Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings

doi:10.1016/j.jand.2012.05.002

Journal of the Academy of Nutrition and Dietetics

Volume 112, Issue 9, September 2012, Pages 1363-1373

https://doi.org/10.1016/j.jand.2012.05.002 Get rights and content

Abstract

Background

A major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources.

Objective

This study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program.

Design

We conducted a 1-year prospective randomized controlled clinical trial.

Participants/setting

The study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007.

Intervention

The intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74).

Main outcome measures

Program delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample.

Statistical analyses performed

Nonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance.

Results

Median weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control).

Conclusions

Both the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.

Section snippets

Study Process and Recruitment

This research expanded the economic analysis for a previously published prospective randomized clinical trial. Recruitment of participants and protection of subjects procedures were reviewed and approved by the full Institutional Review Board Committee at the University of Florida. Full details regarding the main randomized trial and results, including participant recruitment, screening, and randomization procedures have been described in detail elsewhere, but are briefly summarized here as

Results

Of the 559 women screened for study participation, 298 initiated the 6-month lifestyle-modification program, and 234 completed the program and were randomly assigned to the one of the three follow-up maintenance programs. Participants for whom final weight, self-rated health status, and participant cost data were missing were excluded from the analysis (n=19). The final analytic sample for the present cost analysis included the 215 participants assigned to the face-to-face (n=74), telephone

Discussion

Programs that result in successful initial weight loss and subsequent lifestyle maintenance are complex and require tools and support methods that meet the unique needs of participants. Learning which methods and modalities are effective is critical, given the epidemic rates of obesity and associated increased rates of morbidity and mortality. In the present study, both the face-to-face and telephone forms of treatment delivery (interactive) were more effective at helping participants maintain

Conclusions

With obesity rates at an all-time high, it is critical for researchers to develop effective treatment programs that promote weight loss and maintenance in ideal medical settings. But, it is also important to develop these interventions for translation to the real world so they can be implemented in any setting, including rural areas. In the present study, three lifestyle maintenance program formats were compared for salient outcomes of weight change, health status, and cost at 1-year in six

Acknowledgements

We are indebted to the University of Florida Cooperative Extension Service and to the staff of the University of Florida Weight Management Program for their assistance in conducting this study. We also thank Bob Schlenker, PhD, from the University of Colorado Denver, for critical review of an earlier version of the manuscript.

T. A. Radcliff is an associate professor, Department of Family Medicine, University of Colorado Denver, Aurora, and Department of Health Policy and Management, Texas A&M Health Science Center, School of Rural Public Health, College Station.

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Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention.
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L. B. Bobroff is a professor, Department of Food and Nutrition, Institute of Food and Agricultural Sciences, University of Florida, Gainesville.

P. E. Durning is clinical assistant professor, Department of Clinical Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville.

M. J. Daniels is a professor and chair, Department of Statistics, University of Florida, Gainesville.

M. C. Limacher is a professor, Division of Cardiovascular Medicine, School of Medicine, University of Florida, Gainesville.

D. M. Janicke is an associate professor, Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville.

A. D. Martin is a professor, Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville.

M. G. Perri is dean and a professor, College of Public Health and Health Professions, University of Florida, Gainesville.

L. D. Lutes is an associate professor, Department of Psychology, East Carolina University, Greenville, NC.

: FUNDING/SUPPORT This research was funded through a Demonstration and Dissemination Grant from the National Heart, Lung and Blood Institute (NHLBI), Project Number R18 HL073326. NHLBI had no role in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

: STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.

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ResearchOriginal ResearchComparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings

Abstract

Background

Objective

Design

Participants/setting

Intervention

Main outcome measures

Statistical analyses performed

Results

Conclusions

Section snippets

Study Process and Recruitment

Results

Discussion

Conclusions

Acknowledgements

Am J Clin Nutr

Eat Behav

Urban and Rural Health Chartbook: Health United States, 2001

A national study of obesity prevalence and trends by type of rural county

J Rural Health

Is rural residency a risk factor for overweight and obesity for US children?

Obesity (Silver Spring)

Obesity and physical inactivity in rural America

J Rural Health

Rural beneficiaries with chronic conditions: Does prevalence pose a risk to Medicare managed care?

Manag Care Q

Disparities in premature coronary heart disease mortality by region and urbanicity among black and white adults ages 35-64, 1985-1995

Public Health Rep

Diagnoes mental and physical health conditions in the United States nursing home population: Differences between urban and rural facilities

J Rural Health

Health in rural America: Remembering the importance of place

Am J Public Health

Lifestyle intervention to prevent diabetes: Intensive and cost effective

Curr Opin Lipidol

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report

Obes Res

Reduction in incidence of type 2 diabetes with lifestyle intervention or metformin

N Engl J Med

Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: One-year results of the Look AHEAD trial

Diabetes Care

Lifestyle modification for the management of obesity

Gastroenterology

Research
Original Research
Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings