VALUE IN HEALTH REGIONAL ISSUES 9C (2016) 28–35

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Cost-Effectiveness Analysis of the Self-Management Program

for Thai Patients with Metabolic Syndrome
Anut Sakulsupsiri, MSc1, Phantipa Sakthong, PhD2,*, Win Winit-Watjana, PhD3
1
Department of Pharmacy, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; 2Department of Pharmacy Practice, Faculty of
Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand; 3Department of Social and Administrative Pharmacy,
Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand

AB STR A CT

Background: Lifestyle modification programs are partly evaluated for
their usefulness. Objectives: This study aimed to assess the cost-
effectiveness and healthy lifestyle persistence of a self-management
program (SMP) for patients with metabolic syndrome (MetS) in Thai
health care settings. Methods: A cost-effectiveness analysis was
performed on the basis of an intervention study of 90 patients with
MetS randomly allocated to the SMP and control groups. A Markov
model with the Difference-in-Difference method was used to predict
the lifetime costs from a societal perspective and quality-adjusted
life-years (QALYs), of which 95% confidence intervals (CIs) were
estimated by bootstrapping. The cost-effectiveness analysis, along
with healthy lifestyle persistence, was performed using the discount
rate of 3% per annum. Parameter uncertainties were identified using
one-way and probabilistic sensitivity analyses. Results: The lifetime
costs tended to decrease in both groups. The SMP could save lifetime
costs (
2310 baht; 95% CI
5960 to 1400) and gain QALYs (0.0098; 95%
CI
0.0003 to 0.0190), compared with ordinary care. The probability of
cost-effectiveness was 99.4% from the Monte-Carlo simulation, and
the program was deemed cost-effective at dropout rates below 69%
per year as determined by the threshold of 160,000 baht per QALY
gained. The cost of macrovascular complications was the most
influencing variable for the overall incremental cost-effectiveness
ratio. Conclusions: The SMP provided by the health care settings is
marginally cost-effective, and the persistence results support the
implementation of the program to minimize the complications and
economic burden of patients with MetS.
Keywords: cost-effectiveness analysis, metabolic syndrome, self-
management program, Thailand.
Copyright & 2016, International Society for Pharmacoeconomics and
Outcomes Research (ISPOR). Published by Elsevier Inc.

Regarding MetS management, drug therapy can be used to

Introduction
Metabolic syndrome (MetS) is a cluster of metabolic abnormal-
ities induced by an insulin resistance [1,2]. The major features
of MetS include central obesity, hypertriglyceridemia, hyper-
tension, hyperglycemia, and low level of high-density lipopro-
tein. Thus, MetS increases the risk of type 2 diabetes mellitus
(T2DM), cardiovascular disease (CVD) [1,3], and economic bur-
den [4]. The disparity in the prevalence of MetS around the
world was reported by Cameron et al. [5]. They suggested that
the variation in prevalence may stem from differences in
patients’ genetic background, population age, sex structure,
the level of physical activity, or nutritional status in various
countries. Moreover, an increase in the proportion of over-
weight people, obesity, sedentary lifestyles, and rapid urban-
ization have been associated with the escalation in the
incidence of MetS worldwide [6,7]. MetS is therefore a crucial
public health problem nowadays [8].
adjust the metabolic components, for example, blood pressure or
glucose, but a bariatric surgery is indicated for some cases [1]. In
addition, a lifestyle intervention is required to promote healthy
eating habits, suitable exercise, and weight reduction in patients.
The lifestyle modification is usually a prime MetS management
tool because it improves the insulin sensitivity and simultane-
ously reduces all metabolic risk factors [1,9]. In addition, many
studies [10–12] have pointed out that lifestyle modification pro-
grams are not only clinically effective but also cost-effective for
patients with MetS in primary care settings. It enables patients to
minimize all treatment expenditures and prolong life. Never-
theless, the persistence of healthy lifestyles has not yet been
investigated. Failure to keep healthy behaviors results in
increased lifetime costs and reduced benefits of the program [13].
In Thailand, the prevalence of MetS for adults aged 35 years
and older is 32.6% based on the Third Report of the National
Cholesterol Education Program (ATP III) criteria [14]. The

