Cost-effectiveness of telemedicine versus standard care for the management of diabetes mellitus, hypertension and heart failure: meta-analysis of randomized trials. (Preprint)

Background: The effectiveness of telemedicine strategies for the efficient management of chronic diseases has been evaluated in a number of studies, and the most recent umbrella review of meta-analyses on the topic concluded that there is sufficient evidence supporting the use of telehealth for patients with diabetes, hypertension, and heart failure. However, in-depth assessments of the cost-effectiveness of telemedicine are severely lacking. Objective: This meta-analysis aimed at estimating the incremental cost-effectiveness ratios (ICERs) of telemedicine for the management of type 2 diabetes mellitus, hypertension, and heart failure. Methods: We searched MEDLINE, Scopus, ClinicalTrials.gov, and the Tufts Medical Center Cost-Effectiveness Analysis Registry for all randomized or quasi-randomized trials that evaluated the cost-effectiveness of telemedicine vs standard care for managing the selected diseases. The outcomes were the ICER per quality-adjusted life year (QALY) gained, a reduction in systolic blood pressure of 1 mm Hg, or a reduction in hemoglobin A1c of 1% after 12 months of follow-up. Random-effects meta-analyses were run when sufficient data were provided, and weighted ICER means were computed. Results: A total of 27 trials were included in this meta-analysis (with a total of 15,658 patients): 40.7% (n=11) on hypertension, all using telemonitoring; 22.2% (n=6) on heart failure; and 37% (n=10) on diabetes, mostly using telephone support. Meta-analyses were possible for only two outcomes, as most trials did not report a measure of dispersion: (1) the summary estimate of ICER per QALY gained among patients with heart failure based on 11.1% (n=3) of the trials (1825 patients) was US $45,741 (P=.24), whereas the weighted mean based on 18.5% (n=5) of the trials (3288 patients) was US $40,271 (SD 22,933) and (2) the summary estimate of ICER per systolic blood pressure reduction of 1 mm Hg based on 18.5% (n=5) of the studies (1986 patients) was US $27, whereas the weighted mean was US $132 (SD 227) based on 33.3% (n=9) of the trials (3450 patients). The weighted means of ICER per QALY gained for hypertension and diabetes were US $18,966 (SD 13,286; n=3, 11.1% of the studies and 1437 patients) and US $44,725 (SD 18,925; n=5, 18.5% of the studies and 2949 patients), respectively. Finally, the weighted mean of ICER per 1% hemoglobin A1c reduction was US $3349 (SD 2249; n=7, 25.9% of the studies and 4157 patients). Some of the estimates were substantially lower when only recent trials were considered. Conclusions: The results support using telemedicine as a cost-effective strategy to monitor hypertension, heart failure, and, depending on the willingness to pay, diabetes. Further randomized controlled trials reporting CIs for ICER are required to confirm these findings.