Table 3.
Clinical and economic outcomes of the economic evaluation studies included in this review.
| Study | Intervention | Comparator | Effects | Costs (original year and currency) | Costs (converted to 2021 US $) | ICERa; DHIb CEc (yes or no); values inside parentheses are converted to 2021 US Dollars to facilitate comparison across studies | Key cost-effectiveness drivers |
| Yang et al [24] | Telemedicine consultation with remote physician or nurse | Telephone consultation | 31% reduction in patient transfers with DHI | Annual cost savings with DHI: US $4662 per patient (2013) | Annual cost savings with DHI: US $5423 per patient | Cost savings: US $46,620 (US $54,227) per EDd per 10 pediatric patients; CE: yes (dominant from payer perspective) | Reduction in ambulance patient transfer rates |
| Chatterton et al [25] | Stepped care: telephone-delivered 3-stage CBTe | Empirically validated face-to-face CBT program with a therapist | No statistically significant QALYf differences between the 2 study arms | Mean cost savings through stepped care: Aus $1334 in total societal cost, Aus $198 in intervention delivery, and Aus $563 in health sector costs (2015) | Mean cost savings through stepped care: US $1249 in total societal cost, US $185 in intervention delivery, and US $527 in health sector cost | Reported visually as a CE plane; CE: yes (dominant from social perspective) | Reduction in indirect (caregiver) costs and increase in insurance reimbursement availability (Medicare) |
| Olthuis et al [26] | Written material, skill-based videos, and telephone coaching sessions for caregivers | Usual care—mental health services offered by referring agency or other providers | 0.56 improvement with DHI in child behavior checklist scores | Cost savings with DHI: CAD $1059 (2016) | Cost savings with DHI: US $861 | Average bootstrapped ICER: −US $2128 (US $1730) of DHI compared with usual care; CE: yes (dominant) | Reduction in costs of educational and health care services |
| LeFevre et al [27] | SMS text messaging service for pregnant women | No intervention | 95% vs 90% immunization rate in DHI vs control group | US $1.2 million 5-year DHI cost (2015) | US $1.37 million 5-year DHI cost | US $1985 (US $2269) per DALYg in first year; US $200 (US $229) per DALY in fifth year; CE: yes | Increase in number of lives saved and reduction in programmatic costs |
| Jo et al [28] | Comprehensive and basic pregnancy surveillance intervention | SOCh; paper based | 3076 averted deaths in 10 years with DHI | US $43 million (US $115 million) incremental (societal) DHI cost (2018) | US $46.4 million incremental DHI cost and US $124 million incremental societal DHI cost | US $327 (US $353) and US $462 (US $499) per DALY averted; CE: yes | Increase in number of lives saved, population coverage, and implementation duration and reduction in program costs |
| Willcox et al [29] | Interactive voice messages on pregnancy and infant care; appointment reminders for clinical visits | SOC | 59,906 lives saved and cumulative 1,550,028 DALYs averted in 10 years with DHI | DHI cost: US $66,166 per district per year (2014) | DHI cost: US $75,734 per district per year | US $20.94 (US $23.97) per DALY averted and US $586.72 (US $671.56) per death averted; CE: yes | Reduction in still deaths and maternal deaths, personnel time, and program start-up costs (training and equipment) |
| Kawakatsu et al [30] | SMS text message reminder 2 days before in-person appointments | No intervention | 4.8%-6% increase in return rate with DHI | DHI development: US $26,466 (65%); mobile phones: US $6314 (2019) | DHI development: US $28,051 (65%); mobile phones: US $6629 | US $7.90 (US $8.40) per return case; CE: N/Ai | Reduction in number of appointments and increase in geographic coverage of SMS text message reminders |
| Jo et al [31] | Comprehensive pregnancy surveillance intervention | Basic pregnancy surveillance | 354 averted newborn deaths per 1 million with DHI | Total 2-year incremental cost of DHI: US $319,000 (2016) | Total 2-year incremental cost of DHI: US $360,154 | US $31 (US $35) per DALY averted and US $901 (US $1017) per death averted; CE: yes | Reduction in program costs (mainly supervision and training); increase in population coverage |
