Elsevier

Economics & Human Biology

Volume 6, Issue 3, December 2008, Pages 363-376
Economics & Human Biology

Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

https://doi.org/10.1016/j.ehb.2008.06.001Get rights and content

Abstract

Objective

To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002–2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.

Method

A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.

Results

The intervention, as modelled, reached 9685 children aged 5–9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).

Conclusion

Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.

Introduction

With a quarter of Australian children now overweight or obese (Sanigorski et al., 2007, Hesketh et al., 2004), effective management presents a pressing population need that cannot feasibly be addressed solely in the tertiary management or secondary prevention setting. Furthermore, there is an absence of economic evaluations of such targeted interventions in children. Whilst the assessing cost-effectiveness in obesity (ACE-Obesity) study (Haby et al., 2006) had a particular focus on whole-of-population prevention measures, it also endorsed the intent of the Australian Healthy Weight 2008 (National Obesity Taskforce, 2003) document of providing appropriate support through community-based interventions to individuals who are already overweight or obese. This paper evaluates the cost-effectiveness of a family-based management program, delivered in a primary care setting, and targeted to overweight and moderately obese children.

There is some evidence that parent involvement is a key predictor of the success of weight management programs which target overweight or obese children (Israel et al., 1990, Epstein et al., 1984, Flodmark et al., 1993, Brownell et al., 1993, Golan et al., 1998a, Golan et al., 1998b). The Australian National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines recommend the involvement of parents in the management of overweight and obesity in children and adolescents, given their capacity to substantially alter environments, especially for children of primary school age (National Health and Medical Research Council, 2003).

Primary health care services are the first point of entry for many people to the health care system, and there is now a growing body of literature (Dietz and Nelson, 1999, Drohan, 2002, Story et al., 2002, Barlow and Dietz, 2002, Whitaker, 2003, Stettler, 2004) supporting the case for management of childhood obesity within the primary care setting. Wake and McCallum (2004) promoted primary care as an option for a secondary prevention intervention, given issues of stigmatisation, acceptability, family involvement and sustainability associated with targeted programs in the school setting. In Australia, general practitioners (GPs) are the only primary health care service which is in a position to both systematically identify and recruit overweight children and deliver a targeted intervention. In a study of 3000 children in the state of Victoria (Wake et al., 2002), parents reported that 55% of overweight children had attended a GP once or twice in the preceding 6 months, and 22% three or more times.

Whilst Wake and McCallum (2004) identified some barriers to a primary care approach (lack of GP competency in use of behaviour-modification strategies, lack of time and lack of effective treatment models), they reported evidence of the effectiveness of primary care interventions in other disease areas amongst both adults and adolescents. Eakin et al. (2000) found that primary care-based physical activity counselling was moderately effective in the short term, although the potential for long-term maintenance of outcomes was not known. Sanci et al. (2000) illustrated the willingness of general practitioners to complete continuing medical education in adolescent health care and the sustainability of results in terms of improvements in knowledge and skills.

The ACE-Obesity project, funded by the Victorian Department of Human Services, evaluated, using consistent methods, 13 interventions in order to determine the ‘best buys’ for targeting unhealthy weight gain in children. It seemed logical that any package of interventions aimed at childhood obesity should include an intervention based on general practitioners. They are the first, and sometimes only, health service accessed by families, and are generally readily available to the vast majority of Australian families.

Section snippets

Method

A key feature of the ACE approach is that all of the selected interventions are modelled using consistent methods and study parameters. A ‘cost-effectiveness’ evaluation was undertaken whereby the assumptions were varied from the trial conditions to reflect the real-life situation. The incremental cost-effectiveness ratio (ICER) was calculated as the cost ($AUD) per body mass index (BMI) unit saved and disability-adjusted life year (DALY) saved. The intervention was applied to overweight and

Results

As modelled, the GP-mediated intervention for overweight and moderately obese children was cost-effective to 9 months in terms of net costs per DALY saved ($AUD4670 (dominated; $AUD0.1M)) under current assumptions (Table 3). In health economics, the word “dominated” means an intervention costs more for less effect. No comparative ICERs from other studies were available to place these results in a broader CEA context.

When undertaking probabilistic uncertainty analysis, it is common to report the

Discussion

This intervention was cost-effective to 9 months under current assumptions, with only a small chance (9.5%), based on current evidence, that the intervention would result in higher costs but negative benefits. Economic evaluations in Australia commonly quote a threshold value of $AUD50,000 per DALY saved (Haby et al., 2004, George et al., 1997). A saving in DALYs below this threshold is considered a ‘good buy’. In the case of this intervention, there is a 79.8% chance of the ICER being below

Acknowledgements

We thank members of the ACE-Obesity Working Group for their input into the project: Michael Ackland (Deputy Chair), Bill Bellew, John Catford, Elizabeth Develin, Helen Egan, Bonnie Field, Tim Gill, John Goss, Robert Hall (Chair), Brian Harrison, Kellie-Ann Jolly, Mark Lawrence, Amanda Lee, Tony McBride, Karen McIntyre, Jan Norton, Anna Peeters, Boyd Swinburn, Theo Vos, Rowland Watson.

Acknowledgement is made to the LEAP Trial team (Melissa Wake, Louise Baur, Jane Gunn, Kay Gibbons, Lisa Gold,

References (39)

  • W.H. Dietz et al.

    Barriers to the treatment of childhood obesity: a call to act

    Journal of Pediatrics

    (1999)
  • M. Golan et al.

    Parents as the exclusive agent of change in the treatment of childhood obesity

    American Journal of Clinical Nutrition

    (1998)
  • Australian Bureau of Statistics, 2001. Population by age and sex, Cat. No....
  • Australian Bureau of Statistics, 2004. Consumer Price Index, Australia, Cat. No. 6401.0,...
  • Australian Bureau of Statistics et al.

    Information paper: National Nutrition Survey, confidentialised unit record file 1995

    (1998)
  • Australian Divisions of General Practice, 2003. Better Outcomes in Mental Health Care Initiative. Familiarisation...
  • S.E. Barlow et al.

    Management of child and adolescent obesity: summary and recommendations based on reports from paediatricians, paediatric nurse practitioners, and registered dietitians

    Pediatrics

    (2002)
  • K.D. Brownell et al.

    Treatment of obese children with and without their mothers: changes in weight and blood pressure

    Pediatrics

    (1993)
  • Carter, R., Vos, T., Moodie, M., Haby, M., Magnus, A., Mihalopoulos, C., in press. Priority setting in health: origins,...
  • T.J. Cole et al.

    Establishing a standard definition for childhood overweight and obesity worldwide; international survey

    British Medical Journal

    (2000)
  • Dalton, A., Carter, R., Dunt, D., 1997. The Cost-Effectiveness of GP led behavioural change involving weight Reduction:...
  • Dennison, B.A., Sellers, K.F., Sellers, C.T., Baker, I.R., Burdick, P.A., 2005. Reducing early childhood overweight:...
  • S.H. Drohan

    Managing early childhood obesity in the primary care setting. A behaviour modification approach

    Pediatric Nursing

    (2002)
  • E.G. Eakin et al.

    Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research

    The Journal of Family Practice

    (2000)
  • L.H. Epstein et al.

    The effects of diet plus exercise on weight change in parents and children

    Journal of Consulting and Clinical Psychology

    (1984)
  • Ewing, L., Cluss, P., Goldstrohm, S., Colborn, K., Cipriani, L., Wald, E., 2005. Addressing child nutrition and...
  • C.E. Flodmark et al.

    Prevention of progression of severe obesity in a group of schoolchildren treated with family therapy

    Pediatrics

    (1993)
  • B. George et al.

    Reimbursement decisions and the implied value of life: cost effectiveness analysis and decisions to reimburse pharmaceuticals in Australia 1993–1996

  • M. Golan et al.

    Role of behaviour modification in the treatment of childhood obesity with the parents as the exclusive agents of change

    International Journal of Obesity and Related Metabolic Disorders

    (1998)
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