMIC ASSESSMENT TOOL FOR WALKING & CYCLING. Luc Int Panis, Michelle Laeremans, Evi Dons & Jurgen Buekers
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1 HEALTH ECONOMIC ASSESSMENT TOOL FOR WALKING & CYCLING Luc Int Panis, Michelle Laeremans, Evi Dons & Jurgen Buekers VITO Not for distribution 28/02/2018 CYCLE HIGHWAY ACADEMY Essen 1
2 PASTA Physcial Activity Through Sustainable Transport Approaches European project, FP7, 7 cities Objectives: - Promotion & evaluation of active mobility - Reduce health impact of sedentary behaviour - Integration of physical activity in daily routine - Update WHO HEAT tool Longitudinal study: online survey on (active) mobility, PM, accidents etc. Experiments & Top Measure analysis INTRO 2
3
4 AGENDA Inactivity: a global health hazard Health Economic Assessment for walking & cycling Why? What do we need? Relative risks & dose-response functions Monetary values for health Case studies & available models - The Health Economic Assessment Tool (HEAT) for walking & cycling - Flemish model (CWIcalc) Summary & conclusions
5 PHYSICAL INACTIVITY: A GLOBAL HEALTH HAZARD
6 PHYSICAL INACTIVITY: A GLOBAL HEALTH HAZARD 4 th most important cause of premature mortality Active mobility More physical activity (better health) Increases exposure to air pollution Increases accident risk
7 PHYSICAL INACTIVITY: A GLOBAL HEALTH HAZARD Physical inactivity: a risk factor comparable to smoking Source: The Lancet, 2012,
8 Impacts on health in Flanders PHYSICAL INACTIVITY: A GLOBAL HEALTH HAZARD Risk DALYs (avg/year) Healthy life years lost (per capita) Smoking Obesity Air pollution (PM) Physical inactivity Hypertension Traffic accidents* High holesterol Alcohol Passive smoking Tuberculosis <1000 <0.01 Hepatitis B <1000 <0.01
9 PHYSICAL INACTIVITY: A GLOBAL HEALTH HAZARD Health expenditures, high & rising (but not for prevention) Source: De maatschappelijke betekenis van de gezondheidszorg; Karel Van den Bosch, Peter Willemé; januari 2014
10 THE HEALTH ECONOMIC ASSESSMENT TOOL FOR WALKING & CYCLING (HEAT)
11 HEALTH ECONOMIC ASSESSMENT TOOL (HEAT) FOR WALKING & CYCLING: A COLLABORATIVE PROJECT Harry Rutter, Francesca Racioppi, Sonja Kahlmeier, Nick Cavill, Pekka Oja, Heini Sommer, Hywell Dinsdale, Charlie Foster, Paul Kelly, Thomas Götschi, Christian Schweizer Karim Abu-Omar, Lars Bo Andersen, Finn Berggren, Tegan Boehmer, Nils-Axel Braathen, Dushy Clarke, Andy Cope, Audrey de Nazelle, Mark Fenton, Jonas Finger, Richard Fordham, Eszter Füzeki, Frank George, Regine Gerike, Mark Hamer, Max Herry, Marie-Eve Heroux, Michal Krzyzanowski, I-Min Lee, Christoph Lieb, Brian Martin, Markus Maybach, Christoph Schreyer, Marie Murphy, Nanette Mutrie, Luc Int Panis, Laura Perez, Gabe Rousseau, David Rojas Rueda, Candace Rutt, Tom Schmid, Elin Sandberg, Mulugeta Yilma, Daniel Sauter, Peter Schantz, Peter Schnohr, Dave Stone, Jan Sørensen, Gregor Starc, James Woodcock, Wanda Wendel Vos, Paul Wilkinson
12 HEAT FOR WALKING & CYCLING: WHY & HOW? Need for integration between different policy domains (transport, urban planning, health, etc.) HEAT: User friendly tool to estimate economic value of health benefits of cycling & walking Answer the question: Inputs: Data on volume of walking or cycling How many people? Which people? How far/often? For a given volume of walking or cycling what is the economic value of the health benefits? HEAT 12
13 Input required
14 HEAT FOR WALKING & CYCLING: RELATIVE RISKS & DOSE-RESPONSE 1 st HEAT for cycling version: based on Copenhagen only: Dose: 3h cycling; 36 weeks/year Response: RR all-cause mortality = 0.72 Corrected for leisure time PA Lots of criticisms But nevertheless very conservative 2nd HEAT version : Meta-analysis (7 studies): Dose: MET.hours/week or 100 minutes cycling/week; 52 weeks/year (cycling = 6.8 METs) Response: RR all-cause mortality = 0.90 Corrected for leisure time PA Even more conservative Maximum protective benefit (cycling = 45%) New HEAT version 2018 (Beta version currently being tested, Manual also in German & French)
15 HEAT FOR WALKING & CYCLING: RELATIEVE RISICO S & DOSIS-RESPONS RELATIE HEAT 15
