Online asthma management for children is cost-effective

Abstract

To the Editor: eHealth interventions have been proposed as an appealing method to improve health outcomes and reduce healthcare costs [1][2][3]. However, the development of an eHealth intervention is associated with high costs and this investment needs to be balanced by increased clinical effectiveness and related cost savings. Unfortunately, solid evidence for the effectiveness of eHealth with regard to health improvement is still limited [2-5], as is evidence regarding cost-effectiveness. This causes uncertainty about the effectiveness of eHealth and constitutes a barrier towards successful implementation in daily practice [6,7]. Thus, it is necessary to assess both effectiveness and cost-effectiveness to convince colleagues and policymakers of its added value.We assessed the cost-effectiveness of online asthma care for children alongside a randomised controlled trial (RCT) to evaluate the effectiveness of this eHealth intervention on health improvement [8]. In this RCT, 210 asthmatic children were randomly allocated into two groups of asthma management. In the usual care (UC) group, care consisted of routine 4-monthly outpatient visits where asthma control was assessed with an asthma control test (ACT)/children's asthma control test (C-ACT) [9]. Alternatively, in the virtual asthma clinic (VAC) group, outpatient visits were reduced by 50% and asthma control was monitored online with monthly web-based ACT/C-ACT tests. In the VAC group, children had more symptom-free days per month and their ACT/C-ACT scores were more improved. As such, this RCT proved that routine outpatient visits can partly be replaced by online asthma management using the VAC.We carried out an a priori defined cost-effectiveness analysis with the hypothesis that online management via the VAC is cost-effective. Standard cost questionnaires were completed by the parents every 4 months to assess costs from both a healthcare and a societal perspective. Healthcare (or direct) costs included all costs related to medical conditions, prescribed medication and intervention costs (including development of the VAC and estimated hosting and licence costs). Societal (or indirect) costs consisted of the loss of productivity, travel costs for any medical condition and parking expenses. The costs were based on the Dutch guideline for cost analyses [10] although if prices were not available other sources were used. Prices were converted to the 2014 level using the Dutch consumer price index [11].Mean incremental costs were weighted against the mean incremental effects in terms of asthma-related quality of life (QoL) and asthma control. Uncertainty boundaries of 95% for the incremental cost-effectiveness ratio (ICER) were determined nonparametrically using bootstrap analyses. In this bootstrap simulation, 1000 random samples of cost-effect pairs were selected with replacement. Results from the simulation were presented graphically in a scatter plot in which each dot signifies the ICER of one iteration of the bootstrap stimulation. Two validated questionnaires...

Barriers and Facilitators When Implementing Web-Based Disease Monitoring and Management as a Substitution for Regular Outpatient Care in Pediatric Asthma: Qualitative Survey Study

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