Evaluating the Cost Utility and Budget Impact of Telehealth services: A Systematic Review and Meta-Analysis

doi:10.21203/rs.3.rs-4999453/v1

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Systematic Review

Evaluating the Cost Utility and Budget Impact of Telehealth services: A Systematic Review and Meta-Analysis

https://doi.org/10.21203/rs.3.rs-4999453/v1

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Introduction:

Telehealth, a rapidly advancing sector within the healthcare industry, has become a key tool in shaping policy decisions and the future of the healthcare delivery. However, the quality of evidence on telehealth's economic impact is somewhat limited, as many studies treat economic findings as secondary results rather than conducting thorough cost-utility or budget impact analyses. The lack of systematic and generalizable research on the routine use of telehealth limits understanding of its costs, benefits, and barriers to broader adoption.

Methods:

A systematic literature review was conducted, searching databases such as PubMed, Embase, and Cochrane Library for relevant systematic reviews from the past decade. The search terms used were a combination of keywords and Medical Subject Headings (MeSH) terms related to "telehealth," "cost-utility," "economic outcomes," "QALY" (Quality-Adjusted Life Year), "Incremental Cost-Effectiveness Ratio" (ICER), "cost-effectiveness," "cost-benefit," "cost-analysis," and "economic evaluation."

Results:

Based on inclusion and exclusion criteria, 24 studies were finally included in the analysis. The results suggest that telehealth interventions are generally cost-saving on a per-patient basis, but the total financial impact can be higher due to broader implementation or additional costs associated with scaling the intervention.

Conclusion:

Telehealth has great promise for bettering patient outcomes and the delivery of healthcare by facilitating access to treatment and relieving pressure on healthcare systems. However, considering both average and total costs in budget impact analyses is important, as cost savings at an individual level do not always translate into lower overall expenditures. Hence, any decision regarding its implementation should be taken keeping this in mind.

Health Policy

Cost Utility

Budget impact

Tele-Health

Telehealth, a rapidly advancing sector within the healthcare industry, has become a key tool in shaping policy decisions and the future of the healthcare delivery. Fundamentally, telehealth utilizes digital technologies to provide healthcare services remotely, enabling providers to connect with patients and offer care from a distance.(1). This broad concept encompasses a range of services, including clinical care, patient education, and public health administration. It is not just limited to the tele-conferencing services, it has found its utility in speech pathology services (2), tele-rehabilitation services (3), tele-dermatology (4), tele-pathology (5), tele-radiology (6), tele-pharmacy (7), tele-homecare services (8), virtual health assistants and medical chatbots (9) Telehealth services can be delivered through various modes of technology- videoconference, telephone, apps, device or monitoring systems, and web-based technologies, each offering unique benefits (10).

Telehealth has been linked to several positive health outcomes, including lower mortality, morbidity and emergency admission rates, since early intervention and continuous monitoring can lead to early detection and treatment of health issues, potentially reducing & preventing complications, thereby reducing morbidity & mortality rates (11).

The expansion of telehealth has been particularly impactful in improving access to healthcare services. Telehealth can enhance patient outcomes, boost efficiency, and reduce the burden on healthcare systems, especially in underserved communities (12). It addresses the unique challenges faced by the communities such as limited access to specialists, transportation barriers, and shortages of healthcare providers (13). This is crucial in areas where there is a scarcity of healthcare providers, as telehealth enables primary care providers to collaborate with specialists in other locations. (14) Research indicates that telehealth services can lead to positive outcomes, such as higher patient satisfaction, better chronic disease management, and reduced healthcare costs. (12, 13, 15, 16)

The COVID-19 pandemic has accelerated telehealth adoption as healthcare systems quickly adapted to provide care while minimizing in-person contact (17). Consequently, telehealth has been crucial in maintaining care continuity and ensuring patient safety during the pandemic (15). A review of literature from the first six months of the pandemic found a positive sentiment towards telehealth, suggesting it may significantly advance future healthcare (18).

Economic evaluations of telehealth services show mixed results, depending on the context and specific use case. Some studies highlight its cost-effectiveness in home care and access to on-call specialists (19), while others report mixed results for rural services and lack of cost-effectiveness for local services between hospitals and primary care (19–21). For instance, although healthcare services might spend more on telehealth, societal perspectives indicate cost savings due to reduced patient travel. Implementing Telehealth Home Monitoring Services (THMS) necessitates a significant upfront investment. However, in a period of budget constraints, this investment can be economically justified. The initial costs are quickly recouped through immediate reductions in medical resource usage, leading to significant savings over the medium & long term. (22) Some studies also recommend implementing the program in medium and high volume centers to benefit from the effect of fixed cost degression. (23)

Research has shown that the rise in health system expenses can be attributed to the costs of implementing telehealth (such as equipment, software, and staff training), the increased use of other healthcare services (like pharmaceuticals), and the continuous operational costs (including staff salaries). These expenses arise because telehealth is often an addition to traditional healthcare services. Although telehealth is frequently perceived as a cost-effective healthcare solution, with expectations of direct cost savings from decision-makers, this study indicates that telehealth does not consistently lower health system costs. Instead, it can actually lead to higher expenses during both the implementation phase and ongoing service delivery. (24, 25) Conversely, some studies indicate that telehealth interventions have resulted in significantly lower overall healthcare costs compared to standard care for patients (26, 27).

The quality of evidence on telehealth's economic impact is somewhat limited, as many studies treat economic findings as secondary results rather than conducting thorough cost-utility or budget impact analyses (19, 21, 28). Nonetheless, the organizational model of care appears to be a key factor in the value of telehealth services. Programs like telerehabilitation and video conferencing for general practices show potential cost-effectiveness by improving access and quality of care while reducing patient travel and healthcare costs (19). However, results are mixed, with some studies finding no significant difference in outcomes between telehealth and traditional care. In a study, it was found that the cost per quality-adjusted life year (QALY) using telemedicine was significantly lower compared to standard ophthalmoscopy (29).

The lack of systematic and generalizable research on the routine use of telehealth limits understanding of its costs, benefits, and barriers to broader adoption (20). Further research is necessary to better understand the economic impact of telehealth, prompting the need for a comprehensive meta-analysis to consolidate available knowledge.

Study Design

The study aimed to systematically review and analyze the cost-utility and budget impact of telehealth compared to traditional in-person healthcare. This systematic review and meta-analysis were registered with the International Prospective Register of Systematic Reviews (PROSPERO). The methodology adhered strictly to the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-2020) checklist, ensuring a rigorous and standardized approach.

Search Strategy

A comprehensive search strategy was meticulously designed to cover a wide range of studies focused on the economic aspects of telehealth. The search encompassed several key databases including PubMed, Scopus, CINAHL, and the OVID Library, spanning from their inception to the current date. The search terms used were a combination of keywords and Medical Subject Headings (MeSH) terms related to "telehealth," "cost-utility," "economic outcomes," "QALY" (Quality-Adjusted Life Year), "Incremental Cost-Effectiveness Ratio" (ICER), "cost-effectiveness," "cost-benefit," "cost-analysis," and "economic evaluation."

In addition to the database search, the reference lists of included studies and relevant systematic reviews were manually examined to identify further studies. Grey literature sources, such as conference proceedings, thesis repositories, and relevant organizational websites, were explored to capture unpublished studies and reports. To ensure no significant studies were missed, manual searches of reference lists from included studies and relevant reviews were conducted. Moreover, search alerts were set up in the databases to capture any new publications throughout the review process, ensuring that the review remained current.

Study Selection

The selection of studies was conducted in two rigorous phases to enforce eligibility criteria. Initially, two independent reviewers screened the titles and abstracts of the identified records for relevance based on predefined inclusion and exclusion criteria. Records deemed potentially relevant were then moved to the next phase. In the second phase, the full texts of these potentially relevant studies were independently assessed by the same reviewers to determine their final inclusion in the review. Any disagreements that arose during the screening process were resolved by a third reviewer, ensuring a consensus on the studies selected for inclusion. The study selection process was documented using a PRISMA flow diagram, which detailed the number of records identified, screened, assessed for eligibility, and included in the review, along with reasons for exclusions at the full-text stage.