Conflicts of interest: The authors have indicated that there are no conflicts of interest with regard to the content of this article.
* Address correspondence to: Phantipa Sakthong, Faculty of Pharmaceutical Sciences, Department of Pharmacy Practice, Chulalongkorn
University, Phyathai Road, Pathumwan, Bangkok 10330, Thailand.
E-mail: phantipa.s@pharm.chula.ac.th.
2212-1099$36.00 – see front matter Copyright & 2016, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).
Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.vhri.2015.10.004
 VALUE IN HEALTH REGIONAL ISSUES 9C (2016) 28–35
prevalence of MetS is dramatically increasing on account of
sedentary lifestyles and unhealthy consumption behaviors [15–
18]. The government sector, that is, the Ministry of Public Health,
has been aware of the threat that MetS poses and initiated the
Diet and Physical Activity Clinic (DPAC), in collaboration with the
Network of Fatless Belly Thais, to be established in public
hospitals since 2006 [19]. The objective of the DPAC is to promote
healthy behaviors in the Thai population in terms of healthy food,
exercise, and emotion or behaviors [20]. Several Thai researchers
have already assessed some lifestyle programs for patients with
MetS [21–25] and found that they could improve patients’ meta-
bolic parameters and reduce CVD risks. The cost-effectiveness
issue, however, remained unexplored in these studies.
An extensive literature search revealed no study on the cost-
effectiveness and persistence analysis of lifestyle management
programs for patients with MetS in Thailand or other countries
[10–12]. Hence, this study aimed to assess the cost-effectiveness
and healthy lifestyle persistence of the self-management pro-
gram (SMP), which was a lifestyle alteration program that partly
adopted the DPAC procedures.
Methods
This study was approved by the Ethical Committee of Chulalong-
korn University in 2014. A cost-effectiveness analysis (CEA) of the
persistence of healthy lifestyles was performed between July and
November 2014 for the intervention study of Praphasil et al. [23] in
Thai patients with MetS attending the SMP. The SMP study was
selected because it provided complete clinical data, especially for
CVD risks and total cholesterol levels. Based on two patient groups
(SMP vs. ordinary care), the original findings revealed favorable
therapeutic outcomes with marginal effect sizes (P o 0.05), that is,
body mass index (BMI), waist circumference (WC), high-density
lipoprotein, and systolic and diastolic blood pressure, as presented
in Appendix Table A in Supplemental Materials found at http://dx.
doi.org/10.1016/j.vhri.2015.10.004, but no economic outcome was
reported. A societal perspective was contemplated for the CEA,
and a Markov model was used to predict the lifetime costs and
quality-adjusted life-years (QALYs) for individual patients starting
from week 0 until death. The ages at which men and women died
were assumed to be equal to the life expectancies of 72 and 79
years, respectively, based on the Thai statistics report [26]. Details
of the methodology are summarized below.
Overview of the Intervention Study
In the intervention study, patients with MetS who met the
eligibility criteria were randomly allocated to control and inter-
vention groups (44 vs. 46 patients). The former received ordinary
care provided by nurses or doctors as usual, whereas the latter
obtained normal care plus self-management activities, as part of
the SMP. The SMP was set up in a community hospital and two
health promoting centers in Kanchanaburi Province, Thailand. It
was run by a nurse and her assistant. The program activities were
created on the basis of Creer’s self-management theory and
Bandura’s self-efficacy theory [23]. All patients were required to
join in the following activities:
Week 0: The anthropometric data, for example, WC, height,
and metabolic indicators, were measured for all patients. They
were also requested to complete a self-management question-
naire. The control group then received general advice or ordinary
care, such as weight control and exercise, whereas the interven-
tion group participated in an educational session (session 1) to
get information about MetS, metabolic control, and self-
management skills. After that, patients in the intervention group
29
were asked to attend a nutrition session (session 2) and got the
SMP manual.
Week 1: The intervention group took part in an exercise
session (session 3).
Week 4: All patients were invited to fill out the self-
management questionnaire.
Weeks 6 and 9: Each patient in the intervention group was
telephoned by the researcher to check for their retention of
healthy behaviors using the self-management skills and for any
problems that might have arisen.
Week 12: Patients’ anthropometric data and metabolic param-
eters were measured again, and the self-management question-
naire was also filled again by both groups to identify any changes
from the baseline (week 0).
Further details of the intervention study can be found in File 1
in Supplemental Materials found at http://dx.doi.org/10.1016/j.
vhri.2015.10.004.
Markov Model
The Markov model that was adapted from Feldman et al. [10] is
demonstrated in Fig. 1. The model was checked for face validity
by four endocrinologists and one cardiologist. It comprised the
MetS state plus six complication states and two types of deaths.
The entire model was analyzed using Microsoft Excel 2013
(Microsoft Corp., Bangkok, Thailand). All states were presented
by ovals and were mutually exclusive with collective, exhaustive
nature. The cycle length of changing from one state to another
was determined in 1 year. The assumption for this model was
that metabolic parameters at week 12 would be extended to 1
year and then return to baseline (week 0) values before the
patients received the SMP intervention or ordinary care again in
the following years. The transition probabilities in the model
were calculated from the metabolic parameters of individual
participants or relevant incidences found in Thailand as sum-
marized in File 2 in Supplemental Materials found at 10.1016/j.
vhri.2015.10.004. It should be noted that the sequelae of MetS in
SMP and control groups were typically different owing to the
diverse metabolic components of each patient group. Because
transition probabilities were reported in various studies with
specific periods of time, such as 12 years for transitioning from
MetS to T2DM, these were converted to yearly probabilities using
the following formula [27]:

