Candace Rutt, Ph.D.Candace Rutt, Ph.D.

Quantification of Quantification of Health Benefits Health Benefits for Cycling and for Cycling and Walking: The Walking: The Health Economic Health Economic Assessment ToolAssessment Tool

Often Urban Environments Often Urban Environments Favor Motorized Favor Motorized

Transportation…..Transportation…..

…….and Hinder Walking and .and Hinder Walking and CyclingCycling

However, there are Places that However, there are Places that are Conducive to Active are Conducive to Active

TransportationTransportation

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 Chronic Disease and Disease and Risk FactorsRisk Factors

7 out of 10 deaths in the U.S. 7 out of 10 deaths in the U.S. are from chronic diseases such are from chronic diseases such as heart disease, cancer and as heart disease, cancer and stroke stroke

These chronic diseases are These chronic diseases are primarily related to four risk primarily related to four risk behaviorsbehaviors- lack of physical activitylack of physical activity- poor nutritionpoor nutrition- tobacco usetobacco use- excessive alcohol excessive alcohol

consumptionconsumptionSource: http://www.cdc.gov/chronicdisease/overview/index.htm

Behaviors & Environment

70%

Medical Care, 10%

Genetics20%

Prevention, 4%

Medical Services

96%

$2.2 TrillionCurrent Health Care SpendingCurrent Health Care Spending

Factors InfluencingHealth

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”...Get more exercise”...

Source: Wernham, A. Health Impact Project. http://www.healthimpactproject.org/resources#presentations_webinars

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, 2011.

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 CO2 More livable

communities

Why Walking and Cycling?

Why Guidance on Economic Why Guidance on Economic Assessment?Assessment?

Economic evaluation is Economic evaluation is a standard tool of a standard tool of transport planners so it transport planners so it can help the health can help the health sector to speak “their” sector to speak “their” language language

Public health benefits Public health benefits are likely to be great, are likely to be great, esp. if inactive persons esp. if inactive persons can be reachedcan be reached

Need for a transparent Need for a transparent robust methodologyrobust methodology

HEATHEAT

Developed by the WHO with Developed by the WHO with international expertsinternational experts

Economic tool to estimate reductions Economic tool to estimate reductions in mortality due to cycling in mortality due to cycling (transportation) and walking (transportation) and walking (recreaction and transportation)(recreaction and transportation)

Very conservative and does not Very conservative and does not include morbidityinclude morbidity

Currently for adults onlyCurrently for adults only

HEATHEAT

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

HEATHEAT

Data imputs for the model:Data imputs for the model:– Average amount of time spent Average amount of time spent

walking or cyclingwalking or cycling Number of people walking and cycling Number of people walking and cycling

and average distance of tripsand average distance of trips

HEATHEAT

How to get How to get the need the need inputsinputs– Route user Route user

surveyssurveys– Travel surveysTravel surveys– Destination Destination

based surveysbased surveys– Traffic countsTraffic counts– PedometersPedometers

Copenhagen Study – Effect Copenhagen Study – Effect Estimate for Transport CyclingEstimate for Transport Cycling

6,954 regular cycle commuters6,954 regular cycle commuters N = 30,640N = 30,640 Followed for 14.5 yearsFollowed for 14.5 years Mean journey time of 3 hours Mean journey time of 3 hours

per weekper week RR = 0.72 (0.57-0.91)RR = 0.72 (0.57-0.91) Adjusted for age, sex, Adjusted for age, sex,

educational status, leisure time educational status, leisure time physical activity, body mass physical activity, body mass index, blood lipid levels, index, blood lipid levels, smoking and blood pressuresmoking and blood pressure

Effect Estimate for Effect Estimate for WalkingWalking

9 studies were found that accounted 9 studies were found that accounted for OTHER types of leisure-time PAfor OTHER types of leisure-time PA

A meta-analysis weighted by sample A meta-analysis weighted by sample size found a RR of .78 (.64 - .98) for size found a RR of .78 (.64 - .98) for walking 29 minutes a day 7 days a walking 29 minutes a day 7 days a weekweek

Model is still being modifiedModel is still being modified

HEATHEAT

Outputs of the modelOutputs of the model– Number of lives savedNumber of lives saved– Annual benefit in SVL which is $5.8 Annual benefit in SVL which is $5.8

million per person in the U.Smillion per person in the U.S. .