Eligibility Criteria

The eligibility criteria focused on studies that directly compared telehealth to traditional in-person healthcare methods and reported on economic outcomes such as cost savings, cost-utility ratio, ICER, and QALY. The review included only studies published in English in peer-reviewed journals, excluding those that lacked specific economic data or detailed economic evaluations, and those focusing on telemedicine outside the scope of healthcare services. Only original articles on economic analysis were considered, ensuring the inclusion of high-quality, relevant studies.

Data Extraction

The data extraction process was meticulously executed using a detailed and standardized form to ensure the comprehensive collection of pertinent information from each included study. The form was structured to capture various key elements crucial for the review's objectives. Study identifiers were recorded, encompassing the title, DOI, author(s), publication year, and geographical location, facilitating easy reference and categorization of studies. Detailed information on the study design, study population demographics, clinical conditions, and sample size was documented to provide insight into the context and generalizability of the findings.

Economic evaluation metrics were meticulously logged, including the currency reported in the study, conversion to USD (2023) for standardization, types of costs measured (direct and indirect), utility outcomes such as QALYs, cost-utility ratios, and cost-effectiveness outcomes like ICERs, essential for assessing the economic impact of telehealth interventions. Intervention details were comprehensively described, outlining the telehealth intervention and the comparison group, including modality, duration, and intensity, facilitating an understanding of the specific aspects evaluated. Outcome measures were meticulously recorded, encompassing primary and secondary outcomes, types of costs, utilities, and cost-effectiveness outcomes, along with any additional outcomes relevant to the review's objectives.

Economic data were meticulously extracted, including Incremental Cost-Effectiveness Ratios (ICER) with standard deviation (SD), mean, and median; incremental cost-utility ratio (ICUR) with mean and median; interquartile range; total cost for intervention and control groups; average costs for both groups with SD, mean, and median; and a breakdown of direct and indirect costs with SD, mean, and median. This facilitated a comprehensive economic analysis. Health outcome data, including QALYs and Disability-Adjusted Life Years (DALYs) for both intervention and control groups were documented to evaluate the health impact of the interventions.

Quality Assessment

The quality of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, which is specifically designed for evaluating the reporting quality of economic evaluations in healthcare. Each study was evaluated against the CHEERS checklist items to ensure comprehensive coverage of essential aspects such as study objectives, economic importance, choice of comparators, time horizon, choice of health outcomes, measurement of effectiveness, estimation of resources and costs, currency valuation, choice of model for data analysis, analytical methods, and characterizing uncertainty.

Two independent reviewers conducted the quality assessment to minimize bias and ensure reliability in the evaluation process. Any discrepancies in the quality assessment between the reviewers were resolved through discussion or consultation with a third reviewer. The findings from the quality assessment were synthesized to provide an overview of the reporting quality of economic evaluations in the included studies, highlighting strengths and potential areas for improvement.

Statistical Analysis

The statistical analysis plan was designed to synthesize the data extracted from the included studies and assess the cost-utility of telehealth interventions. The analysis was conducted using the ggplot2 library within the R software to create a visually intuitive scatter plot.

For the Cost-Utility Scatter Plot, data spanning from 2010 to 2023 regarding Incremental Cost-Effectiveness Ratios (ICERs) and Quality-Adjusted Life Years (QALYs) from various healthcare interventions were compiled and processed. The 'Year' of each intervention was categorized to facilitate temporal analysis, and ICER values were standardized. A scatter plot was then generated using ggplot2 in R, plotting ICER values against QALY gains, with data points color-coded by year. This visual representation allowed for the analysis of trends and patterns in the cost-effectiveness of telehealth interventions over time.

In the Probability Sensitivity Analysis (PSA), a Monte Carlo simulation was employed to address uncertainties in cost and QALY estimates. Triangular distributions, defined by minimum, most likely, and maximum values, were used for both costs and QALYs. For each of 10,000 iterations, a simulated ICER value was calculated by sampling from these distributions. The resulting ICER values were summarized to produce a density plot, illustrating the distribution of potential cost-effectiveness outcomes and highlighting the most probable ICER values alongside the range and skewness indicative of less cost-effective scenarios.

