@Article{info:doi/10.2196/60488, author="Stanimirovic, Aleksandra and Francis, Troy and Meerai, Sonia and Mathew, Suja and Ibrahim, Sarah and Bowen, M. James and PIkula, Aleksandra and Rac, Valeria", title="Diabetic Retinopathy Screening Among at Risk Populations: Protocol for Distributional Cost-Effectiveness Analysis", journal="JMIR Res Protoc", year="2025", month="Apr", day="30", volume="14", pages="e60488", keywords="diabetic retinopathy", keywords="equity of care", keywords="distributional cost-effectiveness analysis", keywords="health equity", keywords="health care disparities", keywords="intersectionality", keywords="telehealth", keywords="telemedicine", keywords="retinopathy screening", abstract="Background: Diabetic retinopathy (DR) remains the primary vision complication of diabetes and the leading cause of blindness among adults, with up to 30\% prevalence among low-income populations. Tele-retina is a cost-effective screening alternative to vision loss prevention, yet there is an adverse association between screening and income. Intersectionality theory notes that barriers to achieving health equity result from the intersection of personal and social characteristics. Experiences at this intersection are influenced by interpersonal and structural systems of oppression. Studies have found that tele-retina is the preferred strategy over standard of care screening for at-risk populations. No study has assessed the economic equity impact of DR screening using a theoretical foundation. Objective: This study aims to address shortcomings related to the utilization of intersectionality theory in the economic evaluation of DR screening. We propose conducting a distributional cost-effectiveness analysis (DCEA) of the tele-retina program. Methods: The study will be undertaken using a deductive theoretical drive sequential multimethod approach, consisting of two studies: (1) a modified Delphi study and (2) DCEA. The Delphi panel (patient partners, field experts, and decision makers; N=35-50) will select the social constructs (eg, age, gender) for at-risk populations and potential trade-offs between health maximization and equity. The research will be guided by a social theory framework (intersectionality theory) to understand the impact of social constructs on economic outcomes. Social constructs that are selected by the Delphi panel will be integrated into the validated tele-retina cost-effectiveness analysis model, which will serve as a case study for DCEA. Results: We have submitted the research ethics board application to the University Health Network Research Ethics Board and are expecting to begin recruitment for the Delphi study in Spring 2025. We anticipate beginning work on the model in the summer of 2025 and completing it by early 2026. Conclusions: The Delphi study will provide an understanding of which social factors are deemed necessary by the stakeholders for guiding the inequity in care access. Study results will offer information related to the net health benefit of the intervention and the health equity impact of the tele-retina program, hence providing a more comprehensive valuation of the tele-retina program, which is informative to policy makers and governments whose goal is to mitigate the drivers of health inequities. We anticipate that each of these drivers will raise important questions regarding the implications for decision-making that may have not yet been addressed by Canadian health technology assessment bodies, such as the Canada Drug Agency. This is the first Canadian study to (1) have social constructs for DCEA selected by the Delphi panel, (2) mainstream how health equity framework and social constructs are used in economic assessment, (3) improve DR screening programs by using health equity lens, and (4) scale and adopt ``de-novo'' integration of social constructs in economic models for program evaluation. International Registered Report Identifier (IRRID): PRR1-10.2196/60488 ", doi="10.2196/60488", url="https://www.researchprotocols.org/2025/1/e60488", url="http://www.ncbi.nlm.nih.gov/pubmed/40305086" } @Article{info:doi/10.2196/66889, author="Brown, Christian Marsalis and Lin, Quincy Christopher and Jin, Christopher and Rohde, Matthew and Rocos, Brett and Belding, Jonathan and Woods, I. Barrett and Ackerman, J. Stacey", title="Effect of a Digital Health Exercise Program on the Intention for Spinal Surgery in Adult Spinal Deformity: Exploratory Cross-Sectional Survey", journal="JMIR Form Res", year="2025", month="Apr", day="29", volume="9", pages="e66889", keywords="adult spinal deformity", keywords="scoliosis", keywords="nonoperative management", keywords="spinal realignment therapy", keywords="digital health", keywords="program evaluation", abstract="Background: Adult spinal deformity (ASD) is a prevalent condition estimated at 38\%. Symptomatic ASD is associated with substantial health care costs. The role of nonoperative interventions in the management of ASD remains elusive. The National Scoliosis Clinic's (NSC) scoliosis realignment therapy (SRT) is a personalized digital health exercise program for the nonoperative management of ASD. Objective: This exploratory study had two objectives: (1) to evaluate the effect of the SRT program on users' intention of having spinal fusion; and (2) from a US payer perspective, to estimate the annual cost savings per 100,000 beneficiaries by averting spinal surgery. Methods: Individuals were enrolled in the SRT study from October 1, 2023 to September 1, 2024. Participants completed a web-based, cross-sectional survey about their history of prior scoliosis surgery and intent of having surgery before and after use of SRT (on a 4-point Likert scale, where 1 = ``No Intent for Surgery'' and 4 = ``High Intent for Surgery''). Intent for surgery before and after participation in SRT was compared using a nonparametric Wilcoxon signed-rank test for paired data. Annual cost savings per 100,000 beneficiaries by averting spinal fusions were estimated separately for commercial payers and Medicare using published literature and public data sources. Payer expenditures were inflation-adjusted to 2024 US dollars using the Hospital Services component of the Consumer Price Index. Results: A total of 62 NSC members (38.8\%) responded to the survey and were enrolled in the SRT program for an average (SD) of 17 (12) weeks. The mean (SD) age was 65.3 (13.5) years, and the majority were female (47/48, 98\%) and White (45/46, 98\%). Among the SRT users who did not have prior scoliosis surgery (n=56), 14\% (8/56) reported a decrease in intent for surgery (that is, a lower Likert score) with the use of SRT. The mean (SD) intent for surgery scores before compared to after SRT were 1.29 (0.53) and 1.14 (0.35), respectively (mean difference 0.15 [P=.006]). Participants with ``No Intent for Surgery'' pre- versus postuse of SRT (42/56 versus 48/56, respectively) corresponded to an absolute risk reduction of 11\% and a number needed to treat of 9 to avert one spinal fusion. Among the 6 participants who transitioned to ``No Intent'' for spinal surgery with the use of SRT, 3 were aged <65 years and 3 were ?65 years of age. The annual cost savings from averted spinal surgeries were estimated at US \$415,000 per 100,000 commercially-insured beneficiaries and US \$617,000 per 100,000 Medicare beneficiaries. Conclusions: SRT is a personalized, scoliosis-specific digital health exercise program with the potential for averting 1 spinal surgery for every 9 participants, resulting in a substantial reduction in payer expenditures while improving the quality of care for commercial payers and Medicare beneficiaries. ", doi="10.2196/66889", url="https://formative.jmir.org/2025/1/e66889" } @Article{info:doi/10.2196/67269, author="Lowe, Cabella and Atherton, Laura and Lloyd, Peter and Waters, Anna and Morrissey, Dylan", title="Improving Safety, Efficiency, Cost, and Satisfaction Across a Musculoskeletal Pathway Using the Digital Assessment Routing Tool for Triage: Quality Improvement Study", journal="J Med Internet Res", year="2025", month="Apr", day="25", volume="27", pages="e67269", keywords="triage", keywords="musculoskeletal", keywords="quality", keywords="safety", keywords="effectiveness", keywords="improvement", keywords="outcomes", keywords="cost", keywords="value", abstract="Background: Musculoskeletal (MSK) conditions are prevalent and increasing in Western-style economies, associated with an aging population and reduced physical activity levels. Prevention, early detection, and treatment can enable people to live in good health, remain independent and socially connected, and have economic advantages for society, such as reducing pressure on health and social care services. Triaging patients safely and effectively to the right care, for the first time improves outcomes and reduces costs, with digital solutions offering potential advantages over traditional methods. Objective: We evaluated the impact of introducing a digital assessment routing tool (DART) on safety, efficiency, cost, and satisfaction across a National Health Service (NHS) England MSK service. Methods: We designed a quality improvement study using a Plan-Do-Study-Act design and Integrated Knowledge Translation model, with DART as the first point of contact for self-referring patients with MSK conditions. Patients completed a web-based DART assessment independently, or with administrative telephone support. The primary safety outcome was measured by agreement between clinician judgment and safety incident surveillance. Quantitative and qualitative methods were used to measure secondary outcomes of efficiency, cost, and satisfaction. Analysis was completed collaboratively between researchers and the NHS service team with reference to 4 months of prestudy data. Three consecutive study cycles were completed over a 4-month period between February and May 2024 with 4076 self-referring patients between the ages of 16-104 (mean 59) years. Results: Ninety-three percent of patients self-assessed using DART with the remainder assisted by an administrator. All predefined outcome targets were met for all measures. Agreement between clinicians and DART was 96\%, no safety incidents occurred, there was immediate stratification of 401 (9.8\%) urgent cases, and 203 fewer cases requiring clinical escalation following initial clinician contact. Administrative time to process self-referrals was reduced by 51\% with a cost saving of {\textsterling}80.16 (US \$101.30) per 100 referrals. Introduction of a new route to self-management for less complex conditions showed a cost reduction per patient of 73\%, giving a saving of {\textsterling}1272.90 (US \$1605.56) for 100 referrals. Routing to a new osteoarthritis knee program would reduce costs for these patients by 63\%, equating to {\textsterling}220.35 (US \$278.46), if implemented. Further potential savings of {\textsterling}28,476 (US \$37,320)/annum could be realized using DART to screen for service eligibility criteria. Patient satisfaction was consistent throughout the study, with a mean of 90\%. Service administrators and clinicians rated the new process as a positive service improvement. Conclusions: The introduction of DART demonstrated positive outcomes in all measures and presented opportunities to improve safety and efficiency, reduce cost, and improve patient and clinician satisfaction across an NHS MSK pathway. In addition, the successful delivery of an Integrated Knowledge Translation Approach showed the benefits of collaborative working between researchers, clinicians, and other service staff. ", doi="10.2196/67269", url="https://www.jmir.org/2025/1/e67269" } @Article{info:doi/10.2196/59275, author="Wang, Yi and Tyagi, Shilpa and Ng, Liang David Wei and Teo, Ying Valerie Hui and Kok, David and Foo, Dennis and Koh, Choon-Huat Gerald", title="Primary Technology-Enhanced Care for Hypertension Scaling Program: Trial-Based Economic Evaluation Examining Effectiveness and Cost-Effectiveness Using Real-World Data in Singapore", journal="J Med Internet Res", year="2025", month="Apr", day="15", volume="27", pages="e59275", keywords="telehealth monitoring", keywords="hypertension", keywords="cost-effectiveness analysis", keywords="real-world data", keywords="Singapore", keywords="telehealth", keywords="cost-effectiveness", keywords="blood pressure monitoring", keywords="health care", keywords="teleconsultation", keywords="chatbot", keywords="regression analysis", keywords="medical cost", abstract="Background: Telehealth interventions are effective in hypertension management. However, the cost-effectiveness of using them for managing patients with hypertension remains inconclusive. Further research is required to understand the effectiveness and cost-effectiveness in the real-world setting. Objective: The Primary Technology-Enhanced Care for Hypertension (PTEC-HT) scaling program, a telehealth intervention for hypertension management, is currently being scaled nationwide in Singapore. The program comprises remote blood pressure (BP) monitoring at home, health care team support through teleconsultations, and in-app support with a digital chatbot. This study aimed to evaluate the program's effectiveness and cost-effectiveness. Methods: For patients under the PTEC-HT scaling program, BP readings over 6 months and 12 months, age, and gender were collected within the program. Health care use, health care cost, and patient ethnicity were extracted from the National Healthcare Group Polyclinics. For patients in the usual care group, demographic information, clinical data, health care use, and health care costs were extracted from the national claims records. Comparing the PTEC-HT scaling program with usual care, a trial-based economic evaluation using patient-level data was conducted to examine the effectiveness and cost-effectiveness over time horizons of 6 months and 12 months. The health care system's perspective was adopted. Regression analysis and exact matching were used to control for the differences between the PTEC-HT group and the usual care group. Results: For the 6-month analysis, 427 patients were included in the PTEC-HT group, and 64,679 patients were included in the usual care group. For the 12-month analysis, 338 patients were included in the PTEC-HT group, and 7324 patients were included in the usual care group. Using exact matching plus regression, in the 6-month analysis, the probability of having controlled BP was 13.5\% (95\% CI 6.3\%-20.7\%) higher for the PTEC-HT group compared to the usual care group. In the 12-month analysis, the probability of having controlled BP was 16\% (95\% CI 10.7\%-21.3\%) higher for the PTEC-HT group. Without considering the cost of the BP machine and program maintenance cost, the direct medical cost was S \$57.7 (95\% CI 54.4-61.0; a currency exchange rate of S \$1=US \$0.74 was applicable;) lower per patient for the PTEC-HT group in the 6-month analysis and S \$170.9 (95\% CI 151.9-189.9) lower per patient for the PTEC-HT group in the 12-month analysis. With the cost of the BP machine and program maintenance considered, compared to usual care, the PTEC-HT program reached breakeven at around the sixth month and saved S \$52.6 (95\% CI 33.6-71.6) per patient at the 12th month. Conclusions: Implemented in a real-world setting in Singapore, our study showed that the PTEC-HT scaling program is more effective in controlling BP status with lower cost compared to the usual care over 12 months. ", doi="10.2196/59275", url="https://www.jmir.org/2025/1/e59275" } @Article{info:doi/10.2196/63700, author="Havreng-Th{\'e}ry, Charlotte and Fouchard, Arnaud and Denis, Fabrice and Veyron, Jacques-Henri and Belmin, Jo{\"e}l", title="Cost-Effectiveness Analysis of a Machine Learning--Based eHealth System to Predict and Reduce Emergency Department Visits and Unscheduled Hospitalizations of Older People Living at Home: Retrospective Study", journal="JMIR Form Res", year="2025", month="Apr", day="11", volume="9", pages="e63700", keywords="monitoring", keywords="older adult", keywords="predictive tool", keywords="home care aide", keywords="emergency department visit", keywords="cost-effectiveness", keywords="artificial intelligence", keywords="electronic health", keywords="eHealth", keywords="emergency department", keywords="unscheduled hospitalization", keywords="aging", keywords="retrospective study", keywords="medico-economic", keywords="living at home", keywords="nursing home", keywords="emergency visit", keywords="Brittany", keywords="France", keywords="machine learning", keywords="remote monitoring", keywords="digital health", keywords="health informatics", abstract="Background: Dependent older people or those losing their autonomy are at risk of emergency hospitalization. Digital systems that monitor health remotely could be useful in reducing these visits by detecting worsening health conditions earlier. However, few studies have assessed the medico-economic impact of these systems, particularly for older people. Objective: The objective of this study was to compare the clinical and economic impacts of an eHealth device in real life compared with the usual monitoring of older people living at home. Methods: This study was a comparative, retrospective, and controlled trial on data collected between May 31, 2021, and May 31, 2022, in one health care and home nursing center located in Brittany, France. Participants had to be aged >75 years, living at home, and receiving assistance from the home care service for at least 1 month. We implemented among the intervention group an eHealth system that produces an alert for a high risk of emergency department visits or hospitalizations. After each home visit, the home care aides completed a questionnaire on participants' functional status using a smartphone app, and the information was processed in real time by a previously developed machine learning algorithm that identifies patients at risk of an emergency visit within 7 to 14 days. In the case of predicted risk, the eHealth system alerted a coordinating nurse who could then inform the family carer and the patient's nurses or general practitioner. Results: A total of 120 patients were included in the study, with 60 in the control group and 60 in the intervention group. Among the 726 visits from the intervention group that were not followed by an alert, only 4 (0.6\%) resulted in hospitalizations (P<.001), confirming the relevance of the system's alerts. Over the course of the study, 37 hospitalizations were recorded for 25 (20.8\%) of the 120 patients. Additionally, of the 120 patients, 9 (7.5\%) were admitted to a nursing home, and 7 (5.8\%) died. Patients in the intervention group (56/60, 93\%) remained at home significantly more often than those in the control group (48/60, 80\%; P=.03). The total cost of primary care and hospitalization during the study was {\texteuro}167,000 ({\texteuro}1=US \$1.09), with {\texteuro}108,000 (64.81\%) attributed to the intervention group (P=.20). Conclusions: This study presents encouraging results on the impact of a remote medical monitoring system for older adults, demonstrating a reduction in both emergency department visits and hospitalization costs. Trial Registration: ClinicalTrials.gov NCT05221697; https://clinicaltrials.gov/study/NCT05221697 ", doi="10.2196/63700", url="https://formative.jmir.org/2025/1/e63700", url="http://www.ncbi.nlm.nih.gov/pubmed/40215100" } @Article{info:doi/10.2196/70463, author="Sanchez, William and Dewan, Ananya and Budd, Eve and Eifler, M. and Miller, C. Robert and Kahn, Jeffery and Macis, Mario and Gross, Marielle", title="Decentralized Biobanking Apps for Patient Tracking of Biospecimen Research: Real-World Usability and Feasibility Study", journal="JMIR Bioinform Biotech", year="2025", month="Apr", day="10", volume="6", pages="e70463", keywords="patient empowerment", keywords="biobanking", keywords="biospecimens", keywords="transparency", keywords="community engagement", keywords="nonfungible tokens", keywords="NFTs", keywords="blockchain technology", keywords="decentralized biobanking", keywords="pilot studies", keywords="technical feasibility", keywords="biowallet", abstract="Background: Biobank privacy policies strip patient identifiers from donated specimens, undermining transparency, utility, and value for patients, scientists, and society. We are advancing decentralized biobanking apps that reconnect patients with biospecimens and facilitate engagement through a privacy-preserving nonfungible token (NFT) digital twin framework. The decentralized biobanking platform was first piloted for breast cancer biobank members. Objective: This study aimed to demonstrate the technical feasibility of (1) patient-friendly biobanking apps, (2) integration with institutional biobanks, and (3) establishing the foundation of an NFT digital twin framework for decentralized biobanking. Methods: We designed, developed, and deployed a decentralized biobanking mobile app for a feasibility pilot from 2021 to 2023 in the setting of a breast cancer biobank at a National Cancer Institute comprehensive cancer center. The Flutter app was integrated with the biobank's laboratory information management systems via an institutional review board--approved mechanism leveraging authorized, secure devices and anonymous ID codes and complemented with a nontransferable ERC-721 NFT representing the soul-bound connection between an individual and their specimens. Biowallet NFTs were held within a custodial wallet, whereas the user experiences simulated token-gated access to personalized feedback about collection and use of individual and collective deidentified specimens. Quantified app user journeys and NFT deployment data demonstrate technical feasibility complemented with design workshop feedback. Results: The decentralized biobanking app incorporated key features: ``biobank'' (learn about biobanking), ``biowallet'' (track personal biospecimens), ``labs'' (follow research), and ``profile'' (share data and preferences). In total, 405 pilot participants downloaded the app, including 361 (89.1\%) biobank members. A total of 4 central user journeys were captured. First, all app users were oriented to the ?60,000-biospecimen collection, and 37.8\% (153/405) completed research profiles, collectively enhancing annotations for 760 unused specimens. NFTs were minted for 94.6\% (140/148) of app users with specimens at an average cost of US \$4.51 (SD US \$2.54; range US \$1.84-\$11.23) per token, projected to US \$17,769.40 (SD US \$159.52; range US \$7265.62-\$44,229.27) for the biobank population. In total, 89.3\% (125/140) of the users successfully claimed NFTs during the pilot, thereby tracking 1812 personal specimens, including 202 (11.2\%) distributed under 42 unique research protocols. Participants embraced the opportunity for direct feedback, community engagement, and potential health benefits, although user onboarding requires further refinement. Conclusions: Decentralized biobanking apps demonstrate technical feasibility for empowering patients to track donated biospecimens via integration with institutional biobank infrastructure. Our pilot reveals potential to accelerate biomedical research through patient engagement; however, further development is needed to optimize the accessibility, efficiency, and scalability of platform design and blockchain elements, as well as a robust incentive and governance structure for decentralized biobanking. ", doi="10.2196/70463", url="https://bioinform.jmir.org/2025/1/e70463", url="http://www.ncbi.nlm.nih.gov/pubmed/40208659" } @Article{info:doi/10.2196/71535, author="Mohammed, Tallah Heba and Corcoran, Kathleen and Lavergne, Kyle and Graham, Angela and Gill, Daniel and Jones, Kwame and Singal, Shivika and Krishnamoorthy, Malini and Cassata, Amy and Mannion, David and Fraser, J. Robert D.", title="Clinical, Operational, and Economic Benefits of a Digitally Enabled Wound Care Program in Home Health: Quasi-Experimental, Pre-Post Comparative Study", journal="JMIR Nursing", year="2025", month="Apr", day="8", volume="8", pages="e71535", keywords="home health care", keywords="artificial intelligence", keywords="AI", keywords="digital wound care", keywords="wound assessment", keywords="operational efficiency", keywords="clinical outcomes", keywords="healing time", keywords="cost saving", keywords="skilled nursing visits", abstract="Background: The demand for home health care and nursing visits has steadily increased, requiring significant allocation of resources for wound care. Many home health agencies operate below capacity due to clinician shortages, meeting only 61\% to 70\% of demand and frequently declining wound care referrals. Implementing artificial intelligence--powered digital wound care solutions (DWCSs) offers an opportunity to enhance wound care programs by improving scalability and effectiveness through better monitoring and risk identification. Objective: This study assessed clinical and operational outcomes across 14 home health branches that adopted a DWCS, comparing pre- and postadoption data and outcomes with 27 control branches without the technology. Methods: This pre-post comparative study analyzed clinical outcomes, including average days to wound healing, and operational outcomes, such as skilled nursing (SN) visits per episode (VPE) and in-home visit durations, during two 7-month intervals (from November to May in 2020-2021 and 2021-2022). Data were extracted from 14,278 patients who received wound care across adoption and control branches. Projected cost savings were also calculated based on reductions in SN visits. Results: The adoption branches showed a 4.3\% reduction in SN VPE and a 2.5\% reduction in visit duration, saving approximately 309 staff days. In contrast, control branches experienced a 4.5\% increase in SN VPE and a 2.2\% rise in visit duration, adding 42 days. Healing times improved significantly in the adoption branches, with a reduction of 4.3 days on average per wound compared to 1.6 days in control branches (P<.001); pressure injuries, venous ulcers, and surgical wounds showed the most substantial improvements. Conclusions: Integrating digital wound management technology enhances clinical outcomes, operational efficiencies, and cost savings in home health settings. A reduction of 0.3 SN VPE could generate annual savings of up to US \$958,201 across the organization. The adoption branches avoided 1187 additional visits during the study period. If control branches had implemented the DWCS and achieved similar outcomes, they would have saved 18,546 healing days. These findings emphasize the importance of incorporating DWCSs into wound care programs to address increasing demands, clinician shortages, and rising health care costs while maintaining positive clinical outcomes. ", doi="10.2196/71535", url="https://nursing.jmir.org/2025/1/e71535", url="http://www.ncbi.nlm.nih.gov/pubmed/40198913" } @Article{info:doi/10.2196/68486, author="Cook, A. David and Overgaard, Joshua and Pankratz, Shane V. and Del Fiol, Guilherme and Aakre, A. Chris", title="Virtual Patients Using Large Language Models: Scalable, Contextualized Simulation of Clinician-Patient Dialogue With Feedback", journal="J Med Internet Res", year="2025", month="Apr", day="4", volume="27", pages="e68486", keywords="simulation training", keywords="natural language processing", keywords="computer-assisted instruction", keywords="clinical decision-making", keywords="clinical reasoning", keywords="machine learning", keywords="virtual patient", keywords="natural language generation", abstract="Background: Virtual patients (VPs) are computer screen--based simulations of patient-clinician encounters. VP use is limited by cost and low scalability. Objective: We aimed to show that VPs powered by large language models (LLMs) can generate authentic dialogues, accurately represent patient preferences, and provide personalized feedback on clinical performance. We also explored using LLMs to rate the quality of dialogues and feedback. Methods: We conducted an intrinsic evaluation study rating 60 VP-clinician conversations. We used carefully engineered prompts to direct OpenAI's generative pretrained transformer (GPT) to emulate a patient and provide feedback. Using 2 outpatient medicine topics (chronic cough diagnosis and diabetes management), each with permutations representing different patient preferences, we created 60 conversations (dialogues plus feedback): 48 with a human clinician and 12 ``self-chat'' dialogues with GPT role-playing both the VP and clinician. Primary outcomes were dialogue authenticity and feedback quality, rated using novel instruments for which we conducted a validation study collecting evidence of content, internal structure (reproducibility), relations with other variables, and response process. Each conversation was rated by 3 physicians and by GPT. Secondary outcomes included user experience, bias, patient preferences represented in the dialogues, and conversation features that influenced authenticity. Results: The average cost per conversation was US \$0.51 for GPT-4.0-Turbo and US \$0.02 for GPT-3.5-Turbo. Mean (SD) conversation ratings, maximum 6, were overall dialogue authenticity 4.7 (0.7), overall user experience 4.9 (0.7), and average feedback quality 4.7 (0.6). For dialogues created using GPT-4.0-Turbo, physician ratings of patient preferences aligned with intended preferences in 20 to 47 of 48 dialogues (42\%-98\%). Subgroup comparisons revealed higher ratings for dialogues using GPT-4.0-Turbo versus GPT-3.5-Turbo and for human-generated versus self-chat dialogues. Feedback ratings were similar for human-generated versus GPT-generated ratings, whereas authenticity ratings were lower. We did not perceive bias in any conversation. Dialogue features that detracted from authenticity included that GPT was verbose or used atypical vocabulary (93/180, 51.7\% of conversations), was overly agreeable (n=56, 31\%), repeated the question as part of the response (n=47, 26\%), was easily convinced by clinician suggestions (n=35, 19\%), or was not disaffected by poor clinician performance (n=32, 18\%). For feedback, detractors included excessively positive feedback (n=42, 23\%), failure to mention important weaknesses or strengths (n=41, 23\%), or factual inaccuracies (n=39, 22\%). Regarding validation of dialogue and feedback scores, items were meticulously developed (content evidence), and we confirmed expected relations with other variables (higher ratings for advanced LLMs and human-generated dialogues). Reproducibility was suboptimal, due largely to variation in LLM performance rather than rater idiosyncrasies. Conclusions: LLM-powered VPs can simulate patient-clinician dialogues, demonstrably represent patient preferences, and provide personalized performance feedback. This approach is scalable, globally accessible, and inexpensive. LLM-generated ratings of feedback quality are similar to human ratings. ", doi="10.2196/68486", url="https://www.jmir.org/2025/1/e68486", url="http://www.ncbi.nlm.nih.gov/pubmed/39854611" } @Article{info:doi/10.2196/64973, author="McCullough, P. Hannah and Moczygemba, R. Leticia and Avance{\~n}a, V. Anton L. and Baffoe, O. James", title="The Interactive Care Coordination and Navigation mHealth Intervention for People Experiencing Homelessness: Cost Analysis, Exploratory Financial Cost-Benefit Analysis, and Budget Impact Analysis", journal="JMIR Form Res", year="2025", month="Mar", day="18", volume="9", pages="e64973", keywords="people experiencing homelessness", keywords="budget impact analysis", keywords="financial cost-benefit analysis", keywords="mHealth", keywords="care coordination", keywords="care", keywords="mobile health", keywords="smartphones", keywords="homeless", keywords="hospitalization", keywords="cost analysis", keywords="health care cost", keywords="economic", keywords="emergency department", keywords="United States", keywords="cost-benefit", keywords="digital health", abstract="Background: The Interactive Care Coordination and Navigation (iCAN) mobile health intervention aims to improve care coordination and reduce hospital and emergency department visits among people experiencing homelessness. Objective: This study aimed to conduct a three-part economic evaluation of iCAN, including a (1) cost analysis, (2) exploratory financial cost-benefit analysis, and (3) budget impact analysis (BIA). Methods: We collected cost and expenditure data from a randomized controlled trial of iCAN to conduct a cost analysis and exploratory financial cost-benefit analysis. Costs were classified as startup and recurring costs for participants and the program. Startup costs included participant supplies for each participant and SMS implementation costs. Recurring costs included the cost of recurring services, SMS text messaging platform maintenance, health information access fees, and personnel salaries. Using the per participant per year (PPPY) costs of iCAN, the minimum savings reduction in the average health care costs among people experiencing homelessness that would lead to a benefit-cost ratio >1 for iCAN was calculated. This savings threshold was calculated by dividing the PPPY cost of iCAN by the average health care costs among people experiencing homelessness multiplied by 100\%. The benefit-cost ratio of iCAN was calculated under different savings thresholds from 0\% (no savings) to 50\%. Costs were calculated PPPY under different scenarios, and the results were used as inputs in a BIA. A probabilistic sensitivity analysis was conducted to incorporate uncertainty around cost estimates. Costs are in 2022 US \$. Results: The total cost of iCAN was US \$2865 PPPY, which was made up of US \$265 in startup (9\%) and US \$2600 (91\%) in recurring costs PPPY. The minimum savings threshold that would cause iCAN to have a positive return on investment is 7.8\%. This means that if average health care costs (US \$36,917) among people experiencing homelessness were reduced by more than 7.8\% through iCAN, the financial benefits would outweigh the costs of the intervention. When health care costs are reduced by 25\% (\$9229/\$36,917; equal to 56\% [\$9229/\$16,609] of the average cost of an inpatient visit), the benefit-cost ratio is 3.22, which means that iCAN produces US \$2.22 in health care savings per US \$1 spent. The BIA estimated that implementing iCAN for 10,250 people experiencing homelessness over 5 years would have a financial cost of US \$28.7 million, which could be reduced to US \$2.2 million if at least 8\% (\$2880/\$36,917) of average health care costs among people experiencing homelessness are reduced through the intervention. Conclusions: If average costs of emergency department and hospital visits among people experiencing homelessness were reduced by more than 7.8\% (\$2880/\$36,917) through iCAN, the financial benefits would outweigh the costs of the intervention. As the savings threshold increases, it results in a higher benefit-cost ratio. Trial Registration: ClinicalTrials NCT05365867; https://clinicaltrials.gov/study/NCT05365867 ", doi="10.2196/64973", url="https://formative.jmir.org/2025/1/e64973" } @Article{info:doi/10.2196/60170, author="H{\"u}er, Theresa and Walendzik, Anke and Kleinschmidt, Lara and H{\"o}fer, Klemens and Nauendorf, Beatrice and Malsch, Juliane and Brittner, Matthias and Brandenburg, Paul and Aeustergerling, Andr{\'e} and Schneider, Udo and Wadeck, Anja and Liersch, Sebastian and Sehlen, Stephanie and Schwarze, Katharina and Wasem, J{\"u}rgen", title="Use of Video Consultation Between 2017 and 2020 in Outpatient Medical Care in Germany and Characteristics of Their User Groups: Analysis of Claims Data", journal="JMIR Form Res", year="2025", month="Mar", day="14", volume="9", pages="e60170", keywords="video consultation", keywords="outpatient medical care", keywords="user groups", keywords="claims data analysis", keywords="Germany", keywords="physician", keywords="psychotherapist", keywords="sociodemographic", keywords="healthcare", keywords="digital health", keywords="digital consultation", keywords="telehealth", keywords="telemonitoring", keywords="telemedicine", abstract="Background: Supplementing outpatient medical care with the use of video consultations could, among other benefits, improve access, especially in structurally disadvantaged areas. Objective: This claims data analysis, carried out as part of the German research project ``Preference-based use of video consultation in urban and rural regions,'' aimed to analyze the use of video consultations and the characteristics of its user groups. Methods: Claims data from 3 Statutory Health Insurance Funds (SHIFs) and 4 Associations of Statutory Health Insurance Physicians (ASHIPs) from the period April 2017 to the end of 2020 were used. Data from a sample of about 6.1 million insured and 33,100 physicians and psychotherapists were analyzed. In addition to data on the use of video consultations, patient data on sociodemographic characteristics, diagnoses, and place of residence were included. To analyze the physicians' perspectives, specialty groups, demographic characteristics, and the type of practice location were also included. In consideration of the principles of data economy and the fact that data analysis represents merely a preliminary phase within the broader project, the SHIFs and ASHIPs transmitted aggregated data (cross-tabulations per subgroup analysis) to the evaluator. For this reason, the analyses were constrained to a comparison of video consultation users versus nonusers, differentiated according to the aforementioned subgroups. Furthermore, the association between place of residence or type of region of the practice location and the use of video consultation was examined. A significance level of P<.05 was set for chi-square tests. Results: From 2017 to 2019, almost no video consultations were used in outpatient care in the German health care system. Although this changed considerably in relative terms with the start of the COVID-19 pandemic (but still at a very low absolute level), there was also a clear decline in the use of video consultations as the number of infections flattened out. Physicians working in psychotherapy and psychological psychotherapists used video consultations with around 16\% (44,808/282,530) of their treatment cases in the second quarter of 2020, followed by psychotherapists using video consultations for children (10,828/113,293, 10\%). Although the absolute number of treatment cases with video consultations among general practitioners was very high compared with other specialist groups, their share of video consultations in all treatment cases was very low at 0.3\% (29,600/9,837,118). Younger age groups and those located in urban areas used video consultations more frequently; this applies to both patients (age groups: $\chi$27=9903.2, P<.001; region types: $\chi$22=3746.2, P<.001) and service providers (age groups: $\chi$23=11,338.2, P<.001; region types: $\chi$22=8474.1, P<.001). Conclusions: The current use of video consultations is below its potential in terms of scope and user groups. The widespread and lasting use of video consultations will only succeed if the potential user groups accept this form of service provision and recognize its advantages. Further analyses (both qualitative, such as focus group discussions, and quantitative, such as preference surveys) should therefore investigate the preferences of user groups for the use of video consultations. International Registered Report Identifier (IRRID): RR2-10.2196/50932 ", doi="10.2196/60170", url="https://formative.jmir.org/2025/1/e60170", url="http://www.ncbi.nlm.nih.gov/pubmed/40085136" } @Article{info:doi/10.2196/53539, author="Crafoord, Marie-Ther{\'e}se and Ekstrand, Joakim and Sundberg, Kay and Nilsson, I. Marie and Fjell, Maria and Langius-Ekl{\"o}f, Ann", title="Mobile Electronic Patient-Reported Outcomes and Interactive Support During Breast and Prostate Cancer Treatment: Health Economic Evaluation From Two Randomized Controlled Trials", journal="JMIR Cancer", year="2025", month="Mar", day="11", volume="11", pages="e53539", keywords="cost-effectiveness", keywords="ePRO", keywords="mHealth", keywords="disease monitoring", keywords="cancer", keywords="RCT", keywords="randomized controlled trial", keywords="controlled trials", keywords="digital intervention", keywords="patient-reported outcomes", keywords="management", keywords="payers' perspective", keywords="health care costs", keywords="apps", keywords="prostate cancer", keywords="breast cancer", abstract="Background: Digital interventions for supportive care during cancer treatment incorporating electronic patient-reported outcomes (ePROs) can enhance early detection of symptoms and facilitate timely symptom management. However, economic evaluations are needed. Objective: This study aims to conduct a cost-utility analysis of an app for ePRO and interactive support from the perspective of the payer (Region Stockholm Health Care Organization) and to explore its impact on patient health care utilization and costs. Methods: Two open-label randomized controlled trials (RCTs) were conducted, including patients undergoing neoadjuvant chemotherapy for breast cancer (B-RCT; N=149) and radiotherapy for prostate cancer (P-RCT; N=150), recruited from oncology clinics at 2 university hospitals in Stockholm, Sweden. EORTC QLQ-C30 scores were mapped to EQ-5D-3L to calculate quality-adjusted life years (QALYs). Intervention and implementation costs and health care costs, obtained from an administrative database, were used to calculate incremental cost-effectiveness ratios (ICERs) in 3 ways: including all health care costs (ICERa), excluding nonacute health care costs (ICERb), and excluding health care costs altogether (ICERc). Nonparametric bootstrapping was used to explore ICER uncertainty. Health care costs were analyzed by classifying them as disease-related or acute. Results: In both RCT intervention groups, fewer QALYs were lost compared with the control group (P<.001). In the B-RCT, the mean intervention cost was {\texteuro}92 (SD {\texteuro}2; {\texteuro}1=US \$1.03). The mean cost for the intervention and all health care was {\texteuro}36,882 (SD {\texteuro}1032) in the intervention group and {\texteuro}35,427 (SD {\texteuro}959) in the control group (P<.001), with an ICERa of {\texteuro}202,368 (95\% CI {\texteuro}152,008-{\texteuro}252,728). The mean cost for the intervention and acute health care was {\texteuro}3585 (SD {\texteuro}480) in the intervention group and {\texteuro}3235 (SD {\texteuro}494) in the control group (P<.001). ICERb was {\texteuro}49,903 (95\% CI {\texteuro}37,049-{\texteuro}62,758) and ICERc was {\texteuro}13,213 (95\% CI {\texteuro}11,145-{\texteuro}15,281); 22 out of 74 (30\%) intervention group patients and 24 out of 75 (32\%) of the control group patients required acute inpatient care for fever. In the P-RCT, the mean intervention cost was {\texteuro}43 (SD {\texteuro}0.2). The mean cost for the intervention and all health care was {\texteuro}3419 (SD {\texteuro}739) in the intervention group and {\texteuro}3537 (SD {\texteuro}689) in the control group (P<.001), with an ICERa of --{\texteuro}1,092,136 (95\% CI --{\texteuro}3,274,774 to {\texteuro}1,090,502). The mean cost for the intervention and acute health care was {\texteuro}1219 (SD {\texteuro}593) in the intervention group and {\texteuro}802 (SD {\texteuro}281) in the control group (P<.001). ICERb was {\texteuro}745,987 (95\% CI --{\texteuro}247,317 to {\texteuro}1,739,292) and ICERc was {\texteuro}13,118 (95\% CI --68,468 to {\texteuro}94,704). As many as 10 out of the 75 (13\%) intervention group patients had acute inpatient care, with the most common symptom being dyspnea, while 9 out of the 75 (12\%) control group patients had acute inpatient care, with the most common symptom being urinary tract infection. Conclusions: ePRO and interactive support via an app generated a small improvement in QALYs at a low intervention cost and may be cost-effective, depending on the costs considered. Considerable variability in patient health care costs introduced uncertainty around the estimates, preventing a robust determination of cost-effectiveness. Larger studies examining cost-effectiveness from a societal perspective are needed. The study provides valuable insights into acute health care utilization during cancer treatment. Trial Registration: ClinicalTrials.gov NCT02479607; https://clinicaltrials.gov/ct2/show/NCT02479607, ClinicalTrials.gov NCT02477137; https://clinicaltrials.gov/ct2/show/NCT02477137 International Registered Report Identifier (IRRID): RR2-10.1186/s12885-017-3450-y ", doi="10.2196/53539", url="https://cancer.jmir.org/2025/1/e53539" } @Article{info:doi/10.2196/63938, author="Hansen, T. Bo and Klungs{\o}yr, Ole and Labberton, S. Angela and S{\"a}{\"a}ksvuori, Lauri and Rydland, M. Kjersti and {\O}deskaug, E. Liz and Wisl{\o}ff, Torbj{\o}rn and Meijerink, Hinta", title="Effectiveness of Text Messaging Nudging to Increase Coverage of Influenza Vaccination Among Older Adults in Norway (InfluSMS Study): Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2025", month="Feb", day="25", volume="14", pages="e63938", keywords="influenza vaccination", keywords="coverage", keywords="uptake", keywords="behavioral nudging", keywords="vaccine hesitancy", keywords="randomized controlled trial", keywords="undervaccination", keywords="migrant health", keywords="mobile health", keywords="mHealth", keywords="smartphones", keywords="eHealth", keywords="SMS", abstract="Background: The coverage of influenza vaccination among older adults in Norway is insufficient, especially in some immigrant groups. To improve public health, there is a need for an intervention that can increase influenza vaccination coverage. Further, interventions tailored to reduce potential barriers among immigrants can reduce health inequities. Objective: InfluSMS aims to determine if SMS nudging increases vaccination coverage among those aged 65 years or older (1) in Norway's general population; (2) among immigrants born in Poland; and (3) among immigrants born in Ukraine; and evaluate the impact of SMS nudging in Norwegian versus in the official language of the native country of immigrants born in Poland or Ukraine. Methods: InfluSMS is a pragmatic randomized controlled trial conducted among people aged 65 years or older residing in Norway. Influenza vaccination coverage is the main outcome, measured in control and intervention arms for each of the 3 populations listed earlier. In all 3 populations, the control arm is standard care, that is, no individual reminder for influenza vaccination. All populations have an intervention arm that will receive an SMS nudge in the Norwegian language. In addition, the Polish and Ukrainian immigrant populations include a second intervention arm that will receive an SMS nudge in Polish or Ukrainian, respectively. In the general population, at least 23,485 individuals will be randomized to the SMS intervention arm while the rest of the population constitutes the control arm. In each of the 2 immigrant populations, we will randomize all eligible individuals 1:1:1 into the 3 arms. The intervention will take place at the start of the 2025-2026 influenza season. All eligible individuals will be passively followed up through the National Immunisation Registry, SYSVAK, from which individual influenza vaccination status 3 months after the SMS nudge will be collected. Coverage rates between arms within each population and effect sizes between the populations will be compared. The cost-effectiveness of SMS nudging will also be assessed. Results: The inclusion of participants will start in the third quarter of 2025, and the registry data will be available in the first quarter of 2026. Coverage rates of each strategy and coverage differences between strategies will be presented. Conclusions: SMS nudging is a scalable, inexpensive, and nonintrusive intervention that could be integrated into the national influenza vaccination program if the trial shows it effectively increases influenza vaccination coverage among older adults. Further, the trial will establish whether language is a barrier to influenza vaccination uptake among recent immigrant groups that have low influenza vaccination coverage, and to what extent this potential barrier can be diminished by SMS nudging in the official language of their native country. Trial Registration: ClinicalTrials.gov NCT06486766; https://clinicaltrials.gov/study/NCT06486766 International Registered Report Identifier (IRRID): PRR1-10.2196/63938 ", doi="10.2196/63938", url="https://www.researchprotocols.org/2025/1/e63938", url="http://www.ncbi.nlm.nih.gov/pubmed/39998878" } @Article{info:doi/10.2196/68221, author="Nagra, Harpreet and Mines, A. Robert and Dana, Zara", title="Exploring the Impact of Digital Peer Support Services on Meeting Unmet Needs Within an Employee Assistance Program: Retrospective Cohort Study", journal="JMIR Hum Factors", year="2025", month="Feb", day="25", volume="12", pages="e68221", keywords="digital peer support", keywords="peer support", keywords="EAPs", keywords="cost-effectiveness", keywords="SROI", abstract="Background: The World Health Organization estimates that 1 in 4 people worldwide will experience a mental disorder in their lifetime, highlighting the need for accessible support. Objective: This study evaluates the integration of digital peer support (DPS) into an employee assistance program (EAP), testing 3 hypotheses: (1) DPS may be associated with changes in EAP counseling utilization within a 5-session model; (2) DPS users experience reduced sadness, loneliness, and stress; and (3) DPS integration generates a positive social return on investment (SROI). Methods: The study analyzed EAP utilization within a 5-session model using pre-post analysis, sentiment changes during DPS chats via natural language processing models, and SROI outcomes. Results: Among 587 DPS chats, 432 (73.6\%) occurred after business hours, emphasizing the importance of 24/7 availability. A matched cohort analysis (n=72) showed that DPS reduced therapy sessions by 2.07 per participant (P<.001; Cohen d=1.77). Users' messages were evaluated for sentiments of sadness, loneliness, and stress on a 1-10 scale. Significant reductions were observed: loneliness decreased by 55.04\% (6.91 to 3.11), sadness by 57.5\% (6.84 to 2.91), and stress by 56.57\% (6.78 to 2.95). SROI analysis demonstrated value-to-investment ratios of US \$1.66 (loneliness), US \$2.50 (stress), and US \$2.58 (sadness) per dollar invested. Conclusions: Integrating DPS into EAPs provides significant benefits, including increased access, improved emotional outcomes, and a high SROI, reinforcing its value within emotional health support ecosystems. ", doi="10.2196/68221", url="https://humanfactors.jmir.org/2025/1/e68221", url="http://www.ncbi.nlm.nih.gov/pubmed/39998863" } @Article{info:doi/10.2196/67567, author="Zhou, Wenjing and Chen, Yan and Wu, Herui and Zhao, Hao and Li, Yanzhi and Shi, Guangduoji and Wang, Wanxin and Liu, Yifeng and Liao, Yuhua and Zhang, Huimin and Gao, Caihong and Hao, Jiejing and Le, Han Gia and McIntyre, S. Roger and Han, Xue and Lu, Ciyong", title="Cost Utility Analysis of Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder: Randomized Controlled Trial", journal="J Med Internet Res", year="2025", month="Feb", day="19", volume="27", pages="e67567", keywords="cost utility analysis", keywords="CUA", keywords="cost-effectiveness", keywords="economic evaluation", keywords="costs", keywords="quality of life", keywords="internet-based cognitive behavioral therapy", keywords="ICBT", keywords="digital psychiatry", keywords="major depressive disorder", keywords="depression", keywords="China", abstract="Background: Unguided internet-based cognitive behavioral therapy (ICBT) has been proven effective for major depressive disorder (MDD). However, few studies have examined its cost-effectiveness in low-resource countries and under nonspecialist routine care. Objective: This study aimed to evaluate the short- and long-term cost utility of unguided ICBT compared to a waitlist control for persons with MDD from the perspectives of society and the health care system. Methods: This analysis was implemented alongside an 8-week 2-arm randomized controlled trial with a 12-month follow-up period conducted in Shenzhen, China. Outcomes including cost and health utility were collected at the pretreatment and posttreatment time points and 3, 6, and 12 months after the intervention. Direct medical costs and indirect costs were prospectively collected using the hospital information system and the Sheehan Disability Scale. Health outcomes were measured using the Chinese version of the Short-Form Six-Dimension health index. The primary outcome was incremental cost utility ratio (ICUR) expressed as the difference in costs between 2 therapies by the difference in quality-adjusted life years (QALYs). The seemingly unrelated regression model and the bootstrap method were performed to estimate adjusted ICURs. Cost-effectiveness planes and cost-effectiveness acceptability curves were used to demonstrate uncertainty. A series of scenario analyses were conducted to verify the robustness of base-case results. Results: In total, 244 participants with MDD were randomly allocated to the ICBT (n=122, 50\%) or waitlist control (n=122, 50\%) groups. At the pretreatment time point, no statistically significant difference was observed in direct medical cost (P=.41), indirect cost (P=.10), or health utility (P=.11) between the 2 groups. In the base-case analysis, the ICBT group reported higher direct medical costs and better quality of life but lower total costs at the posttreatment time point. The adjusted ICURs at the posttreatment time point were CN {\textyen}--194,720.38 (US \$--26,551.50; 95\% CI CN {\textyen}--198,766.78 to CN {\textyen}--190,673.98 [US \$--27,103.20 to US \$--25,999.70]) and CN {\textyen}49,700.33 (US \$6776.99; 95\% CI CN {\textyen}46,626.34-CN {\textyen}52,774.31 [US \$6357.83-\$7196.15]) per QALY from the societal and health care system perspectives, respectively, with a probability of unguided ICBT being cost-effective of 75.93\% and 54.4\%, respectively, if the willingness to pay was set at 1 time the per-capita gross domestic product. In the scenario analyses, the probabilities increased to 76.85\% and 77.61\%, respectively, indicating the potential of ICBT to be cost-effective over the long term. Conclusions: Unguided ICBT is a cost-effective treatment for MDD. This intervention not only helps patients with MDD improve clinically but also generates societal savings. These findings provide health economic evidence for a potential scalable MDD treatment method in low- and middle-income countries. Trial Registration: Chinese Clinical Trial Registry (ChiCTR) ChiCTR2100046425; https://tinyurl.com/bdcrj4zv ", doi="10.2196/67567", url="https://www.jmir.org/2025/1/e67567" } @Article{info:doi/10.2196/56766, author="Mainer-Pearson, Graham and Stewart, Kurtis and Williams, Kim and Pawlovich, John and Graham, Scott and Riches, Linda and Cressman, Sonya and Ho, Kendall", title="Estimating Patient and Family Costs and CO2 Emissions for Telehealth and In-Person Health Care Appointments in British Columbia, Canada: Geospatial Mixed Methods Study", journal="J Med Internet Res", year="2025", month="Feb", day="19", volume="27", pages="e56766", keywords="virtual care", keywords="economic evaluation", keywords="patient costs", keywords="lost productivity", keywords="informal caregiving", keywords="out-of-pocket costs", keywords="environmental costs", keywords="geospatial", keywords="patient", keywords="family", keywords="CO2", keywords="emission costs", keywords="health care", keywords="Canada", keywords="virtual service", keywords="emergency department", keywords="hospitalization", keywords="physician visit", keywords="consultation", keywords="sensitivity analysis", keywords="patient-paid", keywords="telehealth", abstract="Background: Patients inevitably incur some cost for accessing health care, even in universal systems such as Canada. The COVID-19 pandemic dramatically shifted health care delivery from in-person to telehealth services, also shifting the proportion of costs offset by patients and their families by reducing the need to travel to in-person appointments. Objective: This study aimed to develop a method for estimating the costs patients and their families incur and CO2 emissions attributed to travel needed for emergency department (ED) visits, hospitalizations, and physician appointments. Methods: We present a method to evaluate the costs associated with in-person and telehealth care appointments from the perspective of patients, their families, and the environment. We used ED locations, road distances, and duration of appointment to account for costs paid by patients (ie, lost productivity, informal caregiving, and out-of-pocket expenses) attributed to travel to receive medical care. Costs to the environment were evaluated by calculating the amount of CO2 emitted per medical visit. Using our costs calculated per visit, we apply our method to calculate total patient costs for a simulated population over 1 year. Results: Our method estimates that patients in British Columbia pay up to \$300 (2023 CAD, CAD \$1=US \$0.86) on average to attend an in-person ED visit, depending on where they live; \$166 may be attributed to lost productivity, \$83 to informal caregiving, and \$50 to out-of-pocket expenses. These estimates are higher than most observed cost estimates. In addition, avoiding in-person care diverts up to 13 kg of CO2 per medical visit, depending on the distance and frequency of travel to appointments. This translates to up to \$0.70 in carbon costs per visit, or cumulatively \$44,120 per year in British Columbia, conventionally not included in patient cost estimates. Conclusions: We present a novel method for estimating patient-incurred costs and CO2 emissions from accessing health care and apply it to estimate that every year, patients in British Columbia pay upwards of 30 million dollars to access health care services, primarily for medical travel. Our method adds to the economic evaluation literature by providing a more comprehensive and context-modifiable calculation of patient costs that will allow for more informed decision-making regarding health care services. ", doi="10.2196/56766", url="https://www.jmir.org/2025/1/e56766", url="http://www.ncbi.nlm.nih.gov/pubmed/39969971" } @Article{info:doi/10.2196/64662, author="Smits, M. Michelle J. and Bolman, W. Catherine A. and Mesters, Ilse and Lechner, Lilian", title="Blended Care Intervention for Cancer Aftercare in General Practice Centers: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2025", month="Feb", day="12", volume="14", pages="e64662", keywords="cancer aftercare", keywords="general practice", keywords="blended care", keywords="eHealth", keywords="randomized controlled trial", keywords="cost effectiveness", keywords="general practitioners", keywords="online intervention", abstract="Background: Combining effective eHealth programs with face-to-face consultations in general practice may help general practitioners care for survivors of cancer. Objective: This study protocol describes a 2-armed randomized controlled trial to evaluate the cost-effectiveness of a blended intervention integrating the Cancer Aftercare Guide in general practice centers (GPCs). Methods: A parallel-group design will compare an intervention group with a waiting list control group. Participants will be nested within GPCs and randomization will occur at the GPC level. The participants in the intervention group will receive a blended care intervention. In contrast, the participants in the waiting list control group will receive care as usual for the duration of this study and will receive the online intervention afterward. All participants will be asked to complete an online questionnaire at baseline, 6 months, and 12 months after baseline, measuring self-reported adherence to lifestyle recommendations, psychosocial well-being, and quality of life. A process evaluation and cost evaluation are also included in this study. The effects will be evaluated based on differences in residual change scores between intervention and control group participants, using multilevel linear regression analyses. Moreover, effect analyses will be supplemented with Bayes factor analyses. Finally, an economic evaluation will be conducted from a societal perspective and will include medical costs, productivity costs, and costs of the blended care intervention. Results: This study was funded in July 2020. Data collection started in August 2022 and is likely to be completed by April 2025. As of December 2024, a total of 127 participants have been included in this study, recruited across 26 GPCs in the Netherlands. Data analysis will commence once data collection is completed. Data analysis is estimated to start in the spring of 2025. The results will likely be published in 2026. Conclusions: The results will provide insight into the effectiveness of blended care and may be relevant to cancer aftercare, general practice, and the field of eHealth implementation in general. Potential challenges lie in recruitment due to the strain on the health care system since the COVID-19 pandemic. Trial Registration: ISRCTN ISRCTN12451453; https://www.isrctn.com/ISRCTN12451453 International Registered Report Identifier (IRRID): DERR1-10.2196/64662 ", doi="10.2196/64662", url="https://www.researchprotocols.org/2025/1/e64662" } @Article{info:doi/10.2196/65546, author="Insani, Norma Widya and Zakiyah, Neily and Puspitasari, Melyani Irma and Permana, Yorga Muhammad and Parmikanti, Kankan and Rusyaman, Endang and Suwantika, Abdurrohim Auliya", title="Digital Health Technology Interventions for Improving Medication Safety: Systematic Review of Economic Evaluations", journal="J Med Internet Res", year="2025", month="Feb", day="5", volume="27", pages="e65546", keywords="digital health technology", keywords="drug safety", keywords="adverse drug events", keywords="medication errors", keywords="patient safety", abstract="Background: Medication-related harm, including adverse drug events (ADEs) and medication errors, represents a significant iatrogenic burden in clinical care. Digital health technology (DHT) interventions can significantly enhance medication safety outcomes. Although the clinical effectiveness of DHT for medication safety has been relatively well studied, much less is known about the cost-effectiveness of these interventions. Objective: This study aimed to systematically review the economic impact of DHT interventions on medication safety and examine methodological challenges to inform future research directions. Methods: A systematic search was conducted across 3 major electronic databases (ie, PubMed, Scopus, and EBSCOhost). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for this systematic review. Two independent investigators conducted a full-text review after screening preliminary titles and abstracts. We adopted recommendations from the Panel on Cost-Effectiveness in Health and Medicine for data extraction. A narrative analysis was conducted to synthesize clinical and economic outcomes. The quality of reporting for the included studies was assessed using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines. Results: We included 13 studies that assessed the cost-effectiveness (n=9, 69.2\%), cost-benefit (n=3, 23.1\%), and cost-utility (n=1, 7.7\%) of DHT for medication safety. Of the included studies, more than half (n=7, 53.9\%) evaluated a clinical decision support system (CDSS)/computerized provider order entry (CPOE), 4 (30.8\%) examined automated medication-dispensing systems, and 2 (15.4\%) focused on pharmacist-led outreach programs targeting health care professionals. In 12 (92.3\% ) studies, DHT was either cost-effective or cost beneficial compared to standard care. On average, DHT interventions reduced ADEs by 37.12\% (range 8.2\%-66.5\%) and medication errors by 54.38\% (range 24\%-83\%). The key drivers of cost-effectiveness included reductions in outcomes, the proportion of errors resulting in ADEs, and implementation costs. Despite a significant upfront cost, DHT showed a return on investment within 3-4.25 years due to lower cost related with ADE treatment and improved workflow efficiency. In terms of reporting quality, the studies were classified as good (n=10, 76.9\%) and moderate (n=3, 23.1\%). Key methodological challenges included short follow-up periods, the absence of alert compliance tracking, the lack of ADE and error severity categorization, and omission of indirect costs. Conclusions: DHT interventions are economically viable to improve medication safety, with a substantial reduction in ADEs and medication errors. Future studies should prioritize incorporating alert compliance tracking, ADE and error severity classification, and evaluation of indirect costs, thereby increasing clinical benefits and economic viability. ", doi="10.2196/65546", url="https://www.jmir.org/2025/1/e65546" } @Article{info:doi/10.2196/46047, author="Lonner, H. Jess and Naidu-Helm, Ashwini and Van Andel, David and Anderson, B. Mike and Ditto, Richard and Redfern, E. Roberta and Foran, Jared", title="Smartphone-Based Care Platform Versus Traditional Care in Primary Knee Arthroplasty in the United States: Cost Analysis", journal="JMIR Mhealth Uhealth", year="2025", month="Feb", day="3", volume="13", pages="e46047", keywords="telerehabilitation", keywords="telehealth", keywords="telemedicine", keywords="rehabilitation", keywords="physiotherapy", keywords="mobile health", keywords="knee arthroplasty", abstract="Trial registration: ClinicalTrials.gov NCT03737149; https://clinicaltrials.gov/study/NCT03737149 ", doi="10.2196/46047", url="https://mhealth.jmir.org/2025/1/e46047" } @Article{info:doi/10.2196/56791, author="Mourato, Beatriz Maria and Pratas, Nuno and Branco Pereira, Andreia and Tar{\'e}, Filipa and Chan{\c{c}}a, Raphael and Fronteira, In{\^e}s and Dinis, Rui and Areia, Miguel", title="Effectiveness of Gastric Cancer Endoscopic Screening in Intermediate-Risk Countries: Protocol for a Systematic Review and Meta-Analysis", journal="JMIR Res Protoc", year="2025", month="Feb", day="3", volume="14", pages="e56791", keywords="gastric cancers", keywords="endoscopic screening", keywords="intermediate-risk countries", keywords="neoplasia", keywords="early detection", keywords="diagnosis", keywords="cancer screening", keywords="survival", keywords="meta-analysis", keywords="gastrointestinal cancers", abstract="Background: Gastric cancer (GC) is the fifth most prevalent neoplasm worldwide and the fourth with the highest mortality, and its geographical distribution is not homogeneous with high-risk, intermediate-risk (IR), and low-risk areas. Advanced stages at diagnosis are related to high mortality, but early detection greatly increases the chances of survival. Upper endoscopy with biopsy is the gold standard for GC diagnosis. Several studies have investigated the relevance of endoscopic screening and how to implemente it in IR countries. However, most Western societies recommend screening only in selected populations with high-risk factors for GC. No systematic reviews on GC endoscopic screening in IR countries exist. Objective: We aimed to determine the effectiveness of endoscopic GC screening in IR countries. Methods: We will include randomized and nonrandomized controlled trials, cohort studies, case-control studies, cross-sectional studies, and economic studies focusing on endoscopic screening of GC in the asymptomatic population of IR countries. The search will be conducted in MEDLINE, SCOPUS, Embase, and Web of Science. Other gray literature sources will be additionally searched. Studies published in English, Portuguese, or Spanish until September 2024 will be included. Two independent reviewers will screen the titles and abstracts of all search results. The selected studies will then be fully analyzed, and the data will be collected and coded in a database. To minimize the risk of bias, the included studies will undergo a quality analysis according to Cochrane risk of bias tools, RoB 2 of randomized trials and ROBINS-I for nonrandomized trials; Newcastle-Ottawa Quality Assessment Scale for case-control and cohort studies; and National Heart, Lung and Blood Institute study quality assessment tools for cross-sectional studies. The data collected will be cataloged in 2 categories: efficacy or effectiveness data and economic data, and separate meta-analyses will be performed for each category if appropriate. Results: This study is expected to provide results on the efficacy, effectiveness, and cost-effectiveness of endoscopic screening in an IR population. To date, 969 studies were screened for title and abstract, 75 were selected for full-text screening, and 44 were retained for data analysis. Additionally, 2 studies were selected from our manual search. Currently, the study is in the early stages of data extraction and risk of bias assessment and is expected to be published in the first quarter of 2025. Conclusions: To our knowledge, this review will be the first to provide evidence on the effectiveness of endoscopic GC screening in IR countries. In doing so, we believe we will help guide future research, inform health care decisions and assist policy makers in this area, and support future decisions to implement GC screening programs in this type of population. Trial Registration: PROSPERO CRD42024502174; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=502174 International Registered Report Identifier (IRRID): DERR1-10.2196/56791 ", doi="10.2196/56791", url="https://www.researchprotocols.org/2025/1/e56791", url="http://www.ncbi.nlm.nih.gov/pubmed/39545590" } @Article{info:doi/10.2196/58539, author="Arifi, Dorian and Resch, Bernd and Santillana, Mauricio and Guan, Wendy Weihe and Knoblauch, Steffen and Lautenbach, Sven and Jaenisch, Thomas and Morales, Ivonne and Havas, Clemens", title="Geosocial Media's Early Warning Capabilities Across US County-Level Political Clusters: Observational Study", journal="JMIR Infodemiology", year="2025", month="Jan", day="30", volume="5", pages="e58539", keywords="spatiotemporal epidemiology", keywords="geo-social media data", keywords="digital disease surveillance", keywords="political polarization", keywords="epidemiological early warning", keywords="digital early warning", abstract="Background: The novel coronavirus disease (COVID-19) sparked significant health concerns worldwide, prompting policy makers and health care experts to implement nonpharmaceutical public health interventions, such as stay-at-home orders and mask mandates, to slow the spread of the virus. While these interventions proved essential in controlling transmission, they also caused substantial economic and societal costs and should therefore be used strategically, particularly when disease activity is on the rise. In this context, geosocial media posts (posts with an explicit georeference) have been shown to provide a promising tool for anticipating moments of potential health care crises. However, previous studies on the early warning capabilities of geosocial media data have largely been constrained by coarse spatial resolutions or short temporal scopes, with limited understanding of how local political beliefs may influence these capabilities. Objective: This study aimed to assess how the epidemiological early warning capabilities of geosocial media posts for COVID-19 vary over time and across US counties with differing political beliefs. Methods: We classified US counties into 3 political clusters, democrat, republican, and swing counties, based on voting data from the last 6 federal election cycles. In these clusters, we analyzed the early warning capabilities of geosocial media posts across 6 consecutive COVID-19 waves (February 2020-April 2022). We specifically examined the temporal lag between geosocial media signals and surges in COVID-19 cases, measuring both the number of days by which the geosocial media signals preceded the surges in COVID-19 cases (temporal lag) and the correlation between their respective time series. Results: The early warning capabilities of geosocial media data differed across political clusters and COVID-19 waves. On average, geosocial media posts preceded COVID-19 cases by 21 days in republican counties compared with 14.6 days in democrat counties and 24.2 days in swing counties. In general, geosocial media posts were preceding COVID-19 cases in 5 out of 6 waves across all political clusters. However, we observed a decrease over time in the number of days that posts preceded COVID-19 cases, particularly in democrat and republican counties. Furthermore, a decline in signal strength and the impact of trending topics presented challenges for the reliability of the early warning signals. Conclusions: This study provides valuable insights into the strengths and limitations of geosocial media data as an epidemiological early warning tool, particularly highlighting how they can change across county-level political clusters. Thus, these findings indicate that future geosocial media based epidemiological early warning systems might benefit from accounting for political beliefs. In addition, the impact of declining geosocial media signal strength over time and the role of trending topics for signal reliability in early warning systems need to be assessed in future research. ", doi="10.2196/58539", url="https://infodemiology.jmir.org/2025/1/e58539" } @Article{info:doi/10.2196/60829, author="Karasek, Deborah and Williams, C. Jazzmin and Taylor, A. Michaela and De La Cruz, M. Monica and Arteaga, Stephanie and Bell, Sabra and Castillo, Esperanza and Chand, A. Maile and Coats, Anjeanette and Hubbard, M. Erin and Love-Goodlett, Latriece and Powell, Breezy and Spellen, Solaire and Malawa, Zea and Gomez, Manchikanti Anu", title="Designing the First Pregnancy Guaranteed Income Program in the United States: Qualitative Needs Assessment and Human-Centered Design to Develop the Abundant Birth Project", journal="JMIR Form Res", year="2025", month="Jan", day="27", volume="9", pages="e60829", keywords="maternal and child health", keywords="economics", keywords="public health", keywords="qualitative research methods", keywords="programs (evaluation and funding)", keywords="community-centered", keywords="pregnancy", keywords="first pregnancy", keywords="behavioral interventions", keywords="racial health", keywords="financial stress", keywords="Abundant Birth Project", keywords="infant health", keywords="infant", keywords="Black", abstract="Background: Racial inequities in pregnancy outcomes persist despite investments in clinical, educational, and behavioral interventions, indicating that a new approach is needed to address the root causes of health disparities. Guaranteed income during pregnancy has the potential to narrow racial health inequities for birthing people and infants by alleviating financial stress. Objective: We describe community-driven formative research to design the first pregnancy-guaranteed income program in the United States---the Abundant Birth Project (ABP). Informed by birth equity and social determinants of health perspectives, ABP targets upstream structural factors to improve racial disparities in maternal and infant health. Methods: The research team included community researchers, community members with lived experience as Black or Pacific Islander pregnant, and parenting people in the San Francisco Bay Area. The team conducted needs assessment interviews and facilitated focus groups with participants using human-centered design methods. Needs assessment participants later served as co-designers of the ABP program and research, sharing their experiences with financial hardships and government benefits programs and providing recommendations on key program elements, including fund disbursement, eligibility, and amount. Results: Housing affordability and the high cost of living in San Francisco emerged as significant sources of stress in pregnancy. Participants reported prohibitively low income eligibility thresholds and burdensome enrollment processes as challenges or barriers to existing social services. These insights guided the design of prototypes of ABP's program components, which were used in a design sprint to determine the final components. Based on this design process, the ABP program offered US \$1000/month for 12 months to pregnant Black and Pacific Islander people, selected through a lottery called an abundance drawing. Conclusions: The formative design process maximized community input and shared decision-making to co-design a guaranteed income program for Black and Pacific Islander women and people. Our upstream approach and community research model can inform the development of public health and social service programs. ", doi="10.2196/60829", url="https://formative.jmir.org/2025/1/e60829" } @Article{info:doi/10.2196/50026, author="Jang, Jieun and Kim, Anna and Choi, Mingee and McCarthy, P. Ellen and Olivieri-Mui, Brianne and Park, Mi Chan and Kim, Jae-Hyun and Shin, Jaeyong and Kim, Hyun Dae", title="Association of Frailty Index at 66 Years of Age with Health Care Costs and Utilization Over 10 Years in Korea: Retrospective Cohort Study", journal="JMIR Public Health Surveill", year="2025", month="Jan", day="27", volume="11", pages="e50026", keywords="frailty index", keywords="health care costs", keywords="health care utilization", keywords="elderly", keywords="Korea", keywords="frailty", keywords="aging", keywords="utilization", keywords="older adults", keywords="sociodemographic", keywords="cost", keywords="prevention", abstract="Background: The long-term economic impact of frailty measured at the beginning of elderhood is unknown. Objective: The objective of our study was to examine the association between an individual's frailty index at 66 years of age and their health care costs and utilization over 10 years. Methods: This retrospective cohort study included 215,887 Koreans who participated in the National Screening Program for Transitional Ages at 66 years of age between 2007?2009. Frailty was categorized using a 39-item deficit accumulation frailty index: robust (<0.15), prefrail (0.15?0.24), and frail (?0.25). The primary outcome was total health care cost, while the secondary outcomes were inpatient and outpatient health care costs, inpatient days, and number of outpatient visits. Generalized estimating equations with a gamma distribution and identity link function were used to investigate the association between the frailty index and health care costs and utilization until December 31, 2019. Results: The study population included 53.3\% (n=115,113) women, 32.9\% (n=71,082) with prefrailty, and 9.7\% (n=21,010) with frailty. The frailty level at 66 years of age was associated with higher cumulative total costs (robust to frail: \$19,815 to \$28.281; P<.001), inpatient costs (US \$11,189 to US \$16,627; P<.001), and outpatient costs (US \$8,625 to US \$11,654; P<.001) over the next 10 years. In the robust group, a one-year increase in age was associated with increased total health care costs (mean change per beneficiary per year: US \$206.2; SE: \$1.2; P<.001), inpatient costs (US \$126.8; SE: \$1.0; P<.001), and outpatient costs (US \$74.4; SE: \$0.4; P<.001). In the frail group, the increase in total health care costs was greater compared to the robust group (difference in mean cost per beneficiary per year: US \$120.9; SE: \$5.3; P<.001), inpatient costs (US \$102.8; SE: \$5.22; P<.001), and outpatient costs (US \$15.6; SE: \$1.5; P<.001). Similar results were observed for health care utilization (P<.001). Among the robust group, a one-year increase in age was associated with increased inpatient days (mean change per beneficiary per year: 0.9 d; P<.001) and outpatient visits (2.1 visits; P<.001). In the frail group, inpatient days increased annually compared to the robust group (difference in the mean inpatient days per beneficiary per year: 1.5 d; P<.001), while outpatient visits increased to a lesser extent (difference in the mean outpatient visits per beneficiary per year: ?0.2 visits; P<.001). Conclusions: Our study demonstrates the potential utility of assessing frailty at 66 years of age in identifying older adults who are more likely to incur high health care costs and utilize health care services over the subsequent 10 years. The long-term high health care costs and utilization associated with frailty and prefrailty warrants public health strategies to prevent and manage frailty in aging populations. ", doi="10.2196/50026", url="https://publichealth.jmir.org/2025/1/e50026" } @Article{info:doi/10.2196/65313, author="Reback, J. Cathy and Blue, Thomas and Jalali, Ali and Landovitz, Raphael and Li, J. Michael and Mata, P. Raymond and Ryan, Danielle and Jeng, J. Philip and Murphy, M. Sean", title="Comparative- and Cost-Effectiveness Research Determining the Optimal Intervention for Advancing Transgender Women With HIV to Full Viral Suppression (Text Me, Alexis!): Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2025", month="Jan", day="23", volume="14", pages="e65313", keywords="HIV/AIDS", keywords="transgender women", keywords="SMS text messaging", keywords="peer health navigation", keywords="HIV Care Continuum", abstract="Background: Many transgender women with HIV achieve suboptimal advancement through the HIV Care Continuum, including poor HIV health care usage, retention in HIV medical care, and rates of viral suppression. These issues are exacerbated by comorbid conditions, such as substance use disorder, which is also associated with reduced quality of life, increased overdose deaths, usage of high-cost health care services, engagement in a street economy, and cycles of incarceration. Thus, it is critical that efforts to End the HIV Epidemic include effective interventions to link and retain transgender women in HIV care through full viral suppression. Objective: This study builds on the promising findings from our two Health Resources and Services Administration-funded demonstration projects, The Alexis Project and Text Me, Girl!, which used peer health navigation (PHN) and SMS text messaging, respectively, for advancing transgender women with HIV to full viral suppression. Though the effectiveness of both interventions has been established, their comparative effectiveness, required resources or costs, cost-effectiveness, and heterogeneous effects on subgroups, including those with substance use disorder, have not been evaluated. Given the many negative personal and public health consequences of untreated or undertreated HIV, and that HIV services for transgender women are frequently delivered in resource-limited, community-based settings, a comprehensive economic evaluation is critical to inform decisions of stakeholders, such as providers, insurers, and policy makers. Methods: Text Me, Alexis! is a 3-arm randomized controlled trial. Participants (N=195) will be randomized (1:1:1) into: PHN alone (n=65), SMS text messaging alone (n=65), or PHN+SMS text messaging (n=65). Using the same time points as the Health Resources and Services Administration demonstration projects, the repeated-measures design will assess participants at baseline, 3, 6, 12, and 18 months post randomization. Over the course of the 90 days, participants in the PHN arm will receive unlimited navigation sessions; participants in the SMS text messaging arm will receive 270 theory-based SMS text messages (3 messages daily) that are targeted, tailored, and personalized specifically for transgender women with HIV; and participants in the PHN+SMS text messaging arm will receive a combined PHN and SMS text message intervention. The desired outcome of Text Me, Alexis! is viral suppression and cost-effectiveness. Results: Recruitment began on April 10, 2024, and the first participant was enrolled on April 11, 2024. Data collection is expected to be completed in July 2027. Primary outcome analyses will begin immediately following the conclusion of the follow-up evaluations. Conclusions: Transgender women are a high-priority population for reaching End the HIV Epidemic goals. Findings have the potential to improve individual and population health outcomes by generating significant improvements in viral suppression among transgender women and guiding service provision and public policy. International Registered Report Identifier (IRRID): DERR1-10.2196/65313 ", doi="10.2196/65313", url="https://www.researchprotocols.org/2025/1/e65313", url="http://www.ncbi.nlm.nih.gov/pubmed/39847410" } @Article{info:doi/10.2196/57385, author="Zhang, Lan and Bullen, Christopher and Chen, Jinsong", title="Digital Health Innovations to Catalyze the Transition to Value-Based Health Care", journal="JMIR Med Inform", year="2025", month="Jan", day="20", volume="13", pages="e57385", keywords="digital health", keywords="value-based health care", keywords="VBHC", keywords="patient-reported outcome measures", keywords="PROM", keywords="digital transformation", keywords="health care innovation", keywords="patient-centric care", keywords="health technology", keywords="patient-reported outcome", keywords="PRO", keywords="outcome measure", keywords="telehealth", keywords="telemedicine", keywords="eHealth", keywords="personalized", keywords="customized", keywords="engagement", keywords="patient-centered care", keywords="standardization", keywords="implementation", doi="10.2196/57385", url="https://medinform.jmir.org/2025/1/e57385" } @Article{info:doi/10.2196/59111, author="Gille, Felix and Maa{\ss}, Laura and Ho, Benjamin and Srivastava, Divya", title="From Theory to Practice: Viewpoint on Economic Indicators for Trust in Digital Health", journal="J Med Internet Res", year="2025", month="Jan", day="15", volume="27", pages="e59111", keywords="trust", keywords="economics", keywords="digital health", keywords="digital health innovation", keywords="artificial intelligence", keywords="AI", keywords="economic evaluation", keywords="public trust", keywords="health data", keywords="medical apps", doi="10.2196/59111", url="https://www.jmir.org/2025/1/e59111" } @Article{info:doi/10.2196/60443, author="van den Broek-Altenburg, M. Eline and Atherly, J. Adam", title="The Paradigm Shift From Patient to Health Consumer: 20 Years of Value Assessment in Health", journal="J Med Internet Res", year="2025", month="Jan", day="10", volume="27", pages="e60443", keywords="value assessment", keywords="cost-effectiveness", keywords="quality-adjusted life-years", keywords="QALY", keywords="health consumer", keywords="health technology", keywords="value based", keywords="digital health", keywords="patient centered", keywords="preferences", keywords="health economics", doi="10.2196/60443", url="https://www.jmir.org/2025/1/e60443", url="http://www.ncbi.nlm.nih.gov/pubmed/39793021" } @Article{info:doi/10.2196/64921, author="Kraybill, P. Eric and Chen, David and Khan, Saadat and Kalra, Praveen", title="Reducing Greenhouse Gas Emissions and Modifying Nitrous Oxide Delivery at Stanford: Observational, Pilot Intervention Study", journal="JMIR Perioper Med", year="2025", month="Jan", day="9", volume="8", pages="e64921", keywords="anesthetic gases", keywords="emissions", keywords="green house gas", keywords="sustainability", keywords="pilot study", keywords="electronic health record", keywords="implementation", keywords="nitrous oxide", keywords="global warming", abstract="Background: Inhalational anesthetic agents are a major source of potent greenhouse gases in the medical sector, and reducing their emissions is a readily addressable goal. Nitrous oxide (N2O) has a long environmental half-life relative to carbon dioxide combined with a low clinical potency, leading to relatively large amounts of N2O being stored in cryogenic tanks and H cylinders for use, increasing the chance of pollution through leaks. Building on previous findings, Stanford Health Care's (SHC's) N2O emissions were analyzed at 2 campuses and targeted for waste reduction as a precursor to system-wide reductions. Objective: We aimed to determine the extent of N2O pollution at SHC and subsequently whether using E-cylinders for N2O storage and delivery at the point of care in SHC's ambulatory surgery centers could reduce system-wide emissions. Methods: In phase 1, total SHC (Palo Alto, California) N2O purchase data for calendar year 2022 were collected and compared (volume and cost) to total Palo Alto clinical delivery data using Epic electronic health records. In phase 2, a pilot study was conducted in the 8 operating rooms of SHC campus A (Redwood City). The central N2O pipelines were disconnected, and E-cylinders were used in each operating room. E-cylinders were weighed before and after use on a weekly basis for comparison to Epic N2O delivery data over a 5-week period. In phase 3, after successful implementation, the same methodology was applied to campus B, one of 3 facilities in Palo Alto. Results: In phase 1, total N2O purchased in 2022 was 8,217,449 L (33,201.8 lbs) at a total cost of US \$63,298. Of this, only 780,882.2 L (9.5\%) of N2O was delivered to patients, with 7,436,566.8 L (90.5\%) or US \$57,285 worth lost or wasted. In phase 2, the total mass of N2O use from E-cylinders was 7.4 lbs (1 lb N2O=247.5 L) or 1831.5 L at campus A. Epic data showed that the total N2O volume delivered was 1839.3 L (7.4 lbs). In phase 3, the total mass of N2O use from E-cylinders was 10.4 lbs or 2574 L at campus B (confirming reliability within error propagation margins). Epic data showed that the total N2O volume delivered was 2840.3 L (11.5 lbs). Over phases 2 and 3, total use for campuses A and B was less than the volume of 3 E-cylinders (1 E-cylinder=1590 L). Conclusions: Converting N2O delivery from centralized storage to point-of-care E-cylinders dramatically reduced waste and expense with no detriment to patient care. Our results provide strong evidence for analyzing N2O storage in health care systems that rely on centralized storage, and consideration of E-cylinder implementation to reduce emissions. The reduction in N2O waste will help meet SHC's goal of reducing scope 1 and 2 emissions by 50\% before 2030. ", doi="10.2196/64921", url="https://periop.jmir.org/2025/1/e64921" } @Article{info:doi/10.2196/54975, author="Sang, Ling and Zheng, Bixin and Zeng, Xianzheng and Liu, Huizhen and Jiang, Qing and Liu, Maotong and Zhu, Chenyu and Wang, Maoying and Yi, Zengwei and Song, Keyu and Song, Li", title="Effectiveness of Outpatient Chronic Pain Management for Middle-Aged Patients by Internet Hospitals: Retrospective Cohort Study", journal="JMIR Med Inform", year="2024", month="Dec", day="30", volume="12", pages="e54975", keywords="chronic pain management", keywords="internet hospital", keywords="physical hospital", keywords="quality of life", keywords="outpatient care", keywords="telemedicine", keywords="digital health", abstract="Background: Chronic pain is widespread and carries a heavy disease burden, and there is a lack of effective outpatient pain management. As an emerging internet medical platform in China, internet hospitals have been successfully applied for the management of chronic diseases. There are also a certain number of patients with chronic pain that use internet hospitals for pain management. However, no studies have investigated the effectiveness of pain management via internet hospitals. Objective: The aim of this retrospective cohort study was to explore the effectiveness of chronic pain management by internet hospitals and their advantages and disadvantages compared to traditional physical hospital visits. Methods: This was a retrospective cohort study. Demographic information such as the patient's sex, age, and number of visits was obtained from the IT center. During the first and last patient visits, information on outcome variables such as the Brief Pain Inventory (BPI), medical satisfaction, medical costs, and adverse drug events was obtained through a telephone follow-up. All patients with chronic pain who had 3 or more visits (internet or offline) between September 2021, and February 2023, were included. The patients were divided into an internet hospital group and a physical hospital group, according to whether they had web-based or in-person consultations, respectively. To control for confounding variables, propensity score matching was used to match the two groups. Matching variables included age, sex, diagnosis, and number of clinic visits. Results: A total of 122 people in the internet hospital group and 739 people in the physical hospital group met the inclusion criteria. After propensity score matching, 77 patients in each of the two groups were included in the analysis. There was not a significant difference in the quality of life (QOL; QOL assessment was part of the BPI scale) between the internet hospital group and the physical hospital group (P=.80), but the QOL of both groups of patients improved after pain management (internet hospital group: P<.001; physical hospital group: P=.001). There were no significant differences in the pain relief rate (P=.25) or the incidence of adverse events (P=.60) between the two groups. The total cost (P<.001) and treatment-related cost (P<.001) of the physical hospital group were higher than those of the internet hospital group. In addition, the degree of satisfaction in the internet hospital group was greater than that in the physical hospital group (P=.01). Conclusions: Internet hospitals are an effective way of managing chronic pain. They can improve patients' QOL and satisfaction, reduce treatment costs, and can be used as part of a multimodal strategy for chronic pain self-management. ", doi="10.2196/54975", url="https://medinform.jmir.org/2024/1/e54975" } @Article{info:doi/10.2196/60666, author="Keim-Malpass, Jessica and Muir, Jane K. and Letzkus, C. Lisa and Scheer, Eleanore and Valdez, S. Rupa", title="Examining the Spillover Economic Impacts of Caregiving Among Families of Children With Medical Complexity to Inform Inclusive Economic Models: Qualitative Study", journal="J Particip Med", year="2024", month="Dec", day="30", volume="16", pages="e60666", keywords="caregiving", keywords="children with medical complexity", keywords="social network", keywords="qualitative", keywords="self-management", keywords="care coordination", keywords="economic evaluation", keywords="spillover", keywords="economic model", keywords="care", keywords="mobile phone", abstract="Background: Children with medical complexity represent a heterogeneous group of children with multiple chronic health care conditions. Caregivers of children with medical complexity experience a high intensity of caregiving that is often variable, extends across several networks of care, and often lasts for the entirety of the child's life. The spillover, or indirect, economic impacts of caregiving are understudied in the context the family units of children with medical complexity. There have been recognized limitations to the sole use of quantitative methods when developing economic models of disease, because they lack direct caregiver voice and context of caregiving activities, and existing methods have been noted to be ableist. Objective: This study aimed to explore the economic spillover impacts of caregiving among families of children with medical complexity using their own words and perspectives, with the intent of expanding caregiver-centered perspectives when developing economic models. Methods: This study was a secondary analysis of a qualitative study that was conducted to examine family management practices among caregivers of children with medical complexity and their social networks. Caregivers of children with medical complexity were recruited through a pediatric complex care clinic at an academic medical center in the mid-Atlantic region, United States. This study used inductive qualitative descriptive methods and a template to define features of the person impacted and to define the economic construct as either a direct or indirect (spillover) cost. Results: A total of 20 caregivers were included in this study. Perspectives from the caregivers of children with medical complexity revealed several key themes: (1) time lost from employment, impacting the primary caregivers; (2) physical and mental health impacts, impacting the child themselves, siblings, and the primary caregivers; (3) impacts to leisure activities and self-care, impacting the child themselves, siblings, and the primary caregivers; and (4) impacts to the social network or social capital. Conclusions: The themes described can be operationalized into inclusive family-centered models that represent the impacts of caregiving in the context of the family units of children with medical complexity. The use of qualitative methods to expand our development of quantitative economic models can be adapted to other populations where caregivers are involved in care. Caregivers can and should have an active voice in preference-based assessments that are operationalized in economic contexts to make them more inclusive. International Registered Report Identifier (IRRID): RR2-10.2196/14810 ", doi="10.2196/60666", url="https://jopm.jmir.org/2024/1/e60666", url="http://www.ncbi.nlm.nih.gov/pubmed/38758728" } @Article{info:doi/10.2196/64300, author="Youn, G. Christopher and Kim, Yeon Joo and Yang, B. Vivian and Bae, H. Gordon", title="Improving Affordability in Dermatology: Cost Savings in Mark Cuban Cost Plus Drug Company Versus GoodRx", journal="JMIR Dermatol", year="2024", month="Dec", day="13", volume="7", pages="e64300", keywords="dermatology", keywords="cost", keywords="affordability", keywords="drug company", keywords="United States", keywords="US", keywords="financial burden", keywords="prescription", keywords="medication", keywords="pharmaceutical", keywords="dermatologic", keywords="burden", keywords="financial distress", keywords="health outcomes", keywords="pharmacist", keywords="pharmacy", keywords="convenience", doi="10.2196/64300", url="https://derma.jmir.org/2024/1/e64300" } @Article{info:doi/10.2196/56091, author="Takashi, Naoki and Fujisawa, Misaki and Ohtera, Shosuke", title="Associations Between Successful Home Discharge and Posthospitalization Care Planning: Cross-Sectional Ecological Study", journal="JMIR Form Res", year="2024", month="Dec", day="12", volume="8", pages="e56091", keywords="health services research", keywords="health policy", keywords="quality of care", keywords="access to care", keywords="outcome assessment", keywords="public health", keywords="health service", keywords="accessible", keywords="accessibility", keywords="care coordination", keywords="health outcome", keywords="surveillance", keywords="regional disparities", keywords="nonstandardized care", keywords="nonstandardization", keywords="hospital discharge", keywords="hospital care", keywords="analysis", keywords="Japan", keywords="older adults", abstract="Background: Effective discharge planning is crucial for successful care transitions, reducing hospital length of stay and readmission rates. Japan offers a financial incentive to enhance the coordination of posthospitalization care planning for patients with complex needs. However, the national impact of this incentive remains unclear. Objective: This study aimed to (1) assess the association between the number of claims submitted for discharge planning, as an indicator of the provision of posthospitalization care planning, and key health care outcomes, including discharges to home, 30-day readmissions, length of stay, and medical expenditures at the prefectural level in Japan, and (2) to describe regional differences in the provision of posthospitalization care planning and explore associated factors. Methods: This ecological study used prefectural-level data from fiscal year 2020. Claims submitted for discharge planning were used as indicators that posthospitalization care planning was provided. Supply-adjusted standardized claim ratios (SCRs) were calculated using data from the Seventh National Database of Health Insurance Claims, to evaluate and compare the number of claims across 47 prefectures in Japan, accounting for differences in population structure. Key outcomes included discharges to home, 30-day readmissions, length of stay, and medical expenditures. Multivariate negative binomial regression models assessed associations between SCRs and outcomes, adjusting for socioeconomic covariates. In addition, regional differences in the provision of posthospitalization care planning and associated factors were analyzed using the Mann-Whitney U test. Prefectures were divided into 3 groups (low, medium, and high) based on tertiles of each factor, and supply-adjusted SCRs were compared across these groups. Results: The ratio of the minimum to maximum supply-adjusted SCR was 10.63, highlighting significant regional variation. Higher supply-adjusted SCRs, indicating more frequent provision of posthospitalization care planning, were associated with an increase of 9.68 (95\% CI 0.98-18.47) discharges to home per 1000 patients for each SD increase in supply-adjusted SCR. Several factors contributed to regional differences in the supply-adjusted SCR for posthospitalization care planning. A higher supply-adjusted SCR was significantly associated with a greater number of nurses per 100 hospital beds (median SCR in low, medium, and high groups: 0.055, 0.101, and 0.103, respectively); greater number of care manager offices per 100 km2 of habitable area (0.088, 0.082, and 0.116); higher proportion of hospitals providing electronic medical information to patients (0.083, 0.095, and 0.11); lower proportion of older adults living alone (0.116; 0.092; 0.071); and higher average per capita income (0.078, 0.102, and 0.102). Conclusions: The provision of posthospitalization care planning is associated with an increased likelihood of discharge to home, underscoring its importance in care transitions. However, significant regional disparities in care coordination exist. Addressing these disparities is crucial for equitable health care outcomes. Further research is needed to clarify causal mechanisms. ", doi="10.2196/56091", url="https://formative.jmir.org/2024/1/e56091" } @Article{info:doi/10.2196/64439, author="Pathak, Yuvraj and Muhlestein, David", title="Public Awareness and Use of Price Transparency: Report From a National Survey", journal="Interact J Med Res", year="2024", month="Dec", day="12", volume="13", pages="e64439", keywords="price transparency", keywords="consumer choice", keywords="survey", keywords="questionnaire", keywords="finance", keywords="cost", keywords="economics", keywords="price", keywords="pricing", keywords="consumer", keywords="transparent", keywords="Medicare", keywords="Medicaid", keywords="insurance", doi="10.2196/64439", url="https://www.i-jmr.org/2024/1/e64439" } @Article{info:doi/10.2196/58688, author="Liu, Xuan and Chi, Xiaotong and Chen, Ming and Sun, Wen and Li, Jia", title="Spillover Effects of Paid Functions on Physicians' Unpaid Knowledge Activities: Quasi-Experimental Approach", journal="J Med Internet Res", year="2024", month="Dec", day="10", volume="26", pages="e58688", keywords="health knowledge contribution", keywords="economic incentives", keywords="diversity", keywords="propensity score matching", keywords="multi-period difference in differences", abstract="Background: To promote sustained contributions by physicians to online health care communities, these platforms have introduced a content payment model that offers economic incentives for physicians' online knowledge activities. However, the impact of these paid features on unpaid knowledge activities remains unexplored. Objective: This study investigated how the introduction of economic incentives in online medical communities affects physicians' unpaid knowledge activities in the community. Methods: The data for this study were obtained from the Haodf Online platform in China, which has implemented paid scenarios for its science popularization function, providing economic benefits to physicians. The dataset, which comprises panel data, includes 7453 physicians who participated in both paid and unpaid knowledge contributions on the website. This study examined the impact of paid knowledge activities on physicians' free knowledge contributions, focusing on dimensions including knowledge quantity, quality, and diversity. To address the timing discrepancies in physicians' participation in paid activities, we used a quasi-experimental design that combined the approach of propensity score matching and multi-period difference in differences. Results: In the balance test results of the propensity score matching, the absolute values of the SDs of all matching variables were mostly <5\% after matching, ensuring the accuracy of the results obtained from the difference in differences method. This study found that participation in paid knowledge activities had a positive spillover effect on physicians' free knowledge contributions, which manifested in the increase in post quantity (473.1\%; P<.001), article length (108\%; P=.009), function word frequency (0.6\%; P=.001), causal word frequency (0.2\%; P<.001), and content information entropy (6.6\%; P=.006). The paid function led to a decrease in the consistency between titles and content (--115.5\%; P<.001). Conclusions: The findings of this study contribute to the existing literature on the impact of economic incentives in the medical context. For the platform, providing economic incentives to physicians can have positive significance in promoting the development of the platform's knowledge ecosystem and can effectively encourage physicians to contribute to both paid and free knowledge activities. This study provides a valuable reference for the platform to introduce a paid knowledge model, which is beneficial to the sustainable development of the platform. ", doi="10.2196/58688", url="https://www.jmir.org/2024/1/e58688", url="http://www.ncbi.nlm.nih.gov/pubmed/39656521" } @Article{info:doi/10.2196/56699, author="Li, Qingqing and Cheng, Feng and Zeng, Huatang and Xu, Junfang", title="Health Insurance Payment for Telehealth Services: Scoping Review and Narrative Synthesis", journal="J Med Internet Res", year="2024", month="Dec", day="9", volume="26", pages="e56699", keywords="telehealth", keywords="internet-based health care", keywords="reimbursement", keywords="health insurance payment", keywords="health care", keywords="scoping review", keywords="narrative synthesis", keywords="mobile phone", abstract="Background: As telehealth services have demonstrated significant advantages in providing qualified and accessible care, health insurance payments for telehealth services have been issued by various countries. However, the optimization of health insurance payments for telehealth services remains uncertain. Objective: We conducted a scoping review of the current situation regarding health insurance payments for telehealth services, with the aim of providing evidence to enhance policies related to health insurance payments for such services. Methods: This scoping review was conducted by comprehensively retrieving data from 6 electronic bibliographic databases from inception to October 2023. The databases included China National Knowledge Infrastructure, Wan Fang, Weipu, Web of Science, PubMed, and Embase, following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Two authors independently assessed search results, extracted data, and evaluated the quality of the included studies using the Critical Appraisal Skills Programme checklist. After the initial screening of titles and abstracts, full texts were obtained and examined. The data regarding the first author, date of publication, country, type of telehealth services introduced in health insurance, health insurance reimbursement providers, reimbursement standards for telehealth (eg, the condition for the reimbursement and reimbursement rate), and key findings of studies were extracted and analyzed. Moreover, we also conducted a narrative synthesis to summarize and report the findings. Results: A total of 7232 papers were retrieved. Following quality assessment, 23 papers were finally included, with the covered countries including China, the United States, Australia, France, Japan, the United Kingdom, and Germany. The forms of the services vary across different regions, mainly including consultation services, medical monitoring services, mental health services, health education services, and other services. Payment standards are generally categorized into fee-for-service and global budget payment, with clear health insurance payment quotas or proportions and certain restrictions (eg, specifying the location of medical visits and setting the limitation on distance from home to hospitals). The paying entities for health insurance payment include national health insurance and commercial health insurance. In addition, there are 2 kinds of reimbursement rates---a comparable rate for both telehealth and in-person health care services, and a lower rate for telehealth services compared to in-person health care services. Conclusions: To enhance the accessibility of telehealth services through health insurance payment, it is crucial to further refine the design of health insurance payment for telehealth and strengthen the supervision of services quality, bridging the gap between telehealth and in-person health care services. Additionally, this review did not include studies from all countries, and we recommend that future reviews should include a broader range of countries to provide a more comprehensive view of global telehealth insurance systems. ", doi="10.2196/56699", url="https://www.jmir.org/2024/1/e56699" } @Article{info:doi/10.2196/63288, author="Sj{\"o}str{\"o}m, Anna and Hajdarevic, Senada and H{\"o}rnsten, {\AA}sa and Isaksson, Ulf", title="eHealth Literacy and Health-Related Internet Use Among Swedish Primary Health Care Visitors: Cross-Sectional Questionnaire Study", journal="JMIR Form Res", year="2024", month="Dec", day="5", volume="8", pages="e63288", keywords="eHealth literacy", keywords="primary health care", keywords="health-related internet information", keywords="health literacy", keywords="digitalization", keywords="eHealth", keywords="cost-effective care", keywords="internet", keywords="health applications", keywords="digital health", keywords="patient participation", keywords="health behaviors", keywords="questionnaire", keywords="well-being", abstract="Background: Digitalization has profoundly transformed health care delivery, especially within primary health care, as a crucial avenue for providing accessible, cost-effective care. While eHealth services are frequently highlighted for improving health care availability and promoting equality, it is essential to recognize that digitalization can inadvertently exclude individuals who lack the prerequisites to use eHealth services, that is, those with low eHealth literacy. Previous research has identified lower eHealth literacy among older individuals, those with lower educational levels, and those who use the internet less frequently. However, in a Swedish context, only a few studies have investigated eHealth literacy. Objective: This study investigated eHealth literacy and its association with health-related internet use and sociodemographic characteristics among primary health care visitors. Methods: This cross-sectional study used a quantitative, descriptive approach. Swedish-speaking patients visiting a primary health care center participated by answering the multidimensional eHealth Literacy Questionnaire (eHLQ) and questions regarding sociodemographic characteristics and internet usage. The study compared mean scores using the Mann-Whitney U test and the Kruskal-Wallis test. A logistic regression analysis also explored the associations between eHealth literacy and significant independent variables identified in the univariate analyses. Results: As a group, the 172 participants rated highest in understanding and engagement with their health (median eHLQ score 3, IQR 2.8?3.4), as well as in feeling secure about the confidentiality of eHealth services (median eHLQ score 3, IQR 2?3), while they rated lower in motivation to use eHealth (median eHLQ score 2.6, IQR 2?3), the suitability of eHealth services to their personal needs (median eHLQ score 2.75, IQR 2?3), and their perceived ability to understand and use health-related internet information (median eHLQ score 2.6, IQR 2?3). The logistic regression analysis identified that lower eHealth literacy was associated with older age, particularly in domains related to finding, understanding, and using health-related internet information (odds ratio [OR] 1.02, 95\% CI 1?1.05; P=.03); digital technology use (OR 1.05, 95\% CI 1.02?1.08; P<.001); and accessing well-functioning eHealth services (OR 1.02, 95\% CI 1?1.05; P=.03). Additionally, in the logistic regression analysis, perceiving health-related internet information as not useful was linked to lower literacy in all eHLQ domains except one. Conclusions: Our findings regarding the primary challenges within our sample underscore the importance of developing and tailoring eHealth services to accommodate users' individual needs better, enhancing motivation for eHealth use, and continuing efforts to improve overall health literacy. These measures, which both eHealth developers and health care professionals should consider, are crucial for addressing the digital divide and expanding access to eHealth services for as many people as possible. ", doi="10.2196/63288", url="https://formative.jmir.org/2024/1/e63288" } @Article{info:doi/10.2196/59073, author="Lurtz, Josefine and C Sauter, Thomas and Jacob, Christine", title="Factors Impacting the Adoption and Potential Reimbursement of a Virtual Reality Tool for Pain Management in Switzerland: Qualitative Case Study", journal="JMIR Hum Factors", year="2024", month="Dec", day="4", volume="11", pages="e59073", keywords="eHealth", keywords="mobile health", keywords="mHealth", keywords="digital health", keywords="reimbursement", keywords="emergency", keywords="technology assessment", keywords="technology adoption", keywords="implementation", keywords="VR", keywords="virtual reality", keywords="pain", keywords="experience", keywords="attitude", keywords="opinion", keywords="perception", keywords="acceptance", keywords="adoption", keywords="qualitative", keywords="interview", keywords="hospital", abstract="Background: Pain and its adequate treatment are an issue in hospitals and emergency departments (EDs). A virtual reality (VR) tool to manage pain could act as a valuable complement to common pharmaceutical analgesics. While efficacy could be shown in previous studies, this does not assure clinical adoption in EDs. Objective: The main aim of this study was to investigate which factors affect the adoption and potential reimbursement of a VR tool for pain management in the ED of a Swiss university hospital. Methods: Key informant interviews were conducted using in-depth semistructured interviews with 11 participants reflecting the perspectives of all the relevant stakeholder groups, including physicians, nurses, patients, health technology providers, and