A nationwide physical activity intervention for 654,500 adults in Singapore: a cost-utility analysis (Preprint)

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Abstract
BACKGROUND Increasing physical inactivity is a primary risk factor for diabetes and hypertension, contributing to rising healthcare expenditure and productivity losses. As Singapore's ageing population grows, there is an increased disease burden on her health systems. Large-scale physical activity interventions could potentially reduce the disease burden but face challenges in the uncertainty of long-term health impact and high implementation costs, hindering their adoption. OBJECTIVE We examined the cost-effectiveness of the Singapore National Steps Challenge (NSC), an annual nationwide mHealth intervention to increase physical activity, from both the healthcare provider’s perspective which only considers the direct costs and the societal perspective which considers both the direct and indirect costs. METHODS We used a Markov model to assess the long-term impact of increased physical activity from NSC on adults aged 17 and above. A Monte Carlo simulation with 1,000 samples was conducted to compare two situations: NSC conducted yearly for 10 years against a no-intervention situation with no NSC. The model projected inpatient and outpatient costs and mortality arising from diabetes and hypertension, and their complications. Health outcomes were expressed in terms of the quality-adjusted life-years (QALYs) gained. All future costs and QALYs were discounted at 3% per annum. Sensitivity analyses were done to test the robustness of our model results. RESULTS We estimated that conducting NSC yearly for 10 years on a mean cohort size of 654,500 participants is projected to prevent 6,200 diabetes cases (95% credible interval 3,700 to 9,100), 10,500 hypertension cases (6,550 to 15,200) and 4,930 deaths (3,260 to 6,930). This led to a reduction in healthcare costs of SGD448 million (132 million to 1.09 billion). There would be 78,800 QALYs (55,700 to 102,000) gained. Using a willingness-to-pay threshold of SGD10,000 per QALY gained, NSC would be cost-saving. When indirect costs were included, NSC was estimated to reduce societal costs by SGD1.41 billion (353 million to 3.80 billion). The model was most sensitive to changes in the inpatient cost of treatment for diabetes complications, time horizon and programme compliance. CONCLUSIONS In this modelling study, increasing physical activity by conducting a yearly nationwide physical activity intervention was cost-saving, preventing diabetes and hypertension and reducing mortality from these diseases. Our results provide important information for decision-making in countries that may consider introducing similar large-scale physical activity programmes. CLINICALTRIAL

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