The Budget Impact Analysis involved comparing the average and total costs between the control and intervention groups. Bar charts were created to graphically represent these comparisons, providing a clear visual indication of the economic impact of telehealth interventions.

The study began with a comprehensive search across multiple databases, resulting in 3853 records. After removing duplicates and screening titles and abstracts, 363 full-text articles were assessed for eligibility. Based on inclusion and exclusion criteria, 24 studies were finally included in the analysis. The PRISMA flow diagram effectively illustrates this meticulous selection process, ensuring the inclusion of relevant and high-quality studies.

Quality Assessment: CHEERS Checklist (30)

The Risk of Bias assessment using the CHEERS checklist, as depicted in both the table and the bar chart, provides a comprehensive view of the reporting quality across multiple economic evaluations. The green segments in the bar chart, representing affirmative responses to the CHEERS checklist items, suggest that the majority of the studies adhere to many of the recommended reporting standards. However, notable red segments indicate areas where several studies failed to meet specific criteria. For instance, some checklist items, perhaps those related to the economic model's complexity or the valuation of outcomes (as hypothetical examples, Q14 and Q20), show a higher incidence of non-compliance, suggesting that these are areas where future studies could improve. The predominance of green across most items indicates a general strength in reporting practices, but the presence of red underscores the need for a more rigorous and standardized approach to reporting economic evaluations in health care to ensure clarity, replicability, and transparency.

Basic Characteristics Table

A detailed table summarized the basic characteristics of the included studies, which spanned from 2006 to 2023 and covered various countries and healthcare contexts. These studies investigated the efficacy and cost-effectiveness of diverse telehealth interventions, ranging from telemonitoring and telerehabilitation to digital patient engagement platforms. The interventions were compared against standard care practices, with outcomes primarily focused on the total costs incurred by the intervention and control groups.

Table 1

Basic characteristics of included studies
Author, Year, Place	Study design	Sample size	Types of Telehealth Intervention	Comparator outcome	Outcomes (Total Cost - Intervention)	Outcomes (Total Cost - Control)
Ilan M 2006 et al,Israel (31)	RCT	81	Telepsychiatry treatment via videoconferencing	In-person care.	$14527.5	$77380.8
Giordano A et.al,2009, Italy(32)	RCT	460	Home-based telemonitoring (HBT) program.	Usual care (UC) program.	€843+/-1733.	€1298+/-2322.
Pyne JM et al 2010(33)	RCT	395	A telemedicine-based collaborative care depression intervention.	usual care.
Boyne JJ et al,2013,Netherland (34)	RCT	382	Telemonitoring Programm	Usual care (UC) program	€ 16,687	€ 16,561
Frederix I et al,2015,Belgium (35)	RCT	140	Telerehabilitation programme	conventional cardiac rehabilitation	€2156 ± €126 per patient	€2720 ± €276 per patient
Isetta V et al,2015, Spain (36)	RCT	139	Telemedicine impact on treatment compliance	traditional face-to-face follow-up.	€ 11,619.60	€ 12,628
Kidholm K et.al, 2016,Denmark (37)	RCT	151	Cardiac telerehabilitation (CTR) program	Traditional rehabilitation program at the hospital	€ 5,709	€ 4,045
Celano MC et al 2016, USA (38)	RCT	183	Collaborative care	Usual care	INR48,287	INR20,920
Frederix I et al, 2017, Belgium (39)	RCT	126	Cardiac telerehabilitation program	Classic 12-week center-based cardiac rehabilitation program	€3262 ± €339	€4140 ± €513
Rosner IB et.al,2017,California (40)	cohort study	558	Automated digital patient engagement (DPE) platform	Proximate historical control, comparing patients who underwent total joint arthroplasty (TJA)	$9317.91	$8534.91
Painter TJ et al,2017,USA (41)	RCT	265	telemedicine-based collaborative care model	standard PTSD care provided	$9482.88	$9544.38
Nelson M et.al,2019, Australia (42)	RCT	70	Telerehabilitation program	Traditional in-person care	$487.22	$516.12
Fatoye F et.al,2020,Nigeria (43)	RCT	47	Telerehabilitation-based McKenzie therapy (TBMT).	Clinic-based McKenzie therapy (CBMT).	$61.7	$106.22
Jiang X et.al,2020,china (44)	RCT	10913	Telemonitoring-guided management	Physician's office visits	$243,423	$238146
Longacre FC et.al,2020,USA (45)	RCT	516	Tele-rehabilitation interventions	Usual care	$30481	14130 USD
Niewada M et.al,2021,Poland (46)	RCT	795	Hybrid telerehabilitation	Standard care	1776 PLN	7644 PLN
Brouwers WM et.al,2021, Netherland (47)	RCT	300	Cardiac telerehabilitation (CTR)	Center-based cardiac rehabilitation (CR)	$39168	$26166
Aspvall K et al,2021, Sweden (48)	RCT	152	Stepped-care group utilizing telehealth methods	in-person cognitive behavioral therapy group.	$6081	$7527
Lee YY et 2022, Australia (49)	RCT	1868	a person-centred e-health platform	usual care.	$5554769.99	$856544.52
Langergaard A et al,2022, Denmark (50)	RCT	76	online modules	face-to-face consultations	£1118.4	£1946.81
Senanayake S et.al,2023, Nigeria (51)	RCT	47	Hybrid cardiac telerehabilitation program	Traditional centre-based cardiac rehabilitation	20600000 $	20000000$
Liu T et.al,2023, China (52)	RCT	100	Digital therapeutics	Conventional home-based cardiac rehabilitation	42,300.26 CNY	38,442.11 CNY
Harris A et.al,2023, Australia (53)	RCT	415	Telehealth-delivered exercise programs	Education control group	1,678 ± 3,215 $	1,356 ± 2,635 $
Naversnik et al 2023, Slovenia (54)	Trial	46	E-health service	usual care for depression.	$1368.51	$1216.08