| Zurovac et al [32] | SMS text message reminders sent to health workers on pediatric malaria case management | No intervention | 25% of additional children correctly managed; additional number of febrile children correctly managed—under study conditions: 38,435, under implementation by the Ministry of Health: 38,435, and under national implementation: 2,955,250 | Total costs—under study conditions: US $19,342, under implementation by the Ministry of Health: US $13,920, and under national implementation: US $97,350 (2010) | Total costs—under study conditions: US $24,036, under implementation by the Ministry of Health: US $17,298, and under national implementation: US $120,973 | Cost per additional child correctly treated—under study conditions: US $0.50 (US $0.62), under implementation by the Ministry of Health: US $0.36 (US $0.45), and under national implementation: US $0.03 (US $0.04); CE: yes | Results robust to changes in input parameters in sensitivity analyses |
| Modi et al [33] | Mobile phone app reminders; health promotion and decision support with web interface | SOC | 11 averted infant deaths per 1000 live births with DHI | Annual incremental cost of DHI: US $163,841 (2016) | Annual incremental cost of DHI: US $184,978 | US $84 (US $95) per life years saved and US $5709 (US $6446) per death averted; CE: yes | Increase in district scale-up and program effectiveness |
| Bowser et al [34] | Mobile devices, phones, and tablets for case management and decision support | No intervention | Higher care coverage and 4661 lives saved with DHI, including women, neonates, and stillbirths | Incremental cost savings with DHI: US $610 (2014) | Incremental cost savings with DHI: US $699 | US $13,155 (US $15,057) per life saved and US $568 (US $650) per DALY averted; CE: no (in base case) | Number of unassisted deliveries |
| Prinja et al [35] | Routine care+mobile phone app used by community health workers in MNCHj care | SOC | Reduction of 0.2% and 5.3% in maternal and neonatal deaths, respectively, over 10 years with DHI | Incremental cost of DHI: US $982 million (2015) | Incremental cost of DHI: US $1.1 billion (of which 90% implementation) | Health system perspective: US $205 (US $234) per DALY averted and US $5865 (US $6705) per death averted; societal perspective: DHI is cost saving; CE: yes | Increase in uptake of preventive services and reduction in number of maternal and neonatal illnesses |
| Jolstedt et al [36] | iCBTk | Internet-delivered child-directed play | 48% vs 15% remission rate in DHI vs control | Average societal cost saving with DHI: €493 (2016) | Average societal cost saving with DHI: US $606 | ICER not calculated because of minimal differences in QALYs (0.02 years); CE: yes for CEAl and no for CUAm | Reduction in intervention costs |
| De Bruin et al [37] | iCBTIn | fCBTIo | No significant differences in sleep efficiency and quality of life | No significant cost differences | No significant cost differences | DHI intervention dominates; CE: yes | Reduction in intervention costs and ongoing intervention costs (after trial period) and reduction in willingness-to-pay threshold |
| Lalouni et al [38] | iCBT | Usual treatment (in health and school system) | Significant and substantial improvement in gastrointestinal symptoms, quality of life, and avoidance behaviors in DHI group | Average societal cost savings per patient with DHI: US $974 (2016) | No significant cost differences | DHI intervention dominant; US $1050 (US $1186) cost savings per patient treated with DHI; CE: yes | Results robust to changes in input parameters in sensitivity analyses |
| Lenhard et al [39] | iCBT | Untreated condition (patients on waitlist) | 27% and 0% treatment response in iCBT and control group, respectively | Average societal cost savings per patient with DHI: US $145 (2016) | Average societal cost savings per patient with DHI: US $164 | Societal perspective: iCBT dominant; health care perspective: ICER of US $78 (US $86) per responder; CE: yes | Reduction in health care resource use |
