Candace Rutt, Ph.D.

1. Quantification of Health Benefits for Cycling and Walking: The Health Economic Assessment Tool Candace Rutt, Ph.D.

2. Often Urban Environments Favor Motorized Transportation…..

3. ….and Hinder Walking and Cycling

4. However, there are Places that are Conducive to Active Transportation

5. Why Assess Health Consequences?

7. Source: American Public Health Association, “The Hidden Health Costs of Transportation” Report prepared by Urban Design 4Health, Inc. February 10,2010, pg.2

8. Chronic Disease and Risk Factors • 7 out of 10 deaths in the U.S. are from chronic diseases such as heart disease, cancer and stroke • These chronic diseases are primarily related to four risk behaviors • lack of physical activity • poor nutrition • tobacco use • excessive alcohol consumption Source: http://www.cdc.gov/chronicdisease/overview/index.htm

9. Current Health Care Spending $2.2 Trillion Prevention, 4% Behaviors & Environment 70% Medical Services 96% Genetics 20% Medical Care, 10% 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

10. “Get more exercise”... Source: Wernham, A. Health Impact Project. http://www.healthimpactproject.org/resources#presentations_webinars

11. Transportation, Land Use and Obesity 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.

12. Why Walking and Cycling? Perfect win-win option • Reduce inactivity • Reduce congestion • Improve road safety • Improve air quality and noise • Reduce energy consumption and CO2 • More livable communities

13. Why Guidance on Economic Assessment? • Economic evaluation is a standard tool of transport planners so it can help the health sector to speak “their” language • Public health benefits are likely to be great, esp. if inactive persons can be reached • Need for a transparent robust methodology

14. HEAT • Developed by the WHO with international experts • Economic tool to estimate reductions in mortality due to cycling (transportation) and walking (recreaction and transportation) • Very conservative and does not include morbidity • Currently for adults only

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

16. HEAT • Data imputs for the model: • Average amount of time spent walking or cycling • Number of people walking and cycling and average distance of trips

17. HEAT • How to get the need inputs • Route user surveys • Travel surveys • Destination based surveys • Traffic counts • Pedometers

18. Copenhagen Study – Effect Estimate for Transport Cycling • 6,954 regular cycle commuters • N = 30,640 • Followed for 14.5 years • Mean journey time of 3 hours per week • RR = 0.72 (0.57-0.91) • Adjusted for age, sex, educational status, leisure time physical activity, body mass index, blood lipid levels, smoking and blood pressure

19. Effect Estimate for Walking • 9 studies were found that accounted for OTHER types of leisure-time PA • A meta-analysis weighted by sample size found a RR of .78 (.64 - .98) for walking 29 minutes a day 7 days a week • Model is still being modified

20. HEAT • Outputs of the model • Number of lives saved • Annual benefit in SVL which is $5.8 million per person in the U.S.

21. Uses in Other Countries • Austria: USD: $570 million per year • Pilsen, Czech Republic: $1.2 million if 2% of population took up regular cycling • UK/Scotland: $1.5-3 billion per year if modal share goal of 13% reached • New Zealand: adding cycling and pedestrian facilities to the Auckland Harbour Bridge for a savings of $900,000 per 1000 regular bike commuters

22. Challenges to Adapting to U.S. • US Is much larger and heterogeneous • Travel data only collected nationally every 5 years • Very few local regions collect transport related data • Hard to find good data on bike lanes and sidewalks

23. U.S. Uses • Paper by Götschi(2012) examined cycling in Portland • By 2040, investments in the range of $138 to $605 million will result in health care cost savings of $388 to $594 million, fuel savings of $143to $218 million, and savings in value of statistical lives of $7 to $12 billion. • The cost-benefit ratios for healthcare and fuel savings are between 3.8 and 1.2 to 1

24. Nonmotorized Transportation Pilot Project • FHWA allocated $100 million dollars to 4 pilot communities • Marin County, CA • Minneapolis, MN • Columbia, MO • Sheboygan County, WI • The communities were selected by congress with input from bike and pedestrain advocates as well as communnity leaders. • Several factors were used to pick the communities including demographics, level of readiness and level of urbanization.

25. Nonmotorized Transportation 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.

26. Increases in Walking and Cycling • 85.1 million Vehicle Miles Traveled were averted. • Walking mode share increased 15.8% and cycling mode share increased 44%. • At individual project sites trip counts increased 56% for pedestrian trips and 115% for cycling trips. • ¼ mile network cycling access was expanded to 240,00 people, 160,00 housing units and 102,000 jobs. • Over 70% of projects connected to activity centers.