Cost-Utility

Cost-Utility Analysis

Scatter Plot Analysis:

The Cost-Utility Scatter Plot, which plotted Incremental Cost-Effectiveness Ratios (ICERs) against Quality-Adjusted Life Years (QALYs) from 2010 to 2023, revealed several key insights. The dense clustering of data points towards the origin of the plot indicated that many telehealth interventions were both economically favorable and efficacious. This clustering suggests that telehealth often achieves significant health gains for relatively low incremental costs. Additionally, the plot displayed a trend towards more cost-effective healthcare practices in recent years, with newer interventions appearing lower on the Y-axis, indicating reduced costs per QALY gained.

Temporal Trends and Variability:

Color-coding the data points by year allowed for the observation of temporal trends in the cost-effectiveness of telehealth interventions. Points from recent years, appearing lower on the Y-axis, suggest a trend towards more cost-effective healthcare interventions, possibly due to advancements in telehealth technology and improved healthcare delivery practices. The plot also highlighted inter-year variability, with some years showing tightly clustered data points, indicating consistent reporting and similar intervention types, while other years exhibited broader distributions, reflecting greater variability in the types of interventions and cost-effectiveness assessments.

Quadrant Analysis:

The plot segmented into four quadrants illustrated different cost-effectiveness scenarios. The optimal Southwest quadrant, indicative of interventions that are both less costly and more effective, showed an increase in data points over time. This trend points towards advancements in telehealth technology and policy optimizations that enhance healthcare efficiency. In contrast, the Northeast quadrant, representing costlier yet more effective interventions, had fewer entries, indicating that while some interventions require higher costs, their effectiveness justifies these expenditures. The Southeast quadrant, which would represent more expensive and less effective interventions, was conspicuously sparse, indicating that such interventions are rarely adopted. The Northwest quadrant, capturing less costly but also less effective interventions, had some entries, suggesting that these interventions might be acceptable in budget-constrained circumstances.