| Nordh et al [40] | iCBT | iSUPPORTp—active comparator | Nonsignificant QALY differences | Average societal cost savings per patient with DHI: €1076 (2018) | Average societal cost savings per patient with DHI: US $1393 | ICER: €17,901 (US $23,167) per QALY (iCBT dominant over the active comparator); CE: yes; however, from HCPq perspective, iCBT more costly but more effective | Reduction in education costs and increase in school productivity |
| Aspvall et al [41] | Guided iCBT implemented within a stepped-care model (iCBT+in person) | In-person CBT | 68% treatment response in both groups; mean QALY difference=−0.029 | Average cost savings per patient with DHI: US $2052 (2020) | Average cost savings per patient with DHI: US $2148 | Mean cost savings of US $2104 (US $2203) per participant (39% relative savings) from health care sector perspective and US $1748 (US $1830) per participant from societal perspective; CE: yes | Not reported |
| Lee et al [42] | (1) Internet-delivered depression prevention—uDHIr and iDHIs and (2) face-to-face depression prevention—uF2Ft and iF2Fu | No intervention | uF2F: 3367 DALYs averted; iF2F: 4083 DALYs averted | Incremental net cost of DHI: Aus $37,041 (2013) | Incremental net cost of DHI: US $44,719 | uF2F: ICER of Aus $7350 (US $8874) per DALY averted; iF2F: ICER of Aus $19,550 (US $23,602) per DALY averted; uDHI and iDHI were highly cost-effective when assuming 50%-100% relative effect size compared with F2F; CE: yes | Increase in intervention effect size and long-term health impacts and reduction in intervention costs and indirect costs (time and travel) |
| Sampaio et al [43] | Exposure-based iCBT | Waitlist control | iCBT group had small QALY gains (0.0031) and average improvement of 5.647 points on PedsQLv compared with control | Average incremental cost of DHI per participant: US $170 (2016) | Average incremental cost of DHI per participant: US $192 | CUA: ICER of US $54,916 (US $62,001) per QALY gained with DHI; CEA: US $85.29 (US $96.29) per PedsQL point improvement with DHI; CE: undetermined | Reduction in intervention costs and resource use |
| Wasil et al [44] | Online single-session depression intervention | Online study skills active control | Greater reduction in depressive symptoms in DHI group (PHQ-8w score standardized mean difference=0.5) | Incremental cost of DHI per student: US $3.6 (2020) | Incremental cost of DHI per student: US $3.77 | US $25.35-$34.62 (US $26.54-$36.25) per case; CE: N/A | Reduction in cost components |
| van den Wijngaart et al [45] | VACx—outpatient visits reduced by 50% and monthly web-based asthma control test for monitoring | Usual care—routine 4-monthly outpatient visits including an ACTy | Asthma control higher with VAC than usual care for young children (mean difference=1.17); nonsignificant difference for teenagers | Mean cost saving per patient: €352 for young children and €852 for teenagers (2014) | Mean cost saving per patient: US $556 for young children and US $1345 for teenagers | DHI dominant in all subcohorts for asthma control outcome and in caregiver subcohort for quality-of-life outcome; CE: yes | Number of outpatient clinic visits and reduction in travel expenses |
aICER: incremental cost-effectiveness ratio.
bDHI: digital health intervention.
cCE: cost-effective.
dED: emergency department.
eCBT: cognitive behavioral therapy.
fQALY: quality-adjusted life year.
gDALY: disability-adjusted life year.
hSOC: standard of care.
iN/A: not applicable.
jMNCH: maternal, neonatal, and child health.
kiCBT: internet-delivered CBT.
lCEA: cost-effectiveness analysis.
mCUA: cost-utility analysis.
niCBTI: iCBT for insomnia.
ofCBTI: face-to-face CBT for insomnia.
piSUPPORT: internet-based supportive therapy.
qHCP: health care professional.
ruDHI: universal DHI.
siDHI: indicated DHI.
tuF2F: universal face-to-face depression prevention.
uiF2F: indicated face-to-face depression prevention.
vPedsQL: Pediatric Quality of Life Inventory.
wPHQ-8: 8-item Patient Health Questionnaire.
xVAC: virtual asthma clinic.
yACT: asthma control test.