Uses in Other CountriesUses in Other Countries

Austria: Austria: USD: $570 million per year USD: $570 million per year

Pilsen, Czech Republic: $Pilsen, Czech Republic: $1.2 million if 2% 1.2 million if 2% of population took up regular cyclingof population took up regular cycling

UK/Scotland: $UK/Scotland: $1.5-3 billion per year if 1.5-3 billion per year if modal share goal of 13% reached modal share goal of 13% reached

New Zealand: New Zealand: adding cycling and adding cycling and pedestrian facilities to the Auckland pedestrian facilities to the Auckland Harbour Bridge for a savings of $Harbour Bridge for a savings of $900,000 900,000 per 1000 regular bike commutersper 1000 regular bike commuters

Challenges to Adapting to Challenges to Adapting to U.S.U.S.

US Is much larger and US Is much larger and heterogeneousheterogeneous

Travel data only Travel data only collected nationally collected nationally every 5 yearsevery 5 years

Very few local Very few local regions collect regions collect transport related transport related datadata

Hard to find good Hard to find good data on bike lanes data on bike lanes and sidewalksand sidewalks

U.S. UsesU.S. Uses

Paper by Götschi (2012) examined cycling in Paper by Götschi (2012) examined cycling in PortlandPortland– By 2040, investments in the range of $138 to $605 million By 2040, investments in the range of $138 to $605 million

will result in health care cost savings of $388 to $594 will result in health care cost savings of $388 to $594 million, fuel savings of $143to $218 million, and savings in million, fuel savings of $143to $218 million, and savings in value of statistical lives of $7 to $12 billion. value of statistical lives of $7 to $12 billion.

– The cost-benefit ratios for healthcare and fuel savings are The cost-benefit ratios for healthcare and fuel savings are between 3.8 and 1.2 to 1between 3.8 and 1.2 to 1

Nonmotorized Transportation Nonmotorized Transportation Pilot ProjectPilot Project

FHWA allocated $100 million dollars to 4 pilot FHWA allocated $100 million dollars to 4 pilot communitiescommunities– Marin County, CA– Minneapolis, MN– Columbia, MO– Sheboygan County, WI The communities were selected by congress The communities were selected by congress

with input from bike and pedestrain with input from bike and pedestrain advocates as well as communnity leaders. advocates as well as communnity leaders.

Several factors were used to pick the Several factors were used to pick the communities including demographics, level of communities including demographics, level of readiness and level of urbanization.readiness and level of urbanization.

Nonmotorized Nonmotorized Transportation Pilot ProjectTransportation 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 Increases in Walking and CyclingCycling

85.1 million Vehicle Miles Traveled 85.1 million Vehicle Miles Traveled were averted.were averted.

Walking mode share increased Walking mode share increased 15.8% and cycling mode share 15.8% and cycling mode share increased 44%.increased 44%.

At individual project sites trip At individual project sites trip counts increased 56% for pedestrian counts increased 56% for pedestrian trips and 115% for cycling trips.trips and 115% for cycling trips.

¼ mile network cycling access was ¼ mile network cycling access was expanded to 240,00 people, 160,00 expanded to 240,00 people, 160,00 housing units and 102,000 jobs. housing units and 102,000 jobs.

Over 70% of projects connected to Over 70% of projects connected to activity centersactivity centers..

Economic SavingsEconomic 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.

DiscussionDiscussion

Criticism of HEAT- cycling is that it uses a Criticism of HEAT- cycling is that it uses a RR from CopenhagenRR from Copenhagen

However, similar RR were also found in However, similar RR were also found in ShanghaiShanghai

DiscussionDiscussion

Other outputs could be used:Other outputs could be used:– QALYQALY– DALYDALY– Morbidity by disease (cost of Morbidity by disease (cost of

illness)illness)

Next StepsNext Steps

Adding morbidity into Adding morbidity into both modelsboth models

Modifying input and Modifying input and output parametersoutput parameters

Inform and train Inform and train potential userspotential users

Examine injury and Examine injury and exposure to air exposure to air pollution pollution

Develop a model for Develop a model for childrenchildren

WHO Guidance and ToolWHO Guidance and Tool

Download the guidance document and user guide from www.euro.who.int/transport/policy/20070503_1

HEAT Tool - MinneapolisHEAT Tool - Minneapolis

Q1: Your data: amount of cycling from a single point in Q1: Your data: amount of cycling from a single point in time, or before and after an interventiontime, or before and after an intervention– Single point in timeSingle point in time– Before and afterBefore and after

Q2: Enter your pre-intervention cycling dataQ2: Enter your pre-intervention cycling data– Duration Duration – Distance Distance – Trips Trips