1=t
tp1 ¼1– 1–tpt
where tp1 is the yearly transition probability and tpt is the
reported transition probability for the time period (t).
From MetS at the outset, it may progress to T2DM, coronary
heart disease (CHD), or stroke (ischemic or hemorrhagic types).
Patients with T2DM may then develop microvascular complica-
tions (Micro comp., i.e., retinopathy and nephropathy) or macro-
vascular complications (Macro comp., i.e., CHD and stroke) [28];
neuropathy and peripheral arterial disease were not included
because of lack of probability data. If patients with CHD or stroke
experienced diabetes mellitus, their health states would be
considered as Macro comp. (T2DM with macrovascular complica-
tions). Because in this study there were patients with MetS with
or without T2DM, the model was run from two starting points,
that is, MetS and T2DM states. All states, except for MetS and
T2DM, could end up with specific death (Death-specific) caused by
a particular health state or any type of death (Death-all).
Cost-Effectiveness Analysis
To analyze the cost-effectiveness of the SMP, the best available
incidences, costs, and utility weights from various Thai refer-
ences [23,26,29–39] were entered into the Markov model (see File
30 VALUE IN HEALTH REGIONAL ISSUES 9C (2016) 28–35

Fig. 1 – Markov model with description. Arrow (-), connecting two different states to indicate the state transition; both, both
microvascular and macrovascular complications; curved arrow (↩), probability of staying at the same state; CHD, coronary
heart disease; death-all, death from all causes; death-specific, death caused by the specific disease; macro comp.,
macrovascular complications; micro comp., microvascular complications; stroke, ischemic or hemorrhagic stroke; type 2 DM,
type 2 diabetes mellitus without complications.

