Home Telemonitoring and a Diagnostic Algorithm in the Management of Heart Failure in the Netherlands: Cost-effectiveness Analysis

Abstract

Background Heart failure is a major health concern associated with significant morbidity, mortality, and reduced quality of life in patients. Home telemonitoring (HTM) facilitates frequent or continuous assessment of disease signs and symptoms, and it has shown to improve compliance by involving patients in their own care and prevent emergency admissions by facilitating early detection of clinically significant changes. Diagnostic algorithms (DAs) are predictive mathematical relationships that make use of a wide range of collected data for calculating the likelihood of a particular event and use this output for prioritizing patients with regard to their treatment. Objective This study aims to assess the cost-effectiveness of HTM and a DA in the management of heart failure in the Netherlands. Three interventions were analyzed: usual care, HTM, and HTM plus a DA. Methods A previously published discrete event simulation model was used. The base-case analysis was performed according to the Dutch guidelines for economic evaluation. Sensitivity, scenario, and value of information analyses were performed. Particular attention was given to the cost-effectiveness of the DA at various levels of diagnostic accuracy of event prediction and to different patient subgroups. Results HTM plus the DA extendedly dominates HTM alone, and it has a deterministic incremental cost-effectiveness ratio compared with usual care of €27,712 (currency conversion rate in purchasing power parity at the time of study: €1=US $1.29; further conversions are not applicable in cost-effectiveness terms) per quality-adjusted life year. The model showed robustness in the sensitivity and scenario analyses. HTM plus the DA had a 96.0% probability of being cost-effective at the appropriate €80,000 per quality-adjusted life year threshold. An optimal point for the threshold value for the alarm of the DA in terms of its cost-effectiveness was estimated. New York Heart Association class IV patients were the subgroup with the worst cost-effectiveness results versus usual care, while HTM plus the DA was found to be the most cost-effective for patients aged <65 years and for patients in New York Heart Association class I. Conclusions Although the increased costs of adopting HTM plus the DA in the management of heart failure may seemingly be an additional strain on scarce health care resources, the results of this study demonstrate that, by increasing patient life expectancy by 1.28 years and reducing their hospitalization rate by 23% when compared with usual care, the use of this technology may be seen as an investment, as HTM plus the DA in its current form extendedly dominates HTM alone and is cost-effective compared with usual care at normally accepted thresholds in the Netherlands.

Economic Evaluations of Digital Health Interventions for Patients With Heart Failure: Systematic Review

“…The majority of the studies (25/27, 93%) were from HICs. Of the 27 studies, 6 (22%) were from the United States [ 34 , 43 , 44 , 51 - 53 ]; 3 (11%) each from the Netherlands [ 33 , 37 , 40 ] and the United Kingdom [ 32 , 35 , 50 ]; 2 (7%) each from Germany [ 36 , 38 ], Brazil [ 41 , 45 ], Canada [ 42 , 48 ], Italy [ 55 , 56 ], and Spain [ 46 , 49 ]; and 1 (4%) each from Australia [ 57 ], Poland [ 54 ], France [ 31 ], Hong Kong [ 47 ], and Denmark [ 39 ]. Of the 27 studies, 24 (89%) conducted a cost-utility analysis with cost and QALY as the outcome measures [ 31 - 35 , 37 - 40 , 42 - 51 , 54 , 56 , 57 ], 2 (7%) conducted a cost-effectiveness analysis (1/2, 50% with hospital readmission as the outcome measure [ 41 ] and 1/2, 50% with number of days alive and neither in hospital nor in inpatient care as the outcome measure [ 36 ]), and 1 (3%) conducted a cost-minimization analysis [ 55 ].…”

“…Of the 27 studies, 15 (56%) used a time horizon of >1 year (3/15, 20% were RCTs) [ 31 - 35 , 40 , 44 , 45 , 47 , 48 , 50 - 54 ]; the time horizon in 6 (22%) studies was ≤1 year (all were RCTs) [ 36 , 39 , 41 - 43 , 46 ]; 6 (22%) did not state the time horizon (5/6, 83% were RCTs and 1/6, 17% was model based) [ 37 , 38 , 49 , 55 - 57 ]. Of the 27 studies, 15 (56%) received grants from public organizations [ 31 , 32 , 35 , 36 , 38 - 41 , 43 , 44 , 46 , 49 , 54 , 56 , 57 ], 3 (11%) received funding from industry [ 37 , 50 , 51 ], 2 (7%) received no funding [ 42 , 55 ], and 7 (26%) did not declare their funding source [ 33 , 34 , 45 , 47 , 48 , 52 , 53 ].…”

“…All studies included the direct costs of DHIs, such as the costs of the DHIs, inpatient and outpatient costs, monitoring and follow-up costs, and medication costs. Some of the studies (12/27, 44%) included nonmedical direct costs, such as travel and transportation costs [ 33 , 35 , 38 , 41 , 43 , 46 , 50 , 55 ]. Studies that used a societal perspective (6/27, 22%) also included indirect costs, such as productivity losses [ 33 , 38 , 43 , 46 , 55 , 56 ].…”

“…Some of the studies (12/27, 44%) included nonmedical direct costs, such as travel and transportation costs [ 33 , 35 , 38 , 41 , 43 , 46 , 50 , 55 ]. Studies that used a societal perspective (6/27, 22%) also included indirect costs, such as productivity losses [ 33 , 38 , 43 , 46 , 55 , 56 ]. Details on the perspectives and included costs are provided in Multimedia Appendix 3 [ 19 , 20 , 31 - 57 ].…”

“…Most of the economic evaluations (7/9, 78%) of noninvasive remote monitoring devices were compared to SoC [ 19 , 20 ] as defined in the international guidelines [ 31 , 33 - 35 , 38 , 39 ]. Although the definitions of SoC are similar, some of the studies (2/9, 22%) provided additional details regarding the follow-up procedures, such as SoC with follow-up once a week [ 36 ] or 4 preplanned outpatient clinic visits [ 37 ].…”