Q6.1: Trips: average number of trips per person, or total Q6.1: Trips: average number of trips per person, or total number of trips?: number of trips?: – Average per adultAverage per adult– Total number of trips observedTotal number of trips observed

HEAT Tool- MinneapolisHEAT Tool- Minneapolis Q6.3: Total number of tripsQ6.3: Total number of trips

– Enter the number of trips observed per day:Enter the number of trips observed per day:– 11,241 trips11,241 trips– What proportion of these trips are cycling trips?What proportion of these trips are cycling trips?– 100% percent100% percent

Q6.4: Do you know the number of people who take Q6.4: Do you know the number of people who take cycling trips, or do you wish to estimate the number cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return of cyclists based on the proportion of return journeys out of all trips observed?journeys out of all trips observed?– Enter the number of individuals cyclingEnter the number of individuals cycling– Estimate this based on return journeysEstimate this based on return journeys

HEAT Tool - MinneapolisHEAT Tool - Minneapolis

Q6.5: How many individuals contributed to the Q6.5: How many individuals contributed to the cycling trips entered?cycling trips entered?– Study populationStudy population– 294,729294,729– How many days per year do people cycle?How many days per year do people cycle?– 365 days per year365 days per year– The default is 124 days per year but this was The default is 124 days per year but this was

based on modeling the VOLPE and DOT used to based on modeling the VOLPE and DOT used to calculate daily averagescalculate daily averages

Q6.7: Enter the average trip duration or distanceQ6.7: Enter the average trip duration or distance– DurationDuration– DistanceDistance

HEAT Tool - MinneapolisHEAT Tool - Minneapolis Q6.9: Average trip lengthQ6.9: Average trip length

– Average trip lengthAverage trip length– 2.26 miles2.26 miles– This is the national average of cycling trip length This is the national average of cycling trip length

NHTS dataNHTS data

Q7: How many people benefit?Q7: How many people benefit?– PersonsPersons– 294,729294,729– In some cases this figure will be the number of cyclers In some cases this figure will be the number of cyclers

in your study area, city or country or cycling data may in your study area, city or country or cycling data may be based on a representative sample of a larger be based on a representative sample of a larger population. In this case, you may wish to apply the population. In this case, you may wish to apply the findings to the whole population.findings to the whole population.

HEAT Tool - MinneapolisHEAT Tool - Minneapolis Q2: Enter your Q2: Enter your post-interventionpost-intervention cycling datacycling data

–   DurationDuration– Distance Distance – TripsTrips

Q6.1: Trips: average number of trips per person, or total number of Q6.1: Trips: average number of trips per person, or total number of trips?trips?– Average per adultAverage per adult– Total number of trips observedTotal number of trips observed

Q6.3: Total number of tripsQ6.3: Total number of trips– Enter the number of trips observed per day:Enter the number of trips observed per day:– 17,986 Trips17,986 Trips– What proportion of these trips are cycling trips?What proportion of these trips are cycling trips?– 100 percent100 percent

HEAT Tool - MinneapolisHEAT Tool - Minneapolis Q6.4: Do you know the number of people who take Q6.4: Do you know the number of people who take

cycling trips, or do you wish to estimate the number cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return of cyclists based on the proportion of return journeys out of all trips observed?journeys out of all trips observed?– Enter the number of individuals cyclingEnter the number of individuals cycling– Estimate this based on return journeysEstimate this based on return journeys

Q6.5: How many individuals contributed to the Q6.5: How many individuals contributed to the cycling trips entered?cycling trips entered?– Study populationStudy population– 326,085326,085– How many days per year do people cycle?How many days per year do people cycle?– 365 days per year365 days per year

HEAT Tool - MinneapolisHEAT Tool - Minneapolis Q6.7: Enter the average trip duration or distanceQ6.7: Enter the average trip duration or distance

– DurationDuration– DistanceDistance

Q6.9: Average trip lengthQ6.9: Average trip length– Average trip length:Average trip length:– 2.26 Miles2.26 Miles

Q7: How many people benefit?Q7: How many people benefit?– Number of cyclists:Number of cyclists:– 326,085 persons326,085 persons

HEAT Tool - MinneapolisHEAT Tool - Minneapolis Q9: Proportion of cycling data attributable to your Q9: Proportion of cycling data attributable to your

interventionintervention– Estimate the proportion of cycling which you would Estimate the proportion of cycling which you would

like to attribute to the intervention. like to attribute to the intervention. – It is prudent to assume that not all the cycling, or It is prudent to assume that not all the cycling, or

increase in cycling is due to the intervention.increase in cycling is due to the intervention.– Please enter a proportion between 0-100%Please enter a proportion between 0-100%– 60 percent60 percent

Q10: Time needed to reach full level of cyclingQ10: Time needed to reach full level of cycling– Please select the time period before maximum uptake Please select the time period before maximum uptake

is achieved:is achieved:– 5 years5 years– This is the default valueThis is the default value

HEAT Tool - MinneapolisHEAT Tool - Minneapolis Q11: Mortality rateQ11: Mortality rate

– It is recommended to use the local crude mortality It is recommended to use the local crude mortality rate for the population aged 20-64 years.rate for the population aged 20-64 years.