Probability Sensitivity Analysis (PSA):

The density plot of simulated Incremental Cost-Utility Ratios (ICURs) from the Monte Carlo simulation revealed a unimodal distribution with a pronounced peak at lower ICUR values, indicating that most simulated scenarios resulted in cost-effective interventions. The mean ICUR value was approximately 9,402, with a median around 7,063, suggesting a right-skewed distribution. This skewness implies that while many telehealth interventions are likely to be cost-effective, there is a significant portion with higher costs per QALY. The right tail of the distribution highlighted the potential for less cost-effective scenarios, emphasizing the importance of considering the full range of ICUR values in economic evaluations.

Budget Impact Analysis

Average and Total Costs:

The bar charts comparing average and total costs between the control and intervention groups provided a clear visual representation of the economic impact of telehealth interventions. The average cost per individual for the control group was approximately $18,763, while for the intervention group, it was lower at about $17,847. This difference suggests that, on an individual basis, telehealth interventions can lead to cost savings compared to traditional in-person healthcare.

However, the total costs for the intervention group were higher, at approximately $356,951, compared to $318,972 for the control group. This finding indicates that, despite lower average costs per individual, the overall financial impact of the intervention group was greater. This discrepancy could be attributed to the intervention being applied to a larger population, requiring more resources, or other factors driving up the total cost.

Interpretation:

The results suggest that telehealth interventions are generally cost-saving on a per-patient basis, but the total financial impact can be higher due to broader implementation or additional costs associated with scaling the intervention. These findings highlight the importance of considering both average and total costs in budget impact analyses, as cost savings at an individual level do not always translate into lower overall expenditures.

The purpose of this systematic review and meta-analysis was to assess the cost-utility of telehealth services in relation to conventional techniques. The results show that telehealth interventions were successful and profitable at the same time. The intervention group had a larger overall financial effect while having lower average expenses per person. Taking into consideration the advantages and disadvantages of the included studies, the discussion will focus on the significance of these results for future research, practitioners, and healthcare policymakers.

Economic Aspect of Telehealth services:

The majority of the included studies showed that telehealth treatments had good cost-utility ratios, demonstrating the technology's promise for economically viable healthcare delivery. For example, Ilan M. et al.'s (2006) (31) research showed that videoconferencing for telepsychiatry therapy was both much less expensive and more successful in the intervention group than in the control group, saving $62853.3 per patient. Similar results were seen for other telehealth services as well, such as person-centered e-health platform (49), cognitive behavioural therapy (48), and cardiac telerehabilitation (39). This result is consistent with the larger pattern of healthcare treatments gradually shifting towards more economical methods, as our cost-utility scatter plot illustrates.

There were exceptions to this encouraging conclusion, however. For instance, Kidholm et al. (2016) (37) discovered that a cardiac telerehabilitation programme was more costly and did not result in an improvement in quality of life for patients with chronic heart failure than standard therapy. The cardiac telerehabilitation intervention was shown to be $13002 more expensive than the control group in another research by Brouwers WM et al. in 2021 (47). Similar results were found by Rosner IB et al. (2017)(40) in patients who had total joint arthroplasty (TJA), with the automated digital patient engagement (DPE) platform being more expensive than the traditional approach. This variability emphasises how crucial context-specific assessments are when thinking about telehealth service deployment. The cost-effectiveness of telehealth treatments may be greatly impacted by variables including the kind of telehealth services provided, the patient demographic, and the infrastructure of the healthcare system.

The total expense of telehealth services is a complicated matter that must take into account possible trade-offs, unforeseen effects, and direct and indirect expenses. (55, 56)

The time of the providers, medical supplies, technical infrastructure, and reimbursement rates are direct expenditures related to telehealth services. Resources that help with patient contacts, such clinic space, administrative assistance, and patient transportation, might be included in indirect expenses (56). In the short term, expenses may rise due to the potential need for upfront investments in order to establish and maintain the telehealth-related technology infrastructure (21). Furthermore, because of redundant services or ineffective workflows, telehealth services may raise costs if they are not appropriately incorporated into the current care delivery paradigm (55).