27. Economic 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.

28. Discussion • Criticism of HEAT- cycling is that it uses a RR from Copenhagen • However, similar RR were also found in Shanghai

29. Discussion • Other outputs could be used: • QALY • DALY • Morbidity by disease (cost of illness)

30. Next Steps • Adding morbidity into both models • Modifying input and output parameters • Inform and train potential users • Examine injury and exposure to air pollution • Develop a model for children

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

32. HEAT Tool - Minneapolis • 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 • Q6.1: Trips: average number of trips per person, or total number of trips?: • Average per adult • Total number of trips observed

33. HEAT Tool- Minneapolis • Q6.3: Total number of trips • Enter the number of trips observed per day: • 11,241 trips • What proportion of these trips are cycling trips? • 100% percent • Q6.4: Do you know the number of people who take cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return journeys out of all trips observed? • Enter the number of individuals cycling • Estimate this based on return journeys

34. HEAT Tool - Minneapolis • Q6.5: How many individuals contributed to the cycling trips entered? • Study population • 294,729 • How many days per year do people cycle? • 365 days per year • The default is 124 days per year but this was based on modeling the VOLPE and DOT used to calculate daily averages • Q6.7: Enter the average trip duration or distance • Duration • Distance

35. HEAT Tool - Minneapolis • Q6.9: Average trip length • Average trip length • 2.26 miles • This is the national average of cycling trip length NHTS data • Q7: How many people benefit? • Persons • 294,729 • In some cases this figure will be the number of cyclers in your study area, city or country or cycling data may be based on a representative sample of a larger population. In this case, you may wish to apply the findings to the whole population.

36. HEAT Tool - Minneapolis • Q2: Enter your post-interventioncycling data •  Duration • Distance • Trips • Q6.1: Trips: average number of trips per person, or total number of trips? • Average per adult • Total number of trips observed • Q6.3: Total number of trips • Enter the number of trips observed per day: • 17,986 Trips • What proportion of these trips are cycling trips? • 100 percent

37. HEAT Tool - Minneapolis • Q6.4: Do you know the number of people who take cycling trips, or do you wish to estimate the number of cyclists based on the proportion of return journeys out of all trips observed? • Enter the number of individuals cycling • Estimate this based on return journeys • Q6.5: How many individuals contributed to the cycling trips entered? • Study population • 326,085 • How many days per year do people cycle? • 365 days per year

38. HEAT Tool - Minneapolis • Q6.7: Enter the average trip duration or distance • Duration • Distance • Q6.9: Average trip length • Average trip length: • 2.26 Miles • Q7: How many people benefit? • Number of cyclists: • 326,085 persons

39. HEAT Tool - Minneapolis • Q9: Proportion of cycling data attributable to your intervention • Estimate the proportion of cycling which you would like to attribute to the intervention. • It is prudent to assume that not all the cycling, or increase in cycling is due to the intervention. • Please enter a proportion between 0-100% • 60 percent • Q10: Time needed to reach full level of cycling • Please select the time period before maximum uptake is achieved: • 5 years • This is the default value

40. HEAT Tool - Minneapolis • Q11: Mortality rate • It is recommended to use the local crude mortality rate for the population aged 20-64 years. • HEAT is not appropriate for populations consisting mainly of children, very young adults, or older people, • 793.8 deaths per 100,000 population • Q12: Value of statistical life • The value of a statistical life is derived with a methodology called “willingness to pay” to avoid death in relation to the years this person can expect to live according to the statistical life expectancy. • 5,800,000  dollars

41. HEAT Tool - Minneapolis • Q13: Time period over which benefits are calculated • Please select the time period over which you wish average benefits to be calculated • 25 years • Q14: Costs to include a benefit–cost ratio in the HEAT calculation • Yes •  No • Q16: Discount rate to apply to future benefits • Please enter the rate by which you wish to discount future financial savings • 5 percent

42. HEAT Tool - Results • There are an additional 31,356 individuals regularly cycling compared to baseline • The number of deaths averted per year is 9.15 • The average annual benefit is $21,642,000 • The benefits accumulated over 25 years in $541,051,000

43. Additional 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

44. Multidisciplinary Team Core Group: Nick Cavill, Harry Rutter, Sonja Kahlmeier, Hywell Dinsdale, Francesca Racioppi, Pekka Oja Contributors: Lars Bo Andersen, Finn Berggren, Hana Bruhova-Foltynova, Fiona Bull, Andy Cope, Maria Hagströmer / Michael Sjöström, Eva Gleissenberger / Robert Thaler, Brian Martin, Irina Mincheva Kovacheva, Hanns Moshammer, Bhash Naidoo, Kjartan Saelensminde, Peter Schantz, Thomas Schmid, Heini Sommer, Jan Sørensen, Sylvia Titze, Ardine de Wit / Wanda Wendel Vos, Mulugeta Yilma

45. Contact Candace Rutt awr8@cdc.gov 770-488-6015