health insurance and reimbursement experts. The interviews were recorded and transcribed, and the extracted data were systematically analyzed using a thematic analysis and narrative synthesis of emergent themes. A consolidated framework for eHealth adoption was used to enable a systematic investigation of the topic and help determine which adoption factors are considered as facilitators or barriers or as not particularly relevant for the tool subject of this study. Results: According to the participants, the three key facilitators are (1) organizational environment; (2) tension for change, ease of use, and demonstrability; and (3) employee engagement. Further, the three key barriers to adoption are (1) workload, (2) changes in clinical workflow and habit, and (3) reimbursement. Conclusions: This study concludes that the adoption of a VR tool for pain management in the ED of the hospital subject of this study, although benefiting from a high tension for change in pain and workload management, is highly dependent on the respective organizational environment, engagement of the clinical staff, and reimbursement considerations. While tailored incentive structures and ambassador roles could benefit initial adoption, a change in the reimbursement landscape and further investigation of the positive effects on workflow effectiveness are required to drive long-term adoption. ", doi="10.2196/59073", url="https://humanfactors.jmir.org/2024/1/e59073" } @Article{info:doi/10.2196/51477, author="Ji, Lu and Yao, Yifan and Yu, Dandan and Chen, Wen and Yin, Shanshan and Fu, Yun and Tang, Shangfeng and Yao, Lan", title="Performance of a Full-Coverage Cervical Cancer Screening Program Using on an Artificial Intelligence-- and Cloud-Based Diagnostic System: Observational Study of an Ultralarge Population", journal="J Med Internet Res", year="2024", month="Nov", day="20", volume="26", pages="e51477", keywords="full coverage", keywords="cervical cancer screening", keywords="artificial intelligence", keywords="primary health institutions", keywords="accessibility", keywords="efficiency", abstract="Background: The World Health Organization has set a global strategy to eliminate cervical cancer, emphasizing the need for cervical cancer screening coverage to reach 70\%. In response, China has developed an action plan to accelerate the elimination of cervical cancer, with Hubei province implementing China's first provincial full-coverage screening program using an artificial intelligence (AI) and cloud-based diagnostic system. Objective: This study aimed to evaluate the performance of AI technology in this full-coverage screening program. The evaluation indicators included accessibility, screening efficiency, diagnostic quality, and program cost. Methods: Characteristics of 1,704,461 individuals screened from July 2022 to January 2023 were used to analyze accessibility and AI screening efficiency. A random sample of 220 individuals was used for external diagnostic quality control. The costs of different participating screening institutions were assessed. Results: Cervical cancer screening services were extended to all administrative districts, especially in rural areas. Rural women had the highest participation rate at 67.54\% (1,147,839/1,699,591). Approximately 1.7 million individuals were screened, achieving a cumulative coverage of 13.45\% in about 6 months. Full-coverage programs could be achieved by AI technology in approximately 1 year, which was 87.5 times more efficient than the manual reading of slides. The sample compliance rate was as high as 99.1\%, and compliance rates for positive, negative, and pathology biopsy reviews exceeded 96\%. The cost of this program was CN {\textyen}49 (the average exchange rate in 2022 is as follows: US \$1=CN {\textyen}6.7261) per person, with the primary screening institution and the third-party testing institute receiving CN {\textyen}19 and {\textyen}27, respectively. Conclusions: AI-assisted diagnosis has proven to be accessible, efficient, reliable, and low cost, which could support the implementation of full-coverage screening programs, especially in areas with insufficient health resources. AI technology served as a crucial tool for rapidly and effectively increasing screening coverage, which would accelerate the achievement of the World Health Organization's goals of eliminating cervical cancer. ", doi="10.2196/51477", url="https://www.jmir.org/2024/1/e51477" } @Article{info:doi/10.2196/64248, author="Mira, Joaqu{\'i}n Jos{\'e} and Garc{\'i}a-Torres, Daniel and Bonell-Guerrero, Mar Mar{\'i}a del and C{\'a}ceres-Sevilla, Isabel Ana and Ramirez-Sanz, Martina and Mart{\'i}nez-Lleo, Rosa and Carratal{\'a}, Concepci{\'o}n", title="Patient Profile and Cost Savings of Long-Term Care in a Spanish Hospital: Retrospective Observational Study", journal="Interact J Med Res", year="2024", month="Nov", day="19", volume="13", pages="e64248", keywords="chronicity", keywords="length of stay", keywords="hospital", keywords="chronic", keywords="long-term care", keywords="demographics", keywords="gerontology", keywords="Hospitals for Acute and Chronic Long-Term Extended Stay", keywords="HACLES", keywords="healthcare economics", keywords="cost savings", abstract="Background: Long-term care hospitals have been considered an efficient response to the health care needs of an increasingly aging population. These centers are expected to contribute to better hospital bed management and more personalized care for patients needing continuous care. The evaluation of their outcomes is necessary after a sufficient period to assess their impact. Hospitals for Acute and Chronic Long-Term Extended Stay (HACLES) emerged in Spain in the late 20th century as a response to the aging population and the increase in chronic diseases. Objective: This study aimed to analyze the profile of patients treated in a HACLES, particularly analyzing gender differences, and evaluate the cost savings associated with using these centers. Methods: A retrospective study was conducted based on data from patients 65 years old or older admitted to a HACLES between 2022 and 2023. Gender, age, household cohabitation data, diagnosis and comorbidity, daily medication intake, and degree of dependency were obtained to describe the profile of patients who attended the HACLES. Data coded in SIA-Abucasis (version 37.00.03; Conseller{\'i}a Sanitat, Generalitat Valenciana; a digital medical record system used in the Valencian region) were reviewed, and descriptive statistics and comparison tests were used. The direct cost savings of HACLES admissions were calculated by comparing the daily cost of a general hospital bed with that of a HACLES bed. Results: Data from 123 patients with a mean age of 77 years were analyzed. Most (n=81, 65.9\%) had a cohabiting family member as their primary caregiver. Palliative care was the most frequent reason for admission (n=75, 61\%). The mortality rate (odds ratio [OR] 61.8, 95\% CI 53.2-70.5) was similar between men and women (OR 54.1, 95\% CI 47.8-71.5 vs OR 59.7, 95\% CI 42.2-66.0; P=.23). The cognitive assessment, using the Pfeiffer scale, improved at discharge (mean 3.2, SD 3.2 vs mean 2.5, SD 3.1; P=.003). The length of stay was significantly larger for patients who returned home compared with patients discharged to other facilities (mean 89.8, SD 58.2 versus mean 33.1, SD 43.1 days; P<.001). The direct cost savings were estimated at US \$42,614,846 per 1000 admissions. Conclusions: Patients typically treated in HACLES are older, with a high level of cognitive impairment and physical dependency, and a significant proportion are in palliative care, highlighting the importance of adapting care to the individual needs of the admitted patients. The HACLES model contributes to the sustainability of the public health system. ", doi="10.2196/64248", url="https://www.i-jmr.org/2024/1/e64248" } @Article{info:doi/10.2196/57814, author="Wang, Yipei and Zhang, Pei and Xing, Yan and Shi, Huifeng and Cui, Yunpu and Wei, Yuan and Zhang, Ke and Wu, Xinxia and Ji, Hong and Xu, Xuedong and Dong, Yanhui and Jin, Changxiao", title="Telemedicine Integrated Care Versus In-Person Care Mode for Patients With Short Stature: Comprehensive Comparison of a Retrospective Cohort Study", journal="J Med Internet Res", year="2024", month="Nov", day="19", volume="26", pages="e57814", keywords="telemedicine", keywords="telemedicine integrated care mode", keywords="short stature", keywords="clinical outcomes", keywords="health-seeking behaviors", keywords="cost analysis", keywords="in-person care", keywords="mobile health", keywords="mHealth", keywords="telehealth", keywords="eHealth", keywords="video virtual visit", keywords="access to care", keywords="children", keywords="pediatrics", keywords="China", keywords="accessibility", keywords="temporal", keywords="spatial constraints", keywords="chronic disease", abstract="Background: Telemedicine has demonstrated efficacy as a supplement to traditional in-person care when treating certain diseases. Nevertheless, more investigation is needed to comprehensively assess its potential as an alternative to in-person care and its influence on access to care. The successful treatment of short stature relies on timely and regular intervention, particularly in rural and economically disadvantaged regions where the disease is more prevalent. Objective: This study evaluated the clinical outcomes, health-seeking behaviors, and cost of telemedicine integrated into care for children with short stature in China. Methods: Our study involved 1241 individuals diagnosed with short stature at the pediatric outpatient clinic of Peking University Third Hospital between 2012 and 2023. Patients were divided into in-person care (IPC; 1183 patients receiving only in-person care) and telemedicine integrated care (TIC; 58 patients receiving both in-person and virtual care) groups. For both groups, the initial 71.43\% (average of 58 percentages, with each percentage representing the ratio of patients in the treatment group) of visits were categorized into the pretelemedicine phase. We used propensity score matching to select individuals with similar baseline conditions. We used 7 variables such as age, gender, and medical insurance for the 1:5 closest neighbor match. Eventually, 115 patients in the IPC group and 54 patients in the TIC group were selected. The primary clinical outcome was the change in the standard height percentage. Health-seeking behavior was described by visit intervals in the pre- and post-telemedicine phases. The cost analysis compared costs both between different groups and between different visit modalities of the TIC group in the post-telemedicine phase. Results: In terms of clinical effectiveness, we demonstrated that the increase in height among the TIC group ($\Delta$zTIC=0.74) was more substantial than that for the IPC group ($\Delta$zIPC=0.51, P=.01; paired t test), while no unfavorable changes in other endpoints such as BMI or insulin-like growth factor 1 (IGF-1) levels were observed. As for health-seeking behaviors, the results showed that, during the post-telemedicine phase, the IPC group had a visit interval of 71.08 (IQR 50.75-90.73) days, significantly longer than the prior period (51.25 [IQR 34.75-82.00] days, P<.001; U test), whereas the TIC group's visit interval remained unchanged. As for the cost per visit, there was no difference in the average cost per visit between the 2 groups nor between the pre- and post-telemedicine phases. During the post-telemedicine phase, within the TIC group, in-person visits had a higher average total cost, elevated medical and labor expenses, and greater medical cost compared with virtual visits. Conclusions: We contend that the rise in medical visits facilitated by integrating telemedicine into care effectively restored the previously constrained number of medical visits to their usual levels, without increasing costs. Our research underscores that administering prompt treatment may enable physicians to seize a crucial treatment opportunity for children with short stature, thus attaining superior results. ", doi="10.2196/57814", url="https://www.jmir.org/2024/1/e57814" } @Article{info:doi/10.2196/64226, author="Nagarajan, Radha and Kondo, Midori and Salas, Franz and Sezgin, Emre and Yao, Yuan and Klotzman, Vanessa and Godambe, A. Sandip and Khan, Naqi and Limon, Alfonso and Stephenson, Graham and Taraman, Sharief and Walton, Nephi and Ehwerhemuepha, Louis and Pandit, Jay and Pandita, Deepti and Weiss, Michael and Golden, Charles and Gold, Adam and Henderson, John and Shippy, Angela and Celi, Anthony Leo and Hogan, R. William and Oermann, K. Eric and Sanger, Terence and Martel, Steven", title="Economics and Equity of Large Language Models: Health Care Perspective", journal="J Med Internet Res", year="2024", month="Nov", day="14", volume="26", pages="e64226", keywords="large language model", keywords="LLM", keywords="health care", keywords="economics", keywords="equity", keywords="cloud service providers", keywords="cloud", keywords="health outcome", keywords="implementation", keywords="democratization", doi="10.2196/64226", url="https://www.jmir.org/2024/1/e64226" } @Article{info:doi/10.2196/51412, author="Liao, Wenmin and He, Rong and He, Zhonglian and Shi, Nan and Li, Dan and Zhuang, Aihua and Gan, Feng and Sun, Ying and Li, Chaofeng", title="Influence of Blood Sampling Service Process Reengineering on Medical Services Supply: Quasi-Experimental Study", journal="J Med Internet Res", year="2024", month="Nov", day="12", volume="26", pages="e51412", keywords="process reengineering", keywords="blood sampling", keywords="hospital administration", keywords="medical informatics", keywords="digital health", keywords="patient experience", abstract="Background: Tertiary hospitals in China are confronted with significant challenges due to limited spatial capacity and workforce constraints, leading to saturated allocation of medical resources and restricted growth in medical service provision. The incorporation of digital health into medical service process reengineering (MSPR) marks a pivotal transformation and restructuring of conventional health service delivery models. Specifically, the application of MSPR to blood sampling services processes reengineering (BSSPR) holds promise for substantially enhancing the efficiency and quality of medical services through streamlining and optimizing these procedures. However, the comprehensive impact of BSSPR has been infrequently quantified in existing research. Objective: This study aims to investigate the influence of BSSPR on the efficiency and quality of medical services and to elucidate the key informative technological support points underpinning BSSPR. Methods: Data were collected from both the new and old laboratory information systems from August 1, 2019, to December 31, 2021. A combination of statistical description, chi-square test, and t test was used to compare check-in time and waiting time of outpatients before and after the implementation of BSSPR. An interrupted time-series design was used to analyze the impact of BSSPR on medical service efficiency and quality, enabling the control of confounding variables, including changes in medical human resources and both long- and short-term temporal trends. Results: BSSPR had an impact on the efficiency and quality of medical services. Notably, there was a significant increase in the number of patients receiving blood sampling services, with a daily service volume increase of {\textasciitilde}150 individuals (P=.04). The average waiting time for patients decreased substantially from 29 (SD 36) to 11 (SD 11) minutes, indicating a marked improvement in patient experience. During the peak period, the number of patients receiving blood sampling services per working hour statistically increased from 9.56 to 16.77 (P<.001). The interrupted time-series model results demonstrated a reduction in patients' waiting time by an average of 26.1 (SD 3.8; 95\% CI --33.64 to --18.57) minutes. Although there was an initial decline in the number of outpatients admitted following BSSPR implementation, an upward trend was observed over time ($\beta$=1.13, 95\% CI 0.91-1.36). Conclusions: BSSPR implementation for outpatients not only reduced waiting time and improved patients' experience but also augmented the hospital's capacity to provide medical services. This study's findings offer valuable insights into the potential advantages of BSSPR and underscore the significance of harnessing digital technologies to optimize medical service processes. This research serves as a foundational basis and provides scientific support for the promotion and application of BSSPR in other health care contexts. By continuing to explore and refine the integration of digital technologies in health care, we can further enhance patient outcomes and elevate the overall quality of medical services. ", doi="10.2196/51412", url="https://www.jmir.org/2024/1/e51412" } @Article{info:doi/10.2196/50378, author="Howard-Wilson, Sakeina and Ching, Jack and Gentile, Sherri and Ho, Martin and Garcia, Alex and Ayturk, Didem and Lazar, Peter and Hammerquist, Nova and McManus, David and Barton, Bruce and Bird, Steven and Moore, John and Soni, Apurv", title="Efficacy of a Multimodal Digital Behavior Change Intervention on Lifestyle Behavior, Cardiometabolic Biomarkers, and Medical Expenditure: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Oct", day="30", volume="13", pages="e50378", keywords="health behavior", keywords="fitness", keywords="digital devices", keywords="lifestyle change", keywords="cardiovascular disease", keywords="chronic disease", keywords="physical activity", keywords="nutrition", keywords="sleep", keywords="mindfulness", abstract="Background: The US Preventive Services Task Force recommends providers offer individualized healthy behavior interventions for all adults, independent of their risk of cardiovascular disease. While strong evidence exists to support disease-specific programs designed to improve multiple lifestyle behaviors, approaches to adapting these interventions for a broader population are not well established. Digital behavior change interventions (DBCIs) hold promise as a more generalizable and scalable approach to overcome the resource and time limitations that traditional behavioral intervention programs face, especially within an occupational setting. Objective: We aimed to evaluate the efficacy of a multimodal DBCI on (1) self-reported behaviors of physical activity, nutrition, sleep, and mindfulness; (2) cardiometabolic biomarkers; and (3) chronic disease--related medical expenditure. Methods: We conducted a 2-arm randomized controlled trial for 12 months among employees of an academic health care facility in the United States. The intervention arm received a scale, a smartphone app, an activity tracker, a video library for healthy behavior recommendations, and an on-demand health coach. The control arm received standard employer-provided health and wellness benefits. The primary outcomes of the study included changes in self-reported lifestyle behaviors, cardiometabolic biomarkers, and chronic disease--related medical expenditure. We collected health behavior data via baseline and quarterly web-based surveys, biometric measures via clinic visits at baseline and 12 months, and identified relevant costs through claims datasets. Results: A total of 603 participants were enrolled and randomized to the intervention (n=300, 49.8\%) and control arms (n=303, 50.2\%). The average age was 46.7 (SD 11.2) years, and the majority of participants were female (80.3\%, n=484), White (85.4\%, n=504), and non-Hispanic (90.7\%, n=547), with no systematic differences in baseline characteristics observed between the study arms. We observed retention rates of 86.1\% (n=519) for completing the final survey and 77.9\% (n=490) for attending the exit visit. Conclusions: This study represents the largest and most comprehensive evaluation of DBCIs among participants who were not selected based on their underlying condition to assess its impact on behavior, cardiometabolic biomarkers, and medical expenditure. Trial Registration: ClinicalTrials.gov NCT04712383; https://clinicaltrials.gov/study/NCT04712383 International Registered Report Identifier (IRRID): RR1-10.2196/50378 ", doi="10.2196/50378", url="https://www.researchprotocols.org/2024/1/e50378" } @Article{info:doi/10.2196/56898, author="Mustafa, Khairiyah Noor and Ibrahim, Roszita and Aizuddin, Noor Azimatun and Aljunid, Mohamed Syed and Awang, Zainudin", title="Critical Success Factors and Acceptance of the Casemix System Implementation Within the Total Hospital Information System: Exploratory Factor Analysis of a Pilot Study", journal="JMIR Form Res", year="2024", month="Oct", day="29", volume="8", pages="e56898", keywords="critical success factors", keywords="exploratory factor analysis", keywords="Casemix system", keywords="acceptance", keywords="Total Hospital Information System", abstract="Background: The health care landscape is evolving rapidly due to rising costs, an aging population, and the increasing prevalence of diseases. To address these challenges, the Ministry of Health of Malaysia implemented transformation strategies such as the Casemix system and hospital information system to enhance health care quality, resource allocation, and cost-effectiveness. However, successful implementation relies not just on the technology itself but on the acceptance and engagement of the users involved. Objective: This study aims to develop and refine items of a quantitative instrument measuring the critical success factors influencing acceptance of Casemix system implementation within the Ministry of Health's Total Hospital Information System (THIS). Methods: A cross-sectional pilot study collected data from medical doctors at a hospital equipped with the THIS in the federal territory of Putrajaya, Malaysia. This pilot study's minimum sample size was 125, achieved through proportionate stratified random sampling. Data were collected using a web-based questionnaire adapted from the human, organization, and technology-fit evaluation framework and the technology acceptance model. The pilot data were analyzed using exploratory factor analysis (EFA), and the Cronbach $\alpha$ assessed internal reliability. Both analyses were conducted in SPSS (version 25.0; IBM Corp). Results: This study obtained 106 valid responses, equivalent to an 84.8\% (106/125) response rate. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.859, and the Bartlett test of sphericity yielded statistically significant results (P<.001). Principal component analysis identified 9 components explaining 84.07\% of the total variance, surpassing the minimum requirement of 60\%. In total, 9 unique slopes indicated the identification of 9 components through EFA. While no new components emerged from the other 7 constructs, only the organizational factors construct was divided into 2 components, later named organizational structure and organizational environment. In total, 98\% (41/42) of the items had factor loadings of >0.6, leading to the removal of 1 item for the final instrument for the field study. EFA ultimately identified 8 main constructs influencing Casemix implementation within the THIS: system quality, information quality, service quality, organizational characteristics, perceived ease of use, perceived usefulness, intention to use, and acceptance. Internal reliability measured using the Cronbach $\alpha$ ranged from 0.914 to 0.969, demonstrating high reliability. Conclusions: This study provides insights into the complexities of EFA and the distinct dimensions underlying the constructs that influence Casemix system acceptance in the THIS. While the findings align with extensive technology acceptance literature, the results accentuate the necessity for further research to develop a consensus regarding the most critical factors for successful Casemix adoption. The developed instrument is a substantial step toward better understanding the multidimensional challenges of health care system transformations in Malaysia, postulating an underpinning for future fieldwork and broader application across other hospitals. ", doi="10.2196/56898", url="https://formative.jmir.org/2024/1/e56898", url="http://www.ncbi.nlm.nih.gov/pubmed/39470697" } @Article{info:doi/10.2196/52077, author="Brunner, Lo{\"i}c and Siebert, N. Johan and Ehrler, Fr{\'e}d{\'e}ric and Manzano, Sergio and Marti, Joachim", title="Evaluating the Economic Impact of the PedAMINES App in Reducing Medication Errors in Pediatric Emergency Care: Cost-Effectiveness Analysis", journal="J Med Internet Res", year="2024", month="Oct", day="25", volume="26", pages="e52077", keywords="adverse drug event", keywords="health information technology", keywords="pediatric care", keywords="emergency care", keywords="ambulance care", keywords="economic evaluation", keywords="cost-effectiveness", keywords="epinephrine", keywords="norepinephrine", keywords="midazolam", keywords="dopamine", keywords="evidence-based", keywords="medical app", keywords="medication error", keywords="pediatric", keywords="child", keywords="pediatric emergency care", keywords="PedAMINES", keywords="Pediatric Accurate Medication in Emergency Situations", keywords="Switzerland", keywords="child care", keywords="mobile phone", abstract="Background: The administration of drugs in pediatric emergency care is a time-consuming process and is associated with a higher occurrence of medication errors compared with adult care. This is attributed to the intricacies of administration, which involve calculating doses based on the child's weight or age. To mitigate the occurrence of adverse drug events (ADEs), the PedAMINES (Pediatric Accurate Medication in Emergency Situations; Geneva University Hospitals) mobile app has been developed. This app offers a step-by-step guide for preparing and administering pediatric drugs during emergency interventions by automating the dose calculation process. Although previous simulation-based randomized controlled trials conducted in emergency care have demonstrated the efficacy of the PedAMINES app in reducing drug administration errors, there is a lack of evidence regarding its economic implications. Objective: This study aims to evaluate the cost-effectiveness of implementing the PedAMINES app for 4 emergency drugs: epinephrine, norepinephrine, dopamine, and midazolam. Methods: The economic evaluation was conducted by combining hospital data from 2019, previous trial outcomes, information extracted from existing literature, and PedAMINES maintenance costs. The cost per avoided medication error was calculated, along with the number of administrations needed to achieve a positive return on investment. Subsequently, Monte Carlo simulations were used to identify the key parameters contributing to result uncertainty. Results: The study revealed the number of preventable errors per administration for the 4 examined drugs: 0.513 for epinephrine, 0.484 for norepinephrine, 0.500 for dopamine, and 0.671 for midazolam. The cost-effectiveness ratios per ADE prevented were computed as follows: US \$4808 for epinephrine, US \$9705 for norepinephrine, US \$6957 for dopamine, and US \$2074 for midazolam. Accounting for the economic impact of ADEs, the analysis estimated that 16 administrations of epinephrine, 17 of norepinephrine and dopamine, and 13 of midazolam would be required to attain a positive return on investment. This corresponds to roughly one-third of the annual administrations at a major university hospital in Switzerland. The primary factors influencing the uncertainty in the estimated cost per ADE include the cost of maintenance of the app, the likelihood of an ADE resulting from an administration error, and the frequency of underdosing in the trial's control group. Conclusions: A dedicated mobile app presents an economically viable solution to alleviate the health and economic burden of drug administration errors in in-hospital pediatric emergency care. The widespread adoption of this app is advocated to pool costs and extend the benefits on a national scale in Switzerland. ", doi="10.2196/52077", url="https://www.jmir.org/2024/1/e52077" } @Article{info:doi/10.2196/48481, author="Freund, Johanna and Smit, Filip and Lehr, Dirk and Zarski, Anna-Carlotta and Berking, Matthias and Riper, Heleen and Funk, Burkhardt and Ebert, Daniel David and Buntrock, Claudia", title="A Universal Digital Stress Management Intervention for Employees: Randomized Controlled Trial with Health-Economic Evaluation", journal="J Med Internet Res", year="2024", month="Oct", day="22", volume="26", pages="e48481", keywords="economic evaluation", keywords="cost-effectiveness", keywords="cost-utility", keywords="cost-benefit", keywords="return-on-investment", keywords="employees", keywords="universal prevention", keywords="internet-based", keywords="stress management", abstract="Background: Stress is highly prevalent and known to be a risk factor for a wide range of physical and mental disorders. The effectiveness of digital stress management interventions has been confirmed; however, research on its economic merits is still limited. Objective: This study aims to assess the cost-effectiveness, cost-utility, and cost-benefit of a universal digital stress management intervention for employees compared with a waitlist control condition within a time horizon of 6 months. Methods: Recruitment was directed at the German working population. A sample of 396 employees was randomly assigned to the intervention group (n=198) or the waitlist control condition (WLC) group (n=198). The digital stress management intervention included 7 sessions plus 1 booster session, which was offered without therapeutic guidance. Health service use, patient and family expenditures, and productivity losses were self-assessed and used for costing from a societal and an employer's perspective. Costs were related to symptom-free status (PSS-10 [Perceived Stress Scale] score 2 SDs below the study population baseline mean) and quality-adjusted life years (QALYs) gained. The sampling error was handled using nonparametric bootstrapping. Results: From a societal perspective, the digital intervention was likely to be dominant compared with WLC, with a 56\% probability of being cost-effective at a willingness-to-pay (WTP) of {\texteuro}0 per symptom-free person gained. At the same WTP threshold, the digital intervention had a probability of 55\% being cost-effective per QALY gained relative to the WLC. This probability increased to 80\% at a societal WTP of {\texteuro}20,000 per QALY gained. Taking the employer's perspective, the digital intervention showed a probability of a positive return on investment of 78\%. Conclusions: Digital preventive stress management for employees appears to be cost-effective societally and provides a favorable return on investment for employers. Trial Registration: German Clinical Trials Register DRKS00005699; https://drks.de/search/en/trial/DRKS00005699 ", doi="10.2196/48481", url="https://www.jmir.org/2024/1/e48481" } @Article{info:doi/10.2196/54902, author="Wang, Kun and Zou, Wenxin and Lai, Yingsi and Hao, Chun and Liu, Ning and Ling, Xiang and Liu, Xiaohan and Liu, Ting and Yang, Xin and Zu, Chenxi and Wu, Shaolong", title="Accessibility, Cost, and Quality of an Online Regular Follow-Up Visit Service at an Internet Hospital in China: Mixed Methods Study", journal="J Med Internet Res", year="2024", month="Oct", day="21", volume="26", pages="e54902", keywords="internet hospital", keywords="medical service", keywords="accessibility", keywords="cost", keywords="quality", keywords="regular follow-up", abstract="Background: Telemedicine provides remote health care services to overcome constraints of time and space in accessing medical care. Similarly, internet hospitals in China support and provide remote health care services. Due to the COVID-19 pandemic, there has been a proliferation of internet hospitals. Many new services, including online consultations and regular online follow-up visit services, can now be accessed via internet hospitals in China. However, the accessibility, cost, and quality advantages of regular online follow-up visit services remain unclear. Objective: This study aimed to evaluate the accessibility, costs, and quality of an online regular follow-up visit service provided by an internet hospital in China. By analyzing the accessibility, costs, and quality of this service from the supply and demand sides, we can summarize the practical and theoretical experiences. Methods: A mixed methods study was conducted using clinical records from 18,473 patients receiving 39,239 online regular follow-up visit services at an internet hospital in 2021, as well as interviews with 7 physicians, 2 head nurses, and 3 administrative staff members. The quantitative analysis examined patient demographics, diagnoses, prescriptions, geographic distribution, physician characteristics, accessibility (travel time and costs), and service hours. The qualitative analysis elucidated physician perspectives on ensuring the quality of online health care. Results: Patients were predominantly middle-aged men with chronic diseases like viral hepatitis who were located near the hospital. The vast majority were from Guangdong province where the hospital is based, especially concentrated in Guangzhou city. The online regular follow-up visit service reduced travel time by 1 hour to 9 hours and costs by {\textyen}6 to {\textyen}991 (US \$0.86-\$141.32) depending on proximity, with greater savings for patients farther from the hospital. Consultation times were roughly equivalent between online and in-person visits. Physicians provided most online services during lunch breaks (12 PM to 2 PM) or after work hours (7 PM to 11 PM), indicating increased workload. The top departments providing online regular follow-up visit services were Infectious Diseases, Rheumatology, and Dermatology. The most commonly prescribed medications aligned with the prevalent chronic diagnoses. To ensure quality, physicians conducted initial in-person consultations to fully evaluate patients before allowing online regular follow-up visits, during which they communicated with patients to assess conditions and determine if in-person care was warranted. They also periodically reminded patients to come in person for more comprehensive evaluations. However, they acknowledged online visits cannot fully replace face-to-face care. Conclusions: Telemedicine services such as online regular follow-up visit services provided by internet hospitals must strictly adhere to fundamental medical principles of diagnosis, prescription, and treatment. For patients with chronic diseases, online regular follow-up visit services improve accessibility and reduce cost but cannot fully replace in-person evaluations. Physicians leverage various strategies to ensure the quality of online care. ", doi="10.2196/54902", url="https://www.jmir.org/2024/1/e54902", url="http://www.ncbi.nlm.nih.gov/pubmed/39432365" } @Article{info:doi/10.2196/49190, author="Cengil, Betul Aysenur and Eksioglu, Sandra and Eksioglu, Burak and Eswaran, Hari and Hayes, J. Corey and Bogulski, A. Cari", title="Statistical Analysis of Telehealth Use and Pre- and Postpandemic Insurance Coverage in Selected Health Care Specialties in a Large Health Care System in Arkansas: Comparative Cross-Sectional Study", journal="J Med Internet Res", year="2024", month="Oct", day="18", volume="26", pages="e49190", keywords="appointment scheduling metrics", keywords="insurance coverage", keywords="statistical hypothesis testing", keywords="telehealth", abstract="Background: The COVID-19 pandemic triggered policy changes in 2020 that allowed insurance companies to reimburse telehealth services, leading to increased telehealth use, especially in rural and underserved areas. However, with many emergency rules ending in 2022, patients and health care providers face potential challenges in accessing these services. Objective: This study analyzed telehealth use across specialties in Arkansas before and after the pandemic (2017-2022) using data from electronic medical records from the University of Arkansas for Medical Sciences Medical Center. We explored trends in insurance coverage for telehealth visits and developed metrics to compare the performance of telehealth versus in-person visits across various specialties. The results inform insurance coverage decisions for telehealth services. Methods: We used pre- and postpandemic data to determine the impacts of the COVID-19 pandemic and changes in reimbursement policies on telehealth visits. We proposed a framework to calculate 3 appointment metrics: indirect waiting time, direct waiting time, and appointment length. Statistical analysis tools were used to compare the performance of telehealth and in-person visits across the following specialties: obstetrics and gynecology, psychiatry, family medicine, gerontology, internal medicine, neurology, and neurosurgery. We used data from approximately 4 million in-person visits and 300,000 telehealth visits collected from 2017 to 2022. Results: Our analysis revealed a statistically significant increase in telehealth visits across all specialties (P<.001), showing an 89\% increase from 51,589 visits in 2019 to 97,461 visits in 2020, followed by a 21\% increase to 117,730 visits in 2021. Around 92.57\% (134,221/145,001) of telehealth patients from 2020 to 2022 were covered by Medicare, Blue Cross and Blue Shield, commercial and managed care, Medicaid, and Medicare Managed Care. In-person visits covered by Medicare and Medicaid decreased by 15\%, from 313,196 in 2019 to 264,696 in 2022. During 2020 to 2022, about 22.84\% (33,123/145,001) of total telehealth visits during this period were covered by Medicare and 53.58\% (86,317/161,092) were in psychiatry, obstetrics and gynecology, and family medicine. We noticed a statistically significant decrease (P<.001) in the average indirect waiting time for telehealth visits, from 48.4 to 27.7 days, and a statistically significant reduction in appointment length, from 93.2 minutes in 2020 to 39.59 minutes in 2022. The indirect waiting time for psychiatry telehealth visits was almost 50\% shorter than that for in-person visits. These findings highlight the potential benefits of telehealth in providing access to health care, particularly for patients needing psychiatric care. Conclusions: Reverting to prepandemic regulations could negatively affect Arkansas, where many live in underserved areas. Our analysis shows that telehealth use remained stable beyond 2020, with psychiatry visits continuing to grow. These findings may guide insurance and policy decisions in Arkansas and other regions facing similar access challenges. ", doi="10.2196/49190", url="https://www.jmir.org/2024/1/e49190", url="http://www.ncbi.nlm.nih.gov/pubmed/39423000" } @Article{info:doi/10.2196/51239, author="Oh, Sung-Hee and Kang, Jae-Heon and Kwon, Jin-Won", title="Information and Communications Technology--Based Monitoring Service for Tailored Chronic Disease Management in Primary Care: Cost-Effectiveness Analysis Based on ICT-CM Trial Results", journal="J Med Internet Res", year="2024", month="Oct", day="11", volume="26", pages="e51239", keywords="mHealth", keywords="mobile health", keywords="smartphone application", keywords="cost-effectiveness analysis", keywords="hypertension", keywords="diabetes mellitus", keywords="primary care", keywords="artificial intelligence", keywords="applications digital health", keywords="mobile phone", abstract="Background: Information and communications technology--based tailored management (TM) intervention is a novel automatic system in which a smartphone app for the management of patients with hypertension and diabetes, the provider web, and Bluetooth devices are linked. However, little evidence exists regarding the cost-effectiveness of the interventions using mobile apps. Objective: This study aimed to assess the cost-effectiveness of TM intervention for adult patients with hypertension or diabetes in primary care compared with usual care (UC). Methods: Cost-effectiveness analysis using a Markov model was conducted from the Korean health care system perspective. Based on 6-month outcome data from an information and communications technology--based tailored chronic disease management (ICT-CM) trial, effectiveness over a lifetime beyond the trial periods was extrapolated using a cardiovascular disease risk prediction model. Costs were estimated using ICT-CM trial data and national health insurance claims data. Health utility weights were obtained from the Korea National Health and Nutrition Examination Survey. Results: In the base-case analysis, compared with UC, TM was more costly (US \$23,157 for TM vs US \$22,391 for UC) and more effective (12.006 quality-adjusted life-years [QALYs] for TM vs 11.868 QALYs for UC). The incremental cost-effectiveness ratio was US \$5556 per QALY gained. Probabilistic sensitivity analysis showed that the probability of TM being cost-effective compared with UC was approximately 97\% at an incremental cost-effectiveness ratio threshold of US \$26,515 (KRW 35 million) per QALY gained. Conclusions: Compared with UC, TM intervention is a cost-effective option for patients with hypertension or diabetes in primary care settings. The study results can assist policy makers in making evidence-based decisions when implementing accessible chronic disease management services. ", doi="10.2196/51239", url="https://www.jmir.org/2024/1/e51239" } @Article{info:doi/10.2196/56741, author="Choi, Kyungseon and Park, Jun Sang and Yoon, Hyuna and Choi, Seoyoon and Mun, Yongseok and Kim, Seok and Yoo, Sooyoung and Woo, Joon Se and Park, Hyung Kyu and Na, Junghyun and Suh, Sun Hae", title="Patient-Centered Economic Burden of Diabetic Macular Edema: Retrospective Cohort Study", journal="JMIR Public Health Surveill", year="2024", month="Oct", day="8", volume="10", pages="e56741", keywords="diabetic macular edema", keywords="economic burden", keywords="cost of illness", keywords="retrospective cohort study", keywords="patient-centered care", keywords="Observational Medical Outcomes Partnership Common Data Model", abstract="Background: Diabetic macular edema (DME), a leading cause of blindness, requires treatment with costly drugs, such as anti--vascular endothelial growth factor (VEGF) agents. The prolonged use of these effective but expensive drugs results in an incremental economic burden for patients with DME compared with those with diabetes mellitus (DM) without DME. However, there are no studies on the long-term patient-centered economic burden of DME after reimbursement for anti-VEGFs. Objective: This retrospective cohort study aims to estimate the 3-year patient-centered economic burden of DME compared with DM without DME, using the Common Data Model. Methods: We used medical data from 1,903,603 patients (2003-2020), transformed and validated using the Observational Medical Outcomes Partnership Common Data Model from Seoul National University Bundang Hospital. We defined the group with DME as patients aged >18 years with nonproliferative diabetic retinopathy and intravitreal anti-VEGF or steroid prescriptions. As control, we defined the group with DM without DME as patients aged >18 years with DM or diabetic retinopathy without intravitreal anti-VEGF or steroid prescriptions. Propensity score matching, performed using a regularized logistic regression with a Laplace prior, addressed selection bias. We estimated direct medical costs over 3 years categorized into total costs, reimbursement costs, nonreimbursement costs, out-of-pocket costs, and costs covered by insurance, as well as healthcare resource utilization. An exponential conditional model and a count model estimated unbiased incremental patient-centered economic burden using generalized linear models and a zero-inflation model. Results: In a cohort of 454 patients with DME matched with 1640 patients with DM, the economic burden of DME was significantly higher than that of DM, with total costs over 3 years being 2.09 (95\% CI 1.78-2.47) times higher. Reimbursement costs were 1.89 (95\% CI 1.57-2.28) times higher in the group with DME than with the group with DM, while nonreimbursement costs were 2.54 (95\% CI 2.12-3.06) times higher. Out-of-pocket costs and costs covered by insurance were also higher by a factor of 2.11 (95\% CI 1.58-2.59) and a factor of 2.01 (95\% CI 1.85-2.42), respectively. Patients with DME had a significantly higher number of outpatient (1.87-fold) and inpatient (1.99-fold) visits compared with those with DM (P<.001 in all cases). Conclusions: Patients with DME experience a heightened economic burden compared with diabetic patients without DME. The substantial and enduring economic impact observed in real-world settings underscores the need to alleviate patients' burden through preventive measures, effective management, appropriate reimbursement policies, and the development of innovative treatments. Strategies to mitigate the economic impact of DME should include proactive approaches such as expanding anti-VEGF reimbursement criteria, approving and reimbursing cost-effective drugs such as bevacizumab, advocating for proactive eye examinations, and embracing early diagnosis by ophthalmologists facilitated by cutting-edge methodologies such as artificial intelligence for patients with DM. ", doi="10.2196/56741", url="https://publichealth.jmir.org/2024/1/e56741", url="http://www.ncbi.nlm.nih.gov/pubmed/39378098" } @Article{info:doi/10.2196/46178, author="Ang, Gregory and Tan, Seng Chuen and Teerawattananon, Yot and M{\"u}ller-Riemenschneider, Falk and Chen, Cynthia", title="A Nationwide Physical Activity Intervention for 654,500 Adults in Singapore: Cost-Utility Analysis", journal="JMIR Public Health Surveill", year="2024", month="Oct", day="4", volume="10", pages="e46178", keywords="physical activity", keywords="mHealth", keywords="mobile health", keywords="nationwide program", keywords="Markov model", keywords="diabetes", keywords="hypertension", keywords="prevention", keywords="modeling study", keywords="productivity", keywords="cost", keywords="mortality", keywords="cost-effectiveness", abstract="Background: Increasing physical inactivity is a primary risk factor for diabetes and hypertension, contributing to rising health care expenditure and productivity losses. As Singapore's aging population grows, there is an increased disease burden on Singapore's health systems. Large-scale physical activity interventions could potentially reduce the disease burden but face challenges with 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 mobile health (mHealth) intervention to increase physical activity, from both the health care provider 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 the NSC on adults aged 17 years and older. A Monte Carlo simulation with 1000 samples was conducted to compare two situations: the 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, as well as 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 the NSC yearly for 10 years with a mean cohort size of 654,500 participants was projected to prevent 6200 diabetes cases (95\% credible interval 3700 to 9100), 10,500 hypertension cases (95\% credible interval 6550 to 15,200), and 4930 deaths (95\% credible interval 3260 to 6930). This led to a reduction in health care costs of SGD (Singapore dollar) 448 million (95\% credible interval SGD 132 million to SGD 1.09 billion; SGD 1=US \$0.73 for the year 2019). There would be 78,800 (95\% credible interval 55,700 to 102,000) QALYs gained. Using a willingness-to-pay threshold of SGD 10,000 per QALY gained, the NSC would be cost-saving. When indirect costs were included, the NSC was estimated to reduce societal costs by SGD 1.41 billion (95\% credible interval SGD 353 million to SGD 3.80 billion). The model was most sensitive to changes in the inpatient cost of treatment for diabetes complications, time horizon, and program compliance. Conclusions: In this modeling 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 programs. ", doi="10.2196/46178", url="https://publichealth.jmir.org/2024/1/e46178" } @Article{info:doi/10.2196/56878, author="Dawson, D. Walter and Mattek, Nora and Gothard, Sarah and Kaye, Jeffrey and Lindauer, Allison", title="Ascertaining Out-of-Pocket Costs of Dementia Care: Feasibility Study of a Web-Based Weekly Survey", journal="JMIR Form Res", year="2024", month="Sep", day="25", volume="8", pages="e56878", keywords="Alzheimer disease", keywords="caregiving", keywords="out-of-pocket costs", keywords="behavioral and psychological symptoms of dementia", keywords="technological interventions", keywords="clinical trials", keywords="dementias", abstract="Background: Caring for a family member living with dementia is costly. A major contributor to care demands, and therefore to the costs, are the behavioral symptoms of dementia. Here, we examine the feasibility of ascertaining costs related to caregiving from weekly web-based surveys collected during a telehealth-based behavioral intervention study---Support via Technology: Living and Learning with Advancing Alzheimer Disease. Objective: This study aims to determine the feasibility and acceptability of using a web-based weekly survey to capture real-time data on out-of-pocket caregiving expenses and time commitments associated with dementia care. To examine relationships between behavioral symptoms, care partner reactivity, burden, and out-of-pocket dementia care costs. Methods: Feasibility was measured by accrual, retention, and data completion by participating care partners. Behavioral symptoms, care partner reactivity, and burden were collected before and after the intervention from 13 care partners. Weekly web-based surveys queried Support via Technology: Living and Learning with Advancing Alzheimer Disease care partners about their out-of-pocket costs associated with care-related activities. The surveys included questions on out-of-pocket costs care partners incurred from hospitalizations and emergency department use, primary care provider visits, use of paid in-home care or respite services, use of prescription medications, and use of over-the-counter medications. The surveys also queried the amount of time care partners devoted to these specific care--related activities. Results: Out-of-pocket costs of dementia care were collected via a web-based weekly survey for up to 18 months. In-home assistance was the most frequently reported type of out-of-pocket care expense and the costliest. care partners who paid for in-home assistance or respite reported more behavioral and psychological symptoms of dementia behaviors, higher reactivity, and higher burden than those who did not. Conclusions: This novel web-based weekly survey--based approach offers lessons for designing and implementing future cost-focused studies and care partner--supportive telehealth-based interventions for Alzheimer disease and related dementias (ADRD). The results correspond with the existing understanding of ADRD in that high family-related out-of-pocket costs are a typical part of the caregiving experience, and those costs likely increase with dementia severity. The results may also offer potential insights to health systems and policy makers as they seek to implement telehealth-based and related interventions that seek to better support people living with ADRD and their family care partners. Trial Registration: ClinicalTrials.gov NCT04335110; https://clinicaltrials.gov/ct2/show/NCT04335110 ", doi="10.2196/56878", url="https://formative.jmir.org/2024/1/e56878" } @Article{info:doi/10.2196/56398, author="Dziadzko, Mikhail and Belhassen, Manon and Van Ganse, Eric and Heritier, Fabrice and Berard, Marjorie and Marant-Micallef, Claire and Aubrun, Frederic", title="Health Care Resource Use and Total Mortality After Hospital Admission for Severe COVID-19 Infections During the Initial Pandemic Wave in France: Descriptive Study", journal="JMIR Public Health Surveill", year="2024", month="Sep", day="11", volume="10", pages="e56398", keywords="claims data", keywords="COVID-19 infection", keywords="France", keywords="health care resource utilizationuse", keywords="hospitalization", keywords="mortality", keywords="Post-Acute COVID-19 Syndrome", keywords="PACS", keywords="analysis", keywords="COVID-19", keywords="health care", keywords="infection", keywords="infections", keywords="pandemic", keywords="descriptive study", keywords="resource use", keywords="outpatient care", keywords="retrospective", keywords="cohort study", keywords="women", keywords="female", keywords="females", keywords="population-based", abstract="Background: Little is known about post--hospital health care resource use (HRU) of patients admitted for severe COVID-19, specifically for the care of patients with postacute COVID-19 syndrome (PACS). Objective: A list of HRU domains and items potentially related to PACS was defined, and potential PACS-related HRU (PPRH) was compared between the pre-- and post--COVID-19 periods, to identify new outpatient care likely related to PACS. Methods: A retrospective cohort study was conducted with the French National Health System claims data (SNDS). All patients hospitalized for COVID-19 between February 1, 2020, and June 30, 2020 were described and investigated for 6 months, using discharge date as index date. Patients who died during index stay or within 30 days after discharge were excluded. PPRH was assessed over the 5 months from day 31 after index date to end of follow-up, that is, for the post--COVID-19 period. For each patient, a pre--COVID-19 period was defined that covered the same calendar time in 2019, and pre--COVID-19 PPRH was assessed. Post- or pre- ratios (PP ratios) of the percentage of users were computed with their 95\% CIs, and PP ratios>1.2 were considered as ``major HRU change.'' Results: The final study population included 68,822 patients (median age 64.8 years, 47\% women, median follow-up duration 179.3 days). Altogether, 23\% of the patients admitted due to severe COVID-19 died during the hospital stay or within the 6 months following discharge. A total of 8 HRU domains were selected to study PPRH: medical visits, technical procedures, dispensed medications, biological analyses, oxygen therapy, rehabilitation, rehospitalizations, and nurse visits. PPRs showed novel outpatient care in all domains and in most items, without specificity, with the highest ratios observed for the care of thoracic conditions. Conclusions: Patients hospitalized for severe COVID-19 during the initial pandemic wave had high morbi-mortality. The analysis of HRU domains and items most likely to be related to PACS showed that new care was commonly initiated after discharge but with no specificity, potentially suggesting that any impact of PACS was part of the overall high HRU of this population after hospital discharge. These purely descriptive results need to be completed with methods for controlling for confusion bias through subgroup analyses. Trial Registration: ClinicalTrials.gov NCT05073328; https://clinicaltrials.gov/ct2/show/NCT05073328 ", doi="10.2196/56398", url="https://publichealth.jmir.org/2024/1/e56398" } @Article{info:doi/10.2196/54750, author="Sanjak, S. Jaleal and McAuley, M. Erin and Raybern, Justin and Pinkham, Richard and Tarnowski, Jacob and Miko, Nicole and Rasmussen, Bridgette and Manalo, J. Christian and Goodson, Michael and Stamps, Blake and Necciai, Bryan and Sozhamannan, Shanmuga and Maier, J. Ezekiel", title="Wastewater Surveillance Pilot at US Military Installations: Cost Model Analysis", journal="JMIR Public Health Surveill", year="2024", month="Sep", day="6", volume="10", pages="e54750", keywords="wastewater surveillance", keywords="cost analysis", keywords="military health", keywords="public health", keywords="sanitation", keywords="sanitary", keywords="water", keywords="wastewater", keywords="surveillance", keywords="environment", keywords="environmental", keywords="cost", keywords="costs", keywords="economic", keywords="economics", keywords="finance", keywords="financial", keywords="pathogen", keywords="pathogens", keywords="biosurveillance", abstract="Background: The COVID-19 pandemic highlighted the need for pathogen surveillance systems to augment both early warning and outbreak monitoring/control efforts. Community wastewater samples provide a rapid and accurate source of environmental surveillance data to complement direct patient sampling. Due to its global presence and critical missions, the US military is a leader in global pandemic preparedness efforts. Clinical testing for COVID-19 on US Air Force (USAF) bases (AFBs) was effective but costly with respect to direct monetary costs and indirect costs due to lost time. To remain operating at peak capacity, such bases sought a more passive surveillance option and piloted wastewater surveillance (WWS) at 17 AFBs to demonstrate feasibility, safety, utility, and cost-effectiveness from May 2021 to January 2022. Objective: We model the costs of a wastewater program for pathogens of public health concern within the specific context of US military installations using assumptions based on the results of the USAF and Joint Program Executive Office for Chemical, Biological, Radiological and Nuclear Defense pilot program. The objective was to determine the cost of deploying WWS to all AFBs relative to clinical swab testing surveillance regimes. Methods: A WWS cost projection model was built based on subject matter expert input and actual costs incurred during the WWS pilot program at USAF AFBs. Several SARS-CoV-2 circulation scenarios were considered, and the costs of both WWS and clinical swab testing were projected. Analysis was conducted to determine the break-even point and how a reduction in swab testing could unlock funds to enable WWS to occur in parallel. Results: Our model confirmed that WWS is complementary and highly cost-effective when compared to existing alternative forms of biosurveillance. We found that the cost of WWS was between US \$10.5-\$18.5 million less expensive annually in direct costs as compared to clinical swab testing surveillance. When the indirect cost of lost work was incorporated, including lost work associated with required clinical swab testing, we estimated that over two-thirds of clinical swab testing could be maintained with no additional costs upon implementation of WWS. Conclusions: Our results support the adoption of WWS across US military installations as part of a more comprehensive and early warning system that will enable adaptive monitoring during disease outbreaks in a more cost-effective manner than swab testing alone. ", doi="10.2196/54750", url="https://publichealth.jmir.org/2024/1/e54750" } @Article{info:doi/10.2196/59013, author="Goeldner, Moritz and Gehder, Sara", title="Digital Health Applications (DiGAs) on a Fast Track: Insights From a Data-Driven Analysis of Prescribable Digital Therapeutics in Germany From 2020 to Mid-2024", journal="J Med Internet Res", year="2024", month="Aug", day="29", volume="26", pages="e59013", keywords="digital health application", keywords="DiGA", keywords="data-driven analysis", keywords="clinical evidence", keywords="health economics", keywords="positive care effect", keywords="medical benefit", keywords="patient-relevant structural and procedural improvements", keywords="pSVV", keywords="digital health care act", abstract="Background: This study aimed to analyze the rapidly evolving ecosystem of digital health applications (Digitale Gesundheitsanwendung; DiGAs) in Germany, spurred by the 2019 Digital Healthcare Act. With over 73 million people in Germany now having access to DiGAs, these prescribable digital health apps and web-based applications represent a substantial stride in health care modernization, supporting both patients and health care providers with digital solutions for disease management and care improvement. Objective: Through a data-driven approach, this research aimed to unpack the complexities of DiGA market dynamics, economic factors, and clinical evidence, offering insights into their impact over the past years. Methods: The analysis draws from a range of public data sources, including the DiGA directory, statutory health insurance reports, app store feedback, and clinical study results. Results: As of July 1, 2024, there are 56 DiGAs listed by the Federal Institute for Drugs and Medical Devices (Bundesinstitut f{\"u}r Arzneimittel und Medizinprodukte), divided into 35 permanently and 21 preliminarily listed applications. Our findings reveal that a majority of DiGAs extend beyond the intended 1-year period to achieve permanent listing, reflecting the extensive effort required to demonstrate clinical efficacy. Economic analysis uncovered a dynamic pricing landscape, with initial prices ranging from approximately {\texteuro}200 to {\texteuro}700 ({\texteuro}1=US \$1.07), averaging at a median of {\texteuro}514 for a 3-month DiGA prescription. Following negotiations or arbitration board decisions, prices typically see a 50\% reduction, settling at a median of {\texteuro}221. Prescription data offer valuable insights into DiGA acceptance, with total prescriptions jumping from around 41,000 in the first period to 209,000 in the latest reporting period. The analysis of the top 15 DiGAs, representing 82\% of the total prescriptions, shows that these best-performing apps receive from a minimum of 8 to a maximum of 77 daily prescriptions, with native apps and early market entrants achieving higher rates. Clinical evidence from all 35 permanently listed DiGAs indicates a uniform preference for randomized controlled trials to validate primary end points, with no noteworthy use of alternative study designs encouraged in the Digital Healthcare Act and related regulations. Moreover, all evaluated DiGAs focused on medical benefits, with health status improvement as a key end point, suggesting an underuse of patient-relevant structural and procedural improvement in demonstrating health care impact. Conclusions: This study highlights the growth and challenges within the DiGA sector, suggesting areas for future research, such as the exploration of new study designs and the potential impact of patient-relevant structural and procedural improvements. For DiGA manufacturers, the strategic advantage of early market entry is emphasized. Overall, this paper underscores the evolving landscape of digital health, advocating for a nuanced understanding of digital health technology integration in Germany and beyond. ", doi="10.2196/59013", url="https://www.jmir.org/2024/1/e59013" } @Article{info:doi/10.2196/52734, author="Avance{\~n}a, V. Anton L. and Brody, Carinne and Chhoun, Pheak and Tuot, Sovannary and Yi, Siyan", title="Connecting Female Entertainment Workers in Cambodia to Health Care Services Using mHealth: Economic Evaluation of Mobile Link", journal="JMIR Form Res", year="2024", month="Jul", day="25", volume="8", pages="e52734", keywords="female entertainment workers", keywords="Cambodia", keywords="mHealth", keywords="mobile health", keywords="economic evaluation", keywords="stigmatized populations", keywords="women's health", keywords="sexual health", keywords="STI", keywords="sexually transmitted infection", keywords="STD", keywords="sexually transmitted disease", keywords="economic", keywords="cost", keywords="costs", keywords="affordable", keywords="affordability", keywords="budget", keywords="finance", keywords="financial", abstract="Background: Mobile Link is a mobile phone--based intervention to increase access to, and use of, health care services among female entertainment workers in Cambodia who face higher risks for specific diseases and gender-based violence. A multisite randomized controlled trial showed that Mobile Link connected female entertainment workers with outreach workers for information and escorted referrals after 6 months but did not lead to statistically significant improvements in HIV and sexually transmitted infection testing, contraceptive use, and condom use. Objective: This study aims to conduct a 3-part economic evaluation of Mobile Link to understand its costs, value, and affordability. Methods: We conducted cost, cost-effectiveness, and budget impact analyses of Mobile Link using cost and outcomes data from the Mobile Link trial and other sources. For the cost analysis, we estimated the total, per-person, and incremental costs of Mobile Link compared with usual care. Using probabilistic decision-analytic models, we estimated the 1-year cost-effectiveness of Mobile Link from payer and combined payer and patient perspectives by converting selected primary and secondary outcomes from the trial to disability-adjusted life years (DALYs) averted. Finally, we estimated the financial costs of scaling up Mobile Link's messaging and outreach services to 70\% of female entertainment workers in 5 years. Results: The incremental costs of Mobile Link were US \$199 from a payer perspective and US \$195 per person from a combined payer and patient perspective. With an average of 0.018 (95\% predicted interval --0.088 to 0.126) DALYs averted, Mobile Link's cost-effectiveness was US \$10,955 per DALY from a payer perspective (US \$10,755 per DALY averted from a payer and patient perspective). The costs of Mobile Link would have to decrease by 85\%, or its effectiveness would have to be 5.56 times higher, for the intervention to meet the upper limit of recommended cost-effectiveness thresholds in Cambodia (US \$1671 per DALY averted). The 5-year cost of scaling Mobile Link to 34,790 female entertainment workers was estimated at US \$1.64 million or US \$46 per person per year. Conclusions: This study provided a comprehensive economic evaluation of Mobile Link. We found that Mobile Link is not likely to be cost-effective unless its costs decrease or its effectiveness increases. Scaling up Mobile Link to more female entertainment workers is estimated to cost less than the costs of the trial. Given the importance of linking female entertainment workers to essential services, future research should focus on enhancing the effectiveness of Mobile Link or developing new mobile health interventions for this population. Trial Registration: ClinicalTrials.gov NCT03117842; https://clinicaltrials.gov/study/NCT03117842 ", doi="10.2196/52734", url="https://formative.jmir.org/2024/1/e52734" } @Article{info:doi/10.2196/58832, author="Allaire, C. Jason and Dennis, Consuela and Masturzo, Arti and Wittlin, Steven", title="Exploring the Impact of Device Sourcing on Real-World Adherence and Cost Implications of Continuous Glucose Monitoring in Patients With Diabetes: Retrospective Claims Analysis", journal="JMIR Diabetes", year="2024", month="Jul", day="22", volume="9", pages="e58832", keywords="diabetes", keywords="diabetic", keywords="adherence", keywords="medical costs", keywords="continuous glucose monitor", keywords="propensity score matching", keywords="CGM", keywords="glucose", keywords="cost", keywords="costs", keywords="claim", keywords="claims", keywords="insurance", keywords="economic", keywords="economics", keywords="finance", keywords="financial", abstract="Background: Insurance benefit design influences whether individuals with diabetes who require a continuous glucose monitor (CGM) to provide real-time feedback on their blood glucose levels can obtain the CGM device from either a pharmacy or a durable medical equipment supplier. The impact of the acquisition channel on device adherence and health care costs has not been systematically evaluated. Objective: This study aims to compare the adherence rates for patients new to CGM therapy and the costs of care for individuals who obtained CGM devices from a pharmacy versus acquisition through a durable medical equipment supplier using retrospective claims analysis. Methods: Using the Mariner commercial claims database, individuals aged >18 years with documented diabetes and an initial CGM claim during the first quarter of 2021 (2021 Q1, index date) were identified. Patients had to maintain uninterrupted enrollment for a duration of 15 months but file no CGM claim during the 6 months preceding the index date. We used direct matching to establish comparable pharmacy and durable medical equipment cohorts. Outcomes included quarterly adherence, reinitiation, and costs for the period from 2021 Q1 to the third quarter of 2022 (2022 Q3). Between-cohort differences in adherence rates and reinitiation rates were analyzed using z tests, and cost differences were analyzed using 2-tailed t tests. Results: Direct matching was used to establish comparable pharmacy and durable medical equipment cohorts. A total of 2356 patients were identified, with 1178 in the pharmacy cohort and 1178 in the durable medical equipment cohorts. Although adherence declined over time in both cohorts, the durable medical equipment cohort exhibited significantly superior adherence compared to the pharmacy cohort at 6 months (pharmacy n=615, 52\% and durable medical equipment n=761, 65\%; P<.001), 9 months (pharmacy n=579, 49\% and durable medical equipment cohorts n=714, 61\%; P<.001), and 12 months (pharmacy 48\% and durable medical equipment n=714, 59\%; P<.001). Mean annual total medical costs for adherent patients in the pharmacy cohort were 53\% higher than the durable medical equipment cohort (pharmacy US \$10,635 and durable medical equipment US \$6967; P<.001). In nonadherent patients, the durable medical equipment cohort exhibited a significantly higher rate of therapy reinitiation during the period compared to the pharmacy cohort (pharmacy 61/613, 10\% and durable medical equipment 108/485, 22\%; P<.001). Conclusions: The results from this real-world claims analysis demonstrate that, in a matched set, individuals who received their CGM through a durable medical equipment supplier were more adherent to their device. For individuals who experienced a lapse in therapy, those whose supplies were provided through the durable medical equipment channel were more likely to resume use after an interruption than those who received their supplies from a pharmacy. In the matched cohort analysis, those who received their CGM equipment through a durable medical equipment supplier demonstrated a lower total cost of care. ", doi="10.2196/58832", url="https://diabetes.jmir.org/2024/1/e58832", url="http://www.ncbi.nlm.nih.gov/pubmed/38804821" } @Article{info:doi/10.2196/50483, author="Tarride, Jean-Eric and Hall, N. Justin and Mondoux, Shawn and Dainty, N. Katie and McCarron, Joy and Paterson, Michael J. and Plumptre, Lesley and Borgundvaag, Emily and Ovens, Howard and McLeod, L. Shelley", title="Cost Evaluation of the Ontario Virtual Urgent Care Pilot Program: Population-Based, Matched Cohort Study", journal="J Med Internet Res", year="2024", month="Jul", day="15", volume="26", pages="e50483", keywords="virtual urgent care", keywords="health care expenditures", keywords="Canada", keywords="virtual care", keywords="economic evaluation", keywords="pilot program", keywords="pilot", keywords="Ontario", keywords="urgent care", keywords="care", keywords="emergency department", keywords="users", keywords="patient", keywords="patients", keywords="resources", keywords="resource allocation", keywords="policy decision", keywords="decision-making", keywords="policy", abstract="Background: In 2020, the Ministry of Health (MoH) in Ontario, Canada, introduced a virtual urgent care (VUC) pilot program to provide alternative access to urgent care services and reduce the need for in-person emergency department (ED) visits for patients with low acuity health concerns. Objective: This study aims to compare the 30-day costs associated with VUC and in-person ED encounters from an MoH perspective. Methods: Using administrative data from Ontario (the most populous province of Canada), a population-based, matched cohort study of Ontarians who used VUC services from December 2020 to September 2021 was conducted. As it was expected that VUC and in-person ED users would be different, two cohorts of VUC users were defined: (1) those who were promptly referred to an ED by a VUC provider and subsequently presented to an ED within 72 hours (these patients were matched to in-person ED users with any discharge disposition) and (2) those seen by a VUC provider with no referral to an in-person ED (these patients were matched to patients who presented in-person to the ED and were discharged home by the ED physician). Bootstrap techniques were used to compare the 30-day mean costs of VUC (operational costs to set up the VUC program plus health care expenditures) versus in-person ED care (health care expenditures) from an MoH perspective. All costs are expressed in Canadian dollars (a currency exchange rate of CAD \$1=US \$0.76 is applicable). Results: We matched 2129 patients who presented to an ED within 72 hours of VUC referral and 14,179 patients seen by a VUC provider without a referral to an ED. Our matched populations represented 99\% (2129/2150) of eligible VUC patients referred to the ED by their VUC provider and 98\% (14,179/14,498) of eligible VUC patients not referred to the ED by their VUC provider. Compared to matched in-person ED patients, 30-day costs per patient were significantly higher for the cohort of VUC patients who presented to an ED within 72 hours of VUC referral (\$2805 vs \$2299; difference of \$506, 95\% CI \$139-\$885) and significantly lower for the VUC cohort of patients who did not require ED referral (\$907 vs \$1270; difference of \$362, 95\% CI 284-\$446). Overall, the absolute 30-day costs associated with the 2 VUC cohorts were \$18.9 million (ie, \$6.0 million + \$12.9 million) versus \$22.9 million (\$4.9 million + \$18.0 million) for the 2 in-person ED cohorts. Conclusions: This costing evaluation supports the use of VUC as most complaints were addressed without referral to ED. Future research should evaluate targeted applications of VUC (eg, VUC models led by nurse practitioners or physician assistants with support from ED physicians) to inform future resource allocation and policy decisions. ", doi="10.2196/50483", url="https://www.jmir.org/2024/1/e50483", url="http://www.ncbi.nlm.nih.gov/pubmed/39008348" } @Article{info:doi/10.2196/50240, author="Sobolewski, Jessica and Rothschild, Allie and Freeman, Andrew", title="The Impact of Incentives on Data Collection for Online Surveys: Social Media Recruitment Study", journal="JMIR Form Res", year="2024", month="Jul", day="4", volume="8", pages="e50240", keywords="social media", keywords="online survey recruitment", keywords="incentive", keywords="experiment", keywords="online surveys", keywords="Facebook", keywords="Instagram", keywords="data collection", keywords="users", keywords="cost", keywords="social media recruitment", keywords="survey", abstract="Background: The use of targeted advertisements on social media platforms (eg, Facebook and Instagram) has become increasingly popular for recruiting participants for online survey research. Many of these surveys offer monetary incentives for survey completion in the form of gift cards; however, little is known about whether the incentive amount impacts the cost, speed, and quality of data collection. Objective: This experiment addresses this gap in the literature by examining how different incentives in paid advertising campaigns on Instagram for completing a 10-minute online survey influence the response rate, recruitment advertising cost, data quality, and length of data collection. Methods: This experiment tested three incentive conditions using three Instagram campaigns that were each allocated a US \$1400 budget to spend over a maximum of 4 days; ads targeted users aged 15-24 years in three nonadjacent designated market areas of similar size to avoid overlapping audiences. Four ad creatives were designed for each campaign; all ads featured the same images and text, but the incentive amount varied: no incentive, US \$5 gift card, and US \$15 gift card. All ads had a clickable link that directed users to an eligibility screener and a 10-minute online survey, if eligible. Each campaign ran for either the full allotted time (4 days) or until there were 150 total survey completes, prior to data quality checks for fraud. Results: The US \$15 incentive condition resulted in the quickest and cheapest data collection, requiring 17 hours and ad spending of US \$338.64 to achieve 142 survey completes. The US \$5 condition took more than twice as long (39 hours) and cost US \$864.33 in ad spending to achieve 148 survey completes. The no-incentive condition ran for 60 hours, spending nearly the full budget (US \$1398.23), and achieved only 24 survey completes. The US \$15 and US \$5 incentive conditions had similar levels of fraudulent respondents, whereas the no-incentive condition had no fraudulent respondents. The completion rate for the US \$15 and US \$5 incentive conditions were 93.4\% (155/166) and 89.8\% (149/166), respectively, while the completion rate for the no-incentive condition was 43.6\% (24/55). Conclusions: Overall, we found that a higher incentive resulted in quicker data collection, less money spent on ads, and higher response rates, despite some fraudulent cases that had to be dropped from the sample. However, when considering the total incentive amounts in addition to the ad spending, a US \$5 incentive appeared to be the most cost-effective data collection option. Other costs associated with running a campaign for a longer period should also be considered. A longer experiment is warranted to determine whether fraud varies over time across conditions. ", doi="10.2196/50240", url="https://formative.jmir.org/2024/1/e50240" } @Article{info:doi/10.2196/48043, author="Chen, Wenxiu and Zhang, Bin and Wang, Chen and An, Wei and Guruge, Kumudumali Shashika and Chui, Ho-kwong and Yang, Min", title="A Metric of Societal Burden Based on Virus Succession to Determine Economic Losses and Health Benefits of China's Lockdown Policies: Model Development and Validation", journal="JMIR Public Health Surveill", year="2024", month="Jun", day="7", volume="10", pages="e48043", keywords="SARS-CoV-2", keywords="lockdown", keywords="virus succession", keywords="benefit", keywords="loss", keywords="fatality rate", keywords="pandemic", keywords="blanket lockdown", keywords="partial lockdown", abstract="Background: The COVID-19 pandemic had a profound impact on the global health system and economic structure. Although the implementation of lockdown measures achieved notable success in curbing the spread of the pandemic, it concurrently incurred substantial socioeconomic costs. Objective: The objective of this study was to delineate an equilibrium between the economic losses and health benefits of lockdown measures, with the aim of identifying the optimal boundary conditions for implementing these measures at various pandemic phases. Methods: This study used a model to estimate the half-lives of the observed case fatality rates of different strains. It was based on global infection and death data collected by the World Health Organization and strain sequence time series data provided by Nextstrain. The connection between the health benefits and economic losses brought by lockdown measures was established through the calculation of disability-adjusted life years. Taking China's city lockdowns as an example, this study determined the cost-benefit boundary of various lockdown measures during the evolution of COVID-19. Results: The study reveals a direct proportionality between economic losses due to lockdowns and the observed case fatality rates of virus strains, a relationship that holds true irrespective of population size or per capita economic output. As SARS-CoV-2 strains evolve and population immunity shifts, there has been a notable decrease in the observed case fatality rate over time, exhibiting a half-life of roughly 8 months. This decline in fatality rates may offset the health benefits of maintaining unchanged lockdown measures, given that the resultant economic losses might exceed the health benefits. Conclusions: The initial enforcement of lockdown in Wuhan led to significant health benefits. However, with the decline in the observed case fatality rate of the virus strains, the economic losses increasingly outweighed the health benefits. Consequently, it is essential to consistently refine and enhance lockdown strategies in accordance with the evolving fatality and infection rates of different virus strains, thereby optimizing outcomes in anticipation of future pandemics. ", doi="10.2196/48043", url="https://publichealth.jmir.org/2024/1/e48043", url="http://www.ncbi.nlm.nih.gov/pubmed/38848555" } @Article{info:doi/10.2196/55544, author="Abi Hana, Racha and Abi Ramia, Jinane and Burchert, Sebastian and Carswell, Kenneth and Cuijpers, Pim and Heim, Eva and Knaevelsrud, Christine and Noun, Philip and Sijbrandij, Marit and van Ommeren, Mark and van't Hof, Edith and Wijnen, Ben and Zoghbi, Edwina and El Chammay, Rabih and Smit, Filip", title="Cost-Effectiveness of Digital Mental Health Versus Usual Care During Humanitarian Crises in Lebanon: Pragmatic Randomized Trial", journal="JMIR Ment Health", year="2024", month="May", day="29", volume="11", pages="e55544", keywords="depression", keywords="internet-based intervention", keywords="economic evaluation", keywords="Lebanese", keywords="Syrian", keywords="digital mental health", keywords="digital health", keywords="mental health", keywords="usual care", keywords="Lebanon", keywords="anxiety", keywords="stress-related disorders", keywords="treatment", keywords="symptoms", keywords="large randomized controlled trial", keywords="effectiveness", abstract="Background: There is evidence from meta-analyses and systematic reviews that digital mental health interventions for depression, anxiety, and stress-related disorders tend to be cost-effective. However, no such evidence exists for guided digital mental health care in low and middle-income countries (LMICs) facing humanitarian crises, where the needs are highest. Step-by-Step (SbS), a digital mental health intervention for depression, anxiety, and stress-related disorders, proved to be effective for Lebanese citizens and war-affected Syrians residing in Lebanon. Assessing the cost-effectiveness of SbS is crucial because Lebanon's overstretched health care system must prioritize cost-effective treatment options in the face of continuing humanitarian and economic crises. Objective: This study aims to assess the cost-effectiveness of SbS in a randomized comparison with enhanced usual care (EUC). Methods: The cost-effectiveness analysis was conducted alongside a pragmatic randomized controlled trial in 2 parallel groups comparing SbS (n=614) with EUC (n=635). The primary outcome was cost (in US \$ for the reference year 2019) per treatment response of depressive symptoms, defined as >50\% reduction of depressive symptoms measured using the Patient Health Questionnaire (PHQ). The secondary outcome was cost per remission of depressive symptoms, defined as a PHQ score <5 at last follow-up (5 months post baseline). The evaluation was conducted first from the health care perspective then from the societal perspective. Results: Taking the health care perspective, SbS had an 80\% probability to be regarded as cost-effective compared with EUC when there is a willingness to pay US \$220 per additional treatment response or US \$840 per additional remission. Taking the wider societal perspective, SbS had a >75\% probability to be cost-saving while gaining response or remission. Conclusions: To our knowledge, this study is the first cost-effectiveness analysis based on a large randomized controlled trial (n=1249) of a guided digital mental health intervention in an LMIC. From the principal findings, 2 implications flowed, from the (1) health care perspective and (2) wider societal perspective. First, our findings suggest that SbS is associated with greater health benefits, albeit for higher costs than EUC. It is up to decision makers in health care to decide if they find the balance between additional health gains and additional health care costs acceptable. Second, as seen from the wider societal perspective, there is a substantial likelihood that SbS is not costing more than EUC but is associated with cost-savings as SBS participants become more productive, thus offsetting their health care costs. This finding may suggest to policy makers that it is in the interest of both population health and the wider Lebanese economy to implement SbS on a wide scale. In brief, SbS may offer a scalable, potentially cost-saving response to humanitarian emergencies in an LMIC. Trial Registration: ClinicalTrials.gov NCT03720769; https://clinicaltrials.gov/ct2/show/NCT03720769 International Registered Report Identifier (IRRID): RR2-10.2196/21585 ", doi="10.2196/55544", url="https://mental.jmir.org/2024/1/e55544", url="http://www.ncbi.nlm.nih.gov/pubmed/38810255" } @Article{info:doi/10.2196/53872, author="Yu, Lin and Gong, Jianmei and Sun, Xiaoting and Zang, Min and Liu, Lei and Yu, Shengmiao", title="Assessing the Content and Effect of Web-Based Decision Aids for Postmastectomy Breast Reconstruction: Systematic Review and Meta-Analysis of Randomized Controlled Trials", journal="J Med Internet Res", year="2024", month="May", day="27", volume="26", pages="e53872", keywords="decision aids", keywords="internet", keywords="postmastectomy breast reconstruction", keywords="decision conflicts", keywords="mobile phone", abstract="Background: Web-based decision aids have been shown to have a positive effect when used to improve the quality of decision-making for women facing postmastectomy breast reconstruction (PMBR). However, the existing findings regarding these interventions are still incongruent, and the overall effect is unclear. Objective: We aimed to assess the content of web-based decision aids and its impact on decision-related outcomes (ie, decision conflict, decision regret, informed choice, and knowledge), psychological-related outcomes (ie, satisfaction and anxiety), and surgical decision-making in women facing PMBR. Methods: This systematic review and meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 6 databases, PubMed, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science Core Collection, were searched starting at the time of establishment of the databases to May 2023, and an updated search was conducted on April 1, 2024. MeSH (Medical Subject Headings) terms and text words were used. The Cochrane Risk of Bias Tool for randomized controlled trials was used to assess the risk of bias. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: In total, 7 studies included 579 women and were published between 2008 and 2023, and the sample size in each study ranged from 26 to 222. The results showed that web-based decision aids used audio and video to present the pros and cons of PMBR versus no PMBR, implants versus flaps, and immediate versus delayed PMBR and the appearance and feel of the PMBR results and the expected recovery time with photographs of actual patients. Web-based decision aids help improve PMBR knowledge, decisional conflict (mean difference [MD]=--5.43, 95\% CI --8.87 to --1.99; P=.002), and satisfaction (standardized MD=0.48, 95\% CI 0.00 to 0.95; P=.05) but have no effect on informed choice (MD=--2.80, 95\% CI --8.54 to 2.94; P=.34), decision regret (MD=--1.55, 95\% CI --6.00 to 2.90 P=.49), or anxiety (standardized MD=0.04, 95\% CI --0.50 to 0.58; P=.88). The overall Grading of Recommendations, Assessment, Development, and Evaluation quality of the evidence was low. Conclusions: The findings suggest that the web-based decision aids provide a modern, low-cost, and high dissemination rate effective method to promote the improved quality of decision-making in women undergoing PMBR. Trial Registration: PROSPERO CRD42023450496; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=450496 ", doi="10.2196/53872", url="https://www.jmir.org/2024/1/e53872", url="http://www.ncbi.nlm.nih.gov/pubmed/38801766" } @Article{info:doi/10.2196/52185, author="Lin, Chien-Chung and Shen, Jian-Hong and Chen, Shu-Fang and Chen, Hung-Ming and Huang, Hung-Meng", title="Developing a Cost-Effective Surgical Scheduling System Applying Lean Thinking and Toyota's Methods for Surgery-Related Big Data for Improved Data Use in Hospitals: User-Centered Design Approach", journal="JMIR Form Res", year="2024", month="May", day="24", volume="8", pages="e52185", keywords="algorithm", keywords="process", keywords="computational thinking", keywords="continuous improvement", keywords="customer needs", keywords="lean principles", keywords="problem solving", keywords="Toyota Production System", keywords="value stream map", keywords="need", keywords="needs", keywords="operating room", abstract="Background: Surgical scheduling is pivotal in managing daily surgical sequences, impacting patient experience and hospital resources significantly. With operating rooms costing approximately US \$36 per minute, efficient scheduling is vital. However, global practices in surgical scheduling vary, largely due to challenges in predicting individual surgeon times for diverse patient conditions. Inspired by the Toyota Production System's efficiency in addressing similar logistical challenges, we applied its principles as detailed in the book ``Lean Thinking'' by Womack and Jones, which identifies processes that do not meet customer needs as wasteful. This insight is critical in health care, where waste can compromise patient safety and medical quality. Objective: This study aims to use lean thinking and Toyota methods to develop a more efficient surgical scheduling system that better aligns with user needs without additional financial burdens. Methods: We implemented the 5 principles of the Toyota system: specifying value, identifying the value stream, enabling flow, establishing pull, and pursuing perfection. Value was defined in terms of meeting the customer's needs, which in this context involved developing a responsive and efficient scheduling system. Our approach included 2 subsystems: one handling presurgery patient data and another for intraoperative and postoperative data. We identified inefficiencies in the presurgery data subsystem and responded by creating a comprehensive value stream map of the surgical process. We developed 2 Excel (Microsoft Corporation) macros using Visual Basic for Applications. The first calculated average surgery times from intra- or postoperative historic data, while the second estimated surgery durations and generated concise, visually engaging scheduling reports from presurgery data. We assessed the effectiveness of the new system by comparing task completion times and user satisfaction between the old and new systems. Results: The implementation of the revised scheduling system significantly reduced the overall scheduling time from 301 seconds to 261 seconds (P=.02), with significant time reductions in the revised process from 99 seconds to 62 seconds (P<.001). Despite these improvements, approximately 21\% of nurses preferred the older system for its familiarity. The new system protects patient data privacy and streamlines schedule dissemination through a secure LINE group (LY Corp), ensuring seamless flow. The design of the system allows for real-time updates and has been effectively monitoring surgical durations daily for over 3 years. The ``pull'' principle was demonstrated when an unplanned software issue prompted immediate, user-led troubleshooting, enhancing system reliability. Continuous improvement efforts are ongoing, except for the preoperative patient confirmation step, which requires further enhancement to ensure optimal patient safety. Conclusions: Lean principles and Toyota's methods, combined with computer programming, can revitalize surgical scheduling processes. They offer effective solutions for surgical scheduling challenges and enable the creation of a novel surgical scheduling system without incurring additional costs. ", doi="10.2196/52185", url="https://formative.jmir.org/2024/1/e52185", url="http://www.ncbi.nlm.nih.gov/pubmed/38787610" } @Article{info:doi/10.2196/55529, author="Batterham, J. Philip and Gulliver, Amelia and Heffernan, Cassandra and Calear, L. Alison and Werner-Seidler, Aliza and Turner, Alyna and Farrer, M. Louise and Chatterton, Lou Mary and Mihalopoulos, Cathrine and Berk, Michael", title="A Brief Workplace Training Program to Support Help-Seeking for Mental Ill-Health: Protocol for the Helipad Cluster Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="May", day="24", volume="13", pages="e55529", keywords="help seeking", keywords="mental health", keywords="workplace", keywords="employee", keywords="implementation", keywords="internet", keywords="psychiatry", keywords="psychology", keywords="mobile phone", abstract="Background: Most people with mental health problems do not seek help, with delays of even decades in seeking professional help. Lack of engagement with professional mental health services can lead to poor outcomes and functional impairment. However, few effective interventions have been identified to improve help-seeking in adults, and those that exist are not widely implemented to deliver public health impact. Co-designing interventions with people with lived experience of mental ill-health and other relevant stakeholders is critical to increase the likelihood of uptake and engagement with these programs. Objective: This study aims to (1) test the effectiveness of a co-designed help-seeking program on increasing professional help-seeking intentions in employees in a workplace setting; (2) determine whether the program reduces mental illness stigma and improves help-seeking intentions and behavior, mental health literacy, mental health symptoms, and work and activity functioning relative to the control condition; (3) explore factors that facilitate broader implementation of the co-designed program; and (4) explore the cost-effectiveness of the co-designed program compared to the control condition over 6 months. Methods: A 2-arm cluster randomized controlled trial will be conducted (target sample: N=900 from 30 to 36 workplaces, with n=25 to 35 participants per workplace). The trial will compare the relative effectiveness of an enhanced interactive program (intervention condition) with a standard psychoeducation-alone program (active control condition) on the primary outcome of professional help-seeking intentions as measured by the General Help-Seeking Questionnaire. Secondary outcomes include the impact on mental illness stigma; mental health literacy; help-seeking attitudes and behavior; work and activity functioning; quality of life; and symptoms of mental ill-health including depression, anxiety, and general psychological distress. Results: Facilitators of and risks to the trial are identified and addressed in this protocol. Recruitment of workplaces is scheduled to commence in the first quarter of 2024. Conclusions: If effective, the program has the potential to be ready for rapid dissemination throughout Australia, with the potential to increase appropriate and efficient service use across the spectrum of evidence-based services. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623000270617p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385376 International Registered Report Identifier (IRRID): PRR1-10.2196/55529 ", doi="10.2196/55529", url="https://www.researchprotocols.org/2024/1/e55529", url="http://www.ncbi.nlm.nih.gov/pubmed/38787608" } @Article{info:doi/10.2196/49050, author="Prydz, Beer Monica and Czajkowski, Olavi Nikolai and Eilertsen, Maja and R{\o}ysamb, Espen and Nes, Bang Ragnhild", title="A Web-Based Intervention Using ``Five Ways to Wellbeing'' to Promote Well-Being and Mental Health: Randomized Controlled Trial", journal="JMIR Ment Health", year="2024", month="May", day="20", volume="11", pages="e49050", keywords="well-being", keywords="mental health promotion", keywords="intervention", keywords="web based", keywords="low cost", keywords="broad outreach", keywords="framework", keywords="web-based intervention", keywords="randomized controlled trial", keywords="effectiveness", abstract="Background: Compromised well-being and mental health problems pose a significant threat to individuals and societies worldwide. Resource-intensive psychological treatments alone cannot alleviate this burden. There is a need for low-cost, evidence-based interventions aimed at preventing illness and promoting well-being. Five activity domains appear to be linked with well-being promotion across populations: connecting with others, being active, taking notice, learning, and being generous/giving. The activities mentioned are part of the Five Ways to Wellbeing framework and the web-based intervention Five Ways to Wellbeing for All (5waysA). Objective: This randomized controlled trial aims to test the effects of the 5waysA intervention, a web-based, low-cost, well-being--promoting measure targeting the general population. To date, the Five Ways to Wellbeing framework has not been tested in this specific format. The 5waysA intervention comprises 2 webinars and SMS text message reminders delivered over a 10-week period. Methods: In 2021, a total of 969 study participants from various regions across Norway were openly recruited through a web page. They were then randomly assigned to either an intervention group or 1 of 2 waiting list control groups, namely, active or passive. Self-reported life satisfaction (Satisfaction With Life Scale [SWLS]), flourishing (Flourishing Scale [FS]), positive emotions, anxiety, and depression symptoms (Hopkins Symptom Checklist-8 [HSCL-8]) were assessed before the intervention, at 4 weeks into the intervention, and 1-2 weeks after the intervention (over 10 weeks). Data analysis was conducted using linear mixed (multilevel) models. Results: After 10 weeks, 453 participants (171 in the intervention group and 282 in the waiting list control group) were assessed on outcome variables, with a dropout rate of 53.2\% (516/969). Results revealed a significantly greater increase in the intervention group compared with the controls for SWLS (b=0.13, 95\% CI 0.03-0.23; P=.001), FS (b=0.19, 95\% CI 0.08-0.30; P=.001), positive emotions (b=0.43, 95\% CI 0.27-0.60; P<.001), and these factors combined into a global well-being measure (b=0.28, CI 0.16-0.39; P<.001). Effect sizes (Cohen d) for the well-being outcomes ranged from 0.30 to 0.49. In addition, a significant decrease in anxiety and depressive symptoms was observed (b=--0.17, 95\% CI --0.30 to --0.04; P=.001) with an effect size (Cohen d) of --0.20. Conclusions: The findings suggest that the web-based 5waysA intervention could serve as an effective approach for enhancing well-being and mental health within the general population. This study offers individuals, policy makers, and local stakeholders an accessible and potentially cost-effective well-being intervention that could be easily implemented. Trial Registration: ClinicalTrials.gov NCT04784871; https://clinicaltrials.gov/study/NCT04784871 ", doi="10.2196/49050", url="https://mental.jmir.org/2024/1/e49050", url="http://www.ncbi.nlm.nih.gov/pubmed/38767958" } @Article{info:doi/10.2196/55483, author="Varela-Moreno, Esperanza and Anarte-Ortiz, Teresa Maria and Jodar-Sanchez, Francisco and Garcia-Palacios, Azucena and Monreal-Bartolom{\'e}, Alicia and Gili, Margalida and Garc{\'i}a-Campayo, Javier and Mayoral-Cleries, Fermin", title="Economic Evaluation of a Web Application Implemented in Primary Care for the Treatment of Depression in Patients With Type 2 Diabetes Mellitus: Multicenter Randomized Controlled Trial", journal="JMIR Mhealth Uhealth", year="2024", month="May", day="16", volume="12", pages="e55483", keywords="depression", keywords="depressive", keywords="type 2", keywords="diabetes", keywords="diabetic", keywords="type 2 diabetes mellitus", keywords="eHealth", keywords="web-based intervention", keywords="efficacy", keywords="economic evaluation", keywords="cost-effectiveness", keywords="cost-utility", keywords="randomized controlled trial", keywords="RCT", keywords="randomized", keywords="controlled trial", keywords="controlled trials", keywords="cost", keywords="costs", keywords="economic", keywords="economics", keywords="web based", keywords="internet based", keywords="CBT", keywords="psychotherapy", keywords="cognitive behavioral therapy", keywords="mental health", abstract="Background: Depressive disorder and type 2 diabetes mellitus (T2DM) are prevalent in primary care (PC). Pharmacological treatment, despite controversy, is commonly chosen due to resource limitations and difficulties in accessing face-to-face interventions. Depression significantly impacts various aspects of a person's life, affecting adherence to medical prescriptions and glycemic control and leading to future complications and increased health care costs. To address these challenges, information and communication technologies (eg, eHealth) have been introduced, showing promise in improving treatment continuity and accessibility. However, while eHealth programs have demonstrated effectiveness in alleviating depressive symptoms, evidence regarding glycemic control remains inconclusive. This randomized controlled trial aimed to test the efficacy of a low-intensity psychological intervention via a web app for mild-moderate depressive symptoms in individuals with T2DM compared with treatment as usual (TAU) in PC. Objective: This study aimed to analyze the cost-effectiveness and cost-utility of a web-based psychological intervention to treat depressive symptomatology in people with T2DM compared with TAU in a PC setting. Methods: A multicenter randomized controlled trial was conducted with 49 patients with T2DM, depressive symptoms of moderate severity, and glycosylated hemoglobin (HbA1c) of 7.47\% in PC settings. Patients were randomized to TAU (n=27) or a web-based psychological treatment group (n=22). This web-based treatment consisted of cognitive behavioral therapy, improvement of diabetes self-care behaviors, and mindfulness. Cost-effectiveness analysis for the improvement of depressive symptomatology was conducted based on reductions in 3, 5, or 50 points on the Patient Health Questionnaire--9 (PHQ-9). The efficacy of diabetes control was estimated based on a 0.5\% reduction in HbA1c levels. Follow-up was performed at 3 and 6 months. The cost-utility analysis was performed based on quality-adjusted life years. Results: Efficacy analysis showed that the web-based treatment program was more effective in improving depressive symptoms than TAU but showed only a slight improvement in HbA1c. Incremental cost-effectiveness ratios of 186.76 for a 3-point reduction in PHQ-9 and 206.31 for reductions of 5 and 50 percentage points were obtained. In contrast, the incremental cost-effectiveness ratio for improving HbA1c levels amounted to {\texteuro}1510.90 ({\texteuro}1=US \$1.18 in 2018) per participant. The incremental cost-utility ratio resulted in {\texteuro}4119.33 per quality-adjusted life year gained. Conclusions: The intervention, using web-based modules incorporating cognitive behavioral therapy tools, diabetes self-care promotion, and mindfulness, effectively reduced depressive symptoms and enhanced glycemic control in patients with T2DM. Notably, it demonstrated clinical efficacy and economic efficiency. This supports the idea that eHealth interventions not only benefit patients clinically but also offer cost-effectiveness for health care systems. The study emphasizes the importance of including specific modules to enhance diabetes self-care behaviors in future web-based psychological interventions, emphasizing personalization and adaptation for this population. Trial Registration: ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709 International Registered Report Identifier (IRRID): RR2-10.1186/S12888-019-2037-3 ", doi="10.2196/55483", url="https://mhealth.jmir.org/2024/1/e55483", url="http://www.ncbi.nlm.nih.gov/pubmed/38754101" } @Article{info:doi/10.2196/52145, author="Ambrosio, Graca Maria Da and Lachman, M. Jamie and Zinzer, Paula and Gwebu, Hlengiwe and Vyas, Seema and Vallance, Inge and Calderon, Francisco and Gardner, Frances and Markle, Laurie and Stern, David and Facciola, Chiara and Schley, Anne and Danisa, Nompumelelo and Brukwe, Kanyisile and Melendez-Torres, GJ", title="A Factorial Randomized Controlled Trial to Optimize User Engagement With a Chatbot-Led Parenting Intervention: Protocol for the ParentText Optimisation Trial", journal="JMIR Res Protoc", year="2024", month="May", day="3", volume="13", pages="e52145", keywords="parenting intervention", keywords="chatbot-led public health intervention", keywords="engagement", keywords="implementation science", keywords="mobile phone", abstract="Background: Violence against children (VAC) is a serious public health concern with long-lasting adverse effects. Evidence-based parenting programs are one effective means to prevent VAC; however, these interventions are not scalable in their typical in-person group format, especially in low- and middle-income countries where the need is greatest. While digital delivery, including via chatbots, offers a scalable and cost-effective means to scale up parenting programs within these settings, it is crucial to understand the key pillars of user engagement to ensure their effective implementation. Objective: This study aims to investigate the most effective and cost-effective combination of external components to optimize user engagement with ParentText, an open-source chatbot-led parenting intervention to prevent VAC in Mpumalanga, South Africa. Methods: This study will use a mixed methods design incorporating a 2 {\texttimes} 2 factorial cluster-randomized controlled trial and qualitative interviews. Parents of adolescent girls (32 clusters, 120 participants [60 parents and 60 girls aged 10 to 17 years] per cluster; N=3840 total participants) will be recruited from the Ehlanzeni and Nkangala districts of Mpumalanga. Clusters will be randomly assigned to receive 1 of the 4 engagement packages that include ParentText alone or combined with in-person sessions and a facilitated WhatsApp support group. Quantitative data collected will include pretest-posttest parent- and adolescent-reported surveys, facilitator-reported implementation data, and digitally tracked engagement data. Qualitative data will be collected from parents and facilitators through in-person or over-the-phone individual semistructured interviews and used to expand the interpretation and understanding of the quantitative findings. Results: Recruitment and data collection started in August 2023 and were finalized in November 2023. The total number of participants enrolled in the study is 1009, with 744 caregivers having completed onboarding to the chatbot-led intervention. Female participants represent 92.96\% (938/1009) of the sample population, whereas male participants represent 7.03\% (71/1009). The average participant age is 43 (SD 9) years. Conclusions: The ParentText Optimisation Trial is the first study to rigorously test engagement with a chatbot-led parenting intervention in a low- or middle-income country. The results of this study will inform the final selection of external delivery components to support engagement with ParentText in preparation for further evaluation in a randomized controlled trial in 2024. Trial Registration: Open Science Framework (OSF); https://doi.org/10.17605/OSF.IO/WFXNE International Registered Report Identifier (IRRID): DERR1-10.2196/52145 ", doi="10.2196/52145", url="https://www.researchprotocols.org/2024/1/e52145", url="http://www.ncbi.nlm.nih.gov/pubmed/38700935" } @Article{info:doi/10.2196/53500, author="Zakiyah, Neily and Marulin, Dita and Alfaqeeh, Mohammed and Puspitasari, Melyani Irma and Lestari, Keri and Lim, Keat Ka and Fox-Rushby, Julia", title="Economic Evaluations of Digital Health Interventions for Patients With Heart Failure: Systematic Review", journal="J Med Internet Res", year="2024", month="Apr", day="30", volume="26", pages="e53500", keywords="digital health", keywords="telemonitoring", keywords="telehealth", keywords="heart failure", keywords="cost-effectiveness", keywords="systematic review", keywords="mobile phone", abstract="Background: Digital health interventions (DHIs) have shown promising results in enhancing the management of heart failure (HF). Although health care interventions are increasingly being delivered digitally, with growing evidence on the potential cost-effectiveness of adopting them, there has been little effort to collate and synthesize the findings. Objective: This study's objective was to systematically review the economic evaluations that assess the adoption of DHIs in the management and treatment of HF. Methods: A systematic review was conducted using 3 electronic databases: PubMed, EBSCOhost, and Scopus. Articles reporting full economic evaluations of DHIs for patients with HF published up to July 2023 were eligible for inclusion. Study characteristics, design (both trial based and model based), input parameters, and main results were extracted from full-text articles. Data synthesis was conducted based on the technologies used for delivering DHIs in the management of patients with HF, and the findings were analyzed narratively. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for this systematic review. The reporting quality of the included studies was evaluated using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines. Results: Overall, 27 economic evaluations were included in the review. The economic evaluations were based on models (13/27, 48\%), trials (13/27, 48\%), or a combination approach (1/27, 4\%). The devices evaluated included noninvasive remote monitoring devices (eg, home telemonitoring using digital tablets or specific medical devices that enable transmission of physiological data), telephone support, mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems. Most of the studies (24/27, 89\%) used cost-utility analysis. The majority of the studies (25/27, 93\%) were conducted in high-income countries, particularly European countries (16/27, 59\%) such as the United Kingdom and the Netherlands. Mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems yielded cost-effective results or even emerged as dominant strategies. However, conflicting results were observed, particularly in noninvasive remote monitoring devices and telephone support. In 15\% (4/27) of the studies, these DHIs were found to be less costly and more effective than the comparators (ie, dominant), while 33\% (9/27) reported them to be more costly but more effective with incremental cost-effectiveness ratios below the respective willingness-to-pay thresholds (ie, cost-effective). Furthermore, in 11\% (3/27) of the studies, noninvasive remote monitoring devices and telephone support were either above the willingness-to-pay thresholds or more costly than, yet as effective as, the comparators (ie, not cost-effective). In terms of reporting quality, the studies were classified as good (20/27, 74\%), moderate (6/27, 22\%), or excellent (1/27, 4\%). Conclusions: Despite the conflicting results, the main findings indicated that, overall, DHIs were more cost-effective than non-DHI alternatives. Trial Registration: PROSPERO CRD42023388241; https://tinyurl.com/2p9axpmc ", doi="10.2196/53500", url="https://www.jmir.org/2024/1/e53500", url="http://www.ncbi.nlm.nih.gov/pubmed/38687991" } @Article{info:doi/10.2196/49982, author="Giebel, Denk Godwin and Abels, Carina and Plescher, Felix and Speckemeier, Christian and Schrader, Frederik Nils and B{\"o}rchers, Kirstin and Wasem, J{\"u}rgen and Neusser, Silke and Blase, Nikola", title="Problems and Barriers Related to the Use of mHealth Apps From the Perspective of Patients: Focus Group and Interview Study", journal="J Med Internet Res", year="2024", month="Apr", day="23", volume="26", pages="e49982", keywords="mobile health", keywords="mHealth", keywords="mHealth app", keywords="patient", keywords="problems", keywords="barriers", keywords="digital health applications", keywords="DiGA", keywords="app", keywords="barrier", keywords="mobile app", keywords="health care system", keywords="economic outcome", keywords="context", keywords="mobile phone", abstract="Background: Since fall 2020, mobile health (mHealth) apps have become an integral part of the German health care system. The belief that mHealth apps have the potential to make the health care system more efficient, close gaps in care, and improve the economic outcomes related to health is unwavering and already partially confirmed. Nevertheless, problems and barriers in the context of mHealth apps usually remain unconsidered. Objective: The focus groups and interviews conducted in this study aim to shed light on problems and barriers in the context of mHealth apps from the perspective of patients. Methods: Guided focus groups and individual interviews were conducted with patients with a disease for which an approved mHealth app was available at the time of the interviews. Participants were recruited via self-help groups. The interviews were recorded, transcribed, and subjected to a qualitative content analysis. The content analysis was based on 10 problem categories (``validity,'' ``usability,'' ``technology,'' ``use and adherence,'' ``data privacy and security,'' ``patient-physician relationship,'' ``knowledge and skills,'' ``individuality,'' ``implementation,'' and ``costs'') identified in a previously conducted scoping review. Participants were asked to fill out an additional questionnaire about their sociodemographic data and about their use of technology. Results: A total of 38 patients were interviewed in 5 focus groups (3 onsite and 2 web-based) and 5 individual web-based interviews. The additional questionnaire was completed by 32 of the participants. Patients presented with a variety of different diseases, such as arthrosis, tinnitus, depression, or lung cancer. Overall, 16\% (5/32) of the participants had already been prescribed an app. During the interviews, all 10 problem categories were discussed and considered important by patients. A myriad of problem manifestations could be identified for each category. This study shows that there are relevant problems and barriers in the context of mHealth apps from the perspective of patients, which warrant further attention. Conclusions: There are essentially 3 different areas of problems in the context of mHealth apps that could be addressed to improve care: quality of the respective mHealth app, its integration into health care, and the expandable digital literacy of patients. ", doi="10.2196/49982", url="https://www.jmir.org/2024/1/e49982", url="http://www.ncbi.nlm.nih.gov/pubmed/38652508" } @Article{info:doi/10.2196/47616, author="Raes, Sarah and Prezzi, Andrea and Willems, Rik and Heidbuchel, Hein and Annemans, Lieven", title="Investigating the Cost-Effectiveness of Telemonitoring Patients With Cardiac Implantable Electronic Devices: Systematic Review", journal="J Med Internet Res", year="2024", month="Apr", day="19", volume="26", pages="e47616", keywords="systematic review", keywords="cost-effectiveness", keywords="telemonitoring", keywords="cardiac device", keywords="implantable cardioverter-defibrillator", keywords="ICD", keywords="pacemaker", keywords="monitoring", keywords="patient management", keywords="effectiveness", keywords="cost", keywords="quality of life", keywords="cardiac implantable electronic device", keywords="cardiac", abstract="Background: Telemonitoring patients with cardiac implantable electronic devices (CIEDs) can improve their care management. However, the results of cost-effectiveness studies are heterogeneous. Therefore, it is still a matter of debate whether telemonitoring is worth the investment. Objective: This systematic review aims to investigate the cost-effectiveness of telemonitoring patients with CIEDs, focusing on its key drivers, and the impact of the varying perspectives. Methods: A systematic review was performed in PubMed, Web of Science, Embase, and EconLit. The search was completed on July 7, 2022. Studies were included if they fulfilled the following criteria: patients had a CIED, comparison with standard care, and inclusion of health economic evaluations (eg, cost-effectiveness analyses and cost-utility analyses). Only complete and peer-reviewed studies were included, and no year limits were applied. The exclusion criteria included studies with partial economic evaluations, systematic reviews or reports, and studies without standard care as a control group. Besides general study characteristics, the following outcome measures were extracted: impact on total cost or income, cost or income drivers, cost or income drivers per patient, cost or income drivers as a percentage of the total cost impact, incremental cost-effectiveness ratios, or cost-utility ratios. Quality was assessed using the Consensus Health Economic Criteria checklist. Results: Overall, 15 cost-effectiveness analyses were included. All studies were performed in Western countries, mainly Europe, and had primarily a male participant population. Of the 15 studies, 3 (20\%) calculated the incremental cost-effectiveness ratio, 1 (7\%) the cost-utility ratio, and 11 (73\%) the health and cost impact of telemonitoring. In total, 73\% (11/15) of the studies indicated that telemonitoring of patients with implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy ICDs was cost-effective and cost-saving, both from a health care and patient perspective. Cost-effectiveness results for telemonitoring of patients with pacemakers were inconclusive. The key drivers for cost reduction from a health care perspective were hospitalizations and scheduled in-office visits. Hospitalization costs were reduced by up to US \$912 per patient per year. Scheduled in-office visits included up to 61\% of the total cost reduction. Key drivers for cost reduction from a patient perspective were loss of income, cost for scheduled in-office visits and transport. Finally, of the 15 studies, 8 (52\%) reported improved quality of life, with statistically significance in only 1 (13\%) study (P=.03). Conclusions: From a health care and patient perspective, telemonitoring of patients with an ICD or a cardiac resynchronization therapy ICD is a cost-effective and cost-saving alternative to standard care. Inconclusive results were found for patients with pacemakers. However, telemonitoring can lead to a decrease in providers' income, mainly due to a lack of reimbursement. Introducing appropriate reimbursement could make telemonitoring sustainable for providers while still being cost-effective from a health care payer perspective. Trial Registration: PROSPERO CRD42022322334; https://tinyurl.com/puunapdr ", doi="10.2196/47616", url="https://www.jmir.org/2024/1/e47616", url="http://www.ncbi.nlm.nih.gov/pubmed/38640471" } @Article{info:doi/10.2196/55601, author="Lammers, J. Eline M. and Zijlstra, M. Jos{\'e}e and Ret{\`e}l, P. Valesca and Aleman, P. Berthe M. and van Leeuwen, E. Flora and Nijdam, Annelies and ", title="Effectiveness and Cost-Effectiveness of Survivorship Care for Survivors of Hodgkin Lymphoma (INSIGHT Study): Protocol for a Multicenter Retrospective Cohort Study With a Quasi-Experimental Design", journal="JMIR Res Protoc", year="2024", month="Apr", day="18", volume="13", pages="e55601", keywords="research design", keywords="Hodgkin lymphoma", keywords="late effects of cancer treatment", keywords="survivorship care", keywords="screening", keywords="cost-effectiveness analysis", abstract="Background: Hodgkin lymphoma (HL) occurs at young ages, with the highest incidence between 20 and 40 years. While cure rates have improved to 80\%-90\% over the past decades, survivors of HL are at substantial risk of late treatment--related complications, such as cardiovascular diseases, breast cancer, severe infections, and hypothyroidism. To reduce morbidity and mortality from late treatment effects, the Dutch Better care after lymphoma, Evaluation of long-term Treatment Effects and screening Recommendations (BETER) consortium developed a survivorship care program for 5-year survivors of HL that includes risk-based screening for and treatment of (risk factors for) late adverse events. Even though several cancer survivorship care programs have been established worldwide, there is a lack of knowledge about their effectiveness in clinical practice. Objective: The Improving Nationwide Survivorship care Infrastructure and Guidelines after Hodgkin lymphoma Treatment (INSIGHT) study evaluates whether Dutch BETER survivorship care for survivors of HL decreases survivors' burden of disease from late adverse events after HL treatment and associated health care costs and improves their quality of life. Methods: The INSIGHT study is a multicenter retrospective cohort study with a quasi-experimental design and prospective follow-up, embedded in the national BETER survivorship care infrastructure. The first BETER clinics started in 2013-2016 and several other centers started or will start BETER clinics in 2019-2024. This allows us to compare survivors who did and those who did not receive BETER survivorship care in the last decade. Survivors in the intervention group are matched to controls (n=450 per group) based on sex, age at diagnosis ({\textpm}5 years), age in 2013 ({\textpm}5 years), and treatment characteristics. The primary outcome is the burden of disease in disability-adjusted life years from cardiovascular disease, breast cancer, severe infections, and hypothyroidism. In a cost-effectiveness analysis, we will assess the cost of BETER survivorship care per averted or gained disability-adjusted life year and quality-adjusted life year. Secondary outcomes are BETER clinic attendance, adherence to screening guidelines, and knowledge and distress about late effects among survivors of HL. Study data are collected from a survivor survey, a general practitioner survey, medical records, and through linkages with national disease registries. Results: The study was funded in November 2020 and approved by the institutional review board of the Netherlands Cancer Institute in July 2021. We expect to finalize recruitment by October 2024, data collection by early 2025, and data analysis by May 2025. Conclusions: INSIGHT is the first evaluation of a comprehensive survivorship program using real-world data; it will result in new information on the (cost-)effectiveness of survivorship care in survivors of HL in clinical practice. The results of this study will be used to improve the BETER program where necessary and contribute to more effective evidence-based long-term survivorship care for lymphoma survivors. International Registered Report Identifier (IRRID): PRR1-10.2196/55601 ", doi="10.2196/55601", url="https://www.researchprotocols.org/2024/1/e55601", url="http://www.ncbi.nlm.nih.gov/pubmed/38635308" } @Article{info:doi/10.2196/50466, author="Noh, Jin-Won and Cheon, Jooyoung and Seong, Hohyun and Kwon, Dae Young and Yoo, Ki-Bong", title="Impacts of Smoking Ban Policies on Billiard Hall Sales in South Korea Using Objective Sales Information of a Credit Card Company: Quasi-Experimental Study", journal="JMIR Public Health Surveill", year="2024", month="Apr", day="17", volume="10", pages="e50466", keywords="smoking ban policy", keywords="indoor sports facility", keywords="South Korea", abstract="Background: Smoking ban policies (SBPs) are potent health interventions and offer the potential to influence antismoking behavior. The Korean government completely prohibited smoking in indoor sports facilities, including billiard halls, since the government revised the National Health Promotion Act in December 2017. Objective: This study aimed to examine the impact of the SBP on the economic outcomes of indoor sports facilities, particularly billiard halls. Methods: This study used credit card sales data from the largest card company in South Korea. Data are from January 2017 to December 2018. Monthly sales data were examined across 23 administrative neighborhoods in Seoul, the capital city of South Korea. We conducted the interrupted time series model using the fixed effects model and the linear regression with panel-corrected standard errors (PCSE). Results: The sales and transactions of billiard halls were not significantly changed after the introduction of the SBP in the full PCSE models. The R2 of the full PCSE model was 0.967 for sales and 0.981 for transactions. Conclusions: The introduction of the SBP did not result in substantial economic gains or losses in the sales of billiard halls. In addition to existing price-based policies, the enhanced SBP in public-use facilities, such as billiard halls, can have a positive synergistic effect on reducing smoking prevalence and preventing secondhand smoke. Health policy makers can actively expand the application of SBPs and make an effort to enhance social awareness regarding the necessity and benefits of public SBPs for both smokers and the owners of hospitality facilities. ", doi="10.2196/50466", url="https://publichealth.jmir.org/2024/1/e50466", url="http://www.ncbi.nlm.nih.gov/pubmed/38630526" } @Article{info:doi/10.2196/55369, author="Stefana, Alberto and Vieta, Eduard and Fusar-Poli, Paolo and Youngstrom, A. Eric", title="Enhancing Psychotherapy Outcomes by Encouraging Patients to Regularly Self-Monitor, Reflect on, and Share Their Affective Responses Toward Their Therapist: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Apr", day="8", volume="13", pages="e55369", keywords="adult patients", keywords="evidence-based assessment", keywords="patient's perspective", keywords="psychotherapy", keywords="randomized controlled trial", keywords="systematic client feedback", keywords="therapeutic relationship", keywords="treatment outcome", abstract="Background: The quality of the therapeutic relationship is pivotal in determining psychotherapy outcomes. However, facilitating patients' self-awareness, reflection on, and sharing of their affective responses toward their therapist remains underexplored as a potential tool for enhancing this relationship and subsequent treatment outcomes. Objective: The primary objective of this study is to examine whether and how the patients' regular self-monitoring and self-reflection (fostered by the systematic compilation of a brief postsession battery) on their affective reactions toward the psychotherapist impact the quality of the therapeutic relationship and treatment outcomes in individual psychotherapy. Secondary objectives are to (1) explore whether and how the characteristics of the patient, the therapist, and the process moderate the effect of regular self-monitoring on the therapeutic relationship and outcomes; (2) examine the relationships between the affective response of the patient, the alliance, and the result of the therapy session outcome; and (3) explore how the affective responses of the patient unfold or change throughout the course of the therapy. Methods: We conducted a 1:1 randomized controlled trial of adults in individual psychotherapy versus individual psychotherapy plus self-monitoring. Participants will be enrolled through the web-based recruitment platforms ``ResearchMatch'' and ``Research for Me,'' and data will be collected through web-based surveys. Participants in the control group will receive only their regular individual psychotherapy (treatment as usual) and will not complete postsession questionnaires. Participants in the intervention group will continue their regular individual psychotherapy sessions and complete the ``in-Session Patient Affective Reactions Questionnaire'' and the ``Rift In-Session Questionnaire'' following each therapy session in the 10 weeks of the trial. Additionally, after completion of the postsession battery, they will receive general written feedback encouraging them to discuss their feelings and reflections with their therapist. Participants in both groups will complete a comprehensive psychological assessment at baseline, midtrial (week 5), and end-of-trial (week 10). The primary outcome measure of the trial is the ``Clinical Outcomes in Routine Evaluation-Outcome Measure,'' while the secondary outcomes are the ``Real Relationship Inventory-Client-Short Form,'' the ``Working Alliance Inventory-Short Revised,'' and the number of scheduled therapy sessions that the patient has missed or canceled. Results: The trial was approved by the institutional review board of the University of North Carolina at Chapel Hill. Recruitment started in September 2023. A total of 475 individuals completed the baseline assessment. Data collection was completed in February 2024. The results are expected to be published in the autumn of 2024. Conclusions: This study could reveal key information on how regular self-monitoring and introspection can influence both the therapeutic relationship and treatment outcomes. Findings have the potential to shape interventions, enhance the efficacy of psychotherapeutic sessions, and possibly offer a cost-effective strategy for improving patients' well-being. Trial Registration: ClinicalTrials.gov NCT06038747; https://classic.clinicaltrials.gov/ct2/show/NCT06038747 International Registered Report Identifier (IRRID): DERR1-10.2196/55369 ", doi="10.2196/55369", url="https://www.researchprotocols.org/2024/1/e55369", url="http://www.ncbi.nlm.nih.gov/pubmed/38587881" } @Article{info:doi/10.2196/54352, author="Tan, Yijia Bryan and Tan, Yue Chun and Tan, Leng Tong and Yang, Su-Yin and Chew, Szu Gillian Long and Tan, Ing Siang and Chua, Chun Yu and Yan, Wai Yew and Soh, Quan Derrick Bing and Goh, Hwee Tong and Ng, Jue Pu and Ng, Teck Yee and Kuan, Boey Swee and Teo, Siang Bo and Kong, He Keng and Pereira, Jessica Michelle and Ng, Ping Hui", title="Heat and Acupuncture to Manage Osteoarthritis of the Knee (HARMOKnee): Protocol for an Effectiveness-Implementation Hybrid Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Apr", day="3", volume="13", pages="e54352", keywords="knee osteoarthritis", keywords="acupuncture", keywords="heat therapy", keywords="effectiveness-implementation hybrid study", keywords="randomized controlled trial", keywords="RCT", abstract="Background: Knee osteoarthritis (KOA) is one of most prevalent and fastest-growing causes of pain, impaired mobility, and poor quality of life in the rapidly aging population worldwide. There is a lack of high-quality evidence on the efficacy of traditional Chinese medicine (TCM), particularly acupuncture, and a lack of KOA practice guidelines that are tailored to unique population demographics and tropical climates. Objective: Our HARMOKnee (Heat and Acupuncture to Manage Osteoarthritis of the Knee) trial aims to address these gaps by evaluating the short- and medium-term clinical and cost-effectiveness of acupuncture with heat therapy in addition to standard care, compared to standard care alone. Through a robust process and economic evaluation, we aim to inform evidence-based practice for patients with KOA to facilitate the large-scale implementation of a comprehensive and holistic model of care that harmonizes elements of Western medicine and TCM. We hypothesize that acupuncture with heat therapy as an adjunct to standard care is clinically more effective than standard care alone. Methods: A multicenter, pragmatic, parallel-arm, single-blinded, effectiveness-implementation hybrid randomized controlled trial will be conducted. We intend to recruit 100 patients with KOA randomized to either the control arm (standard care only) or intervention arm (acupuncture with heat therapy, in addition to standard care). The inclusion criteria are being a community ambulator and having primary KOA, excluding patients with secondary arthritis or previous knee replacements. The primary outcome measure is the Knee Osteoarthritis Outcome Score at 6 weeks. Secondary outcome measures include psychological, physical, quality of life, satisfaction, and global outcome measures at 6, 12, and 26 weeks. A mixed method approach through an embedded process evaluation will facilitate large-scale implementation. An economic evaluation will be performed to assess financial sustainability. Results: Patient enrollment has been ongoing since August 2022. The recruitment process is anticipated to conclude by July 2024, and the findings will be analyzed and publicized as they are obtained. As of November 6, 2023, our patient enrollment stands at 65 individuals. Conclusions: The findings of our HARMOKnee study will contribute substantial evidence to the current body of literature regarding the effectiveness of acupuncture treatment for KOA. Additionally, we aim to facilitate the creation of standardized national guidelines for evidence-based practice that are specifically tailored to our unique population demographics. Furthermore, we seek to promote the adoption and integration of acupuncture and heat therapy into existing treatment models. Trial Registration: ClinicalTrials.gov NCT05507619; https://clinicaltrials.gov/study/NCT05507619 International Registered Report Identifier (IRRID): DERR1-10.2196/54352 ", doi="10.2196/54352", url="https://www.researchprotocols.org/2024/1/e54352", url="http://www.ncbi.nlm.nih.gov/pubmed/38568718" } @Article{info:doi/10.2196/54282, author="Boucher, M. Eliane and Ward, Haley and Miles, J. Cynthia and Henry, D. Robert and Stoeckl, Elizabeth Sarah", title="Effects of a Digital Mental Health Intervention on Perceived Stress and Rumination in Adolescents Aged 13 to 17 Years: Randomized Controlled Trial", journal="J Med Internet Res", year="2024", month="Mar", day="29", volume="26", pages="e54282", keywords="digital intervention", keywords="adolescents", keywords="adolescent", keywords="stress management", keywords="mental health", keywords="mobile phone", keywords="mobile health", keywords="mHealth", keywords="teen", keywords="teens", keywords="teenager", keywords="teenagers", keywords="stress", keywords="rumination", keywords="brooding", keywords="randomized controlled trial", keywords="RCT", keywords="randomized", keywords="controlled trial", keywords="controlled trials", keywords="digital mental health intervention", keywords="DMHI", keywords="digital health", abstract="Background: Although adolescents report high levels of stress, they report engaging in few stress management techniques. Consequently, developing effective and targeted programs to help address this transdiagnostic risk factor in adolescence is particularly important. Most stress management programs for adolescents are delivered within schools, and the evidence for these programs is mixed, suggesting a need for alternative options for stress management among adolescents. Objective: The aim of the study is to test the short-term effects of a self-guided digital mental health intervention (DMHI) designed for adolescents on perceived stress and rumination (ie, brooding). Methods: This was a 12-week, 2-arm decentralized randomized controlled trial of adolescents aged 13 to 17 years who presented with elevated levels of perceived stress and brooding. Participants were randomly assigned to engage with a self-guided DMHI (Happify for Teens) or to a waitlist control. Participants assigned to the intervention group were given access to the program for 12 weeks. Happify for Teens consists of various evidence-based activities drawn from therapeutic modalities such as cognitive behavioral therapy, positive psychology, and mindfulness, which are then organized into several programs targeting specific areas of concern (eg, Stress Buster 101). Participants in the waitlist control received access to this product for 12 weeks upon completing the study. Participants in both groups completed measures of perceived stress, brooding, optimism, sleep disturbance, and loneliness at baseline, 4 weeks, 8 weeks, and 12 weeks. Changes in outcomes between the intervention and waitlist control groups were assessed using repeated-measures multilevel models. Results: Of the 303 participants included in data analyses, 132 were assigned to the intervention and 171 to the waitlist. There were significantly greater improvements in the intervention condition for perceived stress (intervention: B=--1.50; 95\% CI --1.82 to --1.19; P<.001 and control: B=--0.09; 95\% CI --0.44 to 0.26; P=.61), brooding (intervention: B=--0.84; 95\% CI --1.00 to --0.68; P<.001 and control: B=--0.30; 95\% CI --0.47 to --0.12; P=.001), and loneliness (intervention: B=--0.96; 95\% CI --1.2 to --0.73; P<.001 and control: B=--0.38; 95\% CI: --0.64 to --0.12; P=.005) over the 12-week study period. Changes in optimism and sleep disturbance were not significantly different across groups (Ps?.096). Conclusions: Happify for Teens was effective at reducing perceived stress, rumination, and loneliness among adolescents over 12 weeks when compared to a waitlist control group. Our data reveal the potential benefits of DMHIs for adolescents, which may present a more scalable, destigmatized, and cost-effective alternative to school-based programs. Trial Registration: ClinicalTrials.gov NCT04567888; https://clinicaltrials.gov/ct2/show/NCT04567888 International Registered Report Identifier (IRRID): RR2-10.2196/25545 ", doi="10.2196/54282", url="https://www.jmir.org/2024/1/e54282", url="http://www.ncbi.nlm.nih.gov/pubmed/38551617" } @Article{info:doi/10.2196/50629, author="Maleki, Negar and Padmanabhan, Balaji and Dutta, Kaushik", title="Usability of Health Care Price Transparency Data in the United States: Mixed Methods Study", journal="J Med Internet Res", year="2024", month="Mar", day="29", volume="26", pages="e50629", keywords="price transparency", keywords="user experiments", keywords="schema analysis", keywords="health care", keywords="patients", keywords="algorithms", abstract="Background: Increasing health care expenditure in the United States has put policy makers under enormous pressure to find ways to curtail costs. Starting January 1, 2021, hospitals operating in the United States were mandated to publish transparent, accessible pricing information online about the items and services in a consumer-friendly format within comprehensive machine-readable files on their websites. Objective: The aims of this study are to analyze the available files on hospitals' websites, answering the question---is price transparency (PT) information as provided usable for patients or for machines?---and to provide a solution. Methods: We analyzed 39 main hospitals in Florida that have published machine-readable files on their website, including commercial carriers. We created an Excel (Microsoft) file that included those 39 hospitals along with the 4 most popular services---Current Procedural Terminology (CPT) 45380, 29827, and 70553 and Diagnosis-Related Group (DRG) 807---for the 4 most popular commercial carriers (Health Maintenance Organization [HMO] or Preferred Provider Organization [PPO] plans)---Aetna, Florida Blue, Cigna, and UnitedHealthcare. We conducted an A/B test using 67 MTurkers (randomly selected from US residents), investigating the level of awareness about PT legislation and the usability of available files. We also suggested format standardization, such as master field names using schema integration, to make machine-readable files consistent and usable for machines. Results: The poor usability and inconsistent formats of the current PT information yielded no evidence of its usefulness for patients or its quality for machines. This indicates that the information does not meet the requirements for being consumer-friendly or machine readable as mandated by legislation. Based on the responses to the first part of the experiment (PT awareness), it was evident that participants need to be made aware of the PT legislation. However, they believe it is important to know the service price before receiving it. Based on the responses to the second part of the experiment (human usability of PT information), the average number of correct responses was not equal between the 2 groups, that is, the treatment group (mean 1.23, SD 1.30) found more correct answers than the control group (mean 2.76, SD 0.58; t65=6.46; P<.001; d=1.52). Conclusions: Consistent machine-readable files across all health systems facilitate the development of tools for estimating customer out-of-pocket costs, aligning with the PT rule's main objective---providing patients with valuable information and reducing health care expenditures. ", doi="10.2196/50629", url="https://www.jmir.org/2024/1/e50629", url="http://www.ncbi.nlm.nih.gov/pubmed/38442238" } @Article{info:doi/10.2196/46412, author="Saravanakumar, Sanjeev and Ostrovsky, Andrey", title="Evaluation of Telehealth Services that are Clinically Appropriate for Reimbursement in the US Medicaid Population: Mixed Methods Study", journal="J Med Internet Res", year="2024", month="Mar", day="28", volume="26", pages="e46412", keywords="mobile phone", keywords="telehealth", keywords="Medicaid reimbursement", keywords="health equity", keywords="Center for Medicare \& Medicaid Services", keywords="telemedicine", keywords="reimbursement", keywords="digital health", keywords="Medicaid", keywords="Public Health Emergency", keywords="access", keywords="equity", keywords="health insurance", keywords="coverage", keywords="reimburse", keywords="equitable", keywords="health policy", keywords="telehealth expansion", abstract="Background: When the US Department of Health and Human Services instituted a State of Public Health Emergency (PHE) during the COVID-19 pandemic, many telehealth flexibilities were fast-tracked to allow state Medicaid agencies to reimburse new specialty services, sites of care, and mediums such as FaceTime to communicate with patients.. This resulted in expanded access to care for financially vulnerable Medicaid patients, as evidenced by an uptick in telehealth use. Research has mostly focused on telehealth reimbursement for limited use cases such as rural primary care, without broader consideration for how telehealth can be appropriately mainstreamed and maintained. Objective: This study sought to (1) evaluate the continuation of flexible telehealth reimbursement broadly, beyond the COVID-19 pandemic; (2) analyze the clinical effectiveness of the new telehealth services; and (3) offer code-by-code reimbursement guidance to state Medicaid leaders. Methods: We surveyed 10 state Medicaid medical directors (MMDs) who are responsible for the scientific and clinical appropriateness of Medicaid policies in their respective states. Participants were asked to complete an internet-based survey with a list of medical billing codes, grouped by service type, and asked if they believed they should be reimbursed by Medicaid on a permanent basis. Additional questions covered more detailed recommendations, such as reimbursing video with audio versus audio-only, guardrails for certain specialty services, and motivations behind responses. Results: The MMDs felt that the majority of services should be reimbursed via some modality of telehealth after the PHE, with the most support for video combined with audio compared to audio-only. There were exceptions on both ends of the spectrum, where services such as pulmonary diagnostics were not recommended to be reimbursed in any form and services such as psychotherapy for mental health had the most support for audio-only. The vast majority of MMDs were supportive of reimbursement for remote monitoring services, but some preferred to have some reimbursement guardrails. We found that 90\% (n=9) of MMDs were supportive of reimbursement for telehealth interprofessional services, while half (n=5) of the respondents felt that there should be continued guardrails for reimbursement. Motivations for continuing reimbursement flexibility were largely attributed to improving access to care, improving outcomes, and improving equity among the Medicaid patient population. Conclusions: There is a strong clinical endorsement to continue the telehealth flexibility enabled by the PHE, primarily for video combined with audio telehealth, with caution against audio-only telehealth in situations where hands-on intervention is necessary for diagnosis or treatment. There is also support for reimbursing remote monitoring services and telehealth interprofessional services, albeit with guardrails. These results are primarily from a perspective of improving access, outcomes, and equity; other state-specific factors such as fiscal impact and technical implementation may need to be taken into account when considering reimbursement decisions on telehealth. ", doi="10.2196/46412", url="https://www.jmir.org/2024/1/e46412", url="http://www.ncbi.nlm.nih.gov/pubmed/38546706" } @Article{info:doi/10.2196/53921, author="Chai, Yulin and Yuan, Xiaoping and Guo, Lin and Chen, Zhongming", title="The Impact of Broadband Infrastructure Construction on Medical Resource Mismatch: Quasi-Natural Experiment From the Broadband China Policy", journal="J Med Internet Res", year="2024", month="Mar", day="21", volume="26", pages="e53921", keywords="broadband", keywords="infrastructure", keywords="medical resources", keywords="resource mismatch", keywords="Broadband China Policy", abstract="Background: Whether the construction of broadband infrastructure can alleviate the problem of mismatched medical resources is crucial to the national information strategy, residents' well-being, and social equity. However, the academic community lacks a comprehensive theoretical analysis and rigorous empirical research on this issue. Objective: This study aims to construct a preliminary theoretical framework to scientifically assess the effects of broadband infrastructure development on the mitigation of health care resource mismatch from both theoretical and empirical perspectives, to explore the potential mechanisms of influence, and ultimately to develop several practical policy recommendations. Methods: We first used a theoretical analysis to propose testable theoretical hypotheses and establish a preliminary theoretical framework. Then, based on balanced panel data from 300 cities from 2010 to 2021, a 2-way fixed effects difference-in-differences model was used for empirical testing. Mechanism tests, robustness analyses, and heterogeneity analyses were further conducted. Results: The research findings demonstrate that the Broadband China Policy significantly reduces the degree of mismatch in medical resources by primarily using innovation effects and integration effects, resulting in a reduction of 13.2\%. In addition, the heterogeneity analysis reveals that the central and eastern regions, cities with large populations, and areas with a high proportion of young people benefit more significantly. Conclusions: This study fully confirms, both theoretically and empirically, that broadband infrastructure construction can effectively reduce the mismatch of medical resources not only by expanding the existing literature on the impact of broadband on public services but also by providing valuable opportunities for policy makers to optimize the allocation of medical resources. ", doi="10.2196/53921", url="https://www.jmir.org/2024/1/e53921", url="http://www.ncbi.nlm.nih.gov/pubmed/38512327" } @Article{info:doi/10.2196/52071, author="Ganeshan, Smitha and Liu, W. Andrew and Kroeger, Anne and Anand, Prerna and Seefeldt, Richard and Regner, Alexis and Vaughn, Diana and Odisho, Y. Anobel and Mourad, Michelle", title="An Electronic Health Record--Based Automated Self-Rescheduling Tool to Improve Patient Access: Retrospective Cohort Study", journal="J Med Internet Res", year="2024", month="Mar", day="19", volume="26", pages="e52071", keywords="appointment", keywords="consultation", keywords="cost", keywords="digital health", keywords="digital tools", keywords="electronic health record", keywords="EHR", keywords="informatics", keywords="patient access", keywords="retrospective review", keywords="revenue", keywords="self-rescheduling tool", keywords="self-scheduling", keywords="waiting time", abstract="Background: In many large health centers, patients face long appointment wait times and difficulties accessing care. Last-minute cancellations and patient no-shows leave unfilled slots in a clinician's schedule, exacerbating delays in care from poor access. The mismatch between the supply of outpatient appointments and patient demand has led health systems to adopt many tools and strategies to minimize appointment no-show rates and fill open slots left by patient cancellations. Objective: We evaluated an electronic health record (EHR)--based self-scheduling tool, Fast Pass, at a large academic medical center to understand the impacts of the tool on the ability to fill cancelled appointment slots, patient access to earlier appointments, and clinical revenue from visits that may otherwise have gone unscheduled. Methods: In this retrospective cohort study, we extracted Fast Pass appointment offers and scheduling data, including patient demographics, from the EHR between June 18, 2022, and March 9, 2023. We analyzed the outcomes of Fast Pass offers (accepted, declined, expired, and unavailable) and the outcomes of scheduled appointments resulting from accepted Fast Pass offers (completed, canceled, and no-show). We stratified outcomes based on appointment specialty. For each specialty, the patient service revenue from appointments filled by Fast Pass was calculated using the visit slots filled, the payer mix of the appointments, and the contribution margin by payer. Results: From June 18 to March 9, 2023, there were a total of 60,660 Fast Pass offers sent to patients for 21,978 available appointments. Of these offers, 6603 (11\%) were accepted across all departments, and 5399 (8.9\%) visits were completed. Patients were seen a median (IQR) of 14 (4-33) days sooner for their appointments. In a multivariate logistic regression model with primary outcome Fast Pass offer acceptance, patients who were aged 65 years or older (vs 20-40 years; P=.005 odds ratio [OR] 0.86, 95\% CI 0.78-0.96), other ethnicity (vs White; P<.001, OR 0.84, 95\% CI 0.77-0.91), primarily Chinese speakers (P<.001; OR 0.62, 95\% CI 0.49-0.79), and other language speakers (vs English speakers; P=.001; OR 0.71, 95\% CI 0.57-0.87) were less likely to accept an offer. Fast Pass added 2576 patient service hours to the clinical schedule, with a median (IQR) of 251 (216-322) hours per month. The estimated value of physician fees from these visits scheduled through 9 months of Fast Pass scheduling in professional fees at our institution was US \$3 million. Conclusions: Self-scheduling tools that provide patients with an opportunity to schedule into cancelled or unfilled appointment slots have the potential to improve patient access and efficiently capture additional revenue from filling unfilled slots. The demographics of the patients accepting these offers suggest that such digital tools may exacerbate inequities in access. ", doi="10.2196/52071", url="https://www.jmir.org/2024/1/e52071", url="http://www.ncbi.nlm.nih.gov/pubmed/38502159" } @Article{info:doi/10.2196/52882, author="Rizvi, Fatima Rubina and Schoephoerster, Ann Jamee and Desphande, Satish Sagar and Usher, Michael and Oien, Elaine Andy and Peters, Marie Maya and Loth, Scott Matthew and Bahr, William Matthew and Ventz, Steffen and Koopmeiners, Stephen Joseph and Melton, B. Genevieve", title="Decreasing Opioid Addiction and Diversion Using Behavioral Economics Applied Through a Digital Engagement Solution: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Mar", day="8", volume="13", pages="e52882", keywords="opioid abuse", keywords="opioid na{\"i}ve patients", keywords="opioid addiction", keywords="behavioral economics", keywords="nudges", keywords="MyChart", keywords="personal health record", keywords="post-operative care", keywords="opioid", keywords="opioid use", keywords="randomized controlled trial", keywords="RCT", keywords="digital engagement", keywords="health crisis", keywords="overdose", keywords="acute pain", keywords="pain", keywords="tool", keywords="tools", keywords="phone app", keywords="website", keywords="application", abstract="Background: Despite strong and growing interest in ending the ongoing opioid health crisis, there has been limited success in reducing the prevalence of opioid addiction and the number of deaths associated with opioid overdoses. Further, 1 explanation for this is that existing interventions target those who are opiate-dependent but do not prevent opioid-na{\"i}ve patients from becoming addicted. Objective: Leveraging behavioral economics at the patient level could help patients successfully use, discontinue, and dispose of their opioid medications in an acute pain setting. The primary goal of this project is to evaluate the effect of the 3 versions of the Opioid Management for You (OPY) tool on measures of opioid use relative to the standard of care by leveraging a pragmatic randomized controlled trial (RCT). Methods: A team of researchers from the Center for Learning Health System Sciences (CLHSS) at the University of Minnesota partnered with M Health Fairview to design, build, and test the 3 versions of the OPY tool: social influence, precommitment, and testimonial version. The tool is being built using the Epic Care Companion (Epic Inc) platform and interacts with the patient through their existing MyChart (Epic Systems Corporation) personal health record account, and Epic patient portal, accessed through a phone app or the MyChart website. We have demonstrated feasibility with pilot data of the social influence version of the OPY app by targeting our pilot to a specific cohort of patients undergoing upper-extremity procedures. This study will use a group sequential RCT design to test the impact of this important health system initiative. Patients who meet OPY inclusion criteria will be stratified into low, intermediate, and high risk of opiate use based on their type of surgery. Results: This study is being funded and supported by the CLHSS Rapid Prospective Evaluation and Digital Technology Innovation Programs, and M Health Fairview. Support and coordination provided by CLHSS include the structure of engagement, survey development, data collection, statistical analysis, and dissemination. The project was initially started in August 2022. The pilot was launched in February 2023 and is still running, with the data last counted in August 2023. The actual RCT is planned to start by early 2024. Conclusions: Through this RCT, we will test our hypothesis that patient opioid use and diverted prescription opioid availability can both be improved by information delivery applied through a behavioral economics lens via sending nudges directly to the opioid users through their personal health record. Trial Registration: ClinicalTrials.gov NCT06124079; https://clinicaltrials.gov/study/NCT06124079 International Registered Report Identifier (IRRID): PRR1-10.2196/52882 ", doi="10.2196/52882", url="https://www.researchprotocols.org/2024/1/e52882", url="http://www.ncbi.nlm.nih.gov/pubmed/38457203" } @Article{info:doi/10.2196/47441, author="Swift, Jim and O'Kelly, Noel and Barker, Chris and Woodward, Alex and Ghosh, Sudip", title="A Digital Respiratory Ward in Leicester, Leicestershire, and Rutland, England, for Patients With COVID-19: Economic Evaluation of the Impact on Acute Capacity and Wider National Health Service Resource Use", journal="JMIR Form Res", year="2024", month="Feb", day="13", volume="8", pages="e47441", keywords="Covid-19", keywords="telemedicine", keywords="digital technology", keywords="home transition", keywords="length of stay", keywords="cost-effectiveness analysis", keywords="cost", keywords="costs", keywords="economic", keywords="economics", keywords="telehealth", keywords="hospitalization", keywords="hospital", keywords="hospitals", keywords="hospitalizations", keywords="resource", keywords="resources", keywords="hospital stay", keywords="ward", keywords="wards", keywords="virtual care", keywords="remote care", keywords="financial", keywords="finance", keywords="finances", keywords="remote", keywords="respiratory", keywords="SARS-CoV-2", keywords="pulmonary", keywords="lung", keywords="lungs", keywords="service", keywords="services", keywords="delivery", abstract="Background: The COVID-19 pandemic stressed global health care systems' acute capacity and caused a diversion of resources from elective care to the treatment of acute respiratory disease. In preparing for a second wave of COVID-19 infections, England's National Health Service (NHS) in Leicester, Leicestershire, and Rutland sought to protect acute capacity in the winter of 2020-2021. Their plans included the introduction of a digital ward where patients were discharged home early and supported remotely by community-based respiratory specialists, who were informed about patient health status by a digital patient monitoring system. Objective: The objective of the digital ward was to maintain acute capacity through safe, early discharge of patients with COVID-19 respiratory disease. The study objective was to establish what impact this digital ward had on overall NHS resource use. Methods: There were no expected differences in patient outcomes. A cost minimization was performed to demonstrate the impact on the NHS resource use from discharging patients into a digital COVID-19 respiratory ward, compared to acute care length of stay (LOS). This evaluation included all 310 patients enrolled in the service from November 2020 (service commencement) to November 2021. Two primary methods, along with sensitivity analyses, were used to help overcome the uncertainty associated with the estimated comparators for the observational data on COVID-19 respiratory acute LOS, compared with the actual LOS of the 279 (90\%) patients who were not discharged on oxygen nor were in critical care. Historic comparative LOS and an ordinary least squares model based on local monthly COVID-19 respiratory median LOS were used as comparators. Actual comparator data were sourced for the 31 (10\%) patients who were discharged home and into the digital ward for oxygen weaning. Resource use associated with delivering care in the digital ward was sourced from the digital system and respiratory specialists. Results: In the base case, the digital ward delivered estimated health care system savings of 846.5 bed-days and US \$504,197 in net financial savings across the 2 key groups of patients---those on oxygen and those not on oxygen at acute discharge (both P<.001). The mean gross and net savings per patient were US \$1850 and US \$1626 in the base case, respectively, without including any savings associated with a potential reduction in readmissions. The 30-day readmission rate was 2.9\%, which was below comparative data. The mean cost of the intervention was US \$223.53 per patient, 12.1\% of the estimated gross savings. It was not until the costs were increased and the effect reduced simultaneously by 78.4\% in the sensitivity analysis that the intervention was no longer cost saving. Conclusions: The digital ward delivered increased capacity and substantial financial savings and did so with a high degree of confidence, at a very low absolute and relative cost. ", doi="10.2196/47441", url="https://formative.jmir.org/2024/1/e47441", url="http://www.ncbi.nlm.nih.gov/pubmed/38349716" } @Article{info:doi/10.2196/51841, author="Kokkonen, Jorma and Mustonen, Pirjo and Heikkil{\"a}, Eija and Leskel{\"a}, Riikka-Leena and Pennanen, Paula and Kr{\"u}hn, Kati and Jalkanen, Arto and Laakso, Jussi-Pekka and Kempers, Jari and V{\"a}is{\"a}nen, Sami and Torkki, Paulus", title="Effectiveness of Telemonitoring in Reducing Hospitalization and Associated Costs for Patients With Heart Failure in Finland: Nonrandomized Pre-Post Telemonitoring Study", journal="JMIR Mhealth Uhealth", year="2024", month="Feb", day="7", volume="12", pages="e51841", keywords="cost", keywords="Finland", keywords="heart failure", keywords="hospital", keywords="resource use", keywords="telemonitoring", abstract="Background: Many patients with chronic heart failure (HF) experience a reduced health status, leading to readmission after hospitalization despite receiving conventional care. Telemonitoring approaches aim to improve the early detection of HF decompensations and prevent readmissions. However, knowledge about the impact of telemonitoring on preventing readmissions and related costs remains scarce. Objective: This study assessed the effectiveness of adding a telemonitoring solution to the standard of care (SOC) for the prevention of hospitalization and related costs in patients with HF in Finland. Methods: We performed a nonrandomized pre-post telemonitoring study to estimate health care costs and resource use during 6 months on SOC followed by 6 months on SOC with a novel telemonitoring solution. The telemonitoring solution consisted of a digital platform for patient-reported symptoms and daily weight and blood pressure measurements, automatically generated alerts triggering phone calls with secondary care nurses, and rapid response to alerts by treating physicians. Telemonitoring solution data were linked to patient register data on primary care, secondary care, and hospitalization. The patient register of the Southern Savonia Social and Health Care Authority (Essote) was used. Eligible patients had at least 1 hospital admission within the last 12 months and self-reported New York Heart Association class II-IV from the central hospital in the Southern Savonia region. Results: Out of 50 recruited patients with HF, 43 completed the study and were included in the analysis. The hospitalization-related cost decreased (49\%; P=.03) from {\texteuro}2189 (95\% CI {\texteuro}1384-{\texteuro}2994; a currency exchange rate of EUR {\texteuro}1=US \$1.10589 is applicable) during SOC to {\texteuro}1114 (95\% CI {\texteuro}425-{\texteuro}1803) during telemonitoring. The number of patients with at least 1 hospitalization due to HF was reduced by 70\% (P=.002) from 20 (47\%) out of 43patients during SOC to 6 (14\%) out of 43 patients in telemonitoring. The estimated mean total health care cost per patient was {\texteuro}3124 (95\% CI {\texteuro}2212-{\texteuro}4036) during SOC and {\texteuro}2104 (95\% CI {\texteuro}1313-{\texteuro}2895) during telemonitoring, resulting in a 33\% reduction (P=.07) in costs with telemonitoring. Conclusions: The results suggest that the telemonitoring solution can reduce hospital-related costs for patients with HF with a recent hospital admission. ", doi="10.2196/51841", url="https://mhealth.jmir.org/2024/1/e51841", url="http://www.ncbi.nlm.nih.gov/pubmed/38324366" } @Article{info:doi/10.2196/52524, author="Modi, Shikha and Feldman, S. Sue and Berner, S. Eta and Schooley, Benjamin and Johnston, Allen", title="Value of Electronic Health Records Measured Using Financial and Clinical Outcomes: Quantitative Study", journal="JMIR Med Inform", year="2024", month="Jan", day="24", volume="12", pages="e52524", keywords="acceptance", keywords="admission", keywords="adoption", keywords="clinical outcome", keywords="cost", keywords="economic", keywords="EHR adoption", keywords="EHR", keywords="electronic health record", keywords="finance", keywords="financial outcome", keywords="financial", keywords="health outcome", keywords="health record", keywords="hospital", keywords="hospitalization", keywords="length of stay", keywords="margin", keywords="moderation analysis", keywords="multivariate", keywords="operating margin", keywords="operating", keywords="operation", keywords="operational", keywords="profit", keywords="project management", keywords="readmission rate", keywords="readmission", keywords="total margin", keywords="value analysis", keywords="value engineering", keywords="value management", abstract="Background: The Health Information Technology for Economic and Clinical Health Act of 2009 was legislated to reduce health care costs, improve quality, and increase patient safety. Providers and organizations were incentivized to exhibit meaningful use of certified electronic health record (EHR) systems in order to achieve this objective. EHR adoption is an expensive investment, given the resources and capital that are invested. Due to the cost of the investment, a return on the EHR adoption investment is expected. Objective: This study performed a value analysis of EHRs. The objective of this study was to investigate the relationship between EHR adoption levels and financial and clinical outcomes by combining both financial and clinical outcomes into one conceptual model. Methods: We examined the multivariate relationships between different levels of EHR adoption and financial and clinical outcomes, along with the time variant control variables, using moderation analysis with a longitudinal fixed effects model. Since it is unknown as to when hospitals begin experiencing improvements in financial outcomes, additional analysis was conducted using a 1- or 2-year lag for profit margin ratios. Results: A total of 5768 hospital-year observations were analyzed over the course of 4 years. According to the results of the moderation analysis, as the readmission rate increases by 1 unit, the effect of a 1-unit increase in EHR adoption level on the operating margin decreases by 5.38\%. Hospitals with higher readmission payment adjustment factors have lower penalties. Conclusions: This study fills the gap in the literature by evaluating individual relationships between EHR adoption levels and financial and clinical outcomes, in addition to evaluating the relationship between EHR adoption level and financial outcomes, with clinical outcomes as moderators. This study provided statistically significant evidence (P<.05), indicating that there is a relationship between EHR adoption level and operating margins when this relationship is moderated by readmission rates, meaning hospitals that have adopted EHRs could see a reduction in their readmission rates and an increase in operating margins. This finding could further be supported by evaluating more recent data to analyze whether hospitals increasing their level of EHR adoption would decrease readmission rates, resulting in an increase in operating margins. Hospitals would incur lower penalties as a result of improved readmission rates, which would contribute toward improved operating margins. ", doi="10.2196/52524", url="https://medinform.jmir.org/2024/1/e52524", url="http://www.ncbi.nlm.nih.gov/pubmed/38265848" } @Article{info:doi/10.2196/51839, author="Oldham, Melissa and Dinu, Larisa and Loebenberg, Gemma and Field, Matt and Hickman, Matthew and Michie, Susan and Brown, Jamie and Garnett, Claire", title="Methodological Insights on Recruitment and Retention From a Remote Randomized Controlled Trial Examining the Effectiveness of an Alcohol Reduction App: Descriptive Analysis Study", journal="JMIR Form Res", year="2024", month="Jan", day="5", volume="8", pages="e51839", keywords="alcohol reduction", keywords="alcohol", keywords="digital care", keywords="digital intervention", keywords="ethnic minority", keywords="methods", keywords="mHealth", keywords="randomised controlled trial", keywords="recruitment", keywords="retention", keywords="social media", abstract="Background: Randomized controlled trials (RCTs) with no in-person contact (ie, remote) between researchers and participants offer savings in terms of cost and time but present unique challenges. Objective: The goal of this study is to examine the differences between different forms of remote recruitment (eg, National Health Service [NHS] website, social media, and radio advertising) in the proportion of participants recruited, demographic diversity, follow-up rates, and cost. We also examine the cost per participant of sequential methods of follow-up (emails, phone calls, postal surveys, and postcards). Finally, our experience with broader issues around study advertising and participant deception is discussed. Methods: We conducted a descriptive analysis of 5602 increasing-and-higher-risk drinkers (Alcohol Use Disorders Identification Test score ?8), taking part in a 2-arm, parallel group, remote RCT with a 1:1 allocation, comparing the intervention (Drink Less app) with usual digital care (NHS alcohol advice web page). Participants were recruited between July 2020 and March 2022 and compensated with gift vouchers of up to {\textsterling}36 (a currency exchange rate of {\textsterling}1=US \$1.26988 is applicable) for completing follow-up surveys, with 4 stages of follow-up: email reminders, phone calls, postal survey, and postcard. Results: The three main recruitment methods were advertisements on (1) social media (2483/5602, 44.32\%), (2) the NHS website (1961/5602, 35.01\%), and (3) radio and newspapers (745/5602, 13.3\%), with the remaining methods of recruitment accounting 7.37\% (413/5602) of the sample. The overall recruitment cost per participant varied from {\textsterling}0 to {\textsterling}11.01. Costs were greater when recruiting participants who were men ({\textsterling}0-{\textsterling}28.85), from an ethnic minority group ({\textsterling}0-{\textsterling}303.81), and more disadvantaged ({\textsterling}0-{\textsterling}49.12). Targeted approaches were useful for recruiting more men but less useful in achieving diversity in ethnicity and socioeconomic status. Follow-up at 6 months was 79.58\% (4458/5602). Of those who responded, 92.4\% (4119/4458) responded by email. Each additional stage of follow-up resulted in an additional 2-3 percentage points of the overall sample being followed up, although phone calls, postal surveys, and postcards were more resource intensive than email reminders. Conclusions: For remote RCTs, researchers could benefit from using a range of recruitment methods and cost-targeted approaches to achieve demographic diversity. Automated emails with substantial financial incentives for prompt completion can achieve good follow-up rates, and sequential, offline follow-up options, such as phone calls and postal surveys, can further increase follow-up rates but are comparatively expensive. We also make broader recommendations focused on striking the right balance when designing remote RCTs. Careful planning, ongoing maintenance, and dynamic decision-making are required throughout a trial to balance the competing demands of participation among those eligible, deceptive participation among those who are not eligible, and ensuring no postrandomization bias is introduced by data-checking protocols. ", doi="10.2196/51839", url="https://formative.jmir.org/2024/1/e51839", url="http://www.ncbi.nlm.nih.gov/pubmed/38180802" } @Article{info:doi/10.2196/50985, author="Chilakam, Nagavalli and Lakshminarayanan, Varsha and Keremutt, Sushanth and Rajendran, Ambigai and Thunga, Girish and Poojari, Gopal Pooja and Rashid, Muhammed and Mukherjee, Nirmalya and Bhattacharya, Paramita and John, Denny", title="Economic Burden of Mosquito-Borne Diseases in Low- and Middle-Income Countries: Protocol for a Systematic Review", journal="JMIR Res Protoc", year="2023", month="Dec", day="11", volume="12", pages="e50985", keywords="cost of illness", keywords="economic burden", keywords="out-of-pocket expenditure", keywords="OOPE", keywords="mosquito-borne diseases", keywords="vector-borne diseases", abstract="Background: Globally, among all the vector-borne diseases, mosquito-borne diseases are responsible for a substantial number of cases and deaths and amount to an economic cost of US \$12 billion per year. However, there is a dearth of systematic research conducted on the economic burden of mosquito-borne diseases. To address the lack of comprehensive information on this topic, a systematic review will be conducted to synthesize evidence for informing targeted policies and strategies addressing this growing burden and for better financial protection of households. Objective: The systematic review aims to review the economic burden of mosquito-borne diseases in low- and middle-income countries (LMICs). The review estimates the total cost, which is the compilation of both the direct costs and indirect costs. Additionally, it reports cost estimates per disease, country, and patient. The review outcome will also discuss the impact of the economic burden in terms of out-of-pocket expenditure, catastrophic health expenditure, impoverishment, and gross domestic product impact due to mosquito-borne diseases in LMICs. Methods: Systematic searches will be conducted in PubMed (MEDLINE), Ovid Embase, Scopus, the cumulative index of nursing and allied health literacy, and Cochrane CENTRAL. Additionally, websites of the World Bank, World Health Organization, and Asian Development Bank as well as grey literature (eg, Malaria No More and the Ministry of Health websites) will be searched to gather comprehensive information on the topic and identify studies published in the English language. The titles and abstracts will be independently screened by 2 reviewers, followed by a full-text review against the inclusion criteria. Disagreements will be resolved through discussion with a third author. The methodological reporting quality of the studies will be evaluated using the Larg and Moss checklist, Cochrane risk-of-bias tool for randomized trials, and the Consensus on Health Economic Criteria. Data will be extracted using a standardized data extraction form. Results: The protocol was registered in PROSPERO (CRD42023427111) prior to the initiation of the search strategy. The review is currently ongoing and will synthesize information from the identified studies through a process involving structured screening, data extraction, and critical appraisal in the form of tables and a narrative summary of studies reporting the economic burden incurred due to mosquito-borne diseases in LMICs. Conclusions: This review seeks to report the economic burden of mosquito-borne diseases. It will act as evidence for policymakers to prioritize their decisions regarding containing the prevalence of mosquito-borne diseases and the means to lowering the incidence of diseases spread by mosquitoes. Trial Registration: PROSPERO CRD42023427111; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=427111 International Registered Report Identifier (IRRID): PRR1-10.2196/50985 ", doi="10.2196/50985", url="https://www.researchprotocols.org/2023/1/e50985", url="http://www.ncbi.nlm.nih.gov/pubmed/38079215" } @Article{info:doi/10.2196/49852, author="Choi, Kyungseon and Park, Jun Sang and Han, Sola and Mun, Yongseok and Lee, Yun Da and Chang, Dong-Jin and Kim, Seok and Yoo, Sooyoung and Woo, Joon Se and Park, Hyung Kyu and Suh, Sun Hae", title="Patient-Centered Economic Burden of Exudative Age-Related Macular Degeneration: Retrospective Cohort Study", journal="JMIR Public Health Surveill", year="2023", month="Dec", day="8", volume="9", pages="e49852", keywords="blindness", keywords="age-related macular degeneration", keywords="economic burden", keywords="cost of illness", keywords="retrospective cohort study", keywords="common data model", abstract="Background: Exudative age-related macular degeneration (AMD), one of the leading causes of blindness, requires expensive drugs such as anti--vascular endothelial growth factor (VEGF) agents. The long-term regular use of effective but expensive drugs causes an economic burden for patients with exudative AMD. However, there are no studies on the long-term patient-centered economic burden of exudative AMD after reimbursement of anti-VEGFs. Objective: This study aimed to evaluate the patient-centered economic burden of exudative AMD for 2 years, including nonreimbursement and out-of-pocket costs, compared with nonexudative AMD using the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). Methods: This retrospective cohort study was conducted using the OMOP CDM, which included 2,006,478 patients who visited Seoul National University Bundang Hospital from June 2003 to July 2019. We defined the exudative AMD group as patients aged >50 years with a diagnosis of exudative AMD and a prescription for anti-VEGFs or verteporfin. The control group was defined as patients aged >50 years without a diagnosis of exudative AMD or a prescription for anti-VEGFs or verteporfin. To adjust for selection bias, controls were matched by propensity scores using regularized logistic regression with a Laplace prior. We measured any medical cost occurring in the hospital as the economic burden of exudative AMD during a 2-year follow-up period using 4 categories: total medical cost, reimbursement cost, nonreimbursement cost, and out-of-pocket cost. To estimate the average cost by adjusting the confounding variable and overcoming the positive skewness of costs, we used an exponential conditional model with a generalized linear model. Results: We identified 931 patients with exudative AMD and matched 783 (84.1\%) with 2918 patients with nonexudative AMD. In the exponential conditional model, the total medical, reimbursement, nonreimbursement, and out-of-pocket incremental costs were estimated at US \$3426, US \$3130, US \$366, and US \$561, respectively, in the first year and US \$1829, US \$1461, US \$373, and US \$507, respectively, in the second year. All incremental costs in the exudative AMD group were 1.89 to 4.25 and 3.50 to 5.09 times higher in the first and second year, respectively, than those in the control group (P<.001 in all cases). Conclusions: Exudative AMD had a significantly greater economic impact (P<.001) for 2 years on reimbursement, nonreimbursement, and out-of-pocket costs than nonexudative AMD after adjusting for baseline demographic and clinical characteristics using the OMOP CDM. Although economic policies could relieve the economic burden of patients with exudative AMD over time, the out-of-pocket cost of exudative AMD was still higher than that of nonexudative AMD for 2 years. Our findings support the need for expanding reimbursement strategies for patients with exudative AMD given the significant economic burden faced by patients with incurable and fatal diseases both in South Korea and worldwide. ", doi="10.2196/49852", url="https://publichealth.jmir.org/2023/1/e49852", url="http://www.ncbi.nlm.nih.gov/pubmed/38064251" } @Article{info:doi/10.2196/44530, author="Killela, Mary and Biddell, Caitlin and Keim-Malpass, Jessica and Schwartz, A. Todd and Soto, Sandra and Williams, Jessica and Santacroce, Sheila", title="The Use of Medical Crowdfunding to Mitigate the Personal Costs of Serious Chronic Illness: Scoping Review", journal="J Med Internet Res", year="2023", month="Dec", day="4", volume="25", pages="e44530", keywords="COVID-19", keywords="chronic illness", keywords="costs", keywords="financial", keywords="stress", keywords="appraisal", keywords="coping", keywords="crowdfunding", keywords="social network", keywords="social support", keywords="caregiver", keywords="systematic scoping review", keywords="medical crowdfunding", keywords="coping behavior", abstract="Background: Persons diagnosed with serious chronic illnesses and their caretakers experience multiple types of financial costs that strain their income and generate financial distress. Many turn to medical crowdfunding (MCF) to mitigate the harms of these costs on their health and quality of life. Objective: This scoping review aims to summarize the research on MCF for persons diagnosed with serious chronic illness regarding study designs and methods; the responsible conduct of research practices; and study foci as they relate to stress, stress appraisals, and the coping processes. Methods: This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Eligible studies were conducted in countries designated as high income by the World Bank and focused on beneficiaries diagnosed with serious chronic illness. The findings of the included studies were summarized as they related to the key concepts in a conceptual framework derived from an established stress, appraisal, and coping framework and a conceptual model of financial toxicity in pediatric oncology. Results: Overall, 26 studies were eligible for inclusion in the review. The main findings included a lack of integration of qualitative and quantitative approaches and the inconsistent reporting of the responsible conduct of research practices. The included studies focused on financial stressors that contributed to financial burden, such as out-of-pocket payments of medical bills, basic living expenses, medical travel expenses, and lost income owing to illness-related work disruptions. Few studies addressed stress appraisals as threatening or the adequacy of available financial resources. When mentioned, appraisals related to the global financial struggle during the COVID-19 pandemic or the capacity of social network members to donate funds. The consequences of MCF included the receipt of 3 forms of social support (tangible, informational, and emotional), privacy loss, embarrassment, and the propagation of scientifically unsupported information. Studies found that friends and family tended to manage MCF campaigns. Although most of the studies (21/26, 81\%) focused on monetary outcomes, a few (5/26, 19\%) concentrated on peoples' experiences with MCF. Conclusions: The identified methodological gaps highlight the need for more robust and reproducible approaches to using the copious data available on public MCF platforms. The integration of quantitative and qualitative methods will allow for nuanced explorations of the MCF experience. A more consistent elaboration of strategies to promote the responsible conduct of research is warranted to minimize risk to populations that are vulnerable and express concerns regarding the loss of privacy. Finally, an examination of the unanticipated consequences of MCF is critical for the development of future interventions to optimize existing supports while providing needed supports, financial and nonfinancial, that are lacking. ", doi="10.2196/44530", url="https://www.jmir.org/2023/1/e44530", url="http://www.ncbi.nlm.nih.gov/pubmed/38048149" } @Article{info:doi/10.2196/43034, author="Koppenaal, Tjarco and van Dongen, M. Johanna and Kloek, JJ Corelien and Arensman, M. Remco and Veenhof, Cindy and Pisters, F. Martijn and Ostelo, WJG Raymond", title="Effectiveness and Cost-Effectiveness of a Stratified Blended Physiotherapy Intervention Compared With Face-to-Face Physiotherapy in Patients With Nonspecific Low Back Pain: Cluster Randomized Controlled Trial", journal="J Med Internet Res", year="2023", month="Nov", day="24", volume="25", pages="e43034", keywords="economic evaluation", keywords="eHealth", keywords="nonspecific low back pain", keywords="physiotherapy", keywords="blended care", keywords="mobile phone", abstract="Background: Nonspecific low back pain (LBP) is a leading contributor to disability worldwide, and its socioeconomic burden is substantial. Self-management support is an important recommendation in clinical guidelines for the physiotherapy treatment of patients with LBP and may support cost-effective management. However, providing adequate individually tailored self-management support is difficult. The integration of web-based applications into face-to-face care (ie, blended care) seems promising to optimize tailored treatment and enhance patients' self-management and, consequently, may reduce LBP-related costs. Objective: We aimed to evaluate the long-term effectiveness and cost-effectiveness of stratified blended physiotherapy (e-Exercise LBP) compared with face-to-face physiotherapy in patients with nonspecific LBP. Methods: An economic evaluation was conducted alongside a prospective, multicenter, cluster randomized controlled trial in primary care physiotherapy. Patients with nonspecific LBP were treated with either stratified blended physiotherapy (e-Exercise LBP) (n=104) or face-to-face physiotherapy (n=104). The content of both interventions was based on the Dutch physiotherapy guidelines for nonspecific LBP. Blended physiotherapy was stratified according to the patients' risk of developing persistent LBP using the STarT Back Screening Tool. The primary clinical outcome was physical functioning (Oswestry Disability Index version 2.1a). For the economic evaluation, quality-adjusted life years (QALYs; EQ-5D-5L) and physical functioning were the primary outcomes. Secondary clinical outcomes included fear avoidance beliefs and self-reported adherence. Costs were measured from societal and health care perspectives using self-report questionnaires. Effectiveness was estimated using linear mixed models. Seemingly unrelated regression analyses were conducted to estimate total cost and effect differences for the economic evaluation. Results: Neither clinically relevant nor statistically substantial differences were found between stratified blended physiotherapy and face-to-face physiotherapy regarding physical functioning (mean difference [MD] ?1.1, 95\% CI ?3.9 to 1.7) and QALYs (MD 0.026, 95\% CI ?0.020 to 0.072) over 12 months. Regarding the secondary outcomes, fear avoidance beliefs showed a statistically significant improvement in favor of stratified blended physiotherapy (MD ?4.3, 95\% CI ?7.3 to ?1.3). Societal and health care costs were higher for stratified blended physiotherapy than for face-to-face physiotherapy, but the differences were not statistically significant (societal: {\texteuro}972 [US \$1027], 95\% CI ?{\texteuro}1090 to {\texteuro}3264 [US --\$1151 to \$3448]; health care: {\texteuro}73 [US \$77], 95\% CI ?{\texteuro}59 to {\texteuro}225 [US --\$62 to \$238]). Among the disaggregated cost categories, only unpaid productivity costs were significantly higher for stratified blended physiotherapy. From both perspectives, a considerable amount of money must be paid per additional QALY or 1-point improvement in physical functioning to reach a relatively low to moderate probability (ie, 0.23-0.81) of stratified blended physiotherapy being cost-effective compared with face-to-face physiotherapy. Conclusions: The stratified blended physiotherapy intervention e-Exercise LBP is neither more effective for improving physical functioning nor more cost-effective from societal or health care perspectives compared with face-to-face physiotherapy for patients with nonspecific LBP. Trial Registration: ISRCTN 94074203; https://www.isrctn.com/ISRCTN94074203 International Registered Report Identifier (IRRID): RR2-10.1186/s12891-020-3174-z ", doi="10.2196/43034", url="https://www.jmir.org/2023/1/e43034", url="http://www.ncbi.nlm.nih.gov/pubmed/37999947" } @Article{info:doi/10.2196/52233, author="Jamieson, Lisa and Luzzi, Liana and Chrisopoulos, Sergio and Roberts, Rachel and Arrow, Peter and Kularatna, Sanjeewa and Mittinty, Murthy and Haag, Dandara and Ribeiro Santiago, Henrique Pedro and Mejia, Gloria", title="Oral Health, Social and Emotional Well-Being, and Economic Costs: Protocol for the Second Australian National Child Oral Health Survey", journal="JMIR Res Protoc", year="2023", month="Nov", day="14", volume="12", pages="e52233", keywords="Australian children", keywords="cost-effective analysis", keywords="dental caries", keywords="social and emotional well-being", abstract="Background: Given the significant investment of governments and families into the provision of child dental care services in Australia, continued population oral health surveillance through national oral health surveys is imperative. Objective: The aims of this study are to conduct a second National Child Oral Health Survey (NCOHS-2) to (1) describe the prevalence, extent, and impact of oral diseases in contemporary Australian children; (2) evaluate changes in the prevalence and extent of oral diseases in the Australian child population and socioeconomic subgroups since the first National Child Oral Health Study (NCOHS-1) in 2012-2013; and (3) use economic modeling to evaluate the burden of child oral disease from the NCOHS-1 and NCOHS-2 and to estimate the cost-effectiveness of targeted programs for high-risk child groups. Methods: The NCOHS-2 will closely mimic the NCOHS-1 in being a cross-sectional survey of a representative sample of Australian children aged 5-14 years. The survey will comprise oral epidemiological examinations and questionnaires to elucidate associations between dental disease in a range of outcomes, including social and emotional well-being. The information will be analyzed within the context of dental service organization and delivery at national and jurisdictional levels. Information from the NCOHS-1 and NCOHS-2 will be used to simulate oral disease and its economic burden using both health system and household costs of childhood oral health disease. Results: Participant recruitment for the NCOHS-2 will commence in February 2024. The first results are expected to be submitted for publication 6 months after NCOHS-2 data collection has been completed. Thematic workshops with key partners and stakeholders will also occur at this time. Conclusions: Regular surveillance of child oral health at an Australian level facilitates timely policy and planning of each state and territory's dental public health sector. This is imperative to enable the most equitable distribution of scarce public monies, especially for socially disadvantaged children who bear the greatest dental disease burden. The last NCOHS was conducted in 2012-2014, meaning that these data need to be updated to better inform effective dental health policy and planning. The NCOHS-2 will enable more up-to-date estimates of dental disease prevalence and severity among Australian children, with cost-effective analysis being useful to determine the economic burden of poor child dental health on social and emotional well-being and other health indicators. International Registered Report Identifier (IRRID): PRR1-10.2196/52233 ", doi="10.2196/52233", url="https://www.researchprotocols.org/2023/1/e52233", url="http://www.ncbi.nlm.nih.gov/pubmed/37962928" } @Article{info:doi/10.2196/51998, author="Htet, Ko Kyaw Ko and Phyu, Nyein Aye and Zayar, Nyi Nyi and Chongsuvivatwong, Virasakdi", title="Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation", journal="JMIR Form Res", year="2023", month="Nov", day="10", volume="7", pages="e51998", keywords="mobile app", keywords="tuberculosis screening", keywords="TB screening", keywords="cost effectiveness", keywords="mHealth", keywords="mobile health", keywords="app", keywords="apps", keywords="application", keywords="applications", keywords="cost", keywords="costs", keywords="economic", keywords="economics", keywords="TB", keywords="tuberculosis", keywords="screening", keywords="communicable", keywords="x-ray", keywords="imaging", keywords="radiography", keywords="decision tree", keywords="detect", keywords="detection", keywords="detecting", abstract="Background: A mobile app that calculates a tuberculosis (TB) risk score based on individual social and pathological characteristics has been shown to be a better predictor of the risk of contracting TB than conventionally used TB signs and symptoms (TBSS) in Myanmar, where the TB burden is high. Its cost-effectiveness, however, has not yet been assessed. Objective: This study aimed to determine the incremental costs of this mobile app and of chest x-rays (CXRs) in averting disability-adjusted life years (DALYs) among missed cases of active TB in the population being screened. Methods: Elements of incremental costs and effectiveness of 3 initial TB screening strategies were examined, including TBSS followed by CXR, the mobile app followed by CXR, and universal CXR. The incremental cost-effectiveness ratio (ICER; ie, the additional cost for each additional DALY averted) was compared to TBSS screening. Based on the latest 2020 gross domestic product (GDP) per capita of Myanmar (US \$1477.50), the ICER was compared to willingness-to-pay (WTP) thresholds of 1, 2, and 3 times the GDP per capita. Probabilistic sensitivity analysis was conducted with a Monte Carlo simulation to compute the levels of probability that the ICER for each strategy was below each WTP threshold. Results: For each 100,000 population, the incremental cost compared to TBSS of active TB screening was US \$345,942 for the mobile app and US \$1,810,712 for universal CXR. The incremental effectiveness was 325 DALYs averted for the mobile app and 576 DALYs averted for universal CXR. For the mobile app, the estimated ICER was US \$1064 (72\% of GDP per capita) per 1 DALY averted. Furthermore, 100\% of the simulated values were below an additional cost of 1 times the GDP per capita for 1 additional DALY averted. The universal CXR strategy has an estimated ICER of US \$3143 (2.1 times the GDP per capita) per 1 DALY averted and an additional 77.2\% DALYs averted compared to the app (ie, 576 -- 325 / 325 DALYs); however, 0.5\% of the simulated values were higher than an additional expenditure of 3 times the GDP per capita. Conclusions: Based on the status of the economy in 2020, the mobile app strategy is affordable for Myanmar. The universal CXR strategy, although it could prevent an additional 77\% of DALYs, is probably unaffordable. Compared to the TBSS strategy, the mobile app system based on social and pathological characteristics of TB has potential as a TB screening tool to identify missing TB cases and to reduce TB morbidity and mortality, thereby helping to achieve the global goal of ``End TB'' in resource-limited settings with a high TB burden. ", doi="10.2196/51998", url="https://formative.jmir.org/2023/1/e51998", url="http://www.ncbi.nlm.nih.gov/pubmed/37948119" } @Article{info:doi/10.2196/45958, author="Stanic, Tijana and Saygin Avsar, Tuba and Gomes, Manuel", title="Economic Evaluations of Digital Health Interventions for Children and Adolescents: Systematic Review", journal="J Med Internet Res", year="2023", month="Nov", day="3", volume="25", pages="e45958", keywords="digital health", keywords="cost-effectiveness", keywords="economic evaluation", keywords="children", keywords="adolescents", abstract="Background: Digital health interventions (DHIs) are defined as digital technologies such as digital health applications and information and communications technology systems (including SMS text messages) implemented to meet health objectives. DHIs implemented using various technologies, ranging from electronic medical records to videoconferencing systems and mobile apps, have experienced substantial growth and uptake in recent years. Although the clinical effectiveness of DHIs for children and adolescents has been relatively well studied, much less is known about the cost-effectiveness of these interventions. Objective: This study aimed to systematically review economic evaluations of DHIs for pediatric and adolescent populations. This study also reviewed methodological issues specific to economic evaluations of DHIs to inform future research priorities. Methods: We conducted a database search in PubMed from 2011 to 2021 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. In total, 2 authors independently screened the titles and abstracts of the search results to identify studies eligible for full-text review. We generated a data abstraction procedure based on recommendations from the Panel on Cost-Effectiveness in Health and Medicine. The types of economic evaluations included in this review were cost-effectiveness analyses (costs per clinical effect), cost-benefit analyses (costs and effects expressed in monetary terms as net benefit), and cost-utility analyses (cost per quality-adjusted life year or disability-adjusted life year). Narrative analysis was used to synthesize the quantitative data because of heterogeneity across the studies. We extracted methodological issues related to study design, analysis framework, cost and outcome measurement, and methodological assumptions regarding the health economic evaluation. Results: We included 22 articles assessing the cost-effectiveness of DHI interventions for children and adolescents. Most articles (14/22, 64\%) evaluated interventions delivered through web-based portals or SMS text messaging, most frequently within the health care specialties of mental health and maternal, newborn, and child health. In 82\% (18/22) of the studies, DHIs were found to be cost-effective or cost saving compared with the nondigital standard of care. The key drivers of cost-effectiveness included population coverage, cost components, intervention effect size and scale-up, and study perspective. The most frequently identified methodological challenges were related to study design (17/22, 77\%), costing (11/22, 50\%), and economic modeling (9/22, 41\%). Conclusions: This is the first systematic review of economic evaluations of DHIs targeting pediatric and adolescent populations. We found that most DHIs (18/22, 82\%) for children and adolescents were cost-effective or cost saving compared with the nondigital standard of care. In addition, this review identified key methodological challenges directly related to the conduct of economic evaluations of DHIs and highlighted areas where further methodological research is required to address these challenges. These included the need for measurement of user involvement and indirect effects of DHIs and the development of children-specific, generic quality-of-life outcomes. ", doi="10.2196/45958", url="https://www.jmir.org/2023/1/e45958", url="http://www.ncbi.nlm.nih.gov/pubmed/37921844" } @Article{info:doi/10.2196/49003, author="van Kessel, Robin and Srivastava, Divya and Kyriopoulos, Ilias and Monti, Giovanni and Novillo-Ortiz, David and Milman, Ran and Zhang-Czabanowski, Wilhelm Wojciech and Nasi, Greta and Stern, Dora Ariel and Wharton, George and Mossialos, Elias", title="Digital Health Reimbursement Strategies of 8 European Countries and Israel: Scoping Review and Policy Mapping", journal="JMIR Mhealth Uhealth", year="2023", month="Sep", day="29", volume="11", pages="e49003", keywords="digital health", keywords="telehealth", keywords="telemedicine", keywords="reimbursement", keywords="policy", keywords="Europe", keywords="policy mapping", keywords="mapping", keywords="pricing", keywords="digital health app", keywords="application", keywords="health care ecosystem", keywords="framework", keywords="integration", abstract="Background: The adoption of digital health care within health systems is determined by various factors, including pricing and reimbursement. The reimbursement landscape for digital health in Europe remains underresearched. Although various emergency reimbursement decisions were made during the COVID-19 pandemic to enable health care delivery through videoconferencing and asynchronous care (eg, digital apps), research so far has primarily focused on the policy innovations that facilitated this outside of Europe. Objective: This study examines the digital health reimbursement strategies in 8 European countries (Belgium, France, Germany, Italy, the Netherlands, Poland, Sweden, and the United Kingdom) and Israel. Methods: We mapped available digital health reimbursement strategies using a scoping review and policy mapping framework. We reviewed the literature on the MEDLINE, Embase, Global Health, and Web of Science databases. Supplementary records were identified through Google Scholar and country experts. Results: Our search strategy yielded a total of 1559 records, of which 40 (2.57\%) were ultimately included in this study. As of August 2023, digital health solutions are reimbursable to some extent in all studied countries except Poland, although the mechanism of reimbursement differs significantly across countries. At the time of writing, the pricing of digital health solutions was mostly determined through discussions between national or regional committees and the manufacturers of digital health solutions in the absence of value-based assessment mechanisms. Financing digital health solutions outside traditional reimbursement schemes was possible in all studied countries except Poland and typically occurs via health innovation or digital health--specific funding schemes. European countries have value-based pricing frameworks that range from nonexistent to embryonic. Conclusions: Studied countries show divergent approaches to the reimbursement of digital health solutions. These differences may complicate the ability of patients to seek cross-country health care in another country, even if a digital health app is available in both countries. Furthermore, the fragmented environment will present challenges for developers of such solutions, as they look to expand their impact across countries and health systems. An increased emphasis on developing a clear conceptualization of digital health, as well as value-based pricing and reimbursement mechanisms, is needed for the sustainable integration of digital health. This study can therein serve as a basis for further, more detailed research as the field of digital health reimbursement evolves. ", doi="10.2196/49003", url="https://mhealth.jmir.org/2023/1/e49003", url="http://www.ncbi.nlm.nih.gov/pubmed/37773610" } @Article{info:doi/10.2196/47473, author="Mitchell, Siobhan Ellen and Fabry, Alexander and Ho, Suh Annabell and May, N. Christine and Baldwin, Matthew and Blanco, Paige and Smith, Kyle and Michaelides, Andreas and Shokoohi, Mostafa and West, Michael and Gotera, Kim and El Massad, Omnya and Zhou, Anna", title="The Impact of a Digital Weight Loss Intervention on Health Care Resource Utilization and Costs Compared Between Users and Nonusers With Overweight and Obesity: Retrospective Analysis Study", journal="JMIR Mhealth Uhealth", year="2023", month="Aug", day="24", volume="11", pages="e47473", keywords="mobile health", keywords="mHealth", keywords="obesity", keywords="overweight", keywords="Noom Weight", keywords="digital weight loss intervention", keywords="health care resource utilization", keywords="costs", keywords="electronic health record", keywords="EHR", keywords="insurance claims", keywords="inverse probability of treatment weighting", keywords="IPTW", keywords="mobile phone", abstract="Background: The Noom Weight program is a smartphone-based weight management program that uses cognitive behavioral therapy techniques to motivate users to achieve weight loss through a comprehensive lifestyle intervention. Objective: This retrospective database analysis aimed to evaluate the impact of Noom Weight use on health care resource utilization (HRU) and health care costs among individuals with overweight and obesity. Methods: Electronic health record data, insurance claims data, and Noom Weight program data were used to conduct the analysis. The study included 43,047 Noom Weight users and 14,555 non--Noom Weight users aged between 18 and 80 years with a BMI of ?25 kg/m{\texttwosuperior} and residing in the United States. The index date was defined as the first day of a 3-month treatment window during which Noom Weight was used at least once per week on average. Inverse probability treatment weighting was used to balance sociodemographic covariates between the 2 cohorts. HRU and costs for inpatient visits, outpatient visits, telehealth visits, surgeries, and prescriptions were analyzed. Results: Within 12 months after the index date, Noom Weight users had less inpatient costs (mean difference [MD] ?US \$20.10, 95\% CI ?US \$30.08 to ?US \$10.12), less outpatient costs (MD ?US \$124.33, 95\% CI ?US \$159.76 to ?US \$88.89), less overall prescription costs (MD ?US \$313.82, 95\% CI ?US \$565.42 to ?US \$62.21), and less overall health care costs (MD ?US \$450.39, 95\% CI ?US \$706.28 to ?US \$194.50) per user than non--Noom Weight users. In terms of HRU, Noom Weight users had fewer inpatient visits (MD ?0.03, 95\% CI ?0.04 to ?0.03), fewer outpatient visits (MD ?0.78, 95\% CI ?0.93 to ?0.62), fewer surgeries (MD ?0.01, 95\% CI ?0.01 to 0.00), and fewer prescriptions (MD ?1.39, 95\% CI ?1.76 to ?1.03) per user than non--Noom Weight users. Among a subset of individuals with 24-month follow-up data, Noom Weight users incurred lower overall prescription costs (MD ?US \$1139.52, 95\% CI ?US \$1972.21 to ?US \$306.83) and lower overall health care costs (MD ?US \$1219.06, 95\% CI ?US \$2061.56 to ?US \$376.55) per user than non--Noom Weight users. The key differences were associated with reduced prescription use. Conclusions: Noom Weight use is associated with lower HRU and costs than non--Noom Weight use, with potential cost savings of up to US \$1219.06 per user at 24 months after the index date. These findings suggest that Noom Weight could be a cost-effective weight management program for individuals with overweight and obesity. This study provides valuable evidence for health care providers and payers in evaluating the potential benefits of digital weight loss interventions such as Noom Weight. ", doi="10.2196/47473", url="https://mhealth.jmir.org/2023/1/e47473", url="http://www.ncbi.nlm.nih.gov/pubmed/37616049" } @Article{info:doi/10.2196/45054, author="Zhang, Wen and Wong, H. Carlos K. and Xin, Yiqiao and Fong, T. Daniel Y. and Wong, H. Janet Y.", title="A Web-Based Sexual Health Intervention to Prevent Sexually Transmitted Infections in Hong Kong: Model-Based Cost-Effectiveness Analysis", journal="J Med Internet Res", year="2023", month="Aug", day="10", volume="25", pages="e45054", keywords="economic evaluation", keywords="web-based intervention", keywords="young adult", keywords="cost-effectiveness", keywords="sexual health", keywords="sexually transmitted infection", keywords="STI", keywords="digital intervention", abstract="Background: Sexually transmitted infections (STIs) remain a significant public health concern, particularly among young adults, and Chlamydia trachomatis (CT) infections are the most common STIs in young women. One of the most effective ways to prevent STIs is the consistent use of condoms during sexual intercourse. There has been no economic evaluation of the interactive web-based sexual health program, Smart Girlfriend, within the Chinese population. Objective: This study aimed to evaluate the long-term cost-effectiveness of Smart Girlfriend in preventing STIs in the Chinese population. The evaluation compared the program with a control intervention that used a 1-page information sheet on condom use. Methods: A decision-analytic model that included a decision tree followed by a Markov structure of CT infections was developed since CT is the most prevalent STI among young women. The model represents the long-term experience of individuals who received either the intervention or the control. One-way and probabilistic sensitivity analyses were conducted. The main outcomes were the number of CT infections and the incremental cost as per quality-adjusted life year (QALY). Results: A cohort of 10,000 sexually active nonpregnant young women initially entered the model in a noninfectious state (ie, ``well''). In the base-case analysis, the implementation of the Smart Girlfriend program resulted in the prevention of 0.45\% of CT infections, 0.3\% of pelvic inflammatory disease, and 0.04\% of chronic pelvic pain, leading to a gain of 70 discounted QALYs and cost savings over a 4-year time horizon, compared to the control group. With more than 4548 users, the intervention would be cost-effective, and with more than 8315 users, the intervention would be cost saving. A 99\% probability of being cost-effective was detected with a willingness to pay US \$17,409 per QALY. Conclusions: Smart Girlfriend is a cost-effective and possibly cost-saving program over a 4-year time horizon. This result was particularly sensitive to the number of website users; launching the website would be cost-effective if more than 4548 people used it. Further work is warranted to explore if the findings could be expanded to apply to women who have sex with women and in the context of other STIs. Trial Registration: ClinicalTrial.gov NCT03695679; https://clinicaltrials.gov/study/NCT03695679 ", doi="10.2196/45054", url="https://www.jmir.org/2023/1/e45054", url="http://www.ncbi.nlm.nih.gov/pubmed/37561571" } @Article{info:doi/10.2196/35857, author="Bettencourt, Nicholas and Wilson, John Conor and Johnson, Jaye Philippa and D'Souza, Fabian", title="A Rebalancing of Financial Valuations and Expectations Moving Forward in the Telehealth Sector as the United States Moves Toward a Post-COVID-19 Reality", journal="J Med Internet Res", year="2023", month="Jul", day="31", volume="25", pages="e35857", keywords="telehealth", keywords="telemedicine", keywords="remote consultation", keywords="eHealth", keywords="internet", keywords="mHealth", keywords="mobile health", keywords="digital health", keywords="delivery of health care", keywords="telecommunication", keywords="web-based care", keywords="web-based medicine", keywords="customer", keywords="economy", keywords="economics", doi="10.2196/35857", url="https://www.jmir.org/2023/1/e35857", url="http://www.ncbi.nlm.nih.gov/pubmed/37523216" } @Article{info:doi/10.2196/47255, author="Boone, Robert Eli and Tai, Heiley and Raich, Ali and Vatsavai, Amulya and Qin, Annie and Thompson, Kayla and Johri, Mohini and Hu, Ruitian and Golla, Vishnukamal and Harris-Gersten, Melissa", title="Financial Health of People Living With Dementia and Their Informal Care Partners: Protocol for a Mixed Methods Study", journal="JMIR Res Protoc", year="2023", month="Jul", day="11", volume="12", pages="e47255", keywords="avoiding care due to cost", keywords="care rationing", keywords="cost", keywords="delayed care due to cost", keywords="dementia", keywords="economic strain", keywords="financial burden", keywords="financial distress", keywords="financial hardship", keywords="financial strain", keywords="financial stress", keywords="financial toxicity", keywords="MCI", keywords="mild cognitive impairment", keywords="out-of-pocket costs", keywords="out-of-pocket spending", abstract="Background: There is a growing body of academic literature focusing on the significant financial burdens placed on people living with cancer, but little evidence exists on the impact of rising costs of care in other vulnerable populations. This financial strain, also known as financial toxicity, can impact behavioral, psychosocial, and material domains of life for people diagnosed with chronic conditions and their care partners. New evidence suggests that populations experiencing health disparities, including those with dementia, face limited access to health care, employment discrimination, income inequality, higher burdens of disease, and exacerbating financial toxicity. Objective: The three study aims are to (1) adapt a survey to capture financial toxicity in people living with dementia and their care partners; (2) characterize the degree and magnitude of different components of financial toxicity in this population; and (3) empower the voice of this population through imagery and critical reflection on their perceptions and experiences relating to financial toxicity. Methods: This study uses a mixed methods approach to comprehensively characterize financial toxicity among people living with dementia and their care partners. To address aim 1, we will adapt elements from previously validated and reliable instruments, including the Comprehensive Score for Financial Toxicity and Patient-Reported Outcomes Measurement Information System, to develop a financial toxicity survey specific to dyads of people living with dementia and their care partners. A total of 100 dyads will complete the survey, and data will be analyzed using descriptive statistics and regression models to address aim 2. Aim 3 will be addressed using the process of ``photovoice,'' which is a qualitative, participatory research method that combines photography, verbal narratives, and critical reflection by groups of individuals to capture aspects of their environment and experiences with a certain topic. Quantitative results and qualitative findings will be integrated using a validated, joint display table mixed methods approach called the pillar integration process. Results: This study is ongoing, with quantitative findings and qualitative results anticipated by December 2023. Integrated findings will enhance the understanding of financial toxicity in individuals living with dementia and their care partners by providing a comprehensive baseline assessment. Conclusions: As one of the first studies on financial toxicity related to dementia care, findings from our mixed methods approach will support the development of new strategies for improving the costs of care. While this work focuses on those living with dementia, this protocol could be replicated for people living with other diseases and serve as a blueprint for future research efforts in this space. International Registered Report Identifier (IRRID): DERR1-10.2196/47255 ", doi="10.2196/47255", url="https://www.researchprotocols.org/2023/1/e47255", url="http://www.ncbi.nlm.nih.gov/pubmed/37432718" } @Article{info:doi/10.2196/41738, author="Portela, Diana and Nogueira-Leite, Diogo and Almeida, Rafael and Cruz-Correia, Ricardo", title="Economic Impact of a Hospital Cyberattack in a National Health System: Descriptive Case Study", journal="JMIR Form Res", year="2023", month="Jun", day="30", volume="7", pages="e41738", keywords="cybersecurity", keywords="medical informatics", keywords="economic impact", keywords="economic", keywords="cost", keywords="security", keywords="privacy", keywords="cyberattack", keywords="data breach", keywords="health system", abstract="Background: Over the last decade, the frequency and size of cyberattacks in the health care industry have increased, ranging from breaches of processes or networks to encryption of files that restrict access to data. These attacks may have multiple consequences for patient safety, as they can, for example, target electronic health records, access to critical information, and support for critical systems, thereby causing delays in hospital activities. The effects of cybersecurity breaches are not only a threat to patients' lives but also have financial consequences due to causing inactivity in health care systems. However, publicly available information on these incidents quantifying their impact is scarce. Objective: We aim, while using public domain data from Portugal, to (1) identify data breaches in the public national health system since 2017 and (2) measure the economic impact using a hypothesized scenario as a case study. Methods: We retrieved data from multiple national and local media sources on cybersecurity from 2017 until 2022 and built a timeline of attacks. In the absence of public information on cyberattacks, reported drops in activity were estimated using a hypothesized scenario for affected resources and percentages and duration of inactivity. Only direct costs were considered for estimates. Data for estimates were produced based on planned activity through the hospital contract program. We use sensitivity analysis to illustrate how a midlevel ransomware attack might impact health institutions' daily costs (inferring a potential range of values based on assumptions). Given the heterogeneity of our included parameters, we also provide a tool for users to distinguish such impacts of different attacks on institutions according to different contract programs, served population size, and proportion of inactivity. Results: From 2017 to 2022, we were able to identify 6 incidents in Portuguese public hospitals using public domain data (there was 1 incident each year and 2 in 2018). Financial impacts were obtained from a cost point of view, where estimated values have a minimum-to-maximum range of {\texteuro}115,882.96 to {\texteuro}2,317,659.11 (a currency exchange rate of {\texteuro}1=US \$1.0233 is applicable). Costs of this range and magnitude were inferred assuming different percentages of affected resources and with different numbers of working days while considering the costs of external consultation, hospitalization, and use of in- and outpatient clinics and emergency rooms, for a maximum of 5 working days. Conclusions: To enhance cybersecurity capabilities at hospitals, it is important to provide robust information to support decision-making. Our study provides valuable information and preliminary insights that can help health care organizations better understand the costs and risks associated with cyber threats and improve their cybersecurity strategies. Additionally, it demonstrates the importance of adopting effective preventive and reactive strategies, such as contingency plans, as well as enhanced investment in improving cybersecurity capabilities in this critical area while aiming to achieve cyber-resilience. ", doi="10.2196/41738", url="https://formative.jmir.org/2023/1/e41738", url="http://www.ncbi.nlm.nih.gov/pubmed/37389934" } @Article{info:doi/10.2196/44585, author="Lewkowicz, Daniel and Bottinger, Erwin and Siegel, Martin", title="Economic Evaluation of Digital Therapeutic Care Apps for Unsupervised Treatment of Low Back Pain: Monte Carlo Simulation", journal="JMIR Mhealth Uhealth", year="2023", month="Jun", day="29", volume="11", pages="e44585", keywords="cost-utility analysis", keywords="cost", keywords="probabilistic sensitivity analysis", keywords="Monte Carlo simulation", keywords="low back pain", keywords="pain", keywords="economic", keywords="cost-effectiveness", keywords="Markov model", keywords="digital therapy", keywords="digital health app", keywords="mHealth, mobile health", keywords="health app", keywords="mobile app", keywords="orthopedic", keywords="QUALY", keywords="DALY", keywords="quality-adjusted life years", keywords="disability-adjusted life years", keywords="time horizon", keywords="veteran", keywords="statistics", abstract="Background: Digital therapeutic care (DTC) programs are unsupervised app-based treatments that provide video exercises and educational material to patients with nonspecific low back pain during episodes of pain and functional disability. German statutory health insurance can reimburse DTC programs since 2019, but evidence on efficacy and reasonable pricing remains scarce. This paper presents a probabilistic sensitivity analysis (PSA) to evaluate the efficacy and cost-utility of a DTC app against treatment as usual (TAU) in Germany. Objective: The aim of this study was to perform a PSA in the form of a Monte Carlo simulation based on the deterministic base case analysis to account for model assumptions and parameter uncertainty. We also intend to explore to what extent the results in this probabilistic analysis differ from the results in the base case analysis and to what extent a shortage of outcome data concerning quality-of-life (QoL) metrics impacts the overall results. Methods: The PSA builds upon a state-transition Markov chain with a 4-week cycle length over a model time horizon of 3 years from a recently published deterministic cost-utility analysis. A Monte Carlo simulation with 10,000 iterations and a cohort size of 10,000 was employed to evaluate the cost-utility from a societal perspective. Quality-adjusted life years (QALYs) were derived from Veterans RAND 6-Dimension (VR-6D) and Short-Form 6-Dimension (SF-6D) single utility scores. Finally, we also simulated reducing the price for a 3-month app prescription to analyze at which price threshold DTC would result in being the dominant strategy over TAU in Germany. Results: The Monte Carlo simulation yielded on average a {\texteuro}135.97 (a currency exchange rate of EUR {\texteuro}1=US \$1.069 is applicable) incremental cost and 0.004 incremental QALYs per person and year for the unsupervised DTC app strategy compared to in-person physiotherapy in Germany. The corresponding incremental cost-utility ratio (ICUR) amounts to an additional {\texteuro}34,315.19 per additional QALY. DTC yielded more QALYs in 54.96\% of the iterations. DTC dominates TAU in 24.04\% of the iterations for QALYs. Reducing the app price in the simulation from currently {\texteuro}239.96 to {\texteuro}164.61 for a 3-month prescription could yield a negative ICUR and thus make DTC the dominant strategy, even though the estimated probability of DTC being more effective than TAU is only 54.96\%. Conclusions: Decision-makers should be cautious when considering the reimbursement of DTC apps since no significant treatment effect was found, and the probability of cost-effectiveness remains below 60\% even for an infinite willingness-to-pay threshold. More app-based studies involving the utilization of QoL outcome parameters are urgently needed to account for the low and limited precision of the available QoL input parameters, which are crucial to making profound recommendations concerning the cost-utility of novel apps. ", doi="10.2196/44585", url="https://mhealth.jmir.org/2023/1/e44585", url="http://www.ncbi.nlm.nih.gov/pubmed/37384379" } @Article{info:doi/10.2196/43980, author="Jaulmes, Luc and Yordanov, Youri and Descamps, Alexandre and Durand-Zaleski, Isabelle and Dinh, Aur{\'e}lien and Jourdain, Patrick and Dechartres, Agn{\`e}s", title="Effectiveness and Medicoeconomic Evaluation of Home Monitoring of Patients With Mild COVID-19: Covidom Cohort Study", journal="J Med Internet Res", year="2023", month="Jun", day="23", volume="25", pages="e43980", keywords="COVID-19", keywords="Covidom", keywords="home monitoring", keywords="telehealth", keywords="tele-surveillance", keywords="primary outcome", keywords="remote monitoring", keywords="digital health intervention", keywords="emergency medical service", keywords="patient care", keywords="digital care", keywords="mobile phone", abstract="Background: Covidom was a telemonitoring solution for home monitoring of patients with mild to moderate COVID-19, deployed in March 2020 in the Greater Paris area in France to alleviate the burden on the health care system. The Covidom solution included a free mobile application with daily monitoring questionnaires and a regional control center to quickly handle patient alerts, including dispatching emergency medical services when necessary. Objective: This study aimed to provide an overall evaluation of the Covidom solution 18 months after its inception in terms of effectiveness, safety, and cost. Methods: Our primary outcome was to measure effectiveness using the number of handled alerts, response escalation, and patient-reported medical contacts outside of Covidom. Then, we analyzed the safety of Covidom by assessing its ability to detect clinical worsening, defined as hospitalization or death, and the number of patients with clinical worsening without any preceding alert. We evaluated the cost of Covidom and compared the cost of hospitalization for Covidom and non-Covidom patients with mild COVID-19 cases seen in the emergency departments of the largest network of hospitals in the Greater Paris area (Assistance Publique-H{\^o}pitaux de Paris). Finally, we reported on user satisfaction. Results: Of the 60,073 patients monitored by Covidom, the regional control center handled 285,496 alerts and dispatched emergency medical services 518 times. Of the 13,204 respondents who responded to either of the follow-up questionnaires, 65.8\% (n=8690) reported having sought medical care outside the Covidom solution during their monitoring period. Of the 947 patients who experienced clinical worsening while adhering to daily monitoring, only 35 (3.7\%) did not previously trigger alerts (35 were hospitalized, including 1 who died). The average cost of Covidom was {\texteuro}54 (US \$1={\texteuro}0.8614) per patient, and the cost of hospitalization for COVID-19 worsening was significantly lower in Covidom than in non-Covidom patients with mild COVID-19 cases seen in the emergency departments of Assistance Publique-H{\^o}pitaux de Paris. The patients who responded to the satisfaction questionnaire had a median rating of 9 (out of 10) for the likelihood of recommending Covidom. Conclusions: Covidom may have contributed to alleviating the pressure on the health care system in the initial months of the pandemic, although its impact was lower than anticipated, with a substantial number of patients having consulted outside of Covidom. Covidom seems to be safe for home monitoring of patients with mild to moderate COVID-19. ", doi="10.2196/43980", url="https://www.jmir.org/2023/1/e43980", url="http://www.ncbi.nlm.nih.gov/pubmed/37134021" } @Article{info:doi/10.2196/45611, author="Zaman, Sameer and Padayachee, Yorissa and Shah, Moulesh and Samways, Jack and Auton, Alice and Quaife, M. Nicholas and Sweeney, Mark and Howard, P. James and Tenorio, Indira and Bachtiger, Patrik and Kamalati, Tahereh and Pabari, A. Punam and Linton, F. Nick W. and Mayet, Jamil and Peters, S. Nicholas and Barton, Carys and Cole, D. Graham and Plymen, M. Carla", title="Smartphone-Based Remote Monitoring in Heart Failure With Reduced Ejection Fraction: Retrospective Cohort Study of Secondary Care Use and Costs", journal="JMIR Cardio", year="2023", month="Jun", day="23", volume="7", pages="e45611", keywords="heart failure", keywords="remote monitoring", keywords="smartphone care", keywords="telemonitoring", keywords="self-management", keywords="admission prevention", keywords="cohort study", keywords="hospitalization", keywords="noninvasive", keywords="smartphone", keywords="vital signs", keywords="diagnosis", abstract="Background: Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospitalizations. Treatment optimization and admission avoidance rely on frequent symptom reviews and monitoring of vital signs. Remote monitoring (RM) aims to prevent admissions by facilitating early intervention, but the impact of noninvasive, smartphone-based RM of vital signs on secondary health care use and costs in the months after a new diagnosis of HFrEF is unknown. Objective: The purpose of this study is to conduct a secondary care health use and health-economic evaluation for patients with HFrEF using smartphone-based noninvasive RM and compare it with matched controls receiving usual care without RM. Methods: We conducted a retrospective study of 2 cohorts of newly diagnosed HFrEF patients, matched 1:1 for demographics, socioeconomic status, comorbidities, and HFrEF severity. They are (1) the RM group, with patients using the RM platform for >3 months and (2) the control group, with patients referred before RM was available who received usual heart failure care without RM. Emergency department (ED) attendance, hospital admissions, outpatient use, and the associated costs of this secondary care activity were extracted from the Discover data set for a 3-month period after diagnosis. Platform costs were added for the RM group. Secondary health care use and costs were analyzed using Kaplan-Meier event analysis and Cox proportional hazards modeling. Results: A total of 146 patients (mean age 63 years; 42/146, 29\% female) were included (73 in each group). The groups were well-matched for all baseline characteristics except hypertension (P=.03). RM was associated with a lower hazard of ED attendance (hazard ratio [HR] 0.43; P=.02) and unplanned admissions (HR 0.26; P=.02). There were no differences in elective admissions (HR 1.03, P=.96) or outpatient use (HR 1.40; P=.18) between the 2 groups. These differences were sustained by a univariate model controlling for hypertension. Over a 3-month period, secondary health care costs were approximately 4-fold lower in the RM group than the control group, despite the additional cost of RM itself (mean cost per patient GBP {\textsterling}465, US \$581 vs GBP {\textsterling}1850, US \$2313, respectively; P=.04). Conclusions: This retrospective cohort study shows that smartphone-based RM of vital signs is feasible for HFrEF. This type of RM was associated with an approximately 2-fold reduction in ED attendance and a 4-fold reduction in emergency admissions over just 3 months after a new diagnosis with HFrEF. Costs were significantly lower in the RM group without increasing outpatient demand. This type of RM could be adjunctive to standard care to reduce admissions, enabling other resources to help patients unable to use RM. ", doi="10.2196/45611", url="https://cardio.jmir.org/2023/1/e45611", url="http://www.ncbi.nlm.nih.gov/pubmed/37351921" } @Article{info:doi/10.2196/44006, author="Robin, Florian and Roy, Maxim and Kuftedjian, Alexandre and Perret, Laurelie and Lavoie, Fr{\'e}d{\'e}ric and Castonguay, Alexandre and Pomey, Marie-Pascale and Zaouter, Cedrick and Pare, Guy", title="A Medicoeconomic Evaluation of a Telehealth Platform for Elective Outpatient Surgeries: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2023", month="Apr", day="24", volume="12", pages="e44006", keywords="outpatient surgery", keywords="cost-effectiveness", keywords="telehealth solution", keywords="surgery", keywords="technologies", keywords="quality", keywords="safety", keywords="support", keywords="patient", keywords="cost", keywords="telecare", keywords="telehealth", keywords="platform", keywords="development", abstract="Background: The number of elective outpatient surgeries in Canada has increased markedly in the last 10 years. However, unanticipated cancellations on the day of surgery and adverse postoperative events are frequent. Modern technologies have been shown to be of great help in the medical field in improving patient care. Thus, it is likely that dedicated technologies could also significantly improve surgical outpatients' pathways. Therefore, the department of anesthesiology at the University of Montreal Medical Center, in collaboration with LeoMed, a telemedicine platform, has developed a telehealth solution to offer more efficient perioperative support and follow-up for patients undergoing ambulatory surgery. Objective: The objective is to evaluate the medicoeconomic benefit of a dedicated perioperative telehealth platform for patients undergoing day surgery. Our hypothesis is that this dedicated telecare solution will allow more efficient patient care, which will reduce all types of medical costs related to day surgery pathways. Methods: This study is a single-center, single-blinded, 2-group randomized controlled trial. One thousand patients aged over 18 years with internet access who are scheduled to undergo ambulatory surgery will be enrolled and randomized either to follow a perioperative path that includes a patient-tailored perioperative digital app via the LeoMed telecare platform for 1 month or to follow the standard of care, which does not offer personalized digital support. The primary outcome will be to evaluate the cost-effectiveness of the telecare platform, assessing direct costs from factors such as unanticipated cancellations on the day of surgery due to preoperative instructions not being followed, calls to the local health information line, calls to the provincial health information line, emergency department consultations, unplanned readmissions, or medical visits for problems related to the surgical procedure within the first 30 days after the intervention. The secondary outcome will be to evaluate cost utility using a questionnaire assessing quality-adjusted life years. A blinded independent research team will analyze outcomes. All data will be analyzed according to the intention-to-treat principle. A sample size of 500 subjects in each group was calculated to detect a 21\% reduction in postoperative complications with a power of 90\%. This study has been approved by the ethics board of Centre hospitalier de l'Universit{\'e} de Montr{\'e}al (University of Montreal Health Centre). No employee of LeoMed was involved in the study conception, and none will be involved in either data collection or analysis. Results: Results of this trial will be useful to determine the economic benefit of a telecare platform specifically developed for surgical outpatient pathways. Conclusions: We believe that the deployment of a dedicated perioperative telehealth app will lead to better patient care and fewer postoperative complications, which will lower all types of costs related to surgical outpatient care. Trial Registration: ClinicalTrials.gov NCT04948632; https://ClinicalTrials.gov/ct2/show/NCT04948632 International Registered Report Identifier (IRRID): DERR1-10.2196/44006 ", doi="10.2196/44006", url="https://www.researchprotocols.org/2023/1/e44006", url="http://www.ncbi.nlm.nih.gov/pubmed/37093634" } @Article{info:doi/10.2196/35865, author="Amorim, de F{\'a}bio Jorge Ramalho and Valen{\c{c}}a-Feitosa, Fernanda and Rios, Cardoso Marcos and Santos Souza, Adriano Carlos and Barros, Cunha Izadora Menezes da and Oliveira-Filho, de Alfredo Dias and Lyra-J{\'u}nior, de Divaldo Pereira", title="The Pharmacoeconomic Impact of Pharmaceutical Care in the Hospital: Protocol for an Overview of Systematic Reviews", journal="JMIR Res Protoc", year="2023", month="Apr", day="21", volume="12", pages="e35865", keywords="pharmacoeconomics", keywords="pharmaceutical care", keywords="hospital", keywords="overview", keywords="cost-effectiveness", keywords="cost benefit", keywords="cost-utility", abstract="Background: The clinical activities developed by pharmacists in a hospital environment can improve health outcomes and generate savings for hospitals. However, to determine whether pharmaceutical interventions are cost effective, it is essential to define a method according to which cost-effectiveness is intended to be measured. In addition, the quality of economic assessments and the amount of information present in systematic reviews in the literature make it difficult to analyze the effects of this intervention. Objective: This paper aims to provide an overview of systematic reviews on the pharmacoeconomic impact of the performance of pharmaceutical care in hospitals. Methods: A systematic search of the Cochrane Library databases, PubMed or MEDLINE, LILACS, Scopus, Web of Science, Google Scholar, and Open Thesis will be performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search will involve the use of keywords determined using the Medical Subject Headings database to define the search terms and include the following terms: ``pharmacoeconomics,'' ``pharmaceutical care,'' and ``hospital.'' The study designs to be included will be systematic reviews of good quality. Studies will be included that address pharmacoeconomics; studies that evaluated pharmaceutical care in hospitals; and studies published in Portuguese, English, or Spanish. The primary outcome sought in the systematic reviews will be the cost ratio in monetary units and the outcomes in monetary or natural units. The secondary economic outcomes considered will be determined based on factors associated with the drugs and translated into benefit, efficacy, or utility. Results: It is intended to start this overview in January 2023. Thus far, only previous searches have been carried out to contextualize the theme and build the protocol. Conclusions: This overview will determine the pharmacoeconomic impact of pharmaceutical care interventions in the hospital environment. In addition, this study will point out which clinical outcomes in natural units are impacted by the performance of pharmaceutical care and the strengths and limitations of each approach. It will also identify gaps in the literature and areas for future work. Trial Registration: PROSPERO CRD42019140665; https://tinyurl.com/bddwnz43 ", doi="10.2196/35865", url="https://www.researchprotocols.org/2023/1/e35865", url="http://www.ncbi.nlm.nih.gov/pubmed/37083592" } @Article{info:doi/10.2196/40460, author="Zhang, Yichi and Leuk, Siew-Pin Jessie and Teo, Wei-Peng", title="Domains, Feasibility, Effectiveness, Cost, and Acceptability of Telehealth in Aging Care: Scoping Review of Systematic Reviews", journal="JMIR Aging", year="2023", month="Apr", day="18", volume="6", pages="e40460", keywords="telehealth", keywords="telemedicine", keywords="telecare", keywords="telemonitoring", keywords="aging care", keywords="health care access", keywords="scoping review", keywords="digital health", keywords="mobile health", keywords="mHealth", keywords="eHealth", abstract="Background: Aging is becoming a major global challenge. Compared with younger adults, the older population has greater health needs but faces inadequate access to appropriate, affordable, and high-quality health care. Telehealth can remove geographic and time boundaries, as well as enabling socially isolated and physically homebound people to access a wider range of care options. The impacts of different telehealth interventions in terms of their effectiveness, cost, and acceptability in aging care are still unclear. Objective: This scoping review of systematic reviews aimed to provide an overview of the domains of telehealth implemented in aging care; synthesize evidence of telehealth's feasibility, effectiveness, cost benefits, and acceptability in the context of aging care; identify gaps in the literature; and determine the priorities for future research. Methods: Guided by the methodological framework of the Joanna Briggs Institute, we reviewed systematic reviews concerning all types of telehealth interventions involving direct communication between older users and health care providers. In total, 5 major electronic databases, PubMed, Embase (Ovid), Cochrane Library, CINAHL, and PsycINFO (EBSCO), were searched on September 16, 2021, and an updated search was performed on April 28, 2022, across the same databases as well as the first 10 pages of the Google search. Results: A total of 29 systematic reviews, including 1 post hoc subanalysis of a previously published large Cochrane systematic review with meta-analysis, were included. Telehealth has been adopted in various domains in aging care, such as cardiovascular diseases, mental health, cognitive impairment, prefrailty and frailty, chronic diseases, and oral health, and it seems to be a promising, feasible, effective, cost-effective, and acceptable alternative to usual care in selected domains. However, it should be noted that the generalizability of the results might be limited, and further studies with larger sample sizes, more rigorous designs, adequate reporting, and more consistently defined outcomes and methodologies are needed. The factors affecting telehealth use among older adults have been categorized into individual, interpersonal, technological, system, and policy levels, which could help direct collaborative efforts toward improving the security, accessibility, and affordability of telehealth as well as better prepare the older population for digital inclusion. Conclusions: Although telehealth remains in its infancy and there is a lack of high-quality studies to rigorously prove the feasibility, effectiveness, cost benefit, and acceptability of telehealth, mounting evidence has indicated that it could play a promising complementary role in the care of the aging population. ", doi="10.2196/40460", url="https://aging.jmir.org/2023/1/e40460", url="http://www.ncbi.nlm.nih.gov/pubmed/37071459" } @Article{info:doi/10.2196/39904, author="Park, Minah and Yun, Choa and Joo, Hong Jae and Kang, Hyun Soo and Jeong, Hoon Sung and Nam, Chung-Mo and Park, Eun-Cheol and Han, Yoondae and Jang, In Sung", title="Regional Differences in Medical Costs of Chronic Kidney Disease in the South Korean Population: Marginalized Two-Part Model", journal="JMIR Public Health Surveill", year="2023", month="Mar", day="30", volume="9", pages="e39904", keywords="chronic kidney disease", keywords="cost analysis", keywords="medical expenses", keywords="medically vulnerable regions", keywords="kidney", keywords="public health", keywords="cost", keywords="economic", keywords="chronic disease", keywords="insurance", keywords="regional", keywords="longitudinal model", abstract="Background: There are regional gaps in the access to medical services for patients with chronic kidney disease (CKD), and it is necessary to reduce those gaps, including the gaps involving medical costs. Objective: This study aimed to analyze regional differences in the medical costs associated with CKD in the South Korean population. Methods: This longitudinal cohort study included participants randomly sampled from the National Health Insurance Service-National Sample Cohort of South Korea. To select those who were newly diagnosed with CKD, we excluded those who were diagnosed in 2002-2003 and 2018-2019. A total of 5903 patients with CKD were finally included. We used a marginalized two-part longitudinal model to assess total medical costs. Results: Our cohort included 4775 (59.9\%) men and 3191 (40.1\%) women. Of these, 971 (12.2\%) and 6995 (87.8\%) lived in medically vulnerable and nonvulnerable regions, respectively. The postdiagnosis costs showed a significant difference between the regions (estimate: --0.0152, 95\% confidence limit: --0.0171 to --0.0133). The difference in medical expenses between the vulnerable and nonvulnerable regions showed an increase each year after the diagnosis. Conclusions: Patients with CKD living in medically vulnerable regions are likely to have higher postdiagnostic medical expenses compared to those living in regions that are not medically vulnerable. Efforts to improve early diagnosis of CKD are needed. Relevant policies should be drafted to decrease the medical costs of patients with CKD disease living in medically deprived areas. ", doi="10.2196/39904", url="https://publichealth.jmir.org/2023/1/e39904", url="http://www.ncbi.nlm.nih.gov/pubmed/36995749" } @Article{info:doi/10.2196/44633, author="Koong, Alex and Gardner, Grant Ulysses and Burton, Jason and Stewart, Caleb and Thompson, Petria and Fuller, David Clifton and Ludmir, Bernard Ethan and Rooney, Kevin Michael", title="Factors Associated With Open Access Publishing Costs in Oncology Journals: Cross-sectional Observational Study", journal="JMIR Form Res", year="2023", month="Mar", day="16", volume="7", pages="e44633", keywords="academic publishing", keywords="article processing charge", keywords="open access", keywords="oncology", keywords="open access publishing", keywords="scholarly communication", abstract="Background: Open access (OA) publishing represents an exciting opportunity to facilitate the dissemination of scientific information to global audiences. However, OA publishing is often associated with significant article processing charges (APCs) for authors, which may thus serve as a barrier to publication. Objective: In this observational cohort study, we aimed to characterize the landscape of OA publishing in oncology and, further, identify characteristics of oncology journals that are predictive of APCs. Methods: We identified oncology journals using the SCImago Journal \& Country Rank database. All journals with an OA publication option and APC data openly available were included. We searched journal websites and tabulated journal characteristics, including APC amount (in US dollars), OA model (hybrid vs full), 2-year impact factor (IF), H-index, number of citable documents, modality/treatment specific (if applicable), and continent of origin. All APCs were converted to US-dollar equivalents for final analyses. Selecting variables with significant associations in the univariable analysis, we generated a multiple regression model to identify journal characteristics independently associated with OA APC amount. An audit of a random 10\% sample of the data was independently performed by 2 authors to ensure data accuracy, precision, and reproducibility. Results: Of 367 oncology journals screened, 251 met the final inclusion criteria. The median APC was US \$2957 (IQR 1958-3450). The majority of journals (n=156, 62\%) adopted the hybrid OA publication model and were based in Europe (n=119, 47\%) or North America (n=87, 35\%). The median (IQR) APC for all journals was US \$2957 (1958-3540). Twenty-five (10\%) journals had APCs greater than US \$4000. There were 10 (4\%) journals that offered OA publication with no publication charge. Univariable testing showed that journals with a greater number of citable documents (P<.001), higher 2-year IF (P<.001), higher H-index (P<.001), and those using the hybrid OA model (P<.001), or originating in Europe or North America (P<.001) tended to have higher APCs. In our multivariable model, the number of citable documents ($\beta$=US \$367, SD US \$133; P=.006), 2-year IF (US \$1144, SD US \$177; P<.001), hybrid OA publishing model (US \$991, SD US \$189; P<.001), and North American origin (US \$838, SD US \$186; P<.001) persisted as significant predictors of processing charges. Conclusions: OA publication costs are greater in oncology journals that publish more citable articles, use the hybrid OA model, have a higher IF, and are based in North America or Europe. These findings may inform targeted action to help the oncology community fully appreciate the benefits of open science. ", doi="10.2196/44633", url="https://formative.jmir.org/2023/1/e44633", url="http://www.ncbi.nlm.nih.gov/pubmed/36927553" } @Article{info:doi/10.2196/45064, author="Zaleski, Amanda and Sigler, Brittany and Leggitt, Alan and Choudhary, Shruti and Berns, Ryan and Rhee, Kyu and Schwarzwald, Heidi", title="The Influence of a Wearable-Based Reward Program on Health Care Costs: Retrospective, Propensity Score--Matched Cohort Study", journal="J Med Internet Res", year="2023", month="Mar", day="14", volume="25", pages="e45064", keywords="digital health intervention", keywords="mobile app", keywords="wellness", keywords="physical activity", keywords="wearable", keywords="cost-effectiveness", keywords="mobile health app", keywords="health plan", keywords="medical cost", keywords="health care cost", abstract="Background: Mobile health (mHealth) technology holds great promise as an easily accessible and effective solution to improve population health at scale. Despite the abundance of mHealth offerings, only a minority are grounded in evidence-based practice, whereas even fewer have line of sight into population-level health care spending, limiting the clinical utility of such tools. Objective: This study aimed to explore the influence of a health plan--sponsored, wearable-based, and reward-driven digital health intervention (DHI) on health care spending over 1 year. The DHI was delivered through a smartphone-based mHealth app available only to members of a large commercial health plan and leveraged a combination of behavioral economics, user-generated sensor data from the connected wearable device, and claims history to create personalized, evidence-based recommendations for each user. Methods: This study deployed a propensity score--matched, 2-group, and pre-post observational design. Adults (?18 years of age) enrolled in a large, national commercial health plan and self-enlisted in the DHI for ?7 months were allocated to the intervention group (n=56,816). Members who were eligible for the DHI but did not enlist were propensity score--matched to the comparison group (n=56,816). Average (and relative change from baseline) medical and pharmacy spending per user per month was computed for each member of the intervention and comparison groups during the pre- (ie, 12 months) and postenlistment (ie, 7-12 months) periods using claims data. Results: Baseline characteristics and medical spending were similar between groups (P=.89). On average, the total included sample population (N=113,632) consisted of young to middle-age (mean age 38.81 years), mostly White (n=55,562, 48.90\%), male (n=46,731, 41.12\%) and female (n=66,482, 58.51\%) participants. Compared to a propensity score--matched cohort, DHI users demonstrated approximately US \$10 per user per month lower average medical spending (P=.02) with a concomitant increase in preventive care activities and decrease in nonemergent emergency department admissions. These savings translated to approximately US \$6.8 million in avoidable health care costs over the course of 1 year. Conclusions: This employer-sponsored, digital health engagement program has a high likelihood for return on investment within 1 year owing to clinically meaningful changes in health-seeking behaviors and downstream medical cost savings. Future research should aim to elucidate health behavior--related mechanisms in support of these findings and continue to explore novel strategies to ensure equitable access of DHIs to underserved populations that stand to benefit the most. ", doi="10.2196/45064", url="https://www.jmir.org/2023/1/e45064", url="http://www.ncbi.nlm.nih.gov/pubmed/36917152" } @Article{info:doi/10.2196/41624, author="Lin, Senlin and Ma, Yingyan and Xu, Yi and Lu, Lina and He, Jiangnan and Zhu, Jianfeng and Peng, Yajun and Yu, Tao and Congdon, Nathan and Zou, Haidong", title="Artificial Intelligence in Community-Based Diabetic Retinopathy Telemedicine Screening in Urban China: Cost-effectiveness and Cost-Utility Analyses With Real-world Data", journal="JMIR Public Health Surveill", year="2023", month="Feb", day="23", volume="9", pages="e41624", keywords="artificial intelligence", keywords="cost", keywords="diabetic retinopathy", keywords="utility", keywords="low- and middle-income countries", keywords="screening", abstract="Background: Community-based telemedicine screening for diabetic retinopathy (DR) has been highly recommended worldwide. However, evidence from low- and middle-income countries (LMICs) on the choice between artificial intelligence (AI)--based and manual grading--based telemedicine screening is inadequate for policy making. Objective: The aim of this study was to test whether the AI model is more worthwhile than manual grading in community-based telemedicine screening for DR in the context of labor costs in urban China. Methods: We conducted cost-effectiveness and cost-utility analyses by using decision-analytic Markov models with 30 one-year cycles from a societal perspective to compare the cost, effectiveness, and utility of 2 scenarios in telemedicine screening for DR: manual grading and an AI model. Sensitivity analyses were performed. Real-world data were obtained mainly from the Shanghai Digital Eye Disease Screening Program. The main outcomes were the incremental cost-effectiveness ratio (ICER) and the incremental cost-utility ratio (ICUR). The ICUR thresholds were set as 1 and 3 times the local gross domestic product per capita. Results: The total expected costs for a 65-year-old resident were US \$3182.50 and US \$3265.40, while the total expected years without blindness were 9.80 years and 9.83 years, and the utilities were 6.748 quality-adjusted life years (QALYs) and 6.753 QALYs in the AI model and manual grading, respectively. The ICER for the AI-assisted model was US \$2553.39 per year without blindness, and the ICUR was US \$15,216.96 per QALY, which indicated that AI-assisted model was not cost-effective. The sensitivity analysis suggested that if there is an increase in compliance with referrals after the adoption of AI by 7.5\%, an increase in on-site screening costs in manual grading by 50\%, or a decrease in on-site screening costs in the AI model by 50\%, then the AI model could be the dominant strategy. Conclusions: Our study may provide a reference for policy making in planning community-based telemedicine screening for DR in LMICs. Our findings indicate that unless the referral compliance of patients with suspected DR increases, the adoption of the AI model may not improve the value of telemedicine screening compared to that of manual grading in LMICs. The main reason is that in the context of the low labor costs in LMICs, the direct health care costs saved by replacing manual grading with AI are less, and the screening effectiveness (QALYs and years without blindness) decreases. Our study suggests that the magnitude of the value generated by this technology replacement depends primarily on 2 aspects. The first is the extent of direct health care costs reduced by AI, and the second is the change in health care service utilization caused by AI. Therefore, our research can also provide analytical ideas for other health care sectors in their decision to use AI. ", doi="10.2196/41624", url="https://publichealth.jmir.org/2023/1/e41624", url="http://www.ncbi.nlm.nih.gov/pubmed/36821353" } @Article{info:doi/10.2196/42396, author="Kyaw, Lin Tun and Ng, Nawi and Theocharaki, Margarita and Wennberg, Patrik and Sahlen, Klas-G{\"o}ran", title="Cost-effectiveness of Digital Tools for Behavior Change Interventions Among People With Chronic Diseases: Systematic Review", journal="Interact J Med Res", year="2023", month="Feb", day="16", volume="12", pages="e42396", keywords="digital tools", keywords="chronic diseases", keywords="cost-effectiveness", keywords="lifestyle", keywords="behavior", keywords="systematic review", keywords="mobile phone", abstract="Background: Chronic diseases, including cardiovascular diseases, diabetes, chronic obstructive pulmonary disease, and cerebrovascular diseases, contribute to the most significant disease burden worldwide, negatively impacting patients and their family members. People with chronic diseases have common modifiable behavioral risk factors, including smoking, alcohol overconsumption, and unhealthy diets. Digital-based interventions for promoting and sustaining behavioral changes have flourished in recent years, although evidence of the cost-effectiveness of such interventions remains inconclusive. Objective: In this study, we aimed to investigate the cost-effectiveness of digital health interventions for behavioral changes among people with chronic diseases. Methods: This systematic review evaluated published studies focused on the economic evaluation of digital tools for behavioral change among adults with chronic diseases. We followed the Population, Intervention, Comparator, and Outcomes framework to retrieve relevant publications from 4 databases: PubMed, CINAHL, Scopus, and Web of Science. We used the Joanna Briggs Institute's criteria for economic evaluation and randomized controlled trials to assess the risk of bias in the studies. Two researchers independently screened, assessed the quality, and extracted data from the studies selected for the review. Results: In total, 20 studies published between 2003 and 2021 fulfilled our inclusion criteria. All the studies were conducted in high-income countries. These studies used telephones, SMS text messaging, mobile health apps, and websites as digital tools for behavior change communication. Most digital tools for interventions focused on diet and nutrition (17/20, 85\%) and physical activity (16/20, 80\%), and a few focused on smoking and tobacco control (8/20, 40\%), alcohol reduction (6/20, 30\%), and reduction of salt intake (3/20, 15\%). Most studies (17/20, 85\%) used the health care payer perspective for economic analysis, and only 15\% (3/20) used the societal perspective. Only 45\% (9/20) of studies conducted a full economic evaluation. Most studies (7/20, 35\%) based on full economic evaluation and 30\% (6/20) of studies based on partial economic evaluation found digital health interventions to be cost-effective and cost-saving. Most studies had short follow-ups and failed to include proper indicators for economic evaluation, such as quality-adjusted life-years, disability-adjusted life-years, lack of discounting, and sensitivity analysis. Conclusions: Digital health interventions for behavioral change among people with chronic diseases are cost-effective in high-income settings and can therefore be scaled up. Similar evidence from low- and middle-income countries based on properly designed studies for cost-effectiveness evaluation is urgently required. A full economic evaluation is needed to provide robust evidence for the cost-effectiveness of digital health interventions and their potential for scaling up in a wider population. Future studies should follow the National Institute for Health and Clinical Excellence recommendations to take a societal perspective, apply discounting, address parameter uncertainty, and apply a lifelong time horizon. ", doi="10.2196/42396", url="https://www.i-jmr.org/2023/1/e42396", url="http://www.ncbi.nlm.nih.gov/pubmed/36795470" } @Article{info:doi/10.2196/44308, author="Bhana, Sindeep and Naidoo, Poobalan and Pillay, Somasundram and Variava, Ebrahim and Naidoo, Kiolan and Rohitlall, Neeresh and Sekhuthe, Lauren and Pauly, Bruno", title="Health Care Resource Utilization in Adults Living With Type 1 Diabetes Mellitus in the South African Public Health Sector: Protocol for a 1-Year Retrospective Analysis With a 5-, 10-, and 25-Year Projection", journal="JMIR Res Protoc", year="2023", month="Feb", day="13", volume="12", pages="e44308", keywords="type 1 diabetes mellitus", keywords="South African public health care system", keywords="health care resource utilization", keywords="pharmacoeconomics", keywords="diabetes", keywords="adults", keywords="insulin", keywords="essential", keywords="policy makers", abstract="Background: Type 1 diabetes mellitus (T1DM) is less common than type 2 diabetes mellitus but is increasing in frequency in South Africa. It tends to affect younger individuals, and upon diagnosis, exogenous insulin is essential for survival. In South Africa, the health care system is divided into private and public health care systems. The private system is well resourced, whereas the public sector, which treats more than 80\% of the population, has minimal resources. There are currently no studies in South Africa, and Africa at large, that have evaluated the immediate and long-term costs of managing people living with T1DM in the public sector. Objective: The primary objective was to quantify the cost of health care resource utilization over a 12-month period in patients with controlled and uncontrolled T1DM in the public health care sector. In addition, we will project costs for 5, 10, and 25 years and determine if there are cost differences in managing subsets of patients who achieve glycemic control (hemoglobin A1c [HbA1c] <7\%) and those who do not. Methods: The study was performed in accordance with Good Epidemiological Practice. Ethical clearance and institutional permissions were acquired. Clinical data were collected from 2 tertiary hospitals in South Africa. Patients with T1DM, who provided written informed consent, and who satisfied the inclusion criteria were enrolled in the study. Data collection included demographic and clinical characteristics, acute and chronic complications, hospital admissions, and so on. We plan to perform a cost-effectiveness analysis to quantify the costs of health care utilization in the preceding 12 months. In addition, we will estimate projected costs over the next 10 years, assuming that study participants maintain their current HbA1c level. The cost-effectiveness analysis will be modeled using the IQVIA CORE Diabetes Model. The primary outcome measures are incremental quality-adjusted life years, incremental costs, incremental cost-effectiveness ratios, and incremental life years. Results: Ethical clearance and institutional approval were obtained (reference number 200407). Enrollment began on February 9, 2021, and was completed on August 24, 2021, with 224 participants. A database lock was performed on October 29, 2021. The statistical analysis and clinical study report were completed in January 2022. Conclusions: At present, there are no data assessing the short- and long-term costs of managing patients with T1DM in the South African public sector. It is hoped that the findings of this study will help policy makers optimally use limited resources to reduce morbidity and mortality in people living with T1DM. International Registered Report Identifier (IRRID): RR1-10.2196/44308 ", doi="10.2196/44308", url="https://www.researchprotocols.org/2023/1/e44308", url="http://www.ncbi.nlm.nih.gov/pubmed/36780227" } @Article{info:doi/10.2196/37596, author="Hu, Yung-Shin Tiffany and Ali, Iman and Heisler, Michele and Levy, Helen and Fagerlin, Angela and Kullgren, T. Jeffrey", title="Helping Patients With Chronic Conditions Overcome Challenges of High-Deductible Health Plans: Mixed Methods Study", journal="JMIR Form Res", year="2023", month="Jan", day="31", volume="7", pages="e37596", keywords="high-deductible health plan", keywords="HDHP", keywords="chronic conditions", keywords="cost-conscious strategies", keywords="consumer behaviors", keywords="health care costs", keywords="out-of-pocket spending", keywords="OOP", keywords="behavioral intervention", keywords="mobile phone", abstract="Background: A growing number of Americans are enrolled in high-deductible health plans (HDHPs). Enrollees in HDHPs, particularly those with chronic conditions, face high out-of-pocket costs and often delay or forgo needed care owing to cost. These challenges could be mitigated by the use of cost-conscious strategies when seeking health care, such as discussing costs with providers, saving for medical expenses, and using web-based tools to compare prices, but few HDHP enrollees engage in such cost-conscious strategies. A novel behavioral intervention could enable HDHP enrollees with chronic conditions to adopt these strategies, but it is unknown which intervention features would be most valued and used by this patient population. Objective: This study aimed to assess preferences among HDHP enrollees with chronic conditions for a novel behavioral intervention that supports the use of cost-conscious strategies when planning for and seeking health care. Methods: In an exploratory sequential mixed methods study among HDHP enrollees with chronic conditions, we conducted 20 semistructured telephone interviews and then surveyed 432 participants using a national internet survey panel. Participants were adult HDHP enrollees with diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, or asthma. The interviews and survey assessed participants' health care experiences when using HDHPs and their preferences for the content, modality, and frequency of use of a novel intervention that would support their use of cost-conscious strategies when seeking health care. Results: Approximately half (11/20, 55\%) of the interview participants reported barriers to using cost-conscious strategies. These included not knowing where to find information and worrying that the use of cost-conscious strategies would be very time consuming. Most (18/20, 90\%) interviewees who had discussed costs with providers, saved for medical expenses, or used web-based price comparison tools found these strategies to be helpful for managing their health care costs. Most (17/20, 85\%) interviewees expressed interest in an intervention delivered through a website or phone app that would help them compare prices for services at different locations. Survey participants were most interested in learning to compare prices and quality, followed by discussing costs with their providers and putting aside money for care, through a website-based or email-based intervention that they would use a few times a year. Conclusions: Regular use of cost-conscious strategies could mitigate financial barriers faced by HDHP enrollees with chronic conditions. Interventions to encourage the use of cost-conscious strategies should be delivered through a web-based modality and focus on helping these patients in navigating their HDHPs to better manage their out-of-pocket spending. ", doi="10.2196/37596", url="https://formative.jmir.org/2023/1/e37596", url="http://www.ncbi.nlm.nih.gov/pubmed/36719718" } @Article{info:doi/10.2196/37190, author="Varriale, Pasquale and M{\"u}ller, Borna and Katz, Gr{\'e}gory and Dallas, Lorraine and Aguaron, Alfonso and Azoulai, Marion and Girard, Nicolas", title="Patient Perspectives on Value Dimensions of Lung Cancer Care: Cross-sectional Web-Based Survey", journal="JMIR Form Res", year="2023", month="Jan", day="26", volume="7", pages="e37190", keywords="lung", keywords="cancer", keywords="health quality of life", keywords="patient reported outcome", keywords="PROM", keywords="economic burden", keywords="cost", keywords="economic", keywords="burden", keywords="perspective", keywords="survey", keywords="QoL", keywords="quality of life", keywords="questionnaire", keywords="caregiver", keywords="caregiving", keywords="physical well-being", keywords="end of life", keywords="palliative", keywords="physical function", keywords="independence", keywords="distress", abstract="Background: While the lung cancer (LC) treatment landscape has rapidly evolved in recent years, easing symptom burden and treatment side effects remain central considerations in disease control. Objective: The aim of this study was to assess the relative importance of dimensions of LC care to patients, and to explore the disease burden, including socioeconomic aspects not commonly covered in patient-reported outcomes instruments. Methods: A questionnaire was sent to patients with LC and their caregivers to rate the value of a diverse set of quality of life dimensions in care, to evaluate communication between health care professionals (HCPs) and patients, and to explore the economic impact on respondents. The survey included questions on the dimensions of care covered by patient-reported outcomes instruments for quality-of-life evaluation (Functional Assessment of Cancer Therapy--Lung scale, EQ-5D, the European Organization for Research and Treatment of Cancer's Core Quality of Life questionnaire, and the European Organization for Research and Treatment of Cancer's Core Quality of Life in lung cancer 13-item questionnaire), as well as the International Consortium for Health Outcomes Measurement (ICHOM) standard set of patient-centered outcomes for LC. The survey respondents were participants on Carenity's patient community platform, living either in France, the United Kingdom, Germany, Italy, or Spain. Results: The survey included 150 respondents (115 patients and 35 caregivers). ``Physical well-being'' and ``end-of-life care'' (median scores of 9.6, IQR 7.7-10, and 9.7, IQR 8.0-10, on a 10-point scale) were rated highest among the different value dimensions assessed. ``Physical well-being and functioning'' was the dimension most frequently discussed with health care professionals (82/150, 55\%), while only (17/100, 17\%) reported discussing ``end-of-life care.'' After diagnosis, 43\% (49/112) of patients younger than 65 years stopped working. Among respondents who indicated their monthly household income before and after diagnosis, 55\% (38/69) reported a loss of income. Conclusions: Our results showed the relevance of a broad range of aspects of care for the quality of life of patients with LC. End-of-life care was the dimension of care rated highest by patients with LC, irrespective of stage at diagnosis; however, this aspect is least frequently discussed with HCPs. The results also highlight the considerable socioeconomic impact of the disease, despite insurance coverage of direct costs. ", doi="10.2196/37190", url="https://formative.jmir.org/2023/1/e37190", url="http://www.ncbi.nlm.nih.gov/pubmed/36416499" } @Article{info:doi/10.2196/44121, author="Walter, J. Robert and Schwab, D. Stephen and Wilkes, Matt and Yourk, Daniel and Zahradka, Nicole and Pugmire, Juliana and Wolfberg, Adam and Merritt, Amanda and Boster, Joshua and Loudermilk, Kevin and Hipp, J. Sean and Morris, J. Michael", title="Financial and Clinical Impact of Virtual Care During the COVID-19 Pandemic: Difference-in-Differences Analysis", journal="J Med Internet Res", year="2023", month="Jan", day="25", volume="25", pages="e44121", keywords="remote patient monitoring", keywords="digital health", keywords="telemedicine", keywords="telehealth", keywords="finance", keywords="financial", keywords="cost", keywords="economic", keywords="remote care", keywords="readmission", keywords="cost savings", keywords="virtual care", keywords="patient care", keywords="digital health intervention", keywords="military health system", keywords="clinical outcome", keywords="military", keywords="soldier", keywords="difference-in-differences", abstract="Background: Virtual care (VC) and remote patient monitoring programs were deployed widely during the COVID-19 pandemic. Deployments were heterogeneous and evolved as the pandemic progressed, complicating subsequent attempts to quantify their impact. The unique arrangement of the US Military Health System (MHS) enabled direct comparison between facilities that did and did not implement a standardized VC program. The VC program enrolled patients symptomatic for COVID-19 or at risk for severe disease. Patients' vital signs were continuously monitored at home with a wearable device (Current Health). A central team monitored vital signs and conducted daily or twice-daily reviews (the nurse-to-patient ratio was 1:30). Objective: Our goal was to describe the operational model of a VC program for COVID-19, evaluate its financial impact, and detail its clinical outcomes. Methods: This was a retrospective difference-in-differences (DiD) evaluation that compared 8 military treatment facilities (MTFs) with and 39 MTFs without a VC program. Tricare Prime beneficiaries diagnosed with COVID-19 (Medicare Severity Diagnosis Related Group 177 or International Classification of Diseases--10 codes U07.1/07.2) who were eligible for care within the MHS and aged 21 years and or older between December 2020 and December 2021 were included. Primary outcomes were length of stay and associated cost savings; secondary outcomes were escalation to physical care from home, 30-day readmissions after VC discharge, adherence to the wearable, and alarms per patient-day. Results: A total of 1838 patients with COVID-19 were admitted to an MTF with a VC program of 3988 admitted to the MHS. Of these patients, 237 (13\%) were enrolled in the VC program. The DiD analysis indicated that centers with the program had a 12\% lower length of stay averaged across all COVID-19 patients, saving US \$2047 per patient. The total cost of equipping, establishing, and staffing the VC program was estimated at US \$3816 per day. Total net savings were estimated at US \$2.3 million in the first year of the program across the MHS. The wearables were activated by 231 patients (97.5\%) and were monitored through the Current Health platform for a total of 3474 (median 7.9, range 3.2-16.5) days. Wearable adherence was 85\% (IQR 63\%-94\%). Patients triggered a median of 1.6 (IQR 0.7-5.2) vital sign alarms per patient per day; 203 (85.7\%) were monitored at home and then directly discharged from VC; 27 (11.4\%) were escalated to a physical hospital bed as part of their initial admission. There were no increases in 30-day readmissions or emergency department visits. Conclusions: Monitored patients were adherent to the wearable device and triggered a manageable number of alarms/day for the monitoring--team-to-patient ratio. Despite only enrolling 13\% of COVID-19 patients at centers where it was available, the program offered substantial savings averaged across all patients in those centers without adversely affecting clinical outcomes. ", doi="10.2196/44121", url="https://www.jmir.org/2023/1/e44121", url="http://www.ncbi.nlm.nih.gov/pubmed/36630301" } @Article{info:doi/10.2196/38204, author="Rohrbach, J. Pieter and Dingemans, E. Alexandra and Evers, Catharine and Van Furth, F. Eric and Spinhoven, Philip and Aardoom, J. Jiska and L{\"a}hde, Irene and Clemens, C. Fleur and Van den Akker-Van Marle, Elske M.", title="Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials", journal="J Med Internet Res", year="2023", month="Jan", day="5", volume="25", pages="e38204", keywords="economic evaluation", keywords="cost-benefit analysis", keywords="methods of economic evaluation", keywords="meta-analysis", keywords="eHealth", keywords="internet-based interventions", keywords="mental disorders", keywords="mental health", keywords="systematic review", keywords="randomized controlled trial", keywords="mobile phone", abstract="Background: The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed. Objective: The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care. Methods: A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled. Results: The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95\% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95\% CI ?0.080 to 0.84; P=.96). The pooled incremental net benefit was US \$255 (95\% CI US \$91 to US \$419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results. Conclusions: The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis. Trial Registration: PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34 ", doi="10.2196/38204", url="https://www.jmir.org/2023/1/e38204", url="http://www.ncbi.nlm.nih.gov/pubmed/36602854" } @Article{info:doi/10.2196/37239, author="Bhavnani, K. Suresh and Zhang, Weibin and Visweswaran, Shyam and Raji, Mukaila and Kuo, Yong-Fang", title="A Framework for Modeling and Interpreting Patient Subgroups Applied to Hospital Readmission: Visual Analytical Approach", journal="JMIR Med Inform", year="2022", month="Dec", day="7", volume="10", number="12", pages="e37239", keywords="visual analytics", keywords="Bipartite Network analysis", keywords="hospital readmission", keywords="precision medicine", keywords="modeling", keywords="Medicare", abstract="Background: A primary goal of precision medicine is to identify patient subgroups and infer their underlying disease processes with the aim of designing targeted interventions. Although several studies have identified patient subgroups, there is a considerable gap between the identification of patient subgroups and their modeling and interpretation for clinical applications. Objective: This study aimed to develop and evaluate a novel analytical framework for modeling and interpreting patient subgroups (MIPS) using a 3-step modeling approach: visual analytical modeling to automatically identify patient subgroups and their co-occurring comorbidities and determine their statistical significance and clinical interpretability; classification modeling to classify patients into subgroups and measure its accuracy; and prediction modeling to predict a patient's risk of an adverse outcome and compare its accuracy with and without patient subgroup information. Methods: The MIPS framework was developed using bipartite networks to identify patient subgroups based on frequently co-occurring high-risk comorbidities, multinomial logistic regression to classify patients into subgroups, and hierarchical logistic regression to predict the risk of an adverse outcome using subgroup membership compared with standard logistic regression without subgroup membership. The MIPS framework was evaluated for 3 hospital readmission conditions: chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and total hip arthroplasty/total knee arthroplasty (THA/TKA) (COPD: n=29,016; CHF: n=51,550; THA/TKA: n=16,498). For each condition, we extracted cases defined as patients readmitted within 30 days of hospital discharge. Controls were defined as patients not readmitted within 90 days of discharge, matched by age, sex, race, and Medicaid eligibility. Results: In each condition, the visual analytical model identified patient subgroups that were statistically significant (Q=0.17, 0.17, 0.31; P<.001, <.001, <.05), significantly replicated (Rand Index=0.92, 0.94, 0.89; P<.001, <.001, <.01), and clinically meaningful to clinicians. In each condition, the classification model had high accuracy in classifying patients into subgroups (mean accuracy=99.6\%, 99.34\%, 99.86\%). In 2 conditions (COPD and THA/TKA), the hierarchical prediction model had a small but statistically significant improvement in discriminating between readmitted and not readmitted patients as measured by net reclassification improvement (0.059, 0.11) but not as measured by the C-statistic or integrated discrimination improvement. Conclusions: Although the visual analytical models identified statistically and clinically significant patient subgroups, the results pinpoint the need to analyze subgroups at different levels of granularity for improving the interpretability of intra- and intercluster associations. The high accuracy of the classification models reflects the strong separation of patient subgroups, despite the size and density of the data sets. Finally, the small improvement in predictive accuracy suggests that comorbidities alone were not strong predictors of hospital readmission, and the need for more sophisticated subgroup modeling methods. Such advances could improve the interpretability and predictive accuracy of patient subgroup models for reducing the risk of hospital readmission, and beyond. ", doi="10.2196/37239", url="https://medinform.jmir.org/2022/12/e37239", url="http://www.ncbi.nlm.nih.gov/pubmed/35537203" } @Article{info:doi/10.2196/42839, author="Muschol, Jennifer and Heinrich, Martin and Heiss, Christian and Hernandez, Mauricio Alher and Knapp, Gero and Repp, Holger and Schneider, Henning and Thormann, Ulrich and Uhlar, Johanna and Unzeitig, Kai and Gissel, Christian", title="Economic and Environmental Impact of Digital Health App Video Consultations in Follow-up Care for Patients in Orthopedic and Trauma Surgery in Germany: Randomized Controlled Trial", journal="J Med Internet Res", year="2022", month="Nov", day="24", volume="24", number="11", pages="e42839", keywords="carbon neutrality", keywords="digital health", keywords="environmental impact", keywords="health economics", keywords="net-zero", keywords="orthopedic", keywords="sustainability", keywords="telemedicine", keywords="trauma surgery", keywords="video consultations", abstract="Background: Following the Riyadh Declaration, digital health technologies were prioritized in many countries to address the challenges of the COVID-19 pandemic. Digital health apps for telemedicine and video consultations help reduce potential disease spread in routine health care, including follow-up care in orthopedic and trauma surgery. In addition to the satisfaction, efficiency, and safety of telemedicine, its economic and environmental effects are highly relevant to decision makers, particularly for the goal of reaching carbon neutrality of health care systems. Objective: This study aims to provide the first comprehensive health economic and environmental analysis of video consultations in follow-up care after knee and shoulder interventions in an orthopedic and trauma surgery department of a German university hospital. The analysis is conducted from a societal perspective. We analyze both economic and environmental impacts of video consultations, taking into account the goal of carbon neutrality for the German health care system by 2030. Methods: We conducted a prospective randomized controlled trial comparing follow-up care with digital health app video consultations (intervention group) to conventional face-to-face consultations in the clinic (control group). Economic impact included the analysis of travel and time costs and production losses. Examination of the environmental impact comprised the emissions of greenhouse gases, carbon monoxide, volatile hydrocarbons, nitrogen oxides, and particulates, and the calculation of environmental costs. Sensitivity analysis included calculations with a higher cost per ton of carbon dioxide equivalent, which gives equal weight to the welfare of present and future generations. Results: Data from 52 patients indicated that, from the patients' point of view, telemedicine helped reduce travel costs, time costs, and production losses, resulting in mean cost savings of {\texteuro}76.52 per video consultation. In addition, emissions of 11.248 kg of greenhouse gases, 0.070 kg of carbon monoxide, 0.011 kg of volatile hydrocarbons, 0.028 kg of nitrogen oxides, and 0.0004 kg of particulates could be saved per patient through avoided travel. This resulted in savings of environmental costs between {\texteuro}3.73 and {\texteuro}9.53 per patient. Conclusions: We presented the first comprehensive analysis of economic and environmental effects of telemedicine in the follow-up care of patients in orthopedic and trauma surgery in Germany. Video consultations were found to reduce the environmental footprint of follow-up care; saved travel costs, travel time, and time costs for patients; and helped to lower production losses. Our findings can support the decision-making on the use of digital health during and beyond the COVID-19 pandemic, providing decision makers with data for both economic and environmental effects. Thanks to the pragmatic design of our study, our findings can be applied to a wide range of clinical contexts and potential digital health applications that substitute outpatient hospital visits with video consultations. Trial Registration: German Clinical Trials Register DRKS00023445; https://tinyurl.com/4pcvhz4n ", doi="10.2196/42839", url="https://www.jmir.org/2022/11/e42839", url="http://www.ncbi.nlm.nih.gov/pubmed/36333935" } @Article{info:doi/10.2196/42555, author="van Cooten, C. Vivette J. and Gielissen, M. Marieke F. and van Mastrigt, G. Ghislaine A. P. and den Hollander, Wouter and Evers, A. Silvia M. A. and Smeets, Odile and Smit, Filip and Boon, Brigitte", title="Smart Continence Care for People With Profound Intellectual and Multiple Disabilities: Protocol for a Cluster Randomized Trial and Trial-Based Economic Evaluation", journal="JMIR Res Protoc", year="2022", month="Nov", day="22", volume="11", number="11", pages="e42555", keywords="care technology", keywords="implementation", keywords="disability care", keywords="profound intellectual and multiple disabilities", keywords="economic evaluation", keywords="continence care", keywords="smart diaper", abstract="Background: People with profound intellectual and multiple disabilities (PIMD) cannot communicate the need to change their incontinence products. The smart continence care (SCC) product Abena Nova signals caregivers when change is needed. This provides the opportunity for more person-centered care, increased quality of life, and a decreased number of leakages. However, there is a need for evidence of the effectiveness and cost-effectiveness of such technology compared with regular continence care (RCC) for people with PIMD. Objective: This paper presents the research protocol for an effectiveness and cost-effectiveness study with people with PIMD living in long-term care facilities in the Netherlands. Methods: A cluster randomized trial will be conducted in 3 consecutive waves across 6 long-term care providers for people with disabilities and 160 participants with PIMD. Long-term care providers are randomized at a 1:1 ratio, resulting in an intervention group and a group continuing RCC. The intervention group will receive implementation guidance and use SCC for 3 months; the other group will continue their RCC as usual and then switch to SCC. This study consists of three components: effectiveness study, economic evaluation, and process evaluation. The primary outcome will be a change in the number of leakages. The secondary outcomes are quality of life, the difference in the number of changes, the work perception of caregivers, cost-effectiveness, and cost utility. Data collection will occur at T0 (baseline), T1 (6 weeks), T2 (12 weeks), and T3 (9-month follow-up) for the first 2 intervention groups. An intention-to-treat analysis will be performed. The economic evaluation will be conducted alongside the trial from the societal and long-term care provider perspectives. Qualitative data collection through interviews and field notes will complement these quantitative results and provide input for the process evaluation. Results: This research was funded in December 2019 by ZonMw, the Netherlands Organization for Health Research and Development. As of June 2022, we enrolled 118 of the 160 participants. The enrollment of participants will continue in the third and fourth quarters of 2022. Conclusions: This study will provide insights into the effectiveness and cost-effectiveness of SCC for people with PIMD, allowing long-term care providers to make informed decisions about implementing such a technology. This is the first time that such a large-scale study is being conducted for people with PIMD. Trial Registration: ClinicalTrials.gov NCT05481840; https://clinicaltrials.gov/ct2/show/NCT05481840 International Registered Report Identifier (IRRID): DERR1-10.2196/42555 ", doi="10.2196/42555", url="https://www.researchprotocols.org/2022/11/e42555", url="http://www.ncbi.nlm.nih.gov/pubmed/36413389" } @Article{info:doi/10.2196/39248, author="Altunkaya, James and Craven, Michael and Lambe, Sin{\'e}ad and Beckley, Ariane and Rosebrock, Laina and Dudley, Robert and Chapman, Kate and Morrison, Anthony and O'Regan, Eileen and Grabey, Jenna and Bergin, Aislinn and Kabir, Thomas and Waite, Felicity and Freeman, Daniel and Leal, Jos{\'e}", title="Estimating the Economic Value of Automated Virtual Reality Cognitive Therapy for Treating Agoraphobic Avoidance in Patients With Psychosis: Findings From the gameChange Randomized Controlled Clinical Trial", journal="J Med Internet Res", year="2022", month="Nov", day="18", volume="24", number="11", pages="e39248", keywords="gameChange", keywords="virtual reality", keywords="National Health Service", keywords="NHS", keywords="cost-effectiveness", keywords="economic evaluation", keywords="maximum price", abstract="Background: An automated virtual reality cognitive therapy (gameChange) has demonstrated its effectiveness to treat agoraphobia in patients with psychosis, especially for high or severe anxious avoidance. Its economic value to the health care system is not yet established. Objective: In this study, we aimed to estimate the potential economic value of gameChange for the UK National Health Service (NHS) and establish the maximum cost-effective price per patient. Methods: Using data from a randomized controlled trial with 346 patients with psychosis (ISRCTN17308399), we estimated differences in health-related quality of life, health and social care costs, and wider societal costs for patients receiving virtual reality therapy in addition to treatment as usual compared with treatment as usual alone. The maximum cost-effective prices of gameChange were calculated based on UK cost-effectiveness thresholds. The sensitivity of the results to analytical assumptions was tested. Results: Patients allocated to gameChange reported higher quality-adjusted life years (0.008 QALYs, 95\% CI --0.010 to 0.026) and lower NHS and social care costs (--{\textsterling}105, 95\% CI --{\textsterling}1135 to {\textsterling}924) compared with treatment as usual ({\textsterling}1=US \$1.28); however, these differences were not statistically significant. gameChange was estimated to be worth up to {\textsterling}341 per patient from an NHS and social care (NHS and personal social services) perspective or {\textsterling}1967 per patient from a wider societal perspective. In patients with high or severe anxious avoidance, maximum cost-effective prices rose to {\textsterling}877 and {\textsterling}3073 per patient from an NHS and personal social services perspective and societal perspective, respectively. Conclusions: gameChange is a promising, cost-effective intervention for the UK NHS and is particularly valuable for patients with high or severe anxious avoidance. This presents an opportunity to expand cost-effective psychological treatment coverage for a population with significant health needs. Trial Registration: ISRCTN Registry ISRCTN17308399; https://www.isrctn.com/ISRCTN17308399 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2019-031606 ", doi="10.2196/39248", url="https://www.jmir.org/2022/11/e39248", url="http://www.ncbi.nlm.nih.gov/pubmed/36399379" } @Article{info:doi/10.2196/38855, author="Yun, Ke and Yu, Jiaming and Liu, Changyang and Zhang, Xinxin", title="A Cost-effectiveness Analysis of a Mobile Phone--Based Integrated HIV-Prevention Intervention Among Men Who Have Sex With Men in China: Economic Evaluation", journal="J Med Internet Res", year="2022", month="Nov", day="2", volume="24", number="11", pages="e38855", keywords="cost-effectiveness", keywords="digital intervention", keywords="men who have sex with men", keywords="mathematical model", abstract="Background: Mobile phone--based digital interventions have been shown to be a promising strategy for HIV prevention among men who have sex with men (MSM). Objective: This study aimed to evaluate the cost-effectiveness of a mobile phone--based digital intervention for HIV prevention among MSM in China from the perspective of a public health provider. Methods: The cost-effectiveness of the mobile phone--based digital intervention was estimated for a hypothetical cohort of 10,000 HIV-negative MSM who were followed for 1 year. A model was developed with China-specific data to project the clinical impact and cost-effectiveness of two mobile phone--based digital strategies for HIV prevention among MSM. The intervention group received an integrated behavioral intervention that included 1) individualized HIV infection risk assessment, 2) recommendation of centers testing for HIV and other STIs, 3) free online order of condoms and HIV and syphilis self-test kits and 4) educational materials about HIV/AIDS. The control group was only given educational materials about HIV/AIDS. Outcomes of interest were the number of HIV infections among MSM averted by the intervention, intervention costs, cost per HIV infection averted by the mobile phone--based digital intervention, and quality-adjusted life-years (QALYs). Univariate and multivariate sensitivity analyses were also conducted to examine the robustness of the results. Results: It is estimated that the intervention can prevent 48 MSM from becoming infected with HIV and can save 480 QALYs. The cost of preventing 1 case of HIV infection was US \$2599.87, and the cost-utility ratio was less than 0. Sensitivity analysis showed that the cost-effectiveness of the mobile phone--based digital intervention was mainly impacted by the average number of sexual behaviors with each sexual partner. Additionally, the higher the HIV prevalence among MSM, the greater the benefit of the intervention. Conclusions: Mobile phone--based digital interventions are a cost-effective HIV-prevention strategy for MSM and could be considered for promotion and application among high-risk MSM subgroups. ", doi="10.2196/38855", url="https://www.jmir.org/2022/11/e38855", url="http://www.ncbi.nlm.nih.gov/pubmed/36322123" } @Article{info:doi/10.2196/37745, author="Powers, Brenton and Bucher, Amy", title="An Economic Impact Model for Estimating the Value to Health Systems of a Digital Intervention for Diabetes Primary Care: Development and Usefulness Study", journal="JMIR Form Res", year="2022", month="Sep", day="26", volume="6", number="9", pages="e37745", keywords="return on investment", keywords="value", keywords="payment model", keywords="cost", keywords="economic impact", keywords="digital health", keywords="eHealth", keywords="diabetes", keywords="primary care", keywords="email", abstract="Background: Diabetes is associated with significant long-term costs for both patients and health systems. Regular primary care visits aligned with American Diabetes Association guidelines could help mitigate those costs while generating near-term revenue for health systems. Digital interventions prompting primary care visits among unengaged patients could provide significant economic value back to the health system as well as individual patients, but only few economic models have been put forth to understand this value. Objective: Our objective is to establish a data-based method to estimate the economic impact to a health system of interventions promoting primary care visits for people with diabetes who have been historically unengaged with their care. The model was built with a focus on a specific digital health intervention, Precision Nudging, but can be used to quantify the value of other interventions driving primary care usage among patients with diabetes. Methods: We developed an economic model to estimate the financial value of a primary care visit of a patient with diabetes to the health system. This model requires segmenting patients with diabetes according to their level of blood sugar control as measured by their most recent hemoglobin A1c value to understand how frequently they should be visiting a primary care provider. The model also accounts for the payer mix among the population with diabetes, documenting the percentage of insurance coverage through a commercial plan, Medicare, or Medicaid, as these influence the reimbursement rates for the services. Then, the model takes into consideration the population base rates of comorbid conditions for patients with diabetes and the associated current procedural terminology codes to understand what a provider can bill as well as the expected inpatient revenue from a subset of patients likely to require hospitalization based on the national hospitalization rates for people with diabetes. Physician reimbursement is subtracted from the total. Finally, the model also accounts for the level of patient engagement with the intervention to ensure a realistic estimate of the impact. Results: We present a model to prospectively estimate the economic impact of a digital health intervention to encourage patients with documented diabetes diagnoses to attend primary care visits. The model leverages both publicly available and health system data to calculate the per appointment value (revenue) to the health system. The model offers a method to understand and test the financial impact of Precision Nudging or other primary care--focused diabetes interventions inclusive of costs driven by comorbid conditions. Conclusions: The proposed economic model can help health systems understand and evaluate the estimated economic benefits of interventions focused on primary care and prevention for patients with diabetes as well as help intervention developers determine pricing for their product. ", doi="10.2196/37745", url="https://formative.jmir.org/2022/9/e37745", url="http://www.ncbi.nlm.nih.gov/pubmed/36155985" } @Article{info:doi/10.2196/35300, author="McCombe, Geoff and Swan, Davina and Lambert, S. John and O'Connor, Eileen and Ward, Zoe and Vickerman, Peter and Avramovic, Gordana and Crowley, Des and Tinago, Willard and Mafirakureva, Nyashadzaishe and Cullen, Walter", title="Integrating Hepatitis C Care for Opioid Substitution Treatment Patients Attending General Practice: Feasibility, Clinical, and Cost-Effectiveness Analysis", journal="Interact J Med Res", year="2022", month="Aug", day="23", volume="11", number="2", pages="e35300", keywords="hepatitis C", keywords="integrated HCV care", keywords="people who inject drugs", keywords="primary health care", abstract="Background: Hepatitis C virus (HCV) infection is common among people who inject drugs, yet well-described barriers mean that only a minority have accessed HCV treatment. Recent developments in HCV diagnosis and treatment facilitate innovative approaches to HCV care that improve access to, and uptake of, care by people who inject drugs. Objective: This study aims to examine feasibility, acceptability, likely clinical effectiveness, and cost-effectiveness of an integrated model of HCV care for patients receiving opioid substitution treatment in general practice. Methods: A pre- and postintervention design with an embedded economic analysis was used to establish the feasibility, acceptability, and clinical and cost-effectiveness of a complex intervention to optimize HCV identification and linkage to HCV treatment among patients prescribed methadone in primary care. The ``complex intervention'' comprised general practitioner (GP)/practice staff education, nurse-led clinical support, and enhanced community-based HCV assessment of patients. General practices in North Dublin were recruited from the professional networks of the research team and from GPs who attended educational sessions. Results: A total of 135 patients from 14 practices participated. Follow-up data were collected 6 months after intervention from 131 (97.0\%) patients. With regard to likely clinical effectiveness, among patients with HCV antibody positivity, there was a significant increase in the proportions of patients who had a liver FibroScan (17/101, 16.8\% vs 52/100, 52.0\%; P<.001), had attended hepatology/infectious diseases services (51/101, 50.5\% vs 61/100 61.0\%; P=.002), and initiated treatment (20/101, 19.8\% vs 30/100, 30.0\%; P=.004). The mean incremental cost-effectiveness ratio of the intervention was {\texteuro}13,255 (US \$13,965.14) per quality-adjusted life-year gained at current full drug list price ({\texteuro}39,729 [US \$41,857.48] per course), which would be cost saving if these costs are reduced by 88\%. Conclusions: The complex intervention involving clinical support, access to assessment, and practitioner education has the potential to enhance patient care, improving access to assessment and treatment in a cost-effective manner. ", doi="10.2196/35300", url="https://www.i-jmr.org/2022/2/e35300", url="http://www.ncbi.nlm.nih.gov/pubmed/35998029" } @Article{info:doi/10.2196/33703, author="Gomez Rossi, Jesus and Feldberg, Ben and Krois, Joachim and Schwendicke, Falk", title="Evaluation of the Clinical, Technical, and Financial Aspects of Cost-Effectiveness Analysis of Artificial Intelligence in Medicine: Scoping Review and Framework of Analysis", journal="JMIR Med Inform", year="2022", month="Aug", day="12", volume="10", number="8", pages="e33703", keywords="artificial intelligence", keywords="cost-effectiveness", keywords="systematic review", keywords="framework", keywords="health policy", keywords="research and development", keywords="cost", keywords="economics", abstract="Background: Cost-effectiveness analysis of artificial intelligence (AI) in medicine demands consideration of clinical, technical, and economic aspects to generate impactful research of a novel and highly versatile technology. Objective: We aimed to systematically scope existing literature on the cost-effectiveness of AI and to extract and summarize clinical, technical, and economic dimensions required for a comprehensive assessment. Methods: A scoping literature review was conducted to map medical, technical, and economic aspects considered in studies on the cost-effectiveness of medical AI. Based on these, a framework for health policy analysis was developed. Results: Among 4820 eligible studies, 13 met the inclusion criteria for our review. Internal medicine and emergency medicine were the clinical disciplines most frequently analyzed. Most of the studies included were from the United States (5/13, 39\%), assessed solutions requiring market access (9/13, 69\%), and proposed optimization of direct resources as the most frequent value proposition (7/13, 53\%). On the other hand, technical aspects were not uniformly disclosed in the studies we analyzed. A minority of articles explicitly stated the payment mechanism assumed (5/13, 38\%), while it remained unspecified in the majority (8/13, 62\%) of studies. Conclusions: Current studies on the cost-effectiveness of AI do not allow to determine if the investigated AI solutions are clinically, technically, and economically viable. Further research and improved reporting on these dimensions seem relevant to recommend and assess potential use cases for this technology. ", doi="10.2196/33703", url="https://medinform.jmir.org/2022/8/e33703", url="http://www.ncbi.nlm.nih.gov/pubmed/35969458" } @Article{info:doi/10.2196/35798, author="Powell, Adam and Dolan, Paul", title="Moving to Personalized Medicine Requires Personalized Health Plans", journal="J Particip Med", year="2022", month="Aug", day="4", volume="14", number="1", pages="e35798", keywords="quality-adjusted life years", keywords="health insurance", keywords="personalized outcomes", keywords="patient preferences", keywords="cost-effectiveness", keywords="managed care", doi="10.2196/35798", url="https://jopm.jmir.org/2022/1/e35798", url="http://www.ncbi.nlm.nih.gov/pubmed/35925669" } @Article{info:doi/10.2196/31302, author="Albuquerque de Almeida, Fernando and Corro Ramos, Isaac and Al, Maiwenn and Rutten-van M{\"o}lken, Maureen", title="Home Telemonitoring and a Diagnostic Algorithm in the Management of Heart Failure in the Netherlands: Cost-effectiveness Analysis", journal="JMIR Cardio", year="2022", month="Aug", day="4", volume="6", number="2", pages="e31302", keywords="discrete event simulation", keywords="cost-effectiveness", keywords="early warning systems", keywords="home telemonitoring", keywords="diagnostic algorithm", keywords="heart failure", 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 {\texteuro}27,712 (currency conversion rate in purchasing power parity at the time of study: {\texteuro}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 {\texteuro}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. ", doi="10.2196/31302", url="https://cardio.jmir.org/2022/2/e31302", url="http://www.ncbi.nlm.nih.gov/pubmed/35925670" } @Article{info:doi/10.2196/29420, author="Smith, A. Maureen and Yu, Menggang and Huling, D. Jared and Wang, Xinyi and DeLonay, Allie and Jaffery, Jonathan", title="Impactability Modeling for Reducing Medicare Accountable Care Organization Payments and Hospital Events in High-Need High-Cost Patients: Longitudinal Cohort Study", journal="J Med Internet Res", year="2022", month="Jun", day="13", volume="24", number="6", pages="e29420", keywords="case management", keywords="high-risk patients", keywords="benefit score", abstract="Background: Impactability modeling promises to help solve the nationwide crisis in caring for high-need high-cost patients by matching specific case management programs with patients using a ``benefit'' or ``impactability'' score, but there are limitations in tailoring each model to a specific program and population. Objective: We evaluated the impact on Medicare accountable care organization savings from developing a benefit score for patients enrolled in a historic case management program, prospectively implementing the score, and evaluating the results in a new case management program. Methods: We conducted a longitudinal cohort study of 76,140 patients in a Medicare accountable care organization with multiple before-and-after measures of the outcome, using linked electronic health records and Medicare claims data from 2012 to 2019. There were 489 patients in the historic case management program, with 1550 matched comparison patients, and 830 patients in the new program, with 2368 matched comparison patients. The historic program targeted high-risk patients and assigned a centrally located registered nurse and social worker to each patient. The new program targeted high- and moderate-risk patients and assigned a nurse physically located in a primary care clinic. Our primary outcomes were any unplanned hospital events (admissions, observation stays, and emergency department visits), count of event-days, and Medicare payments. Results: In the historic program, as expected, high-benefit patients enrolled in case management had fewer events, fewer event-days, and an average US \$1.15 million reduction in Medicare payments per 100 patients over the subsequent year when compared with the findings in matched comparison patients. For the new program, high-benefit high-risk patients enrolled in case management had fewer events, while high-benefit moderate-risk patients enrolled in case management did not differ from matched comparison patients. Conclusions: Although there was evidence that a benefit score could be extended to a new case management program for similar (ie, high-risk) patients, there was no evidence that it could be extended to a moderate-risk population. Extending a score to a new program and population should include evaluation of program outcomes within key subgroups. With increased attention on value-based care, policy makers and measure developers should consider ways to incorporate impactability modeling into program design and evaluation. ", doi="10.2196/29420", url="https://www.jmir.org/2022/6/e29420", url="http://www.ncbi.nlm.nih.gov/pubmed/35699983" } @Article{info:doi/10.2196/36012, author="Sado, Mitsuhiro and Yamada, Masashi and Ninomiya, Akira and Nagaoka, Maki and Goto, Naho and Koreki, Akihiro and Nakagawa, Atsuo and Segal, Zindel and Mimura, Masaru", title="Effectiveness and Cost-effectiveness of Online Brief Mindfulness-based Cognitive Therapy for the Improvement of Productivity in the Workplace: Study Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2022", month="Jun", day="13", volume="11", number="6", pages="e36012", keywords="mindfulness-based cognitive therapy", keywords="mindfulness", keywords="cognitive therapy", keywords="occupational health", keywords="workplace", keywords="randomized controlled trial", keywords="cost-effectiveness", keywords="cost", keywords="online", keywords="internet-based", keywords="eHealth", keywords="mental health", keywords="heath outcome", keywords="work", keywords="stress", keywords="burnout", keywords="productivity", keywords="employee", abstract="Background: Numerous studies have demonstrated the effectiveness of mindfulness-based programs (MBPs) among both clinical and nonclinical populations. These data document positive impacts in the workplace, including reducing perceived stress and burnout and increasing well-being. However, the effectiveness for productivity, which is of most interest to managers and administrators, is still unclear. In addition, MBPs in the workplace tend to be modified by reducing the number of the program sessions or delivering content online to improve accessibility. To date, however, the impact of MBPs that feature these modifications on productivity in the workplace has not been investigated. Objective: The study aims to investigate the effectiveness and cost-effectiveness of online-delivered brief mindfulness-based cognitive therapy (bMBCT) for improving productivity and other work-related outcomes among healthy workers compared to the waitlist control. Methods: We will conduct a 4-week randomized controlled trial (RCT) with a 6-month follow-up. Employees are included in the study if they (1) are between the ages of 20 and 65 years and (2) work longer than 30 hours weekly. Employees are randomly allocated to either the bMBCT group or the waitlist control group. The primary outcome of the study is the mean difference of productivity measured by the World Health Organization Health and Work Performance Questionnaire (WHO-HPQ) between the groups at 4, 16, and 28 weeks. Secondary outcomes include several clinical outcomes and health economics evaluation. Results: We started recruiting participants in August 2021, and the intervention began in October 2021. A total of 104 participants have been enrolled in the study as of October 2021. The intervention is scheduled to be completed in December 2023. Data collection will be completed by the end of January 2024. Conclusions: The novelty of the study is that (1) it will investigate bMBCT's effectiveness on productivity, which is still unclear, and (2) samples are recruited from 3 companies in different industries. The limitations of the study are that (1) all measures assessed are in self-report format and (2) we lack an active control group. This study has the potential to provide new data on the relationship between MBPs and occupational health and productivity. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000044721; https://tinyurl.com/4e2fh873 International Registered Report Identifier (IRRID): DERR1-10.2196/36012 ", doi="10.2196/36012", url="https://www.researchprotocols.org/2022/6/e36012", url="http://www.ncbi.nlm.nih.gov/pubmed/35387762" } @Article{info:doi/10.2196/32147, author="Apantaku, Glory and Mitton, Craig and Wong, Hubert and Ho, Kendall", title="Home Telemonitoring Technology for Patients With Heart Failure: Cost-Consequence Analysis of a Pilot Study", journal="JMIR Form Res", year="2022", month="Jun", day="2", volume="6", number="6", pages="e32147", keywords="cost-consequence analysis", keywords="feasibility study", keywords="pilot study", keywords="heart failure", keywords="cardiology", keywords="cardiovascular disease", keywords="economic analysis", keywords="telehealth", keywords="health care cost", keywords="home monitoring", keywords="digital monitor", keywords="health monitor", abstract="Background: Heart failure (HF) is a costly health condition and a major public health problem. It is estimated that 2\%-3\% of the population in developed countries has HF, and the prevalence increases to 8\% among patients aged ?75 years. Home telemonitoring is a form of noninvasive, remote patient monitoring that aims to improve the care and management of patients with chronic HF. Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring (TEC4Home) is a project that implements and evaluates a comprehensive home monitoring protocol designed to support patients with HF as they transition from the emergency department to home. Objective: The aim of this study is to assess the cost of using the home monitoring platform (TEC4Home) relative to usual care for patients with HF. Methods: This study is a cost-consequence analysis of the TEC4Home pilot study. The analysis was conducted from a partial societal perspective, including direct and indirect health care costs. The aim is to assess the costs of the home monitoring platform relative to usual care and track costs related to health care utilization during the 90-day postdischarge period. Results: Economic analysis of the TEC4Home pilot study showed a positive trend in cost savings for patients using TEC4Home. From both the health system perspective (Pre TEC4Home cost per patient: CAD \$2924 vs post TEC4Home cost per patient: CAD \$1293; P=.01) and partial societal perspective (Pre TEC4Home cost per patient: CAD \$2411 vs post TEC4Home cost per patient: CAD \$1108; P=.01), we observed a statistically significant cost saving per patient. Conclusions: In line with the advantages of conducting an economic analysis alongside a feasibility study, the economic analysis of the TEC4Home pilot study facilitated the piloting of patient questionnaires and informed the methodology for a full clinical trial. ", doi="10.2196/32147", url="https://formative.jmir.org/2022/6/e32147", url="http://www.ncbi.nlm.nih.gov/pubmed/35653179" } @Article{info:doi/10.2196/32002, author="Huguet, Marius and Sarazin, Marianne and Perrier, Lionel and Augusto, Vincent", title="How We Can Reap the Full Benefit of Teleconsultations: Economic Evaluation Combined With a Performance Evaluation Through a Discrete-Event Simulation", journal="J Med Internet Res", year="2022", month="May", day="20", volume="24", number="5", pages="e32002", keywords="telemedicine", keywords="telehealth", keywords="teleconsultation", keywords="discrete-event simulation", keywords="economic evaluation", keywords="propensity score matching", abstract="Background: In recent years, the rapid development of information and communications technology enabled by innovations in videoconferencing solutions and the emergence of connected medical devices has contributed to expanding the scope of application and expediting the development of telemedicine. Objective: This study evaluates the use of teleconsultations (TCs) for specialist consultations at hospitals in terms of costs, resource consumption, and patient travel time. The key feature of our evaluation framework is the combination of an economic evaluation through a cost analysis and a performance evaluation through a discrete-event simulation (DES) approach. Methods: Three data sets were used to obtain detailed information on the characteristics of patients, characteristics of patients' residential locations, and usage of telehealth stations. A total of 532 patients who received at least one TC and 18,559 patients who received solely physical consultations (CSs) were included in the initial sample. The TC patients were recruited during a 7-month period (ie, 2020 data) versus 19 months for the CS patients (ie, 2019 and 2020 data). A propensity score matching procedure was applied in the economic evaluation. To identify the best scenarios for reaping the full benefits of TCs, various scenarios depicting different population types and deployment strategies were explored in the DES model. Associated break-even levels were calculated. Results: The results of the cost evaluation reveal a higher cost for the TC group, mainly induced by higher volumes of (tele)consultations per patient and the substantial initial investment required for TC equipment. On average, the total cost per patient over 298 days of follow-up was {\texteuro}356.37 (US \$392) per TC patient and {\texteuro}305.18 (US \$336) per CS patient. However, the incremental cost of TCs was not statistically significant: {\texteuro}356.37 -- {\texteuro}305.18 = {\texteuro}51.19 or US \$392 -- US \$336 = US \$56 (95\% CI --35.99 to 114.25; P=.18). Sensitivity analysis suggested heterogeneous economic profitability levels within subpopulations and based on the intensity of use of TC solutions. In fact, the DES model results show that TCs could be a cost-saving strategy in some cases, depending on population characteristics, the amortization speed of telehealth equipment, and the locations of telehealth stations. Conclusions: The use of TCs has the potential to lead to a major organizational change in the health care system in the near future. Nevertheless, TC performance is strongly related to the context and deployment strategy involved. ", doi="10.2196/32002", url="https://www.jmir.org/2022/5/e32002", url="http://www.ncbi.nlm.nih.gov/pubmed/35594065" } @Article{info:doi/10.2196/30236, author="Treskes, Willem Roderick and van den Akker-van Marle, Elske M. and van Winden, Louise and van Keulen, Nicole and van der Velde, Tjeerd Enno and Beeres, Saskia and Atsma, Douwe and Schalij, Jan Martin", title="The Box---eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis", journal="J Med Internet Res", year="2022", month="Apr", day="25", volume="24", number="4", pages="e30236", keywords="smart technology", keywords="myocardial infarction", keywords="cost-utility", keywords="outpatients", keywords="cost-effectiveness", keywords="eHealth", keywords="remote monitoring", keywords="cost of care", keywords="quality of life", abstract="Background: Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care. Objective: The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI). Methods: In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated. Results: Mean costs per patient were {\texteuro}2417{\textpm}2043 (US \$2657{\textpm}2246) for the intervention and {\texteuro}2888{\textpm}2961 (US \$3175{\textpm}3255) for the control group. This yielded a cost reduction of {\texteuro}471 (US \$518) per patient. This difference was not statistically significant (95\% CI --{\texteuro}275 to {\texteuro}1217; P=.22, US \$--302 to \$1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference --0.05, 95\% CI --0.09 to --0.01; P=.01). Conclusions: eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings. Trial Registration: ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8038 ", doi="10.2196/30236", url="https://www.jmir.org/2022/4/e30236", url="http://www.ncbi.nlm.nih.gov/pubmed/35468091" } @Article{info:doi/10.2196/35075, author="Miranda, N. Rafael and Bhuiya, R. Aunima and Thraya, Zak and Hancock-Howard, Rebecca and Chan, CF Brian and Steele Gray, Carolyn and Wodchis, P. Walter and Thavorn, Kednapa", title="An Electronic Patient-Reported Outcomes Tool for Older Adults With Complex Chronic Conditions: Cost-Utility Analysis", journal="JMIR Aging", year="2022", month="Apr", day="20", volume="5", number="2", pages="e35075", keywords="eHealth", keywords="multimorbidity", keywords="primary care", keywords="cost-effectiveness", keywords="older adult", keywords="elder", keywords="cost", keywords="patient reported outcome", keywords="community", keywords="complex care", keywords="aging", keywords="Canada", keywords="North America", keywords="chronic disease", keywords="chronic condition", keywords="decision tree", keywords="model", keywords="sensitivity analysis", abstract="Background: eHealth technologies for self-management can improve quality of life, but little is known about whether the benefits gained outweigh their costs. The electronic patient-reported outcome (ePRO) mobile app and portal system supports patients with multiple chronic conditions to collaborate with primary health care providers to set and monitor health-related goals. Objective: This study aims to estimate the cost of ePRO and the cost utility of the ePRO intervention compared with usual care provided to patients with multiple chronic conditions and complex needs living in the community, from the perspective of the publicly funded health care payer in Ontario, Canada. Methods: We developed a decision tree model to estimate the incremental cost per quality-adjusted life year (QALY) gained for the ePRO tool versus usual care over a time horizon of 15 months. Resource utilization and effectiveness of the ePRO tool were drawn from a randomized clinical trial with 6 family health teams involving 45 participants. Unit costs associated with health care utilization (adjusted to 2020 Canadian dollars) were drawn from literature and publicly available sources. A series of sensitivity analyses were conducted to assess the robustness of the findings. Results: The total cost of the ePRO tool was CAD \$79,467 ({\textasciitilde}US \$ 63,581; CAD \$1733 [{\textasciitilde}US \$1386] per person). Compared with standard care, the ePRO intervention was associated with higher costs (CAD \$1710 [{\textasciitilde}US \$1368]) and fewer QALYs (--0.03). The findings were consistent with the clinical evidence, suggesting no statistical difference in health-related quality of life between ePRO and usual care groups. However, the tool would be considered a cost-effective option if it could improve by at least 0.03 QALYs. The probability that the ePRO is cost-effective was 17.3\% at a willingness-to-pay (WTP) threshold of CAD \$50,000 ({\textasciitilde}US \$40,000)/QALY. Conclusions: The ePRO tool is not a cost-effective technology at the commonly used WTP value of CAD \$50,000 ({\textasciitilde}US \$40,000)/QALY, but long-term and the societal impacts of ePRO were not included in this analysis. Further research is needed to better understand its impact on long-term outcomes and in real-world settings. The present findings add to the growing evidence about eHealth interventions' capacity to respond to complex aging populations within finite-resourced health systems. Trial Registration: ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954 ", doi="10.2196/35075", url="https://aging.jmir.org/2022/2/e35075", url="http://www.ncbi.nlm.nih.gov/pubmed/35442194" } @Article{info:doi/10.2196/29408, author="Luo, Xueyan and Xu, Wei and Ming, Wai-Kit and Jiang, Xinchan and Yuan, Quan and Lai, Han and Huang, Chunji and Zhong, Xiaoni", title="Cost-Effectiveness of Mobile Health--Based Integrated Care for Atrial Fibrillation: Model Development and Data Analysis", journal="J Med Internet Res", year="2022", month="Apr", day="19", volume="24", number="4", pages="e29408", keywords="mobile health", keywords="integrated care", keywords="ABC pathway", keywords="atrial fibrillation", keywords="model-based", keywords="cost-effectiveness", keywords="health economic evaluation", abstract="Background: Mobile health (mHealth) technology is increasingly used in disease management. Using mHealth tools to integrate and streamline care has improved clinical outcomes of patients with atrial fibrillation (AF). Objective: The aim of this study was to investigate the potential clinical and health economic outcomes of mHealth-based integrated care for AF from the perspective of a public health care provider in China. Methods: A Markov model was designed to compare outcomes of mHealth-based care and usual care in a hypothetical cohort of patients with AF in China. The time horizon was 30 years with monthly cycles. Model outcomes measured were direct medical cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to examine the robustness of the base-case results. Results: In the base-case analysis, mHealth-based care gained higher QALYs of 0.0730 with an incurred cost of US \$1090. Using US \$33,438 per QALY (three times the gross domestic product) as the willingness-to-pay threshold, mHealth-based care was cost-effective, with an ICER of US \$14,936 per QALY. In one-way sensitivity analysis, no influential factor with a threshold value was identified. In probabilistic sensitivity analysis, mHealth-based care was accepted as cost-effective in 92.33\% of 10,000 iterations. Conclusions: This study assessed the expected cost-effectiveness of applying mHealth-based integrated care for AF according to a model-based health economic evaluation. The exploration suggested the potential cost-effective use of mHealth apps in streamlining and integrating care via the Atrial fibrillation Better Care (ABC) pathway for AF in China. Future economic evaluation alongside randomized clinical trials is highly warranted to verify the suggestion and investigate affecting factors such as geographical variations in patient characteristics, identification of subgroups, and constraints on local implementation. ", doi="10.2196/29408", url="https://www.jmir.org/2022/4/e29408", url="http://www.ncbi.nlm.nih.gov/pubmed/35438646" } @Article{info:doi/10.2196/29291, author="Jones, C. Amanda and Grout, Leah and Wilson, Nick and Nghiem, Nhung and Cleghorn, Christine", title="The Cost-effectiveness of a Mass Media Campaign to Promote Smartphone Apps for Weight Loss: Updated Modeling Study", journal="JMIR Form Res", year="2022", month="Apr", day="19", volume="6", number="4", pages="e29291", keywords="mass media", keywords="smartphone apps", keywords="weight loss", keywords="cost-effectiveness", keywords="simulation modeling", keywords="health equity", keywords="mobile phone", abstract="Background: Evidence suggests that smartphone apps can be effective in the self-management of weight. Given the low cost, broad reach, and apparent effectiveness of weight loss apps, governments may seek to encourage their uptake as a tool to reduce excess weight in the population. Mass media campaigns are 1 mechanism for promoting app use. However, the cost and potential cost-effectiveness are important considerations. Objective: The aim of our study was to use modeling to assess the health impacts, health system costs, cost-effectiveness, and health equity of a mass media campaign to promote high-quality smartphone apps for weight loss in New Zealand. Methods: We used an established proportional multistate life table model that simulates the 2011 New Zealand adult population over the lifetime, subgrouped by age, sex, and ethnicity (M?ori [Indigenous] or non-M?ori). The risk factor was BMI. The model compared business as usual to a one-off mass media campaign intervention, which included the pooled effect size from a recent meta-analysis of smartphone weight loss apps. The resulting impact on BMI and BMI-related diseases was captured through changes in health gain (quality-adjusted life years) and in health system costs. The difference in total health system costs was the net sum of intervention costs and downstream cost offsets because of altered disease rates. An annual discount rate of 3\% was applied to health gains and health system costs. Multiple scenarios and sensitivity analyses were conducted, including an equity adjustment. Results: Across the remaining lifetime of the modeled 2011 New Zealand population, the mass media campaign to promote weight loss app use had an estimated overall health gain of 181 (95\% uncertainty interval 113-270) quality-adjusted life years and health care costs of --NZ \$606,000 (--US \$408,000; 95\% uncertainty interval --NZ \$2,540,000 [--US \$1,709,000] to NZ \$907,000 [US \$610,000]). The mean health care costs were negative, representing overall savings to the health system. Across the outcomes examined in this study, the modeled mass media campaign to promote weight loss apps among the general population would be expected to provide higher per capita health gain for M?ori and hence reduce health inequities arising from high BMI, assuming that the intervention would be as effective for M?ori as it is for non-M?ori. Conclusions: A modeled mass media campaign to encourage the adoption of smartphone apps to promote weight loss among the New Zealand adult population is expected to yield an overall gain in health and to be cost-saving to the health system. Although other interventions in the nutrition and physical activity space are even more beneficial to health and produce larger cost savings (eg, fiscal policies and food reformulation), governments may choose to include strategies to promote health app use as complementary measures. ", doi="10.2196/29291", url="https://formative.jmir.org/2022/4/e29291", url="http://www.ncbi.nlm.nih.gov/pubmed/35438643" } @Article{info:doi/10.2196/33372, author="Chua, Valerie and Koh, Hean Jin and Koh, Gerald Choon Huat and Tyagi, Shilpa", title="The Willingness to Pay for Telemedicine Among Patients With Chronic Diseases: Systematic Review", journal="J Med Internet Res", year="2022", month="Apr", day="13", volume="24", number="4", pages="e33372", keywords="willingness to pay", keywords="telemedicine", keywords="chronic disease", keywords="patients", keywords="systematic review", keywords="mobile phone", abstract="Background: Telemedicine is increasingly being leveraged, as the need for remote access to health care has been driven by the rising chronic disease incidence and the COVID-19 pandemic. It is also important to understand patients' willingness to pay (WTP) for telemedicine and the factors contributing toward it, as this knowledge may inform health policy planning processes, such as resource allocation or the development of a pricing strategy for telemedicine services. Currently, most of the published literature is focused on cost-effectiveness analysis findings, which guide health care financing from the health system's perspective. However, there is limited exploration of the WTP from a patient's perspective, despite it being pertinent to the sustainability of telemedicine interventions. Objective: To address this gap in research, this study aims to conduct a systematic review to describe the WTP for telemedicine interventions and to identify the factors influencing WTP among patients with chronic diseases in high-income settings. Methods: We systematically searched 4 databases (PubMed, PsycINFO, Embase, and EconLit). A total of 2 authors were involved in the appraisal. Studies were included if they reported the WTP amounts or identified the factors associated with patients' WTP, involved patients aged ?18 years who were diagnosed with chronic diseases, and were from high-income settings. Results: A total of 11 studies from 7 countries met this study's inclusion criteria. The proportion of people willing to pay for telemedicine ranged from 19\% to 70\% across the studies, whereas the values for WTP amounts ranged from US \$0.89 to US \$821.25. We found a statistically significant correlation of age and distance to a preferred health facility with the WTP for telemedicine. Higher age was associated with a lower WTP, whereas longer travel distance was associated with a higher WTP. Conclusions: On the basis of our findings, the following are recommendations that may enhance the WTP: exposure to the telemedicine intervention before assessing the WTP, the lowering of telemedicine costs, and the provision of patient education to raise awareness on telemedicine's benefits and address patients' concerns. In addition, we recommend that future research be directed at standardizing the reporting of WTP studies with the adoption of a common metric for WTP amounts, which may facilitate the generalization of findings and effect estimates. ", doi="10.2196/33372", url="https://www.jmir.org/2022/4/e33372", url="http://www.ncbi.nlm.nih.gov/pubmed/35416779" } @Article{info:doi/10.2196/30144, author="John, Jari", title="Modeling Years of Life Lost Due to COVID-19, Socioeconomic Status, and Nonpharmaceutical Interventions: Development of a Prediction Model", journal="JMIRx Med", year="2022", month="Apr", day="12", volume="3", number="2", pages="e30144", keywords="COVID-19", keywords="pandemic", keywords="socioeconomic status", keywords="mortality", keywords="nonpharmaceutical interventions", keywords="prediction model", keywords="low-income status", keywords="life expectancy", keywords="public health", keywords="income groups", abstract="Background: Research in the COVID-19 pandemic focused on the health burden, thereby largely neglecting the potential harm to life from welfare losses. Objective: This paper develops a model that compares the years of life lost (YLL) due to COVID-19 and the potential YLL due to the socioeconomic consequences of its containment. Methods: It improves on existing estimates by conceptually disentangling YLL due to COVID-19 and socioeconomic status. By reconciling the normative life table approach with socioeconomic differences in life expectancy, it accounts for the fact that people with low socioeconomic status are hit particularly hard by the pandemic. The model also draws on estimates of socioeconomic differences in life expectancy to ascertain potential YLL due to income loss, school closures, and extreme poverty. Results: Tentative results suggest that if only one-tenth of the current socioeconomic damage becomes permanent in the future, it may carry a higher YLL burden than COVID-19 in the more likely pandemic scenarios. The model further suggests that the socioeconomic harm outweighs the disease burden due to COVID-19 more quickly in poorer and more unequal societies. Most urgently, the substantial increase in extreme poverty needs immediate attention. Avoiding a relatively minor number of 4 million unemployed, 1 million extremely poor, and 2 million students with a higher learning loss may save a similar amount of life years as saving 1 million people from dying from COVID-19. Conclusions: Primarily, the results illustrate the urgent need for redistributive policy interventions and global solidarity. In addition, the potentially high YLL burden from income and learning losses raises the burden of proof for the efficacy and necessity of school and business closures in the containment of the pandemic, especially where social safety nets are underdeveloped. ", doi="10.2196/30144", url="https://med.jmirx.org/2022/2/e30144", url="http://www.ncbi.nlm.nih.gov/pubmed/35438949" } @Article{info:doi/10.2196/36166, author="H{\"o}per, Christina Anje and Terjesen, Lilja Christoffer and Fleten, Nils", title="Comparing the New Interdisciplinary Health in Work Intervention With Conventional Monodisciplinary Welfare Interventions at Norwegian Workplaces: Protocol for a Pragmatic Cluster Randomized Trial", journal="JMIR Res Protoc", year="2022", month="Apr", day="7", volume="11", number="4", pages="e36166", keywords="sickness absence", keywords="work environment", keywords="work environment intervention", keywords="health related quality of life", keywords="cluster randomized trial", keywords="cost-effectiveness-analysis", keywords="cost-benefit-analysis", keywords="health in work", abstract="Background: Musculoskeletal and mental health complaints are the dominant diagnostic categories in long-term sick leave and disability pensions in Norway. Continuing to work despite health complaints is often beneficial, and a good work environment can improve work inclusion for people affected. In 2001, the Norwegian Labour and Welfare Administration began to offer inclusive work measures to improve the psychosocial work environment and work inclusion of people with health complaints. In 2018, the Norwegian Labour and Welfare Administration and specialist health services started offering the new collaborative Health in work program. Its workplace intervention presents health and welfare information that may improve employees' coping ability regarding common health complaints. It encourages understanding of coworkers' health complaints and appropriate work adjustments to increase work participation. Objective: This protocol presents an ongoing, 2-arm, pragmatic cluster-randomized trial. Its aim is to compare the effect of monodisciplinary inclusive work measures (treatment as usual) and interdisciplinary Health in work in terms of changes in overall sickness absence, health care use, health-related quality of life, and costs. The secondary objectives are to compare changes in individual sickness absence, psychosocial work environment, job and life satisfaction, health, and health anxiety at both the individual and group levels. Methods: Data will be collected from national registers, trial-specific registrations, and questionnaires. Effects will be explored using difference-in-difference analysis and regression modeling. Multilevel analysis will visualize any cluster effects using intraclass correlation coefficients. Results: Inclusion was completed in July 2021 with 97 workplaces and 1383 individual consents. Data collection will be completed with the last questionnaires to be sent out in July 2023. Conclusions: This trial will contribute to filling knowledge gaps regarding the effectiveness and costs of workplace interventions, thereby benefiting health and welfare services, political decision makers, and the public and business sectors. The findings will be disseminated in reports, peer-reviewed journals, and conferences. Trial Registration: ClinicalTrials.gov NCT04000035; https://clinicaltrials.gov/ct2/show/NCT04000035 International Registered Report Identifier (IRRID): DERR1-10.2196/36166 ", doi="10.2196/36166", url="https://www.researchprotocols.org/2022/4/e36166", url="http://www.ncbi.nlm.nih.gov/pubmed/35388792" } @Article{info:doi/10.2196/29988, author="Thorpe, Dan and Fouyaxis, John and Lipschitz, M. Jessica and Nielson, Amy and Li, Wenhao and Murphy, A. Susan and Bidargaddi, Niranjan", title="Cost and Effort Considerations for the Development of Intervention Studies Using Mobile Health Platforms: Pragmatic Case Study", journal="JMIR Form Res", year="2022", month="Mar", day="31", volume="6", number="3", pages="e29988", keywords="health informatics", keywords="human computer interaction", keywords="digital health", keywords="mobile health", keywords="ecological momentary assessment", keywords="ecological momentary intervention", keywords="behavioral activation", keywords="interventional research", keywords="mobile health costs", abstract="Background: The research marketplace has seen a flood of open-source or commercial mobile health (mHealth) platforms that can collect and use user data in real time. However, there is a lack of practical literature on how these platforms are developed, integrated into study designs, and adopted, including important information around cost and effort considerations. Objective: We intend to build critical literacy in the clinician-researcher readership into the cost, effort, and processes involved in developing and operationalizing an mHealth platform, focusing on Intui, an mHealth platform that we developed. Methods: We describe the development of the Intui mHealth platform and general principles of its operationalization across sites. Results: We provide a worked example in the form of a case study. Intui was operationalized in the design of a behavioral activation intervention in collaboration with a mental health service provider. We describe the design specifications of the study site, the developed software, and the cost and effort required to build the final product. Conclusions: Study designs, researcher needs, and technical considerations can impact effort and costs associated with the use of mHealth platforms. Greater transparency from platform developers about the impact of these factors on practical considerations relevant to end users such as clinician-researchers is crucial to increasing critical literacy around mHealth, thereby aiding in the widespread use of these potentially beneficial technologies and building clinician confidence in these tools. ", doi="10.2196/29988", url="https://formative.jmir.org/2022/3/e29988", url="http://www.ncbi.nlm.nih.gov/pubmed/35357313" } @Article{info:doi/10.2196/35461, author="Lambert-Obry, Veronique and Lafrance, Jean-Philippe and Savoie, Michelle and Lachaine, Jean", title="The Impact of Hypoglycemia on Productivity Loss and Utility in Patients With Type 2 Diabetes Treated With Insulin in Real-world Canadian Practice: Protocol for a Prospective Study", journal="JMIR Res Protoc", year="2022", month="Mar", day="28", volume="11", number="3", pages="e35461", keywords="real-world evidence", keywords="work productivity", keywords="health-related quality of life", keywords="diabetes", keywords="hypoglycemia", abstract="Background: Type 2 diabetes mellitus (T2DM) imposes a substantial burden owing to its increasing prevalence and life-threatening complications. In patients who do not achieve glycemic targets with oral antidiabetic drugs, the initiation of insulin is recommended. However, a serious concern regarding insulin is drug-induced hypoglycemia. Hypoglycemia is known to affect quality of life and the use of health care resources. However, health economics and outcomes research (HEOR) data for economic modelling are limited, particularly regarding utility values and productivity losses. Objective: This real-world prospective study aims to assess the impact of hypoglycemia on productivity and utility in insulin-treated adults with T2DM from Ontario and Quebec, Canada. Methods: This noninterventional, multicenter, 3-month prospective study will recruit patients from 4 medical clinics and 2 endocrinology or diabetes clinics. Patients will be identified using appointment lists and enrolled through consecutive sampling during routinely scheduled consultations. To be eligible, patients must be aged ?18 years, diagnosed with T2DM, and treated with insulin. Utility and productivity will be measured using the EQ-5D-5L questionnaire and Institute for Medical Technology Assessment Productivity Cost Questionnaire, respectively. Questionnaires will be completed 4, 8, and 12 weeks after recruitment. Generalized estimating equation models will be used to investigate productivity losses and utility decrements associated with incident hypoglycemic events while controlling for individual patient characteristics. A total of 500 patients will be enrolled to ensure the precision of HEOR estimates. Results: This study is designed to fill a gap in the Canadian evidence on the impact of hypoglycemia on HEOR outcomes. More specifically, it will generate productivity and utility inputs for the economic modeling of T2DM. Conclusions: Insulin therapy is expensive, and hypoglycemia is a significant component of economic evaluation. Robust HEOR data may help health technology assessment agencies in future reimbursement decision-making. International Registered Report Identifier (IRRID): PRR1-10.2196/35461 ", doi="10.2196/35461", url="https://www.researchprotocols.org/2022/3/e35461", url="http://www.ncbi.nlm.nih.gov/pubmed/35343912" } @Article{info:doi/10.2196/33212, author="Howson, N. Stephanie and McShea, J. Michael and Ramachandran, Raghav and Burkom, S. Howard and Chang, Hsien-Yen and Weiner, P. Jonathan and Kharrazi, Hadi", title="Improving the Prediction of Persistent High Health Care Utilizers: Retrospective Analysis Using Ensemble Methodology", journal="JMIR Med Inform", year="2022", month="Mar", day="24", volume="10", number="3", pages="e33212", keywords="persistent high utilizers", keywords="ensemble methodology", keywords="utilization", keywords="prediction", keywords="machine learning", keywords="population health analytics", keywords="retrospective", keywords="observational", abstract="Background: A small proportion of high-need patients persistently use the bulk of health care services and incur disproportionate costs. Population health management (PHM) programs often refer to these patients as persistent high utilizers (PHUs). Accurate PHU prediction enables PHM programs to better align scarce health care resources with high-need PHUs while generally improving outcomes. While prior research in PHU prediction has shown promise, traditional regression methods used in these studies have yielded limited accuracy. Objective: We are seeking to improve PHU predictions with an ensemble approach in a retrospective observational study design using insurance claim records. Methods: We defined a PHU as a patient with health care costs in the top 20\% of all patients for 4 consecutive 6-month periods. We used 2013 claims data to predict PHU status in next 24 months. Our study population included 165,595 patients in the Johns Hopkins Health Care plan, with 8359 (5.1\%) patients identified as PHUs in 2014 and 2015. We assessed the performance of several standalone machine learning methods and then an ensemble approach combining multiple models. Results: The candidate ensemble with complement na{\"i}ve Bayes and random forest layers produced increased sensitivity and positive predictive value (PPV; 49.0\% and 50.3\%, respectively) compared to logistic regression (46.8\% and 46.1\%, respectively). Conclusions: Our results suggest that ensemble machine learning can improve prediction of care management needs. Improved PPV implies reduced incorrect referral of low-risk patients. With the improved sensitivity/PPV balance of this approach, resources may be directed more efficiently to patients needing them most. ", doi="10.2196/33212", url="https://medinform.jmir.org/2022/3/e33212", url="http://www.ncbi.nlm.nih.gov/pubmed/35275063" } @Article{info:doi/10.2196/27588, author="Mujcic, Ajla and Blankers, Matthijs and Boon, Brigitte and Verdonck-de Leeuw, M. Irma and Smit, Filip and van Laar, Margriet and Engels, Rutger", title="Effectiveness, Cost-effectiveness, and Cost-Utility of a Digital Smoking Cessation Intervention for Cancer Survivors: Health Economic Evaluation and Outcomes of a Pragmatic Randomized Controlled Trial", journal="J Med Internet Res", year="2022", month="Mar", day="17", volume="24", number="3", pages="e27588", keywords="smoking cessation", keywords="cancer survivors", keywords="effectiveness", keywords="cost-effectiveness", keywords="eHealth", abstract="Background: Smoking cessation (SC) interventions may contribute to better treatment outcomes and the general well-being of cancer survivors. Objective: This study aims to evaluate the effectiveness, cost-effectiveness, and cost-utility of a digital interactive SC intervention compared with a noninteractive web-based information brochure for cancer survivors. Methods: A health economic evaluation alongside a pragmatic 2-arm parallel-group randomized controlled trial was conducted with follow-ups at 3, 6, and 12 months. The study was conducted in the Netherlands over the internet from November 2016 to September 2019. The participants were Dutch adult smoking cancer survivors with the intention to quit smoking. In total, 165 participants were included and analyzed: 83 (50.3\%) in the MyCourse group and 82 (49.7\%) in the control group. In the intervention group, participants had access to a newly developed, digital, minimally guided SC intervention (MyCourse-Quit Smoking). Control group participants received a noninteractive web-based information brochure on SC. Both groups received unrestricted access to usual care. The primary outcome was self-reported 7-day smoking abstinence at the 6-month follow-up. Secondary outcomes were quality-adjusted life years gained, number of cigarettes smoked, nicotine dependence, and treatment satisfaction. For the health economic evaluation, intervention costs, health care costs, and costs stemming from productivity losses were assessed over a 12-month horizon. Results: At the 6-month follow-up, the quit rates were 28\% (23/83) and 26\% (21/82) in the MyCourse and control groups, respectively (odds ratio 0.47, 95\% CI 0.03-7.86; P=.60). In both groups, nicotine dependence scores were reduced at 12 months, and the number of smoked cigarettes was reduced by approximately half. The number of cigarettes decreased more over time, and the MyCourse group demonstrated a significantly greater reduction at the 12-month follow-up (incidence rate ratio 0.87; 95\% CI 0.76-1.00; P=.04). Intervention costs were estimated at US \$193 per participant for the MyCourse group and US \$74 for the control group. The mean per-participant societal costs were US \$25,329 (SD US \$29,137) and US \$21,836 (SD US \$25,792), respectively. In the cost-utility analysis, MyCourse was not preferred over the control group from a societal perspective. With smoking behavior as the outcome, the MyCourse group led to marginally better results per reduced pack-year against higher societal costs, with a mean incremental cost-effectiveness ratio of US \$52,067 (95\% CI US \$32,515-US \$81,346). Conclusions: At 6 months, there was no evidence of a differential effect on cessation rates; in both groups, approximately a quarter of the cancer survivors quit smoking and their number of cigarettes smoked was reduced by half. At 12 months, the MyCourse intervention led to a greater reduction in the number of smoked cigarettes, albeit at higher costs than for the control group. No evidence was found for a differential effect on quality-adjusted life years. Trial Registration: The Netherlands Trial Register NTR6011; https://www.trialregister.nl/trial/5434 International Registered Report Identifier (IRRID): RR2-10.1186/s12885-018-4206-z ", doi="10.2196/27588", url="https://www.jmir.org/2022/3/e27588", url="http://www.ncbi.nlm.nih.gov/pubmed/35297777" } @Article{info:doi/10.2196/25821, author="Zheng, Qishi and Shi, Luming and Zhu, Lixia and Jiao, Nana and Chong, Seng Yap and Chan, Wai-Chi Sally and Chan, Huak Yiong and Luo, Nan and Wang, Wenru and He, Honggu", title="Cost-effectiveness of Web-Based and Home-Based Postnatal Psychoeducational Interventions for First-time Mothers: Economic Evaluation Alongside Randomized Controlled Trial", journal="J Med Internet Res", year="2022", month="Mar", day="11", volume="24", number="3", pages="e25821", keywords="anxiety", keywords="cost-effectiveness", keywords="depression", keywords="first-time mother", keywords="home-based", keywords="postnatal", keywords="psychoeducational", keywords="self-efficacy", keywords="social support", keywords="web-based", abstract="Background: The cost-effectiveness of interventions has attracted increasing interest among researchers. Although web-based and home-based psychoeducational interventions have been developed to improve first-time mothers' postnatal health outcomes, very limited studies have reported their cost-effectiveness. Objective: The aim of this study was to evaluate the cost-effectiveness of web-based and home-based postnatal psychoeducational interventions for first-time mothers during the early postpartum period. Methods: A randomized controlled 3-group pretest and posttest design was adopted, and cost-effectiveness analysis from the health care's perspective was conducted. A total of 204 primiparas were recruited from a public tertiary hospital in Singapore from October 2016 to August 2017 who were randomly allocated to the web-based intervention (n=68), home-based intervention (n=68), or control (n=68) groups. Outcomes of maternal parental self-efficacy, social support, postnatal depression, anxiety, and health care resource utilization were measured using valid and reliable instruments at baseline and at 1 month, 3 months, and 6 months after childbirth. The generalized linear regression models on effectiveness and cost were used to assess the incremental cost-effectiveness ratios of the web-based and home-based intervention programs compared to routine care. Projections of cumulative cost over 5 years incurred by the 3 programs at various coverage levels (ie, 10\%, 50\%, and 100\%) were also estimated. Results: The web-based intervention program dominated the other 2 programs (home-based program and routine care) with the least cost (adjusted costs of SGD 376.50, SGD 457.60, and SGD 417.90 for web-based, home-based, and control group, respectively; SGD 1=USD 0.75) and the best improvements in self-efficacy, social support, and psychological well-being. When considering the implementation of study programs over the next 5 years by multiplying the average cost per first-time mother by the estimated average number of first-time mothers in Singapore during the 5-year projection period, the web-based program was the least costly program at all 3 coverage levels. Based on the 100\% coverage, the reduced total cost reached nearly SGD 7.1 million and SGD 11.3 million when compared to control and home-based programs at the end of the fifth year, respectively. Conclusions: The web-based approach was promisingly cost-effective to deliver the postnatal psychoeducational intervention to first-time mothers and could be adopted by hospitals as postnatal care support. Trial Registration: ISRCTN registry ISRCTN45202278; https://www.isrctn.com/ISRCTN45202278 ", doi="10.2196/25821", url="https://www.jmir.org/2022/3/e25821", url="http://www.ncbi.nlm.nih.gov/pubmed/35275078" } @Article{info:doi/10.2196/30795, author="Ingels, B. Justin and Corso, S. Phaedra and Prinz, J. Ronald and Metzler, W. Carol and Sanders, R. Matthew", title="Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis", journal="JMIR Pediatr Parent", year="2022", month="Mar", day="11", volume="5", number="1", pages="e30795", keywords="online parenting intervention", keywords="child disruptive behavior problems", keywords="cost-minimization analysis", keywords="online versus staff delivery", keywords="evidence-based parenting support", keywords="population reach", abstract="Background: High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality. Objective: This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers. Methods: A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches. Results: For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t168=23.2; P<.001), family costs (t185=9.2; P<.001), and total costs (t171=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was \$1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of \$1483 per case. All costs were valued or adjusted in 2017 US dollars. Conclusions: The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal. Trial Registration: ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431 ", doi="10.2196/30795", url="https://pediatrics.jmir.org/2022/1/e30795", url="http://www.ncbi.nlm.nih.gov/pubmed/35275084" } @Article{info:doi/10.2196/31350, author="Penz, Dianne Erika and Fenton, John Benjamin and Hu, Nianping and Marciniuk, Darcy", title="Economic Burden of Chronic Obstructive Pulmonary Disease and Lung Cancer Between 2000 and 2015 in Saskatchewan: Study Protocol", journal="JMIR Res Protoc", year="2022", month="Mar", day="4", volume="11", number="3", pages="e31350", keywords="lung cancer", keywords="COPD", keywords="chronic obstructive pulmonary disease", keywords="productivity loss", keywords="years of life lost", keywords="premature years of life lost", keywords="working years lost", keywords="economic burden of disease", keywords="lung disease", keywords="health economics", keywords="Stats Canada", keywords="epidemiology", keywords="pulmonary disease", keywords="pulmonary health", keywords="disease burden", abstract="Background: Chronic obstructive pulmonary disease (COPD) and lung cancer are both detrimental diseases that present great burdens on society. Years of life lost (YLL), premature years of life lost (PYLL), working years lost (WYL), and productivity loss are all effective measures in identifying economic burden of disease. Objective: We propose a population-based study to analyze comprehensive provincial cohorts of Saskatchewan residents with COPD, lung cancer, and combined COPD and lung cancer in order to identify the burden these diseases present. Methods: Saskatchewan residents over the age of 35 years who had COPD, lung cancer, or both, between January 1, 2000, and December 31, 2015, will be identified and used in this study. Data for analysis including age, gender, and date of death, alongside Statistics Canada income estimates, will be used to estimate productivity loss and WYL. Statistics Canada life tables will be used to calculate YLL and PYLL by subtracting the patients' ages at death by their life expectancies, adjusted using sex and age at death.We will link the Saskatchewan cancer registry with Saskatchewan health administrative databases to create three cohorts: (1) COPD; (2) lung cancer; and (3) COPD and lung cancer. Individuals with lung cancer will be identified using ICDO-T (International Classification of Diseases for Oncology-Topography) codes, and those with COPD will be defined and identified as individuals who had at least 1 visit to a physician with a diagnosis of COPD or 1 hospital separation with a diagnosis of COPD. Those without a valid health care coverage for a consecutive 12 months prior to the first diagnostic code will be excluded from the study. Those with a combined diagnosis of COPD and lung cancer will be identified as individuals who were diagnosed with COPD in the 12 months following their lung cancer diagnosis or anytime preceding their lung cancer diagnosis. Results: As of April 2021, we have had access to all relevant data for this study, have received funding (January 2020), and have begun the preliminary analysis of our data set. Conclusions: It is well documented that COPD and lung cancer are both destructive diseases in terms of YLL, PYLL, WYL, and productivity loss; however, no studies have been conducted to analyze a cohort with combined COPD and lung cancer. Understanding the economic burden associated with each of our 3 cohorts is necessary in understanding and thus reducing the societal impact of COPD and lung cancer. International Registered Report Identifier (IRRID): RR1-10.2196/31350 ", doi="10.2196/31350", url="https://www.researchprotocols.org/2022/3/e31350", url="http://www.ncbi.nlm.nih.gov/pubmed/35254280" } @Article{info:doi/10.2196/33191, author="Li, Yuanyuan and Xu, Junfang and Gu, Yuxuan and Sun, Xueshan and Dong, Hengjin and Chen, Changgui", title="The Disease and Economic Burdens of Esophageal Cancer in China from 2013 to 2030: Dynamic Cohort Modeling Study", journal="JMIR Public Health Surveill", year="2022", month="Mar", day="2", volume="8", number="3", pages="e33191", keywords="esophageal cancer", keywords="disease burden", keywords="disability-adjusted life year", keywords="economic burden", abstract="Background: Esophageal cancer (EC) is the sixth leading cause of tumor-related deaths worldwide. Estimates of the EC burden are necessary and could offer evidence-based suggestions for local cancer control. Objective: The aim of this study was to predict the disease burden of EC in China through the estimation of disability-adjusted life years (DALYs) and direct medical expenditure by sex from 2013 to 2030. Methods: A dynamic cohort Markov model was developed to simulate EC prevalence, DALYs, and direct medical expenditure by sex. Input data were collected from the China Statistical Yearbooks, Statistical Report of China Children's Development, World Population Prospects 2019, and published papers. The JoinPoint Regression Program was used to calculate the average annual percentage change (AAPC) of DALY rates, whereas the average annual growth rate (AAGR) was applied to analyze the changing direct medical expenditure trend over time. Results: From 2013 to 2030, the predicted EC prevalence is projected to increase from 61.0 to 64.5 per 100,000 people, with annual EC cases increasing by 11.5\% (from 835,600 to 931,800). The DALYs will increase by 21.3\% (from 30,034,000 to 36,444,000), and the years of life lost (YLL) will account for over 90\% of the DALYs. The DALY rates per 100,000 people will increase from 219.2 to 252.3; however, there was a difference between sexes, with an increase from 302.9 to 384.3 in males and a decline from 131.2 to 115.9 in females. The AAPC was 0.8\% (95\% CI 0.8\% to 0.9\%), 1.4\% (95\% CI 1.3\% to 1.5\%), and --0.7\% (95\% CI --0.8\% to --0.7\%) for both sexes, males, and females, respectively. The direct medical expenditure will increase by 128.7\% (from US \$33.4 to US \$76.4 billion), with an AAGR of 5.0\%. The direct medical expenditure is 2-3 times higher in males than in females. Conclusions: EC still causes severe disease and economic burdens. YLL are responsible for the majority of DALYs, which highlights an urgent need to establish a beneficial policy to reduce the EC burden. ", doi="10.2196/33191", url="https://publichealth.jmir.org/2022/3/e33191", url="http://www.ncbi.nlm.nih.gov/pubmed/34963658" } @Article{info:doi/10.2196/32918, author="Farmer, Andrew and Jones, Louise and Newhouse, Nikki and Kenning, Cassandra and Williams, Nicola and Chi, Yuan and Bartlett, Kiera Y. and Plumpton, Catrin and McSharry, Jenny and Cholerton, Rachel and Holmes, Emily and Robinson, Stephanie and Allen, Julie and Gudgin, Bernard and Velardo, Carmelo and Rutter, Heather and Horne, Rob and Tarassenko, Lionel and Williams, Veronika and Locock, Louise and Rea, Rustam and Yu, Ly-Mee and Hughes, Dyfrig and Bower, Peter and French, David", title="Supporting People With Type 2 Diabetes in the Effective Use of Their Medicine Through Mobile Health Technology Integrated With Clinical Care to Reduce Cardiovascular Risk: Protocol for an Effectiveness and Cost-effectiveness Randomized Controlled Trial", journal="JMIR Res Protoc", year="2022", month="Feb", day="21", volume="11", number="2", pages="e32918", keywords="diabetes", keywords="SMS text messages", keywords="cardiovascular risk prevention", keywords="medication adherence", keywords="digital health", keywords="randomized controlled trial", abstract="Background: Type 2 diabetes is a common lifelong condition that affects over 400 million people worldwide. The use of effective medications and active self-management can reduce the risk of serious complications. However, people often have concerns when starting new medications and face difficulties in taking their medications regularly. Support provided by brief messages delivered through mobile phone--based SMS text messages can be effective in some long-term conditions. We have identified promising behavior change techniques (BCTs) to promote medication adherence in this population via a systematic review and developed SMS text messages that target these BCTs. Feasibility work has shown that these messages have fidelity to intended BCTs, are acceptable to patients, and are successful in changing the intended determinants of medication adherence. We now plan to test this intervention on a larger scale in a clinical trial. Objective: The aim of this trial is to determine the effectiveness and cost-effectiveness of this intervention for reducing cardiovascular risk in people with type 2 diabetes by comparing it with usual care. Methods: The trial will be a 12-month, multicenter, individually randomized controlled trial in primary care and will recruit adults (aged ?35 years) with type 2 diabetes in England. Consenting participants will be randomized to receive short SMS text messages intended to affect a change in medication adherence 3 to 4 times per week in addition to usual care. The aim is to test the effectiveness and cost-effectiveness of the intervention when it is added to usual care. The primary clinical outcome will be a composite cardiovascular risk measure. Data including patient-reported measures will be collected at baseline, at 13 and 26 weeks, and at the end of the 12-month follow-up period. With 958 participants (479 in each group), the trial is powered at 92.5\% to detect a 4--percentage point difference in cardiovascular risk. The analysis will follow a prespecified plan. A nested quantitative and qualitative process analysis will be used to examine the putative mechanisms of behavior change and wider contextual influences. A health economic analysis will be used to assess the cost-effectiveness of the intervention. Results: The trial has completed the recruitment phase and is in the follow-up phase. The publication of results is anticipated in 2024. Conclusions: This trial will provide evidence regarding the effectiveness and cost-effectiveness of this intervention for people with type 2 diabetes. Trial Registration: ISRCTN Registry ISRCTN15952379; https://www.isrctn.com/ISRCTN15952379 International Registered Report Identifier (IRRID): DERR1-10.2196/32918 ", doi="10.2196/32918", url="https://www.researchprotocols.org/2022/2/e32918", url="http://www.ncbi.nlm.nih.gov/pubmed/35188478" } @Article{info:doi/10.2196/31109, author="Park, S. Linda and Chih, Ming-Yuan and Stephenson, Christine and Schumacher, Nicholas and Brown, Randall and Gustafson, David and Barrett, Bruce and Quanbeck, Andrew", title="Testing an mHealth System for Individuals With Mild to Moderate Alcohol Use Disorders: Protocol for a Type 1 Hybrid Effectiveness-Implementation Trial", journal="JMIR Res Protoc", year="2022", month="Feb", day="18", volume="11", number="2", pages="e31109", keywords="mHealth", keywords="mobile health", keywords="alcohol use disorder", keywords="alcohol reduction", keywords="wellness", keywords="risky drinking", keywords="quality of life", keywords="protocol", abstract="Background: The extent of human interaction needed to achieve effective and cost-effective use of mobile health (mHealth) apps for individuals with mild to moderate alcohol use disorder (AUD) remains largely unexamined. This study seeks to understand how varying levels of human interaction affect the ways in which an mHealth intervention for the prevention and treatment of AUDs works or does not work, for whom, and under what circumstances. Objective: The primary aim is to detect the effectiveness of an mHealth intervention by assessing differences in self-reported risky drinking patterns and quality of life between participants in three study groups (self-monitored, peer-supported, and clinically integrated). The cost-effectiveness of each approach will also be assessed. Methods: This hybrid type 1 study is an unblinded patient-level randomized clinical trial testing the effects of using an evidence-based mHealth system on participants' drinking patterns and quality of life. There are two groups of participants for this study: individuals receiving the intervention and health care professionals practicing in the broader health care environment. The intervention is a smartphone app that encourages users to reduce their alcohol consumption within the context of integrative medicine using techniques to build healthy habits. The primary outcomes for quantitative analysis will be participant data on their risky drinking days and quality of life as well as app use from weekly and quarterly surveys. Cost measures include intervention and implementation costs. The cost per participant will be determined for each study arm, with intervention and implementation costs separated within each group. There will also be a qualitative assessment of health care professionals' engagement with the app as well as their thoughts on participant experience with the app. Results: This protocol was approved by the Health Sciences Minimal Risk Institutional Review Board on November 18, 2019, with subsequent annual reviews. Recruitment began on March 6, 2020, but was suspended on March 13, 2020, due to the COVID-19 pandemic restrictions. Limited recruitment resumed on July 6, 2020. Trial status as of November 17, 2021, is as follows: 357 participants were enrolled in the study for a planned enrollment of 546 participants. Conclusions: The new knowledge gained from this study could have wide and lasting benefits related to the integration of mHealth systems for individuals with mild to moderate AUDs. The results of this study will guide policy makers and providers toward cost-effective ways to incorporate technology in health care and community settings. Trial Registration: ClinicalTrials.gov NCT04011644; https://clinicaltrials.gov/ct2/show/NCT04011644 International Registered Report Identifier (IRRID): DERR1-10.2196/31109 ", doi="10.2196/31109", url="https://www.researchprotocols.org/2022/2/e31109", url="http://www.ncbi.nlm.nih.gov/pubmed/35179502" } @Article{info:doi/10.2196/28612, author="Milne-Ives, Madison and Leyden, John and Maramba, Inocencio and Chatterjee, Arunangsu and Meinert, Edward", title="The Potential Impacts of a Digital Preoperative Assessment Service on Appointments, Travel-Related Carbon Dioxide Emissions, and User Experience: Case Study", journal="JMIR Perioper Med", year="2022", month="Feb", day="16", volume="5", number="1", pages="e28612", keywords="preoperative care", keywords="preoperative period", keywords="telemedicine", keywords="telehealth", keywords="appointments", keywords="cost-effective", keywords="economic", abstract="Background: The National Health Service (NHS) cannot keep up with the demand for operations and procedures. Preoperative assessments can be conducted on the internet to improve efficiency and reduce wait times for operations. MyPreOp is a cloud-based platform where patients can complete preoperative questionnaires. These are reviewed by a nurse who determines whether they need a subsequent face-to-face appointment. Objective: The primary objective of this study is to describe the potential impact of MyPreOp (Ultramed Ltd) on the number of face-to-face appointments. The secondary objectives are to examine the time spent on preoperative assessments completed using MyPreOp in NHS Trusts and user ratings of usability and acceptability. Methods: The study design was a case study service evaluation. Data were collected using the MyPreOp system from 2 NHS Trusts (Guy's and St Thomas' and Royal United Hospitals Bath) and the private BMI Bath Clinic during the 4-month period from September to December 2020. Participants were adults of any age and health status at the participating hospitals who used MyPreOp to complete a preoperative assessment before a scheduled surgery. The primary outcome was the number of face-to-face appointments avoided by patients who used MyPreOp. The investigated secondary outcomes included the length of time spent by nurses completing preoperative assessments, associated travel-related carbon dioxide emissions compared with standard care, and quantitative user feedback. User feedback was assessed at all 3 sites; however, the other outcomes could only be examined in the Royal United Hospitals Bath sample because of data limitations. Results: Data from 2500 participants were included. Half of the assessed patients did not need a further face-to-face appointment and required a median of only 5.3 minutes of nurses' time to review. The reduction in appointments was associated with a small saving of carbon dioxide equivalent emissions (9.05 tons). Patient feedback was generally positive: 79.8\% (317/397) of respondents rated MyPreOp as easy or very easy to use, and 85.2\% (340/399) thought the overall experience was good or very good. Conclusions: This evaluation demonstrates the potential benefits of MyPreOp. However, further research using rigorous scientific methodology and a larger sample of NHS Trusts and users is needed to provide strong evidence of MyPreOp's efficacy, usability, and cost-effectiveness. ", doi="10.2196/28612", url="https://periop.jmir.org/2022/1/e28612", url="http://www.ncbi.nlm.nih.gov/pubmed/35171104" } @Article{info:doi/10.2196/35042, author="Lewkowicz, Daniel and Wohlbrandt, M. Attila and Bottinger, Erwin", title="Digital Therapeutic Care Apps With Decision-Support Interventions for People With Low Back Pain in Germany: Cost-Effectiveness Analysis", journal="JMIR Mhealth Uhealth", year="2022", month="Feb", day="7", volume="10", number="2", pages="e35042", keywords="cost-utility analysis", keywords="low back pain", keywords="back pain", keywords="cost-effectiveness", keywords="Markov model", keywords="digital therapy", keywords="digital health app", keywords="mHealth", keywords="orthopedic", keywords="eHealth", keywords="mobile health", keywords="digital health", keywords="pain management", keywords="health apps", abstract="Background: Digital therapeutic care apps provide a new effective and scalable approach for people with nonspecific low back pain (LBP). Digital therapeutic care apps are also driven by personalized decision-support interventions that support the user in self-managing LBP, and may induce prolonged behavior change to reduce the frequency and intensity of pain episodes. However, these therapeutic apps are associated with high attrition rates, and the initial prescription cost is higher than that of face-to-face physiotherapy. In Germany, digital therapeutic care apps are now being reimbursed by statutory health insurance; however, price targets and cost-driving factors for the formation of the reimbursement rate remain unexplored. Objective: The aim of this study was to evaluate the cost-effectiveness of a digital therapeutic care app compared to treatment as usual (TAU) in Germany. We further aimed to explore under which circumstances the reimbursement rate could be modified to consider value-based pricing. Methods: We developed a state-transition Markov model based on a best-practice analysis of prior LBP-related decision-analytic models, and evaluated the cost utility of a digital therapeutic care app compared to TAU in Germany. Based on a 3-year time horizon, we simulated the incremental cost and quality-adjusted life years (QALYs) for people with nonacute LBP from the societal perspective. In the deterministic sensitivity and scenario analyses, we focused on diverging attrition rates and app cost to assess our model's robustness and conditions for changing the reimbursement rate. All costs are reported in Euro ({\texteuro}1=US \$1.12). Results: Our base case results indicated that the digital therapeutic care strategy led to an incremental cost of {\texteuro}121.59, but also generated 0.0221 additional QALYs compared to the TAU strategy, with an estimated incremental cost-effectiveness ratio (ICER) of {\texteuro}5486 per QALY. The sensitivity analysis revealed that the reimbursement rate and the capability of digital therapeutic care to prevent reoccurring LBP episodes have a significant impact on the ICER. At the same time, the other parameters remained unaffected and thus supported the robustness of our model. In the scenario analysis, the different model time horizons and attrition rates strongly influenced the economic outcome. Reducing the cost of the app to {\texteuro}99 per 3 months or decreasing the app's attrition rate resulted in digital therapeutic care being significantly less costly with more generated QALYs, and is thus considered to be the dominant strategy over TAU. Conclusions: The current reimbursement rate for a digital therapeutic care app in the statutory health insurance can be considered a cost-effective measure compared to TAU. The app's attrition rate and effect on the patient's prolonged behavior change essentially influence the settlement of an appropriate reimbursement rate. Future value-based pricing targets should focus on additional outcome parameters besides pain intensity and functional disability by including attrition rates and the app's long-term effect on quality of life. ", doi="10.2196/35042", url="https://mhealth.jmir.org/2022/2/e35042", url="http://www.ncbi.nlm.nih.gov/pubmed/35129454" } @Article{info:doi/10.2196/30095, author="Mujcic, Ajla and Blankers, Matthijs and Boon, Brigitte and Berman, H. Anne and Riper, Heleen and van Laar, Margriet and Engels, Rutger", title="Effectiveness, Cost-effectiveness, and Cost-Utility of a Digital Alcohol Moderation Intervention for Cancer Survivors: Health Economic Evaluation and Outcomes of a Pragmatic Randomized Controlled Trial", journal="J Med Internet Res", year="2022", month="Feb", day="1", volume="24", number="2", pages="e30095", keywords="alcohol", keywords="brief interventions", keywords="cancer survivors", keywords="effectiveness", keywords="cost-effectiveness", keywords="eHealth", keywords="mobile phone", abstract="Background: Alcohol moderation (AM) interventions may contribute to better treatment outcomes and the general well-being of cancer survivors. Objective: This study evaluates the effectiveness, cost-effectiveness, and cost-utility of MyCourse, a digital AM intervention, compared with a noninteractive digital information brochure for cancer survivors. Methods: A health economic evaluation alongside a pragmatic 2-arm parallel-group randomized controlled trial was conducted with follow-ups at 3, 6, and 12 months after randomization. The study was conducted on the web in the Netherlands from 2016 to 2019. Participants were adult 10-year cancer survivors drinking over the Dutch-recommended drinking guidelines (?7 standard units [10 g of alcohol] per week) with the intention to moderate or quit drinking. Overall, 103 participants were randomized and analyzed: 53 (51.5\%) in the MyCourse group and 50 (48.5\%) in the control group. In the MyCourse group, participants had access to a newly developed, digital, minimally guided AM intervention, MyCourse--Moderate Drinking. The primary outcome was the self-reported number of standard drinks (10 g of ethanol) consumed in the past 7 days at the 6-month follow-up. The secondary outcome measures were alcohol-related problems as measured by the Alcohol Use Disorders Identification Test (AUDIT) and treatment satisfaction. For the health economic evaluation, health care costs, costs because of productivity losses, and intervention costs were assessed over a 12-month horizon. Results: Alcohol use at the 6-month follow-up decreased by 38\% in the MyCourse group and by 33\% in the control group. No difference in 7-day alcohol use was found between the groups (B=2.1, 95\% CI ?7.6 to 3.1; P=.22) at any of the follow-ups. AUDIT scores for alcohol-related problems decreased over time in both groups, showing no significant difference between the groups (Cohen d=0.3, 95\% CI ?0.1 to 0.6; P=.21). Intervention costs per participant were estimated at US \$279 for the MyCourse group and US \$74 for the control group. The mean societal costs were US \$18,092 (SD 25,662) and US \$23,496 (SD 34,327), respectively. The MyCourse group led to fewer gained quality-adjusted life years at lower societal costs in the cost-utility analysis. In the cost-effectiveness analysis, the MyCourse group led to a larger reduction in drinking units over time at lower societal costs (incremental cost-effectiveness ratio per reduced drink: US \$ ?1158, 95\% CI ?1609 to ?781). Conclusions: At 6 months, alcohol use was reduced by approximately one-third in both groups, with no significant differences between the digital intervention MyCourse and a noninteractive web-based brochure. At 12 months, cost-effectiveness analyses showed that MyCourse led to a larger reduction in drinking units over time, at lower societal costs. The MyCourse group led to marginally fewer gained quality-adjusted life years, also at lower societal costs. Trial Registration: Netherlands Trial Register NTR6010; https://www.trialregister.nl/trial/5433 International Registered Report Identifier (IRRID): RR2-10.1186/s12885-018-4206-z ", doi="10.2196/30095", url="https://www.jmir.org/2022/2/e30095", url="http://www.ncbi.nlm.nih.gov/pubmed/35103605" } @Article{info:doi/10.2196/33776, author="Sado, Mitsuhiro and Ninomiya, Akira and Nagaoka, Maki and Koreki, Akihiro and Goto, Naho and Sasaki, Yohei and Takamori, Chie and Kosugi, Teppei and Yamada, Masashi and Park, Sunre and Sato, Yasunori and Fujisawa, Daisuke and Nakagawa, Atsuo and Mimura, Masaru", title="Effectiveness of Mindfulness-Based Cognitive Therapy With Follow-Up Sessions for Pharmacotherapy-Refractory Anxiety Disorders: Protocol for a Feasibility Randomized Controlled Trial", journal="JMIR Res Protoc", year="2022", month="Jan", day="21", volume="11", number="1", pages="e33776", keywords="mindfulness-based cognitive therapy", keywords="anxiety disorders", keywords="long-term effects", keywords="randomized controlled trial", keywords="cost-effectiveness", abstract="Background: Augmented mindfulness-based cognitive therapy (MBCT) with treatment as usual (mainly pharmacotherapy) is reported to be effective after treatment for anxiety disorders. However, whether its effectiveness persists in the long term is unclear. Objective: This study aims to examine the feasibility, acceptability, and effectiveness of a follow-up program by conducting a feasibility randomized controlled trial (RCT) that compares augmented MBCT with follow-up sessions and that without follow-up sessions in preparation for a definitive RCT. Methods: The study involves an 8-week MBCT with a 10-month follow-up. Patients aged 20 to 65 years who meet the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for panic disorder, agoraphobia, or social anxiety disorder, which is not remitted with usual treatment for at least 4 weeks, will be included in the study and randomly allocated to receive augmented MBCT with follow-up sessions or augmented MBCT without follow-up sessions. For this feasibility RCT, the primary outcomes are (1) study inclusion rate, (2) dropout rate, (3) attendance rate, and (4) mean and standard deviation of several clinical measures at 8 weeks and 5, 8, and 12 months. Results: We started recruiting participants in January 2020, and 43 participants have been enrolled up to January 2021. The study is ongoing, and data collection will be completed by May 2022. Conclusions: This study is novel in terms of its design, which compares augmented MBCT with and without follow-up sessions. The limitations of the trial are as follows: (1) mixed participants in terms of the delivery mode of the intervention, and (2) lack of a pharmacotherapy-alone arm. Owing to its novelty and significance, this study will provide fruitful knowledge for future definitive RCTs. Trial Registration: UMIN Clinical Trials Registry UMIN000038626; https://tinyurl.com/2p9dtxzh International Registered Report Identifier (IRRID): DERR1-10.2196/33776 ", doi="10.2196/33776", url="https://www.researchprotocols.org/2022/1/e33776", url="http://www.ncbi.nlm.nih.gov/pubmed/34787573" } @Article{info:doi/10.2196/31628, author="Adroher Mas, Cristina and Esposito Catal{\`a}, Candela and Batlle Boada, Astrid and Casadevall Llandrich, Ricard and Millet Elizalde, Marta and Garc{\'i}a Garc{\'i}a, Jos{\'e} Juan and del Castillo Rey, Manel and Garc{\'i}a Cuy{\`a}s, Francesc and Pons Serra, Miquel and L{\'o}pez Segu{\'i}, Francesc", title="Pediatric Tele--Home Care Compared to Usual Care: Cost-Minimization Analysis", journal="JMIR Pediatr Parent", year="2022", month="Jan", day="20", volume="5", number="1", pages="e31628", keywords="cost analysis", keywords="pediatric tele--home care", keywords="home care service", keywords="health economics", keywords="telehealth", keywords="economic evaluation", keywords="telemedicine", keywords="pediatrics", abstract="Background: Although home hospitalization has been a well-known and widespread practice for some time in the adult population, it has not been the same case in the pediatric setting. Simultaneously, telemedicine tools are a facilitator of the change in the health care model, which is increasingly focused on home care. In a pioneering way in Spain, the in-home hospitalization program of the Hospital Sant Joan de D{\'e}u in Barcelona allows the child to be in their home environment at the time they are being monitored and clinically followed by the professionals. Besides being the preferred option for families, previous experience suggests that pediatric home hospitalization reduces costs, primarily thanks to savings on the structural cost of the stay. Objective: The aim of this study is to compare the average cost of a discharge by tele--home care with the usual care and to analyze the main drivers of the differential costs of both care models. Methods: A cost-minimization analysis is conducted under a hospital's perspective, based on observational data, and estimated retrospectively. A historical control group of similar patients in terms of clinical casuistry to children hospitalized at home was used for comparison. Results: A 24-hour stay at the hospital costs US \$574.19, while the in-home hospitalization costs US \$301.71 per day, representing a saving of almost half (48\%) of the cost compared to usual care. The main saving drivers were the personnel costs (US \$102.83/US \$284.53, 35.5\% of the total), intermediate noncare costs (US \$6.09/US \$284.53, 33.17\%), and structural costs (US \$55.16/US \$284.53, 19.04\%). Home hospitalization involves a total stay 27.61\% longer, but at almost half the daily cost, and thus represents a saving of US \$176.70 (9.01\%) per 24-hour stay. Conclusions: The cost analysis conducted under a hospital perspective shows that pediatric tele--home care is 9\% cheaper compared to regular hospital care. These results motivate the most widespread implementation of the service from the point of view of economic efficiency, adding to previous experiences that suggest that it is also preferable from the perspective of user satisfaction. ", doi="10.2196/31628", url="https://pediatrics.jmir.org/2022/1/e31628", url="http://www.ncbi.nlm.nih.gov/pubmed/35049513" } @Article{info:doi/10.2196/26299, author="Braekman, Elise and Demarest, Stefaan and Charafeddine, Rana and Drieskens, Sabine and Berete, Finaba and Gisle, Lydia and Van der Heyden, Johan and Van Hal, Guido", title="Unit Response and Costs in Web Versus Face-To-Face Data Collection: Comparison of Two Cross-sectional Health Surveys", journal="J Med Internet Res", year="2022", month="Jan", day="7", volume="24", number="1", pages="e26299", keywords="health interview surveys", keywords="data collection mode", keywords="face-to-face", keywords="web", keywords="unit response", keywords="response rate", keywords="nonresponse", keywords="data collection costs", keywords="web data", keywords="health surveys", keywords="internet penetration", keywords="web survey", keywords="costs", abstract="Background: Potential is seen in web data collection for population health surveys due to its combined cost-effectiveness, implementation ease, and increased internet penetration. Nonetheless, web modes may lead to lower and more selective unit response than traditional modes, and this may increase bias in the measured indicators. Objective: This research assesses the unit response and costs of a web study versus face-to-face (F2F) study. Methods: Alongside the Belgian Health Interview Survey by F2F edition 2018 (BHISF2F; net sample used: 3316), a web survey (Belgian Health Interview Survey by Web [BHISWEB]; net sample used: 1010) was organized. Sociodemographic data on invited individuals was obtained from the national register and census linkages. Unit response rates considering the different sampling probabilities of both surveys were calculated. Logistic regression analyses examined the association between mode system and sociodemographic characteristics for unit nonresponse. The costs per completed web questionnaire were compared with the costs for a completed F2F questionnaire. Results: The unit response rate is lower in BHISWEB (18.0\%) versus BHISF2F (43.1\%). A lower response rate was observed for the web survey among all sociodemographic groups, but the difference was higher among people aged 65 years and older (15.4\% vs 45.1\%), lower educated people (10.9\% vs 38.0\%), people with a non-Belgian European nationality (11.4\% vs 40.7\%), people with a non-European nationality (7.2\% vs 38.0\%), people living alone (12.6\% vs 40.5\%), and people living in the Brussels-Capital (12.2\% vs 41.8\%) region. The sociodemographic characteristics associated with nonresponse are not the same in the 2 studies. Having another European (OR 1.60, 95\% CI 1.20-2.13) or non-European nationality (OR 2.57, 95\% CI 1.79-3.70) compared to a Belgian nationality and living in the Brussels-Capital (OR 1.72, 95\% CI 1.41-2.10) or Walloon (OR 1.47, 95\% CI 1.15-1.87) regions compared to the Flemish region are associated with a higher nonresponse only in the BHISWEB study. In BHISF2F, younger people (OR 1.31, 95\% CI 1.11-1.54) are more likely to be nonrespondents than older people, and this was not the case in BHISWEB. In both studies, lower educated people have a higher probability of being nonrespondent, but this effect is more pronounced in BHISWEB (low vs high education level: Web, OR 2.71, 95\% CI 2.21-3.39 and F2F OR 1.70, 95\% CI 1.48-1.95). The BHISWEB study had a considerable advantage; the cost per completed questionnaire was almost 3 times lower ({\texteuro}41 [US \$48]) compared with F2F data collection ({\texteuro}111 [US \$131]). Conclusions: The F2F unit response rate was generally higher, yet for certain groups the difference between web and F2F was more limited. Web data collection has a considerable cost advantage. It is therefore worth experimenting with adaptive mixed-mode designs to optimize financial resources without increasing selection bias (eg, only inviting sociodemographic groups who are keener to participate online for web surveys while continuing to focus on increasing F2F response rates for other groups). ", doi="10.2196/26299", url="https://www.jmir.org/2022/1/e26299", url="http://www.ncbi.nlm.nih.gov/pubmed/34994701" } @Article{info:doi/10.2196/30368, author="Mudaranthakam, Pal Dinesh and Brown, Alexandra and Kerling, Elizabeth and Carlson, E. Susan and Valentine, J. Christina and Gajewski, Byron", title="The Successful Synchronized Orchestration of an Investigator-Initiated Multicenter Trial Using a Clinical Trial Management System and Team Approach: Design and Utility Study", journal="JMIR Form Res", year="2021", month="Dec", day="22", volume="5", number="12", pages="e30368", keywords="data management", keywords="data quality", keywords="metrics", keywords="trial execution", keywords="clinical trials", keywords="cost", keywords="accrual", keywords="accrual inequality", keywords="rare diseases", keywords="healthcare", keywords="health care", keywords="health operations", abstract="Background: As the cost of clinical trials continues to rise, novel approaches are required to ensure ethical allocation of resources. Multisite trials have been increasingly utilized in phase 1 trials for rare diseases and in phase 2 and 3 trials to meet accrual needs. The benefits of multisite trials include easier patient recruitment, expanded generalizability, and more robust statistical analyses. However, there are several problems more likely to arise in multisite trials, including accrual inequality, protocol nonadherence, data entry mistakes, and data integration difficulties. Objective: The Biostatistics \& Data Science department at the University of Kansas Medical Center developed a clinical trial management system (comprehensive research information system [CRIS]) specifically designed to streamline multisite clinical trial management. Methods: A National Institute of Child Health and Human Development--funded phase 3 trial, the ADORE (assessment of docosahexaenoic acid [DHA] on reducing early preterm birth) trial fully utilized CRIS to provide automated accrual reports, centralize data capture, automate trial completion reports, and streamline data harmonization. Results: Using the ADORE trial as an example, we describe the utility of CRIS in database design, regulatory compliance, training standardization, study management, and automated reporting. Our goal is to continue to build a CRIS through use in subsequent multisite trials. Reports generated to suit the needs of future studies will be available as templates. Conclusions: The implementation of similar tools and systems could provide significant cost-saving and operational benefit to multisite trials. Trial Registration: ClinicalTrials.gov NCT02626299; https://tinyurl.com/j6erphcj ", doi="10.2196/30368", url="https://formative.jmir.org/2021/12/e30368", url="http://www.ncbi.nlm.nih.gov/pubmed/34941552" } @Article{info:doi/10.2196/31702, author="Grout, Leah and Telfer, Kendra and Wilson, Nick and Cleghorn, Christine and Mizdrak, Anja", title="Prescribing Smartphone Apps for Physical Activity Promotion in Primary Care: Modeling Study of Health Gain and Cost Savings", journal="J Med Internet Res", year="2021", month="Dec", day="20", volume="23", number="12", pages="e31702", keywords="physical activity", keywords="smartphone apps", keywords="mobile health", keywords="mHealth", keywords="modeling", keywords="primary care", keywords="mobile phone", abstract="Background: Inadequate physical activity is a substantial cause of health loss worldwide, and this loss is attributable to diseases such as coronary heart disease, diabetes, stroke, and certain forms of cancer. Objective: This study aims to assess the potential impact of the prescription of smartphone apps in primary care settings on physical activity levels, health gains (in quality-adjusted life years [QALYs]), and health system costs in New Zealand (NZ). Methods: A proportional multistate lifetable model was used to estimate the change in physical activity levels and predict the resultant health gains in QALYs and health system costs over the remaining life span of the NZ population alive in 2011 at a 3\% discount rate. Results: The modeled intervention resulted in an estimated 430 QALYs gained (95\% uncertainty interval 320-550), with net cost savings of 2011 NZ \$2.2 million (2011 US \$1.5 million) over the remaining life span of the 2011 NZ population. On a per capita basis, QALY gains were generally larger in women than in men and larger in M?ori than in non-M?ori. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions on intervention uptake and decay. For example, the scenario analysis with the largest benefits, which assumed a 5-year maintenance of additional physical activity levels, delivered 1750 QALYs and 2011 NZ \$22.5 million (2011 US \$15.1 million) in cost savings. Conclusions: The prescription of smartphone apps for promoting physical activity in primary care settings is likely to generate modest health gains and cost savings at the population level in this high-income country. Such gains may increase with ongoing improvements in app design and increased health worker promotion of the apps to patients. ", doi="10.2196/31702", url="https://www.jmir.org/2021/12/e31702", url="http://www.ncbi.nlm.nih.gov/pubmed/34931993" } @Article{info:doi/10.2196/32891, author="Whitton, Clare and Healy, D. Janelle and Collins, E. Clare and Mullan, Barbara and Rollo, E. Megan and Dhaliwal, S. Satvinder and Norman, Richard and Boushey, J. Carol and Delp, J. Edward and Zhu, Fengqing and McCaffrey, A. Tracy and Kirkpatrick, I. Sharon and Atyeo, Paul and Mukhtar, Aqif Syed and Wright, L. Janine and Ramos-Garc{\'i}a, C{\'e}sar and Pollard, M. Christina and Kerr, A. Deborah", title="Accuracy and Cost-effectiveness of Technology-Assisted Dietary Assessment Comparing the Automated Self-administered Dietary Assessment Tool, Intake24, and an Image-Assisted Mobile Food Record 24-Hour Recall Relative to Observed Intake: Protocol for a Randomized Crossover Feeding Study", journal="JMIR Res Protoc", year="2021", month="Dec", day="16", volume="10", number="12", pages="e32891", keywords="24-hour recall", keywords="Automated Self-Administered Dietary Assessment Tool", keywords="Intake24", keywords="mobile food record", keywords="image-assisted dietary assessment", keywords="validation", keywords="controlled feeding", keywords="accuracy", keywords="dietary measurement error", keywords="self-report", keywords="energy intake", keywords="adult", keywords="cost-effectiveness", keywords="acceptability", keywords="mobile technology", keywords="diet surveys", keywords="mobile phone", abstract="Background: The assessment of dietary intake underpins population nutrition surveillance and nutritional epidemiology and is essential to inform effective public health policies and programs. Technological advances in dietary assessment that use images and automated methods have the potential to improve accuracy, respondent burden, and cost; however, they need to be evaluated to inform large-scale use. Objective: The aim of this study is to compare the accuracy, acceptability, and cost-effectiveness of 3 technology-assisted 24-hour dietary recall (24HR) methods relative to observed intake across 3 meals. Methods: Using a controlled feeding study design, 24HR data collected using 3 methods will be obtained for comparison with observed intake. A total of 150 healthy adults, aged 18 to 70 years, will be recruited and will complete web-based demographic and psychosocial questionnaires and cognitive tests. Participants will attend a university study center on 3 separate days to consume breakfast, lunch, and dinner, with unobtrusive documentation of the foods and beverages consumed and their amounts. Following each feeding day, participants will complete a 24HR process using 1 of 3 methods: the Automated Self-Administered Dietary Assessment Tool, Intake24, or the Image-Assisted mobile Food Record 24-Hour Recall. The sequence of the 3 methods will be randomized, with each participant exposed to each method approximately 1 week apart. Acceptability and the preferred 24HR method will be assessed using a questionnaire. Estimates of energy, nutrient, and food group intake and portion sizes from each 24HR method will be compared with the observed intake for each day. Linear mixed models will be used, with 24HR method and method order as fixed effects, to assess differences in the 24HR methods. Reporting bias will be assessed by examining the ratios of reported 24HR intake to observed intake. Food and beverage omission and intrusion rates will be calculated, and differences by 24HR method will be assessed using chi-square tests. Psychosocial, demographic, and cognitive factors associated with energy misestimation will be evaluated using chi-square tests and multivariable logistic regression. The financial costs, time costs, and cost-effectiveness of each 24HR method will be assessed and compared using repeated measures analysis of variance tests. Results: Participant recruitment commenced in March 2021 and is planned to be completed by the end of 2021. Conclusions: This protocol outlines the methodology of a study that will evaluate the accuracy, acceptability, and cost-effectiveness of 3 technology-enabled dietary assessment methods. This will inform the selection of dietary assessment methods in future studies on nutrition surveillance and epidemiology. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12621000209897; https://tinyurl.com/2p9fpf2s International Registered Report Identifier (IRRID): DERR1-10.2196/32891 ", doi="10.2196/32891", url="https://www.researchprotocols.org/2021/12/e32891", url="http://www.ncbi.nlm.nih.gov/pubmed/34924357" } @Article{info:doi/10.2196/32170, author="Roberts, J. Derek and Dreksler, Hannah and Nagpal, K. Sudhir and Li, Allen and Parsons Leigh, Jeanna and Brandys, Timothy and Jetty, Prasad and Dubois, Luc and Stelfox, T. Henry and McIsaac, I. Daniel", title="Outcomes After Receipt of Neuraxial or Regional Anesthesia Instead of General Anesthesia for Lower Limb Revascularization Surgery: Protocol for a Systematic Review and Meta-analysis", journal="JMIR Res Protoc", year="2021", month="Nov", day="26", volume="10", number="11", pages="e32170", keywords="epidural anesthesia", keywords="lower limb revascularization surgery", keywords="neuraxial anesthesia", keywords="peripheral artery disease", keywords="spinal anesthesia", keywords="vascular surgery", keywords="anesthesia", keywords="surgery", keywords="limb", keywords="nerves", keywords="spine", keywords="outcome", keywords="protocol", keywords="review", keywords="artery", keywords="cardiovascular", keywords="hospital", abstract="Background: Patients undergoing lower limb revascularization surgery for peripheral artery disease (PAD) have a high risk of perioperative morbidity and mortality and often have long hospital stays. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients. Objective: The aim is to conduct a systematic review and meta-analysis to determine whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes and costs and a shorter length of hospitalization. Methods: We will search electronic bibliographic databases (MEDLINE, EMBASE, the seven databases in Evidence-Based Medicine Reviews, medRxiv, bioRxiv, and Google Scholar), review papers identified during the search, and included article bibliographies. We will include randomized and nonrandomized studies comparing the use of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD. Two investigators will independently evaluate the risk of bias. The primary outcome will be short-term (in-hospital or 30-day) mortality. Secondary outcomes will include longer-term mortality; major adverse cardiovascular, pulmonary, renal, and limb events; delirium; deep vein thrombosis or pulmonary embolism; neuraxial or regional anesthesia--related complications; graft-related outcomes; length of operation and hospital stay; costs; and patient-reported or functional outcomes. We will calculate summary odds ratios (ORs) and standardized mean differences (SMDs) using random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. We will assess for publication bias using the Begg and Egger tests and use the trim-and-fill method to estimate the potential influence of this bias on summary estimates. Finally, we will use Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to make an overall rating of the quality of evidence in our effect estimates. Results: The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We executed the peer-reviewed search strategy on March 2, 2021. We completed the review of titles and abstracts on July 30, 2021, and plan to complete the review of full-text papers by September 30, 2021. We will complete full-text study data extraction and the risk-of-bias assessment by November 15, 2021, and conduct qualitative and then quantitative data synthesis and GRADE assessment of results by January 1, 2022, before drafting the manuscript. We anticipate that we will be able to submit the manuscript for peer review by the end of February 2022. Conclusions: This study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes, graft patency, and costs and a shorter length of hospital stay. Study results will be used to inform practice and future research, including creation of a pilot and then multicenter randomized controlled trial. Trial Registration: Prospero CRD42021237060; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=237060 International Registered Report Identifier (IRRID): PRR1-10.2196/32170 ", doi="10.2196/32170", url="https://www.researchprotocols.org/2021/11/e32170", url="http://www.ncbi.nlm.nih.gov/pubmed/34507273" } @Article{info:doi/10.2196/31442, author="Ramachandran, Raghav and McShea, J. Michael and Howson, N. Stephanie and Burkom, S. Howard and Chang, Hsien-Yen and Weiner, P. Jonathan and Kharrazi, Hadi", title="Assessing the Value of Unsupervised Clustering in Predicting Persistent High Health Care Utilizers: Retrospective Analysis of Insurance Claims Data", journal="JMIR Med Inform", year="2021", month="Nov", day="25", volume="9", number="11", pages="e31442", keywords="persistent high users", keywords="persistent high utilizers", keywords="latent class analysis", keywords="comorbidity patterns", keywords="utilization prediction", keywords="unsupervised clustering", keywords="population health analytics", keywords="health care", keywords="prediction models", keywords="health care services", keywords="health care costs", abstract="Background: A high proportion of health care services are persistently utilized by a small subpopulation of patients. To improve clinical outcomes while reducing costs and utilization, population health management programs often provide targeted interventions to patients who may become persistent high users/utilizers (PHUs). Enhanced prediction and management of PHUs can improve health care system efficiencies and improve the overall quality of patient care. Objective: The aim of this study was to detect key classes of diseases and medications among the study population and to assess the predictive value of these classes in identifying PHUs. Methods: This study was a retrospective analysis of insurance claims data of patients from the Johns Hopkins Health Care system. We defined a PHU as a patient incurring health care costs in the top 20\% of all patients' costs for 4 consecutive 6-month periods. We used 2013 claims data to predict PHU status in 2014-2015. We applied latent class analysis (LCA), an unsupervised clustering approach, to identify patient subgroups with similar diagnostic and medication patterns to differentiate variations in health care utilization across PHUs. Logistic regression models were then built to predict PHUs in the full population and in select subpopulations. Predictors included LCA membership probabilities, demographic covariates, and health utilization covariates. Predictive powers of the regression models were assessed and compared using standard metrics. Results: We identified 164,221 patients with continuous enrollment between 2013 and 2015. The mean study population age was 19.7 years, 55.9\% were women, 3.3\% had ?1 hospitalization, and 19.1\% had 10+ outpatient visits in 2013. A total of 8359 (5.09\%) patients were identified as PHUs in both 2014 and 2015. The LCA performed optimally when assigning patients to four probability disease/medication classes. Given the feedback provided by clinical experts, we further divided the population into four diagnostic groups for sensitivity analysis: acute upper respiratory infection (URI) (n=53,232; 4.6\% PHUs), mental health (n=34,456; 12.8\% PHUs), otitis media (n=24,992; 4.5\% PHUs), and musculoskeletal (n=24,799; 15.5\% PHUs). For the regression models predicting PHUs in the full population, the F1-score classification metric was lower using a parsimonious model that included LCA categories (F1=38.62\%) compared to that of a complex risk stratification model with a full set of predictors (F1=48.20\%). However, the LCA-enabled simple models were comparable to the complex model when predicting PHUs in the mental health and musculoskeletal subpopulations (F1-scores of 48.69\% and 48.15\%, respectively). F1-scores were lower than that of the complex model when the LCA-enabled models were limited to the otitis media and acute URI subpopulations (45.77\% and 43.05\%, respectively). Conclusions: Our study illustrates the value of LCA in identifying subgroups of patients with similar patterns of diagnoses and medications. Our results show that LCA-derived classes can simplify predictive models of PHUs without compromising predictive accuracy. Future studies should investigate the value of LCA-derived classes for predicting PHUs in other health care settings. ", doi="10.2196/31442", url="https://medinform.jmir.org/2021/11/e31442", url="http://www.ncbi.nlm.nih.gov/pubmed/34592712" } @Article{info:doi/10.2196/27054, author="Hurst, Rachel and Liljenquist, Kendra and Lowry, J. Sarah and Szilagyi, G. Peter and Fiscella, A. Kevin and Weaver, R. Marcia and Porras-Javier, Lorena and Ortiz, Janette and Sotelo Guerra, J. Laura and Coker, R. Tumaini", title="A Parent Coach--Led Model of Well-Child Care for Young Children in Low-Income Communities: Protocol for a Cluster Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="Nov", day="25", volume="10", number="11", pages="e27054", keywords="preventive care", keywords="well-child care", keywords="community health centers", abstract="Background: The Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT) intervention was created as a team-based approach to well-child care (WCC) that relies on a health educator (Parent Coach) to provide the bulk of WCC services, address specific needs faced by families in low-income communities, and decrease reliance on the clinician as the primary provider of WCC services. Objective: This study aims to evaluate the impact of PARENT using a cluster randomized controlled trial. Methods: This study tested the effectiveness of PARENT at 10 clinical sites in 2 federally qualified health centers in Tacoma, Washington, and Los Angeles, California. We conducted a cluster randomized controlled trial that included 916 families with children aged ?12 months at the time of the baseline survey. Parents will be followed up at 6 and 12 months after enrollment. The Parent Coach, the main element of PARENT, provides anticipatory guidance, psychosocial screening and referral, developmental and behavioral surveillance, screening, and guidance at each WCC visit. The coach is supported by parent-focused previsit screening and visit prioritization, a brief, problem-focused clinician encounter for a physical examination and any concerns that require a clinician's attention, and an automated text message parent reminder and education service for periodic, age-specific messages to reinforce key health-related information recommended by Bright Futures national guidelines. We will examine parent-reported quality of care (receipt of nationally recommended WCC services, family-centeredness of care, and parental experiences of care), and health care use (WCC, urgent care, emergency department, and hospitalizations), conduct a cost analysis, and conduct a separate time-motion study of clinician time allocation to assess efficiency. We will also collect data on exploratory measures of parent-and parenting-focused outcomes. Our primary outcomes were receipt of anticipatory guidance and emergency department use. Results: Participant recruitment began in March 2019. After recruitment, 6- and 12-month follow-up surveys will be completed. As of August 30, 2021, we enrolled a total of 916 participants. Conclusions: This large pragmatic trial of PARENT in partnership with federally qualified health centers will assess its utility as an evidence-based and financially sustainable model for the delivery of preventive care services to children in low-income communities. Trial Registration: ClinicalTrials.gov: NCT03797898; https://clinicaltrials.gov/ct2/show/NCT03797898 International Registered Report Identifier (IRRID): DERR1-10.2196/27054 ", doi="10.2196/27054", url="https://www.researchprotocols.org/2021/11/e27054", url="http://www.ncbi.nlm.nih.gov/pubmed/34842563" } @Article{info:doi/10.2196/29467, author="Anneveldt, J. Kimberley and Nijholt, M. Ingrid and Schutte, M. Joke and Dijkstra, R. Jeroen and Frederix, J. Geert W. and Ista, Erwin and Verpalen, M. Inez and Veersema, Sebastiaan and Huirne, F. Judith A. and Hehenkamp, K. Wouter J. and Boomsma, F. Martijn", title="Comparison of (Cost-)Effectiveness of Magnetic Resonance Image--Guided High-Intensity--Focused Ultrasound With Standard (Minimally) Invasive Fibroid Treatments: Protocol for a Multicenter Randomized Controlled Trial (MYCHOICE)", journal="JMIR Res Protoc", year="2021", month="Nov", day="24", volume="10", number="11", pages="e29467", keywords="high-intensity--focused ultrasound ablation", keywords="magnetic resonance imaging, interventional", keywords="leiomyoma", keywords="randomized controlled trial", keywords="cost-effectiveness analysis", keywords="clinical trial protocol", abstract="Background: Magnetic resonance image--guided high-intensity--focused ultrasound (MR-HIFU) is a rather new, noninvasive option for the treatment of uterine fibroids. It is safe, effective, and has a very short recovery time. However, a lack of prospectively collected data on long-term (cost-)effectiveness of the MR-HIFU treatment compared with standard uterine fibroid care prevents the MR-HIFU treatment from being reimbursed for this indication. Therefore, at this point, when conservative treatment for uterine fibroid symptoms has failed or is not accepted by patients, standard care includes the more invasive treatments hysterectomy, myomectomy, and uterine artery embolization (UAE). Primary outcomes of currently available data on MR-HIFU treatment often consist of technical outcomes, instead of patient-centered outcomes such as quality of life (QoL), and do not include the use of the latest equipment or most up-to-date treatment strategies. Moreover, data on cost-effectiveness are rare and seldom include data on a societal level such as productivity loss or use of painkillers. Because of the lack of reimbursement, broad clinical implementation has not taken place, nor is the proper role of MR-HIFU in uterine fibroid care sufficiently clear. Objective: The objective of our study is to determine the long-term (cost-)effectiveness of MR-HIFU compared with standard (minimally) invasive fibroid treatments. Methods: The MYCHOICE study is a national, multicenter, open randomized controlled trial with randomization in a 2:1 ratio to MR-HIFU or standard care including hysterectomy, myomectomy, and UAE. The sample size is 240 patients in total. Women are included when they are 18 years or older, in premenopausal stage, diagnosed with symptomatic uterine fibroids, conservative treatment has failed or is not accepted, and eligible for MR-HIFU. Primary outcomes of the study are QoL 24 months after treatment and costs of treatment including direct health care costs, loss of productivity, and patient costs. Results: Inclusion for the MYCHOICE study started in November 2020 and enrollment will continue until 2024. Data collection is expected to be completed in 2026. Conclusions: By collecting data on the long-term (cost-)effectiveness of the MR-HIFU treatment in comparison to current standard fibroid care, we provide currently unavailable evidence about the proper place of MR-HIFU in the fibroid treatment spectrum. This will also facilitate reimbursement and inclusion of MR-HIFU in (inter)national uterine fibroid care guidelines. Trial Registration: Netherlands Trial Register NL8863; https://www.trialregister.nl/trial/8863 International Registered Report Identifier (IRRID): DERR1-10.2196/29467 ", doi="10.2196/29467", url="https://www.researchprotocols.org/2021/11/e29467", url="http://www.ncbi.nlm.nih.gov/pubmed/34821569" } @Article{info:doi/10.2196/30690, author="Taguchi, Kayoko and Numata, Noriko and Takanashi, Rieko and Takemura, Ryo and Yoshida, Tokiko and Kutsuzawa, Kana and Yoshimura, Kensuke and Nozaki-Taguchi, Natsuko and Ohtori, Seiji and Shimizu, Eiji", title="Clinical Effectiveness and Cost-effectiveness of Videoconference-Based Integrated Cognitive Behavioral Therapy for Chronic Pain: Randomized Controlled Trial", journal="J Med Internet Res", year="2021", month="Nov", day="22", volume="23", number="11", pages="e30690", keywords="cognitive behavioral therapy", keywords="chronic pain", keywords="medical economic evaluation", keywords="EQ-5D-5L", keywords="telemedicine", abstract="Background: Cognitive behavioral therapy is known to improve the management of chronic pain. However, the components of this therapy are still being investigated and debated. Objective: This study aimed to examine the effectiveness of an integrated cognitive behavioral therapy program with new components (attention-shift, memory work, video feedback, and image training) delivered via videoconferencing. Methods: This study was unblinded and participants were recruited and assessed face-to-face in the outpatient department. We conducted a randomized controlled trial for chronic pain to compare 16 weekly videoconference-based cognitive behavioral therapy (vCBT) sessions provided by a therapist with treatment as usual (TAU). Thirty patients (age range, 22-75 years) with chronic pain were randomly assigned to either vCBT (n=15) or TAU (n=15). Patients were evaluated at week 1 (baseline), week 8 (midintervention), and week 16 (postintervention). The primary outcome was the change in pain intensity, which was recorded using the numerical rating scale at 16 weeks from the baseline. Secondary outcomes were pain severity and pain interference, which were assessed using the Brief Pain Inventory. Additionally, we evaluated disability, pain catastrophizing cognition, depression, anxiety, quality of life, and cost utility. Results: In the eligibility assessment, 30 patients were eventually randomized and enrolled; finally, 15 patients in the vCBT and 14 patients in the TAU group were analyzed. Although no significant difference was found between the 2 groups in terms of changes in pain intensity by the numerical rating scale scores at week 16 from baseline (P=.36), there was a significant improvement in the comprehensive evaluation of pain by total score of Brief Pain Inventory (--1.43, 95\% CI --2.49 to --0.37, df=24; P=.01). Further, significant improvement was seen in pain interference by using the Brief Pain Inventory (--9.42, 95\% CI --14.47 to --4.36, df=25; P=.001) and in disability by using the Pain Disability Assessment Scale (--1.95, 95\% CI --3.33 to --0.56, df=24; P=.008) compared with TAU. As for the Medical Economic Evaluation, the incremental cost-effectiveness ratio for 1 year was estimated at 2.9 million yen (about US \$25,000) per quality-adjusted life year gained. Conclusions: The findings of our study suggest that integrated cognitive behavioral therapy delivered by videoconferencing in regular medical care may reduce pain interference but not pain intensity. Further, this treatment method may be cost-effective, although this needs to be further verified using a larger sample size. Trial Registration: University Hospital Medical Information Network UMIN000031124; https://tinyurl.com/2pr3xszb ", doi="10.2196/30690", url="https://www.jmir.org/2021/11/e30690", url="http://www.ncbi.nlm.nih.gov/pubmed/34813489" } @Article{info:doi/10.2196/33183, author="Vidrine, J. Damon and Bui, C. Thanh and Businelle, S. Michael and Shih, Tina Ya-Chen and Sutton, K. Steven and Shahani, Lokesh and Hoover, Stewart Diana and Bowles, Kristina and Vidrine, I. Jennifer", title="Evaluating the Efficacy of Automated Smoking Treatment for People With HIV: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="Nov", day="17", volume="10", number="11", pages="e33183", keywords="smoking cessation", keywords="health disparities", keywords="HIV/AIDS", keywords="mHealth", keywords="mobile phone", abstract="Background: Smoking prevalence rates among people with HIV are nearly 3 times higher than those in the general population. Nevertheless, few smoking cessation trials targeting smokers with HIV have been reported in the literature. Efforts to develop and evaluate sustainable, low-cost, and evidence-based cessation interventions for people with HIV are needed. Given the widespread proliferation of mobile phones, the potential of using mobile health apps to improve the reach and efficacy of cessation interventions is promising, but evidence of efficacy is lacking, particularly among people with HIV. Objective: This study will consist of a 2-group randomized controlled trial to evaluate a fully automated smartphone intervention for people with HIV seeking cessation treatment. Methods: Participants (N=500) will be randomized to receive either standard treatment (ST; 250/500, 50\%) or automated treatment (AT; 250/500, 50\%). ST participants will be connected to the Florida Quitline and will receive nicotine replacement therapy in the form of transdermal patches and lozenges. This approach, referred to as Ask Advise Connect, was developed by our team and has been implemented in numerous health systems. ST will be compared with AT, a fully automated behavioral treatment approach. AT participants will receive nicotine replacement therapy and an interactive smartphone-based intervention that comprises individually tailored audiovisual and text content. The major goal is to determine whether AT performs better in terms of facilitating long-term smoking abstinence than the more resource-intensive ST approach. Our primary aim is to evaluate the efficacy of AT in facilitating smoking cessation among people with HIV. As a secondary aim, we will explore potential mediators and moderators and conduct economic evaluations to assess the cost and cost-effectiveness of AT compared with ST. Results: The intervention content has been developed and finalized. Recruitment and enrollment will begin in the fall of 2021. Conclusions: There is a critical need for efficacious, cost-effective, and sustainable cessation treatments for people with HIV who smoke. The AT intervention was designed to help fill this need. If efficacy is established, the AT approach will be readily adoptable by HIV clinics and community-based organizations, and it will offer an efficient way to allocate limited public health resources to tobacco control interventions. Trial Registration: ClinicalTrials.gov NCT05014282; https://clinicaltrials.gov/ct2/show/NCT05014282 International Registered Report Identifier (IRRID): PRR1-10.2196/33183 ", doi="10.2196/33183", url="https://www.researchprotocols.org/2021/11/e33183", url="http://www.ncbi.nlm.nih.gov/pubmed/34787590" } @Article{info:doi/10.2196/21142, author="Wasfi, Rania and Poirier Stephens, Zoe and Sones, Meridith and Laberee, Karen and Pugh, Caitlin and Fuller, Daniel and Winters, Meghan and Kestens, Yan", title="Recruiting Participants for Population Health Intervention Research: Effectiveness and Costs of Recruitment Methods for a Cohort Study", journal="J Med Internet Res", year="2021", month="Nov", day="12", volume="23", number="11", pages="e21142", keywords="recruitment methods", keywords="Facebook recruitment", keywords="cost-effectiveness", keywords="built environment", keywords="intervention research", keywords="natural experiment", keywords="mobile phone", abstract="Background: Public health research studies often rely on population-based participation and draw on various recruitment methods to establish samples. Increasingly, researchers are turning to web-based recruitment tools. However, few studies detail traditional and web-based recruitment efforts in terms of costs and potential biases. Objective: This study aims to report on and evaluate the cost-effectiveness, time effectiveness, and sociodemographic representation of diverse recruitment methods used to enroll participants in 3 cities of the Interventions, Research, and Action in Cities Team (INTERACT) study, a cohort study conducted in Canadian cities. Methods: Over 2017 and 2018 in Vancouver, Saskatoon, and Montreal, the INTERACT study used the following recruitment methods: mailed letters, social media (including sponsored Facebook advertisements), news media, partner communications, snowball recruitment, in-person recruitment, and posters. Participation in the study involved answering web-based questionnaires (at minimum), activating a smartphone app to share sensor data, and wearing a device for mobility and physical activity monitoring. We describe sociodemographic characteristics by the recruitment method and analyze performance indicators, including cost, completion rate, and time effectiveness. Effectiveness included calculating cost per completer (ie, a participant who completed at least one questionnaire), the completion rate of a health questionnaire, and the delay between completion of eligibility and health questionnaires. Cost included producing materials (ie, printing costs), transmitting recruitment messages (ie, mailing list rental, postage, and sponsored Facebook posts charges), and staff time. In Montreal, the largest INTERACT sample, we modeled the number of daily recruits through generalized linear models accounting for the distributed lagged effects of recruitment campaigns. Results: Overall, 1791 participants were recruited from 3 cities and completed at least one questionnaire: 318 in Vancouver, 315 in Saskatoon, and 1158 in Montreal. In all cities, most participants chose to participate fully (questionnaires, apps, and devices). The costs associated with a completed participant varied across recruitment methods and by city. Facebook advertisements generated the most recruits (n=687), at a cost of CAD \$15.04 (US \$11.57; including staff time) per completer. Mailed letters were the costliest, at CAD \$108.30 (US \$83.3) per completer but served to reach older participants. All methods resulted in a gender imbalance, with women participating more, specifically with social media. Partner newsletters resulted in the participation of younger adults and were cost-efficient (CAD \$5.16 [US \$3.97] per completer). A generalized linear model for daily Montreal recruitment identified 2-day lag effects on most recruitment methods, except for the snowball campaign (4 days), letters (15 days), and reminder cards (5 days). Conclusions: This study presents comprehensive data on the costs, effectiveness, and bias of population recruitment in a cohort study in 3 Canadian cities. More comprehensive documentation and reporting of recruitment efforts across studies are needed to improve our capacity to conduct inclusive intervention research. ", doi="10.2196/21142", url="https://www.jmir.org/2021/11/e21142", url="http://www.ncbi.nlm.nih.gov/pubmed/34587586" } @Article{info:doi/10.2196/28874, author="Laursen, Lund Sidsel and Helweg-J{\o}rgensen, Stig and Langergaard, Astrid and S{\o}ndergaard, Jesper and S{\o}rensen, Storgaard Sabrina and Mathiasen, Kim and Lichtenstein, Beck Mia and Ehlers, Holger Lars", title="Mobile Diary App Versus Paper-Based Diary Cards for Patients With Borderline Personality Disorder: Economic Evaluation", journal="J Med Internet Res", year="2021", month="Nov", day="11", volume="23", number="11", pages="e28874", keywords="borderline personality disorder", keywords="dialectical behavior therapy", keywords="mobile app", keywords="psychotherapy", keywords="cost-consequence", keywords="mHealth", keywords="mobile phone", abstract="Background: The cost-effectiveness of using a mobile diary app as an adjunct in dialectical behavior therapy (DBT) in patients with borderline personality disorder is unknown. Objective: This study aims to perform an economic evaluation of a mobile diary app compared with paper-based diary cards in DBT treatment for patients with borderline personality disorder in a psychiatric outpatient facility. Methods: This study was conducted alongside a pragmatic, multicenter, randomized controlled trial. The participants were recruited at 5 Danish psychiatric outpatient facilities and were randomized to register the emotions, urges, and skills used in a mobile diary app or on paper-based diary cards. The participants in both groups received DBT delivered by the therapists. A cost-consequence analysis with a time horizon of 12 months was performed. Consequences included quality-adjusted life years (QALYs), depression severity, borderline severity, suicidal behavior, health care use, treatment compliance, and system usability. All relevant costs were included. Focus group interviews were conducted with patients, therapists, researchers, and industry representatives to discuss the potential advantages and disadvantages of using a mobile diary app. Results: A total of 78 participants were included in the analysis. An insignificantly higher number of participants in the paper group dropped out before the start of treatment (P=.07). Of those starting treatment, participants in the app group had an average of 37.1 (SE 27.55) more days of treatment and recorded an average of 3.16 (SE 5.10) more skills per week than participants in the paper group. Participants in both groups had a QALY gain and a decrease in depression severity, borderline severity, and suicidal behavior. Significant differences were found in favor of the paper group for both QALY gain (adjusted difference ?0.054; SE 0.03) and reduction in depression severity (adjusted difference ?1.11; SE 1.57). The between-group difference in total costs ranged from US \$107.37 to US \$322.10 per participant during the 12 months. The use of services in the health care sector was similar across both time points and groups (difference: psychiatric hospitalization <5 and <5; general practice ?1.32; SE 3.68 and 2.02; SE 3.19). Overall, the patients showed high acceptability and considered the app as being easy to use. Therapists worried about potential negative influences on the therapist-patient interaction from new work tasks accompanying the introduction of the new technology but pointed at innovation potential from digital database registrations. Conclusions: This study suggests both positive and negative consequences of mobile diary apps as adjuncts to DBT compared with paper diary cards. More research is needed to draw conclusions regarding its cost-effectiveness. Trial Registration: ClinicalTrials.gov NCT03191565; http://clinicaltrials.gov/ct2/show/NCT03191565 International Registered Report Identifier (IRRID): RR2-10.2196/17737 ", doi="10.2196/28874", url="https://www.jmir.org/2021/11/e28874", url="http://www.ncbi.nlm.nih.gov/pubmed/34762057" } @Article{info:doi/10.2196/28191, author="Levati, Sara and Mellacqua, Zefiro and Caiata-Zufferey, Maria and Soldini, Emiliano and Albanese, Emiliano and Alippi, Maddalena and Bolla, Emilio and Colombo, Ada Raffaella and Cordasco, Severino and Kawohl, Wolfram and Larghi, Giuseppina and Lisi, Angela and Lucchini, Mario and Rossa, Simona and Traber, Rafael and Crivelli, Luca", title="Home Treatment for Acute Mental Health Care: Protocol for the Financial Outputs, Risks, Efficacy, Satisfaction Index and Gatekeeping of Home Treatment (FORESIGHT) Study", journal="JMIR Res Protoc", year="2021", month="Nov", day="9", volume="10", number="11", pages="e28191", keywords="acute mental healthcare", keywords="home treatment", keywords="crisis resolution", keywords="home visits", keywords="mental health", keywords="home care", keywords="crisis", keywords="home", keywords="community-based", keywords="mental health services", keywords="economic", keywords="risk", keywords="risks", keywords="efficacy", keywords="public health", keywords="accessibility", abstract="Background: Crisis Resolution and Home Treatment (CRHT) teams represent a community-based mental health service offering a valid alternative to hospitalization. CRHT teams have been widely implemented in various mental health systems worldwide, and their goal is to provide care for people with severe acute mental disorders who would be considered for admission to acute psychiatric wards. The evaluation of several home-treatment experiences shows promising results; however, it remains unclear which specific elements and characteristics of CRHT are more effective and acceptable. Objective: This study aims to assess the acceptability, effectiveness, and cost-effectiveness of a new CRHT intervention in Ticino, Southern Switzerland. Methods: This study includes an interventional, nonrandomized, quasi-experimental study combined with a qualitative study and an economic evaluation to be conducted over a 48-month period. The quasi-experimental evaluation involves two groups: patients in the northern area of the region who were offered the CRHT service (ie, intervention group) and patients in the southern area of the region who received care as usual (ie, control group). Individual interviews will be conducted with patients receiving the home treatment intervention and their family members. CRHT members will also be asked to participate in a focus group. The economic evaluation will include a cost-effectiveness analysis. Results: The project is funded by the Swiss National Science Foundation as part of the National Research Program NRP74 for a period of 48 months starting from January 2017. As of October 2021, data for the nonrandomized, quasi-experimental study and the qualitative study have been collected, and the results are expected to be published by the end of the year. Data are currently being collected for the economic evaluation. Conclusions: Compared to other Swiss CRHT experiences, the CRHT intervention in Ticino represents a unique case, as the introduction of the service is backed by the closing of one of its acute wards. The proposed study will address several areas where there are evidence gaps or contradictory findings relating to the home treatment of acute mental crisis. Findings from this study will allow local services to improve their effectiveness in a challenging domain of public health and contribute to improving access to more effective care for people with severe mental disorders. Trial Registration: ISRCTN registry ISRCTN38472626; https://www.isrctn.com/ISRCTN38472626 International Registered Report Identifier (IRRID): DERR1-10.2196/28191 ", doi="10.2196/28191", url="https://www.researchprotocols.org/2021/11/e28191", url="http://www.ncbi.nlm.nih.gov/pubmed/34751660" } @Article{info:doi/10.2196/31951, author="Sabherwal, Shalinder and Chinnakaran, Anand and Sood, Ishaana and Garg, K. Gaurav and Singh, P. Birendra and Shukla, Rajan and Reddy, A. Priya and Gilbert, Suzanne and Bassett, Ken and Murthy, S. Gudlavalleti V. and ", title="Effect of Door-to-Door Screening and Awareness Generation Activities in the Catchment Areas of Vision Centers on Service Use: Protocol for a Randomized Experimental Study", journal="JMIR Res Protoc", year="2021", month="Nov", day="4", volume="10", number="11", pages="e31951", keywords="study protocol", keywords="randomized intervention study", keywords="vision centers", keywords="door-to-door screening", keywords="cost-effectiveness", keywords="sustainability", keywords="screening", keywords="awareness", keywords="vision", keywords="eye", keywords="utilization", keywords="usage", keywords="India", keywords="rural", keywords="intervention", keywords="engagement", keywords="scalability", abstract="Background: A vision center (VC) is a significant eye care service model to strengthen primary eye care services. VCs have been set up at the block level, covering a population of 150,000-250,000 in rural areas in North India. Inadequate use by rural communities is a major challenge to sustainability of these VCs. This not only reduces the community's vision improvement potential but also impacts self-sustainability and limits expansion of services in rural areas. The current literature reports a lack of awareness regarding eye diseases and the need for care, social stigmas, low priority being given to eye problems, prevailing gender discrimination, cost, and dependence on caregivers as factors preventing the use of primary eye care. Objective: Our organization is planning an awareness-cum-engagement intervention---door-to-door basic eye checkup and visual acuity screening in VCs coverage areas---to connect with the community and improve the rational use of VCs. Methods: In this randomized, parallel-group experimental study, we will select 2 VCs each for the intervention arm and the control arm from among poor, low-performing VCs (ie, walk-in of ?10 patients/day) in our 2 operational regions (Vrindavan, Mathura District, and Mohammadi, Kheri District) of Uttar Pradesh. Intervention will include door-to-door screening and awareness generation in 8-12 villages surrounding the VCs, and control VCs will follow existing practices of awareness generation through community activities and health talks. Data will be collected from each VC for 4 months of intervention. Primary outcomes will be an increase in the number of walk-in patients, spectacle advise and uptake, referral and uptake for cataract and specialty surgery, and operational expenses. Secondary outcomes will be uptake of refraction correction and referrals for cataract and other eye conditions. Differences in the number of walk-in patients, referrals, uptake of services, and cost involved will be analyzed. Results: Background work involved planning of interventions and selection of VCs has been completed. Participant recruitment has begun and is currently in progress. Conclusions: Through this study, we will analyze whether our door-to-door intervention is effective in increasing the number of visits to a VC and, thus, overall sustainability. We will also study the cost-effectiveness of this intervention to recommend its scalability. Trial Registration: ClinicalTrials.gov NCT04800718; https://clinicaltrials.gov/ct2/show/NCT04800718 International Registered Report Identifier (IRRID): DERR1-10.2196/31951 ", doi="10.2196/31951", url="https://www.researchprotocols.org/2021/11/e31951", url="http://www.ncbi.nlm.nih.gov/pubmed/34734839" } @Article{info:doi/10.2196/28554, author="Barbosa, Ana and Brito, Jo{\~a}o and Figueiredo, Pedro and Seabra, Andr{\'e} and Mendes, Romeu", title="Effectiveness of a Walking Football Program for Middle-Aged and Older Men With Type 2 Diabetes: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="Nov", day="3", volume="10", number="11", pages="e28554", keywords="type 2 diabetes", keywords="cardiovascular risk factors", keywords="physical activity", keywords="exercise", keywords="football", keywords="soccer", keywords="walking", keywords="randomized controlled trial", abstract="Background: Studies on walking football have found positive effects on health; however, there are still several research gaps when applying walking football programs for patients with type 2 diabetes. Objective: This study aims to test the effectiveness of a walking football exercise program on glycemic control and cardiovascular risk factors in middle-aged and older men with type 2 diabetes. Methods: The study will be run as a randomized controlled trial with a 6-month duration in Portugal. Eligible participants will be randomized using a 1:1 ratio for intervention or control groups and compared using an intention-to-treat analysis. The intervention will consist of a walking football exercise program. The control group will continue with usual care in primary health care units. The primary outcome will be the mean difference in glycated hemoglobin between intervention and control groups after 6 months. Secondary outcomes include the mean differences in fasting blood glucose, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, systolic and diastolic blood pressure, body mass index, waist circumference, fat-free mass, and fat mass. Additionally, secondary outcomes include the incidence of exercise-related injuries and adverse events and the walking football exercise program's cost-utility. Results: The study protocol is being prepared to be submitted to the Health Ethics Committee of the Northern Regional Health Administration, Portugal. After approval, participant recruitment will start in primary health care units in Porto's metropolitan area by family medicine doctors. Conclusions: Walking football might have the potential to be effective in improving glycemic control and cardiovascular risk factors, with a low rate of exercise-related injuries and adverse events and a good cost-utility ratio. Therefore, walking football may be a sustainable intervention strategy for type 2 diabetes management. International Registered Report Identifier (IRRID): PRR1-10.2196/28554 ", doi="10.2196/28554", url="https://www.researchprotocols.org/2021/11/e28554", url="http://www.ncbi.nlm.nih.gov/pubmed/34730549" } @Article{info:doi/10.2196/28723, author="Belli, M. Hayley and Troxel, B. Andrea and Blecker, B. Saul and Anderman, Judd and Wong, Christina and Martinez, R. Tiffany and Mann, M. Devin", title="A Behavioral Economics--Electronic Health Record Module to Promote Appropriate Diabetes Management in Older Adults: Protocol for a Pragmatic Cluster Randomized Controlled Trial", journal="JMIR Res Protoc", year="2021", month="Oct", day="27", volume="10", number="10", pages="e28723", keywords="diabetes", keywords="behavioral economics", keywords="electronic health records", keywords="clinical decision support", keywords="randomized controlled trial", keywords="pragmatic", abstract="Background: The integration of behavioral economics (BE) principles and electronic health records (EHRs) using clinical decision support (CDS) tools is a novel approach to improving health outcomes. Meanwhile, the American Geriatrics Society has created the Choosing Wisely (CW) initiative to promote less aggressive glycemic targets and reduction in pharmacologic therapy in older adults with type 2 diabetes mellitus. To date, few studies have shown the effectiveness of combined BE and EHR approaches for managing chronic conditions, and none have addressed guideline-driven deprescribing specifically in type 2 diabetes. We previously conducted a pilot study aimed at promoting appropriate CW guideline adherence using BE nudges and EHRs embedded within CDS tools at 5 clinics within the New York University Langone Health (NYULH) system. The BE-EHR module intervention was tested for usability, adoption, and early effectiveness. Preliminary results suggested a modest improvement of 5.1\% in CW compliance. Objective: This paper presents the protocol for a study that will investigate the effectiveness of a BE-EHR module intervention that leverages BE nudges with EHR technology and CDS tools to reduce overtreatment of type 2 diabetes in adults aged 76 years and older, per the CW guideline. Methods: A pragmatic, investigator-blind, cluster randomized controlled trial was designed to evaluate the BE-EHR module. A total of 66 NYULH clinics will be randomized 1:1 to receive for 18 months either (1) a 6-component BE-EHR module intervention + standard care within the NYULH EHR, or (2) standard care only. The intervention will be administered to clinicians during any patient encounter (eg, in person, telemedicine, medication refill, etc). The primary outcome will be patient-level CW compliance. Secondary outcomes will measure the frequency of intervention component firings within the NYULH EHR, and provider utilization and interaction with the BE-EHR module components. Results: Study recruitment commenced on December 7, 2020, with the activation of all 6 BE-EHR components in the NYULH EHR. Conclusions: This study will test the effectiveness of a previously developed, iteratively refined, user-tested, and pilot-tested BE-EHR module aimed at providing appropriate diabetes care to elderly adults, compared to usual care via a cluster randomized controlled trial. This innovative research will be the first pragmatic randomized controlled trial to use BE principles embedded within the EHR and delivered using CDS tools to specifically promote CW guideline adherence in type 2 diabetes. The study will also collect valuable information on clinician workflow and interaction with the BE-EHR module, guiding future research in optimizing the timely delivery of BE nudges within CDS tools. This work will address the effectiveness of BE-inspired interventions in diabetes and chronic disease management. Trial Registration: ClinicalTrials.gov NCT04181307; https://clinicaltrials.gov/ct2/show/NCT04181307 International Registered Report Identifier (IRRID): DERR1-10.2196/28723 ", doi="10.2196/28723", url="https://www.researchprotocols.org/2021/10/e28723", url="http://www.ncbi.nlm.nih.gov/pubmed/34704959" } @Article{info:doi/10.2196/28622, author="Porter, Gwenndolyn and Michaud, L. Tzeyu and Schwab, J. Robert and Hill, L. Jennie and Estabrooks, A. Paul", title="Reach Outcomes and Costs of Different Physician Referral Strategies for a Weight Management Program Among Rural Primary Care Patients: Type 3 Hybrid Effectiveness-Implementation Trial", journal="JMIR Form Res", year="2021", month="Oct", day="20", volume="5", number="10", pages="e28622", keywords="weight management", keywords="rural", keywords="RE-AIM", keywords="hybrid effectiveness-implementation", keywords="primary care", keywords="obesity", keywords="physicians", keywords="digital health", keywords="health technology", keywords="mobile phone", abstract="Background: Rural residents are at high risk for obesity; however, little resources exist to address this disproportional burden of disease. Primary care may provide an opportunity to connect primary care patients with overweight and obesity to effective weight management programming. Objective: The purpose of this study is to examine the utility of different physician referral and engagement processes for improving the reach of an evidence-based and technology-delivered weight management program with counseling support for rural primary care patients. Methods: A total of 5 rural primary care physicians were randomly assigned a sequence of four referral strategies: point-of-care (POC) referral with active telephone follow-up (ATF); POC referral, no ATF; a population health registry--derived letter referral with ATF; and letter referral, no ATF. For registry-derived referrals, physicians screened a list of patients with BMI ?25 and approved patients for participation to receive a personalized referral letter via mail. Results: Out of a potential 991 referrals, 573 (57.8\%) referrals were made over 16 weeks, and 98 (9.9\%) patients were enrolled in the program (58/98, 59.2\% female). Differences based on letter (485/991, 48.9\%) versus POC (506/991, 51.1\%) referrals were identified for completion (100\% vs 7\%; P<.001) and for proportion screened (36\% vs 12\%; P<.001) but not for proportion enrolled (12\% vs 8\%; P=.10). Patients receiving ATF were more likely to be screened (47\% vs 7\%; P<.001) and enrolled (15\% vs 7\%; P<.001) than those not receiving ATF. On the basis of the number of referrals made in each condition, we found variations in the proportion and number of enrollees (POC with ATF: 27/190, 50\%; POC no ATF: 14/316, 41\%; letter ATF: 30/199; 15.1\%; letter no ATF: 27/286, 9.4\%). Across all conditions, participants were representative of the racial and ethnic characteristics of the region (60\% female, P=.15; 94\% White individuals, P=.60; 94\% non-Hispanic, P=.19). Recruitment costs totaled US \$6192, and the overall recruitment cost per enrolled participant was US \$63. Cost per enrolled participant ranged from POC with ATF (US \$47), registry-derived letter without ATF (US \$52), and POC without ATF (US \$56) to registry-derived letter with ATF (US \$91). Conclusions: Letter referral with ATF appears to be the best option for enrolling a large number of patients in a digitally delivered weight management program; however, POC with ATF and letters without ATF yielded similar numbers at a lower cost. The best referral option is likely dependent on the best fit with clinical resources. Trial Registration: ClinicalTrials.gov NCT03690557; http://clinicaltrials.gov/ct2/show/NCT03690557 ", doi="10.2196/28622", url="https://formative.jmir.org/2021/10/e28622", url="http://www.ncbi.nlm.nih.gov/pubmed/34668873" } @Article{info:doi/10.2196/24072, author="Turino, Cecilia and Ben{\'i}tez, D. Ivan and Rafael-Palou, Xavier and Mayoral, Ana and Lopera, Alejandro and Pascual, Lydia and Vaca, Rafaela and Cortijo, Anunciaci{\'o}n and Moncus{\'i}-Moix, Anna and Dalmases, Mireia and Vargiu, Eloisa and Blanco, Jordi and Barb{\'e}, Ferran and de Batlle, Jordi", title="Management and Treatment of Patients With Obstructive Sleep Apnea Using an Intelligent Monitoring System Based on Machine Learning Aiming to Improve Continuous Positive Airway Pressure Treatment Compliance: Randomized Controlled Trial", journal="J Med Internet Res", year="2021", month="Oct", day="18", volume="23", number="10", pages="e24072", keywords="obstructive sleep apnea", keywords="continuous positive airway pressure", keywords="patient compliance", keywords="remote monitoring", keywords="machine learning", abstract="Background: Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA), but treatment compliance is often unsatisfactory. Objective: The aim of this study was to assess the effectiveness and cost-effectiveness of an intelligent monitoring system for improving CPAP compliance. Methods: This is a prospective, open label, parallel, randomized controlled trial including 60 newly diagnosed patients with OSA requiring CPAP (Apnea--Hypopnea Index [AHI] >15) from Lleida, Spain. Participants were randomized (1:1) to standard management or the MiSAOS intelligent monitoring system, involving (1) early compliance detection, thus providing measures of patient's CPAP compliance from the very first days of usage; (2) machine learning--based prediction of midterm future CPAP compliance; and (3) rule-based recommendations for the patient (app) and care team. Clinical and anthropometric variables, daytime sleepiness, and quality of life were recorded at baseline and after 6 months, together with patient's compliance, satisfaction, and health care costs. Results: Randomized patients had a mean age of 57 (SD 11) years, mean AHI of 50 (SD 27), and 13\% (8/60) were women. Patients in the intervention arm had a mean (95\% CI) of 1.14 (0.04-2.23) hours/day higher adjusted CPAP compliance than controls (P=.047). Patients' satisfaction was excellent in both arms, and up to 88\% (15/17) of intervention patients reported willingness to keep using the MiSAOS app in the future. No significant differences were found in costs (control: mean {\texteuro}90.2 (SD 53.14) (US \$105.76 [SD 62.31]); intervention: mean {\texteuro}96.2 (SD 62.13) (US \$112.70 [SD 72.85]); P=.70; {\texteuro}1=US \$1.17 was considered throughout). Overall costs combined with results on compliance demonstrated cost-effectiveness in a bootstrap-based simulation analysis. Conclusions: A machine learning--based intelligent monitoring system increased daily compliance, reported excellent patient satisfaction similar to that reported in usual care, and did not incur in a substantial increase in costs, thus proving cost-effectiveness. This study supports the implementation of intelligent eHealth frameworks for the management of patients with CPAP-treated OSA and confirms the value of patients' empowerment in the management of chronic diseases. Trial Registration: ClinicalTrials.gov NCT03116958; https://clinicaltrials.gov/ct2/show/NCT03116958 ", doi="10.2196/24072", url="https://www.jmir.org/2021/10/e24072", url="http://www.ncbi.nlm.nih.gov/pubmed/34661550" } @Article{info:doi/10.2196/29495, author="Adu, Kofi Medard and Shalaby, Reham and Eboreime, Ejemai and Sapara, Adegboyega and Nkire, Nnamdi and Chawla, Rajan and Chima, Chidi and Achor, Michael and Osiogo, Felix and Chue, Pierre and Greenshaw, J. Andrew and Agyapong, Israel Vincent", title="Text Messaging Versus Email Messaging to Support Patients With Major Depressive Disorder: Protocol for a Randomized Hybrid Type II Effectiveness-Implementation Trial", journal="JMIR Res Protoc", year="2021", month="Oct", day="13", volume="10", number="10", pages="e29495", keywords="email messaging", keywords="text messaging", keywords="supportive", keywords="major depressive disorder", keywords="randomized trial", keywords="mental health", keywords="digital health", keywords="mobile health", keywords="mHealth", keywords="patient care", keywords="health policy", keywords="decision-making", keywords="health care resources", abstract="Background: Major depressive disorder (MDD) accounts for 40.5\% of disability-adjusted life years?caused by mental and substance use disorders. Barriers such as stigma and financial and physical access to care have been reported, highlighting the need for innovative, accessible, and cost-effective psychological interventions. The effectiveness of supportive SMS text messaging in alleviating depression symptoms has been proven in clinical trials, but this approach can only help those with mobile phones. Objective: This paper presents the protocol for a study that will aim to evaluate the feasibility, comparative effectiveness, and user satisfaction of daily supportive email messaging as an effective strategy compared to daily supportive text messaging as part of the treatment of patients with MDD. Methods: This trial will be carried out using a hybrid type II implementation-effectiveness design. This design evaluates the effectiveness of an implementation strategy or intervention, while also evaluating the implementation context associated with the intervention. Patients with MDD receiving usual care will be randomized to receive either daily supportive email messaging or daily supportive text messaging of the same content for 6 months. The Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the 5-item World Health Organization Well-Being Index will be used to evaluate the effectiveness of both strategies. The implementation evaluation will be guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, as well as the Consolidated Framework for Implementation Research. All outcome measures will be analyzed using descriptive and inferential statistics. Qualitative data will be analyzed using thematic analysis. Results: Data collection for this trial began in April 2021. We expect the study results to be available within 18 months of study commencement. The results will shed light on the feasibility, acceptability, and effectiveness of using automated emails as a strategy for delivering supportive messages to patients with MDD in comparison to text messaging. Conclusions: The outcome of this trial will have translational impact on routine patient care and access to mental health, as well as potentially support mental health policy decision-making for health care resource allocation. Trial Registration: ClinicalTrials.gov NCT04638231; https://clinicaltrials.gov/ct2/show/NCT04638231 International Registered Report Identifier (IRRID): DERR1-10.2196/29495 ", doi="10.2196/29495", url="https://www.researchprotocols.org/2021/10/e29495", url="http://www.ncbi.nlm.nih.gov/pubmed/34643541" } @Article{info:doi/10.2196/26164, author="Vera Cruz dos Santos, Daniela and Coelho de So{\'a}rez, Patr{\'i}cia and Cavero, Victoria and U Rocha, I. Tha{\'i}s and Aschar, Suzana and Daley, Louise Kate and Garcia Claro, Helo{\'i}sa and Abud Scotton, George and Fernandes, Ivan and Diez-Canseco, Francisco and Brandt, Rebeca Lena and Toyama, Mauricio and Martins Castro, Carolina Hellen and Miranda, Jaime J. and Araya, Ricardo and Quayle, Julieta and Rossi Menezes, Paulo", title="A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru", journal="JMIR Res Protoc", year="2021", month="Oct", day="13", volume="10", number="10", pages="e26164", keywords="cost-effectiveness", keywords="depression", keywords="diabetes", keywords="hypertension", keywords="noncommunicable diseases", keywords="randomized trials", keywords="low- and middle-income countries", keywords="mHealth", keywords="task shifting", keywords="behavioral activation", abstract="Background: Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. Objective: This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. Methods: The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in S{\~a}o Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50\% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top--down and bottom--up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95\% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. Results: The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. Conclusions: We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. Trial Registration: ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426 International Registered Report Identifier (IRRID): DERR1-10.2196/26164 ", doi="10.2196/26164", url="https://www.researchprotocols.org/2021/10/e26164", url="http://www.ncbi.nlm.nih.gov/pubmed/34643538" } @Article{info:doi/10.2196/31976, author="Hulbert-Williams, J. Nicholas and Leslie, Monica and Hulbert-Williams, Lee and Koczwara, Bogda and Watson, K. Eila and Hall, S. Peter and Ashley, Laura and Coulson, S. Neil and Jackson, Richard and Millington, Sue and and Beatty, Lisa", title="The Finding My Way UK Clinical Trial: Adaptation Report and Protocol for a Replication Randomized Controlled Efficacy Trial of a Web-Based Psychological Program to Support Cancer Survivors", journal="JMIR Res Protoc", year="2021", month="Sep", day="20", volume="10", number="9", pages="e31976", keywords="cancer", keywords="survivorship", keywords="psychosocial intervention", keywords="digital health", keywords="quality of life", keywords="protocol", keywords="mobile phone", abstract="Background: Cancer survivors frequently report a range of unmet psychological and supportive care needs; these often continue after treatment has finished and are predictive of psychological distress and poor health-related quality of life. Web-based interventions demonstrate good efficacy in addressing these concerns and are more accessible than face-to-face interventions. Finding My Way (FMW) is a web-based, psycho-educational, and cognitive behavioral therapy intervention for cancer survivors developed in Australia. Previous trials have demonstrated that FMW is acceptable, highly adhered to, and effective in reducing the impact of distress on quality of life while leading to cost savings through health resource use reduction. Objective: This study aims to adapt the Australian FMW website for a UK cancer care context and then undertake a single-blinded, randomized controlled trial of FMW UK against a treatment-as-usual waitlist control. Methods: To an extent, our trial design replicates the existing Australian randomized controlled trial of FMW. Following a comprehensive adaptation of the web resource, we will recruit 294 participants (147 per study arm) from across clinical sites in North West England and North Wales. Participants will have been diagnosed with cancer of any type in the last 6 months, have received anticancer treatment with curative intent, be aged ?16 years, be proficient in English, and have access to the internet and an active email address. Participants will be identified and recruited through the National Institute for Health Research clinical research network. Measures of distress, quality of life, and health economic outcomes will be collected using a self-report web-based questionnaire at baseline, midtreatment, posttreatment, and both 3- and 6-month follow-up. Quantitative data will be analyzed using intention-to-treat mixed model repeated measures analysis. Embedded semistructured qualitative interviews will probe engagement with, and experiences of using, FMW UK and suggestions for future improvements. Results: The website adaptation work was completed in January 2021. A panel of cancer survivors and health care professionals provided feedback on the test version of FMW UK. Feedback was positive overall, although minor updates were made to website navigation, inclusivity, terminology, and the wording of the Improving Communication and Sexuality and Intimacy content. Recruitment for the clinical trial commenced in April 2021. We aim to report on findings from mid-2023. Conclusions: Replication studies are an important aspect of the scientific process, particularly in psychological and clinical trial literature, especially in different geographical settings. Before replicating the FMW trial in the UK setting, content updating was required. If FMW UK now replicates Australian findings, we will have identified a novel and cost-effective method of psychosocial care delivery for cancer survivors in the United Kingdom. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 14317248; https://www.isrctn.com/ISRCTN14317248 International Registered Report Identifier (IRRID): DERR1-10.2196/31976 ", doi="10.2196/31976", url="https://www.researchprotocols.org/2021/9/e31976", url="http://www.ncbi.nlm.nih.gov/pubmed/34542420" } @Article{info:doi/10.2196/24542, author="Wang, Yi-Chen and Tsan, Chin-Yuan and Chen, Meng-Chun", title="Implementation of an Automated Dispensing Cabinet System and Its Impact on Drug Administration: Longitudinal Study", journal="JMIR Form Res", year="2021", month="Sep", day="17", volume="5", number="9", pages="e24542", keywords="automated dispensing cabinets", keywords="medication administration system", keywords="medication errors", keywords="dispensing", keywords="medication", keywords="nursing", keywords="Taiwan", abstract="Background: A technology that has been widely implemented in hospitals in the United States is the automated dispensing cabinet (ADC), which has been shown to reduce nurse drug administration errors and the time nurses spend administering drugs. Objective: This study aimed to determine the impact of an ADC system on medication administration by nurses as well as safety before and after ADC implementation. Methods: We conducted a 24-month-long longitudinal study at the National Taiwan University Hospital in Taipei, Taiwan. Clinical observations and questionnaires were used to evaluate the time differences in drug preparation, delivery, and returns in the inpatient ward by nurses before and after using the ADC. Drug errors recorded in the Medical Incident Events system were assessed the year before and after ADC implementation. Results: The drug preparation time of the wards increased significantly (all P<.005). On average, 2 minutes of preparation time is needed for each patient. Only 1 unit showed an increase in the drug return time, but this was not significant. There were 9 (45\%) adverse events during the drug administration phase, and 11 (55\%) events occurred during the drug-dispensing phase. Although a decrease in the mean number of events reported was observed during the ADC implementation period, this difference was not significant. As for the questionnaire that were administered to the nurses, the overall mean score was 3.90; the highest score was for the item ``I now spend less time waiting for medications that come from the pharmacy than before the ADC was implemented'' (score=4.24). The item with the lowest score was ``I have to wait in line to get my patient medications'' (score=3.32). Conclusions: The nurses were generally satisfied with ADC use over the 9 months following complete implementation and integration of the system. It was acknowledged that the ADC offers benefits in terms of pharmaceutical stock management; however, this comes at the cost of increased nursing time. In general, the nurses remained supportive of the benefits for their patients, despite consequences to their workflows. Their acceptance of the ADC system in this study demonstrates this. ", doi="10.2196/24542", url="https://formative.jmir.org/2021/9/e24542", url="http://www.ncbi.nlm.nih.gov/pubmed/34533467" } @Article{info:doi/10.2196/31621, author="Tully, Louise and Sorensen, Jan and O'Malley, Grace", title="Pediatric Weight Management Through mHealth Compared to Face-to-Face Care: Cost Analysis of a Randomized Control Trial", journal="JMIR Mhealth Uhealth", year="2021", month="Sep", day="14", volume="9", number="9", pages="e31621", keywords="childhood obesity", keywords="pediatric weight management", keywords="economic evaluation", keywords="digital health", keywords="telemedicine", keywords="mHealth", abstract="Background: Mobile health (mHealth) may improve pediatric weight management capacity and the geographical reach of services, and overcome barriers to attending physical appointments using ubiquitous devices such as smartphones and tablets. This field remains an emerging research area with some evidence of its effectiveness; however, there is a scarcity of literature describing economic evaluations of mHealth interventions. Objective: We aimed to assess the economic viability of using an mHealth approach as an alternative to standard multidisciplinary care by evaluating the direct costs incurred within treatment arms during a noninferiority randomized controlled trial (RCT). Methods: A digitally delivered (via a smartphone app) maintenance phase of a pediatric weight management program was developed iteratively with patients and families using evidence-based approaches. We undertook a microcosting exercise and budget impact analysis to assess the costs of delivery from the perspective of the publicly funded health care system. Resource use was analyzed alongside the RCT, and we estimated the costs associated with the staff time and resources for service delivery per participant. Results: In total, 109 adolescents participated in the trial, and 84 participants completed the trial (25 withdrew from the trial). We estimated the mean direct cost per adolescent attending usual care at {\texteuro}142 (SD 23.7), whereas the cost per adolescent in the mHealth group was {\texteuro}722 (SD 221.1), with variations depending on the number of weeks of treatment completion. The conversion rate for the reference year 2013 was \$1={\texteuro}0.7525. The costs incurred for those who withdrew from the study ranged from {\texteuro}35 to {\texteuro}681, depending on the point of dropout and study arm. The main driver of the costs in the mHealth arm was the need for health professional monitoring and support for patients on a weekly basis. The budget impact for offering the mHealth intervention to all newly referred patients in a 1-year period was estimated at {\texteuro}59,046 using the assessed approach. Conclusions: This mHealth approach was substantially more expensive than usual care, although modifications to the intervention may offer opportunities to reduce the mHealth costs. The need for monitoring and support from health care professionals (HCPs) was not eliminated using this delivery model. Further research is needed to explore the cost-effectiveness and economic impact on families and from a wider societal perspective. Trial Registration: ClinicalTrials.gov NCT01804855; https://clinicaltrials.gov/ct2/show/NCT01804855 ", doi="10.2196/31621", url="https://mhealth.jmir.org/2021/9/e31621", url="http://www.ncbi.nlm.nih.gov/pubmed/34519665" } @Article{info:doi/10.2196/26802, author="Jung, Young Se and Kim, Taehyun and Hwang, Ju Hyung and Hong, Kyungpyo", title="Mechanism Design of Health Care Blockchain System Token Economy: Development Study Based on Simulated Real-World Scenarios", journal="J Med Internet Res", year="2021", month="Sep", day="13", volume="23", number="9", pages="e26802", keywords="mechanism design", keywords="optimization", keywords="blockchain", keywords="token economy", keywords="eHealth", keywords="electronic health records", keywords="healthcare", keywords="economy", keywords="health records", abstract="Background: Despite the fact that the adoption rate of electronic health records has increased dramatically among high-income nations, it is still difficult to properly disseminate personal health records. Token economy, through blockchain smart contracts, can better distribute personal health records by providing incentives to patients. However, there have been very few studies regarding the particular factors that should be considered when designing incentive mechanisms in blockchain. Objective: The aim of this paper is to provide 2 new mathematical models of token economy in real-world scenarios on health care blockchain platforms. Methods: First, roles were set for the health care blockchain platform and its token flow. Second, 2 scenarios were introduced: collecting life-log data for an incentive program at a life insurance company to motivate customers to exercise more and recruiting participants for clinical trials of anticancer drugs. In our 2 scenarios, we assumed that there were 3 stakeholders: participants, data recipients (companies), and data providers (health care organizations). We also assumed that the incentives are initially paid out to participants by data recipients, who are focused on minimizing economic and time costs by adapting mechanism design. This concept can be seen as a part of game theory, since the willingness-to-pay of data recipients is important in maintaining the blockchain token economy. In both scenarios, the recruiting company can change the expected recruitment time and number of participants. Suppose a company considers the recruitment time to be more important than the number of participants and rewards. In that case, the company can increase the time weight and adjust cost. When the reward parameter is fixed, the corresponding expected recruitment time can be obtained. Among the reward and time pairs, the pair that minimizes the company's cost was chosen. Finally, the optimized results were compared with the simulations and analyzed accordingly. Results: To minimize the company's costs, reward--time pairs were first collected. It was observed that the expected recruitment time decreased as rewards grew, while the rewards decreased as time cost grew. Therefore, the cost was represented by a convex curve, which made it possible to obtain a minimum---an optimal point---for both scenarios. Through sensitivity analysis, we observed that, as the time weight increased, the optimized reward increased, while the optimized time decreased. Moreover, as the number of participants increased, the optimization reward and time also increased. Conclusions: In this study, we were able to model the incentive mechanism of blockchain based on a mechanism design that recruits participants through a health care blockchain platform. This study presents a basic approach to incentive modeling in personal health records, demonstrating how health care organizations and funding companies can motivate one another to join the platform. ", doi="10.2196/26802", url="https://www.jmir.org/2021/9/e26802", url="http://www.ncbi.nlm.nih.gov/pubmed/34515640" } @Article{info:doi/10.2196/27571, author="Vassolo, Santiago Roberto and Mac Cawley, Francisco Alejandro and Tortorella, Luz Guilherme and Fogliatto, Sanson Flavio and Tlapa, Diego and Narayanamurthy, Gopalakrishnan", title="Hospital Investment Decisions in Healthcare 4.0 Technologies: Scoping Review and Framework for Exploring Challenges, Trends, and Research Directions", journal="J Med Internet Res", year="2021", month="Aug", day="26", volume="23", number="8", pages="e27571", keywords="healthcare 4.0", keywords="scoping review", keywords="investments", keywords="real options", keywords="health technology assessment", keywords="technological bundles", keywords="decision-makers", keywords="hospital", keywords="public health", keywords="technology", keywords="health technology", keywords="smart technology", keywords="hospital management", keywords="health care investment", keywords="decision making", keywords="new technologies", abstract="Background: Alternative approaches to analyzing and evaluating health care investments in state-of-the-art technologies are being increasingly discussed in the literature, especially with the advent of Healthcare 4.0 (H4.0) technologies or eHealth. Such investments generally involve computer hardware and software that deal with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making. Besides, the use of these technologies significantly increases when addressed in bundles. However, a structured and holistic approach to analyzing investments in H4.0 technologies is not available in the literature. Objective: This study aims to analyze previous research related to the evaluation of H4.0 technologies in hospitals and characterize the most common investment approaches used. We propose a framework that organizes the research associated with hospitals' H4.0 technology investment decisions and suggest five main research directions on the topic. Methods: To achieve our goal, we followed the standard procedure for scoping reviews. We performed a search in the Crossref, PubMed, Scopus, and Web of Science databases with the keywords investment, health, industry 4.0, investment, health technology assessment, healthcare 4.0, and smart in the title, abstract, and keywords of research papers. We retrieved 5701 publications from all the databases. After removing papers published before 2011 as well as duplicates and performing further screening, we were left with 244 articles, from which 33 were selected after in-depth analysis to compose the final publication portfolio. Results: Our findings show the multidisciplinary nature of the research related to evaluating hospital investments in H4.0 technologies. We found that the most common investment approaches focused on cost analysis, single technology, and single decision-maker involvement, which dominate bundle analysis, H4.0 technology value considerations, and multiple decision-maker involvement. Conclusions: Some of our findings were unexpected, given the interrelated nature of H4.0 technologies and their multidimensional impact. Owing to the absence of a more holistic approach to H4.0 technology investment decisions, we identified five promising research directions for the topic: development of economic valuation methodologies tailored for H4.0 technologies; accounting for technology interrelations in the form of bundles; accounting for uncertainties in the process of evaluating such technologies; integration of administrative, medical, and patient perspectives into the evaluation process; and balancing and handling complexity in the decision-making process. ", doi="10.2196/27571", url="https://www.jmir.org/2021/8/e27571", url="http://www.ncbi.nlm.nih.gov/pubmed/34435967" } @Article{info:doi/10.2196/26887, author="Patel, N. Kunal and Mazurenko, Olena and Ford, Eric", title="Analysis of Hospital Quality Measures and Web-Based Chargemasters, 2019: Cross-sectional Study", journal="JMIR Form Res", year="2021", month="Aug", day="19", volume="5", number="8", pages="e26887", keywords="chargemaster", keywords="standard charge", keywords="price transparency", keywords="health care", keywords="diagnosis-related group", keywords="DRG", keywords="quality measures", keywords="the Centers for Medicare and Medicaid Services regulation", keywords="CMS", abstract="Background: The federal health care price transparency regulation from 2019 is aimed at bending the health care cost curve by increasing the availability of hospital pricing information for the public. Objective: This study aims to examine the associations between publicly reported diagnosis-related group chargemaster prices on the internet and quality measures, process indicators, and patient-reported experience measures. Methods: In this cross-sectional study, we collected and analyzed a random 5.02\% (212/4221) stratified sample of US hospital prices in 2019 using descriptive statistics and multivariate analysis. Results: We found extreme price variation in shoppable services and significantly greater price variation for medical versus surgical services (P=.006). In addition, we found that quality indicators were positively associated with standard charges, such as mortality ($\beta$=.929; P<.001) and readmissions ($\beta$=.514; P<.001). Other quality indicators, such as the effectiveness of care ($\beta$=?.919; P<.001), efficient use of medical imaging ($\beta$=?.458; P=.001), and patient recommendation scores ($\beta$=?.414; P<.001), were negatively associated with standard charges. Conclusions: We found that hospital chargemasters display wide variations in prices for medical services and procedures and match variations in quality measures. Further work is required to investigate 100\% of US hospital prices posted publicly on the internet and their relationship with quality measures. ", doi="10.2196/26887", url="https://formative.jmir.org/2021/8/e26887", url="http://www.ncbi.nlm.nih.gov/pubmed/34420914" } @Article{info:doi/10.2196/23799, author="He, Xianying and Wang, Linlin and Wang, Li and Gao, Jinghong and Cui, Fangfang and Ma, Qianqian and Zhang, Wenjie and Wang, Lin and Zhai, Yunkai and Zhao, Jie", title="Effectiveness of a Cloud-Based Telepathology System in China: Large-Sample Observational Study", journal="J Med Internet Res", year="2021", month="Jul", day="29", volume="23", number="7", pages="e23799", keywords="telepathology", keywords="cloud-based system", keywords="whole-slide imaging", keywords="turnaround time", keywords="diagnostic accuracy", keywords="economic benefits", abstract="Background: Whole-slide imaging allows the entire slide to be viewed in a manner that simulates microscopy; therefore, it is widely used in telepathology. However, managing the large digital files needed for whole-slide imaging is difficult. To solve this problem, we set up the Chinese National Cloud-Based Telepathology System (CNCTPS). CNCTPS has been running for more than 4 years and has accumulated a large amount of data. Objective: The main purpose of this study was to comprehensively evaluate the effectiveness of the CNCTPS based on a large sample. The evaluation indicators included service volume, turnaround time, diagnosis accuracy, and economic benefits. Methods: Details of 23,167 cases submitted to the CNCTPS from January 2016 to December 2019 were collected to analyze the service volume, turnaround time, and economic benefits. A total of 564 patients who visited the First Affiliated Hospital of Zhengzhou University and obtained final diagnoses were followed up to analyze the diagnostic accuracy of the CNCTPS. Results: From 2016 to 2019, the service volume of the CNCTPS increased from 2335 to 9240, and the number of participating hospitals increased from 60 to 74. Consultation requests from county-level hospitals accounted for 86.57\% (20,287/23,167). A total of 17,495 of 23,167 cases (75.52\%) were confirmed, including 12,088 benign lesions, 5217 malignant lesions, and 190 borderline lesions. Of the cases, 3.85\% (893/23,167) failed to be diagnosed for reasons such as poor slice quality and incomplete sampling. The median turnaround time was 16.93 hours and was shortened yearly (between 2018 and 2019: adjusted P=.01; other groups: adjusted P<.001); 82.88\% cases were diagnosed in 48 hours. There was a discrepancy between the diagnosis and final diagnosis for 11 cases, including 4 false-positive cases and 7 false-negative cases. The sensitivity and specificity were 97.66\% and 98.49\%, respectively. The diagnostic accuracy of the system was 98.05\%, with no statistical difference from the final diagnosis in the hospital (P=.55). By using this system, a total of US \$300,000 was saved for patients every year. Conclusions: The novel cloud-based telepathology system has the potential to relieve the shortage of pathologists in primary hospitals. It can also simultaneously reduce medical costs for patients in China. It should, therefore, be further promoted to enhance the efficiency, quantity, and quality of telepathology diagnoses. ", doi="10.2196/23799", url="https://www.jmir.org/2021/7/e23799", url="http://www.ncbi.nlm.nih.gov/pubmed/34326037" } @Article{info:doi/10.2196/24634, author="van der Kamp, Mattienne and Reimering Hartgerink, Pamela and Driessen, Jean and Thio, Bernard and Hermens, Hermie and Tabak, Monique", title="Feasibility, Efficacy, and Efficiency of eHealth-Supported Pediatric Asthma Care: Six-Month Quasi-Experimental Single-Arm Pretest-Posttest Study", journal="JMIR Form Res", year="2021", month="Jul", day="26", volume="5", number="7", pages="e24634", keywords="telemedicine", keywords="feasibility studies", keywords="child", keywords="self-management", keywords="asthma", keywords="patient acceptance of health care", keywords="ambulatory care", keywords="remote sensing technology", keywords="cost-benefit analysis", keywords="health care costs", abstract="Background: Early detection of loss of asthma control can effectively reduce the burden of the disease. However, broad implementation in clinical practice has not been accomplished so far. We are in need of research investigating the operationalization of eHealth pediatric asthma care in practice, which can provide the most potential benefits in terms of adoption, efficiency, and effectiveness. Objective: The aim of this study was to investigate the technical and clinical feasibility, including an exploration of the efficacy and cost-efficiency, of an eHealth program implemented in daily clinical pediatric asthma practice. Methods: We designed an eHealth-supported pediatric asthma program facilitating early detection of loss of asthma control while increasing symptom awareness and self-management. In the 6-month program, asthma control was monitored by 4 health care professionals (HCPs) by using objective home measurements and the web-based Puffer app to allow timely medical anticipation and prevent treatment delay. Technical feasibility was assessed by technology use, system usability, and technology acceptance. Clinical feasibility was assessed by participation and patient-reported health and care outcomes and via a focus group with HCPs regarding their experiences of implementing eHealth in daily practice. The efficacy and cost-efficiency were explored by comparing pretest-posttest program differences in asthma outcomes (asthma control, lung function, and therapy adherence) and medical consumption. Results: Of 41 children, 35 children with moderate-to-severe asthma volunteered for participation. With regard to technical feasibility, the Puffer app scored a good usability score of 78 on the System Usability Scale and a score of 70 for technology acceptance on a scale of 1 to 100. Approximately 75\% (18/24) of the children indicated that eHealth helped them to control their asthma during the program. HCPs indicated that home measurements and real time communication enabled them to make safe and substantiated medical decisions during symptom manifestations. With an average time commitment of 15 minutes by patients, eHealth care led to a 80\% gross reduction (from {\texteuro}71,784 to {\texteuro}14,018, US \$1={\texteuro}0.85) in health care utilization, 8.6\% increase (from 18.6 to 20.2, P=.40) in asthma control, 25.0\% increase (from 2.8 to 3.5, P=.04) in the self-management level, and 20.4\% improved (from 71.2 to 76.8, P=.02) therapy adherence. Conclusions: eHealth asthma care seems to be technically and clinically feasible, enables safe remote care, and seems to be beneficial for pediatric asthma care in terms of health outcomes and health care utilization. Follow-up research should focus on targeted effectiveness studies with the lessons learned, while also enabling individualization of eHealth for personalized health care. ", doi="10.2196/24634", url="https://formative.jmir.org/2021/7/e24634", url="http://www.ncbi.nlm.nih.gov/pubmed/34309568" } @Article{info:doi/10.2196/26284, author="Sato, Kenichiro and Niimi, Yoshiki and Ihara, Ryoko and Suzuki, Kazushi and Toda, Tatsushi and Iwata, Atsushi and Iwatsubo, Takeshi", title="Efficacy and Cost-effectiveness of Promotion Methods to Recruit Participants to an Online Screening Registry for Alzheimer Disease Prevention Trials: Observational Study", journal="J Med Internet Res", year="2021", month="Jul", day="22", volume="23", number="7", pages="e26284", keywords="online clinical study", keywords="promotion", keywords="advertisement", keywords="cost-effectiveness", keywords="Trial-Ready Cohort", keywords="preclinical Alzheimer disease", keywords="clinical trial", keywords="Alzheimer", keywords="dementia", keywords="recruitment", abstract="Background: Web-based screening may be suitable for identifying individuals with presymptomatic latent diseases for recruitment to clinical studies, as such people do not often visit hospitals in the presymptomatic stage. The promotion of such online screening studies is critical to their success, although it remains uncertain how the effectiveness of such promotion can differ, depending on the different promotion methods, domains of interest, or countries of implementation. Objective: The Japanese Trial-Ready Cohort (J-TRC) web study is our ongoing online screening registry to identify individuals with presymptomatic Alzheimer disease (AD), aimed at facilitating the clinical trials for AD prevention. Within the first 9 months of its 2019 launch, the J-TRC web study recruited thousands of online participants via multiple methods of promotion, including press releases, newspaper advertisements, web advertisements, or direct email invitations. Here, we aimed to quantitatively evaluate efficacy and cost-effectiveness of each of these multimodal promotion methods. Methods: We applied the vector-autoregression model to assess the degree of contribution of each type of promotion to the following target metrics: number of daily visitors to the J-TRC website, number of daily registrants to the J-TRC web study, daily rate of registration among visitors, daily rate of eligible participants among registrants, and median age of daily registrants. The average cost-effectiveness for each promotion method was also calculated using the total cost and the coefficients in the vector-autoregression model. Results: During the first 9 months of the reviewed period from October 31, 2019 to June 17, 2020, there were 48,334 website visitors and 4429 registrations (9.16\% of 48,334 visitors), of which 3081 (69.56\%) were eligible registrations. Initial press release reports and newspaper advertisements had a marked effect on increasing the number of daily visitors and daily registrants. Web advertisements significantly contributed to the increase in daily visitors (P<.001) but not to the daily registrants, and it also lowered the rate of registrations and the median age of daily registrants. Website visitors from the direct email invitation sent to other cognitive registries seem to have registered with the highest reliability. The calculated average cost-effectiveness for the initial press release was US \$24.60 per visitor and US \$96.10 per registrant, while the calculated average cost-effectiveness for the newspaper advertisements was US \$28.60 per visitor and US \$227.90 per registrant. Conclusions: Our multivariate time-series analysis showed that each promotion method had different features in their effect of recruiting participants to the J-TRC web study. Under the advertisement condition settings thus far, newspaper advertisements and initial press releases were the most effective promotion methods, with fair cost-effectiveness that was equivalent to earlier online studies. These results can provide important suggestions for future promotions for the recruitment of presymptomatic participants to AD clinical trials in Japan. ", doi="10.2196/26284", url="https://www.jmir.org/2021/7/e26284", url="http://www.ncbi.nlm.nih.gov/pubmed/34292159" } @Article{info:doi/10.2196/24917, author="Winward, Sam and Patel, Tejal and Al-Saffar, Mazin and Noble, Matthew", title="The Effect of 24/7, Digital-First, NHS Primary Care on Acute Hospital Spending: Retrospective Observational Analysis", journal="J Med Internet Res", year="2021", month="Jul", day="22", volume="23", number="7", pages="e24917", keywords="primary health care", keywords="family practice", keywords="general practice", keywords="cost", keywords="cost analysis", keywords="telemedicine", keywords="digital technology", keywords="digital health", keywords="digital care", keywords="virtual care", keywords="hospital", keywords="retrospective", keywords="observational", keywords="cohort", keywords="finance", keywords="economics", keywords="health services research", abstract="Background: Digital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective. Objective: The aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending. Methods: A retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or ``weight'' the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20. Results: The NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was {\textsterling}1.6 billion and {\textsterling}1.65 billion (a currency exchange rate of {\textsterling}1=US \$1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12\%, 31\%, and 54\% ({\textsterling}93, P=.047; {\textsterling}223, P<.001; and {\textsterling}389, P<.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15\%, 35\%, and 51\% ({\textsterling}114, P=.006; {\textsterling}246, P<.001; and {\textsterling}362, P<.001) lower. This amounted to lower costs for the Babylon GP at Hand population of {\textsterling}1.37, {\textsterling}4.40 million, and {\textsterling}11.6 million, respectively, in FY18/19; and {\textsterling}3.26 million, {\textsterling}9.54 million, and {\textsterling}18.8 million, respectively, in FY19/20. Conclusions: Patients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs. ", doi="10.2196/24917", url="https://www.jmir.org/2021/7/e24917", url="http://www.ncbi.nlm.nih.gov/pubmed/34292160" } @Article{info:doi/10.2196/27327, author="Corbett, F. Cynthia and Combs, M. Elizabeth and Chandarana, S. Peyton and Stringfellow, Isabel and Worthy, Karen and Nguyen, Thien and Wright, J. Pamela and O'Kane, M. Jason", title="Medication Adherence Reminder System for Virtual Home Assistants: Mixed Methods Evaluation Study", journal="JMIR Form Res", year="2021", month="Jul", day="13", volume="5", number="7", pages="e27327", keywords="medication adherence", keywords="medication", keywords="virtual home assistants", keywords="virtual assistant", keywords="public health", keywords="health care costs", keywords="Echo device", keywords="device usability", keywords="digital health", keywords="mobile phone", abstract="Background: Medication nonadherence is a global public health challenge that results in suboptimal health outcomes and increases health care costs. Forgetting to take medicines is one of the most common reasons for unintentional medication nonadherence. Research findings indicate that voice-activated virtual home assistants, such as Amazon Echo and Google Home devices, may be useful in promoting medication adherence. Objective: This study aims to create a medication adherence app (skill), MedBuddy, for Amazon Echo devices and measure the use, usability, and usefulness of this medication-taking reminder skill. Methods: A single-group, mixed methods, cohort feasibility study was conducted with women who took oral contraceptives (N=25). Participants were undergraduate students (age: mean 21.8 years, SD 6.2) at an urban university in the Southeast United States. Participants were given an Amazon Echo Dot with MedBuddy---a new medication reminder skill for Echo devices created by our team---attached to their study account, which they used for 60 days. Participants self-reported their baseline and poststudy medication adherence. MedBuddy use was objectively evaluated by tracking participants' interactions with MedBuddy through Amazon Alexa. The usability and usefulness of MedBuddy were evaluated through a poststudy interview in which participants responded to both quantitative and qualitative questions. Results: Participants' interactions with MedBuddy, as tracked through Amazon Alexa, only occurred on half of the study days (mean 50.97, SD 29.5). At study end, participants reported missing their medication less in the past 1 and 6 months compared with baseline ($\chi$21=0.9 and $\chi$21=0.4, respectively; McNemar test: P<.001 for both). However, there was no significant difference in participants' reported adherence to consistently taking medication within the same 2-hour time frame every day in the past 1 or 6 months at the end of the study compared with baseline ($\chi$21=3.5 and $\chi$21=0.4, respectively; McNemar test: P=.63 and P=.07, respectively). Overall feedback about usability was positive, and participants provided constructive feedback about the skill's features that could be improved. Participants' evaluation of MedBuddy's usefulness was overwhelmingly positive---most (15/23, 65\%) said that they would continue using MedBuddy as a medication reminder if provided with the opportunity and that they would recommend it to others. MedBuddy features that participants enjoyed were an external prompt separate from their phone, the ability to hear the reminder prompt from a separate room, multiple reminders, and verbal responses to prompts. Conclusions: The findings of this feasibility study indicate that the MedBuddy medication reminder skill may be useful in promoting medication adherence. However, the skill could benefit from further usability enhancements. ", doi="10.2196/27327", url="https://formative.jmir.org/2021/7/e27327", url="http://www.ncbi.nlm.nih.gov/pubmed/34255669" } @Article{info:doi/10.2196/26391, author="Nichol, A. Ariadne and Batten, N. Jason and Halley, C. Meghan and Axelrod, K. Julia and Sankar, L. Pamela and Cho, K. Mildred", title="A Typology of Existing Machine Learning--Based Predictive Analytic Tools Focused on Reducing Costs and Improving Quality in Health Care: Systematic Search and Content Analysis", journal="J Med Internet Res", year="2021", month="Jun", day="22", volume="23", number="6", pages="e26391", keywords="machine learning", keywords="artificial intelligence", keywords="ethics", keywords="regulation", keywords="health care quality", keywords="costs", abstract="Background: Considerable effort has been devoted to the development of artificial intelligence, including machine learning--based predictive analytics (MLPA) for use in health care settings. The growth of MLPA could be fueled by payment reforms that hold health care organizations responsible for providing high-quality, cost-effective care. Policy analysts, ethicists, and computer scientists have identified unique ethical and regulatory challenges from the use of MLPA in health care. However, little is known about the types of MLPA health care products available on the market today or their stated goals. Objective: This study aims to better characterize available MLPA health care products, identifying and characterizing claims about products recently or currently in use in US health care settings that are marketed as tools to improve health care efficiency by improving quality of care while reducing costs. Methods: We conducted systematic database searches of relevant business news and academic research to identify MLPA products for health care efficiency meeting our inclusion and exclusion criteria. We used content analysis to generate MLPA product categories and characterize the organizations marketing the products. Results: We identified 106 products and characterized them based on publicly available information in terms of the types of predictions made and the size, type, and clinical training of the leadership of the companies marketing them. We identified 5 categories of predictions made by MLPA products based on publicly available product marketing materials: disease onset and progression, treatment, cost and utilization, admissions and readmissions, and decompensation and adverse events. Conclusions: Our findings provide a foundational reference to inform the analysis of specific ethical and regulatory challenges arising from the use of MLPA to improve health care efficiency. ", doi="10.2196/26391", url="https://www.jmir.org/2021/6/e26391", url="http://www.ncbi.nlm.nih.gov/pubmed/34156338" } @Article{info:doi/10.2196/27772, author="Alavi, Nazanin and Stephenson, Callum and Yang, Megan and Shirazi, Amirhossein and Shao, Yijia and Kumar, Anchan and Yee, S. Caitlin and Miller, Shad{\'e} and Stefatos, Anthi and Gholamzadehmir, Maedeh and Abbaspour, Zara and Patel, Archana and Patel, Charmy and Reshetukha, Taras and Omrani, Mohsen and Groll, Dianne", title="Determining the Efficacy of Electronic Cognitive Behavioral Therapy for Generalized Anxiety Disorder Compared to Pharmaceutical Interventions: Protocol for a Quasi-Experimental Study", journal="JMIR Res Protoc", year="2021", month="May", day="27", volume="10", number="5", pages="e27772", keywords="eHealth", keywords="mental health", keywords="anxiety", keywords="generalized anxiety disorder", keywords="cognitive behavioral therapy", keywords="psychotherapy", keywords="online", keywords="internet", keywords="electronic", keywords="virtual", keywords="mental health care", abstract="Background: Generalized anxiety disorder (GAD) is an extremely prevalent and debilitating mental health disorder. Currently, the gold standard treatment for GAD is cognitive behavioral therapy (CBT) and/or pharmacotherapy. The most common medications used to treat GAD are selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors. While CBT is the gold standard treatment for GAD, it is costly, time-consuming, and often inaccessible. Fortunately, the electronic delivery of CBT (e-CBT) has emerged as a promising solution to address these barriers. e-CBT has shown to offer comparable results to in-person CBT while improving accessibility for patients and time efficiency for clinicians. Objective: This study aims to investigate the treatment efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD. Methods: This study will use a quasi-experimental design to allow patients the freedom to choose which treatment modality they would like to receive. Participants with a diagnosis of GAD will be enrolled in 1 of 3 possible treatment arms: (1) e-CBT, (2) medication, or (3) a combination of e-CBT and medication. The e-CBT program will include a 12-week psychotherapy program delivered through the Online Psychotherapy Tool---a secure, cloud-based, digital mental health platform. The treatment efficacy of e-CBT will be compared with that of medication alone and medication in combination with e-CBT. Results: The study received ethics approval in April 2019 and participant recruitment began in June 2019. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, 146 participants (e-CBT: n=53; medication: n=49; combination: n=44) have been recruited. Data collection is expected to conclude by June 2021, and data analysis is expected to be completed by October 2021. Linear regression (for continuous outcomes) and binomial regression (for categorical outcomes) analysis will be conducted using interpretive qualitative methods. Conclusions: If either the efficacy of e-CBT is shown to be comparable to that of medication or the effects of both treatments are augmented when used in tandem, these findings could have major implications on the mental health care system. e-CBT is a more accessible and affordable treatment that could increase mental health care capacity 4-fold if proven viable. Trial Registration: ClinicalTrials.gov NCT04478526; https://clinicaltrials.gov/ct2/show/NCT04478526 International Registered Report Identifier (IRRID): DERR1-10.2196/27772 ", doi="10.2196/27772", url="https://www.researchprotocols.org/2021/5/e27772", url="http://www.ncbi.nlm.nih.gov/pubmed/33857917" } @Article{info:doi/10.2196/22461, author="Joo, Hyeon and Burns, Michael and Kalidaikurichi Lakshmanan, Saradha Sai and Hu, Yaokun and Vydiswaran, Vinod V. G.", title="Neural Machine Translation--Based Automated Current Procedural Terminology Classification System Using Procedure Text: Development and Validation Study", journal="JMIR Form Res", year="2021", month="May", day="26", volume="5", number="5", pages="e22461", keywords="CPT classification", keywords="natural language processing", keywords="machine learning", keywords="neural machine translation", abstract="Background: Administrative costs for billing and insurance-related activities in the United States are substantial. One critical cause of the high overhead of administrative costs is medical billing errors. With advanced deep learning techniques, developing advanced models to predict hospital and professional billing codes has become feasible. These models can be used for administrative cost reduction and billing process improvements. Objective: In this study, we aim to develop an automated anesthesiology current procedural terminology (CPT) prediction system that translates manually entered surgical procedure text into standard forms using neural machine translation (NMT) techniques. The standard forms are calculated using similarity scores to predict the most appropriate CPT codes. Although this system aims to enhance medical billing coding accuracy to reduce administrative costs, we compare its performance with that of previously developed machine learning algorithms. Methods: We collected and analyzed all operative procedures performed at Michigan Medicine between January 2017 and June 2019 (2.5 years). The first 2 years of data were used to train and validate the existing models and compare the results from the NMT-based model. Data from 2019 (6-month follow-up period) were then used to measure the accuracy of the CPT code prediction. Three experimental settings were designed with different data types to evaluate the models. Experiment 1 used the surgical procedure text entered manually in the electronic health record. Experiment 2 used preprocessing of the procedure text. Experiment 3 used preprocessing of the combined procedure text and preoperative diagnoses. The NMT-based model was compared with the support vector machine (SVM) and long short-term memory (LSTM) models. Results: The NMT model yielded the highest top-1 accuracy in experiments 1 and 2 at 81.64\% and 81.71\% compared with the SVM model (81.19\% and 81.27\%, respectively) and the LSTM model (80.96\% and 81.07\%, respectively). The SVM model yielded the highest top-1 accuracy of 84.30\% in experiment 3, followed by the LSTM model (83.70\%) and the NMT model (82.80\%). In experiment 3, the addition of preoperative diagnoses showed 3.7\%, 3.2\%, and 1.3\% increases in the SVM, LSTM, and NMT models in top-1 accuracy over those in experiment 2, respectively. For top-3 accuracy, the SVM, LSTM, and NMT models achieved 95.64\%, 95.72\%, and 95.60\% for experiment 1, 95.75\%, 95.67\%, and 95.69\% for experiment 2, and 95.88\%, 95.93\%, and 95.06\% for experiment 3, respectively. Conclusions: This study demonstrates the feasibility of creating an automated anesthesiology CPT classification system based on NMT techniques using surgical procedure text and preoperative diagnosis. Our results show that the performance of the NMT-based CPT prediction system is equivalent to that of the SVM and LSTM prediction models. Importantly, we found that including preoperative diagnoses improved the accuracy of using the procedure text alone. ", doi="10.2196/22461", url="https://formative.jmir.org/2021/5/e22461", url="http://www.ncbi.nlm.nih.gov/pubmed/34037526" } @Article{info:doi/10.2196/25609, author="Buntrock, Claudia and Lehr, Dirk and Smit, Filip and Horvath, Hanne and Berking, Matthias and Spiegelhalder, Kai and Riper, Heleen and Ebert, Daniel David", title="Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Health-Economic Evaluation From the Societal and Public Health Care Perspective Alongside a Randomized Controlled Trial", journal="J Med Internet Res", year="2021", month="May", day="24", volume="23", number="5", pages="e25609", keywords="insomnia", keywords="internet-based cognitive behavioural therapy", keywords="iCBT-I", keywords="economic evaluation", keywords="cost-effectiveness", keywords="cost-utility", keywords="cognitive behavioral therapy", keywords="behavior", keywords="sleep", keywords="economics", keywords="public health", keywords="perspective", abstract="Background: The evidence base for internet-based cognitive behavioral therapy for insomnia (iCBT-I) is firm; however, little is known about iCBT-I's health-economic effects. Objective: This study aimed to evaluate the cost-effectiveness and cost--utility of iCBT-I in reducing insomnia among schoolteachers. Methods: Schoolteachers (N=128) with clinically significant insomnia symptoms and work-related rumination were randomized to guided iCBT-I or a wait list control group, both with unrestricted access to treatment as usual. Health care use, patient and family expenditures, and productivity losses were self-assessed and used for costing from a societal and a public health care perspective. Costs were related to symptom-free status (score <8 on the insomnia severity index) and quality-adjusted life years (QALYs) gained. Sampling error was handled using nonparametric bootstrapping. Results: Statistically significant differences favoring the intervention group were found for both health outcomes (symptom-free status yes or no: $\beta$=.30; 95\% CI 0.16-0.43; QALYs: $\beta$=.019, 95\% CI 0.01-0.03). From a societal perspective, iCBT-I had a 94\% probability of dominating the wait list control for both health outcomes. From a public health care perspective, iCBT-I was more effective but also more expensive than the wait list control, resulting in an incremental cost-effectiveness ratio of {\texteuro}650 per symptom-free individual. In terms of QALYs, the incremental cost-effectiveness ratio was {\texteuro}11,285. At a willingness-to-pay threshold of {\texteuro}20,000 per QALY gained, the intervention's probability of being cost-effective was 89\%. Conclusions: Our trial indicates that iCBT could be considered as a good value-for-money intervention for insomnia. Trial Registration: German Clinical Trial Registry: DRKS00004700; https://tinyurl.com/2nnk57jm International Registered Report Identifier (IRRID): RR2-10.1186/1745-6215-14-169 ", doi="10.2196/25609", url="https://www.jmir.org/2021/5/e25609", url="http://www.ncbi.nlm.nih.gov/pubmed/34028361" } @Article{info:doi/10.2196/27410, author="Piera-Jim{\'e}nez, Jordi and Etzelmueller, Anne and Kolovos, Spyros and Folkvord, Frans and Lupi{\'a}{\~n}ez-Villanueva, Francisco", title="Guided Internet-Based Cognitive Behavioral Therapy for Depression: Implementation Cost-Effectiveness Study", journal="J Med Internet Res", year="2021", month="May", day="11", volume="23", number="5", pages="e27410", keywords="digital health", keywords="telemedicine", keywords="eHealth", keywords="e--mental health", keywords="internet-based cognitive behavioral therapy", keywords="depression", keywords="iCBT", keywords="implementation", keywords="cost-effectiveness", keywords="cognitive behavioral therapy", keywords="CBT", keywords="cost", abstract="Background: Major depressive disorder is a chronic condition; its prevalence is expected to grow with the aging trend of high-income countries. Internet-based cognitive-behavioral therapy has proven efficacy in treating major depressive disorder. Objective: The objective of this study was to assess the cost-effectiveness of implementing a community internet-based cognitive behavioral therapy intervention (Super@, the Spanish program for the MasterMind project) for treating major depressive disorder. Methods: The cost-effectiveness of the Super@ program was assessed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, using a 3-state Markov model. Data from the cost and effectiveness of the intervention were prospectively collected from the implementation of the program by a health care provider in Badalona, Spain; the corresponding data for usual care were gathered from the literature. The health states, transition probabilities, and utilities were computed using Patient Health Questionnaire--9 scores. Results: The analysis was performed using data from 229 participants using the Super@ program. Results showed that the intervention was more costly than usual care; the discounted (3\%) and nondiscounted incremental cost-effectiveness ratios were {\texteuro}29,367 and {\texteuro}26,484 per quality-adjusted life-year, respectively (approximately US \$35,299 and \$31,833, respectively). The intervention was cost-effective based on the {\texteuro}30,000 willingness-to-pay threshold typically applied in Spain (equivalent to approximately \$36,060). According to the deterministic sensitivity analyses, the potential reduction of costs associated with intervention scale-up would reduce the incremental cost-effectiveness ratio of the intervention, although it remained more costly than usual care. A discount in the incremental effects up to 5\% exceeded the willingness-to-pay threshold of {\texteuro}30,000. Conclusions: The Super@ program, an internet-based cognitive behavioral therapy intervention for treating major depressive disorder, cost more than treatment as usual. Nevertheless, its implementation in Spain would be cost-effective from health care and societal perspectives, given the willingness-to-pay threshold of {\texteuro}30,000 compared with treatment as usual. ", doi="10.2196/27410", url="https://www.jmir.org/2021/5/e27410", url="http://www.ncbi.nlm.nih.gov/pubmed/33973857" } @Article{info:doi/10.2196/23961, author="Beauvais, Bradley and Kruse, Scott Clemens and Fulton, Lawrence and Shanmugam, Ramalingam and Ramamonjiarivelo, Zo and Brooks, Matthew", title="Association of Electronic Health Record Vendors With Hospital Financial and Quality Performance: Retrospective Data Analysis", journal="J Med Internet Res", year="2021", month="Apr", day="14", volume="23", number="4", pages="e23961", keywords="electronic health records", keywords="medical informatics", keywords="hospitals", keywords="delivery of health care", keywords="financial management", keywords="quality of health care", keywords="treatment outcome", abstract="Background: Electronic health records (EHRs) are a central feature of care delivery in acute care hospitals; however, the financial and quality outcomes associated with system performance remain unclear. Objective: In this study, we aimed to evaluate the association between the top 3 EHR vendors and measures of hospital financial and quality performance. Methods: This study evaluated 2667 hospitals with Cerner, Epic, or Meditech as their primary EHR and considered their performance with regard to net income, Hospital Value--Based Purchasing Total Performance Score (TPS), and the unweighted subdomains of efficiency and cost reduction; clinical care; patient- and caregiver-centered experience; and patient safety. We hypothesized that there would be a difference among the 3 vendors for each measure. Results: None of the EHR systems were associated with a statistically significant financial relationship in our study. Epic was positively associated with TPS outcomes (R2=23.6\%; $\beta$=.0159, SE 0.0079; P=.04) and higher patient perceptions of quality (R2=29.3\%; $\beta$=.0292, SE 0.0099; P=.003) but was negatively associated with patient safety quality scores (R2=24.3\%; $\beta$=?.0221, SE 0.0102; P=.03). Cerner and Epic were positively associated with improved efficiency (R2=31.9\%; Cerner: $\beta$=.0330, SE 0.0135, P=.01; Epic: $\beta$=.0465, SE 0.0133, P<.001). Finally, all 3 vendors were associated with positive performance in the clinical care domain (Epic: $\beta$=.0388, SE 0.0122, P=.002; Cerner: $\beta$=.0283, SE 0.0124, P=.02; Meditech: $\beta$=.0273, SE 0.0123, P=.03) but with low explanatory power (R2=4.2\%). Conclusions: The results of this study provide evidence of a difference in clinical outcome performance among the top 3 EHR vendors and may serve as supportive evidence for health care leaders to target future capital investments to improve health care delivery. ", doi="10.2196/23961", url="https://www.jmir.org/2021/4/e23961", url="http://www.ncbi.nlm.nih.gov/pubmed/33851924" } @Article{info:doi/10.2196/25980, author="Soberg, Lundgaard Helene and Moksnes, {\O}greid H{\aa}kon and Anke, Audny and R{\o}ise, Olav and R{\o}e, Cecilie and Aas, Eline and Sveen, Unni and Gaarder, Christine and N{\ae}ss, Aksel P{\aa}l and Helseth, Eirik and Dahl, Margrete Hilde and Becker, Frank and L{\o}vstad, Marianne and Bartnes, Kristian and Sch{\"a}fer, Christoph and Rasmussen, S. Mari and Perrin, Paul and Lu, Juan and Hellstr{\o}m, Torgeir and Andelic, Nada", title="Rehabilitation Needs, Service Provision, and Costs in the First Year Following Traumatic Injuries: Protocol for a Prospective Cohort Study", journal="JMIR Res Protoc", year="2021", month="Apr", day="14", volume="10", number="4", pages="e25980", keywords="trauma", keywords="rehabilitation needs", keywords="health services", keywords="costs", keywords="rehabilitation", keywords="traumatic injury", keywords="injury", abstract="Background: Traumatic injuries, defined as physical injuries with sudden onset, are a major public health problem worldwide. There is a paucity of knowledge regarding rehabilitation needs and service provision for patients with moderate and major trauma, even if rehabilitation research on a spectrum of specific injuries is available. Objective: This study aims to describe the prevalence of rehabilitation needs, the provided services, and functional outcomes across all age groups, levels of injury severity, and geographical regions in the first year after trauma. Direct and indirect costs of rehabilitation provision will also be assessed. The overarching aim is to better understand where to target future efforts. Methods: This is a population-based prospective follow-up study. It encompasses patients of all ages with moderate and severe acute traumatic injury (New Injury Severity Score >9) admitted to the regional trauma centers in southeastern and northern Norway over a 1-year period (2020). Sociodemographic and injury data will be collected. Upon hospital discharge, rehabilitation physicians estimate rehabilitation needs. Rehabilitation needs are assessed by the Rehabilitation Complexity Scale Extended--Trauma (RCS E--Trauma; specialized inpatient rehabilitation), Needs and Provision Complexity Scale (NPCS; community-based rehabilitation and health care service delivery), and Family Needs Questionnaire--Pediatric Version (FNQ-P). Patients, family caregivers, or both will complete questionnaires at 6- and 12-month follow-ups, which are supplemented by telephone interviews. Data on functioning and disability, mental health, health-related quality of life measured by the EuroQol Questionnaire (EQ-5D), and needs and provision of rehabilitation and health care services are collected by validated outcome measures. Unmet needs are represented by the discrepancies between the estimates of the RCS E--Trauma and NPCS at the time of a patient's discharge and the rehabilitation services the patient has actually received. Formal service provision (including admission to inpatient- or outpatient-based rehabilitation), informal care, and associated costs will be collected. Results: The project was funded in December 2018 and approved by the Regional Committee for Medical and Health Research Ethics in October 2019. Inclusion of patients began at Oslo University Hospital on January 1, 2020, and at the University Hospital of North Norway on February 1, 2020. As of February 2021, we have enrolled 612 patients, and for 286 patients the 6-month follow-up has been completed. Papers will be drafted for publication throughout 2021 and 2022. Conclusions: This study will improve our understanding of existing service provision, the gaps between needs and services, and the associated costs for treating patients with moderate and major trauma. This may guide the improvement of rehabilitation and health care resource planning and allocation. International Registered Report Identifier (IRRID): DERR1-10.2196/25980 ", doi="10.2196/25980", url="https://www.researchprotocols.org/2021/4/e25980", url="http://www.ncbi.nlm.nih.gov/pubmed/33688841" } @Article{info:doi/10.2196/26214, author="Rodriguez-Jimenez, Roberto and Corripio, Iluminada and Campos, Ricardo and P{\'a}ramo, Mario and Franco-Martin, Manuel and Segura, Estefan{\'i}a and Gonz{\'a}lez, Sergio and Mart{\'i}nez-Raga, Jos{\'e}", title="Structure and Functioning of Acute Inpatient Psychiatric Units in Spain: Qualitative Study", journal="JMIR Res Protoc", year="2021", month="Apr", day="7", volume="10", number="4", pages="e26214", keywords="acute inpatient psychiatric units", keywords="organization", keywords="resources", keywords="scorecard", keywords="Spain", abstract="Background: As a consequence of the decentralization of health care provision to the different Regions (called Autonomous Communities) in Spain, different health care models and resources have been developed for psychiatric patients. It would be very useful to obtain comprehensive and comparative data on health care models, resources, and activity of acute inpatient psychiatric units (AIPUs) as a key part of mental health systems. Objective: The aim of this study was to determine the current state of AIPUs in Spain through a national scorecard that allows the current situation to be visualized in terms of resources, processes, and outputs. Methods: A 104-item online questionnaire was sent to all the AIPUs of the different Regions in Spain. It was divided into 11 sections, including data on the resources, processes, and outputs of the AIPUs plus general data, an indicator dashboard, and good practices. Results: The questionnaire was completed by 60.0\% (117/195) of the AIPUs invited to participate. The information collected has allowed us to obtain a detailed snapshot of the current situation of AIPUs in Spain at the levels of infrastructure and material resources, staffing, organization and activity of the units, coordination with other units, guidelines, processes and protocols used, participation and communication with patients and their families, teaching activity, and research linked to the units. Conclusions: This project aimed to help understand the general situation of AIPUs in Spain and its different Regions, contribute to enhancing the benchmarking and harmonization among Spanish Regions, and provide data for future comparisons with other countries. International Registered Report Identifier (IRRID): RR1-10.2196/26214 ", doi="10.2196/26214", url="https://www.researchprotocols.org/2021/4/e26214", url="http://www.ncbi.nlm.nih.gov/pubmed/33729167" } @Article{info:doi/10.2196/21892, author="Ren, Dixuan and Ma, Baolong", title="Effectiveness of Interactive Tools in Online Health Care Communities: Social Exchange Theory Perspective", journal="J Med Internet Res", year="2021", month="Mar", day="12", volume="23", number="3", pages="e21892", keywords="efforts", keywords="income", keywords="privacy disease", keywords="platform", keywords="social exchange", abstract="Background: Although the COVID-19 pandemic will have a negative effect on China's economy in the short term, it also represents a major opportunity for internet-based medical treatment in the medium and long term. Compared with normal times, internet-based medical platforms including the Haodf website were visited by 1.11 billion people, the number of new registered users of all platforms increased by 10, and the number of new users' daily consultations increased by 9 during the pandemic. The continuous participation of physicians is a major factor in the success of the platform, and economic return is an important reason for physicians to provide internet-based services. However, no study has provided the effectiveness of interactive tools in online health care communities to influence physicians' returns. Objective: The effect of internet-based effort on the benefits and effectiveness of interactive effort tools in internet-based health care areas remains unclear. Thus, the goals of this study are to examine the effect of doctors' internet-based service quality on their economic returns during COVID-19 social restrictions, to examine the effect of mutual help groups on doctors' economic returns during COVID-19 social restrictions, and to explore the moderating effect of disease privacy on doctors' efforts and economic returns during COVID-19 social restrictions. Methods: On the basis of the social exchange theory, this study establishes an internet-based effort exchange model for doctors. We used a crawler to download information automatically from Haodf website. From March 5 to 7, 2020, which occurred during the COVID-19 pandemic in China, cross-sectional information of 2530 doctors were collected. Results: Hierarchical linear regression showed that disease privacy ($\beta$=.481; P<.001), reputation ($\beta$=.584; P<.001), and service quality ($\beta$=.560; P<.001) had a significant positive effect on the economic returns of the physicians. The influence of mutual help groups on earnings increases with an increase in the degree of disease privacy ($\beta$=.189; P<.001), indicating that mutual help groups have a stronger effect on earnings when patients ask questions about diseases regarding which they desire privacy. Conclusions: For platform operators, the results of this study can help the platform understand how to improve doctors' economic returns, especially regarding helping a specific doctor group improve its income to retain good doctors. For physicians on the platform, this study will help doctors spend their limited energy and time on tools that can improve internet-based consultation incomes. Patients who receive internet-based health care services extract information about a doctor based on the doctor's internet-based efforts to understand the doctor's level of professionalism and personality to choose the doctor they like the most. The data used in this study may be biased or not representative of all medical platforms, as they were collected from a single website. ", doi="10.2196/21892", url="https://www.jmir.org/2021/3/e21892", url="http://www.ncbi.nlm.nih.gov/pubmed/33709940" } @Article{info:doi/10.2196/25581, author="Rele, Siddharth and Shadbolt, Cade and Schilling, Chris and Taylor, F. Nicholas and Dowsey, M. Michelle and Choong, M. Peter F.", title="The Impact of Enhanced Recovery After Surgery on Total Joint Arthroplasty: Protocol for a Systematic Review and Meta-analysis", journal="JMIR Res Protoc", year="2021", month="Mar", day="12", volume="10", number="3", pages="e25581", keywords="enhanced recovery after surgery", keywords="total knee arthroplasty", keywords="total hip arthroplasty", keywords="systematic review", keywords="meta-analysis", keywords="postoperative outcomes", keywords="economic evaluation", abstract="Background: The number of total joint arthroplasties (TJAs) being performed is increasing worldwide. To match this increasing demand, there has been focus on hastening patients' recovery of function. This effort has culminated in the formulation of enhanced recovery after surgery (ERAS) strategies. However, with evolving ERAS programs and new recommendations, a review of current evidence is required to provide clinicians with up-to-date information about its effect on outcomes for TJA. Objective: The objective of this study is to assess the utility of ERAS programs on patient, health service, and economic outcomes for primary, elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: A systematic search will be conducted in Medline (Ovid), EMCARE (Ovid), EMBASE (Ovid), Web of Science, CINAHL, National Health Service Economic Evaluations Database, and the Cochrane Library. Analytical, observational, and experimental designs will be included in this systematic review. Only studies including patients undergoing primary TKA and THA comparing ERAS programs with conventional surgery and postoperative care will be included. Data related to patient outcomes, health service outcomes, safety, and economic evaluation will be extracted. Results: The search terms and primary database searches have been finalized. Findings will be reported in narrative and tabular form. Where appropriate, random effects meta-analyses will be conducted for each outcome, and heterogeneity quantified with Cochran Q test and I2 statistic. Measures of effect or mean differences will be reported with 95\% confidence intervals. The results of this systematic review will be disseminated in a peer-reviewed journal. Conclusions: This protocol will guide a systematic review assessing outcomes associated with ERAS surgery in primary THA and TKA. Trial Registration: Open Science Framework osf.io/y4bhs; https://osf.io/y4bhs International Registered Report Identifier (IRRID): PRR1-10.2196/25581 ", doi="10.2196/25581", url="https://www.researchprotocols.org/2021/3/e25581", url="http://www.ncbi.nlm.nih.gov/pubmed/33709944" } @Article{info:doi/10.2196/13681, author="Meinert, Edward and Eerens, Jessie and Banks, Christina and Maloney, Stephen and Rivers, George and Ilic, Dragan and Walsh, Kieran and Majeed, Azeem and Car, Josip", title="Exploring the Cost of eLearning in Health Professions Education: Scoping Review", journal="JMIR Med Educ", year="2021", month="Mar", day="11", volume="7", number="1", pages="e13681", keywords="education", keywords="distance education", keywords="professional education", keywords="online education", keywords="online learning", keywords="costs and cost analysis", keywords="economics", abstract="Background: Existing research on the costs associated with the design and deployment of eLearning in health professions education is limited. The relative costs of these learning platforms to those of face-to-face learning are also not well understood. The lack of predefined costing models used for eLearning cost data capture has made it difficult to complete cost evaluation. Objective: The key aim of this scoping review was to explore the state of evidence concerning cost capture within eLearning in health professions education. The review explores the available data to define cost calculations related to eLearning. Methods: The scoping review was performed using a search strategy with Medical Subject Heading terms and related keywords centered on eLearning and cost calculation with a population scope of health professionals in all countries. The search was limited to articles published in English. No restriction was placed on literature publication date. Results: In total, 7344 articles were returned from the original search of the literature. Of these, 232 were relevant to associated keywords or abstract references following screening. Full-text review resulted in 168 studies being excluded. Of these, 61 studies were excluded because they were unrelated to eLearning and focused on general education. In addition, 103 studies were excluded because of lack of detailed information regarding costs; these studies referred to cost in ways either indicating cost favorability or unfavorability, but without data to support findings. Finally, 4 studies were excluded because of limited cost data that were insufficient for analysis. In total, 42 studies provided data and analysis of the impact of cost and value in health professions education. The most common data source was total cost of training (n=29). Other sources included cost per learner, referring to the cost for individual students (n=13). The population most frequently cited was medical students (n=15), although 12 articles focused on multiple populations. A further 22 studies provide details of costing approaches for the production and delivery of eLearning. These studies offer insight into the ways eLearning has been budgeted and project-managed through implementation. Conclusions: Although cost is a recognized factor in studies detailing eLearning design and implementation, the way cost is captured is inconsistent. Despite a perception that eLearning is more cost-effective than face-to-face instruction, there is not yet sufficient evidence to assert this conclusively. A rigorous, repeatable data capture method is needed, in addition to a means to leverage existing economic evaluation methods that can then test eLearning cost-effectiveness and how to implement eLearning with cost benefits and advantages over traditional instruction. ", doi="10.2196/13681", url="https://mededu.jmir.org/2021/1/e13681", url="http://www.ncbi.nlm.nih.gov/pubmed/33704073" } @Article{info:doi/10.2196/24363, author="S{\"u}lz, Sandra and van Elten, J. Hilco and Askari, Marjan and Weggelaar-Jansen, Marie Anne and Huijsman, Robbert", title="eHealth Applications to Support Independent Living of Older Persons: Scoping Review of Costs and Benefits Identified in Economic Evaluations", journal="J Med Internet Res", year="2021", month="Mar", day="9", volume="23", number="3", pages="e24363", keywords="cost", keywords="benefit", keywords="eHealth", keywords="aged", keywords="economic evaluation", abstract="Background: eHealth applications are constantly increasing and are frequently considered to constitute a promising strategy for cost containment in health care, particularly if the applications aim to support older persons. Older persons are, however, not the only major eHealth stakeholder. eHealth suppliers, caregivers, funding bodies, and health authorities are also likely to attribute value to eHealth applications, but they can differ in their value attribution because they are affected differently by eHealth costs and benefits. Therefore, any assessment of the value of eHealth applications requires the consideration of multiple stakeholders in a holistic and integrated manner. Such a holistic and reliable value assessment requires a profound understanding of the application's costs and benefits. The first step in measuring costs and benefits is identifying the relevant costs and benefit categories that the eHealth application affects. Objective: The aim of this study is to support the conceptual phase of an economic evaluation by providing an overview of the relevant direct and indirect costs and benefits incorporated in economic evaluations so far. Methods: We conducted a systematic literature search covering papers published until December 2019 by using the Embase, Medline Ovid, Web of Science, and CINAHL EBSCOhost databases. We included papers on eHealth applications with web-based contact possibilities between clients and health care providers (mobile health apps) and applications for self-management, telehomecare, telemedicine, telemonitoring, telerehabilitation, and active healthy aging technologies for older persons. We included studies that focused on any type of economic evaluation, including costs and benefit measures. Results: We identified 55 papers with economic evaluations. These studies considered a range of different types of costs and benefits. Costs pertained to implementation activities and operational activities related to eHealth applications. Benefits (or consequences) could be categorized according to stakeholder groups, that is, older persons, caregivers, and health care providers. These benefits can further be divided into stakeholder-specific outcomes and resource usage. Some cost and benefit types have received more attention than others. For instance, patient outcomes have been predominantly captured via quality-of-life considerations and various types of physical health status indicators. From the perspective of resource usage, a strong emphasis has been placed on home care visits and hospital usage. Conclusions: Economic evaluations of eHealth applications are gaining momentum, and studies have shown considerable variation regarding the costs and benefits that they include. We contribute to the body of literature by providing a detailed and up-to-date framework of cost and benefit categories that any interested stakeholder can use as a starting point to conduct an economic evaluation in the context of independent living of older persons. ", doi="10.2196/24363", url="https://www.jmir.org/2021/3/e24363", url="http://www.ncbi.nlm.nih.gov/pubmed/33687335" } @Article{info:doi/10.2196/26516, author="Jiang, Xinchan and Yao, Jiaqi and You, Hoi-Sze Joyce", title="Cost-effectiveness of a Telemonitoring Program for Patients With Heart Failure During the COVID-19 Pandemic in Hong Kong: Model Development and Data Analysis", journal="J Med Internet Res", year="2021", month="Mar", day="3", volume="23", number="3", pages="e26516", keywords="telemonitoring", keywords="mobile health", keywords="smartphone", keywords="heart failure", keywords="COVID-19", keywords="health care avoidance", keywords="cost-effectiveness", abstract="Background: The COVID-19 pandemic has caused patients to avoid seeking medical care. Provision of telemonitoring programs in addition to usual care has demonstrated improved effectiveness in managing patients with heart failure (HF). Objective: We aimed to examine the potential clinical and health economic outcomes of a telemonitoring program for management of patients with HF during the COVID-19 pandemic from the perspective of health care providers in Hong Kong. Methods: A Markov model was designed to compare the outcomes of a care under COVID-19 (CUC) group and a telemonitoring plus CUC group (telemonitoring group) in a hypothetical cohort of older patients with HF in Hong Kong. The model outcome measures were direct medical cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Sensitivity analyses were performed to examine the model assumptions and the robustness of the base-case results. Results: In the base-case analysis, the telemonitoring group showed a higher QALY gain (1.9007) at a higher cost (US \$15,888) compared to the CUC group (1.8345 QALYs at US \$15,603). Adopting US \$48,937/QALY (1 {\texttimes} the gross domestic product per capita of Hong Kong) as the willingness-to-pay threshold, telemonitoring was accepted as a highly cost-effective strategy, with an incremental cost-effective ratio of US \$4292/QALY. No threshold value was identified in the deterministic sensitivity analysis. In the probabilistic sensitivity analysis, telemonitoring was accepted as cost-effective in 99.22\% of 10,000 Monte Carlo simulations. Conclusions: Compared to the current outpatient care alone under the COVID-19 pandemic, the addition of telemonitoring-mediated management to the current care for patients with HF appears to be a highly cost-effective strategy from the perspective of health care providers in Hong Kong. ", doi="10.2196/26516", url="https://www.jmir.org/2021/3/e26516", url="http://www.ncbi.nlm.nih.gov/pubmed/33656440" } @Article{info:doi/10.2196/25583, author="Moreno, Georgina and van Mierlo, Trevor", title="A Digital Health Tool to Understand and Prevent Cannabis-Impaired Driving Among Youth: A Cross-sectional Study of Responses to a Brief Intervention for Cannabis Use", journal="JMIR Form Res", year="2021", month="Mar", day="2", volume="5", number="3", pages="e25583", keywords="cannabis use", keywords="driving after cannabis use", keywords="internet", keywords="intervention", keywords="online intervention", keywords="digital health", keywords="cannabis", keywords="drug", keywords="online tool", keywords="youth", keywords="adolescent", keywords="Canada", abstract="Background: Cannabis legalization has raised concern about an increased risk of cannabis-impaired driving, particularly among youth. Youth advocates and policy makers require cost-effective tools to target educational resources to promote responsible cannabis use. Objective: The objective of this paper is threefold. First, it describes how a youth advocacy organization disseminated a low-cost digital brief intervention to educate and inform young people about responsible cannabis use. Second, it illustrates how digital tools can help promote understanding about attitudes and behaviors toward cannabis while simultaneously offering tailored education. Finally, this paper contributes to examining behavioral factors associated with youth cannabis-impaired driving by quantifying relationships between cannabis users' willingness to drive impaired and self-reported demographic and behavioral factors. Methods: This paper analyzed data from 1110 completed Check Your Cannabis (CYC) brief interventions between March 2019 and October 2020. The CYC asks respondents a brief set of questions about their cannabis use and their personal beliefs and behaviors. Respondents receive comprehensive feedback about their cannabis use and how it compares with others. They also receive a summary of reported behaviors with brief advice. An ordered probit model was used to test relationships between cannabis use, demographics, and driving behaviors to gain further insights. Results: The vast majority (817/1110, 73.6\%) of respondents reported using cannabis. However, a much smaller share of respondents reported problems associated with their cannabis use (257/1110, 23.2\%) or driving after cannabis use (342/1110, 30.8\%). We found statistically significant relationships between driving after cannabis use and age; Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) risk score; and polysubstance use. However, we did not find gender to be a significant determinant of driving after cannabis use. We estimated that every 10-point increase in the ASSIST score increased the probability of sometimes driving after cannabis use by 7.3\% (P<.001). Relative to respondents who reported never drinking alcohol or using other substances with cannabis, those who sometimes drink or use other substances with cannabis were 13\% (P<.001) more likely to sometimes or always drive after using cannabis. Conclusions: The digital health tool cost the youth advocacy organization approximately Can \$0.90 (US \$0.71) per use. Due to the tool's unlimited use structure, the per-use cost would further decrease with increased use by the organization's target population. Based on our results, public health campaigns and other interventions may consider tailoring resources to frequent cannabis users, youth with high ASSIST scores, and those with polysubstance abuse. The cost-effectiveness of delivering digital brief interventions with unlimited use is attractive, as increased use decreases the per-user cost. Further research examining the efficacy of digital health interventions targeting problematic cannabis use is required. ", doi="10.2196/25583", url="https://formative.jmir.org/2021/3/e25583", url="http://www.ncbi.nlm.nih.gov/pubmed/33650982" } @Article{info:doi/10.2196/25619, author="Berthelot, Simon and Breton, Mylaine and Guertin, Robert Jason and Archambault, Michel Patrick and Berger Pelletier, Elyse and Blouin, Danielle and Borgundvaag, Bjug and Duhoux, Arnaud and Harvey Labb{\'e}, Laurie and Laberge, Maude and Lachapelle, Philippe and Lapointe-Shaw, Lauren and Layani, G{\'e}raldine and Lefebvre, Gabrielle and Mallet, Myriam and Matthews, Deborah and McBrien, Kerry and McLeod, Shelley and Mercier, Eric and Messier, Alexandre and Moore, Lynne and Morris, Judy and Morris, Kathleen and Ovens, Howard and Pageau, Paul and Paquette, Jean-S{\'e}bastien and Perry, Jeffrey and Schull, Michael and Simon, Mathieu and Simonyan, David and Stelfox, Thomas Henry and Talbot, Denis and Vaillancourt, Samuel", title="A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study", journal="JMIR Res Protoc", year="2021", month="Feb", day="22", volume="10", number="2", pages="e25619", keywords="emergency department", keywords="primary care", keywords="walk-in clinic", keywords="health economics", keywords="quality of care", keywords="patient preferences", keywords="patient-reported outcomes", keywords="outcome assessment, health care", abstract="Background: In Canada, 30\%-60\% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. Objective: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Methods: A multicenter prospective cohort study will be performed in Ontario and Qu{\'e}bec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. Results: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. Conclusions: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. International Registered Report Identifier (IRRID): PRR1-10.2196/25619 ", doi="10.2196/25619", url="https://www.researchprotocols.org/2021/2/e25619", url="http://www.ncbi.nlm.nih.gov/pubmed/33616548" } @Article{info:doi/10.2196/15598, author="O'Cathail, Micheal and Aznar-Garcia, Luis and Sivanandan, Ananth and Diver, Claire and Patel, Poulam and Tang, Pui-Shan and Christian, Judith", title="Use of Teleconsultations in a Regional Stereotactic Radiosurgery Service: Pilot Study", journal="JMIR Form Res", year="2021", month="Feb", day="5", volume="5", number="2", pages="e15598", keywords="telemedicine", keywords="teleconsultations", keywords="brain metastases", keywords="stereotactic radiosurgery", keywords="mobile phone", abstract="Background: The National Health Service Long Term Plan details plans to make digital interactions available to all patients in 5 years. Teleconsultations can improve access to specialist services; however, there is a lack of evidence for the use of teleconsultations in an oncology setting in the United Kingdom. Objective: We aim to describe a service evaluation of teleconsultations for patients attending a regional brain metastases clinic. These patients have unique travel restrictions that prevent them from driving. Methods: From April to October 2018, all patients attending the brain metastases clinic were offered the choice of teleconsultation in place of a face-to-face appointment. Feedback was assessed using a satisfaction questionnaire, and data of all clinic attendances were collected. Results: A total of 69 individual patients had 119 appointments over the duration of the pilot, of which 36 (30.2\%) were new patient appointments and 73 (61.3\%) were follow-ups. Of the 69 patients, 24 (35\%) took part in teleconsultations (41/119, 34.5\%). User satisfaction was high, and no patients who took part in a teleconsultation reverted to face-to-face appointments. These patients avoided 2521 miles (61.6 miles per appointment) of hospital-associated travel and travel costs of {\textsterling}441.48 (US \$599.83) to {\textsterling}10.78 (US \$14.65) per appointment. Conclusions: Teleconsultations appear to be acceptable in this cohort of patients with brain metastases attending a regional stereotactic radiosurgery service with the potential for significant savings in travel and expenses. ", doi="10.2196/15598", url="http://formative.jmir.org/2021/2/e15598/", url="http://www.ncbi.nlm.nih.gov/pubmed/33544082" } @Article{info:doi/10.2196/22902, author="Marsden, Lesley Dianne and Boyle, Kerry and Jordan, Louise-Anne and Dunne, Anne Judith and Shipp, Jodi and Minett, Fiona and Styles, Amanda and Birnie, Jaclyn and Ormond, Sally and Parrey, Kim and Buzio, Amanda and Lever, Sandra and Paul, Michelle and Hill, Kelvin and Pollack, P. Michael R. and Wiggers, John and Oldmeadow, Christopher and Cadilhac, Ann-Michele Dominique and Duff, Jed and ", title="Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study", journal="JMIR Res Protoc", year="2021", month="Feb", day="4", volume="10", number="2", pages="e22902", keywords="urinary incontinence", keywords="lower urinary tract symptoms", keywords="inpatient", keywords="practice-gap", keywords="practice improvement", keywords="protocol", abstract="Background: Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18\% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41\% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care. Objective: This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards. Methods: This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47\% metropolitan, 8/15, 53\% regional) in Australia. Data will be collected at 3 time points: before implementation (T0), immediately after the 6-month implementation period (T1), and again after a 6-month maintenance period (T2). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined. Results: This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T0) was completed in March 2020. As of November 2020, 87\% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T1). Conclusions: Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package. International Registered Report Identifier (IRRID): DERR1-10.2196/22902 ", doi="10.2196/22902", url="https://www.researchprotocols.org/2021/2/e22902", url="http://www.ncbi.nlm.nih.gov/pubmed/33538703" } @Article{info:doi/10.2196/23654, author="Lai, Claudia and Deber, Raisa and Jadad, R. Alejandro and Shachak, Aviv", title="Income-Generating Processes of Free Web-Based Digital Health Tools to Engage Patients: Qualitative Analysis", journal="J Med Internet Res", year="2021", month="Feb", day="3", volume="23", number="2", pages="e23654", keywords="digital health", keywords="patient engagement", keywords="eHealth", keywords="health information", abstract="Background: In recent years, digital tools have become a viable means for patients to address their health and information needs. Governments and health care organizations are offering digital tools such as self-assessment tools, symptom tracking tools, or chatbots. Other sources of digital tools, such as those offered through patient platforms, are available on the internet free of charge. We define patient platforms as health-specific websites that offer tools to anyone with internet access to engage them in their health care process with peer networks to support their learning. Although numerous social media platforms engage users without up-front charges, patient platforms are specific to health. As little is known about their business model, there is a need to understand what else these platforms are trying to achieve beyond supporting patients so that patients can make informed decisions about the benefits and risks of using the digital tools they offer. Objective: The aim of this study is to explore what patient platforms are trying to achieve beyond supporting patients and how their digital tools can be used to generate income. Methods: Textual and visual data collected from a purposeful selection of 11 patient platforms from September 2013 to August 2014 were analyzed using framework analysis. Data were systematically and rigorously coded and categorized according to key issues and themes by following 5 steps: familiarizing, identifying a thematic framework, indexing, charting, and mapping and interpretation. We used open coding to identify additional concepts not captured in the initial thematic framework. This paper reports on emergent findings on the business models of the platforms and their income-generating processes. Results: Our analysis revealed that in addition to patients, the platforms support other parties with interests in health and information exchanges. Patient platforms did not charge up-front fees but generated income from other sources, such as advertising, sponsorship, marketing (eg, sending information to users on behalf of sponsors or providing means for sponsors to reach patients directly), supporting other portals, and providing research services. Conclusions: This study reports on the mechanisms by which some patient platforms generate income to support their operations, gain profit, or both. Although income-generating processes exist elsewhere on social media platforms in general, they pose unique challenges in the health context because digital tools engage patients in health and information exchanges. This study highlights the need to minimize the potential for unintended consequences that can pose health risks to patients or can lead to increased health expenses. By understanding other interests that patient platforms support, our findings point to important policy implications, such as whether (and how) authorities might protect users from processes that may not always be in their best interests and can potentially incur costs to the health system. ", doi="10.2196/23654", url="http://www.jmir.org/2021/2/e23654/", url="http://www.ncbi.nlm.nih.gov/pubmed/33533722" } @Article{info:doi/10.2196/16829, author="Jones, N. Chris and Morrison, L. Ben and Kelliher, JS Leigh and Dickinson, Matthew and Scott, Michael and Cecconi Ebm, Claudia and Karanjia, Nariman and Quiney, Nial", title="Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial", journal="JMIR Perioper Med", year="2021", month="Feb", day="1", volume="4", number="1", pages="e16829", keywords="enhanced recovery after surgery", keywords="enhanced recovery", keywords="liver resection", keywords="enhanced recovery program", keywords="health economics", keywords="survival", abstract="Background: The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective: We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods: The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice aday compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results: Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were {\textsterling}9538.279 ({\textsterling}1=US \$1.60) for ERP and {\textsterling}14,793.05 for standard treatment. This results in a cost-effectiveness ratio of --{\textsterling}6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91\% (42/46) for patients receiving ERP versus 73\% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions: ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings. ", doi="10.2196/16829", url="http://periop.jmir.org/2021/1/e16829/", url="http://www.ncbi.nlm.nih.gov/pubmed/33522982" } @Article{info:doi/10.2196/13888, author="Neyt, Mattias and Christiaens, Annick and Aloi, Marina and de Ridder, Lissy and Croft, M. Nicholas and Koletzko, Sibylle and Levine, Arie and Turner, Dan and Russell, K. Richard and Ruemmele, M. Frank and Veereman, Gigi", title="Identifying Health Economic Considerations to Include in the Research Protocol of a Randomized Controlled Trial (the REDUCE-RISK Trial): Systematic Literature Review and Assessment", journal="JMIR Form Res", year="2021", month="Jan", day="25", volume="5", number="1", pages="e13888", keywords="Crohn disease", keywords="cost-benefit analysis", keywords="adalimumab", keywords="clinical trial", keywords="protocol", keywords="technology assessment, biomedical", abstract="Background: The REDUCE-RISK trial was set up to compare the effectiveness of weekly subcutaneously administered methotrexate with daily oral azathioprine or 6-mercaptopurine in low-risk Crohn disease (CD) or subcutaneously administered adalimumab (ADA) in high-risk CD in a pediatric population (age 6-17 years). Objective: The aim of this study is to perform a systematic review to provide input into the research protocol to gather the necessary information to improve the performance of an evidence-based economic evaluation when the trial is finished. Methods: The Centre for Reviews and Dissemination (CRD) Health Technology Assessment (HTA) database, websites of HTA institutes, CRD's National Health Service Economic Evaluation Database, MEDLINE (OVID), and Embase databases were consulted to retrieve (reviews of) relevant economic evaluations. Studies were eligible if they included a pediatric or adult population with inflammatory bowel diseases (CD and ulcerative colitis [UC]) treated with ADA (Humira). There were no restrictions on the comparator. Only economic evaluations expressing outcomes in life years gained or quality-adjusted life years gained were selected. Results: A total of 12 primary studies were identified. None of these studies included a pediatric population because of a lack of supporting trials. The economic evaluations identified in our systematic review indicate that ADA is an appropriate intervention for inclusion in such a trial. From a health economic point of view, it is important to make an incremental analysis comparing such an intervention with standard care and not immediately versus another (expensive) biological treatment. Information on the impact of children's school attendance and parents' productivity is currently lacking in economic evaluations, and none of the underlying trials measured quality of life (QoL) using a generic utility instrument. Conclusions: The review of the economic literature on ADA for the treatment of patients with CD supports the performance of a trial with biologicals in pediatric patients, including making a distinction according to disease severity. Conducting an economic literature review enabled us to decide which variables should be added to the research protocol from an economic point of view. Measurements for children's and parents' QoL (EuroQol 5-Dimension questionnaires), children's school attendance, and parents' productivity (WPAI-CD-CG questionnaire) were added to the research protocol. This will provide support for the calculation of the cost-effectiveness of the interventions evaluated in the REDUCE-RISK trial. Trial Registration: ClinicalTrials.gov NCT02852694; https://clinicaltrials.gov/ct2/show/NCT02852694 ", doi="10.2196/13888", url="http://formative.jmir.org/2021/1/e13888/", url="http://www.ncbi.nlm.nih.gov/pubmed/33492239" } @Article{info:doi/10.2196/23190, author="Shah, Shailendra Sachin and Gvozdanovic, Andrew and Knight, Matthew and Gagnon, Julien", title="Mobile App--Based Remote Patient Monitoring in Acute Medical Conditions: Prospective Feasibility Study Exploring Digital Health Solutions on Clinical Workload During the COVID Crisis", journal="JMIR Form Res", year="2021", month="Jan", day="15", volume="5", number="1", pages="e23190", keywords="mHealth", keywords="remote patient monitoring", keywords="digital health", keywords="COVID-19", keywords="service improvement", keywords="cost-effectiveness", keywords="monitoring", abstract="Background: Digital remote patient monitoring can add value to virtual wards; this has become more apparent in the context of the COVID-19 pandemic. Health care providers are overwhelmed, resulting in clinical teams spread more thinly. We aimed to assess the impact of introducing an app-based remote patient monitoring system (Huma Therapeutics) on a clinician's workload in the context of a COVID-19--specific virtual ward. Objective: This prospective feasibility study aimed to evaluate the health economic effects (in terms of clinical workload) of a mobile app on a telephone-based virtual ward used in the monitoring of patients with COVID-19 who are clinically ready for discharge from the hospital. Methods: A prospective feasibility study was carried out over 1 month where clinician workload was monitored, and full-time equivalents savings were determined. An NHS hospital repurposed a telephone-based respiratory virtual ward for COVID-19. Patients with COVID-19 in the amber zone (according to the National Health Service definition) were monitored for 14 days postdischarge to help identify deteriorating patients earlier. A smartphone-based app was introduced to monitor data points submitted by the patients via communication over telephone calls. We then comparatively evaluated the clinical workload between patients monitored by telephone only (cohort 1) with those monitored via mobile app and telephone (cohort 2). Results: In all, 56 patients were enrolled in the app-based virtual ward (cohort 2). Digital remote patient monitoring resulted in a reduction in the number of phone calls from a mean total of 9 calls to 4 calls over the monitoring period. There was no change in the mean duration of phone calls (8.5 minutes) and no reports of readmission or mortality. These results equate to a mean saving of 47.60 working hours. Moreover, it translates to 3.30 fewer full-time equivalents (raw phone call data), resulting in 1.1 fewer full-time equivalents required to monitor 100 patients when adjusted for time spent reviewing app data. Individual clinicians spent an average of 10.9 minutes per day reviewing data. Conclusions: Smartphone-based remote patient monitoring technologies may offer tangible reductions in clinician workload at a time when service is severely strained. In this small-scale pilot study, we demonstrated the economic and operational impact that digital remote patient monitoring technology can have in improving working efficiency and reducing operational costs. Although this particular RPM solution was deployed for the COVID-19 pandemic, it may set a precedent for wider utilization of digital, remote patient monitoring solutions in other clinical scenarios where increased care delivery efficiency is sought. ", doi="10.2196/23190", url="http://formative.jmir.org/2021/1/e23190/", url="http://www.ncbi.nlm.nih.gov/pubmed/33400675" } @Article{info:doi/10.2196/22135, author="de Batlle, Jordi and Massip, Mireia and Vargiu, Eloisa and Nadal, Nuria and Fuentes, Araceli and Ortega Bravo, Marta and Miralles, Felip and Barb{\'e}, Ferran and Torres, Gerard and ", title="Implementing Mobile Health--Enabled Integrated Care for Complex Chronic Patients: Intervention Effectiveness and Cost-Effectiveness Study", journal="JMIR Mhealth Uhealth", year="2021", month="Jan", day="14", volume="9", number="1", pages="e22135", keywords="chronic disease", keywords="cost-benefit analysis", keywords="delivery of health care, integrated", keywords="mHealth", keywords="eHealth", keywords="quality of life", abstract="Background: Integrated care can generate health and social care efficiencies through the defragmentation of care and adoption of patient-centered preventive models. eHealth can be a key enabling technology for integrated care. Objective: The aim of this study was to assess the effectiveness and cost-effectiveness of the implementation of a mobile health (mHealth)-enabled integrated care model for complex chronic patients. Methods: As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, two-arm, parallel implementation trial was held in a rural region of Catalonia, Spain. During 3 months, elderly patients with chronic obstructive pulmonary disease or heart failure and their carers experienced the combined benefits of the CONNECARE organizational integrated care model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care. We assessed changes in health status with the 12-Item Short-Form Survey (SF-12), unplanned visits and admissions during a 6-month follow up, and the incremental cost-effectiveness ratio (ICER). Results: A total of 48 patients were included in the integrated care arm and 28 patients receiving usual care were included in the control arm (mean age 82 years, SD 7 years; mean Charlson index 7, SD 2). Integrated care patients showed a significant increase in the SF-12 physical domain with a mean change of +3.7 (SD 8.4) (P=.004) and total SF-12 score with a mean change of +5.8 (SD 12.8) (P=.003); however, the differences in differences between groups were not statistically significant. Integrated care patients had 57\% less unplanned visits (P=.004) and 50\% less hospital admissions related to their main chronic diseases (P=.32). The integrated care program generated savings in different cost scenarios and the ICER demonstrated the cost-effectiveness of the program. Conclusions: The implementation of a patient-centered mHealth-enabled integrated care model empowering the patient, and connecting primary, hospital, and social care professionals reduced unplanned contacts with the health system and health costs, and was cost-effective. These findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement integrated care. ", doi="10.2196/22135", url="https://mhealth.jmir.org/2021/1/e22135", url="http://www.ncbi.nlm.nih.gov/pubmed/33443486" } @Article{info:doi/10.2196/19761, author="Mohammadi, Ramin and Jain, Sarthak and Namin, T. Amir and Scholem Heller, Melissa and Palacholla, Ramya and Kamarthi, Sagar and Wallace, Byron", title="Predicting Unplanned Readmissions Following a Hip or Knee Arthroplasty: Retrospective Observational Study", journal="JMIR Med Inform", year="2020", month="Nov", day="27", volume="8", number="11", pages="e19761", keywords="deep learning", keywords="natural language processing", keywords="electronic health records", keywords="auto ML", keywords="30-days readmission", keywords="hip arthroplasty", keywords="knee arthroplasty", abstract="Background: Total joint replacements are high-volume and high-cost procedures that should be monitored for cost and quality control. Models that can identify patients at high risk of readmission might help reduce costs by suggesting who should be enrolled in preventive care programs. Previous models for risk prediction have relied on structured data of patients rather than clinical notes in electronic health records (EHRs). The former approach requires manual feature extraction by domain experts, which may limit the applicability of these models. Objective: This study aims to develop and evaluate a machine learning model for predicting the risk of 30-day readmission following knee and hip arthroplasty procedures. The input data for these models come from raw EHRs. We empirically demonstrate that unstructured free-text notes contain a reasonably predictive signal for this task. Methods: We performed a retrospective analysis of data from 7174 patients at Partners Healthcare collected between 2006 and 2016. These data were split into train, validation, and test sets. These data sets were used to build, validate, and test models to predict unplanned readmission within 30 days of hospital discharge. The proposed models made predictions on the basis of clinical notes, obviating the need for performing manual feature extraction by domain and machine learning experts. The notes that served as model inputs were written by physicians, nurses, pathologists, and others who diagnose and treat patients and may have their own predictions, even if these are not recorded. Results: The proposed models output readmission risk scores (propensities) for each patient. The best models (as selected on a development set) yielded an area under the receiver operating characteristic curve of 0.846 (95\% CI 82.75-87.11) for hip and 0.822 (95\% CI 80.94-86.22) for knee surgery, indicating reasonable discriminative ability. Conclusions: Machine learning models can predict which patients are at a high risk of readmission within 30 days following hip and knee arthroplasty procedures on the basis of notes in EHRs with reasonable discriminative power. Following further validation and empirical demonstration that the models realize predictive performance above that which clinical judgment may provide, such models may be used to build an automated decision support tool to help caretakers identify at-risk patients. ", doi="10.2196/19761", url="https://medinform.jmir.org/2020/11/e19761", url="http://www.ncbi.nlm.nih.gov/pubmed/33245283" } @Article{info:doi/10.2196/19570, author="Steegers-Theunissen, R{\'e}gine and Hoek, Annemieke and Groen, Henk and Bos, Annelies and van den Dool, Grada and Schoonenberg, Marieke and Smeenk, Jesper and Creutzberg, Eva and Vecht, Loes and Starmans, Luc and Laven, Joop", title="Pre-Conception Interventions for Subfertile Couples Undergoing Assisted Reproductive Technology Treatment: Modeling Analysis", journal="JMIR Mhealth Uhealth", year="2020", month="Nov", day="23", volume="8", number="11", pages="e19570", keywords="fertility, periconception, pregnancy chance, Smarter Pregnancy, cost-effectiveness, nutrition, obesity, IVF treatment", keywords="mobile and web-based lifestyle apps", abstract="Background: Approximately 1 in 7 couples experience subfertility, many of whom have lifestyles that negatively affect fertility, such as poor nutrition, low physical activity, obesity, smoking, or alcohol consumption. Reducing lifestyle risk factors prior to pregnancy or assisted reproductive technology treatment contributes to the improvement of reproductive health, but cost-implications are unknown. Objective: The goal of this study was to evaluate reproductive, maternal pregnancy, and birth outcomes, as well as the costs of pre-conception lifestyle intervention programs in subfertile couples and obese women undergoing assisted reproductive technology. Methods: Using a hypothetical model based on quantitative parameters from published literature and expert opinion, we evaluated the following lifestyle intervention programs: (1) Smarter Pregnancy, an online tool; (2) LIFEstyle, which provides outpatient support for obese women; (3) concurrent use of both Smarter Pregnancy and LIFEstyle for obese women; (4) smoking cessation in men; and (5) a mindfulness mental health support program using group therapy sessions. The model population was based on data from the Netherlands. Results: All model-based analyses of the lifestyle interventions showed a reduction in the number of in vitro fertilization, intracytoplasmic sperm injection, or intrauterine insemination treatments required to achieve pregnancy and successful birth for couples in the Netherlands. Smarter Pregnancy was modeled to have the largest increase in spontaneous pregnancy rate (13.0\%) and the largest absolute reduction in potential assisted reproductive technology treatments. Among obese subfertile women, LIFEstyle was modeled to show a reduction in the occurrence of gestational diabetes, maternal hypertensive pregnancy complications, and preterm births by 4.4\%, 3.8\%, and 3.0\%, respectively, per couple. Modeled cost savings per couple per year were {\texteuro}41 (US \$48.66), {\texteuro}360 (US \$427.23), {\texteuro}513 (US \$608.80), {\texteuro}586 (US \$695.43), and {\texteuro}1163 (US \$1380.18) for smoking cessation, mindfulness, Smarter Pregnancy, combined Smarter Pregnancy AND LIFEstyle, and LIFEstyle interventions, respectively. Conclusions: Although we modeled the potential impact on reproductive outcomes and costs of fertility treatment rather than collecting real-world data, our model suggests that of the lifestyle interventions for encouraging healthier behaviors, all are likely to be cost effective and appear to have positive effects on reproductive, maternal pregnancy, and birth outcomes. Further real-world data are required to determine the cost-effectiveness of pre-conception lifestyle interventions, including mobile apps and web-based tools that help improve lifestyle, and their effects on reproductive health. We believe that further implementation of the lifestyle app Smarter Pregnancy designed for subfertile couples seeking assistance to become pregnant is likely to be cost-effective and would allow reproductive health outcomes to be collected. ", doi="10.2196/19570", url="https://mhealth.jmir.org/2020/11/e19570", url="http://www.ncbi.nlm.nih.gov/pubmed/33226349" } @Article{info:doi/10.2196/23315, author="von Wedel, Philip and Hagist, Christian", title="Economic Value of Data and Analytics for Health Care Providers: Hermeneutic Systematic Literature Review", journal="J Med Internet Res", year="2020", month="Nov", day="18", volume="22", number="11", pages="e23315", keywords="digital health", keywords="health information technology", keywords="healthcare provider economics", keywords="electronic health records", keywords="data analytics", keywords="artificial intelligence", abstract="Background: The benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools. Objective: This paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist. Methods: A systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering. Results: The review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62\% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits. Conclusions: The research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base. ", doi="10.2196/23315", url="http://www.jmir.org/2020/11/e23315/", url="http://www.ncbi.nlm.nih.gov/pubmed/33206056" } @Article{info:doi/10.2196/18812, author="Powell, Adam and Torous, John", title="A Patient-Centered Framework for Measuring the Economic Value of the Clinical Benefits of Digital Health Apps: Theoretical Modeling", journal="JMIR Ment Health", year="2020", month="Oct", day="30", volume="7", number="10", pages="e18812", keywords="value", keywords="digital health", keywords="apps", keywords="payment models", abstract="Background: As digital health tools such as smartphone apps evolve and enter clinical use, questions regarding their value must be addressed. Although there are scarce generalizable data on the value of health apps given their nascency and diverse use cases, it is possible to estimate the economic value of the clinical improvement they bring to patients using a quality-adjusted life-year (QALY)-based approach and generalized values from existing literature. Objective: This paper aims to provide a patient-centered framework for assessing the economic value of the clinical benefits delivered by digital health apps. Methods: We proposed a model based upon 5 levers: country-specific monetary value of a QALY, QALYs lost due to the condition, engagement rate of app users, average effect size of the app's health impact, and duration of the app's impact before remission. Results: Using 2 digital health apps from the United States and United Kingdom as examples, we explored how this model could generate country-specific estimates of the economic value of the clinical benefits of health apps. Conclusions: This new framework can help drive research priorities for digital health by elucidating the factors that influence the economic value. ", doi="10.2196/18812", url="https://mental.jmir.org/2020/10/e18812", url="http://www.ncbi.nlm.nih.gov/pubmed/33124995" } @Article{info:doi/10.2196/17298, author="Snoswell, L. Centaine and Taylor, L. Monica and Comans, A. Tracy and Smith, C. Anthony and Gray, C. Leonard and Caffery, J. Liam", title="Determining if Telehealth Can Reduce Health System Costs: Scoping Review", journal="J Med Internet Res", year="2020", month="Oct", day="19", volume="22", number="10", pages="e17298", keywords="cost-benefit analysis", keywords="telemedicine", keywords="review", abstract="Background: Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services. Objective: This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized. Methods: A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence. Results: The cost analyses reviewed provided evidence that telehealth reduced costs when health system--funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians. Conclusions: Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system. ", doi="10.2196/17298", url="http://www.jmir.org/2020/10/e17298/", url="http://www.ncbi.nlm.nih.gov/pubmed/33074157" } @Article{info:doi/10.2196/20938, author="Piera-Jim{\'e}nez, Jordi and Daugbjerg, Signe and Stafylas, Panagiotis and Meyer, Ingo and M{\"u}ller, Sonja and Lewis, Leo and da Col, Paolo and Folkvord, Frans and Lupi{\'a}{\~n}ez-Villanueva, Francisco", title="BeyondSilos, a Telehealth-Enhanced Integrated Care Model in the Domiciliary Setting for Older Patients: Observational Prospective Cohort Study for Effectiveness and Cost-Effectiveness Assessments", journal="JMIR Med Inform", year="2020", month="Oct", day="6", volume="8", number="10", pages="e20938", keywords="integrated care", keywords="telemedicine", keywords="telecare", keywords="digital health", keywords="cost-effectiveness", keywords="clinical effectiveness", keywords="chronic disease", abstract="Background: Information and communication technology may provide domiciliary care programs with continuity of care. However, evidence about the effectiveness and cost-effectiveness of information and communication technology in the context of integrated care models is relatively scarce. Objective: The objective of our study was to provide evidence on the clinical effectiveness and cost-effectiveness of the BeyondSilos project for patients enrolled in the Badalona city pilot site in Spain. Methods: A quasi-experimental study was used to assess the cost-effectiveness of information and communication technology--enhanced integration of health and social care, including the third sector (intervention), compared to basic health and social care coordination (comparator). The study was conducted in Badalona between 2015 and 2016. Participants were followed for 8 months. Results: The study included 198 patients: 98 in the intervention group and 100 in the comparator group. The mean Barthel index remained unchanged in the intervention group (mean change 0.14, 95\% CI --4.51 to 4.78; P=.95) but decreased in the comparator group (mean change --3.23, 95\% CI --5.34 to --1.11; P=.003). Instrumental Activities of Daily Living significantly decreased in both groups: mean changes of --0.23 (95\% CI --0.44 to --0.02; P=.03) and --0.33 (95\% CI --0.46 to --0.20; P<.001) in the intervention and comparator groups, respectively. No differences were found in the Geriatric Depression Scale (intervention: mean change 0.28, 95\% CI --0.44 to 1.01, P=.44; comparator: mean change --0.29, 95\% CI --0.59 to 0.01, P=.06). The intervention showed cost-effectiveness (incremental cost-effectiveness ratio {\texteuro}6505.52, approximately US \$7582). Conclusions: The information and communication technology--enhanced integrated domiciliary care program was cost-effective. The beneficial effects of this approach strongly rely upon the commitment of the professional staff involved. Trial Registration: ClinicalTrials.gov NCT03111004; http://clinicaltrials.gov/ct2/show/ NCT03111004 ", doi="10.2196/20938", url="https://medinform.jmir.org/2020/10/e20938", url="http://www.ncbi.nlm.nih.gov/pubmed/33021490" } @Article{info:doi/10.2196/20496, author="Giebel, D. Godwin", title="Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis", journal="JMIR Mhealth Uhealth", year="2020", month="Oct", day="6", volume="8", number="10", pages="e20496", keywords="mHealth", keywords="atrial fibrillation", keywords="screening devices", keywords="strokes", keywords="cost-effectiveness", keywords="photoplethysmography", abstract="Background: With an estimated prevalence of around 3\% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy. Objective: The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome. Methods: A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA2DS2-VASc (Congestive heart failure, Hypertension, Age?75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes. Results: The CHA2DS2-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75\% ECG confirmation rate) resulted in additional costs ({\texteuro}1=US \$1.12) of {\texteuro}441, {\texteuro}567, {\texteuro}536, {\texteuro}520, {\texteuro}606, {\texteuro}625, {\texteuro}623, {\texteuro}692, and {\texteuro}847 per patient for a CHA2DS2-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75\% ECG confirmation rate) resulted in 25 (7), --68 (--54), 98 (--5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA2DS2-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes. Conclusions: The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA2DS2-VASc scores, the risk for stroke and death from stroke can be markedly reduced. ", doi="10.2196/20496", url="http://mhealth.jmir.org/2020/10/e20496/", url="http://www.ncbi.nlm.nih.gov/pubmed/33021489" } @Article{info:doi/10.2196/16053, author="Tsuji, Shintaro and Ishikawa, Tomoki and Morii, Yasuhiro and Zhang, Hongjian and Suzuki, Teppei and Tanikawa, Takumi and Nakaya, Jun and Ogasawara, Katsuhiko", title="Cost-Effectiveness of a Continuous Glucose Monitoring Mobile App for Patients With Type 2 Diabetes Mellitus: Analysis Simulation", journal="J Med Internet Res", year="2020", month="Sep", day="17", volume="22", number="9", pages="e16053", keywords="Markov model", keywords="telehealth", keywords="continuous glucose monitoring (CGM)", keywords="type 2 diabetes mellitus", keywords="cost-effectiveness", keywords="incremental cost and effective ratio (ICER)", abstract="Background: Apps for real-time continuous glucose monitoring (CGM) on smartphones and other devices linked to CGM systems have recently been developed, and such CGM apps are also coming into use in Japan. In comparison with conventional retrospective CGM, the use of CGM apps improves patients' own blood glucose control, which is expected to help slow the progression of type 2 diabetes mellitus (DM) and prevent complications, but the effect of their introduction on medical costs remains unknown. Objective: Our objective in this study was to perform an economic appraisal of CGM apps from the viewpoint of assessing public medical costs associated with type 2 DM, using the probability of developing type 2 DM--associated complications, and data on medical costs and utility value to carry out a medical cost simulation using a Markov model in order to ascertain the cost-effectiveness of the apps. Methods: We developed a Markov model with the transition states of insulin therapy, nephrosis, dialysis, and cardiovascular disease, all of which have a major effect on medical costs, to identify changes in medical costs and utility values resulting from the introduction of a CGM app and calculated the incremental cost-effectiveness ratio (ICER). Results: The ICER for CGM app use was US \$33,039/quality-adjusted life year (QALY). Conclusions: Sensitivity analyses showed that, with the exception of conditions where the transition probability of insulin therapy, utility value, or increased medical costs increases, the ICER for the introduction of CGM apps was below the threshold of US \$43,478/QALY used by the Central Social Insurance Medical Council. Our results provide basic data on the cost-effectiveness of introducing CGM apps, which are currently starting to come into use. ", doi="10.2196/16053", url="https://www.jmir.org/2020/9/e16053", url="http://www.ncbi.nlm.nih.gov/pubmed/32940613" } @Article{info:doi/10.2196/18632, author="Elbers, Stefan and Pool, Jan and Wittink, Harri{\"e}t and K{\"o}ke, Alb{\`e}re and Scheffer, Else and Smeets, Rob", title="Mobile Health App (AGRIPPA) to Prevent Relapse After Successful Interdisciplinary Treatment for Patients With Chronic Pain: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2020", month="Aug", day="18", volume="9", number="8", pages="e18632", keywords="telemedicine", keywords="chronic pain", keywords="recurrence", keywords="clinical trial protocol", keywords="rehabilitation", keywords="randomized controlled trial", keywords="cost-benefit analysis", keywords="treatment adherence and compliance", keywords="mobile apps", keywords="patient care team", abstract="Background: To facilitate adherence to adaptive pain management behaviors after interdisciplinary multimodal pain treatment, we developed a mobile health app (AGRIPPA app) that contains two behavior regulation strategies. Objective: The aims of this project are (1) to test the effectiveness of the AGRIPPA app on pain disability; (2) to determine the cost-effectiveness; and (3) to explore the levels of engagement and usability of app users. Methods: We will perform a multicenter randomized controlled trial with two parallel groups. Within the 12-month inclusion period, we plan to recruit 158 adult patients with chronic pain during the initial stage of their interdisciplinary treatment program in one of the 6 participating centers. Participants will be randomly assigned to the standard treatment condition or to the enhanced treatment condition in which they will receive the AGRIPPA app. Patients will be monitored from the start of the treatment program until 12 months posttreatment. In our primary analysis, we will evaluate the difference over time of pain-related disability between the two conditions. Other outcome measures will include health-related quality of life, illness perceptions, pain self-efficacy, app system usage data, productivity loss, and health care expenses. Results: The study was approved by the local Medical Research Ethics Committee in October 2019. As of March 20, 2020, we have recruited 88 patients. Conclusions: This study will be the first step in systematically evaluating the effectiveness and efficiency of the AGRIPPA app. After 3 years of development and feasibility testing, this formal evaluation will help determine to what extent the app will influence the maintenance of treatment gains over time. The outcomes of this trial will guide future decisions regarding uptake in clinical practice. Trial Registration: Netherlands Trial Register NL8076; https://www.trialregister.nl/trial/8076 International Registered Report Identifier (IRRID): DERR1-10.2196/18632 ", doi="10.2196/18632", url="https://www.researchprotocols.org/2020/8/e18632", url="http://www.ncbi.nlm.nih.gov/pubmed/32808931" } @Article{info:doi/10.2196/17351, author="Piera-Jim{\'e}nez, Jordi and Winters, Marjolein and Broers, Eva and Valero-Bover, Dami{\`a} and Habibovic, Mirela and Widdershoven, G. Jos W. M. and Folkvord, Frans and Lupi{\'a}{\~n}ez-Villanueva, Francisco", title="Changing the Health Behavior of Patients With Cardiovascular Disease Through an Electronic Health Intervention in Three Different Countries: Cost-Effectiveness Study in the Do Cardiac Health: Advanced New Generation Ecosystem (Do CHANGE) 2 Randomized Controlled Trial", journal="J Med Internet Res", year="2020", month="Jul", day="28", volume="22", number="7", pages="e17351", keywords="cost-effectiveness", keywords="randomized controlled trial", keywords="RCT", keywords="eHealth", keywords="cardiovascular disease", keywords="engagement", keywords="behavior change", keywords="digital health", abstract="Background: During the last few decades, preventing the development of cardiovascular disease has become a mainstay for reducing cardiovascular morbidity and mortality. It has been suggested that interventions should focus more on committed approaches of self-care, such as electronic health techniques. Objective: This study aimed to provide evidence to understand the financial consequences of implementing the ``Do Cardiac Health: Advanced New Generation Ecosystem'' (Do CHANGE 2) intervention, which was evaluated in a multisite randomized controlled trial to change the health behavior of patients with cardiovascular disease. Methods: The cost-effectiveness analysis of the Do CHANGE 2 intervention was performed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, based on a Markov model of five health states. The following two types of costs were considered for both study groups: (1) health care costs (ie, costs associated with the time spent by health care professionals on service provision, including consultations, and associated unplanned hospitalizations, etc) and (2) societal costs (ie, costs attributed to the time spent by patients and informal caregivers on care activities). Results: The Do CHANGE 2 intervention was less costly in Spain (incremental cost was ?{\texteuro}2514.90) and more costly in the Netherlands and Taiwan (incremental costs were {\texteuro}1373.59 and {\texteuro}1062.54, respectively). Compared with treatment as usual, the effectiveness of the Do CHANGE 2 program in terms of an increase in quality-adjusted life-year gains was slightly higher in the Netherlands and lower in Spain and Taiwan. Conclusions: In general, we found that the incremental cost-effectiveness ratio strongly varied depending on the country where the intervention was applied. The Do CHANGE 2 intervention showed a positive cost-effectiveness ratio only when implemented in Spain, indicating that it saved financial costs in relation to the effect of the intervention. Trial Registration: ClinicalTrials.gov NCT03178305; https://clinicaltrials.gov/ct2/show/NCT03178305 ", doi="10.2196/17351", url="http://www.jmir.org/2020/7/e17351/", url="http://www.ncbi.nlm.nih.gov/pubmed/32720908" } @Article{info:doi/10.2196/17846, author="Jiang, Xinchan and Yao, Jiaqi and You, HS Joyce", title="Telemonitoring Versus Usual Care for Elderly Patients With Heart Failure Discharged From the Hospital in the United States: Cost-Effectiveness Analysis", journal="JMIR Mhealth Uhealth", year="2020", month="Jul", day="6", volume="8", number="7", pages="e17846", keywords="telemedicine", keywords="heart failure", keywords="hospitalization", keywords="cost", keywords="quality-adjusted life year", keywords="cost-effectiveness analysis", abstract="Background: Telemonitoring-guided interventional management reduces the need for hospitalization and mortality of patients with chronic heart failure (CHF). Objective: This study aimed to analyze the cost-effectiveness of usual care with and without telemonitoring-guided management in patients with CHF discharged from the hospital, from the perspective of US health care providers. Methods: A lifelong Markov model was designed to estimate outcomes of (1) usual care alone for all postdischarge patients with CHF (New York Heart Association [NYHA] class I-IV), (2) usual care and telemonitoring for all postdischarge patients with CHF, (3) usual care for all postdischarge patients with CHF and telemonitoring for patients with NYHA class III to IV, and (4) usual care for all postdischarge patients with CHF plus telemonitoring for patients with NYHA class II to IV. Model inputs were derived from the literature and public data. Sensitivity analyses were conducted to assess the robustness of model. The primary outcomes were total direct medical cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Results: In the base case analysis, universal telemonitoring group gained the highest QALYs (6.2967 QALYs), followed by the telemonitoring for NYHA class II to IV group (6.2960 QALYs), the telemonitoring for NYHA class III to IV group (6.2450 QALYs), and the universal usual care group (6.1530 QALYs). ICERs of the telemonitoring for NYHA class III to IV group (US \$35,393 per QALY) and the telemonitoring for NYHA class II to IV group (US \$38,261 per QALY) were lower than the ICER of the universal telemonitoring group (US \$100,458 per QALY). One-way sensitivity analysis identified five critical parameters: odds ratio of hospitalization for telemonitoring versus usual care, hazard ratio of all-cause mortality for telemonitoring versus usual care, CHF hospitalization cost and monthly outpatient costs for NYHA class I, and CHF hospitalization cost for NYHA class II. In probabilistic sensitivity analysis, probabilities of the universal telemonitoring, telemonitoring for NYHA class II to IV, telemonitoring for NYHA class III to IV, and universal usual care groups to be accepted as cost-effective at US \$50,000 per QALY were 2.76\%, 76.31\%, 18.6\%, and 2.33\%, respectively. Conclusions: Usual care for all discharged patients with CHF plus telemonitoring-guided management for NYHA class II to IV patients appears to be the preferred cost-effective strategy. ", doi="10.2196/17846", url="https://mhealth.jmir.org/2020/7/e17846", url="http://www.ncbi.nlm.nih.gov/pubmed/32407288" } @Article{info:doi/10.2196/19172, author="Brandt, J. Carl and Christensen, Reffstrup Jeanette and Lauridsen, T. J{\o}rgen and Nielsen, Bo Jesper and S{\o}ndergaard, Jens and Sorts{\o}, Camilla", title="Evaluation of the Clinical and Economic Effects of a Primary Care Anchored, Collaborative, Electronic Health Lifestyle Coaching Program in Denmark: Protocol for a Two-Year Randomized Controlled Trial", journal="JMIR Res Protoc", year="2020", month="Jun", day="25", volume="9", number="6", pages="e19172", keywords="type 2 diabetes management", keywords="digital behavioral coaching", keywords="lifestyle change", keywords="health behavior change", keywords="obesity", keywords="weight loss", keywords="interactive advice", keywords="participant engagement", keywords="quality of life", abstract="Background: Obesity is linked to a number of chronic health conditions, such as type 2 diabetes, heart disease, and cancer, and weight loss interventions are often expensive. Recent systematic reviews concluded that app and web-based interventions can improve lifestyle behaviors and weight loss at a reasonable cost, but long-term sustainability needs to be demonstrated. Objective: This study protocol is for a 2-year randomized controlled trial that aims to evaluate the clinical and economic effects of a primary care, anchored, collaborative, electronic health (eHealth) lifestyle coaching program (long-term Lifestyle change InterVention and eHealth Application [LIVA] 2.0) in obese participants with and without type 2 diabetes. The program's primary outcome is weight loss. Its secondary outcome is the hemoglobin A1c (HbA1c) level, and its tertiary outcomes are retention rate, quality of life (QOL), and cost effectiveness. Analytically, the focus is on associations of participant characteristics with outcomes and sustainability. Methods: We conduct a multicenter trial with a 1-year intervention and 1-year retention. LIVA 2.0 is implemented in municipalities within administrative regions in Denmark, specifically eight municipalities located within the Region of Southern Denmark and two municipalities located within the Capital Region of Denmark. The participants are assessed at baseline and at 6-, 12-, and 24-month follow-ups. Individual data from the LIVA 2.0 platform are combined with clinical measurements, questionnaires, and participants' usage of municipality and health care services. The participants have a BMI ?30 but ?45 kg/m2, and 50\% of the participants have type 2 diabetes. The participants are randomized in an approximately 60:40 manner, and based on sample size calculations on weight loss and intention-to-treat statistics, 200 participants are randomized to an intervention group and 140 are randomized to a control group. The control group is offered the conventional preventive program of the municipality, and it is compared to the intervention group, which follows the LIVA 2.0 in addition to the conventional preventive program. Results: The first baseline assessments have been carried out in March 2018, and the 2-year follow-up will be carried out between March 2020 and April 2021. The hypothesis is that the trial results will demonstrate decreased body weight and that the number of patients who show normalization of their HbA1c levels in the intervention group will be much higher than that in the control group. The participants in the intervention group are also expected to show a greater decrease in their use of glucose-lowering medication and a greater improvement in their QOL when compared with the control group. Operational costs are expected to be lower than standard care, and the intervention is expected to be cost-effective. Conclusions: This is the first time that an app and web-based eHealth lifestyle coaching program implemented in Danish municipalities will be clinically and economically evaluated. If the LIVA 2.0 eHealth lifestyle coaching program is proven to be effective, there is great potential for decreasing the rates of obesity, diabetes, and related chronic diseases. Trial Registration: ClinicalTrials.gov NCT03788915; https://clinicaltrials.gov/ct2/show/NCT03788915 International Registered Report Identifier (IRRID): DERR1-10.2196/19172 ", doi="10.2196/19172", url="http://www.researchprotocols.org/2020/6/e19172/", url="http://www.ncbi.nlm.nih.gov/pubmed/32584260" } @Article{info:doi/10.2196/15375, author="Fatoye, Francis and Gebrye, Tadesse and Fatoye, Clara and Mbada, E. Chidozie and Olaoye, I. Mistura and Odole, C. Adesola and Dada, Olumide", title="The Clinical and Cost-Effectiveness of Telerehabilitation for People With Nonspecific Chronic Low Back Pain: Randomized Controlled Trial", journal="JMIR Mhealth Uhealth", year="2020", month="Jun", day="24", volume="8", number="6", pages="e15375", keywords="cost-utility analysis", keywords="quality-adjusted life years", keywords="telerehabilitation", keywords="low back pain", keywords="mobile phone", abstract="Background: Telerehabilitation can facilitate multidisciplinary management for people with nonspecific chronic low back pain (NCLBP). It provides health care access to individuals who are physically and economically disadvantaged. Objective: This study aimed to evaluate the clinical and cost-effectiveness of telerehabilitation compared with a clinic-based intervention for people with NCLBP in Nigeria. Methods: A cost-utility analysis alongside a randomized controlled trial from a health care perspective was conducted. Patients with NCLBP were assigned to either telerehabilitation-based McKenzie therapy (TBMT) or clinic-based McKenzie therapy (CBMT). Interventions were carried out 3 times weekly for a period of 8 weeks. Patients' level of disability was measured using the Oswestry Disability Index (ODI) at baseline, week 4, and week 8. To estimate the health-related quality of life of the patients, the ODI was mapped to the short-form six dimensions instrument to generate quality-adjusted life years (QALYs). Health care resource use and costs were assessed based on the McKenzie extension protocol in Nigeria in 2019. Descriptive and inferential data analyses were also performed to assess the clinical effectiveness of the interventions. Bootstrapping was conducted to generate the point estimate of the incremental cost-effectiveness ratio (ICER). Results: A total of 47 patients (TBMT, n=21 and CBMT, n=26), with a mean age of 47 (SD 11.6) years for telerehabilitation and 50 (SD 10.7) years for the clinic-based intervention, participated in this study. The mean cost estimates of TBMT and CBMT interventions per person were 22,200 naira (US \$61.7) and 38,200 naira (US \$106), respectively. QALY gained was 0.085 for TBMT and 0.084 for CBMT. The TBMT arm was associated with an additional 0.001 QALY (95\% CI 0.001 to 0.002) per participant compared with the CBMT arm. Thus, the ICER showed that the TBMT arm was less costly and more effective than the CBMT arm. Conclusions: The findings of the study suggested that telerehabilitation for people with NCLBP was cost saving. Given the small number of participants in this study, further examination of effects and costs of the interventions is needed within a larger sample size. In addition, future studies are required to assess the cost-effectiveness of this intervention in the long term from the patient and societal perspective. ", doi="10.2196/15375", url="http://mhealth.jmir.org/2020/6/e15375/", url="http://www.ncbi.nlm.nih.gov/pubmed/32357128" } @Article{info:doi/10.2196/18014, author="Mizdrak, Anja and Telfer, Kendra and Direito, Artur and Cobiac, J. Linda and Blakely, Tony and Cleghorn, L. Christine and Wilson, Nick", title="Health Gain, Cost Impacts, and Cost-Effectiveness of a Mass Media Campaign to Promote Smartphone Apps for Physical Activity: Modeling Study", journal="JMIR Mhealth Uhealth", year="2020", month="Jun", day="11", volume="8", number="6", pages="e18014", keywords="physical activity", keywords="mHealth", keywords="mobile health", keywords="smartphone apps", keywords="modeling", keywords="mass media campaigns", abstract="Background: Physical activity smartphone apps are a promising strategy to increase population physical activity, but it is unclear whether government mass media campaigns to promote these apps would be a cost-effective use of public funds. Objective: We aimed to estimate the health impacts, costs, and cost-effectiveness of a one-off national mass media campaign to promote the use of physical activity apps. Methods: We used an established multistate life table model to estimate the lifetime health gains (in quality-adjusted life years [QALYs]) that would accrue if New Zealand adults were exposed to a one-off national mass media campaign to promote physical activity app use, with a 1-year impact on physical activity, compared to business-as-usual. A health-system perspective was used to assess cost-effectiveness. and a 3\% discount rate was applied to future health gains and health system costs. Results: The modeled intervention resulted in 28 QALYs (95\% uncertainty interval [UI] 8-72) gained at a cost of NZ \$81,000/QALY (2018 US \$59,500; 95\% UI 17,000-345,000), over the remaining life course of the 2011 New Zealand population. The intervention had a low probability (20\%) of being cost-effective at a cost-effectiveness threshold of NZ \$45,000 (US \$32,900) per QALY. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions around the maintenance of physical activity behaviors beyond the duration of the intervention. Conclusions: A mass media campaign to promote smartphone apps for physical activity is unlikely to generate much health gain or be cost-effective at the population level. Other investments to promote physical activity, particularly those that result in sustained behavior change, are likely to have greater health impacts. ", doi="10.2196/18014", url="http://mhealth.jmir.org/2020/6/e18014/", url="http://www.ncbi.nlm.nih.gov/pubmed/32525493" } @Article{info:doi/10.2196/16896, author="Bian, Yanyan and Xiang, Yongbo and Tong, Bingdu and Feng, Bin and Weng, Xisheng", title="Artificial Intelligence--Assisted System in Postoperative Follow-up of Orthopedic Patients: Exploratory Quantitative and Qualitative Study", journal="J Med Internet Res", year="2020", month="May", day="26", volume="22", number="5", pages="e16896", keywords="artificial intelligence", keywords="conversational agent", keywords="follow-up", keywords="cost-effectiveness", abstract="Background: Patient follow-up is an essential part of hospital ward management. With the development of deep learning algorithms, individual follow-up assignments might be completed by artificial intelligence (AI). We developed an AI-assisted follow-up conversational agent that can simulate the human voice and select an appropriate follow-up time for quantitative, automatic, and personalized patient follow-up. Patient feedback and voice information could be collected and converted into text data automatically. Objective: The primary objective of this study was to compare the cost-effectiveness of AI-assisted follow-up to manual follow-up of patients after surgery. The secondary objective was to compare the feedback from AI-assisted follow-up to feedback from manual follow-up. Methods: The AI-assisted follow-up system was adopted in the Orthopedic Department of Peking Union Medical College Hospital in April 2019. A total of 270 patients were followed up through this system. Prior to that, 2656 patients were followed up by phone calls manually. Patient characteristics, telephone connection rate, follow-up rate, feedback collection rate, time spent, and feedback composition were compared between the two groups of patients. Results: There was no statistically significant difference in age, gender, or disease between the two groups. There was no significant difference in telephone connection rate (manual: 2478/2656, 93.3\%; AI-assisted: 249/270, 92.2\%; P=.50) or successful follow-up rate (manual: 2301/2478, 92.9\%; AI-assisted: 231/249, 92.8\%; P=.96) between the two groups. The time spent on 100 patients in the manual follow-up group was about 9.3 hours. In contrast, the time spent on the AI-assisted follow-up was close to 0 hours. The feedback rate in the AI-assisted follow-up group was higher than that in the manual follow-up group (manual: 68/2656, 2.5\%; AI-assisted: 28/270, 10.3\%; P<.001). The composition of feedback was different in the two groups. Feedback from the AI-assisted follow-up group mainly included nursing, health education, and hospital environment content, while feedback from the manual follow-up group mostly included medical consultation content. Conclusions: The effectiveness of AI-assisted follow-up was not inferior to that of manual follow-up. Human resource costs are saved by AI. AI can help obtain comprehensive feedback from patients, although its depth and pertinence of communication need to be improved. ", doi="10.2196/16896", url="http://www.jmir.org/2020/5/e16896/", url="http://www.ncbi.nlm.nih.gov/pubmed/32452807" } @Article{info:doi/10.2196/15688, author="Snoswell, L. Centaine and North, B. John and Caffery, J. Liam", title="Economic Advantages of Telehealth and Virtual Health Practitioners: Return on Investment Analysis", journal="JMIR Perioper Med", year="2020", month="May", day="21", volume="3", number="1", pages="e15688", keywords="clinical services", keywords="e-health", keywords="health economics", keywords="health funding and financing", keywords="rural and remote health", keywords="workforce", abstract="Background: Telehealth is a disruptive modality that challenges the traditional model of having a clinician or patient physically present for an appointment. The benefit is that it offers the opportunity to redesign the way services are offered. For instance, a virtual health practitioner can provide videoconference consultations while being located anywhere in the world that has internet. A virtual health practitioner also obviates the issues of attracting a specialist medical workforce to rural areas, and allows the rural health service to control the specialist services that they offer. Objective: The aim of this research was to evaluate the economic effects of 3 different models of care on rural and metropolitan hospital sites. The models of care examined were patient travel, telehealth using videoconferencing, and employment of a virtual health practitioner by a rural site. Methods: Using retrospective activity data for 3 years, a return on investment (ROI) analysis was undertaken from the perspective of a rural site and metropolitan partner site using a telehealth orthopedic fracture clinic as an example. Further analysis was conducted to calculate the number of patients that would be required to attend the clinic in each model of care for the sites to break even. Results: The only service model that resulted in a positive ROI for the rural site over the 3-year period was the virtual health practitioner model. The breakeven analysis demonstrated that the rural site required the lowest number of patients to recoup costs in the virtual health practitioner model of care. The rural site was unable to recoup its costs within the travel model due to the lack of opportunity for reimbursement for services and the requirement to cover the cost of travel for patients. Conclusions: Our model demonstrated that rural health care providers can increase their ROI by employing a virtual health practitioner. ", doi="10.2196/15688", url="http://periop.jmir.org/2020/1/e15688/", url="http://www.ncbi.nlm.nih.gov/pubmed/33393922" } @Article{info:doi/10.2196/17098, author="Pot-Kolder, Roos and Veling, Wim and Geraets, Chris and Lokkerbol, Joran and Smit, Filip and Jongeneel, Alyssa and Ising, Helga and van der Gaag, Mark", title="Cost-Effectiveness of Virtual Reality Cognitive Behavioral Therapy for Psychosis: Health-Economic Evaluation Within a Randomized Controlled Trial", journal="J Med Internet Res", year="2020", month="May", day="5", volume="22", number="5", pages="e17098", keywords="psychosis", keywords="virtual reality", keywords="cognitive behavioral therapy", keywords="cost-effectiveness", abstract="Background: Evidence was found for the effectiveness of virtual reality-based cognitive behavioral therapy (VR-CBT) for treating paranoia in psychosis, but health-economic evaluations are lacking. Objective: This study aimed to determine the short-term cost-effectiveness of VR-CBT. Methods: The health-economic evaluation was embedded in a randomized controlled trial evaluating VR-CBT in 116 patients with a psychotic disorder suffering from paranoid ideation. The control group (n=58) received treatment as usual (TAU) for psychotic disorders in accordance with the clinical guidelines. The experimental group (n=58) received TAU complemented with add-on VR-CBT to reduce paranoid ideation and social avoidance. Data were collected at baseline and at 3 and 6 months postbaseline. Treatment response was defined as a pre-post improvement of symptoms of at least 20\% in social participation measures. Change in quality-adjusted life years (QALYs) was estimated by using Sanderson et al's conversion factor to map a change in the standardized mean difference of Green's Paranoid Thoughts Scale score on a corresponding change in utility. The incremental cost-effectiveness ratios were calculated using 5000 bootstraps of seemingly unrelated regression equations of costs and effects. The cost-effectiveness acceptability curves were graphed for the costs per treatment responder gained and per QALY gained. Results: The average mean incremental costs for a treatment responder on social participation ranged between {\texteuro}8079 and {\texteuro}19,525, with 90.74\%-99.74\% showing improvement. The average incremental cost per QALY was {\texteuro}48,868 over the 6 months of follow-up, with 99.98\% showing improved QALYs. Sensitivity analyses show costs to be lower when relevant baseline differences were included in the analysis. Average costs per treatment responder now ranged between {\texteuro}6800 and {\texteuro}16,597, while the average cost per QALY gained was {\texteuro}42,030. Conclusions: This study demonstrates that offering VR-CBT to patients with paranoid delusions is an economically viable approach toward improving patients' health in a cost-effective manner. Long-term effects need further research. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 12929657; http://www.isrctn.com/ISRCTN12929657 ", doi="10.2196/17098", url="https://www.jmir.org/2020/5/e17098", url="http://www.ncbi.nlm.nih.gov/pubmed/32369036" } @Article{info:doi/10.2196/15685, author="Wang, Yanan and Wu, Hong and Xia, Chenxi and Lu, Naiji", title="Impact of the Price of Gifts From Patients on Physicians' Service Quality in Online Consultations: Empirical Study Based on Social Exchange Theory", journal="J Med Internet Res", year="2020", month="May", day="5", volume="22", number="5", pages="e15685", keywords="gift giving", keywords="gift price", keywords="service price", keywords="online consultation service quality", keywords="information support", keywords="emotional support", keywords="online health communities", abstract="Background: Gift giving from patients to physicians, which is prohibited in traditional clinical settings in China, has been found to occur in online health communities. However, there is debate on the validity of online gifts since physicians gain an economic benefit. Moreover, the potential impact of these gifts, particularly with respect to the financial value of the gift, on the online consultation service quality remains unexplored. Objective: The aim of this study was to explore the impact of gift price on the quality of physicians' online consultation service. Insight into this impact is expected to help resolve existing debate on the appropriateness of the gift-giving practice in online consultations. Methods: A dataset of 141 physicians and 4249 physician-patient interactions was collected from the Good Physician Online website, which is the largest online consultation platform in China. Based on social exchange theory, we investigated how gift price affects the quality of physicians' online consultation service and how this impact changes according to the physician's service price and number of all gifts received. Manual annotation was used to identify the information support paragraphs and emotional support paragraphs in the answers of physicians. The quality of the information support paragraphs, rather than the complete answer, was used to test the robustness of our model. Results: Gift price had a positive impact on the quality of physicians' online consultation service ($\beta$=4.941, P<.01). This impact was negatively mediated by both the physician's service price ($\beta$=--9.245, P<.001) and the total number of gifts they received ($\beta$=--5.080, P<.001). Conclusions: Gift price has a positive impact on physicians' online behavior, although the impact varies among physicians. ", doi="10.2196/15685", url="http://www.jmir.org/2020/5/e15685/", url="http://www.ncbi.nlm.nih.gov/pubmed/32369028" } @Article{info:doi/10.2196/16276, author="Hill, Jeremy and McGinn, Jourdan and Cairns, John and Free, Caroline and Smith, Chris", title="A Mobile Phone--Based Support Intervention to Increase Use of Postabortion Family Planning in Cambodia: Cost-Effectiveness Evaluation", journal="JMIR Mhealth Uhealth", year="2020", month="Feb", day="25", volume="8", number="2", pages="e16276", keywords="mHealth", keywords="digital health", keywords="cost-effectiveness", keywords="contraception", keywords="postabortion contraception", keywords="postabortion family planning", keywords="Cambodia", abstract="Background: Despite progress over the last decade, there is a continuing unmet need for contraception in Cambodia. Interventions delivered by mobile phone could help increase uptake and continuation of contraception, particularly among hard-to-reach populations, by providing interactive personalized support inexpensively wherever the person is located and whenever needed. Objective: The objective of this study was to evaluate the cost-effectiveness of mobile phone--based support added to standard postabortion family planning care in Cambodia, according to the results of the MOTIF (MObile Technology for Improved Family planning) trial. Methods: A model was created to estimate the costs and effects of the intervention versus standard care. We adopted a societal perspective when estimating costs, including direct and indirect costs for users. The incremental cost-effectiveness ratio was calculated for the base case, as well as a deterministic and probabilistic sensitivity analysis, which we compared against a range of likely cost-effectiveness thresholds. Results: The incremental cost of mobile phone--based support was estimated to be an additional US \$8160.49 per 1000 clients, leading to an estimated 518 couple-years of protection (CYPs) gained per 1000 clients and 99 disability-adjusted life-years (DALYs) averted. The incremental cost-effectiveness ratio was US \$15.75 per additional CYP and US \$82.57 per DALY averted. The model was most sensitive to personnel and mobile service costs. Assuming a range of cost-effectiveness thresholds from US \$58 to US \$176 for Cambodia, the probability of the intervention being cost-effective ranged from 11\% to 95\%. Conclusions: This study demonstrates that the cost-effectiveness of the intervention delivered by mobile phone assessed in the MOTIF trial lies within the estimated range of the cost-effectiveness threshold for Cambodia. When assessing value in interventions to improve the uptake and adherence of family planning services, the use of interactive mobile phone messaging and counselling for women who have had an abortion should be considered as an option by policy makers. Trial Registration: ClinicalTrials.gov NCT01823861; https://clinicaltrials.gov/ct2/show/NCT01823861 ", doi="10.2196/16276", url="http://mhealth.jmir.org/2020/2/e16276/", url="http://www.ncbi.nlm.nih.gov/pubmed/32130166" } @Article{info:doi/10.2196/16866, author="Wolff, Justus and Pauling, Josch and Keck, Andreas and Baumbach, Jan", title="The Economic Impact of Artificial Intelligence in Health Care: Systematic Review", journal="J Med Internet Res", year="2020", month="Feb", day="20", volume="22", number="2", pages="e16866", keywords="telemedicine", keywords="artificial intelligence", keywords="machine learning", keywords="cost-benefit analysis", abstract="Background: Positive economic impact is a key decision factor in making the case for or against investing in an artificial intelligence (AI) solution in the health care industry. It is most relevant for the care provider and insurer as well as for the pharmaceutical and medical technology sectors. Although the broad economic impact of digital health solutions in general has been assessed many times in literature and the benefit for patients and society has also been analyzed, the specific economic impact of AI in health care has been addressed only sporadically. Objective: This study aimed to systematically review and summarize the cost-effectiveness studies dedicated to AI in health care and to assess whether they meet the established quality criteria. Methods: In a first step, the quality criteria for economic impact studies were defined based on the established and adapted criteria schemes for cost impact assessments. In a second step, a systematic literature review based on qualitative and quantitative inclusion and exclusion criteria was conducted to identify relevant publications for an in-depth analysis of the economic impact assessment. In a final step, the quality of the identified economic impact studies was evaluated based on the defined quality criteria for cost-effectiveness studies. Results: Very few publications have thoroughly addressed the economic impact assessment, and the economic assessment quality of the reviewed publications on AI shows severe methodological deficits. Only 6 out of 66 publications could be included in the second step of the analysis based on the inclusion criteria. Out of these 6 studies, none comprised a methodologically complete cost impact analysis. There are two areas for improvement in future studies. First, the initial investment and operational costs for the AI infrastructure and service need to be included. Second, alternatives to achieve similar impact must be evaluated to provide a comprehensive comparison. Conclusions: This systematic literature analysis proved that the existing impact assessments show methodological deficits and that upcoming evaluations require more comprehensive economic analyses to enable economic decisions for or against implementing AI technology in health care. ", doi="10.2196/16866", url="http://www.jmir.org/2020/2/e16866/", url="http://www.ncbi.nlm.nih.gov/pubmed/32130134" } @Article{info:doi/10.2196/16765, author="Jiang, Jinglu and Cameron, Ann-Frances and Yang, Ming", title="Analysis of Massive Online Medical Consultation Service Data to Understand Physicians' Economic Return: Observational Data Mining Study", journal="JMIR Med Inform", year="2020", month="Feb", day="18", volume="8", number="2", pages="e16765", keywords="Web-based health services", keywords="remote consultation", keywords="machine learning", keywords="data mining", keywords="decision tree", keywords="patient involvement", abstract="Background: Online health care consultation has become increasingly popular and is considered a potential solution to health care resource shortages and inefficient resource distribution. However, many online medical consultation platforms are struggling to attract and retain patients who are willing to pay, and health care providers on the platform have the additional challenge of standing out in a crowd of physicians who can provide comparable services. Objective: This study used machine learning (ML) approaches to mine massive service data to (1) identify the important features that are associated with patient payment, as opposed to free trial--only appointments; (2) explore the relative importance of these features; and (3) understand how these features interact, linearly or nonlinearly, in relation to payment. Methods: The dataset is from the largest China-based online medical consultation platform, which covers 1,582,564 consultation records between patient-physician pairs from 2009 to 2018. ML techniques (ie, hyperparameter tuning, model training, and validation) were applied with four classifiers---logistic regression, decision tree (DT), random forest, and gradient boost---to identify the most important features and their relative importance for predicting paid vs free-only appointments. Results: After applying the ML feature selection procedures, we identified 11 key features on the platform, which are potentially useful to predict payment. For the binary ML classification task (paid vs free services), the 11 features as a whole system achieved very good prediction performance across all four classifiers. DT analysis further identified five distinct subgroups of patients delineated by five top-ranked features: previous offline connection, total dialog, physician response rate, patient privacy concern, and social return. These subgroups interact with the physician differently, resulting in different payment outcomes. Conclusions: The results show that, compared with features related to physician reputation, service-related features, such as service delivery quality (eg, consultation dialog intensity and physician response rate), patient source (eg, online vs offline returning patients), and patient involvement (eg, provide social returns and reveal previous treatment), appear to contribute more to the patient's payment decision. Promoting multiple timely responses in patient-provider interactions is essential to encourage payment. ", doi="10.2196/16765", url="http://medinform.jmir.org/2020/2/e16765/", url="http://www.ncbi.nlm.nih.gov/pubmed/32069213" } @Article{info:doi/10.2196/13355, author="Dieng, Aissata and He, Jie and Poder, G. Thomas", title="Web Comparison of Three Contingent Valuation Techniques in Women of Childbearing Age: The Case of Ovulation Induction in Quebec", journal="Interact J Med Res", year="2020", month="Feb", day="6", volume="9", number="1", pages="e13355", keywords="contingent valuation", keywords="elicitation technique", keywords="dichotomous choice", keywords="multiple-bounded discrete choice", keywords="willingness to pay", keywords="failed ovulation", keywords="ovulation induction", abstract="Background: In Canada, 11.5\% to 15.7\% of couples suffer from infertility. Anovulation, or failed ovulation, is one of the main causes of infertility in women. In Quebec, the treatment for ovulation induction and other services related to assisted reproductive technology (ART) have been partially reimbursed by the government since 2010. Objective: This study aimed to compare the willingness to pay (WTP) of women of childbearing age to receive drug treatment in the event of failed ovulation according to 3 different contingent valuation methods. Methods: The following elicitation techniques were used: simple bid price dichotomous choice (DC), followed by an open-ended question (DC-OE), and a simplified multiple-bounded discrete choice (MBDC). Each participant was randomly assigned to 1 of 3 elicitation techniques. Bid prices ranged from Can \$200 to Can \$5000. Of the 7 bid prices, 1 was randomly proposed to each participant in the DC and DC-OE groups. For the DC-OE group, if the answer to the DC bid price was no, respondents were asked what was the maximum amount they were willing to pay. For the MBDC group, each respondent was offered an initial bid price of Can \$1500, and the subsequent bid price offer increased or decreased according to the answer provided. ``Do not know'' responses were considered as a ``no'', and each individual was questioned as to their certainty after each choice. WTP values were estimated using probit and bivariate models; the Welsh and Poe model was also performed for the MBDC group. Results: The survey was conducted from 2009 to 2010 with a total sample of 680 women. Analyses were performed on 610 respondents (199 DC, 230 DC-OE, and 181 MBDC). Of the 70 respondents who were excluded, 6 did not meet the age criterion, 45 had an annual income less than Can \$2500, and 19 did not respond to the WTP question. Mean WTP values were Can \$4033.26, Can \$1857.90, and Can \$1630.63 for DC, DC-OE, and MBDC, respectively. The WTP for MBDC ``definitely yes'' and ``probably yes'' values were Can \$1516.73 and Can \$1871.22, respectively. The 3 elicitation techniques provided WTP value differences that were statistically significant (P<.01). The MBDC was the most accurate method, with a lower confidence interval (Can \$557) and a lower (CI/mean) ratio (0.34). Conclusions: A positive WTP for ovulation induction was found in Quebec. Adding a follow-up question resulted in more accurate WTP values. The MBDC technique provided a more accurate estimate of the WTP with a smaller and, therefore, more efficient confidence interval. To help decision making and improve the effectiveness of the fiscal policy related to the ART program, the WTP value elicited with the MBDC technique should be used. ", doi="10.2196/13355", url="https://www.i-jmr.org/2020/1/e13355" } @Article{info:doi/10.2196/14261, author="Kooistra, Catharine Lisa and Wiersma, Elize Jenneke and Ruwaard, Jeroen and Neijenhuijs, Koen and Lokkerbol, Joran and van Oppen, Patricia and Smit, Filip and Riper, Heleen", title="Cost and Effectiveness of Blended Versus Standard Cognitive Behavioral Therapy for Outpatients With Depression in Routine Specialized Mental Health Care: Pilot Randomized Controlled Trial", journal="J Med Internet Res", year="2019", month="Oct", day="29", volume="21", number="10", pages="e14261", keywords="depression", keywords="blended cognitive behavioral therapy", keywords="specialized mental health care", keywords="cost-effectiveness", keywords="randomized controlled trial", abstract="Background: Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability. Objective: This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT. Methods: Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations. Results: Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95\% CI ?0.05 to 0.19), response to treatment (RD 0.03, 95\% CI ?0.10 to 0.15), and QALYs (mean difference 0.01, 95\% CI ?0.03 to 0.04). Mean societal costs for blended CBT were {\texteuro}1183 higher than standard CBT. This difference was not significant (95\% CI ?399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of {\texteuro}25,000. For health care providers, mean costs for blended CBT were {\texteuro}176 lower than standard CBT. This difference was not significant (95\% CI ?659 to 343). At {\texteuro}0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of {\texteuro}5000 for an added treatment response, and to 0.85 at {\texteuro}10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects. Conclusions: This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted. Trial Registration: Netherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-014-0290-z ", doi="10.2196/14261", url="http://www.jmir.org/2019/10/e14261/", url="http://www.ncbi.nlm.nih.gov/pubmed/31663855" } @Article{info:doi/10.2196/15505, author="Del Hoyo, Javier and Nos, Pilar and Bastida, Guillermo and Faubel, Raquel and Mu{\~n}oz, Diana and Garrido-Mar{\'i}n, Alejandro and Valero-P{\'e}rez, Elena and Bejar-Serrano, Sergio and Aguas, Mariam", title="Telemonitoring of Crohn's Disease and Ulcerative Colitis (TECCU): Cost-Effectiveness Analysis", journal="J Med Internet Res", year="2019", month="Sep", day="13", volume="21", number="9", pages="e15505", keywords="telemedicine", keywords="eHealth", keywords="cost-effectiveness", keywords="inflammatory bowel diseases", keywords="Crohn disease", keywords="colitis, ulcerative", abstract="Background: Although electronic health interventions are considered safe and efficient, evidence regarding the cost-effectiveness of telemonitoring in inflammatory bowel disease is lacking. Objective: We aimed to evaluate the cost-effectiveness and cost-utility of the Telemonitorizaci{\'o}n de la Enfermedad de Crohn y Colitis Ulcerosa (Telemonitoring of Crohn's Disease and Ulcerative Colitis [TECCU]) Web platform (G\_TECCU intervention group) for telemonitoring complex inflammatory bowel disease, compared with standard care (G\_control) and nurse-assisted telephone care (G\_NT intervention group). Methods: We analyzed cost-effectiveness from a societal perspective by comparing the 3 follow-up methods used in a previous 24-week randomized controlled trial, conducted at a tertiary university hospital in Spain. Patients with inflammatory bowel disease who initiated immunosuppressants or biologic agents, or both, to control inflammatory activity were recruited consecutively. Data on the effects on disease activity (using clinical indexes) and quality-adjusted life-years (using the EuroQol 5 dimensions questionnaire) were collected. We calculated the costs of health care, equipment, and patients' productivity and social activity impairment. We compared the mean costs per patient, utilities, and bootstrapped differences. Results: We included 63 patients (21 patients per group). TECCU saved {\texteuro}1005 (US \$1100) per additional patient in remission compared with G\_control (95\% CI {\texteuro}--13,518 to 3137; US \$--14,798 to 3434), with a 79.96\% probability of being more effective at lower costs. Compared with G\_NT, TECCU saved {\texteuro}2250 (US \$2463) per additional patient in remission (95\% CI {\texteuro}--15,363 to 11,086; US \$--16,817 to 12,135), and G\_NT saved {\texteuro}538 (US \$589) compared with G\_control (95\% CI {\texteuro}--6475 to 5303; US \$--7088 to 5805). G\_TECCU and G\_NT showed an 84\% and 67\% probability, respectively, of producing a cost saving per additional quality-adjusted life-year (QALY) compared with G\_control, considering those simulations that involved negative incremental QALYs as well. Conclusions: There is a high probability that the TECCU Web platform is more cost-effective than standard and telephone care in the short term. Further research considering larger cohorts and longer time horizons is required. Trial Registration: ClinicalTrials.gov NCT02943538; https://clinicaltrials.gov/ct2/show/NCT02943538 (http://www. webcitation.org/746CRRtDN) ", doi="10.2196/15505", url="http://www.jmir.org/2019/9/e15505/", url="http://www.ncbi.nlm.nih.gov/pubmed/31538948" } @Article{info:doi/10.2196/14675, author="Linds{\"a}ter, Elin and Axelsson, Erland and Salomonsson, Sigrid and Santoft, Fredrik and Lj{\'o}tsson, Brj{\'a}nn and {\AA}kerstedt, Torbj{\"o}rn and Lekander, Mats and Hedman-Lagerl{\"o}f, Erik", title="Cost-Effectiveness of Therapist-Guided Internet-Based Cognitive Behavioral Therapy for Stress-Related Disorders: Secondary Analysis of a Randomized Controlled Trial", journal="J Med Internet Res", year="2019", month="Sep", day="13", volume="21", number="9", pages="e14675", keywords="psychological stress", keywords="adjustment disorder", keywords="exhaustion disorder", keywords="cognitive behavioral therapy", keywords="cost effectiveness", keywords="internet", abstract="Background: Stress-related disorders are associated with significant suffering, functional impairment, and high societal costs. Internet-based cognitive behavioral therapy (ICBT) is a promising treatment for stress-related disorders but has so far not been subjected to health economic evaluation. Objective: The objective of this study was to evaluate the cost-effectiveness and cost-utility of ICBT for patients with stress-related disorders in the form of adjustment disorder (AD) or exhaustion disorder (ED). We hypothesized that ICBT, compared with a waitlist control (WLC) group, would generate improvements at low net costs, thereby making it cost-effective. Methods: Health economic data were obtained in tandem with a randomized controlled trial of a 12-week ICBT in which patients (N=100) were randomized to an ICBT (n=50) or a WLC (n=50) group. Health outcomes and costs were surveyed pre- and posttreatment. We calculated incremental cost-effectiveness ratios (ICERs) based on remission rates and incremental cost-utility ratios (ICURs) based on health-related quality of life. Bootstrap sampling was used to assess the uncertainty of our results. Results: The ICER indicated that the most likely scenario was that ICBT led to higher remission rates compared with the WLC and was associated with slightly larger reductions in costs from pre- to posttreatment. ICBT had a 60\% probability of being cost-effective at a willingness to pay (WTP) of US \$0 and a 96\% probability of being cost-effective at a WTP of US \$1000. The ICUR indicated that ICBT also led to improvements in quality of life at no net societal cost. Sensitivity analyses supported the robustness of our results. Conclusions: The results suggest that ICBT is a cost-effective treatment for patients suffering from AD or ED. Compared with no treatment, ICBT for these patients yields large effects at no or minimal societal net costs. Trial Registration: ClinicalTrials.gov NCT02540317;?https://clinicaltrials.gov/ct2/show/NCT02540317 ", doi="10.2196/14675", url="https://www.jmir.org/2019/9/e14675", url="http://www.ncbi.nlm.nih.gov/pubmed/31586370" } @Article{info:doi/10.2196/14685, author="Jing, Dong and Jin, Yu and Liu, Jianwei", title="The Impact of Monetary Incentives on Physician Prosocial Behavior in Online Medical Consulting Platforms: Evidence From China", journal="J Med Internet Res", year="2019", month="Jul", day="26", volume="21", number="7", pages="e14685", keywords="online medical consultation", keywords="monetary incentives", keywords="physicians' prosocial behaviors", keywords="self-recognition", keywords="others' recognition", abstract="Background: In online medical consulting platforms, physicians can get both economic and social returns by offering online medical services, such as answering questions or sharing health care knowledge with patients. Physicians' online prosocial behavior could bring many benefits to the health care industry. Monetary incentives could encourage physicians to engage more in online medical communities. However, little research has studied the impact of monetary incentives on physician prosocial behavior and the heterogeneity of this effect. Objective: This study aims to explore the effects of monetary incentives on physician prosocial behavior and investigate the moderation effects of self-recognition and recognition from others of physician competence. Methods: This study was a fixed-effect specification-regression model based on a difference-in-differences design with robust standard errors clustered at the physician level using monthly panel data. It included 26,543 physicians in 3851 hospitals over 133 months (November 2006-December 2017) from a leading online health care platform in China. We used the pricing strategy of physicians and satisfaction levels to measure their own and patients' degree of recognition, respectively. Physicians' prosocial behavior was measured by free services offered. Results: The introduction of monetary incentives had a positive effect on physician prosocial behavior ($\beta$=1.057, P<.01). Higher self-recognition and others' recognition level of physician competence increased this promotion effect ($\gamma$=0.275, P<.01 and $\gamma$=0.325, P<.01). Conclusions: This study explored the positive effect of the introduction of monetary incentives on physician prosocial behavior. We found this effect was enhanced for physicians with a high level of self-recognition and others' recognition of their competence. We provide evidence of the effect of monetary incentives on physicians' prosocial behaviors in the telemedicine markets and insight for relevant stakeholders into how to design an effective incentive mechanism to improve physicians' prosocial engagements. ", doi="10.2196/14685", url="http://www.jmir.org/2019/7/e14685/", url="http://www.ncbi.nlm.nih.gov/pubmed/31350834" } @Article{info:doi/10.2196/13166, author="Jiang, Xinchan and Ming, Wai-Kit and You, HS Joyce", title="The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review", journal="J Med Internet Res", year="2019", month="Jun", day="17", volume="21", number="6", pages="e13166", keywords="telemedicine", keywords="cardiovascular diseases", keywords="stroke", keywords="heart failure", keywords="myocardial infarction", keywords="heart attack", keywords="cost-effectiveness", keywords="medical economics", keywords="decision modeling", keywords="systematic review", abstract="Background: With the advancement in information technology and mobile internet, digital health interventions (DHIs) are improving the care of cardiovascular diseases (CVDs). The impact of DHIs on cost-effective management of CVDs has been examined using the decision analytic model--based health technology assessment approach. Objective: The aim of this study was to perform a systematic review of the decision analytic model--based studies evaluating the cost-effectiveness of DHIs on the management of CVDs. Methods: A literature review was conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Scopus, Web of Science, Center for Review and Dissemination, and Institute for IEEE Xplore between 2001 and 2018. Studies were included if the following criteria were met: (1) English articles, (2) DHIs that promoted or delivered clinical interventions and had an impact on patients' cardiovascular conditions, (3) studies that were modeling works with health economic outcomes of DHIs for CVDs, (4) studies that had a comparative group for assessment, and (5) full economic evaluations including a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis, and cost-consequence analysis. The primary outcome collected was the cost-effectiveness of the DHIs, presented by incremental cost per additional quality-adjusted life year (QALY). The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards. Results: A total of 14 studies met the defined criteria and were included in the review. Among the included studies, heart failure (7/14, 50\%) and stroke (4/14, 29\%) were two of the most frequent CVDs that were managed by DHIs. A total of 9 (64\%) studies were published between 2015 and 2018 and 5 (36\%) published between 2011 and 2014. The time horizon was ?1 year in 3 studies (21\%), >1 year in 10 studies (71\%), and 1 study (7\%) did not declare the time frame. The types of devices or technologies used to deliver the health interventions were short message service (1/14, 7\%), telephone support (1/14, 7\%), mobile app (1/14, 7\%), video conferencing system (5/14, 36\%), digital transmission of physiologic data (telemonitoring; 5/14, 36\%), and wearable medical device (1/14, 7\%). The DHIs gained higher QALYs with cost saving in 43\% (6/14) of studies and gained QALYs at a higher cost at acceptable incremental cost-effectiveness ratio (ICER) in 57\% (8/14) of studies. The studies were classified as excellent (0/14, 0\%), good (9/14, 64\%), moderate (4/14, 29\%), and low (1/14, 7\%) quality. Conclusions: This study is the first systematic review of decision analytic model--based cost-effectiveness analyses of DHIs in the management of CVDs. Most of the identified studies were published recently, and the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame. All the included studies found the DHIs to be cost-effective. ", doi="10.2196/13166", url="http://www.jmir.org/2019/6/e13166/", url="http://www.ncbi.nlm.nih.gov/pubmed/31210136" } @Article{info:doi/10.2196/13574, author="Meinert, Edward and Alturkistani, Abrar and Foley, A. Kimberley and Brindley, David and Car, Josip", title="Examining Cost Measurements in Production and Delivery of Three Case Studies Using E-Learning for Applied Health Sciences: Cross-Case Synthesis", journal="J Med Internet Res", year="2019", month="Jun", day="04", volume="21", number="6", pages="e13574", keywords="education", keywords="distance education", keywords="professional education", keywords="online education", keywords="online learning", keywords="costs and cost analysis", keywords="economics", abstract="Background: The World Health Report (2006) by the World Health Organization conveys that a significant increase is needed in global health care resourcing to meet the current and future demand for health professionals. Electronic learning (e-Learning) presents a possible opportunity to change and optimize training by providing a scalable means for instruction, thus reducing the costs for training health professionals and providing patient education. Research literature often suggests that a benefit of e-Learning is its cost-effectiveness compared with face-to-face instruction, yet there is limited evidence with respect to the comparison of design and production costs with other forms of instruction or the establishment of standards pertaining to budgeting for these costs. Objective: To determine the potential cost favorability of e-Learning in contrast to other forms of learning, there must first be an understanding of the components and elements for building an e-Learning course. Without first taking this step, studies lack the essential financial accounting rigor for course planning and have an inconsistent basis for comparison. This study aimed to (1) establish standard ingredients for the cost of e-Learning course production and (2) determine the variance instructional design has on the production costs of e-Learning courses. Methods: This study made use of a cross-case method among 3 case studies using mixed methods, including horizontal budget variance calculation and qualitative interpretation of responses from course designers for budget variance using total quality management themes. The different implementation-specific aspects of these cases were used to establish common principles in the composition of budgets in the production and delivery of an applied health professional e-Learning course. Results: A total of 2 case studies reported significant negative budget variances caused by issues surrounding underreporting of personnel costs, inaccurate resource task estimation, lack of contingency planning, challenges in third-party resource management, and the need to update health-related materials that became outdated during course production. The third study reported a positive budget variance because of the cost efficiency derived from previous implementation, the strong working relationship of the course project team, and the use of iterative project management methods. Conclusions: This research suggests that the delivery costs of an e-Learning course could be underestimated or underreported and identifies factors that could be used to better control budgets. Through consistent management of factors affecting the cost of course production, further research could be undertaken using standard economic evaluation methods to evaluate the advantages of using e-Learning. ", doi="10.2196/13574", url="https://www.jmir.org/2019/6/e13574/", url="http://www.ncbi.nlm.nih.gov/pubmed/31165718" } @Article{info:doi/10.2196/12201, author="Krishnan, Anirudh and Finkelstein, Andrew Eric and Levine, Erica and Foley, Perry and Askew, Sandy and Steinberg, Dori and Bennett, G. Gary", title="A Digital Behavioral Weight Gain Prevention Intervention in Primary Care Practice: Cost and Cost-Effectiveness Analysis", journal="J Med Internet Res", year="2019", month="May", day="17", volume="21", number="5", pages="e12201", keywords="cost-effectiveness", keywords="cost-benefit analysis", keywords="obesity", keywords="telemedicine", keywords="women's health", keywords="minority health", keywords="weight gain prevention", keywords="weight gain", abstract="Background: Obesity is one of the largest drivers of health care spending but nearly half of the population with obesity demonstrate suboptimal readiness for weight loss treatment. Black women are disproportionately likely to have both obesity and limited weight loss readiness. However, they have been shown to be receptive to strategies that prevent weight gain. Objective: The aim of this study was to evaluate the costs and cost-effectiveness of a digital weight gain prevention intervention (Shape) for black women. Shape consisted of adaptive telephone-based coaching by health system personnel, a tailored skills training curriculum, and patient self-monitoring delivered via a fully automated interactive voice response system. Methods: A cost and cost-effectiveness analysis based on a randomized clinical trial of the Shape intervention was conducted from the payer perspective. Costs included those of delivering the program to 91 intervention participants in the trial and were summarized by program elements: self-monitoring, skills training, coaching, and administration. Effectiveness was measured in quality-adjusted life years (QALYs). The primary outcome was the incremental cost per QALY of Shape relative to usual care. Results: Shape cost an average of US \$758 per participant. The base-case model in which quality of life benefits decay linearly to zero 5 years post intervention cessation, generated an incremental cost-effectiveness ratio (ICER) of US \$55,264 per QALY. Probabilistic sensitivity analyses suggest an ICER below US \$50,000 per QALY and US \$100,000 per QALY in 39\% and 98\% of simulations, respectively. Results are highly sensitive to durability of benefits, rising to US \$165,730 if benefits end 6 months post intervention. Conclusions: Results suggest that the Shape intervention is cost-effective based on established benchmarks, indicating that it can be a part of a successful strategy to address the nation's growing obesity epidemic in low-income at-risk communities. ", doi="10.2196/12201", url="http://www.jmir.org/2019/5/e12201/", url="http://www.ncbi.nlm.nih.gov/pubmed/31102373" } @Article{info:doi/10.2196/10866, author="K{\"a}hlke, Fanny and Buntrock, Claudia and Smit, Filip and Berking, Matthias and Lehr, Dirk and Heber, Elena and Funk, Burkhardt and Riper, Heleen and Ebert, Daniel David", title="Economic Evaluation of an Internet-Based Stress Management Intervention Alongside a Randomized Controlled Trial", journal="JMIR Ment Health", year="2019", month="May", day="15", volume="6", number="5", pages="e10866", keywords="work", keywords="occupational stress", keywords="economic evaluation", keywords="internet", keywords="quality of life", keywords="clinical trials, randomized", abstract="Background: Work-related stress is widespread among employees and associated with high costs for German society. Internet-based stress management interventions (iSMIs) are effective in reducing such stress. However, evidence for their cost-effectiveness is scant. Objective: The aim of this study was to assess the cost-effectiveness of a guided iSMI for employees. Methods: A sample of 264 employees with elevated symptoms of perceived stress (Perceived Stress Scale?22) was assigned to either the iSMI or a waitlist control condition (WLC) with unrestricted access to treatment as usual. Participants were recruited in Germany in 2013 and followed through 2014, and data were analyzed in 2017. The iSMI consisted of 7 sessions plus 1 booster session. It was based on problem-solving therapy and emotion regulation techniques. Costs were measured from the societal perspective, including all direct and indirect medical costs. We performed a cost-effectiveness analysis and a cost-utility analysis relating costs to a symptom-free person and quality-adjusted life years (QALYs) gained, respectively. Sampling uncertainty was handled using nonparametric bootstrapping (N=5000). Results: When the society is not willing to pay anything to get an additional symptom-free person (eg, willingness-to-pay [WTP]={\texteuro}0), there was a 70\% probability that the intervention is more cost-effective than WLC. This probability rose to 85\% and 93\% when the society is willing to pay {\texteuro}1000 and {\texteuro}2000, respectively, for achieving an additional symptom-free person. The cost-utility analysis yielded a 76\% probability that the intervention is more cost-effective than WLC at a conservative WTP threshold of {\texteuro}20,000 (US \$25,800) per QALY gained. Conclusions: Offering an iSMI to stressed employees has an acceptable likelihood of being cost-effective compared with WLC. Trial Registration: German Clinical Trials Register DRKS00004749; https://www.drks.de/DRKS00004749 International Registered Report Identifier (IRRID): RR2-10.1186/1471-2458-13-655 ", doi="10.2196/10866", url="https://mental.jmir.org/2019/5/e10866/", url="http://www.ncbi.nlm.nih.gov/pubmed/31094355" } @Article{info:doi/10.2196/11330, author="Buvik, Astrid and Bergmo, S. Trine and Bugge, Einar and Smaabrekke, Arvid and Wilsgaard, Tom and Olsen, Abel Jan", title="Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial", journal="J Med Internet Res", year="2019", month="Feb", day="19", volume="21", number="2", pages="e11330", keywords="telemedicine", keywords="orthopedics", keywords="videoconferencing", keywords="remote consultation", keywords="outpatients", keywords="randomized controlled trial", keywords="economic evaluation", keywords="cost-effectiveness analysis", keywords="QALY", abstract="Background: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. Objective: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. Methods: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. Results: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to {\texteuro}18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. Conclusions: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. Trial Registration: ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX) ", doi="10.2196/11330", url="http://www.jmir.org/2019/2/e11330/", url="http://www.ncbi.nlm.nih.gov/pubmed/30777845" } @Article{info:doi/10.2196/mhealth.9990, author="Somers, Camilla and Grieve, Eleanor and Lennon, Marilyn and Bouamrane, Matt-Mouley and Mair, S. Frances and McIntosh, Emma", title="Valuing Mobile Health: An Open-Ended Contingent Valuation Survey of a National Digital Health Program", journal="JMIR Mhealth Uhealth", year="2019", month="Jan", day="17", volume="7", number="1", pages="e3", keywords="mHealth", keywords="public health", keywords="delivery of health care", keywords="public health systems research", abstract="Background: Changing population demographics and technology developments have resulted in growing interest in the potential of consumer-facing digital health. In the United Kingdom, a {\textsterling}37 million (US \$49 million) national digital health program delivering assisted living lifestyles at scale (dallas) aimed to deploy such technologies at scale. However, little is known about how consumers value such digital health opportunities. Objective: This study explored consumers' perspectives on the potential value of digital health technologies, particularly mobile health (mHealth), to promote well-being by examining their willingness-to-pay (WTP) for such health solutions. Methods: A contingent valuation study involving a UK-wide survey that asked participants to report open-ended absolute and marginal WTP or willingness-to-accept for the gain or loss of a hypothetical mHealth app, Healthy Connections. Results: A UK-representative cohort (n=1697) and a dallas-like (representative of dallas intervention communities) cohort (n=305) were surveyed. Positive absolute and marginal WTP valuations of the app were identified across both cohorts (absolute WTP: UK-representative cohort {\textsterling}196 or US \$258 and dallas-like cohort {\textsterling}162 or US \$214; marginal WTP: UK-representative cohort {\textsterling}160 or US \$211 and dallas-like cohort {\textsterling}151 or US \$199). Among both cohorts, there was a high prevalence of zeros for both the absolute WTP (UK-representative cohort: 467/1697, 27.52\% and dallas-like cohort: 95/305, 31.15\%) and marginal WTP (UK-representative cohort: 487/1697, 28.70\% and dallas-like cohort: 99/305, 32.5\%). In both cohorts, better general health, previous amount spent on health apps (UK-representative cohort 0.64, 95\% CI 0.27 to 1.01; dallas-like cohort: 1.27, 95\% CI 0.32 to 2.23), and age had a significant (P>.00) association with WTP (UK-representative cohort: ?0.1, 95\% CI ?0.02 to ?0.01; dallas-like cohort: ?0.02, 95\% CI ?0.03 to ?0.01), with younger participants willing to pay more for the app. In the UK-representative cohort, as expected, higher WTP was positively associated with income up to {\textsterling}30,000 or US \$39,642 (0.21, 95\% CI 0.14 to 0.4) and increased spending on existing phone and internet services (0.52, 95\% CI 0.30 to 0.74). The amount spent on existing health apps was shown to be a positive indicator of WTP across cohorts, although the effect was marginal (UK-representative cohort 0.01, 95\% CI 0.01 to 0.01; dallas-like cohort 0.01, 95\% CI 0.01 to 0.02). Conclusions: This study demonstrates that consumers value mHealth solutions that promote well-being, social connectivity, and health care control, but it is not universally embraced. For mHealth to achieve its potential, apps need to be tailored to user accessibility and health needs, and more understanding of what hinders frequent users of digital technologies and those with long-term conditions is required. This novel application of WTP in a digital health context demonstrates an economic argument for investing in upskilling the population to promote access and expedite uptake and utilization of such digital health and well-being apps. ", doi="10.2196/mhealth.9990", url="http://mhealth.jmir.org/2019/1/e3/", url="http://www.ncbi.nlm.nih.gov/pubmed/30664488" } @Article{info:doi/10.2196/11655, author="Na, Xu and Guo, Haihong and Zhang, Yu and Shen, Liu and Wu, Sizhu and Li, Jiao", title="Mining Open Payments Data: Analysis of Industry Payments to Thoracic Surgeons From 2014-2016", journal="J Med Internet Res", year="2018", month="Nov", day="30", volume="20", number="11", pages="e11655", keywords="open payments data", keywords="pharmaceutical industry", keywords="thoracic surgeons", keywords="transfer of value", abstract="Background: The financial relationship between physicians and industries has become a hotly debated issue globally. The Physician Payments Sunshine Act of the US Affordable Care Act (2010) promoted transparency of the transactions between industries and physicians by making remuneration data publicly accessible in the Open Payments Program database. Meanwhile, according to the World Health Organization, the majority of all noncommunicable disease deaths were caused by cardiovascular disease. Objective: This study aimed to investigate the distribution of non-research and non-ownership payments made to thoracic surgeons, to explore the regularity of financial relationships between industries and thoracic surgeons. Methods: Annual statistical data were obtained from the Open Payments Program general payment dataset from 2014-2016. We characterized the distribution of annual payments with single payment transactions greater than US \$10,000, quantified the major expense categories (eg, Compensation, Consulting Fees, Travel and Lodging), and identified the 30 highest-paying industries. Moreover, we drew out the financial relations between industries to thoracic surgeons using chord diagram visualization. Results: The three highest categories with single payments greater than US \$10,000 were Royalty or License, Compensation, and Consulting Fees. Payments related to Royalty or License transferred from only 5.38\% of industries to 0.75\% of surgeons with the highest median (US \$13,753, \$11,992, and \$10,614 respectively) in 3-year period. In contrast, payments related to Food and Beverage transferred from 93.50\% of industries to 98.48\% of surgeons with the lowest median (US \$28, \$27, and \$27). The top 30 highest-paying industries made up approximately 90\% of the total payments (US \$21,036,972, \$23,304,996, and \$28,116,336). Furthermore, just under 9\% of surgeons received approximately 80\% of the total payments in each of the 3 years. Specifically, the 100 highest cumulative payments, accounting for 52.69\% of the total, transferred from 27 (6.05\%) pharmaceutical industries to 86 (1.89\%) thoracic surgeons from 2014-2016; 7 surgeons received payments greater than US \$1,000,000; 12 surgeons received payments greater than US \$400,000. The majority (90\%) of these surgeons received tremendous value from only one industry. Conclusions: There exists a great discrepancy in the distribution of payments by categories. Royalty or License Fees, Compensation, and Consulting Fees are the primary transferring channels of single large payments. The massive transfer from industries to surgeons has a strong ``apical dominance'' and excludability. Further research should focus on discovering the fundamental driving factors for the strong concentration of certain medical devices and how these payments will affect the industry itself. ", doi="10.2196/11655", url="http://www.jmir.org/2018/11/e11655/", url="http://www.ncbi.nlm.nih.gov/pubmed/30504119" } @Article{info:doi/10.2196/10437, author="Klein, S. Nicola and Bockting, LH Claudi and Wijnen, Ben and Kok, D. Gemma and van Valen, Evelien and Riper, Heleen and Cuijpers, Pim and Dekker, Jack and van der Heiden, Colin and Burger, Huibert and Smit, Filip", title="Economic Evaluation of an Internet-Based Preventive Cognitive Therapy With Minimal Therapist Support for Recurrent Depression: Randomized Controlled Trial", journal="J Med Internet Res", year="2018", month="Nov", day="26", volume="20", number="11", pages="e10437", keywords="major depressive disorders", keywords="recurrence", keywords="cognitive therapy", keywords="internet", keywords="prevention", keywords="cost effectiveness", abstract="Background: Major depressive disorder (MDD) is highly recurrent and has a significant disease burden. Although the effectiveness of internet-based interventions has been established for the treatment of acute MDD, little is known about their cost effectiveness, especially in recurrent MDD. Objectives: Our aim was to evaluate the cost effectiveness and cost utility of an internet-based relapse prevention program (mobile cognitive therapy, M-CT). Methods: The economic evaluation was performed alongside a single-blind parallel group randomized controlled trial. Participants were recruited via media, general practitioners, and mental health care institutions. In total, 288 remitted individuals with a history of recurrent depression were eligible, of whom 264 were randomly allocated to M-CT with minimal therapist support added to treatment as usual (TAU) or TAU alone. M-CT comprised 8 online lessons, and participants were advised to complete 1 lesson per week. The economic evaluation was performed from a societal perspective with a 24-month time horizon. The health outcomes were number of depression-free days according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) criteria assessed with the Structured Clinical Interview for DSM-IV axis I disorders by blinded interviewers after 3, 12, and 24 months. Quality-adjusted life years (QALYs) were self-assessed with the three level version of the EuroQol Five Dimensional Questionnaire (EQ-5D-3L). Costs were assessed with the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness (TiC-P). Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that M-CT is cost effective compared to TAU. Results: Mean total costs over 24 months were {\texteuro}8298 (US \$9415) for M-CT and {\texteuro}7296 (US \$8278) for TAU. No statistically significant differences were found between M-CT and TAU regarding depression-free days and QALYs (P=.37 and P=.92, respectively). The incremental costs were {\texteuro}179 (US \$203) per depression-free day and {\texteuro}230,816 (US \$261,875) per QALY. The cost-effectiveness acceptability curves suggested that for depression-free days, high investments have to be made to reach an acceptable probability that M-CT is cost effective compared to TAU. Regarding QALYs, considerable investments have to be made but the probability that M-CT is cost effective compared to TAU does not rise above 40\%. Conclusions: The results suggest that adding M-CT to TAU is not effective and cost effective compared to TAU alone. Adherence rates were similar to other studies and therefore do not explain this finding. The participants scarcely booked additional therapist support, resulting in 17.3 minutes of mean total therapist support. More studies are needed to examine the cost effectiveness of internet-based interventions with respect to long-term outcomes and the role and optimal dosage of therapist support. Overall, more research is needed on scalable and cost-effective interventions that can reduce the burden of recurrent MDD. Trial registration: Netherlands Trial Register NTR2503; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2503 (Archived by WebCite at http://www.webcitation.org/73aBn41r3) ", doi="10.2196/10437", url="http://www.jmir.org/2018/11/e10437/", url="http://www.ncbi.nlm.nih.gov/pubmed/30478021" } @Article{info:doi/10.2196/medinform.9577, author="Kim, Wook Sung and Madan, Jason and Dritsaki, Melina and Bryce, Carol and Forjaz, Vera and Fraser, Joe and Griffiths, Frances and Hamilton, Kathryn and Huxley, Caroline and Sturt, Jackie", title="Benefits and Costs of Digital Consulting in Clinics Serving Young People With Long-Term Conditions: Mixed-Methods Approach", journal="JMIR Med Inform", year="2018", month="Oct", day="30", volume="6", number="4", pages="e48", keywords="digital consulting", keywords="long-term conditions", keywords="costing analysis", keywords="young people", keywords="mental health", keywords="diabetes", abstract="Background: Since the introduction of digital health technologies in National Health Service (NHS), health professionals are starting to use email, text, and other digital methods to consult with their patients in a timely manner. There is lack of evidence regarding the economic impact of digital consulting in the United Kingdom (UK) NHS. Objective: This study aimed to estimate the direct costs associated with digital consulting as an adjunct to routine care at 18 clinics serving young people aged 16-24 years with long-term conditions. Methods: This study uses both quantitative and qualitative approaches. Semistructured interviews were conducted with 173 clinical team members on the impacts of digital consulting. A structured questionnaire was developed and used for 115 health professionals across 12 health conditions at 18 sites in the United Kingdom to collect data on time and other resources used for digital consulting. A follow-up semistructured interview was conducted with a single senior clinician at each site to clarify the mechanisms through which digital consulting use might lead to outcomes relevant to economic evaluation. We used the two-part model to see the association between the time spent on digital consulting and the job role of staff, type of clinic, and the average length of the working hours using digital consulting. Results: When estimated using the two-part model, consultants spent less time on digital consulting compared with nurses (95.48 minutes; P<.001), physiotherapists (55.3 minutes; P<.001), and psychologists (31.67 minutes; P<.001). Part-time staff spent less time using digital consulting than full-time staff despite insignificant result (P=.15). Time spent on digital consulting differed across sites, and no clear pattern in using digital consulting was found. Health professionals qualitatively identified the following 4 potential economic impacts for the NHS: decreasing adverse events, improving patient well-being, decreasing wait lists, and staff workload. We did not find evidence to suggest that the clinical condition was associated with digital consulting use. Conclusions: Nurses and physiotherapists were the greatest users of digital consulting. Teams appear to use an efficient triage system with the most expensive members digitally consulting less than lower-paid team members. Staff report showed concerns regarding time spent digitally consulting, which implies that direct costs increase. There remain considerable gaps in evidence related to cost-effectiveness of digital consulting, but this study has highlighted important cost-related outcomes for assessment in future cost-effectiveness trials of digital consulting. ", doi="10.2196/medinform.9577", url="http://medinform.jmir.org/2018/4/e48/", url="http://www.ncbi.nlm.nih.gov/pubmed/30377145" } @Article{info:doi/10.2196/10776, author="Quinn, C. Charlene and Swasey, K. Krystal and Torain, M. Jamila and Shardell, D. Michelle and Terrin, L. Michael and Barr, A. Erik and Gruber-Baldini, L. Ann", title="An mHealth Diabetes Intervention for Glucose Control: Health Care Utilization Analysis", journal="JMIR Mhealth Uhealth", year="2018", month="Oct", day="15", volume="6", number="10", pages="e10776", keywords="cluster randomized clinical trial", keywords="health care", keywords="health service utilization", keywords="mHealth", keywords="type 2 diabetes", abstract="Background: Type 2 diabetes (T2D) is a major chronic condition requiring management through lifestyle changes and recommended health service visits. Mobile health (mHealth) is a promising tool to encourage self-management, but few studies have investigated the impact of mHealth on health care utilization. Objective: The objective of this analysis was to determine the change in 2-year health service utilization and whether utilization explained a 1.9\% absolute decrease in glycated hemoglobin (HbA1c) over 1-year in the Mobile Diabetes Intervention Study (MDIS). Methods: We used commercial claims data from 2006 to 2010 linked to enrolled patients' medical chart data in 26 primary care practices in Maryland, USA. Secondary claims data analyses were available for 56\% (92/163) of participants. In the primary MDIS study, physician practices were recruited and randomized to usual care and 1 of 3 increasingly complex interventions. Patients followed physician randomization assignment. The main variables in the analysis included health service utilization by type of service and change in HbA1c. The claims data was aggregated into 12 categories of utilization to assess change in 2-year health service usage, comparing rates of usage pre- and posttrial. We also examined whether utilization explained the 1.9\% decrease in HbA1c over 1 year in the MDIS cluster randomized clinical trial. Results: A significant group by time effect was observed in physician office visits, general practitioner visits, other outpatient services, prescription medications, and podiatrist visits. Physician office visits (P=.01) and general practitioner visits (P=.02) both decreased for all intervention groups during the study period, whereas prescription claims (P<.001) increased. The frequency of other outpatient services (P=.001) and podiatrist visits (P=.04) decreased for the control group and least complex intervention group but increased for the 2 most complex intervention groups. No significant effects of utilization were observed to explain the clinically significant change in HbA1c. Conclusions: Claims data analyses identified patterns of utilization relevant to mHealth interventions. Findings may encourage patients and health providers to discuss the utilization of treatment-recommended services, lab tests, and prescribed medications. Trial Registration: ClinicalTrials.gov NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by Webcite at http://www.webcitation.org/72XgTaxIj) ", doi="10.2196/10776", url="http://mhealth.jmir.org/2018/10/e10776/", url="http://www.ncbi.nlm.nih.gov/pubmed/30322839" } @Article{info:doi/10.2196/jmir.9997, author="Ferwerda, Maaike and van Beugen, Sylvia and van Middendorp, Henri{\"e}t and Visser, Henk and Vonkeman, Harald and Creemers, Marjonne and van Riel, Piet and Kievit, Wietske and Evers, Andrea", title="Tailored, Therapist-Guided Internet-Based Cognitive Behavioral Therapy Compared to Care as Usual for Patients With Rheumatoid Arthritis: Economic Evaluation of a Randomized Controlled Trial", journal="J Med Internet Res", year="2018", month="Oct", day="11", volume="20", number="10", pages="e260", keywords="cost-utility analysis", keywords="cognitive behavioral treatment", keywords="Internet-based therapy", keywords="rheumatoid arthritis", abstract="Background: Internet-based cognitive behavioral therapy can aid patients with rheumatoid arthritis with elevated levels of distress to enhance their quality of life. However, implementation is currently lacking and there is little evidence available on the (cost-) effectiveness of different treatment strategies. Objective: Cost-benefit ratios are necessary for informing stakeholders and motivating them to implement effective treatment strategies for improving health-related quality of life (HRQoL) of patients with rheumatoid arthritis. A cost-effectiveness study from a societal perspective was conducted alongside a randomized controlled trial on a tailored, therapist-guided internet-based cognitive behavioral therapy (ICBT) intervention for patients with rheumatoid arthritis with elevated levels of distress as an addition to care as usual (CAU). Methods: Data were collected at baseline or preintervention, 6 months or postintervention, and every 3 months thereafter during the 1-year follow-up. Effects were measured in terms of quality-adjusted life years (QALYs) and costs from a societal perspective, including health care sector costs (health care use, medication, and intervention costs), patient travel costs for health care use, and costs associated with loss of labor. Results: The intervention improved the quality of life compared with only CAU ($\Delta$ QALYs=0.059), but at a higher cost ($\Delta$={\texteuro}4211). However, this increased cost substantially reduced when medication costs were left out of the equation ($\Delta$={\texteuro}1863). Of all, 93\% (930/1000) of the simulated incremental cost-effectiveness ratios were in the north-east quadrant, indicating a high probability that the intervention was effective in improving HRQoL, but at a greater monetary cost for society compared with only CAU. Conclusions: A tailored and guided ICBT intervention as an addition to CAU for patients with rheumatoid arthritis with elevated levels of distress was effective in improving quality of life. Consequently, implementation of ICBT into standard health care for patients with rheumatoid arthritis is recommended. However, further studies on cost reductions in this population are warranted. Trial Registration: Nederlands Trial Register NTR2100; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2100 (Archived by WebCite at http://www.webcitation.org/724t9pvr2) ", doi="10.2196/jmir.9997", url="https://www.jmir.org/2018/10/e260/", url="http://www.ncbi.nlm.nih.gov/pubmed/30309835" } @Article{info:doi/10.2196/10455, author="Wijnen, FM Ben and Lokman, Suzanne and Leone, Stephanie and Evers, MAA Silvia and Smit, Filip", title="Complaint-Directed Mini-Interventions for Depressive Symptoms: A Health Economic Evaluation of Unguided Web-Based Self-Help Interventions Based on a Randomized Controlled Trial", journal="J Med Internet Res", year="2018", month="Oct", day="01", volume="20", number="10", pages="e10455", keywords="prevention", keywords="depression", keywords="internet-based intervention", keywords="economic evaluation", keywords="quality of life", keywords="cost-effectiveness analysis", keywords="cost-utility analysis", keywords="early medical intervention", keywords="cost-benefit analysis", abstract="Background: Depression prevention and early intervention have become a top priority in the Netherlands, but with considerable room for improvement. To address this, Web-based complaint-directed mini-interventions (CDMIs) were developed. These brief and low-threshold interventions focus on psychological stress, sleep problems, and worry, because these complaints are highly prevalent, are demonstrably associated with depression, and have substantial economic impact. Objective: The objective of this economic evaluation was to examine the added value of Web-based, unguided, self-help CDMIs compared with a wait-listed control group with unrestricted access to usual care from both a societal and a health care perspective. Methods: This health economic evaluation was embedded in a randomized controlled trial. The study entailed 2 arms, in which 3 Web-based CDMIs were compared with a no-intervention waiting-list control group (which received the intervention after 3 months). We conducted measurements at baseline, and at 3 and 6 months. The primary outcome was the rate of responders to treatment on depressive symptoms as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). We estimated change in quality of life by calculating effect sizes (Cohen d) for individual pre- and posttreatment IDS-SR scores using a conversion factor to map a change in standardized effect size onto a corresponding change in utility. We calculated incremental cost-effectiveness ratios using bootstraps (5000 times) of seemingly unrelated regression equations and constructed cost-effectiveness acceptability curves for the costs per quality-adjusted life-year (QALY) gained. Results: Of 329 study participants, we randomly assigned 165 to the CDMI group. At 3 months, the rate of responders to treatment was 13.9\% (23/165) in the CDMI group and 7.3\% (12/164) in the control group. At 3 months, participants in the CDMI group gained 0.15 QALYs compared with baseline, whereas participants in the control group gained 0.03 QALYs. Average total costs per patient at 3 months were {\texteuro}2094 for the CDMI group and {\texteuro}2230 for the control group (excluding baseline costs). Bootstrapped seemingly unrelated regression equations models resulted in a dominant incremental cost-effectiveness ratio (ie, lower costs and a higher rate of responders to treatment) for the CDMI group compared with the control group at 3 months, with the same result for the costs per QALY gained. Various sensitivity analyses attested to the robustness of the findings of the main analysis. Conclusions: Brief and low-threshold Web-based, unguided, self-help CDMIs have the potential to be a cost-effective addition to usual care for adults with mild to moderate depressive symptoms. The CDMIs improved health status, while reducing participant health care costs, and hence dominated the care-as-usual control condition. As intervention costs were relatively low, and the internet is readily available in the Western world, we believe CDMIs can be easily implemented on a large scale. Trial Registration: Netherlands Trial Register NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM) ", doi="10.2196/10455", url="https://www.jmir.org/2018/10/e10455/", url="http://www.ncbi.nlm.nih.gov/pubmed/30274958" } @Article{info:doi/10.2196/10254, author="Agboola, Stephen and Simons, Mariana and Golas, Sara and op den Buijs, Jorn and Felsted, Jennifer and Fischer, Nils and Schertzer, Linda and Orenstein, Allison and Jethwani, Kamal and Kvedar, Joseph", title="Health Care Cost Analyses for Exploring Cost Savings Opportunities in Older Patients: Longitudinal Retrospective Study", journal="JMIR Aging", year="2018", month="Aug", day="01", volume="1", number="2", pages="e10254", keywords="health care cost analysis", keywords="cost acuity pyramid", keywords="patient segmentation", keywords="multicenter study", keywords="Markov chains", abstract="Background: Half of Medicare reimbursement goes toward caring for the top 5\% of the most expensive patients. However, little is known about these patients prior to reaching the top or how their costs change annually. To address these gaps, we analyzed patient flow and associated health care cost trends over 5 years. Objective: To evaluate the cost of health care utilization in older patients by analyzing changes in their long-term expenditures. Methods: This was a retrospective, longitudinal, multicenter study to evaluate health care costs of 2643 older patients from 2011 to 2015. All patients had at least one episode of home health care during the study period and used a personal emergency response service (PERS) at home for any length of time during the observation period. We segmented all patients into top (5\%), middle (6\%-50\%), and bottom (51\%-100\%) segments by their annual expenditures and built cost pyramids based thereon. The longitudinal health care expenditure trends of the complete study population and each segment were assessed by linear regression models. Patient flows throughout the segments of the cost acuity pyramids from year to year were modeled by Markov chains. Results: Total health care costs of the study population nearly doubled from US \$17.7M in 2011 to US \$33.0M in 2015 with an expected annual cost increase of US \$3.6M (P=.003). This growth was primarily driven by a significantly higher cost increases in the middle segment (US \$2.3M, P=.003). The expected annual cost increases in the top and bottom segments were US \$1.2M (P=.008) and US \$0.1M (P=.004), respectively. Patient and cost flow analyses showed that 18\% of patients moved up the cost acuity pyramid yearly, and their costs increased by 672\%. This was in contrast to 22\% of patients that moved down with a cost decrease of 86\%. The remaining 60\% of patients stayed in the same segment from year to year, though their costs also increased by 18\%. Conclusions: Although many health care organizations target intensive and costly interventions to their most expensive patients, this analysis unveiled potential cost savings opportunities by managing the patients in the lower cost segments that are at risk of moving up the cost acuity pyramid. To achieve this, data analytics integrating longitudinal data from electronic health records and home monitoring devices may help health care organizations optimize resources by enabling clinicians to proactively manage patients in their home or community environments beyond institutional settings and 30- and 60-day telehealth services. ", doi="10.2196/10254", url="http://aging.jmir.org/2018/2/e10254/", url="http://www.ncbi.nlm.nih.gov/pubmed/31518241" } @Article{info:doi/10.2196/10429, author="Subramanian, Sujha and Kaganova, Yevgeniya and Zhang, Yuying and Hoover, Sonja and Nyambe, Namakau and Pinder, Leeya and Chibwesha, Carla and Kapambwe, Sharon and Parham, Groesbeck", title="Patient Preferences and Willingness to Pay for Cervical Cancer Prevention in Zambia: Protocol for a Multi-Cohort Discrete Choice Experiment", journal="JMIR Res Protoc", year="2018", month="Jul", day="25", volume="7", number="7", pages="e10429", keywords="discrete choice experiment", keywords="cervical cancer prevention", keywords="economic evaluation", abstract="Background: Although most countries in southern Africa have cervical cancer screening programs, these programs generally fail to reach a significant majority of women because they are often implemented as pilot or research projects, and this limits their scope and ability to scale up screening. Some countries have planned larger-scale programs, but these have either never been implemented or have not been successfully scaled up. Most of the global burden of cervical cancer is experienced in countries with limited resources, and mortality from cervical cancer is the most common cause of cancer-related deaths among women in Sub-Saharan Africa. Objective: The purpose of this study is to learn about preferences for cervical cancer screening in Zambia, to identify barriers and facilitators for screening uptake, and to evaluate willingness to pay for screening services to support the scaling up of cervical cancer screening programs. Methods: We will conduct a discrete choice experiment by interviewing women and men and asking them to choose among constructed scenarios with varying combinations of attributes relevant to cervical cancer screening. To inform the discrete choice experiment, we will conduct focus groups and interviews about general knowledge and attitudes about cervical screening, perception about the availability of screening, stigma associated with cancer and HIV, and payment for health care services. For the discrete choice experiment, we will have a maximum design of 120 choice sets divided into 15 sets of 8 tasks each with a sample size of 320-400 respondents. We will use a hierarchical Bayesian estimation procedure to assess attributes at the following two levels: group and individual levels. Results: The model will generate preferences for attributes to assess the most important features and allow for the assessment of differences among cohorts. We will conduct policy simulations reflecting potential changes in the attributes of the screening facilities and calculate the projected changes in preference for choosing to undergo cervical cancer screening. The findings from the discrete choice experiment will be supplemented with interviews, focus groups, and patient surveys to ensure a comprehensive and context-based interpretation of the results. Conclusions: Because willingness to pay for cervical cancer screening has not been previously assessed, this will be a unique and important contribution to the literature. This study will take into account the high HIV prevalence in Sub-Saharan Africa and prevailing gender attitudes to identify an optimal package of interventions to reduce cervical cancer incidence. This simulation of women's decisions (and men's support) to undergo screening will lay the foundation for understanding the stated preferences and willingness to pay to help design future screening programs. Registered Report Identifier: RR1-10.2196/10429 ", doi="10.2196/10429", url="http://www.researchprotocols.org/2018/7/e10429/", url="http://www.ncbi.nlm.nih.gov/pubmed/30045833" } @Article{info:doi/10.2196/10405, author="Rosner, I. Benjamin and Gottlieb, Marc and Anderson, N. William", title="Accuracy of Internet-Based Patient Self-Report of Postdischarge Health Care Utilization and Complications Following Orthopedic Procedures: Observational Cohort Study", journal="J Med Internet Res", year="2018", month="Jul", day="20", volume="20", number="7", pages="e10405", keywords="patient-generated health data", keywords="patient reported outcome measures", keywords="patient self-report", keywords="complications", keywords="utilization", keywords="patient readmission", keywords="emergency room", keywords="hospital economics", abstract="Background: The accuracy of patient self-report of health care utilization and complications has yet to be determined. If patients are accurate and engaged self-reporters, collecting this information in a manner that is temporally proximate to the health care utilization events themselves may prove valuable to health care organizations undertaking quality improvement initiatives for which such data are often unavailable. Objective: The objective of this study was to measure the accuracy of patient self-report of health care utilization and complications in the 90 days following orthopedic procedures using an automated digital patient engagement platform. Methods: We conducted a multicenter real-world observational cohort study across 10 orthopedic practices in California and Nevada. A total of 371 Anthem members with claims data meeting inclusion criteria who had undergone orthopedic procedures between March 1, 2015, and July 1, 2016, at participating practices already routinely using an automated digital patient engagement platform for asynchronous remote guidance and telemonitoring were sent surveys through the platform (in addition to the other materials being provided to them through the platform) regarding 90-day postencounter health care utilization and complications. Their self-reports to structured survey questions of health care utilization and complications were compared to claims data as a reference. Results: The mean age of the 371 survey recipients was 56.5 (SD 15.7) years, 48.8\% (181/371) of whom were female; 285 individuals who responded to 1 or more survey questions had a mean age of 56.9 (SD 15.4) years and a 49.5\% (141/285) female distribution. There were no significant differences in demographics or event prevalence rates between responders and nonresponders. With an overall survey completion rate of 76.8\% (285/371), patients were found to have accuracy of self-report characterized by a kappa of 0.80 and agreement of 0.99 and a kappa of 1.00 and agreement of 1.00 for 90-day hospital admissions and pulmonary embolism, respectively. Accuracy of self-report of 90-day emergency room/urgent care visits and of surgical site infection were characterized by a kappa of 0.45 and agreement of 0.96 and a kappa of 0.53 and agreement of 0.97, respectively. Accuracy for other complications such as deep vein thrombosis, hemorrhage, severe constipation, and fracture/dislocation was lower, influenced by low event prevalence rates within our sample. Conclusions: In this multicenter observational cohort study using an automated internet-based digital patient engagement platform, we found that patients were most accurate self-reporters of 90-day hospital admissions and pulmonary embolism, followed by 90-day surgical site infection and emergency room/urgent care visits. They were less accurate for deep vein thrombosis and least accurate for hemorrhage, severe constipation, and fracture/dislocation. A total of 76.8\% (285/371) of patients completed surveys without the need for clinical staff to collect responses, suggesting the acceptability to patients of internet-based survey dissemination from and collection by clinical teams. While our methods enabled detection of events outside of index institutions, assessment of accuracy of self-report for presence and absence of events and nonresponse bias analysis, low event prevalence rates, particularly for several of the complications, limit the conclusions that may be drawn for some of the findings. Nevertheless, this investigation suggests the potential that engaging patients in self-report through such survey modalities may offer for the timely and accurate measurement of matters germane to health care organizations engaged in quality improvement efforts post discharge. ", doi="10.2196/10405", url="http://www.jmir.org/2018/7/e10405/", url="http://www.ncbi.nlm.nih.gov/pubmed/30030212" } @Article{info:doi/10.2196/mhealth.9493, author="Campbell, R. Amber and Kinvig, Karen and C{\^o}t{\'e}, CF H{\'e}l{\`e}ne and Lester, T. Richard and Qiu, Q. Annie and Maan, J. Evelyn and Alimenti, Ariane and Pick, Neora and Murray, CM Melanie", title="Health Care Provider Utilization and Cost of an mHealth Intervention in Vulnerable People Living With HIV in Vancouver, Canada: Prospective Study", journal="JMIR Mhealth Uhealth", year="2018", month="Jul", day="09", volume="6", number="7", pages="e152", keywords="HIV", keywords="mHealth", keywords="health care provider", keywords="cost", keywords="health care utilization", keywords="adherence", abstract="Background: Improving adherence to combined antiretroviral therapy (cART) can be challenging, especially among vulnerable populations living with HIV. Even where cART is available free of charge, social determinants of health act as barriers to optimal adherence rates. Patient-centered approaches exploiting mobile phone communications (mHealth) have been shown to improve adherence to cART and promote achievement of suppressed HIV plasma viral loads. However, data are scarce on the health care provider (HCP) time commitments and health care costs associated with such interventions. This knowledge is needed to inform policy and programmatic implementation. Objective: The purpose of this study was to approximate the resources required and to provide an estimate of the costs associated with running an mHealth intervention program to improve medication adherence in people living with HIV (PLWH). Methods: This prospective study of HCP utilization and costs was embedded within a repeated measures effectiveness study of the WelTel short-message service (SMS) mHealth program. The study included 85 vulnerable, nonadherent PLWH in Vancouver, Canada, and resulted in improved medication adherence and HIV plasma viral load among participants. Study participants were provided mobile phones with unlimited texting (where required) and received weekly bidirectional text messages to inquire on their status for one year. A clinic nurse triaged and managed participants' responses, immediately logging all patient interactions by topic, HCP involvement, and time dedicated to addressing issues raised by participants. Interaction costs were determined in Canadian dollars based on HCP type, median salary within our health authority, and their time utilized as part of the intervention. Results: Participant-identified problems within text responses included health-related, social, and logistical issues. Taken together, management of problems required a median of 43 minutes (interquartile range, IQR 17-99) of HCP time per participant per year, for a median yearly cost of Can \$36.72 (IQR 15.50-81.60) per participant who responded with at least one problem. The clinic nurse who monitored the texts solved or managed 65\% of these issues, and the remaining were referred to a variety of other HCPs. The total intervention costs, including mobile phones, plans, and staffing were a median Can \$347.74/highly vulnerable participant per year for all participants or Can \$383.18/highly vulnerable participant per year for those who responded with at least one problem. Conclusions: Bidirectional mHealth programs improve HIV care and treatment outcomes for PLWH. Knowledge about the HCP cost associated, here less than Can \$50/year, provides stakeholders and decision makers with information relevant to determining the feasibility and sustainability of mHealth programs in a real-world setting. Trial Registration: ClinicalTrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/70IYqKUjV). ", doi="10.2196/mhealth.9493", url="http://mhealth.jmir.org/2018/7/e152/", url="http://www.ncbi.nlm.nih.gov/pubmed/29986845" } @Article{info:doi/10.2196/jmir.9225, author="Turner, M. Ralph and Ma, Qinli and Lorig, Kate and Greenberg, Jay and DeVries, R. Andrea", title="Evaluation of a Diabetes Self-Management Program: Claims Analysis on Comorbid Illnesses, Health Care Utilization, and Cost", journal="J Med Internet Res", year="2018", month="Jun", day="22", volume="20", number="6", pages="e207", keywords="diabetes mellitus", keywords="patient education", keywords="health care utilization", keywords="cost", abstract="Background: An estimated 30.3 million Americans have diabetes mellitus. The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to improve the quality of life for people who either have or are at risk for diabetes mellitus, and hence, lower the personal and national economic burden of this debilitating chronic disease. Diabetes self-management education interventions are a primary focus of this initiative. Objective: The aim of this study was to evaluate the impact of the Better Choices Better Health Diabetes (BCBH-D) self-management program on comorbid illness related to diabetes mellitus, health care utilization, and cost. Methods: A propensity score matched two-group, pre-post design was used for this study. Retrospective administrative medical and pharmacy claims data from the HealthCore Integrated Research Environment were used for outcome variables. The intervention cohort included diabetes mellitus patients who were recruited to a diabetes self-management program. Control cohort subjects were identified from the HealthCore Integrated Research Environment by at least two diabetes-associated claims (International Classification of Diseases-Ninth Revision, ICD-9 250.xx) within 2 years before the program launch date (October 1, 2011-September 30, 2013) but did not participate in BCBH-D. Controls were matched to cases in a 3:1 propensity score match. Outcome measures included pre- and postintervention all-cause and diabetes-related utilization and costs. Cost outcomes are reported as least squares means. Repeated measures analyses (generalized estimating equation approach) were conducted for utilization, comorbid conditions, and costs. Results: The program participants who were identified in HealthCore Integrated Research Environment claims (N=558) were matched to a control cohort of 1669 patients. Following the intervention, the self-management cohort experienced significant reductions for diabetes mellitus--associated comorbid conditions, with the postintervention disease burden being significantly lower (mean 1.6 [SD 1.6]) compared with the control cohort (mean 2.1 [SD 1.7]; P=.001). Postintervention all-cause utilization was decreased in the intervention cohort compared with controls with ?40/1000 emergency department visits vs +70/1000; P=.004 and ?5780 outpatient visits per 1000 vs ?290/1000; P=.001. Unadjusted total all-cause medical cost was decreased by US \$2207 in the intervention cohort compared with a US \$338 decrease in the controls; P=.001. After adjustment for other variables through structural equation analysis, the direct effect of the BCBH-D was --US \$815 (P=.049). Conclusions: Patients in the BCBH-D program experienced reduced all-cause health care utilization and costs. Direct cost savings were US \$815. Although encouraging, given the complexity of the patient population, further study is needed to cross-validate the results. ", doi="10.2196/jmir.9225", url="http://www.jmir.org/2018/6/e207/", url="http://www.ncbi.nlm.nih.gov/pubmed/29934284" } @Article{info:doi/10.2196/jmir.9256, author="Li, Jinshuo and Parrott, Steve and Sweeting, Michael and Farmer, Andrew and Ross, Jamie and Dack, Charlotte and Pal, Kingshuk and Yardley, Lucy and Barnard, Maria and Hudda, Mohammed and Alkhaldi, Ghadah and Murray, Elizabeth", title="Cost-Effectiveness of Facilitated Access to a Self-Management Website, Compared to Usual Care, for Patients With Type 2 Diabetes (HeLP-Diabetes): Randomized Controlled Trial", journal="J Med Internet Res", year="2018", month="Jun", day="08", volume="20", number="6", pages="e201", keywords="cost-effectiveness", keywords="type 2 diabetes mellitus", keywords="self-management", keywords="internet", abstract="Background: Type 2 diabetes mellitus is one of the most common long-term conditions, and costs health services approximately 10\% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. While the existing evidence suggested that uptake of self-management education was low, the development of internet-based technology might improve the situation. Objective: To establish the cost-effectiveness of a Web-based self-management program for people with type 2 diabetes (HeLP-Diabetes) compared to usual care. Methods: An incremental cost-effectiveness analysis was conducted, from a National Health Service and personal and social services perspective, based on data collected from a multi-center, two-arm individually randomized controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomized to either usual care plus HeLP-Diabetes, an interactive, theoretically-informed Web-based self-management program, or to usual care plus access to a comparator website containing basic information only. The participants' intervention costs and wider health care resource use were collected as well as two health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to handle the missing data. Results: In total, 374 participants were randomized, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios of {\textsterling}58 (95\% CI --411 to 587) per unit improvement on PAID scale and {\textsterling}5550 (95\% CI --21,077 to 52,356) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and higher uncertainty with incremental cost-effectiveness ratios of {\textsterling}116 (95\% CI --1299 to 1690) per unit improvement on PAID scale and {\textsterling}18,500 (95\% CI --203,949 to 190,267) per QALY. The cost-effectiveness acceptability curve showed an 87\% probability of cost-effectiveness at {\textsterling}20,000 per QALY willingness-to-pay threshold. The one-way sensitivity analyses estimated 363 users would be needed to use the intervention for it to become less costly than usual care. Conclusions: Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of {\textsterling}20,000 to {\textsterling}30,000 per QALY by National Institute of Health and Care Excellence. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 02123133; http://www.controlled-trials.com/ISRCTN02123133 (Archived by WebCite at http://www.webcitation.org/6zqjhmn00) ", doi="10.2196/jmir.9256", url="http://www.jmir.org/2018/6/e201/", url="http://www.ncbi.nlm.nih.gov/pubmed/29884608" } @Article{info:doi/10.2196/resprot.9478, author="Kaur, Amandeep and Isaranuwatchai, Wanrudee and Jaffer, Aliya and Ferguson, Genevieve and Abi-Jaoude, Alexxa and Johnson, Andrew and Hollenberg, Elisa and Wiljer, David", title="A Web- and Mobile-Based Map of Mental Health Resources for Postsecondary Students (Thought Spot): Protocol for an Economic Evaluation", journal="JMIR Res Protoc", year="2018", month="Mar", day="29", volume="7", number="3", pages="e83", keywords="economic evaluation", keywords="health economics", keywords="transition-aged youths", keywords="participatory action research", keywords="mental health", abstract="Background: Youth demonstrate a low propensity to seek help for mental health issues and exhibit low use of health services despite the high prevalence of mental health challenges in this population. Research has found that delivering interventions via the internet and mobile devices is an effective way to reach youth. Thought Spot, a Web- and mobile-based map, was developed to help transition-aged youth in postsecondary settings overcome barriers to help-seeking, thereby reducing the economic burden associated with untreated mental health issues. Objective: This paper presents the protocol for an economic evaluation that will be conducted in conjunction with a randomized controlled trial (RCT) to evaluate the effectiveness and cost of Thought Spot compared with usual care in terms of self-efficacy for mental health help-seeking among postsecondary students. Methods: A partially blinded RCT will be conducted to assess the impact of Thought Spot on the self-efficacy of students for mental health help-seeking. Students from 3 postsecondary institutions in Ontario, Canada will be randomly allocated to 1 of 2 intervention groups (resource pamphlet or Thought Spot) for 6 months. The economic evaluation will focus on the perspective of postsecondary institutions or other organizations interested in using Thought Spot. Costs and resources for operating and maintaining the platform will be reported and compared with the costs and resource needs associated with usual care. The primary outcome will be change in help-seeking intentions, measured using the General Help-Seeking Questionnaire. The cost-effectiveness of the intervention will be determined by calculating the incremental cost-effectiveness ratio, which will then be compared with willingness to pay. Results: The RCT is scheduled to begin in February 2018 and will run for 6 months, after which the economic evaluation will be completed. Conclusions: We expect to demonstrate that Thought Spot is a cost-effective way to improve help-seeking intentions and encourage help-seeking behavior among postsecondary students. The findings of this study will help inform postsecondary institutions when they are allocating resources for mental health initiatives. Trial Registration: ClinicalTrials.gov NCT03412461; https://clinicaltrials.gov/ct2/show/NCT03412461 (Archived at WebCite at http://www.webcitation.org/6xy5lWpnZ) ", doi="10.2196/resprot.9478", url="http://www.researchprotocols.org/2018/3/e83/", url="http://www.ncbi.nlm.nih.gov/pubmed/29599106" } @Article{info:doi/10.2196/jmir.9552, author="Lanssens, Dorien and Vandenberk, Thijs and Smeets, JP Christophe and De Canni{\`e}re, H{\'e}l{\`e}ne and Vonck, Sharona and Claessens, Jade and Heyrman, Yenthel and Vandijck, Dominique and Storms, Valerie and Thijs, M. Inge and Grieten, Lars and Gyselaers, Wilfried", title="Prenatal Remote Monitoring of Women With Gestational Hypertensive Diseases: Cost Analysis", journal="J Med Internet Res", year="2018", month="Mar", day="26", volume="20", number="3", pages="e102", keywords="remote monitoring", keywords="gestational hypertensive diseases", keywords="reimbursement", keywords="cost-effectiveness", abstract="Background: Remote monitoring in obstetrics is relatively new; some studies have shown its effectiveness for both mother and child. However, few studies have evaluated the economic impact compared to conventional care, and no cost analysis of a remote monitoring prenatal follow-up program for women diagnosed with gestational hypertensive diseases (GHD) has been published. Objective: The aim of this study was to assess the costs of remote monitoring versus conventional care relative to reported benefits. Methods: Patient data from the Pregnancy Remote Monitoring (PREMOM) study were used. Health care costs were calculated from patient-specific hospital bills of Ziekenhuis Oost-Limburg (Genk, Belgium) in 2015. Cost comparison was made from three perspectives: the Belgian national health care system (HCS), the National Institution for Insurance of Disease and Disability (RIZIV), and costs for individual patients. The calculations were made for four major domains: prenatal follow-up, prenatal admission to the hospital, maternal and neonatal care at and after delivery, and total amount of costs. A simulation exercise was made in which it was calculated how much could be demanded of RIZIV for funding the remote monitoring service. Results: A total of 140 pregnancies were included, of which 43 received remote monitoring (30.7\%) and 97 received conventional care (69.2\%). From the three perspectives, there were no differences in costs for prenatal follow-up. Compared to conventional care, remote monitoring patients had 34.51\% less HCS and 41.72\% less RIZIV costs for laboratory test results (HCS: mean {\texteuro}0.00 [SD {\texteuro}55.34] vs mean {\texteuro}38.28 [SD {\texteuro} 44.08], P<.001; RIZIV: mean {\texteuro}21.09 [SD {\texteuro}27.94] vs mean {\texteuro}36.19 [SD {\texteuro}41.36], P<.001) and a reduction of 47.16\% in HCS and 48.19\% in RIZIV costs for neonatal care (HCS: mean {\texteuro}989.66 [SD {\texteuro}3020.22] vs mean {\texteuro}1872.92 [SD {\texteuro}5058.31], P<.001; RIZIV: mean {\texteuro}872.97 [SD {\texteuro}2761.64] vs mean {\texteuro}1684.86 [SD {\texteuro}4702.20], P<.001). HCS costs for medication were 1.92\% lower in remote monitoring than conventional care (mean {\texteuro}209.22 [SD {\texteuro}213.32] vs mean {\texteuro}231.32 [SD 67.09], P=.02), but were 0.69\% higher for RIZIV (mean {\texteuro}122.60 [SD {\texteuro}92.02] vs mean {\texteuro}121.78 [SD {\texteuro}20.77], P<.001). Overall HCS costs for remote monitoring were mean {\texteuro}4233.31 (SD {\texteuro}3463.31) per person and mean {\texteuro}4973.69 (SD {\texteuro}5219.00) per person for conventional care (P=.82), a reduction of {\texteuro}740.38 (14.89\%) per person, with savings mainly for RIZIV of {\texteuro}848.97 per person (23.18\%; mean {\texteuro}2797.42 [SD {\texteuro}2905.18] vs mean {\texteuro}3646.39 [SD {\texteuro}4878.47], P=.19). When an additional fee of {\texteuro}525.07 per month per pregnant woman for funding remote monitoring costs is demanded, remote monitoring is acceptable in their costs for HCS, RIZIV, and individual patients. Conclusions: In the current organization of Belgian health care, a remote monitoring prenatal follow-up of women with GHD is cost saving for the global health care system, mainly via savings for the insurance institution RIZIV. ", doi="10.2196/jmir.9552", url="http://www.jmir.org/2018/3/e102/", url="http://www.ncbi.nlm.nih.gov/pubmed/29581094" } @Article{info:doi/10.2196/resprot.8294, author="Molinari, Michele and Puttarajappa, Chethan and Wijkstrom, Martin and Ganoza, Armando and Lopez, Roberto and Tevar, Amit", title="Robotic Versus Open Renal Transplantation in Obese Patients: Protocol for a Cost-Benefit Markov Model Analysis", journal="JMIR Res Protoc", year="2018", month="Mar", day="08", volume="7", number="3", pages="e74", keywords="renal transplantation", keywords="obesity", keywords="cost benefit analysis", keywords="markov model", abstract="Background: Recent studies have reported a significant decrease in wound problems and hospital stay in obese patients undergoing renal transplantation by robotic-assisted minimally invasive techniques with no difference in graft function. Objective: Due to the lack of cost-benefit studies on the use of robotic-assisted renal transplantation versus open surgical procedure, the primary aim of our study is to develop a Markov model to analyze the cost-benefit of robotic surgery versus open traditional surgery in obese patients in need of a renal transplant. Methods: Electronic searches will be conducted to identify studies comparing open renal transplantation versus robotic-assisted renal transplantation. Costs associated with the two surgical techniques will incorporate the expenses of the resources used for the operations. A decision analysis model will be developed to simulate a randomized controlled trial comparing three interventional arms: (1) continuation of renal replacement therapy for patients who are considered non-suitable candidates for renal transplantation due to obesity, (2) transplant recipients undergoing open transplant surgery, and (3) transplant patients undergoing robotic-assisted renal transplantation. TreeAge Pro 2017 R1 TreeAge Software, Williamstown, MA, USA) will be used to create a Markov model and microsimulation will be used to compare costs and benefits for the two competing surgical interventions. Results: The model will simulate a randomized controlled trial of adult obese patients affected by end-stage renal disease undergoing renal transplantation. The absorbing state of the model will be patients' death from any cause. By choosing death as the absorbing state, we will be able simulate the population of renal transplant recipients from the day of their randomization to transplant surgery or continuation on renal replacement therapy to their death and perform sensitivity analysis around patients' age at the time of randomization to determine if age is a critical variable for cost-benefit analysis or cost-effectiveness analysis comparing renal replacement therapy, robotic-assisted surgery or open renal transplant surgery. After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. Conclusions: After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. ", doi="10.2196/resprot.8294", url="http://www.researchprotocols.org/2018/3/e74/", url="http://www.ncbi.nlm.nih.gov/pubmed/29519780" } @Article{info:doi/10.2196/jmir.8353, author="Ebert, Fynboe Jonas and Huibers, Linda and Christensen, Bo and Christensen, Bondo Morten", title="Paper- or Web-Based Questionnaire Invitations as a Method for Data Collection: Cross-Sectional Comparative Study of Differences in Response Rate, Completeness of Data, and Financial Cost", journal="J Med Internet Res", year="2018", month="Jan", day="23", volume="20", number="1", pages="e24", keywords="questionnaire study", keywords="response rate", keywords="completeness of data", keywords="financial costs", keywords="missing values", keywords="selection bias", keywords="digital post", keywords="digital survey invitation", keywords="Web-based questionnaire", abstract="Background: Paper questionnaires have traditionally been the first choice for data collection in research. However, declining response rates over the past decade have increased the risk of selection bias in cross-sectional studies. The growing use of the Internet offers new ways of collecting data, but trials using Web-based questionnaires have so far seen mixed results. A secure, online digital mailbox (e-Boks) linked to a civil registration number became mandatory for all Danish citizens in 2014 (exemption granted only in extraordinary cases). Approximately 89\% of the Danish population have a digital mailbox, which is used for correspondence with public authorities. Objective: We aimed to compare response rates, completeness of data, and financial costs for different invitation methods: traditional surface mail and digital mail. Methods: We designed a cross-sectional comparative study. An invitation to participate in a survey on help-seeking behavior in out-of-hours care was sent to two groups of randomly selected citizens from age groups 30-39 and 50-59 years and parents to those aged 0-4 years using either traditional surface mail (paper group) or digital mail sent to a secure online mailbox (digital group). Costs per respondent were measured by adding up all costs for handling, dispatch, printing, and work salary and then dividing the total figure by the number of respondents. Data completeness was assessed by comparing the number of missing values between the two methods. Socioeconomic variables (age, gender, family income, education duration, immigrant status, and job status) were compared both between respondents and nonrespondents and within these groups to evaluate the degree of selection bias. Results: A total 3600 citizens were invited in each group; 1303 (36.29\%) responded to the digital invitation and 1653 (45.99\%) to the paper invitation (difference 9.66\%, 95\% CI 7.40-11.92). The costs were {\texteuro}1.51 per respondent for the digital group and {\texteuro}15.67 for paper group respondents. Paper questionnaires generally had more missing values; this was significant in five of 17 variables (P<.05). Substantial differences were found in the socioeconomic variables between respondents and nonrespondents, whereas only minor differences were seen within the groups of respondents and nonrespondents. Conclusions: Although we found lower response rates for Web-based invitations, this solution was more cost-effective (by a factor of 10) and had slightly lower numbers of missing values than questionnaires sent with paper invitations. Analyses of socioeconomic variables showed almost no difference between nonrespondents in both groups, which could imply that the lower response rate in the digital group does not necessarily increase the level of selection bias. Invitations to questionnaire studies via digital mail may be an excellent option for collecting research data in the future. This study may serve as the foundational pillar of digital data collection in health care research in Scandinavia and other countries considering implementing similar systems. ", doi="10.2196/jmir.8353", url="http://www.jmir.org/2018/1/e24/", url="http://www.ncbi.nlm.nih.gov/pubmed/29362206" } @Article{info:doi/10.2196/formative.8202, author="Oremus, Mark and Sharafoddini, Anis and Morgano, Paolo Gian and Jin, Xuejing and Xie, Feng", title="A Computer-Assisted Personal Interview App in Research Electronic Data Capture for Administering Time Trade-off Surveys (REDCap): Development and Pretest", journal="JMIR Formativ Res", year="2018", month="Jan", day="23", volume="2", number="1", pages="e3", keywords="computer-assisted personal interview", keywords="health-related quality-of-life", keywords="REDCap", keywords="time trade-off", abstract="Background: The time trade-off (TTO) task is a method of eliciting health utility scores, which range from 0 (equivalent to death) to 1 (equivalent to perfect health). These scores numerically represent a person's health-related quality of life. Software apps exist to administer the TTO task; however, most of these apps are poorly documented and unavailable to researchers. Objective: To fill the void, we developed an online app to administer the TTO task for a research study that is examining general public proxy health-related quality of life estimates for persons with Alzheimer's disease. This manuscript describes the development and pretest of the app. Methods: We used Research Electronic Data Capture (REDCap) to build the TTO app. The app's modular structure and REDCap's object-oriented environment facilitated development. After the TTO app was built, we recruited a purposive sample of 11 members of the general public to pretest its functionality and ease of use. Results: Feedback from the pretest group was positive. Minor modifications included clarity enhancements, such as rearranging some paragraph text into bullet points, labeling the app to delineate different question sections, and revising or deleting text. We also added a research question to enable the identification of respondents who know someone with Alzheimer's disease. Conclusions: We developed an online app to administer the TTO task. Other researchers may access and customize the app for their own research purposes. ", doi="10.2196/formative.8202", url="http://formative.jmir.org/2018/1/e3/", url="http://www.ncbi.nlm.nih.gov/pubmed/30684429" } @Article{info:doi/10.2196/jmir.9082, author="Wang, Jying-Nan and Chiu, Ya-Ling and Yu, Haiyan and Hsu, Yuan-Teng", title="Understanding a Nonlinear Causal Relationship Between Rewards and Physicians' Contributions in Online Health Care Communities: Longitudinal Study", journal="J Med Internet Res", year="2017", month="Dec", day="21", volume="19", number="12", pages="e427", keywords="online health care community", keywords="physician online contribution", keywords="psychological reward", keywords="material reward", abstract="Background: The online health care community is not just a place for the public to share physician reviews or medical knowledge, but also a physician-patient communication platform. The medical resources of developing countries are relatively inadequate, and the online health care community is a potential solution to alleviate the phenomenon of long hospital queues and the lack of medical resources in rural areas. However, the success of the online health care community depends on online contributions by physicians. Objective: The aim of this study is to examine the effect of incentive mechanisms on physician's online contribution behavior in the online health community. We addressed the following questions: (1) from which specialty area are physicians more likely to participate in online health care community activities, (2) what are the factors affecting physician online contributions, and (3) do incentive mechanisms, including psychological and material rewards, result in differences of physician online contributions? Methods: We designed a longitudinal study involving a data sample in three waves. All data were collected from the Good Doctor website, which is the largest online health care community in China. We first used descriptive statistics to investigate the physician online contribution behavior in its entirety. Then multiple linear and quadratic regression models were applied to verify the causal relationship between rewards and physician online contribution. Results: Our sample included 40,300 physicians from 3607 different hospitals, 10 different major specialty areas, and 31 different provinces or municipalities. Based on the multiple quadratic regression model, we found that the coefficients of the control variables, past physician online contributions, doctor review rating, clinic title, hospital level, and city level, were .415, .189, --.099, --.106, and --.143, respectively. For the psychological (or material) rewards, the standardized coefficient of the main effect was 0.261 (or 0.688) and the standardized coefficient of the quadratic effect was --0.015 (or --0.049). All estimates were statistically significant (P<.001). Conclusions: Physicians with more past physician online contribution, with higher review ratings, coming from lower level clinics, not coming from tertiary hospitals, and not coming from big cities were more willing to participate in online health care community activities. To promote physician online contribution, it is necessary to establish an appropriate incentive mechanism including psychological and material rewards. Finally, our findings suggest two guidelines for designing a useful incentive mechanism to facilitate physician online contribution. First, material reward is more useful than psychological reward. Second, as indicated by the concave-down-increasing causal relationship between rewards and physician online contribution, although an appropriate reward is effective in encouraging willingness on the part of physicians to contribute to the online health care community, the effect of additional rewards is limited. ", doi="10.2196/jmir.9082", url="http://www.jmir.org/2017/12/e427/", url="http://www.ncbi.nlm.nih.gov/pubmed/29269344" } @Article{info:doi/10.2196/mhealth.8288, author="Valenzuela Espinoza, Alexis and Devos, Stefanie and van Hooff, Robbert-Jan and Fobelets, Maaike and Dupont, Alain and Moens, Maarten and Hubloue, Ives and Lauwaert, Door and Cornu, Pieter and Brouns, Raf and Putman, Koen", title="Time Gain Needed for In-Ambulance Telemedicine: Cost-Utility Model", journal="JMIR Mhealth Uhealth", year="2017", month="Nov", day="24", volume="5", number="11", pages="e175", keywords="telemedicine", keywords="prehospital", keywords="stroke", keywords="cost effectiveness", abstract="Background: Stroke is a very time-sensitive pathology, and many new solutions target the optimization of prehospital stroke care to improve the stroke management process. In-ambulance telemedicine, defined by live bidirectional audio-video between a patient and a neurologist in a moving ambulance and the automated transfer of vital parameters, is a promising new approach to speed up and improve the quality of acute stroke care. Currently, no evidence exists on the cost effectiveness of in-ambulance telemedicine. Objective: We aim to develop a first cost effectiveness model for in-ambulance telemedicine and use this model to estimate the time savings needed before in-ambulance telemedicine becomes cost effective. Methods: Current standard stroke care is compared with current standard stroke care supplemented with in-ambulance telemedicine using a cost-utility model measuring costs and quality-adjusted life-years (QALYs) from a health care perspective. We combine a decision tree with a Markov model. Data from the UZ Brussel Stroke Registry (2282 stroke patients) and linked hospital claims data at individual level are combined with literature data to populate the model. A 2-way sensitivity analysis varying both implementation costs and time gain is performed to map the different cost-effective combinations and identify the time gain needed for cost effectiveness and dominance. For several modeled time gains, the cost-effectiveness acceptability curve is calculated and mapped in 1 figure. Results: Under the base-case scenario (implementation cost of US \$159,425) and taking a lifetime horizon into account, in-ambulance telemedicine is a cost-effective strategy compared to standard stroke care alone starting from a time gain of 6 minutes. After 12 minutes, in-ambulance telemedicine becomes dominant, and this results in a mean decrease of costs by US --\$30 (95\% CI --\$32 to --\$29) per patient with 0.00456 (95\% CI 0.00448 to 0.00463) QALYs on average gained per patient. In over 82\% of all probabilistic simulations, in-ambulance telemedicine remains under the cost-effectiveness threshold of US \$47,747. Conclusions: Our model suggests that in-ambulance telemedicine can be cost effective starting from a time gain of 6 minutes and becomes a dominant strategy after approximately 15 minutes. This indicates that in-ambulance telemedicine has the potential to become a cost-effective intervention assuming time gains in clinical implementations are realized in the future. ", doi="10.2196/mhealth.8288", url="http://mhealth.jmir.org/2017/11/e175/", url="http://www.ncbi.nlm.nih.gov/pubmed/29175808" } @Article{info:doi/10.2196/ijmr.7461, author="Kaga, Satoshi and Suzuki, Teppei and Ogasawara, Katsuhiko", title="Willingness to Pay for Elderly Telecare Service Using the Internet and Digital Terrestrial Broadcasting", journal="Interact J Med Res", year="2017", month="Oct", day="24", volume="6", number="2", pages="e21", keywords="health services for the elderly", keywords="health information", keywords="remote consultation", abstract="Background: In Japan over the past few years, more attention has been focused on unnoticed solitary death in the context of an aging society and the trend toward nuclear family. A number of institutions and companies have implemented a prevention measure with digital terrestrial broadcasting telecare services for the elderly: Hokkaido University; TV-Asahi Corporation; Hitachi, Ltd; Iwamizawa City; Hokkaido Television Broadcasting Co, Ltd; and Hamanasu Information Co, Ltd. Although this system is provided free of charge as a demonstration test, determining the appropriate price for the service is required for its sustainable operation. Objective: The aim of this study was to quantify individual willingness to pay (WTP) so as to test the tenability of digital terrestrial broadcasting service for elderly telecare. Methods: We used the contingent valuation method (CVM) to estimate the WTP for this service among 305 citizens (valid response rate 76.0\%) living in Japan. A questionnaire survey was conducted for people aged 18 to 100 years according to Japanese age distribution from September 2016. To elicit WTP, we adopted a double-bound dichotomous choice method to ask the respondents whether they agree or disagree with the price we offered. Results: The median WTP for this service's monthly fee is estimated to be 431 JPY (approximately US \$3.7). The finding suggests that gender (0.66, P=.01), health consciousness (1.08, P=.01), willingness to use (2.38, P<.001), and seeing others less than once a week (1.00, P=.06) made a positive effect on WTP. Conclusions: We conclude that reliable WTP was elicited by CVM based on an Internet survey. Calculated median WTP for digital terrestrial broadcasting service for elderly telecare was 431 JPY (approximately US \$3.7). In the analysis of factors that affect WTP, constant factors, log-bid, health consciousness, gender, see others less than one time for week, and willingness to use made positive effect to probability of acceptance. In comparison of WTP in different groups, age groups showed that WTP of the elderly group was higher than WTP of the middle age group and younger age group. However, WTP surveys need to be carefully conducted to minimize the sampling bias and allocate accurate structure of gender distribution. ", doi="10.2196/ijmr.7461", url="http://www.i-jmr.org/2017/2/e21/", url="http://www.ncbi.nlm.nih.gov/pubmed/29066428" } @Article{info:doi/10.2196/medinform.7308, author="Celler, Branko and Varnfield, Marlien and Nepal, Surya and Sparks, Ross and Li, Jane and Jayasena, Rajiv", title="Impact of At-Home Telemonitoring on Health Services Expenditure and Hospital Admissions in Patients With Chronic Conditions: Before and After Control Intervention Analysis", journal="JMIR Med Inform", year="2017", month="Sep", day="08", volume="5", number="3", pages="e29", keywords="telehealth", keywords="telemonitoring", keywords="chronic disease management", keywords="healthcare outcomes", keywords="BACI analysis", abstract="Background: Telemonitoring is becoming increasingly important for the management of patients with chronic conditions, especially in countries with large distances such as Australia. However, despite large national investments in health information technology, little policy work has been undertaken in Australia in deploying telehealth in the home as a solution to the increasing demands and costs of managing chronic disease. Objective: The objective of this trial was to evaluate the impact of introducing at-home telemonitoring to patients living with chronic conditions on health care expenditure, number of admissions to hospital, and length of stay (LOS). Methods: A before and after control intervention analysis model was adopted whereby at each location patients were selected from a list of eligible patients living with a range of chronic conditions. Each test patient was case matched with at least one control patient. Test patients were supplied with a telehealth vital signs monitor and were remotely managed by a trained clinical care coordinator, while control patients continued to receive usual care. A total of 100 test patients and 137 control patients were analyzed. Primary health care benefits provided to Australian patients were investigated for the trial cohort. Time series data were analyzed using linear regression and analysis of covariance for a period of 3 years before the intervention and 1 year after. Results: There were no significant differences between test and control patients at baseline. Test patients were monitored for an average of 276 days with 75\% of patients monitored for more than 6 months. Test patients 1 year after the start of their intervention showed a 46.3\% reduction in rate of predicted medical expenditure, a 25.5\% reduction in the rate of predicted pharmaceutical expenditure, a 53.2\% reduction in the rate of predicted unscheduled admission to hospital, a 67.9\% reduction in the predicted rate of LOS when admitted to hospital, and a reduction in mortality of between 41.3\% and 44.5\% relative to control patients. Control patients did not demonstrate any significant change in their predicted trajectory for any of the above variables. Conclusions: At-home telemonitoring of chronically ill patients showed a statistically robust positive impact increasing over time on health care expenditure, number of admissions to hospital, and LOS as well as a reduction in mortality. Trial Registration: Retrospectively registered with the Australian and New Zealand Clinical Trial Registry ACTRN12613000635763; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364030 (Archived by WebCite at http://www.webcitation.org/6sxqjkJHW) ", doi="10.2196/medinform.7308", url="http://medinform.jmir.org/2017/3/e29/", url="http://www.ncbi.nlm.nih.gov/pubmed/28887294" } @Article{info:doi/10.2196/jmir.7383, author="Sj{\"o}str{\"o}m, Malin and Lindholm, Lars and Samuelsson, Eva", title="Mobile App for Treatment of Stress Urinary Incontinence: A Cost-Effectiveness Analysis", journal="J Med Internet Res", year="2017", month="May", day="08", volume="19", number="5", pages="e154", keywords="mobile application", keywords="pelvic floor", keywords="urinary incontinence, stress", keywords="self care", keywords="cost-benefit analysis", abstract="Background: Mobile apps can increase access to care, facilitate self-management, and improve adherence to treatment. Stress urinary incontinence (SUI) affects 10-35\% of women and, currently, an app with instructions for pelvic floor muscle training (PFMT) is available as first-line treatment. A previous randomized controlled study demonstrated that the app benefitted symptom severity and quality of life (QoL); in this study we investigate the cost-effectiveness of the app. Objective: The objective of this study was to evaluate the health economy of the app for treating SUI. Methods: This deterministic cost-utility analysis, with a 1-year societal perspective, compared the app treatment with no treatment. Health economic data were collected alongside a randomized controlled trial performed in Sweden from March 2013 to October 2014. This study included 123 community-dwelling women participants of 18 years and above, with stress urinary incontinence ?1 time per week. Participants were self-assessed with validated questionnaires and 2-day leakage diaries, and then randomized to 3 months of treatment (app group, n=62) or no treatment (controls, n=61). The app focused on pelvic floor muscle training, prescribed 3 times daily. We continuously registered treatment delivery costs. Data were collected on each participant's training time, incontinence aids, and laundry at baseline and at a 3-month follow-up. We measured quality of life with the International Consultation on Incontinence Modular Questionnaire on Lower Urinary Tract Symptoms and Quality of Life, and calculated the quality-adjusted life years (QALYs) gained. Data from the 3-month follow-up were extrapolated to 1 year for the calculations. Our main outcome was the incremental cost-effectiveness ratios compared between app and control groups. One-way and multiway sensitivity analyses were performed. Results: The mean age of participants was 44.7 years (SD 9.4). Annual costs were {\texteuro}547.0 for the app group and {\texteuro}482.4 for the control group. Annual gains in quality-adjusted life years for app and control groups were 0.0101 and 0.0016, respectively. Compared with controls, the extra cost per quality-adjusted life year for the app group ranged from ?{\texteuro}2425.7 to {\texteuro}14,870.6, which indicated greater gains in quality-adjusted life years at similar or slightly higher cost. Conclusions: The app for treating stress urinary incontinence is a new, cost-effective, first-line treatment with potential for increasing access to care in a sustainable way for this patient group. ", doi="10.2196/jmir.7383", url="http://www.jmir.org/2017/5/e154/", url="http://www.ncbi.nlm.nih.gov/pubmed/28483745" } @Article{info:doi/10.2196/mededu.6357, author="Maloney, Stephen and Tunnecliff, Jacqueline and Morgan, Prue and Gaida, James and Keating, Jennifer and Clearihan, Lyn and Sadasivan, Sivalal and Ganesh, Shankar and Mohanty, Patitapaban and Weiner, John and Rivers, George and Ilic, Dragan", title="Continuing Professional Development via Social Media or Conference Attendance: A Cost Analysis", journal="JMIR Med Educ", year="2017", month="Mar", day="30", volume="3", number="1", pages="e5", keywords="social media", keywords="knowledge translation", keywords="continuing medical education", abstract="Background: Professional development is essential in the health disciplines. Knowing the cost and value of educational approaches informs decisions and choices about learning and teaching practices. Objective: The primary aim of this study was to conduct a cost analysis of participation in continuing professional development via social media compared with live conference attendance. Methods: Clinicians interested in musculoskeletal care were invited to participate in the study activities. Quantitative data were obtained from an anonymous electronic questionnaire. Results: Of the 272 individuals invited to contribute data to this study, 150 clinicians predominantly from Australia, United States, United Kingdom, India, and Malaysia completed the outcome measures. Half of the respondents (78/150, 52.0\%) believed that they would learn more with the live conference format. The median perceived participation costs for the live conference format was Aus \$1596 (interquartile range, IQR 172.50-2852.00). The perceived cost of participation for equivalent content delivered via social media was Aus \$15 (IQR 0.00-58.50). The majority of the clinicians (114/146, 78.1\%, missing data n=4) indicated that they would pay for a subscription-based service, delivered by social media, to the median value of Aus \$59.50. Conclusions: Social media platforms are evolving into an acceptable and financially sustainable medium for the continued professional development of health professionals. When factoring in the reduced costs of participation and the reduced loss of employable hours from the perspective of the health service, professional development via social media has unique strengths that challenge the traditional live conference delivery format. ", doi="10.2196/mededu.6357", url="http://mededu.jmir.org/2017/1/e5/", url="http://www.ncbi.nlm.nih.gov/pubmed/28360023" } @Article{info:doi/10.2196/jmir.6716, author="Christensen, Tina and Riis, H. Anders and Hatch, E. Elizabeth and Wise, A. Lauren and Nielsen, G. Marie and Rothman, J. Kenneth and S{\o}rensen, Toft Henrik and Mikkelsen, M. Ellen", title="Costs and Efficiency of Online and Offline Recruitment Methods: A Web-Based Cohort Study", journal="J Med Internet Res", year="2017", month="Mar", day="01", volume="19", number="3", pages="e58", keywords="participant recruitment", keywords="Web-based study", keywords="costs per participant", keywords="Internet", keywords="advertising", abstract="Background: The Internet is widely used to conduct research studies on health issues. Many different methods are used to recruit participants for such studies, but little is known about how various recruitment methods compare in terms of efficiency and costs. Objective: The aim of our study was to compare online and offline recruitment methods for Internet-based studies in terms of efficiency (number of recruited participants) and costs per participant. Methods: We employed several online and offline recruitment methods to enroll 18- to 45-year-old women in an Internet-based Danish prospective cohort study on fertility. Offline methods included press releases, posters, and flyers. Online methods comprised advertisements placed on five different websites, including Facebook and Netdoktor.dk. We defined seven categories of mutually exclusive recruitment methods and used electronic tracking via unique Uniform Resource Locator (URL) and self-reported data to identify the recruitment method for each participant. For each method, we calculated the average cost per participant and efficiency, that is, the total number of recruited participants. Results: We recruited 8252 study participants. Of these, 534 were excluded as they could not be assigned to a specific recruitment method. The final study population included 7724 participants, of whom 803 (10.4\%) were recruited by offline methods, 3985 (51.6\%) by online methods, 2382 (30.8\%) by online methods not initiated by us, and 554 (7.2\%) by other methods. Overall, the average cost per participant was {\texteuro}6.22 for online methods initiated by us versus {\texteuro}9.06 for offline methods. Costs per participant ranged from {\texteuro}2.74 to {\texteuro}105.53 for online methods and from {\texteuro}0 to {\texteuro}67.50 for offline methods. Lowest average costs per participant were for those recruited from Netdoktor.dk ({\texteuro}2.99) and from Facebook ({\texteuro}3.44). Conclusions: In our Internet-based cohort study, online recruitment methods were superior to offline methods in terms of efficiency (total number of participants enrolled). The average cost per recruited participant was also lower for online than for offline methods, although costs varied greatly among both online and offline recruitment methods. We observed a decrease in the efficiency of some online recruitment methods over time, suggesting that it may be optimal to adopt multiple online methods. ", doi="10.2196/jmir.6716", url="http://www.jmir.org/2017/3/e58/", url="http://www.ncbi.nlm.nih.gov/pubmed/28249833" } @Article{info:doi/10.2196/jmir.6257, author="Larsen, Britta and Marcus, Bess and Pekmezi, Dori and Hartman, Sheri and Gilmer, Todd", title="A Web-Based Physical Activity Intervention for Spanish-Speaking Latinas: A Costs and Cost-Effectiveness Analysis", journal="J Med Internet Res", year="2017", month="Feb", day="22", volume="19", number="2", pages="e43", keywords="cost-effectiveness", keywords="physical activity", keywords="Latinos", keywords="Latinas", keywords="Web-based interventions", keywords="health disparities", abstract="Background: Latinas report particularly low levels of physical activity and suffer from greater rates of lifestyle-related conditions such as obesity and diabetes. Interventions are needed that can increase physical activity in this growing population in a large-scale, cost-effective manner. Web-based interventions may have potential given the increase in Internet use among Latinas and the scalability of Web-based programs. Objective: To examine the costs and cost-effectiveness of a Web-based, Spanish-language physical activity intervention for Latinas compared to a wellness contact control. Methods: Healthy adult Latina women (N=205) were recruited from the community and randomly assigned to receive a Spanish-language, Web-based, individually tailored physical activity intervention (intervention group) or were given access to a website with content on wellness topics other than physical activity (control group). Physical activity was measured using the 7-Day Physical Activity Recall interview and ActiGraph accelerometers at baseline, 6 months (ie, postintervention), and 12 months (ie, maintenance phase). Costs were estimated from a payer perspective and included all features necessary to implement the intervention in a community setting, including staff time (ie, wages, benefits, and overhead), materials, hardware, website hosting, and routine website maintenance. Results: At 6 months, the costs of running the intervention and control groups were US \$17 and US \$8 per person per month, respectively. These costs fell to US \$12 and US \$6 per person per month at 12 months, respectively. Linear interpolation showed that intervention participants increased their physical activity by 1362 total minutes at 6 months (523 minutes by accelerometer) compared to 715 minutes for control participants (186 minutes by accelerometer). At 6 months, each minute increase in physical activity for the intervention group cost US \$0.08 (US \$0.20 by accelerometer) compared to US \$0.07 for control participants (US \$0.26 by accelerometer). Incremental cost-per-minute increases associated with the intervention were US \$0.08 at 6 months and US \$0.04 at 12 months (US \$0.16 and US \$0.08 by accelerometer, respectively). Sensitivity analyses showed variations in staffing costs or intervention effectiveness yielded only modest changes in incremental costs. Conclusions: While the Web-based physical activity intervention was more expensive than the wellness control, both were quite low cost compared to face-to-face or mail-delivered interventions. Cost-effectiveness ranged markedly based on physical activity measure and was similar between the two conditions. Overall, the Web-based intervention was effective and low cost, suggesting a promising channel for increasing physical activity on a large scale in this at-risk population. ClinicalTrial: Clinicaltrials.gov NCT01834287; https://clinicaltrials.gov/ct2/show/NCT01834287 (Archived by WebCite at http://www.webcitation.org/6nyjX9Jrh) ", doi="10.2196/jmir.6257", url="http://www.jmir.org/2017/2/e43/", url="http://www.ncbi.nlm.nih.gov/pubmed/28228368" } @Article{info:doi/10.2196/jmir.6587, author="Buntrock, Claudia and Berking, Matthias and Smit, Filip and Lehr, Dirk and Nobis, Stephanie and Riper, Heleen and Cuijpers, Pim and Ebert, David", title="Preventing Depression in Adults With Subthreshold Depression: Health-Economic Evaluation Alongside a Pragmatic Randomized Controlled Trial of a Web-Based Intervention", journal="J Med Internet Res", year="2017", month="Jan", day="04", volume="19", number="1", pages="e5", keywords="prevention", keywords="major depressive disorders", keywords="Internet", keywords="early intervention", keywords="cost effectiveness", abstract="Background: Psychological interventions for the prevention of depression might be a cost-effective way to reduce the burden associated with depressive disorders. Objective: To evaluate the cost-effectiveness of a Web-based guided self-help intervention to prevent major depressive disorder (MDD) in people with subthreshold depression (sD). Methods: A pragmatic randomized controlled trial was conducted with follow-up at 12 months. Participants were recruited from the general population via a large statutory health insurance company and an open access website. Participants were randomized to a Web-based guided self-help intervention (ie, cognitive-behavioral therapy and problem-solving therapy assisted by supervised graduate students or health care professionals) in addition to usual care or to usual care supplemented with Web-based psycho-education (enhanced usual care). Depression-free years (DFYs) were assessed by blinded diagnostic raters using the telephone-administered Structured Clinical Interview for DSM-IV Axis Disorders at 6- and 12-month follow-up, covering the period to the previous assessment. Costs were self-assessed through a questionnaire. Costs measured from a societal and health care perspective were related to DFYs and quality-adjusted life years (QALYs). Results: In total, 406 participants were enrolled in the trial. The mean treatment duration was 5.84 (SD 4.37) weeks. On average, participants completed 4.93 of 6 sessions. Significantly more DFYs were gained in the intervention group (0.82 vs 0.70). Likewise, QALY health gains were in favor of the intervention, but only statistically significant when measured with the more sensitive SF-6D. The incremental per-participant costs were {\texteuro}136 ({\textsterling}116). Taking the health care perspective and assuming a willingness-to-pay of {\texteuro}20,000 ({\textsterling}17,000), the intervention's likelihood of being cost-effective was 99\% for gaining a DFY and 64\% or 99\% for gaining an EQ-5D or a SF-6D QALY. Conclusions: Our study supports guidelines recommending Web-based treatment for sD and adds that this not only restores health in people with sD, but additionally reduces the risk of developing a MDD. Offering the intervention has an acceptable likelihood of being more cost-effective than enhanced usual care and could therefore reach community members on a wider scale. Trial registration: German Clinical Trials Register: DRKS00004709; http://www.drks.de/DRKS00004709 (Archived by WebCite at http://www.webcitation.org/6kAZVUxy9) ", doi="10.2196/jmir.6587", url="http://www.jmir.org/2017/1/e5/", url="http://www.ncbi.nlm.nih.gov/pubmed/28052841" } @Article{info:doi/10.2196/medinform.5012, author="Vannieuwenborg, Frederic and Van der Auwermeulen, Thomas and Van Ooteghem, Jan and Jacobs, An and Verbrugge, Sofie and Colle, Didier", title="Evaluating the Economic Impact of Smart Care Platforms: Qualitative and Quantitative Results of a Case Study", journal="JMIR Med Inform", year="2016", month="Oct", day="31", volume="4", number="4", pages="e33", keywords="medical informatics applications", keywords="home care services", keywords="ambulatory care information systems", keywords="evaluation studies as topic", keywords="cost-benefit analysis", abstract="Background: In response to the increasing pressure of the societal challenge because of a graying society, a gulf of new Information and Communication Technology (ICT) supported care services (eCare) can now be noticed. Their common goal is to increase the quality of care while decreasing its costs. Smart Care Platforms (SCPs), installed in the homes of care-dependent people, foster the interoperability of these services and offer a set of eCare services that are complementary on one platform. These eCare services could not only result in more quality care for care receivers, but they also offer opportunities to care providers to optimize their processes. Objective: The objective of the study was to identify and describe the expected added values and impacts of integrating SCPs in current home care delivery processes for all actors. In addition, the potential economic impact of SCP deployment is quantified from the perspective of home care organizations. Methods: Semistructured and informal interviews and focus groups and cocreation workshops with service providers, managers of home care organizations, and formal and informal care providers led to the identification of added values of SCP integration. In a second step, process breakdown analyses of home care provisioning allowed defining the operational impact for home care organization. Impacts on 2 different process steps of providing home care were quantified. After modeling the investment, an economic evaluation compared the business as usual (BAU) scenario versus the integrated SCP scenario. Results: The added value of SCP integration for all actors involved in home care was identified. Most impacts were qualitative such as increase in peace of mind, better quality of care, strengthened involvement in care provisioning, and more transparent care communication. For home care organizations, integrating SCPs could lead to a decrease of 38\% of the current annual expenses for two administrative process steps namely, care rescheduling and the billing for care provisioning. Conclusions: Although integrating SCP in home care processes could affect both the quality of life of the care receiver and informal care giver, only scarce and weak evidence was found that supports this assumption. In contrast, there exists evidence that indicates the lack of the impact on quality of life of the care receiver while it increases the cost of care provisioning. However, our cost-benefit quantification model shows that integrating SCPs in home care provisioning could lead to a considerable decrease of costs for care administrative tasks. Because of this cost decreasing impact, we believe that the integration of SCPs will be driven by home care organizations instead of the care receivers themselves. ", doi="10.2196/medinform.5012", url="http://medinform.jmir.org/2016/4/e33/", url="http://www.ncbi.nlm.nih.gov/pubmed/27799137" } @Article{info:doi/10.2196/jmir.6423, author="Li, Jia and Zhang, Ya and Ma, Ling and Liu, Xuan", title="The Impact of the Internet on Health Consultation Market Concentration: An Econometric Analysis of Secondary Data", journal="J Med Internet Res", year="2016", month="Oct", day="28", volume="18", number="10", pages="e276", keywords="long tail effect", keywords="superstar effect", keywords="E-consultation", keywords="market concentration", keywords="information asymmetry", keywords="signaling theory", keywords="online reputation", keywords="self-representation", abstract="Background: Many markets have traditionally been dominated by a few best-selling products, and this is also the case for the health care industry. However, we do not know whether the market will be more or less concentrated when health care services are delivered online (known as E-consultation), nor do we know how to reduce the concentration of the E-consultation market. Objective: The aim of this study was to investigate the concentration of the E-consultation market and how to reduce its concentration through information disclosure mechanisms (online reputation and self-representation). Methods: We employed a secondary data econometric analysis using transaction data obtained from an E-consultation Website (haodf.com) for three diseases (infantile pneumonia, diabetes, and pancreatic cancer) from 2008 to 2015. We included 2439 doctors in the analysis. Results: The E-consultation market largely follows the 20/80 principle, namely that approximately 80\% of orders are fulfilled by nearly 20\% of doctors. This is much higher than the offline health care market. Meanwhile, the market served by doctors with strong online reputations (beta=0.207, P<.001) or strong online self-representation (beta=0.386, P<.001) is less concentrated. Conclusions: When health care services are delivered online, the market will be more concentrated (known as the ``Superstar'' effect), indicating poor service efficiency for society as a whole. To reduce market concentration, E-consultation websites should provide important design elements such as ratings of doctors (user feedback), articles contributed by doctors, and free consultation services (online representation). A possible and important way to reduce the market concentration of the E-consultation market is to accumulate enough highly rated or highly self-represented doctors. ", doi="10.2196/jmir.6423", url="http://www.jmir.org/2016/10/e276/", url="http://www.ncbi.nlm.nih.gov/pubmed/27793793" } @Article{info:doi/10.2196/mhealth.6425, author="Badawy, M. Sherif and Kuhns, M. Lisa", title="Economic Evaluation of Text-Messaging and Smartphone-Based Interventions to Improve Medication Adherence in Adolescents with Chronic Health Conditions: A Systematic Review", journal="JMIR Mhealth Uhealth", year="2016", month="Oct", day="25", volume="4", number="4", pages="e121", keywords="adolescent", keywords="text messaging", keywords="smartphone", keywords="medication adherence", keywords="chronic disease", keywords="cost-benefit analysis", abstract="Background: The rate of chronic health conditions (CHCs) in children and adolescents has doubled in the past 20 years, with increased health care costs. Technology-based interventions have demonstrated efficacy to improving medication adherence. However, data to support the cost effectiveness of these interventions are lacking. Objective: The objective of this study is to conduct an economic evaluation of text-messaging and smartphone-based interventions that focus on improving medication adherence in adolescents with CHCs. Methods: Searches included PubMed MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science, and Inspec. Eligibility criteria included age (12-24 years old), original articles, outcomes for medication adherence, and economic outcomes. Results: Our search identified 1118 unique articles that were independently screened. A total of 156 articles met inclusion criteria and were then examined independently with full-text review. A total of 15 articles met most criteria but lacked economic outcomes such as cost effectiveness or cost-utility data. No articles met all predefined criteria to be included for final review. Only 4 articles (text messaging [n=3], electronic directly observed therapy [n=1]) described interventions with possible future cost-saving but no formal economic evaluation. Conclusions: The evidence to support the cost effectiveness of text-messaging and smartphone-based interventions in improving medication adherence in adolescents with CHCs is insufficient. This lack of research highlights the need for comprehensive economic evaluation of such interventions to better understand their role in cost-savings while improving medication adherence and health outcomes. Economic evaluation of technology-based interventions can contribute to more evidence-based assessment of the scalability, sustainability, and benefits of broader investment of such technology tools in adolescents with CHCs. ", doi="10.2196/mhealth.6425", url="http://mhealth.jmir.org/2016/4/e121/", url="http://www.ncbi.nlm.nih.gov/pubmed/27780795" } @Article{info:doi/10.2196/jmir.5221, author="M{\"u}ller, Ivar Kai and Alstadhaug, Bj{\o}rnar Karl and Bekkelund, Ivar Svein", title="Acceptability, Feasibility, and Cost of Telemedicine for Nonacute Headaches: A Randomized Study Comparing Video and Traditional Consultations", journal="J Med Internet Res", year="2016", month="May", day="30", volume="18", number="5", pages="e140", keywords="headache", keywords="management", keywords="consultation", keywords="telemedicine", keywords="burden", keywords="cost", keywords="feasibility", keywords="rural", keywords="randomization", abstract="Background: The feasibility of telemedicine in diagnosing and treating nonacute headaches, such as primary headaches (migraine and tension-type) and medication-overuse headaches has not been previously investigated. By eliminating the need of travel to specialists, telemedicine may offer significant time and money savings. Objectives: Our objective was to estimate the acceptance of telemedicine and investigate the feasibility and cost savings of telemedicine consultations in diagnosing and treating nonacute headaches. Methods: From September 2012 to March 2015, nonacute headache patients from Northern Norway who were referred to neurologists through an electronic application system were consecutively screened and randomized to participate in either telemedicine or traditional specialist visits. All patients were consulted by two neurologists at the neurological department in Troms{\o} University Hospital. Feasibility outcomes were compared between telemedicine and traditional groups. Baseline characteristics and costs were then compared between rural and urban patients. Travel costs were calculated by using the probabilistic method of the Norwegian traveling agency: the cheapest means of public transport for each study participant. Loss of pay was calculated based on the Norwegian full-time employee's average salary: < 3.5 hours=a half day's salary, > 3.5 hours spent on travel and consultation=one day's salary. Distance and time spent on travel were estimated by using Google Maps. Results: Of 557 headache patients screened, 479 were found eligible and 402 accepted telemedicine participation (83.9\%, 402/479) and were included in the final analyses. Of these, 202 received traditional specialist consultations and 200 received telemedicine. All patients in the telemedicine group were satisfied with the video quality, and 198 (99\%, 198/200) were satisfied with the sound quality. The baseline characteristics as well as headache diagnostics and follow-up appointments, and the investigation, advice, and prescription practices were not statistically different between the two randomized groups. In addition, telemedicine consultations were shorter than traditional visits (38.8 vs 43.7 min, P<.001). The travel cost per rural individual (292/402, 73\%) was {\texteuro}249, and estimated lost income was {\texteuro}234 per visit. The travel cost in the urban area (110/402, 27\%) was {\texteuro}6, and estimated lost income was {\texteuro}117 per visit. The median traveling distance for rural patients was 526 km (range 1892 km), and the median traveling time was 7.8 hours (range 27.3 hours). Rural patients had a longer waiting time than urban patients (64 vs 47 days, P=.001), and fewer women were referred from rural areas (P=.04). Rural women reported higher pain scores than urban women (P=.005). Conclusion: Our study shows that telemedicine is an accepted, feasible, time-saving, and cost-saving alternative to traditional specialist consultations for nonacute headaches. Trial Registration: Clinicaltrials.gov NCT02270177; http://clinicaltrials.gov/ct2/show/NCT02270177 (Archived by WebCite at http://www.webcitation.org/6hmoHGo9Q) ", doi="10.2196/jmir.5221", url="http://www.jmir.org/2016/5/e140/", url="http://www.ncbi.nlm.nih.gov/pubmed/27241876" } @Article{info:doi/10.2196/jmir.5223, author="Drost, MWA Ruben and Paulus, TG Aggie and Jander, F. Astrid and Mercken, Liesbeth and de Vries, Hein and Ruwaard, Dirk and Evers, MAA Silvia", title="A Web-Based Computer-Tailored Alcohol Prevention Program for Adolescents: Cost-Effectiveness and Intersectoral Costs and Benefits", journal="J Med Internet Res", year="2016", month="Apr", day="21", volume="18", number="4", pages="e93", keywords="adolescents", keywords="alcohol use", keywords="cluster randomized controlled trial", keywords="game", keywords="computer tailoring", keywords="education", keywords="criminal justice", keywords="costs and cost analysis", keywords="economic evaluation", keywords="intersectoral costs and benefits", abstract="Background: Preventing excessive alcohol use among adolescents is important not only to foster individual and public health, but also to reduce alcohol-related costs inside and outside the health care sector. Computer tailoring can be both effective and cost-effective for working with many lifestyle behaviors, yet the available information on the cost-effectiveness of computer tailoring for reducing alcohol use by adolescents is limited as is information on the costs and benefits pertaining to sectors outside the health care sector, also known as intersectoral costs and benefits (ICBs). Objective: The aim was to assess the cost-effectiveness of a Web-based computer-tailored intervention for reducing alcohol use and binge drinking by adolescents from a health care perspective (excluding ICBs) and from a societal perspective (including ICBs). Methods: Data used were from the Alcoholic Alert study, a cluster randomized controlled trial with randomization at the level of schools into two conditions. Participants either played a game with tailored feedback on alcohol awareness after the baseline assessment (intervention condition) or received care as usual (CAU), meaning that they had the opportunity to play the game subsequent to the final measurement (waiting list control condition). Data were recorded at baseline (T0=January/February 2014) and after 4 months (T1=May/June 2014) and were used to calculate incremental cost-effectiveness ratios (ICERs), both from a health care perspective and a societal perspective. Stochastic uncertainty in the data was dealt with by using nonparametric bootstraps (5000 simulated replications). Additional sensitivity analyses were conducted based on excluding cost outliers. Subgroup cost-effectiveness analyses were conducted based on several background variables, including gender, age, educational level, religion, and ethnicity. Results: From both the health care perspective and the societal perspective for both outcome measures, the intervention was more costly and more effective in comparison with CAU. ICERs differed for both perspectives, namely {\texteuro}40 and {\texteuro}79 from the health care perspective to {\texteuro}62 and {\texteuro}144 for the societal perspective per incremental reduction of one glass of alcohol per week and one binge drinking occasion per 30 days, respectively. Subgroup analyses showed, from both perspectives and for both outcome measures, that the intervention was cost-effective for older adolescents (aged 17-19 years) and those at a lower educational level and, from a health care perspective, the male and nonreligious adolescent subgroups. Conclusions: Computer-tailored feedback could be a cost-effective way to target alcohol use and binge drinking among adolescents. Including ICBs in the economic evaluation had an impact on the cost-effectiveness results of the analysis. It could be worthwhile to aim the intervention specifically at specific subgroups. Trial Registration: Nederlands Trial Register: NTR4048; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4048 (Archived by Webcite at http://www.webcitation.org/6c7omN8wG) ", doi="10.2196/jmir.5223", url="http://www.jmir.org/2016/4/e93/", url="http://www.ncbi.nlm.nih.gov/pubmed/27103154" } @Article{info:doi/10.2196/jmir.5244, author="Roettl, Johanna and Bidmon, Sonja and Terlutter, Ralf", title="What Predicts Patients' Willingness to Undergo Online Treatment and Pay for Online Treatment? Results from a Web-Based Survey to Investigate the Changing Patient-Physician Relationship", journal="J Med Internet Res", year="2016", month="Feb", day="04", volume="18", number="2", pages="e32", keywords="physician-patient relationship, online treatment", keywords="general practitioners", keywords="willingness to pay", abstract="Background: Substantial research has focused on patients' health information--seeking behavior on the Internet, but little is known about the variables that may predict patients' willingness to undergo online treatment and willingness to pay additionally for online treatment. Objective: This study analyzed sociodemographic variables, psychosocial variables, and variables of Internet usage to predict willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the general practitioner (GP). Methods: An online survey of 1006 randomly selected German patients was conducted. The sample was drawn from an e-panel maintained by GfK HealthCare. Missing values were imputed; 958 usable questionnaires were analyzed. Variables with multi-item measurement were factor analyzed. Willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the GP were predicted using 2 multiple regression models. Results: Exploratory factor analyses revealed that the disposition of patients' personality to engage in information-searching behavior on the Internet was unidimensional. Exploratory factor analysis with the variables measuring the motives for Internet usage led to 2 separate factors: perceived usefulness (PU) of the Internet for health-related information searching and social motives for information searching on the Internet. Sociodemographic variables did not serve as significant predictors for willingness to undergo online treatment offered by the GP, whereas PU (B=.092, P=.08), willingness to communicate with the GP more often in the future (B=.495, P<.001), health-related information--seeking personality (B=.369, P<.001), actual use of online communication with the GP (B=.198, P<.001), and social motive (B=.178, P=.002) were significant predictors. Age, gender, satisfaction with the GP, social motive, and trust in the GP had no significant impact on the willingness to pay additionally for online treatment, but it was predicted by health-related information--seeking personality (B=.127, P=.07), PU (B=--.098, P=.09), willingness to undergo online treatment (B=.391, P<.001), actual use of online communication with the GP (B=.192, P=.001), highest education level (B=.178, P<.001), monthly household net income (B=.115, P=.01), and willingness to communicate with the GP online more often in the future (B=.076, P=.03). Conclusions: Age, gender, and trust in the GP were not significant predictors for either willingness to undergo online treatment or to pay additionally for online treatment. Willingness to undergo online treatment was partly determined by the actual use of online communication with the GP, willingness to communicate online with the GP, health information--seeking personality, and social motivation for such behavior. Willingness to pay extra for online treatment was influenced by the monthly household net income category and education level. The results of this study are useful for online health care providers and physicians who are considering offering online treatments as a viable number of patients would appreciate the possibility of undergoing an online treatment offered by their GP. ", doi="10.2196/jmir.5244", url="http://www.jmir.org/2016/2/e32/", url="http://www.ncbi.nlm.nih.gov/pubmed/26846162" } @Article{info:doi/10.2196/jmir.4207, author="Solomon, Daniela and Proudfoot, Judith and Clarke, Janine and Christensen, Helen", title="e-CBT (myCompass), Antidepressant Medication, and Face-to-Face Psychological Treatment for Depression in Australia: A Cost-Effectiveness Comparison", journal="J Med Internet Res", year="2015", month="Nov", day="11", volume="17", number="11", pages="e255", keywords="cost-utility analysis", keywords="depression", keywords="self-help", keywords="computer-assisted therapy", abstract="Background: The economic cost of depression is becoming an ever more important determinant for health policy and decision makers. Internet-based interventions with and without therapist support have been found to be effective options for the treatment of mild to moderate depression. With increasing demands on health resources and shortages of mental health care professionals, the integration of cost-effective treatment options such as Internet-based programs into primary health care could increase efficiency in terms of resource use and costs. Objective: Our aim was to evaluate the cost-effectiveness of an Internet-based intervention (myCompass) for the treatment of mild-to-moderate depression compared to treatment as usual and cognitive behavior therapy in a stepped care model. Methods: A decision model was constructed using a cost utility framework to show both costs and health outcomes. In accordance with current treatment guidelines, a stepped care model included myCompass as the first low-intervention step in care for a proportion of the model cohort, with participants beginning from a low-intensity intervention to increasing levels of treatment. Model parameters were based on data from the recent randomized controlled trial of myCompass, which showed that the intervention reduced symptoms of depression, anxiety, and stress and improved work and social functioning for people with symptoms in the mild-to-moderate range. Results: The average net monetary benefit (NMB) was calculated, identifying myCompass as the strategy with the highest net benefit. The mean incremental NMB per individual for the myCompass group was AUD 1165.88 compared to treatment as usual and AUD 522.58 for the cognitive behavioral therapy model. Conclusions: Internet-based interventions can provide cost-effective access to treatment when provided as part of a stepped care model. Widespread dissemination of Internet-based programs can potentially reduce demands on primary and tertiary services and reduce unmet need. ", doi="10.2196/jmir.4207", url="http://www.jmir.org/2015/11/e255/", url="http://www.ncbi.nlm.nih.gov/pubmed/26561555" } @Article{info:doi/10.2196/jmir.4521, author="Bergmo, Strand Trine", title="How to Measure Costs and Benefits of eHealth Interventions: An Overview of Methods and Frameworks", journal="J Med Internet Res", year="2015", month="Nov", day="09", volume="17", number="11", pages="e254", keywords="eHealth", keywords="telemedicine", keywords="telehealth", keywords="telemonitoring", keywords="health economics", keywords="economic evaluation", keywords="cost-benefit analysis", keywords="cost-effectiveness analysis", keywords="cost-utility analysis", keywords="quality-adjusted life years (QALYs)", doi="10.2196/jmir.4521", url="http://www.jmir.org/2015/11/e254/", url="http://www.ncbi.nlm.nih.gov/pubmed/26552360" } @Article{info:doi/10.2196/jmir.4346, author="Maloney, Stephen and Nicklen, Peter and Rivers, George and Foo, Jonathan and Ooi, Ying Ying and Reeves, Scott and Walsh, Kieran and Ilic, Dragan", title="A Cost-Effectiveness Analysis of Blended Versus Face-to-Face Delivery of Evidence-Based Medicine to Medical Students", journal="J Med Internet Res", year="2015", month="Jul", day="21", volume="17", number="7", pages="e182", keywords="evidence-based medicine", keywords="economic evaluation", keywords="eLearning", keywords="medical education", abstract="Background: Blended learning describes a combination of teaching methods, often utilizing digital technologies. Research suggests that learner outcomes can be improved through some blended learning formats. However, the cost-effectiveness of delivering blended learning is unclear. Objective: This study aimed to determine the cost-effectiveness of a face-to-face learning and blended learning approach for evidence-based medicine training within a medical program. Methods: The economic evaluation was conducted as part of a randomized controlled trial (RCT) comparing the evidence-based medicine (EBM) competency of medical students who participated in two different modes of education delivery. In the traditional face-to-face method, students received ten 2-hour classes. In the blended learning approach, students received the same total face-to-face hours but with different activities and additional online and mobile learning. Online activities utilized YouTube and a library guide indexing electronic databases, guides, and books. Mobile learning involved self-directed interactions with patients in their regular clinical placements. The attribution and differentiation of costs between the interventions within the RCT was measured in conjunction with measured outcomes of effectiveness. An incremental cost-effectiveness ratio was calculated comparing the ongoing operation costs of each method with the level of EBM proficiency achieved. Present value analysis was used to calculate the break-even point considering the transition cost and the difference in ongoing operation cost. Results: The incremental cost-effectiveness ratio indicated that it costs 24\% less to educate a student to the same level of EBM competency via the blended learning approach used in the study, when excluding transition costs. The sunk cost of approximately AUD \$40,000 to transition to the blended model exceeds any savings from using the approach within the first year of its implementation; however, a break-even point is achieved within its third iteration and relative savings in the subsequent years. The sensitivity analysis indicates that approaches with higher transition costs, or staffing requirements over that of a traditional method, are likely to result in negative value propositions. Conclusions: Under the study conditions, a blended learning approach was more cost-effective to operate and resulted in improved value for the institution after the third year iteration, when compared to the traditional face-to-face model. The wider applicability of the findings are dependent on the type of blended learning utilized, staffing expertise, and educational context. ", doi="10.2196/jmir.4346", url="http://www.jmir.org/2015/7/e182/", url="http://www.ncbi.nlm.nih.gov/pubmed/26197801" } @Article{info:doi/10.2196/jmir.3844, author="Tousignant, Michel and Moffet, H{\'e}l{\`e}ne and Nadeau, Sylvie and M{\'e}rette, Chantal and Boissy, Patrick and Corriveau, H{\'e}l{\`e}ne and Marquis, Fran{\c{c}}ois and Cabana, Fran{\c{c}}ois and Ranger, Pierre and Belzile, L. {\'E}tienne and Dimentberg, Ronald", title="Cost Analysis of In-Home Telerehabilitation for Post-Knee Arthroplasty", journal="J Med Internet Res", year="2015", month="Mar", day="31", volume="17", number="3", pages="e83", keywords="telemedicine", keywords="economics", keywords="cost analysis", keywords="knee arthroplasty", abstract="Background: Rehabilitation provided through home visits is part of the continuum of care after discharge from hospital following total knee arthroplasty (TKA). As demands for rehabilitation at home are growing and becoming more difficult to meet, in-home telerehabilitation has been proposed as an alternate service delivery method. However, there is a need for robust data concerning both the effectiveness and the cost of dispensing in-home telerehabilitation. Objective: The objective of this study was to document, analyze, and compare real costs of two service delivery methods: in-home telerehabilitation and conventional home visits. Methods: The economic analysis was conducted as part of a multicenter randomized controlled trial (RCT) on telerehabilitation for TKA, and involved data from 197 patients, post-TKA. Twice a week for 8 weeks, participants received supervised physiotherapy via two delivery methods, depending on their study group allocation: in-home telerehabilitation (TELE) and home-visit rehabilitation (VISIT). Patients were recruited from eight hospitals in the province of Quebec, Canada. The TELE group intervention was delivered by videoconferencing over high-speed Internet. The VISIT group received the same intervention at home. Costs related to the delivery of the two services (TELE and VISIT) were calculated. Student's t tests were used to compare costs per treatment between the two groups. To take distance into account, the two treatment groups were compared within distance strata using two-way analyses of variance (ANOVAs). Results: The mean cost of a single session was Can \$93.08 for the VISIT group (SD \$35.70) and \$80.99 for the TELE group (SD \$26.60). When comparing both groups, real total cost analysis showed a cost differential in favor of the TELE group (TELE minus VISIT: -\$263, 95\% CI -\$382 to -\$143). However, when the patient's home was located less than 30 km round-trip from the health care center, the difference in costs between TELE and VISIT treatments was not significant (P=.25, .26, and .11 for the <10, 10-19, and 20-29 km strata, respectively). The cost of TELE treatments was lower than VISIT treatments when the distance was 30 km or more (30-49 km: \$81<\$103, P=.002; ?50 km: \$90<\$152, P<.001). Conclusions: To our knowledge, this is the first study of the actual costs of in-home telerehabilitation covering all subcosts of telerehabilitation and distance between the health care center and the patient's home. The cost for a single session of in-home telerehabilitation compared to conventional home-visit rehabilitation was lower or about the same, depending on the distance between the patient's home and health care center. Under the controlled conditions of an RCT, a favorable cost differential was observed when the patient was more than 30 km from the provider. Stakeholders and program planners can use these data to guide decisions regarding introducing telerehabilitation as a new service in their clinic. Trial Registration: International Standard Registered Clinical Study Number (ISRCTN): 66285945; http://www.isrctn.com/ISRCTN66285945 (Archived by WebCite at http://www.webcitation.org/6WlT2nuX4). ", doi="10.2196/jmir.3844", url="http://www.jmir.org/2015/3/e83/", url="http://www.ncbi.nlm.nih.gov/pubmed/25840501" } @Article{info:doi/10.2196/jmir.3528, author="Armstrong, A. Kathleen and Semple, L. John and Coyte, C. Peter", title="Replacing Ambulatory Surgical Follow-Up Visits With Mobile App Home Monitoring: Modeling Cost-Effective Scenarios", journal="J Med Internet Res", year="2014", month="Sep", day="22", volume="16", number="9", pages="e213", keywords="cost-effectiveness", keywords="ambulatory surgical procedures", keywords="mobile apps", keywords="ambulatory monitoring", abstract="Background: Women's College Hospital (WCH) offers specialized surgical procedures, including ambulatory breast reconstruction in post-mastectomy breast cancer patients. Most patients receiving ambulatory surgery have low rates of postoperative events necessitating clinic visits. Increasingly, mobile monitoring and follow-up care is used to overcome the distance patients must travel to receive specialized care at a reduced cost to society. WCH has completed a feasibility study using a mobile app (QoC Health Inc, Toronto) that suggests high patient satisfaction and adequate detection of postoperative complications. Objective: The proposed cost-effectiveness study models the replacement of conventional, in-person postoperative follow-up care with mobile app follow-up care following ambulatory breast reconstruction in post-mastectomy breast cancer patients. Methods: This is a societal perspective cost-effectiveness analysis, wherein all costs are assessed irrespective of the payer. The patient/caregiver, health care system, and externally borne costs are calculated within the first postoperative month based on cost information provided by WCH and QoC Health Inc. The effectiveness of telemedicine and conventional follow-up care is measured as successful surgical outcomes at 30-days postoperative, and is modeled based on previous clinical trials containing similar patient populations and surgical risks. Results: This costing assumes that 1000 patients are enrolled in bring-your-own-device (BYOD) mobile app follow-up per year and that 1.64 in-person follow-ups are attended in the conventional arm within the first month postoperatively. The total cost difference between mobile app and in-person follow-up care is \$245 CAD (\$223 USD based on the current exchange rate), with in-person follow-up being more expensive (\$381 CAD) than mobile app follow-up care (\$136 CAD). This takes into account the total of health care system, patient, and external borne costs. If we examine health care system costs alone, in-person follow-up is \$38 CAD (\$35 USD) more expensive than mobile app follow-up care over the first postoperative month. The baseline difference in effect is modeled to be zero based on clinical trials examining the effectiveness of telephone follow-up care in similar patient populations. An incremental cost-effectiveness ratio (ICER) is not reportable in this scenario. An incremental net benefit (INB) is reportable, and reflects merely the cost difference between the two interventions for any willingness-to-pay value (INB=\$245 CAD). The cost-effectiveness of mobile app follow-up even holds in scenarios where all mobile patients attend one in-person follow-up. Conclusions: Mobile app follow-up care is suitably targeted to low-risk postoperative ambulatory patients. It can be cost-effective from a societal and health care system perspective. ", doi="10.2196/jmir.3528", url="http://www.jmir.org/2014/9/e213/", url="http://www.ncbi.nlm.nih.gov/pubmed/25245774" } @Article{info:doi/10.2196/resprot.3236, author="Bouwsma, VA Esther and Anema, R. Johannes and Vonk Noordegraaf, Antonie and Knol, L. Dirk and Bosmans, E. Judith and Schraffordt Koops, E. Steven and van Kesteren, JM Paul and van Baal, Marchien W. and Lips, P. Jos and Emanuel, H. Mark and Scholten, C. Petrus and Mozes, Alexander and Adriaanse, H. Albert and Br{\"o}lmann, AM Hans and Huirne, AF Judith", title="The Cost Effectiveness of a Tailored, Web-Based Care Program to Enhance Postoperative Recovery in Gynecologic Patients in Comparison With Usual Care: Protocol of a Stepped Wedge Cluster Randomized Controlled Trial", journal="JMIR Res Protoc", year="2014", month="Jun", day="18", volume="3", number="2", pages="e30", keywords="gynecology", keywords="Internet", keywords="telemedicine", keywords="convalescence", keywords="return to work", keywords="economic evaluation", abstract="Background: The length of recovery after benign gynecological surgery and return to work frequently exceeds the period that is recommended or expected by specialists. A prolonged recovery is associated with a poorer quality of life. In addition, costs due to prolonged sick leave following gynecological surgery cause a significant financial burden on society. Objective: The objective of our study was to present the protocol of a stepped wedge cluster randomized controlled trial to evaluate the cost effectiveness of a new care program for patients undergoing hysterectomy and/or adnexal surgery for benign disease, compared to the usual care. Methods: The care program under study, designed to improve convalescence and to prevent delayed return to work, targets two levels. At the hospital level, guidelines will be distributed among clinical staff in order to stimulate evidence-based patient education. At the patient level, additional perioperative guidance is provided by means of an eHealth intervention, equipping patients with tailored convalescence advice, and an occupational intervention is available for those patients at risk of prolonged sick leave. Due to the stepped wedge design of the trial, the care program will be sequentially rolled out among the 9 participating hospitals, from which the patients are recruited. Eligible for this study are employed women, 18-65 years of age, who are scheduled for hysterectomy and/or laparoscopic adnexal surgery. The primary outcome is full sustainable return to work. The secondary outcomes include general recovery, quality of life, self-efficacy, coping, and pain. The data will be collected by means of self-reported electronic questionnaires before surgery and at 2, 6, 12, 26, and 52 weeks after surgery. Sick leave and cost data are measured by monthly sick leave calendars, and cost diaries during the 12 month follow-up period. The economic evaluation will be performed from the societal perspective. All statistical analyses will be conducted according to the intention-to-treat principle. Results: The enrollment of the patients started October 2011. The follow-up period will be completed in August 2014. Data cleaning or analysis has not begun as of this article's submission. Conclusions: We hypothesize the care program to be effective by means of improving convalescence and reducing costs associated with productivity losses following gynecological surgery. The results of this study will enable health care policy makers to decide about future implementation of this care program on a broad scale. Trial Registration: Netherlands Trial Register: NTR2933; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2933 (Archived by WebCite at http://www.webcitation.org/6Q7exPG84). ", doi="10.2196/resprot.3236", url="http://www.researchprotocols.org/2014/2/e30/", url="http://www.ncbi.nlm.nih.gov/pubmed/24943277" } @Article{info:doi/10.2196/jmir.3346, author="Ho, Yi-Lwun and Yu, Jiun-Yu and Lin, Yen-Hung and Chen, Ying-Hsien and Huang, Ching-Chang and Hsu, Tse-Pin and Chuang, Pao-Yu and Hung, Chi-Sheng and Chen, Ming-Fong", title="Assessment of the Cost-Effectiveness and Clinical Outcomes of a Fourth-Generation Synchronous Telehealth Program for the Management of Chronic Cardiovascular Disease", journal="J Med Internet Res", year="2014", month="Jun", day="10", volume="16", number="6", pages="e145", keywords="cardiovascular disease", keywords="cost-benefit analysis", keywords="telehealth", abstract="Background: Telehealth programs are a growing field in the care of patients. The evolution of information technology has resulted in telehealth becoming a fourth-generation synchronous program. However, long-term outcomes and cost-effectiveness analysis of fourth-generation telehealth programs have not been reported in patients with chronic cardiovascular diseases. Objective: We conducted this study to assess the clinical outcomes and cost-effectiveness of a fourth-generation synchronous telehealth program for patients with chronic cardiovascular diseases. Methods: We retrospectively analyzed 575 patients who had joined a telehealth program and compared them with 1178 patients matched for sex, age, and Charlson comorbidity index. The program included: (1) instant transmission of biometric data, (2) daily telephone interview, and (3) continuous decision-making support. Data on hospitalization, emergency department (ED) visits, and medical costs were collected from the hospital's database and were adjusted to the follow-up months. Results: The mean age was 64.5 years (SD 16.0). The mean number of monthly ED visits (mean 0.06 SD 0.13 vs mean 0.09 SD 0.23, P<.001), hospitalizations (mean 0.05 SD 0.12 vs mean 0.11 SD 0.21, P<.001), length of hospitalization (mean 0.77 days SD 2.78 vs mean 1.4 SD 3.6, P<.001), and intensive care unit admissions (mean 0.01 SD 0.07 vs mean 0.036 SD 0.14, P<.001) were lower in the telehealth group. The monthly mean costs of ED visits (mean US\$20.90 SD 66.60 vs mean US\$37.30 SD 126.20, P<.001), hospitalizations (mean US\$386.30 SD 1424.30 vs mean US\$878.20 SD 2697.20, P<.001), and all medical costs (mean US\$587.60 SD 1497.80 vs mean US\$1163.60 SD 3036.60, P<.001) were lower in the telehealth group. The intervention costs per patient were US\$224.80 per month. Multivariate analyses revealed that age, telehealth care, and Charlson index were the independent factors for ED visits, hospitalizations, and length of hospitalization. A bootstrap method revealed the dominant cost-effectiveness of telehealth care over usual care. Conclusions: Better cost-effectiveness and clinical outcomes were noted with the use of a fourth-generation synchronous telehealth program in patients with chronic cardiovascular diseases. The intervention costs of this new generation of telehealth program do not increase the total costs for patient care. ", doi="10.2196/jmir.3346", url="http://www.jmir.org/2014/6/e145/", url="http://www.ncbi.nlm.nih.gov/pubmed/24915187" } @Article{info:doi/10.2196/jmir.2790, author="Elbert, J. Niels and van Os-Medendorp, Harmieke and van Renselaar, Wilco and Ekeland, G. Anne and Hakkaart-van Roijen, Leona and Raat, Hein and Nijsten, EC Tamar and Pasmans, GMA Suzanne", title="Effectiveness and Cost-Effectiveness of eHealth Interventions in Somatic Diseases: A Systematic Review of Systematic Reviews and Meta-Analyses", journal="J Med Internet Res", year="2014", month="Apr", day="16", volume="16", number="4", pages="e110", keywords="eHealth", keywords="telehealth", keywords="telemedicine", keywords="review", keywords="program effectiveness", keywords="cost effectiveness", abstract="Background: eHealth potentially enhances quality of care and may reduce health care costs. However, a review of systematic reviews published in 2010 concluded that high-quality evidence on the benefits of eHealth interventions was still lacking. Objective: We conducted a systematic review of systematic reviews and meta-analyses on the effectiveness/cost-effectiveness of eHealth interventions in patients with somatic diseases to analyze whether, and to what possible extent, the outcome of recent research supports or differs from previous conclusions. Methods: Literature searches were performed in PubMed, EMBASE, The Cochrane Library, and Scopus for systematic reviews and meta-analyses on eHealth interventions published between August 2009 and December 2012. Articles were screened for relevance based on preset inclusion and exclusion criteria. Citations of residual articles were screened for additional literature. Included papers were critically appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement before data were extracted. Based on conclusions drawn by the authors of the included articles, reviews and meta-analyses were divided into 1 of 3 groups: suitable, promising, or limited evidence on effectiveness/cost-effectiveness. Cases of uncertainty were resolved by consensus discussion. Effect sizes were extracted from papers that included a meta-analysis. To compare our results with previous findings, a trend analysis was performed. Results: Our literature searches yielded 31 eligible reviews, of which 20 (65\%) reported on costs. Seven papers (23\%) concluded that eHealth is effective/cost-effective, 13 (42\%) underlined that evidence is promising, and others found limited or inconsistent proof. Methodological quality of the included reviews and meta-analyses was generally considered high. Trend analysis showed a considerable accumulation of literature on eHealth. However, a similar percentage of papers concluded that eHealth is effective/cost-effective or evidence is at least promising (65\% vs 62\%). Reviews focusing primarily on children or family caregivers still remained scarce. Although a pooled (subgroup) analysis of aggregate data from randomized studies was performed in a higher percentage of more recently published reviews (45\% vs 27\%), data on economic outcome measures were less frequently reported (65\% vs 85\%). Conclusions: The number of reviews and meta-analyses on eHealth interventions in patients with somatic diseases has increased considerably in recent years. Most articles show eHealth is effective/cost-effective or at least suggest evidence is promising, which is consistent with previous findings. Although many researchers advocate larger, well-designed, controlled studies, we believe attention should be given to the development and evaluation of strategies to implement effective/cost-effective eHealth initiatives in daily practice, rather than to further strengthen current evidence. ", doi="10.2196/jmir.2790", url="http://www.jmir.org/2014/4/e110/", url="http://www.ncbi.nlm.nih.gov/pubmed/24739471" } @Article{info:doi/10.2196/jmir.3159, author="Schulz, N. Daniela and Smit, S. Eline and Stanczyk, E. Nicola and Kremers, PJ Stef and de Vries, Hein and Evers, MAA Silvia", title="Economic Evaluation of a Web-Based Tailored Lifestyle Intervention for Adults: Findings Regarding Cost-Effectiveness and Cost-Utility From a Randomized Controlled Trial", journal="J Med Internet Res", year="2014", month="Mar", day="20", volume="16", number="3", pages="e91", keywords="randomized controlled trial", keywords="economic evaluation", keywords="cost-effectiveness", keywords="cost-utility", keywords="lifestyle behaviors", keywords="Internet interventions", keywords="Web-based", keywords="computer-tailoring", abstract="Background: Different studies have reported the effectiveness of Web-based computer-tailored lifestyle interventions, but economic evaluations of these interventions are scarce. Objective: The objective was to assess the cost-effectiveness and cost-utility of a sequential and a simultaneous Web-based computer-tailored lifestyle intervention for adults compared to a control group. Methods: The economic evaluation, conducted from a societal perspective, was part of a 2-year randomized controlled trial including 3 study groups. All groups received personalized health risk appraisals based on the guidelines for physical activity, fruit intake, vegetable intake, alcohol consumption, and smoking. Additionally, respondents in the sequential condition received personal advice about one lifestyle behavior in the first year and a second behavior in the second year; respondents in the simultaneous condition received personal advice about all unhealthy behaviors in both years. During a period of 24 months, health care use, medication use, absenteeism from work, and quality of life (EQ-5D-3L) were assessed every 3 months using Web-based questionnaires. Demographics were assessed at baseline, and lifestyle behaviors were assessed at both baseline and after 24 months. Cost-effectiveness and cost-utility analyses were performed based on the outcome measures lifestyle factor (the number of guidelines respondents adhered to) and quality of life, respectively. We accounted for uncertainty by using bootstrapping techniques and sensitivity analyses. Results: A total of 1733 respondents were included in the analyses. From a willingness to pay of {\texteuro}4594 per additional guideline met, the sequential intervention (n=552) was likely to be the most cost-effective, whereas from a willingness to pay of {\texteuro}10,850, the simultaneous intervention (n=517) was likely to be most cost-effective. The control condition (n=664) appeared to be preferred with regard to quality of life. Conclusions: Both the sequential and the simultaneous lifestyle interventions were likely to be cost-effective when it concerned the lifestyle factor, whereas the control condition was when it concerned quality of life. However, there is no accepted cutoff point for the willingness to pay per gain in lifestyle behaviors, making it impossible to draw firm conclusions. Further economic evaluations of lifestyle interventions are needed. Trial Registration: Dutch Trial Register NTR2168; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2168 (Archived by WebCite at http://www.webcitation.org/6MbUqttYB). ", doi="10.2196/jmir.3159", url="http://www.jmir.org/2014/3/e91/", url="http://www.ncbi.nlm.nih.gov/pubmed/24650860" } @Article{info:doi/10.2196/jmir.2592, author="Naver{\vs}nik, Klemen and Mrhar, Ale{\vs}", title="Routine Real-Time Cost-Effectiveness Monitoring of a Web-Based Depression Intervention: A Risk-Sharing Proposal", journal="J Med Internet Res", year="2014", month="Feb", day="27", volume="16", number="2", pages="e67", keywords="depression", keywords="medical economics", keywords="value-based purchasing", abstract="Background: A new health care technology must be cost-effective in order to be adopted. If evidence regarding cost-effectiveness is uncertain, then the decision maker faces two choices: (1) adopt the technology and run the risk that it is less effective in actual practice, or (2) reject the technology and risk that potential health is forgone. A new depression eHealth service was found to be cost-effective in a previously published study. The results, however, were unreliable because it was based on a pilot clinical trial. A conservative decision maker would normally require stronger evidence for the intervention to be implemented. Objective: Our objective was to evaluate how to facilitate service implementation by shifting the burden of risk due to uncertainty to the service provider and ensure that the intervention remains cost-effective during routine use. Methods: We propose a risk-sharing scheme, where the service cost depends on the actual effectiveness of the service in real-life setting. Routine efficacy data can be used as the input to the cost-effectiveness model, which employs a mapping function to translate a depression specific score into quality-adjusted life-years. The latter is the denominator in the cost-effectiveness ratio calculation, required by the health care decision maker. The output of the model is a ``value graph'', showing intervention value as a function of its observed (future) efficacy, using the {\texteuro}30,000 per quality-adjusted life-year (QALY) threshold. Results: We found that the eHealth service should improve the patient's outcome by at least 11.9 points on the Beck Depression Inventory scale in order for the cost-effectiveness ratio to remain below the {\texteuro}30,000/QALY threshold. The value of a single point improvement was found to be between {\texteuro}200 and {\texteuro}700, depending on depression severity at treatment start. Value of the eHealth service, based on the current efficacy estimates, is {\texteuro}1900, which is significantly above its estimated cost ({\texteuro}200). Conclusions: The eHealth depression service is particularly suited to routine monitoring, since data can be gathered through the Internet within the service communication channels. This enables real-time cost-effectiveness evaluation and allows a value-based price to be established. We propose a novel pricing scheme where the price is set to a point in the interval between cost and value, which provides an economic surplus to both the payer and the provider. Such a business model will assure that a portion of the surplus is retained by the payer and not completely appropriated by the private provider. If the eHealth service were to turn out less effective than originally anticipated, then the price would be lowered in order to achieve the cost-effectiveness threshold and this risk of financial loss would be borne by the provider. ", doi="10.2196/jmir.2592", url="http://www.jmir.org/2014/2/e67/", url="http://www.ncbi.nlm.nih.gov/pubmed/24583773" } @Article{info:doi/10.2196/jmir.2587, author="Zanaboni, Paolo and Landolina, Maurizio and Marzegalli, Maurizio and Lunati, Maurizio and Perego, B. Giovanni and Guenzati, Giuseppe and Curnis, Antonio and Valsecchi, Sergio and Borghetti, Francesca and Borghi, Gabriella and Masella, Cristina", title="Cost-Utility Analysis of the EVOLVO Study on Remote Monitoring for Heart Failure Patients With Implantable Defibrillators: Randomized Controlled Trial", journal="J Med Internet Res", year="2013", month="May", day="30", volume="15", number="5", pages="e106", keywords="telemedicine", keywords="heart failure", keywords="implantable defibrillators", keywords="cost-effectiveness", abstract="Background: Heart failure patients with implantable defibrillators place a significant burden on health care systems. Remote monitoring allows assessment of device function and heart failure parameters, and may represent a safe, effective, and cost-saving method compared to conventional in-office follow-up. Objective: We hypothesized that remote device monitoring represents a cost-effective approach. This paper summarizes the economic evaluation of the Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators (EVOLVO) study, a multicenter clinical trial aimed at measuring the benefits of remote monitoring for heart failure patients with implantable defibrillators. Methods: Two hundred patients implanted with a wireless transmission--enabled implantable defibrillator were randomized to receive either remote monitoring or the conventional method of in-person evaluations. Patients were followed for 16 months with a protocol of scheduled in-office and remote follow-ups. The economic evaluation of the intervention was conducted from the perspectives of the health care system and the patient. A cost-utility analysis was performed to measure whether the intervention was cost-effective in terms of cost per quality-adjusted life year (QALY) gained. Results: Overall, remote monitoring did not show significant annual cost savings for the health care system ({\texteuro}1962.78 versus {\texteuro}2130.01; P=.80). There was a significant reduction of the annual cost for the patients in the remote arm in comparison to the standard arm ({\texteuro}291.36 versus {\texteuro}381.34; P=.01). Cost-utility analysis was performed for 180 patients for whom QALYs were available. The patients in the remote arm gained 0.065 QALYs more than those in the standard arm over 16 months, with a cost savings of {\texteuro}888.10 per patient. Results from the cost-utility analysis of the EVOLVO study show that remote monitoring is a cost-effective and dominant solution. Conclusions: Remote management of heart failure patients with implantable defibrillators appears to be cost-effective compared to the conventional method of in-person evaluations. Trial Registration: ClinicalTrials.gov NCT00873899; http://clinicaltrials.gov/show/NCT00873899 (Archived by WebCite at http://www.webcitation.org/6H0BOA29f). ", doi="10.2196/jmir.2587", url="http://www.jmir.org/2013/5/e106/", url="http://www.ncbi.nlm.nih.gov/pubmed/23722666" } @Article{info:doi/10.2196/jmir.2091, author="Chen, Ying-Hsien and Lin, Yen-Hung and Hung, Chi-Sheng and Huang, Ching-Chang and Yeih, Deng-Feng and Chuang, Pao-Yu and Ho, Yi-Lwun and Chen, Ming-Fong", title="Clinical Outcome and Cost-Effectiveness of a Synchronous Telehealth Service for Seniors and Nonseniors with Cardiovascular Diseases: Quasi-Experimental Study", journal="J Med Internet Res", year="2013", month="Apr", day="24", volume="15", number="4", pages="e87", keywords="age factors", keywords="telehealth", keywords="cost-benefit analysis", keywords="cardiovascular diseases", abstract="Background: Telehealth based on advanced information technology is an emerging health care strategy for managing chronic diseases. However, the cost-effectiveness and clinical effect of synchronous telehealth services in older patients with cardiovascular diseases has not yet been studied. Since 2009, the Telehealth Center at the National Taiwan University Hospital has provided a range of telehealth services (led by a cardiologist and staffed by cardiovascular nursing specialists) for cardiovascular disease patients including (1) instant transmission of blood pressure, pulse rate, electrocardiography, oximetry, and glucometry for analysis, (2) mutual telephone communication and health promotion, and (3) continuous analytical and decision-making support. Objective: To evaluate the impact of a synchronous telehealth service on older patients with cardiovascular diseases. Methods: Between November 2009 and April 2010, patients with cardiovascular disease who received telehealth services at the National Taiwan University Hospital were recruited. We collected data on hospital visits and health expenditures for the 6-month period before and the 6-month period after the opening of the Telehealth Center to assess the clinical impact and cost-effectiveness of telehealth services on cardiovascular patients. Results: A total of 141 consecutive cardiovascular disease patients were recruited, including 93 aged ?65 years (senior group) and 48 aged <65 years (nonsenior group). The telehealth intervention significantly reduced the all-cause admission rate per month per person in the nonsenior group (pretelehealth: median 0.09, IQR 0-0.14; posttelehealth: median 0, IQR 0-0; P=.002) and the duration (days per month per person) of all-cause hospital stay (pretelehealth: median 0.70, IQR 0-1.96; posttelehealth: median 0, IQR 0-0; P<.001) with increased all-cause outpatient visits per month per person (pretelehealth: median 0.77, IQR 0.20-1.64; posttelehealth: mean 1.60, IQR 1.06-2.57; P=.002). In the senior group, the telehealth intervention also significantly reduced the all-cause admission rate per month per person (pretelehealth: median 0.10, IQR 0-0.18; posttelehealth: median 0, IQR 0-0; P<.001) and the duration (days per month per person) of all-cause hospital stay (pretelehealth: median 0.59, IQR 0-2.24; posttelehealth: median 0, IQR 0-0; P<.001) with increased all-cause outpatient visits per month per person (pretelehealth: median 1.40, IQR 0.52-2.63; posttelehealth: median 1.76, IQR 1.12-2.75; P=.02). In addition, telehealth intervention reduced the inpatient cost in the nonsenior group from \$814.93 (SD 1000.40) to US \$217.39 (SD 771.01, P=.001) and the total cost per month from US \$954.78 (SD 998.70) to US \$485.06 (SD 952.47, P<.001). In the senior group, the inpatient cost per month was reduced from US \$768.27 (SD 1148.20) to US \$301.14 (SD 926.92, P<.001) and the total cost per month from US \$928.20 (SD 1194.11) to US \$494.87 (SD 1047.08, P<.001). Conclusions: Synchronous telehealth intervention may reduce costs, decrease all-cause admission rates, and decrease durations of all-cause hospital stays in cardiovascular disease patients, regardless of age. ", doi="10.2196/jmir.2091", url="http://www.jmir.org/2013/4/e87/", url="http://www.ncbi.nlm.nih.gov/pubmed/23615318" } @Article{info:doi/10.2196/jmir.2059, author="Smit, Suzanne Eline and Evers, MAA Silvia and de Vries, Hein and Hoving, Ciska", title="Cost-Effectiveness and Cost-Utility of Internet-Based Computer Tailoring for Smoking Cessation", journal="J Med Internet Res", year="2013", month="Mar", day="14", volume="15", number="3", pages="e57", keywords="randomized controlled trial", keywords="economic evaluation", keywords="smoking cessation", keywords="Internet", keywords="computer-tailoring", keywords="general practice", abstract="Background: Although effective smoking cessation interventions exist, information is limited about their cost-effectiveness and cost-utility. Objective: To assess the cost-effectiveness and cost-utility of an Internet-based multiple computer-tailored smoking cessation program and tailored counseling by practice nurses working in Dutch general practices compared with an Internet-based multiple computer-tailored program only and care as usual. Methods: The economic evaluation was embedded in a randomized controlled trial, for which 91 practice nurses recruited 414 eligible smokers. Smokers were randomized to receive multiple tailoring and counseling (n=163), multiple tailoring only (n=132), or usual care (n=119). Self-reported cost and quality of life were assessed during a 12-month follow-up period. Prolonged abstinence and 24-hour and 7-day point prevalence abstinence were assessed at 12-month follow-up. The trial-based economic evaluation was conducted from a societal perspective. Uncertainty was accounted for by bootstrapping (1000 times) and sensitivity analyses. Results: No significant differences were found between the intervention arms with regard to baseline characteristics or effects on abstinence, quality of life, and addiction level. However, participants in the multiple tailoring and counseling group reported significantly more annual health care--related costs than participants in the usual care group. Cost-effectiveness analysis, using prolonged abstinence as the outcome measure, showed that the mere multiple computer-tailored program had the highest probability of being cost-effective. Compared with usual care, in this group {\texteuro}5100 had to be paid for each additional abstinent participant. With regard to cost-utility analyses, using quality of life as the outcome measure, usual care was probably most efficient. Conclusions: To our knowledge, this was the first study to determine the cost-effectiveness and cost-utility of an Internet-based smoking cessation program with and without counseling by a practice nurse. Although the Internet-based multiple computer-tailored program seemed to be the most cost-effective treatment, the cost-utility was probably highest for care as usual. However, to ease the interpretation of cost-effectiveness results, future research should aim at identifying an acceptable cutoff point for the willingness to pay per abstinent participant. ", doi="10.2196/jmir.2059", url="http://www.jmir.org/2013/3/e57/", url="http://www.ncbi.nlm.nih.gov/pubmed/23491820" } @Article{info:doi/10.2196/jmir.2361, author="Isetta, Valentina and Lopez-Agustina, Carme and Lopez-Bernal, Esther and Amat, Maribel and Vila, Montserrat and Valls, Carme and Navajas, Daniel and Farre, Ramon", title="Cost-Effectiveness of a New Internet-Based Monitoring Tool for Neonatal Post-Discharge Home Care", journal="J Med Internet Res", year="2013", month="Feb", day="18", volume="15", number="2", pages="e38", keywords="Telemedicine", keywords="telenursing", keywords="Internet", keywords="neonatology", keywords="cost-effectiveness", abstract="Background: The application of information and communication technologies in nursing care is becoming more widespread, but few applications have been reported in neonatal care. A close monitoring of newborns within the first weeks of life is crucial to evaluating correct feeding, growth, and health status. Conventional hospital-based postdischarge monitoring could be improved in terms of costs and clinical effectiveness by using a telemedicine approach. Objective: To evaluate the cost-effectiveness of a new Internet-based system for monitoring low-risk newborns after discharge compared to the standard hospital-based follow-up, with specific attention to prevention of emergency department (ED) visits in the first month of life. Methods: We performed a retrospective cohort study of two low-risk newborn patient groups. One group, born between January 1, 2011, and June 30, 2011, received the standard hospital-based follow-up visit within 48 hours after discharge. After implementing an Internet-based monitoring system, another group, born between July 19, 2011, and January 19, 2012, received their follow-up with this system. Results: A total of 18 (15.8\%) out of 114 newborns who received the standard hospital-based follow-up had an ED visit in the first month of life compared with 5 (5.6\%; P=.026) out of 90 infants who were monitored by the Internet-based system. The cost of the hospital-based follow-up was 182.1{\texteuro} per patient, compared with 86.1{\texteuro} for the Internet-based follow-up. Conclusion: Our Internet-based monitoring approach proved to be both more effective and less costly than the conventional hospital-based follow-up, particularly through reducing subsequent ED visits. ", doi="10.2196/jmir.2361", url="http://www.jmir.org/2013/2/e38/", url="http://www.ncbi.nlm.nih.gov/pubmed/23419609" } @Article{info:doi/10.2196/jmir.2422, author="Lintvedt, K. Ove and Griffiths, M. Kathleen and Eisemann, Martin and Waterloo, Knut", title="Evaluating the Translation Process of an Internet-Based Self-Help Intervention for Prevention of Depression: A Cost-Effectiveness Analysis", journal="J Med Internet Res", year="2013", month="Jan", day="23", volume="15", number="1", pages="e18", keywords="Internet", keywords="Internet intervention", keywords="Cognitive Behavior Therapy", keywords="Quality-Adjusted Life Years", keywords="Cost Effectiveness", keywords="Mental health", keywords="Depression", abstract="Background: Depression is common and treatable with cognitive behavior therapy (CBT), for example. However, access to this therapy is limited. Internet-based interventions have been found to be effective in reducing symptoms of depression. The International Society for Research on Internet Interventions has highlighted the importance of translating effective Internet programs into multiple languages to enable worldwide dissemination. Objective: The aim of the current study was to determine if it would be cost effective to translate an existing English-language Internet-based intervention for use in a non-English-speaking country. Methods: This paper reports an evaluation of a trial in which a research group in Norway translated two English-language Internet-based interventions into Norwegian (MoodGYM and BluePages) that had previously been shown to reduce symptoms of depression. The translation process and estimates of the cost-effectiveness of such a translation process is described. Estimated health effect was found by using quality-adjusted life years (QALY). Results: Conservative estimates indicate that for every 1000 persons treated, 16 QALYs are gained. The investment is returned 9 times and the cost-effectiveness ratio (CER) is 3432. The costs of the translation project totaled to approximately 27\% of the estimated original English-language version development costs. Conclusions: The economic analysis shows that the cost-effectiveness of the translation project was substantial. Hopefully, these results will encourage others to do similar analyses and report cost-effectiveness data in their research reports. ", doi="10.2196/jmir.2422", url="http://www.jmir.org/2013/1/e18/", url="http://www.ncbi.nlm.nih.gov/pubmed/23343481" } @Article{info:doi/10.2196/jmir.2052, author="Blankers, Matthijs and Nabitz, Udo and Smit, Filip and Koeter, WJ Maarten and Schippers, M. Gerard", title="Economic Evaluation of Internet-Based Interventions for Harmful Alcohol Use Alongside a Pragmatic Randomized Controlled Trial", journal="J Med Internet Res", year="2012", month="Oct", day="29", volume="14", number="5", pages="e134", keywords="Cost-benefit analysis", keywords="randomized controlled trial", keywords="alcohol-induced disorders", keywords="self-help", keywords="computer-assisted therapy", abstract="Background: Internet interventions with and without therapist support have been found to be effective treatment options for harmful alcohol users. Internet-based therapy (IT) leads to larger and longer-lasting positive effects than Internet-based self-help (IS), but it is also more costly to provide. Objective: To evaluate the cost effectiveness and cost utility of Internet-based interventions for harmful use of alcohol through the assessment of the incremental cost effectiveness of IT compared with IS. Methods: This study was performed in a substance abuse treatment center in Amsterdam, the Netherlands. We collected data over the years 2008--2009. A total of 136 participants were included, 70 (51\%) were female, and mean age was 41.5 (SD 9.83) years. Reported alcohol consumption and Alcohol Use Disorders Identification Test (AUDIT) scores indicated harmful drinking behavior at baseline. We collected self-reported outcome data prospectively at baseline and 6 months after randomization. Cost data were extracted from the treatment center's cost records, and sex- and age-specific mean productivity cost data for the Netherlands. Results: The median incremental cost-effectiveness ratio was estimated at {\texteuro}3683 per additional treatment responder and {\texteuro}14,710 per quality-adjusted life-year (QALY) gained. At a willingness to pay {\texteuro}20,000 for 1 additional QALY, IT had a 60\% likelihood of being more cost effective than IS. Sensitivity analyses attested to the robustness of the findings. Conclusions: IT offers better value for money than IS and might therefore be considered as a treatment option, either as first-line treatment in a matched-care approach or as a second-line treatment in the context of a stepped-care approach. Trial Registration: Netherlands Trial Register NTR-TC1155; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1155 (Archived by WebCite at http://www.webcitation.org/6AqnV4eTU) ", doi="10.2196/jmir.2052", url="http://www.jmir.org/2012/5/e134/", url="http://www.ncbi.nlm.nih.gov/pubmed/23103771" } @Article{info:doi/10.2196/jmir.1966, author="van Spijker, A.J Bregje and Majo, Cristina M. and Smit, Filip and van Straten, Annemieke and Kerkhof, J.F.M Ad", title="Reducing Suicidal Ideation: Cost-Effectiveness Analysis of a Randomized Controlled Trial of Unguided Web-Based Self-help", journal="J Med Internet Res", year="2012", month="Oct", day="26", volume="14", number="5", pages="e141", keywords="suicidal ideation", keywords="randomized controlled trial", keywords="cost-effectiveness", keywords="Internet", keywords="cognitive behavior therapy", abstract="Background: Suicidal ideation is highly prevalent, but often remains untreated. The Internet can be used to provide accessible interventions. Objective: To evaluate the cost-effectiveness of an online, unguided, self-help intervention for reducing suicidal ideation. Methods: A total of 236 adults with mild to moderate suicidal thoughts, defined as scores between 1-26 on the Beck Scale for Suicide Ideation (BSS), were recruited in the general population and randomized to the intervention (n = 116) or to a waitlist, information-only, control group (n = 120). The intervention aimed to decrease the frequency and intensity of suicidal ideation and consisted of 6 modules based on cognitive behavioral techniques. Participants in both groups had unrestricted access to care as usual. Assessments took place at baseline and 6 weeks later (post-test). All questionnaires were self-report and administered via the Internet. Treatment response was defined as a clinically significant decrease in suicidal ideation on the BSS. Total per-participant costs encompassed costs of health service uptake, participants' out-of-pocket expenses, costs stemming from production losses, and intervention costs. These were expressed in Euros ({\texteuro}) for the reference year 2009. Results: At post-test, treatment response was 35.3\% and 20.8\% in the experimental and control conditions, respectively. The incremental effectiveness was 0.35 ? 0.21 = 0.15 (SE 0.06, P = .01). The annualized incremental costs were ?{\texteuro}5039 per participant. Therefore, the mean incremental cost-effectiveness ratio (ICER) was estimated to be ?{\texteuro}5039/0.15 = ?{\texteuro}34,727 after rounding (US ?\$41,325) for an additional treatment response, indicating annual cost savings per treatment responder. Conclusions: This is the first trial to indicate that online self-help to reduce suicidal ideation is feasible, effective, and cost saving. Limitations included reliance on self-report and a short timeframe (6 weeks). Therefore, replication with a longer follow-up period is recommended. ", doi="10.2196/jmir.1966", url="http://www.jmir.org/2012/5/e141/", url="http://www.ncbi.nlm.nih.gov/pubmed/23103835" } @Article{info:doi/10.2196/jmir.2040, author="Maloney, Stephen and Haas, Romi and Keating, L. Jenny and Molloy, Elizabeth and Jolly, Brian and Sims, Jane and Morgan, Prue and Haines, Terry", title="Breakeven, Cost Benefit, Cost Effectiveness, and Willingness to Pay for Web-Based Versus Face-to-Face Education Delivery for Health Professionals", journal="J Med Internet Res", year="2012", month="Apr", day="02", volume="14", number="2", pages="e47", keywords="Economics", keywords="education", keywords="training programs", keywords="teaching methods", keywords="performance", abstract="Background: The introduction of Web-based education and open universities has seen an increase in access to professional development within the health professional education marketplace. Economic efficiencies of Web-based education and traditional face-to-face educational approaches have not been compared under randomized controlled trial conditions. Objective: To compare costs and effects of Web-based and face-to-face short courses in falls prevention education for health professionals. Methods: We designed two short courses to improve the clinical performance of health professionals in exercise prescription for falls prevention. One was developed for delivery in face-to-face mode and the other for online learning. Data were collected on learning outcomes including participation, satisfaction, knowledge acquisition, and change in practice, and combined with costs, savings, and benefits, to enable a break-even analysis from the perspective of the provider, cost-effectiveness analysis from the perspective of the health service, and cost-benefit analysis from the perspective of the participant. Results: Face-to-face and Web-based delivery modalities produced comparable outcomes for participation, satisfaction, knowledge acquisition, and change in practice. Break-even analysis identified the Web-based educational approach to be robustly superior to face-to-face education, requiring a lower number of enrollments for the program to reach its break-even point. Cost-effectiveness analyses from the perspective of the health service and cost-benefit analysis from the perspective of the participant favored face-to-face education, although the outcomes were contingent on the sensitivity analysis applied (eg, the fee structure used). Conclusions: The Web-based educational approach was clearly more efficient from the perspective of the education provider. In the presence of relatively equivocal results for comparisons from other stakeholder perspectives, it is likely that providers would prefer to deliver education via a Web-based medium. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12610000135011; http://www.anzctr.org.au/trial\_view.aspx?id=335135 (Archived by WebCite at http://www.webcitation.org/668POww4L) ", doi="10.2196/jmir.2040", url="http://www.jmir.org/2012/2/e47/", url="http://www.ncbi.nlm.nih.gov/pubmed/22469659" } @Article{info:doi/10.2196/jmir.1694, author="Smit, Filip and Lokkerbol, Joran and Riper, Heleen and Majo, Cristina Maria and Boon, Brigitte and Blankers, Matthijs", title="Modeling the Cost-Effectiveness of Health Care Systems for Alcohol Use Disorders: How Implementation of eHealth Interventions Improves Cost-Effectiveness", journal="J Med Internet Res", year="2011", month="Aug", day="11", volume="13", number="3", pages="e56", keywords="Alcohol-related disorders", keywords="early intervention", keywords="health care systems", keywords="cost-effectiveness", abstract="Background: Informing policy decisions about the cost-effectiveness of health care systems (ie, packages of clinical interventions) is probably best done using a modeling approach. To this end, an alcohol model (ALCMOD) was developed. Objective: The aim of ALCMOD is to estimate the cost-effectiveness of competing health care systems in curbing alcohol use at the national level. This is illustrated for scenarios where new eHealth technologies for alcohol use disorders are introduced in the Dutch health care system. Method: ALCMOD assesses short-term (12-month) incremental cost-effectiveness in terms of reductions in disease burden, that is, disability adjusted life years (DALYs) and health care budget impacts. Results: Introduction of new eHealth technologies would substantially increase the cost-effectiveness of the Dutch health care system for alcohol use disorders: every euro spent under the current system returns a value of about the same size ({\texteuro} 1.08, ie, a ``surplus'' of 8 euro cents) while the new health care system offers much better returns on investment, that is, every euro spent generates {\texteuro} 1.62 in health-related value. Conclusion: Based on the best available evidence, ALCMOD's computations suggest that implementation of new eHealth technologies would make the Dutch health care system more cost-effective. This type of information may help (1) to identify opportunities for system innovation, (2) to set agendas for further research, and (3) to inform policy decisions about resource allocation. ", doi="10.2196/jmir.1694", url="http://www.jmir.org/2011/3/e56/", url="http://www.ncbi.nlm.nih.gov/pubmed/21840836" }