Another factor that can impact the cost-effectiveness of telehealth is the specific application and context in which it is used. Numerous technologies fall under the umbrella of telehealth, and the financial consequences might differ greatly based on the specific intervention, patient demographic, and healthcare environment. For instance, speciality settings like telepsychiatry, where there is a greater chance of better access and shorter travel times, may make the cost-effectiveness of telehealth easier to verify (56).

Budget Implications:

On doing budget impact analysis, we found that the average cost per individual for the interventional group was lower than the control group. This difference suggests that, compared to conventional in-person healthcare, telemedicine treatments may result in cost savings for each individual. On the other hand, the intervention group's total cost was higher as compared to the control group's expenditures. This disparity may be from applying the solution to a wider population, which would need more resources, or from other variables that raise the overall cost. These findings are similar to a scoping review by Snoswell CL et al. (2020) (21) which concluded that telehealth can result in a reduced marginal cost per patient overall, however Increased productivity under activity-based funding, fee-for-service, or a capitation reimbursement model will increase the total cost for the health system. According to another review that included fourteen studies found that telehealth actually raise expenses during the deployment and continuing service delivery phases and does not consistently save costs for the health system. (25)

The inherent variation and uncertainty in economic assessments of telehealthcare technology is shown by the probability sensitivity analysis carried out in this research. A variety of possible cost-effectiveness outcomes were shown by the density plot of simulated incremental cost-utility ratio (ICUR) values, with a central tendency around cost-effective values and a significant probability of running into less cost-effective situations. In order to ensure complete understanding and well-informed choices about the implementation of telerehabilitation, decision-makers need to take into account the whole spectrum of possible consequences.

Strengths & Limitations of the study-

This SRMA has many key strengths. First is the inclusion of studies from all countries, involving the major data bases- pubmed, scopus. The review included studies involving a variety of telehealth interventions not just limited to tele-monitoring or tele-rehabilitation. The meticulous selection process, including the removal of duplicates and screening of titles and abstracts, followed by a full-text review, demonstrates a rigorous methodology aimed at including only high-quality studies.

The systematic review and meta-analysis on telehealth interventions has demonstrated a positive effect size, highlighting the strength and robustness of the available evidence. The heterogeneity of the studies included in the review is a key factor in assessing the strength and generalizability of the findings. The systematic review has synthesized a large and disparate body of evidence on the impact of telehealth on clinical outcomes. The review has mapped the existing literature on telehealth, providing an overview of the current state of evidences and identifying areas where further research is needed.

Even though the heterogeneity is a key factor in generalising the study finding, this can still be a limiting factor as heterogeneity in terms of telehealth interventions, study population, clinical settings, the limited number of heterogeneous studies all make it difficult to draw definite conclusions, as many other factors too play a role including. the heterogeneity of telehealth interventions, patient populations, and clinical settings can also pose challenges for systematic reviews and meta-analyses, which can make it difficult to draw definitive conclusions.

Telehealth is a broad term that encompasses a wide range of technologies and modalities, each with its own unique characteristics and potential impacts. Consequently, it can be challenging to synthesize the evidence and draw meaningful conclusions about the overall effectiveness of telehealth.

Strengths:

This SRMA has many key strengths. First is the inclusion of studies from all countries, involving the major data bases- pubmed, scopus etc. The review included studies involving a variety of telehealth interventions not just limited to telemonitoring or tele rehabilitation. This comprehensive study provides a holistic assessment of the cost-utility of telehealth services across various medical fields and geographical locations. The rigorous methodological approach, including thorough selection criteria, screening processes, and the use of standardized checklists for assessing reporting quality, ensures the reliability and validity of the findings.

The study includes detailed economic evaluations, such as cost-utility ratios, budget impact analysis, and probability sensitivity analysis, offering a nuanced understanding of the financial implications of telehealth interventions. The findings acknowledge the variability in cost-effectiveness based on the type of telehealth service, patient demographics, and healthcare settings, providing crucial context-specific insights for tailoring telehealth implementations to specific needs and environments. The review has mapped the existing literature on telehealth, providing an overview of the current state of evidence and identifying areas where further research is needed.