16 HEAT FOR WALKING & CYCLING: MONETARY VALUATION OF HEALTH BENEFITS Value of a Statistical Life (VSL) willingness to pay to reduce mortality risk e.g. from 3/10000 to 2/10000? Different for each country WHO European region average België Hongarije EUR EUR EUR Should be discounted
17 HEAT FOR WALKING & CYCLING:WHAT IS/WAS MISSING? Interaction between transport related PA & air pollution Accidents/crashes Morbidity Climate Noise Social HEAT 17
18 HIGH AIRPOLLUTION CONCENTRATION ON CYCLE LANES Near park (Louisa Square, KDG avenue) Busy street canyon rue de la Loi Quiet street (rue Jozef II)
19 ACCIDENTS/CRASHES 19
20 HEAT FOR WALKING & CYCLING: WHAT IS/WAS MISSING? 20
21
22 HEAT FOR WALKING & CYCLING: WHAT IS/WAS MISSING? De Hartog et al What if: people switch from car to bike for daily short trips? More air pollution exposure: days lost Accidents: 5-9 days lost Increased physical activity: 3-14 months gained Benefits even larger if social benefits are included No morbidity impacts included in most studies or models (increases complexity & uncertainty)
23 HEAT FOR WALKING & CYCLING: AIR POLLUTION IS HARD TO EXTRAPOLATE Source: Presentation of Aphekom findings at the Policy Workshop: EU Year of Air how can we reduce air pollution to improve health? 13 September 2012, Brussels, Belgium,
24 AIR POLLUTION IS USUALLY NOT A PROBLEM IN EUROPE Woodcock, Tainio et al m/sites/urbancycling/
25 HEAT FOR WALKING & CYCLING: CONCRETE What? Planning of new projects (infrastructure or other) Monetise health benefits of estimated use Evaluation of finished projects Monetise health benefits of observed change in use As part of general economic evaluation of transportation projects (e.g. relative to cost of investment, ROI, )
26 CASE STUDIES
27 HEAT FOR WALKING & CYCLING: CASE STUDY Example 1: Cycling bridge over ring road in Antwerp Connects Bicycle highway F1 (Antwerpen-Mechelen) with Berchem train station and city center. Expectations: New cyclists Safer Faster (traffic lights)
28 HEAT FOR WALKING & CYCLING: CASE STUDY 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 Duration Distance Trips Q4: Pre-intervention cycling data Average distance cycled/day: 28 km Number of days per year: 200 Q7: How many people benefit? Number of cyclists: 2365 High level of cycling 5600 km/person/year Protective benefit: 45%
29 HEAT FOR WALKING & CYCLING: CASE STUDY Q2: Enter your post-intervention cycling data Duration Distance Trips Q4: Post-intervention cycling data Average distance cycled/day: 28 km Number of days per year: 200 Q7: How many people benefit Number of cyclists: 2601 High level of cycling 5600 km/person/year Protective benefit: 45%
30 HEAT FOR WALKING & CYCLING: CASE STUDY Q9: How much of the change is attributed to the intervention Proportion: 100% Q10: Time needed to reach full level of cycling Years: 1 year Q11: mortality rate Age Average population (20-64 years old) Younger average population (20-44 years old) Older average population (45-64 years old) Country mortality data: Belgium (524 deaths/ persons/year)
31 HEAT FOR WALKING & CYCLING: CASE STUDY Q9: How much of the change is attributed to the intervention Proportion: 100% Q10: Time needed to reach full level of cycling Years: 1 year Q11: mortality rate Age Average population (20-64 years old) Younger average population (20-44 years old) Older average population (45-64 years old) Country mortality data: Belgium (524 deaths/ persons/year)
32 HEAT FOR WALKING & CYCLING: CASE STUDY Q12: Value of a statistical life? Belgium ( Euro) Q13: Time period over which benefits are calculated? Years: 10 years Q14: Costs to include a benefit-cost ratio in the HEAT calculation? Yes No Q15: Cost associated with promoting cycling? Total costs: Euro Duration to calculate benefit-cost ratio: 10 years (standard this is equal to Q13) Q16: Discount rate to apply to future benefits: 5%
33 HEAT FOR WALKING & CYCLING: CASE STUDY
34 HEAT FOR WALKING & CYCLING: CASE STUDY
35 HEAT FOR WALKING & CYCLING: CASE STUDY
36 HEAT FOR WALKING & CYCLING: CASE STUDY Example 2: Estimate the value of the present level of walking on an existing trail in Belgium. 100 elderly people walk 3 km every day What is the value of that level of physical activity over 10 years?