2 in Supplemental Materials). The input data are described
below.
Transition probabilities
The probability of each participant for developing T2DM was
calculated from their metabolic components by using the risk
equation of Aekplakorn et al. [29], which was created from Thai
samples, whereas the CVD and macrovascular risks were com-
puted by using the equation of Khonputsa et al. [32]. This
equation was recalibrated from the Framingham equation by
using the Thai epidemiologic data. The probability for developing
microvascular complications was derived from the study of
Potisat et al. [34], which included the risks of retinopathy and
nephropathy. The patients with CVD or stroke would experience
the Macro comp. state with the risks calculated from the equation
of Aekplakorn et al. [29]. The risks of death from diabetic
complications were obtained from the study of Pratipanawatr
et al. [35], and the probabilities of death from all causes, CHD, and
stroke were adopted from the Thai public health statistics [26].
Cost data
Costs of SMP and ordinary care were computed from activities
reported in the relevant literature and interviews with the SMP
organizer. Because the SMP was assumed to occur every year
until the patients die, the costs of the program and ordinary care
were calculated on an yearly basis. The program costs were
divided into two periods of time. The first-year cost was for the
investment in devices, such as scale, sphygmomanometer, and
pedometers; the devices were supposed to be used for at least 5
years [40]. The second- to fifth-year costs did not take into
account the expenditure incurred in purchasing the devices but
included other costs. For the sixth year, the costs of the SMP and
ordinary care would restart with the same costs as those for the
first year; the seventh-year costs were like those of the second
year and so on. All diabetes-related costs were gathered from the
study of Riewpaiboon et al. [36]. The costs of CHD and stroke
were derived from the data of Anukoolsawat et al. [30] and
Khiaocharoen et al. [31], respectively. All costs were accounted
for from the societal perspective in 2014 and presented as
Thai baht.
Utility data
The utility data on all health states were gathered from the three-
level EuroQoL five-dimensional questionnaire with the Thai
preference weights. The utility data of participants with MetS
and T2DM were obtained from the large cohort study of Kimman
et al. [33], whereas those of CHD, stroke, and T2DM and its
complications were from the study of Saiguay and Sakthong [37],
Wannasiri and Kapol [39], and Sakthong et al. [38], respectively.
These utility results were collected from Thai patients with
specific diseases.
A discount rate of 3% per annum was applied to the costs and
QALYs as suggested by the World Health Organization and
Thailand’s Health Technology Assessment guidance [41,42].
Because some patients’ baseline parameters, namely, BMI, total
cholesterol, and low-density lipoprotein, were significantly differ-
ent between two groups, the Difference-in-Difference (DD)
method was adopted to find the intervention effects from the
unequal baseline data of the two groups. The DD method follows
the assumption of common trends—the trends of outcomes
would be the same in both groups in case of the intervention
absence and the deviation from these common trends is affected
by the intervention given [43]. For the SMP and control groups,
the metabolic components of each patient in weeks 0 and 12 were
calculated for their costs and QALYs. Then, the costs and QALYs
in week 12 were subtracted from those in week 0 of each group.
After that, the subtraction products from both groups were
further subtracted to yield between-group differences or DD
results used for the CEA. In this study, the CEA was performed
 VALUE IN HEALTH REGIONAL ISSUES 9C (2016) 28–35 31

with two aspects: base-case and sensitivity analyses. The former

0.0098 (
0.0003 to 0.0190)

was to report an incremental cost-effectiveness ratio (ICER)

2,310 (
5,690 to 1,400)

calculated from the means of lifetime costs, utilities, and tran-
sition probabilities, whereas the latter illustrated the effects of
parameter uncertainties. To estimate the 95% confidence interval

DD
(CI) of the base-case data, a nonparametric bootstrapping with
1000 samples was generated by using Microsoft Excel 2013 and
the statistical analysis was computed by using IBM SPSS Statistics
22 (IBM Corp., Bangkok, Thailand).