The study's findings offer valuable insights for healthcare policymakers, highlighting the potential cost savings and financial sustainability of telehealth services. The study provides recommendations for creating conducive environments for telehealth adoption and the importance of strong assessment frameworks, which can inform policy decisions and support the widespread implementation of telehealth.

Limitations:

The included studies in the review varied widely in terms of the types of interventions, patient populations, and healthcare settings. For ex- One study included is of cardiac telerehabilitation conducted in Netherland and another in Nigeria; (47, 51) while the study intervention is almost same but the study population is very diverse, while one is a developed nation, the other a very underdeveloped country. This heterogeneity can make it challenging to draw definitive conclusions and generalize the findings across all telehealth applications.

Most of the included studies focus on the short- to medium-term cost-utility of telehealth interventions. For ex- Ilan m et al. (31) conducted a study to see the effectiveness of telepsychiatry via videoconferencing in Israel, but then the follow up was for only 1 year. This short to medium term follow doesn’t showcase the complete treatment cost in the long run. There is a need for more longitudinal studies to assess the long-term economic effects and sustainability of these services.

The study also highlights potential implementation challenges, such as the need for upfront investments in technology infrastructure and the risk of increased costs if telehealth services are not well-integrated into existing healthcare delivery models.

Recommendations-

Standardize Cost-Utility Analyses: Future research should prioritize the development and implementation of standardized methodologies for conducting and reporting cost-utility analyses of telehealth interventions. This includes clearly defining cost components, measuring outcomes consistently, and employing appropriate analytical techniques.

Focus on Technological Trends: Future research should prioritize evaluating telehealth interventions that reflect the current technological landscape. To ensure the relevance of findings, it is crucial to conduct continuous updates and re-evaluations.
Address Long-Term Sustainability: Investing in longitudinal studies is essential to understand the long-term economic impacts and sustainability of telehealth services.. This involves assessing the scalability of these interventions, evaluating their impact on healthcare utilization patterns over extended periods, and exploring innovative funding models to support their continued implementation.
Enhance Integration and Interoperability: Policymakers and healthcare institutions should focus on promoting the seamless integration of telehealth services into existing healthcare delivery systems. This includes addressing issues related to interoperability, data sharing, and reimbursement policies to facilitate the efficient and effective utilization of telehealth technologies.
Prioritize Patient-Centered Outcomes: Economic evaluations of telehealth interventions should prioritize patient-centered outcomes, such as quality of life, patient satisfaction, and access to care. This will provide a more comprehensive understanding of the value proposition of telehealth from the patient's perspective.
Promote Digital Literacy and Access: Efforts should be made to bridge the digital divide and ensure equitable access to telehealth services. This includes promoting digital literacy among patients, expanding broadband internet access in underserved areas, and addressing language barriers and other potential disparities in telehealth utilization.
Establish Robust Policy Frameworks: Policymakers should develop and implement comprehensive policy frameworks that consider the diverse healthcare needs, patient demographics, and technological capabilities across different regions and healthcare settings.

This will enable informed decision-making regarding the adoption and scaling of telehealth services. These recommendations can help guide future research, policymaking, and the implementation of telehealth interventions to ensure their long-term sustainability and maximize their cost-effectiveness for the healthcare system and its patients.

The present systematic review and meta-analysis aimed to synthesize the available evidence on the economic impact of telehealth interventions compared to conventional in-person healthcare approaches.

The results provide strong evidence in favour of the lower average costs seen in the intervention group when juxtaposed with conventional in-person techniques. Most of the studies showed favourable cost-utility ratios and indicated that better health outcomes may be achieved at similar or lower prices.

However, the review also highlighted that the nation's economy is negatively impacted by the total costs incurred. When integrating telehealth services into healthcare systems, these findings will have a significant impact on practitioners and policymakers in the healthcare industry. Hence, the findings of this study be handled with caution.

The wide range of cost-effectiveness results underscores the need for context-specific analyses and the consideration of potential uncertainties. Future research should focus on filling the gaps and providing more thorough proof of the long-term economic effects of telehealth.

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The authors declare no competing interests.

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Evaluating the Cost Utility and Budget Impact of Telehealth services: A Systematic Review and Meta-Analysis

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