Text messaging with or without financial incentives versus a waitlist control for weight loss in men: cost-effectiveness analysis of the Game of Stones randomised controlled trial

Abstract

Background: Cost-effective weight loss interventions are needed for people with obesity, particularly men, who are less likely to engage with weight loss programmes. This study aimed to investigate the cost-effectiveness of text messaging plus financial incentives and text messaging alone compared to a waitlist control to help men lose weight.

Methods: 585 men with obesity were recruited to Game of Stones (GoS): a 3-arm randomised controlled trial in 3 UK areas. Text messaging alone participants received daily automated behavioural texts for 12-months (3% weight loss). Text messaging with financial incentives participants also received loss-framed financial incentives linked to achieving weight loss targets at 12-months (5% significant weight loss). A control group received no intervention for 12 months (1.3% weight loss) followed by 3 months of texts. We conducted a 24-month within-trial cost-effectiveness analysis and lifetime decision model from a UK NHS perspective. The PRIMEtime model extrapolated the impact of GoS weight-loss data on lifetime obesity related disease incidence, costs, and QALYs. Weight regain assumptions were explored in scenario analyses.

Findings: Text messaging with financial incentives costs £243 and text messaging alone costs £110 per participant to deliver. There were no significant differences between 24-month total costs or QALYs across groups. When modelled over lifetime, the mean discounted QALYs per person were 12.48, 12.49, and 12.46 for text messaging with financial incentives, text messaging alone, and waitlist control, respectively. The corresponding mean discounted total costs per person were £15,277, £15,117, and £15,100. The between group results for text messaging with financial incentives versus control were: QALY difference (95% CI): 0.02 (0.007, 0.029); cost difference: £176 (£43; £311); Incremental cost-effectiveness ratio (ICER): £9748 (£7,705, £11,791). For text messaging alone versus control: QALY difference: 0.03 (0.015, 0.037); cost difference: £16.5 (-£117; £152); ICER: £628 (£-5,914, £5384).

Interpretation: Text messaging with financial incentives and text messaging alone are cost-effective compared to waitlist control. Both are relatively low-cost interventions that can be scaled to improve weight loss for men. The optimal strategy between them depends on weight regain assumptions after 12 months.

Funding: National Institute for Health and Care Research (Ref: NIHR 129703). Trial Registration isrctn.org Identifier: ISRCTN91974895.

Keywords: Cost-effectiveness; Financial incentives; Obesity; QALYs; Text messaging; Weight loss.

Fig. 1

A threshold analysis diagram indicating the text messaging with financial incentives strategy becomes the optimal strategy with ICER below 20,000 when the weight regain time is slower from 4.9 years (base case) to 6.5 years.

Fig. 2

Preferred strategy in terms of cost-effectiveness for a range of willingness to pay (WTP) values. Preferred strategy is the strategy with the highest probability when compared to the other strategies considered. Strategies compared were (1) Wait list Control, (2) Text messaging alone, (3) Text messaging with financial incentives. A much faster weight regain time was used for text messaging with financial incentives in the base case analysis. In the base case, multiple imputation by chained equation was applied for handling missing weight measurements before calculating the weight regain.