Uncertainty Analyses

0.0022 (
0.0035 to 0.0096)

One-way and probabilistic sensitivity analyses were performed
for the parameter uncertainties. The one-way sensitivity analysis

1,370 (
4,260 to 970)

Within-group
was accomplished by varying each variable value with the

difference
discount rate of 0% or 6% and 95% CI for all variables was
calculated [44]. The probabilistic sensitivity analysis was con-
ducted using the Monte-Carlo simulation of 1000 iterations from
the data given in File 2 in Supplemental Materials. The beta
distribution (0–1) was assumed for transition probabilities and
utility data, and the gamma distribution (0–þ1) for cost data [45].
Program costs and probability data derived from the risk equa-
tions, however, were fixed values because the former were
calculated from pertinent literature and the latter from individ-

Control group (n ¼ 44)

562,060 (502,000–617,500)
560,680 (501,800–618,860)
uals’ data. To interpret the cost-effectiveness result, ICER was

9.8358 (9.2883–10.3933)
9.8335 (9.2839–10.4368)
compared with the willingness-to-pay (WTP) threshold for Thai-
land, which was 160,000 baht per QALY gained [41]. In addition, a
threshold analysis was performed by gradually increasing the
program costs (first-year cost and second- to fifth-year costs)
from the base-case values to find out the maximum costs that
provided an ICER of less than 160,000 baht per QALY gained.
Value (95% CI*)

Persistence Analysis
Regarding the healthy lifestyle persistence, it was assumed that
the SMP was introduced to patients every year. If they missed

3,680 (
6,220 to
1,340)
some sessions or dropped out of the program, they would not

0.0120 (0.0051–0.0191)

CI, confidence interval; DD, Difference-in-Difference; QALY, quality-adjusted life-year.

Within-group

retain their healthy lifestyles, or simply there would be lack of

difference

persistence. The annual dropout rates were varied from 0% to

Table 1 – Base-case results for the cost-effectiveness analysis.

100% in the intervention group. The variable dropout rates

enabled the ICER to change from the dominant status (lower
lifetime costs and higher QALYs), through cost-effective or not, to
the dominated status. The dominated one is usually rejected by
policymakers because the program requires higher costs but
offers lower QALYs.
10.7762 (10.1288–11.4474)
567,600 (512,150–623,740)
563,920 (508,370–621,580)

10.7642 (10.0590–11.4421)

Results
Intervention group

The base-case results are delineated in Table 1. The lifetime cost

(n ¼ 46)

of the intervention group decreased from weeks 0 to 12 approx-

imately by
3680 baht (95% CI
6220 to
1340), whereas the
decrease in the control group was
1370 baht (95% CI
4260 to
*Estimated by the bootstrapping method.

970). When taking the change in costs into consideration, it

rendered a between-group difference (or DD) of
2310 baht (95%
CI
5690 to 1400). Regarding QALYs, the DD value was 0.0098 (95%
CI
0.0003 to 0.0190). The negative resultant ICER was interpreted
as cost-effective from the societal perspective.
With respect to the one-way sensitivity results presented in
Table 2, the SMP was also cost-effective when patients’ ages were
extended from the termination age (72 years for men and 79
Lifetime cost (baht)

years for women) to 120 years. From the provider’s point of views,
the lifetime costs (540 baht) were slightly reduced with the same
QALYs gained as the societal perspective, thus suggesting that
Week 12

Week 12
Week 0

Week 0

the SMP was cost-effective from both perspectives. Considering a

Result

subgroup analysis, the SMP for diabetic patients (n ¼ 20) was

QALY

construed as cost-effective, but the program for those without

diabetes (n ¼ 26) needed to pay 862,180 baht per QALY gained.
32 VALUE IN HEALTH REGIONAL ISSUES 9C (2016) 28–35

Table 2 – Scenario analysis.

Data Lifetime cost (baht)* QALY* ICER (baht/QALY gained)
Societal perspective
Base case for all patients (from Table 1)
2,310 0.0098 Dominant†
Patients with extended termination age of 120 y
3,300 0.0156 Dominant†
Patients with diabetes (n ¼ 20 vs. n ¼ 32)
1,620 0.0070 Dominant†
Patients without diabetes (n ¼ 26 vs. n ¼ 12) 1,230 0.0014 862,180
Discount rate per annum
0%
3,480 0.0149 Dominant†
6%
1,620 0.0067 Dominant†
Provider’s perspective
540 0.0098 Dominant†
ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year.
*Presented as the Difference-in-Difference value for the intervention and control groups between weeks 0 and 12.
†
Negative ICER due to the lower lifetime cost and higher QALY of the intervention group compared with the control group.

Moreover, the annual undiscounted (0%) or 6% discount rate
provided a cost-effective program. Nevertheless, with the 6% rate,
the program providers saved less money and gained less QALYs.
The high percentage changes in ICERs for five variables (i.e., cost
of macrovascular complications, cost of microvascular complica-
tions, utility weight of both complications, utility weight of
microvascular complications, and utility weight of macrovascular
complications) are depicted in the tornado diagram in Fig. 2. Of
these five variables, the cost of macrovascular complications had
the greatest impact on the overall ICER.
The results of probabilistic sensitivity analysis were reported
by the cost-effectiveness plane and the acceptability curve, as
illustrated in Fig. 3. From the Monte-Carlo simulation, the plane
with 1000 ICERs implied that the SMP could increase the QALYs
from 0.0052 to 0.0133 and the impact on the lifetime costs ranging
from
16,700 to 2,230 baht (data not included in Fig. 3A). Almost
all gray dots (or ICERs), except six of them, gathered around the
base-case value and below the WTP line. This signified that the
SMP program was cost-effective, whether having a negative or a
positive cost impact. In Fig. 3B, the WTP was varied from 0 to
180,000 baht per QALY gained. As determined by the Thai WTP
threshold (160,000 baht per QALY gained), the SMP was cost-
effective up to 99.4%. If the society was not willing to pay for the
program (0 baht per QALY gained), the probability of cost-
effectiveness would still be 88.9%. Furthermore, the SMP was still
cost-effective if the program cost in the first year was less than
81,850 baht per patient and the program costs in the second to
fifth years were less than 69,710 baht per patient per year, or 42
times that of the base-case value.
With the dropout rates below 62% per year, the SMP was cost-
effective due to the negative ICERs (Table 3). Nevertheless, the
costs incurred for the program with a dropout rate of 63% to 69%
were more than those in the control group until they reached the
threshold of 160,000 baht, thereby leading to positive ICERs. The
SMP would not be cost-effective if the dropout rate was as high as
70% or above.
Discussion
This was the first CEA study on the SMP for patients with MetS in
Thailand. The study was unique in that it encompassed the
effects of patient adherence and separately evaluated transition
probabilities and relevant data on the basis of metabolic param-
eters of individual patients. Thus, it was more accurate than a
normal Markov model. Aside from that, all data entered into the
model, except for the CVD risks [32], were obtained from various
studies in Thai samples. This mirrored the authentic findings in
the Thai population although the CVD risk equation was derived
from the Framingham equation. Khonputsa et al. [32] previously

Fig. 2 – Tornado diagram.

 VALUE IN HEALTH REGIONAL ISSUES 9C (2016) 28–35 33

Fig. 3 – Probabilistic sensitivity results with description. (A) Cost-effectiveness plane of the self-management program
compared with ordinary care (the black dot denotes the base-case value) and (B) acceptability curve of the self-management
program for patients with metabolic syndrome compared with ordinary care. QALY, quality-adjusted life-year; WTP,
willingness to pay.

recalibrated the equation using the Thai epidemiologic data.
With the analysis of the dropout-rate threshold, policymakers
can get the most out of the results, as part of the economic
information, for the future SMP plan.
The base-case results were comparable to those of other
studies in the United States or Sweden [10–12] that reported that
lifestyle modification programs are cost-effective in comparison
with the thresholds of US $20,000 or €20,000 per QALY gained.
There was no statistical difference, however, between the two
groups from the base-case results, as evidenced by the 95% CI
results. The sensitivity analysis also disclosed the cost-
ineffectiveness in the subgroup without diabetes; the SMP was
supposed to benefit all the patients with MetS with or without
diabetes. These findings differed from the findings of the study by
Saha et al. [11], which found that the ICER, including the base
case, of this patient group was cost-effective. Some possible
explanations for this discrepancy might be that the Swedish
study applied the 3-year Björknäs intervention with more ses-
sions and longer periods of active activities, but the SMP study
was carried out with three sessions in three months. Because
small samples in the subgroup without diabetes (26 vs. 12
patients) was used in this present study, any differences in
metabolic parameters between SMP and control groups were
probably due to random errors. In addition, the equation for
diabetes used in this Markov model was not sensitive enough to
identify any changes in patients’ metabolic parameters because
BMI and WC in the equation are specified in ranges rather than
actual values. Most importantly, relevant costs and data for this
study might considerably differ from the Scandinavian context.
For the subgroup without diabetes, however, the SMP could still

Table 3 – Patients’ persistence of healthy lifestyles.

Dropout rate (% Intervention group Control group DD ICER (baht/QALY
per year) gained)
Lifetime cost QALY* Lifetime cost QALY* Lifetime cost QALY
(baht)* (baht)* (baht)

0
3,680 0.0120
1,370 0.0022
2,310 0.0098 Dominant†

10
3,310 0.0108
1,370 0.0022
1,940 0.0086 Dominant†
61
1,440 0.0047
1,370 0.0022
60 0.0024 Dominant†
62
1,400 0.0046
1,370 0.0022
20 0.0023 Dominant†
63
1,360 0.0044
1,370 0.0022 10 0.0022 5,670
64
1,330 0.0043
1,370 0.0022 50 0.0021 23,700
68
1,180 0.0038
1,370 0.0022 200 0.0016 122,830
69
1,140 0.0037
1,370 0.0022 230 0.0015 157,660
70
1,100 0.0036
1,370 0.0022 270 0.0014 198,630
80
740 0.0024
1,370 0.0022 640 0.0002 3,972,970
81
700 0.0023
1,370 0.0022 680 0 16,582,820
82
660 0.0022
1,370 0.0022 710
0.0001 Dominated‡
90
370 0.0012
1,370 0.0022 1,010
0.0010 Dominated‡
100 0 0
1,370 0.0022 1,370
0.0022 Dominated‡
DD, Difference-in-Difference; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year.
*Presented as the within-group difference between weeks 0 and 12.
†
Negative ICER due to the lower lifetime cost and higher QALY of the intervention group compared with the control group.
‡
Negative ICER due to the higher lifetime cost and lower QALY of the intervention group compared with the control group.
34 VALUE IN HEALTH REGIONAL ISSUES 9C (2016) 28–35
help reduce 5860 baht. This meant that promoting the SMP
among patients without diabetes was also worthwhile because
it would decrease the future costs of disease management.
From the tornado diagram, the cost and utility weight of
diabetic complications mostly impacted the ICER, possibly on
account of the wide range of manifestations from the early to end
stages of the abnormalities. Hence, the costs and utility weights
of these patients varied with their clinical symptoms. The
findings from the acceptability curve, threshold analysis, and
persistence analysis seemed promising. This demonstrated the
program’s capacity to modify patients’ metabolic risk factors,
thus leading to a reduction in the MetS complications and future
costs. Details of any lifestyle alteration programs, however, need
to be contemplated owing to their variations [46,47]. If a program
offered more sessions with longer intervention periods, the
program costs would be augmented and the probability of cost-
effectiveness plus the dropout-rate threshold might be
comparatively low.
Owing to the impermanent effects of all lifestyle modification
programs, the retention time, or the duration of program effects, is
usually assumed. Few studies, for example, the Diabetes Prevention
Program [48] and the Finnish Diabetes Prevention Study [49],
concluded that the effects of lifestyle interventions can be retained
for more than 1 year. The SMP in this study provided only three
intervention sessions in 3 months, whereas the Diabetes Prevention
Program had 16 sessions in the core curriculum and the Finnish one
provided 20 sessions. Therefore, in this study, only 1-year retention
was assumed rather than longer periods in the two studies.
Furthermore, the SMP was assumed to have a yearly activity and
patients were self-motivated or self-managed to maintain their
healthy behaviors throughout the year. The program costs of the
present study were thus separated into the first-year cost and
subsequent-year costs according to the 5-year service guidance [40].
This cost concept differed from that in other studies [10,11] because
they treated the program costs as a one-time investment and
assumed that the program effects could sustain for 1 to 10 years
or for a lifelong period.
Study Limitations
In any intervention study, the baseline characteristics should
ideally be the same so that the impact of the SMP can be directly
assessed, but it was not the case for this study. The DD method
was therefore exploited to adjust the variations. As with most
lifestyle intervention research, this study was not initially
planned for an economic evaluation. Therefore, the program
costs, as well as cost-of-illness and utility data, were not directly
measured in the first place. Furthermore, the equation used to
predict the risk for diabetes allowed BMI and WC only in ranges
(i.e., BMI o 23, 23–27.5, or 427.5 kg/m2, or WC Z 90 cm for men or
Z 80 cm for women) to be substituted with corresponding
coefficients. For instance, a BMI of either 24 kg/m2 or 27 kg/m2
yielded the same risk scores. This made it insensitive enough to
detect any changes in the risk for diabetes from weeks 0 to 12. In
reality, the actual values should be substituted in the equation
instead. Although Brown et al. [50] found that lifestyle interven-
tions can prevent some cancers in addition to MetS complica-
tions, the risk of cancers was not included in the Markov model to
avoid making the model more complex. Given the findings of the
study without implications for cancer, the benefits of the SMP
might be slightly underestimated.
Conclusions
This CEA revealed the positive impact of the SMP for patients
with MetS on the raised QALYs and saving the future costs.
Overall, the program implemented in Thai health care settings
seems to be marginally cost-effective. Moreover, the persistence
analysis supports the economic benefits of this program. Health
care professionals and policymakers should pay more attention
to this SMP, which is unlike other lifestyle alteration programs,
because it primarily focuses on self-efficacy and self-
management skills that enable patients to control their own
MetS and slow down its progression. In other words, the program
can help minimize the complications and economic burden of
the patients. Further studies are required to confirm and evaluate
the effects of this program on the economic outcomes together
with clinical issues in a large group of patients with MetS or other
chronic diseases. If feasible, a large-scale assessment should be
carried out in the DPACs across the country with more partic-
ipants, several sessions, and longer intervention periods to reflect
the actual benefits of the lifestyle modification program as
a whole.
Acknowledgments
We acknowledge the assistance of the experts (i.e., Drs. Thiti
Snabboon, Sunant Benjajareanwong, Poj Tannirandorn, Prin
Vathesatogkit, and Panudda Srichomkwan) for their useful rec-
ommendations and model validation. Moreover, we thank Miss
Orawan Praphasil and other researchers for providing the
research team with all the necessary data, and also health
economists for their valuable suggestions.
Source of financial support: This study was funded by the
National Research Council of Thailand (fiscal year 2015).
Supplemental material
Supplemental material accompanying this article can be found in
the online version as a hyperlink at http://dx.doi.org/10.1016/j.
vhri.2015.10.004 or, if a hard copy of article, at www.valuein
healthjournal.com/issues (select volume, issue, and article).
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