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Health Economics

Cost-effectiveness of goal-directed and outcome-based financial incentives for weight loss in low-income populations: the FIReWoRk randomized clinical trial

International Journal of Obesity volume 48, pages 231–239 (2024)Cite this article

Subjects

Abstract

Background

The Financial Incentives for Weight Reduction (FIReWoRk) clinical trial showed that financial incentive weight-loss strategies designed using behavioral economics were more effective than provision of weight-management resources only. We now evaluate cost-effectiveness.

Methods

Cost-effectiveness analysis of a multisite randomized trial enrolling 668 participants with obesity living in low-income neighborhoods. Participants were randomized to (1) goal-directed incentives (targeting behavioral goals), (2) outcome-based incentives (targeting weight-loss), and (3) resources only, which were provided to all participants and included a 1-year commercial weight-loss program membership, wearable activity monitor, food journal, and digital scale. We assessed program costs, time costs, quality of life, weight, and incremental cost-effectiveness in dollars-per-kilogram lost.

Results

Mean program costs at 12 months, based on weight loss program attendance, physical activity participation, food diary use, self-monitoring of weight, and incentive payments was $1271 in the goal-directed group, $1194 in the outcome-based group, and $834 in the resources-only group (difference, $437 [95% CI, 398 to 462] and $360 [95% CI, 341–363] for goal-directed or outcome-based vs resources-only, respectively; difference, $77 [95% CI, 58–130] for goal-directed vs outcome-based group). Quality of life did not differ significantly between the groups, but weight loss was substantially greater in the incentive groups (difference, 2.34 kg [95% CI, 0.53–4.14] and 1.79 kg [95% CI, −0.14 to 3.72] for goal-directed or outcome-based vs resources only, respectively; difference, 0.54 kg [95% CI, −1.29 to 2.38] for goal-directed vs outcome-based). Cost-effectiveness of incentive strategies based on program costs was $189/kg lost in the goal-directed group (95% CI, $124/kg to $383/kg) and $186/kg lost in the outcome-based group (95% CI, $113/kg to $530/kg).

Conclusions

Goal-directed and outcome-based financial incentives were cost-effective strategies for helping low-income individuals with obesity lose weight. Their incremental cost per kilogram lost were comparable to other weight loss interventions.

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Fig. 1: Bootstrap analysis of incremental cost-effectiveness ratio of goal-directed vs resources only.
Fig. 2: Bootstrap analysis of incremental cost-effectiveness ratio of outcome-based vs resources only.

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Data availability

Individual participant data and data dictionary will be made available upon request, following approval of an analysis proposal by principal investigators. Statistical analysis code will be made available upon request.

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Acknowledgements

This study was supported by the National Institutes of Health (NIH), National Institute on Minority Health and Health Disparities (NIMHD) through Grant Award Number R01MD011544 and National Center for Advancing Translational Sciences (NCATS) through Grant Award Number UL1TR001445. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Drs. Ladapo and Tseng had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Author contributors

JAL and MJ were multiple principal investigators and SWa was a site principal investigator and were involved in all aspects of the study design, implementation, data interpretation, and writing. JAL, MJ, SLO, NRP, C-HT, SWi, JW-R, SBS and NJG developed data collection tools. JAL developed the analysis plan and JAL, C-HT and UYRC and C-HT analyzed and verified the data. JAL, C-HT, UYRC, MJ, SLO, NRP, SWa, JW-R, SBS, and NJG were involved in data interpretation. JAL drafted the paper. All coauthors critically reviewed and approved the final manuscript.

Funding

National Institutes of Health, R01MD011544 and National Center for Advancing Translational Sciences (NCATS), UL1TR001445.

Author information

Authors and Affiliations

  1. Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA

    Joseph A. Ladapo

  2. Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY, USA

    Stephanie L. Orstad, Nikhil R. Patel & Melanie Jay

  3. Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA

    Judith Wylie-Rosett

  4. Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Chi-Hong Tseng & Un Young Rebecca Chung

  5. Cornell Dyson School of Applied Economics and Management, Ithaca, NY, USA

    Suzanne B. Shu

  6. Anderson School of Management at UCLA, Los Angeles, CA, USA

    Noah J. Goldstein

  7. Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA

    Soma Wali

  8. Veterans Affairs, New York Harbor, New York, NY, USA

    Melanie Jay

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  1. Joseph A. Ladapo
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Correspondence to Joseph A. Ladapo.

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Ladapo, J.A., Orstad, S.L., Wylie-Rosett, J. et al. Cost-effectiveness of goal-directed and outcome-based financial incentives for weight loss in low-income populations: the FIReWoRk randomized clinical trial. Int J Obes 48, 231–239 (2024). https://doi.org/10.1038/s41366-023-01404-3

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