37 HEAT FOR WALKING & CYCLING: CASE STUDY
38 HEAT FOR WALKING & CYCLING: CASE STUDY
39 HEAT FOR WALKING & CYCLING: CASE STUDY
40 HEAT FOR WALKING & CYCLING: CASE STUDY
41 HEAT FOR WALKING & CYCLING: CASE STUDY
42 HEAT FOR WALKING & CYCLING: CASE STUDY
43 HEAT FOR WALKING & CYCLING: CASE STUDY
44 HEAT FOR WALKING & CYCLING: CASE STUDY More than for cyclist example because 74y is upper limit
45 HEAT FOR WALKING & CYCLING: CASE STUDY
46 HEAT FOR WALKING & CYCLING: CASE STUDY
47 HEAT FOR WALKING & CYCLING: CASE STUDY
48 HEAT FOR WALKING & CYCLING: CASE STUDY
49 HEAT FOR WALKING & CYCLING: CASE STUDY
50 SUMMARY & CONCLUSION
51 HEAT FOR WALKING & CYCLING: CONCLUSION Input How many people walk/cycle? Time, distance or #trips Cost of Intervention infrastructure or promotion campaign Defaults mortality rate VSL Time frame Discount rate
52 HEAT FOR WALKING & CYCLING: CONCLUSION Output Protective benefit Average benefit per year (key output) Over longer period (default = 10 years) Discounted benefit per year (Cost-Benefit ratio) Tool designed for transport planners Evidence-based Transparent Simple to use Order of magnitude only 52
53 HEAT FOR WALKING & CYCLING: CONCLUSIE HEAT 53
54 CWICALC: A DEDICATED MODEL FOR FLANDERS Accidents & health Air pollution & health Physical activity & health Investment 54
55 Accidents Bicycle/Walk data Air pollution & health Physical activity & health MODEL Investment Indicator = 55
56 HEAT compared to CWICalc - Estimate benefits of regular cycling/walking - Estimate external benefits - Compare with investment (e.g. building bicycle highway) - New update: including air pollution, accidents, climate (but not morbidity) - Order of magnitude - VSL (country specific) - Estimate benefits of regular cycling/walking - DALY s & external benefits/costs - Impact of increase in cycling accidents - Impacts of air pollution: PM2.5 - Compare with investment (e.g. bicycle highway) - YOLL & Cost of Illness & WTP (Willingness To Pay) - VOLY (Flanders) - Order of magnitude + Mortality & Morbidity: ischaemic HD, cancer (bowel, breast) diabetes type II, depression, dementia (>70j) + Option: congestion, CO 2, noise 56
57 Model specifics - Adults - Shift car => cycling / walking - Establishing health benefits takes years - Health benefit is capped - VOLY: euro (some use up to euro; euro = conservative). => CWICalc is very conservative! - Specifieke values for Flanders (Belgium). Treatment costs depend on national organisation of health care system - Air pollution : PM2.5 only (WHO preferred indicator) 57
58 Counting cyclists on Bicycle highways 58
59 CWICalc application: fietsostrades / fietssnelwegen Why Flanders? lots of data on cycling (counts) high air pollution data on accidents - Scenario 1: - F1 Mechelen-Antwerpen cyclists - 27 km/day - 4 days per week - 20 year evaluation period - Building Cost: Euro 59
60 60
61 CWICALC MODEL Accidents Data on cycling/walking PM2.5 Physical activity MODEL Investment Indicators 61
62 Results (DALY) Crash risk over estimated or under estimated? 62
63 Results (costs in ) 63
64 Costs of cycling accidents weight Avg. cost ( ) CI_low ( ) CI_high ( ) NO_I 22.4% LIGHT_I 47.5% ABI_ST 25.7% ABI_LT 4.4% minor accident 100% Risk of minor accident is 155 per million kilometers cycled (link) (one accident every 6500 km) Risk of injury is 121 per million kilometers cycled (one injury each 8300 km) Average cost of minor accident is 841 euro (vs for major non-fatal accident) (0.125 euro/ km) Total cost of minor accidents in Belgium is million /year Cycling highways expected to lower both the risk and the cost
65 Results (costs/benefits) 65
66 Results: (costs/benefits) Most scenarios positive. 66
67 RESULTS IN THE NEWSPAPERS 67
68 OTHER SCENARIOS 68
69 CONCLUSION Research shows that cycling is healthier than not cycling (If it increases the physical acitivity of sedentary people) Air pollution Exposure peaks can be very high Physiological changes are evident Scientifically challenging May lead to clinical effects in the long term Policy should reduce exposure (e.g. bicycle highways) Accidents Risk of minor accident in general traffic is much higher than is higher than expected (even among experienced cyclists) Costs are high => Policy should eliminate conflicts, risks, consequences (e.g. bicycle highway design) Cost efficient policies/infrastructure is possible Benefits almost always (much) higher than cost
70 More info oldheatwalkingcycling.org Buekers J, Dons E, Elen E, Int Panis L. Health impact model for modal shift from car use to cycling or walking in Flanders: application to two bicycle highways. Journal of Transport and Health, 2, , Aertsens J et al Commuting by bike in Belgium, the costs of minor accidents. Accident; analysis and prevention 42(6):
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