– HEAT is not appropriate for populations consisting HEAT is not appropriate for populations consisting mainly of children, very young adults, or older mainly of children, very young adults, or older people, people,

– 793.8 deaths per 100,000 population 793.8 deaths per 100,000 population

Q12: Value of statistical lifeQ12: Value of statistical life– The value of a statistical life is derived with a The value of a statistical life is derived with a

methodology called “willingness to pay” to avoid methodology called “willingness to pay” to avoid death in relation to the years this person can expect death in relation to the years this person can expect to live according to the statistical life expectancy. to live according to the statistical life expectancy.

– 5,800,000  dollars5,800,000  dollars

HEAT Tool - MinneapolisHEAT Tool - Minneapolis Q13: Time period over which benefits are calculatedQ13: Time period over which benefits are calculated

– Please select the time period over which you wish Please select the time period over which you wish average benefits to be calculatedaverage benefits to be calculated

– 25 years25 years

Q14: Costs to include a benefit–cost ratio in the HEAT Q14: Costs to include a benefit–cost ratio in the HEAT calculationcalculation– Yes Yes –   No No

Q16: Discount rate to apply to future benefitsQ16: Discount rate to apply to future benefits– Please enter the rate by which you wish to discount Please enter the rate by which you wish to discount

future financial savingsfuture financial savings– 5 percent 5 percent

HEAT Tool - ResultsHEAT Tool - Results

There are an additional 31,356 individuals There are an additional 31,356 individuals regularly cycling compared to baselineregularly cycling compared to baseline

The number of deaths averted per year is The number of deaths averted per year is 9.159.15

The average annual benefit is $21,642,000The average annual benefit is $21,642,000 The benefits accumulated over 25 years in The benefits accumulated over 25 years in

$541,051,000$541,051,000

Additional ResourcesAdditional Resources

Report to the U.S. Congress on the Outcomes of the Nonmotorized Transportation Pilot Program SAFETEA-LU Section 1807: http://www.fhwa.dot.gov/environment/bicycle_pedestrian/ntpp/2012_report/final_report_april_2012.pdfQuantification of health benefits of cyling and walking

Transport, Health and Environment Pan European Programme (THE PEP) www.thepep.org

HEPA Europe (European network for promotion of health-enhancing physical activity)www.euro.who.int/hepa

Multidisciplinary TeamMultidisciplinary Team

Core Group:Core Group:Nick Cavill, Harry Rutter, Sonja Nick Cavill, Harry Rutter, Sonja Kahlmeier, Hywell Dinsdale, Kahlmeier, Hywell Dinsdale, Francesca Racioppi, Pekka OjaFrancesca Racioppi, Pekka Oja

Contributors:Contributors:Lars Bo Andersen, Finn Lars Bo Andersen, Finn Berggren, Hana Bruhova-Berggren, Hana Bruhova-Foltynova, Fiona Bull, Andy Foltynova, Fiona Bull, Andy Cope, Maria Hagströmer / Cope, Maria Hagströmer / Michael Sjöström, Eva Michael Sjöström, Eva Gleissenberger / Robert Gleissenberger / Robert Thaler, Brian Martin, Irina Thaler, Brian Martin, Irina Mincheva Kovacheva, Hanns Mincheva Kovacheva, Hanns Moshammer, Bhash Naidoo, Moshammer, Bhash Naidoo, Kjartan Saelensminde, Peter Kjartan Saelensminde, Peter Schantz, Thomas Schmid, Heini Schantz, Thomas Schmid, Heini Sommer, Jan Sørensen, Sylvia Sommer, Jan Sørensen, Sylvia Titze, Ardine de Wit / Wanda Titze, Ardine de Wit / Wanda Wendel Vos, Mulugeta Yilma Wendel Vos, Mulugeta Yilma

ContactContact

Candace RuttCandace Ruttawr8@cdc.gov770-488-6015770-488-6015