Cost and Cost-Effectiveness of Digital Technologies for Support of Tuberculosis Treatment Adherence: A Systematic Review

Abstract

Background: Digital adherence technologies (DATs) may provide a patient-centered approach for supporting tuberculosis (TB) medication adherence and improving treatment outcomes. We synthesized evidence addressing costs and cost-effectiveness of DATs to support TB treatment.Methods: A systematic review (PROSPERO-CRD42022313531) identified relevant literature from January 2000-April 2023 in MEDLINE, Embase, CENTRAL, CINAHL, Web of Science along with preprints from medRxiv, Europe PMC and clinicaltrials.gov. Studies with observational, experimental, or quasi-experimental designs (minimum 20 participants) and modelling studies reporting quantitative data on the cost or cost-effectiveness of DATs for TB infection or disease treatment were included. Study characteristics, cost and cost-effectiveness outcomes were extracted.Results: Of 3,619 titles identified by our systematic search, 29 studies met inclusion criteria, of which 9 addressed cost-effectiveness. DATs included SMS reminders, phone-based technologies, digital pillboxes, ingestible sensors, and video observed treatment (VOT). VOT was the most extensively studied (16 studies) and was generally cost saving when compared to healthcare provider directly observed therapy (DOT), particularly when costs to patients were included--though findings were largely from high-income countries. Cost-effectiveness findings were highly variable, ranging from no clinical effect in one study (SMS), to greater effectiveness with concurrent cost savings (VOT) in others. Only 8 studies adequately reported at least 80% of the elements required by CHEERS, a standard reporting checklist for health economic evaluations.Conclusion: DATs may be cost-saving or cost-effective compared to healthcare provider DOT, particularly in high-income settings. However, more data of higher quality are needed, notably in lower- and middle-income countries which have the greatest TB burden.

Contextual factors influencing implementation of tuberculosis digital adherence technologies: a scoping review guided by the RE-AIM framework

“…Similarly, a recent systematic review found that the cost-effectiveness of TB DATs was highly influenced by the alternative care model to which the DAT-based model was being compared, with DAT-based models being more likely to be cost-effective when compared with more intensive in-person DOT. [88] As such, findings from DAT studies—whether related to convenience, stigma, or cost-effectiveness—are often as much a reflection of challenges or benefits of prior or alternative care models as they are reflections of the DAT interventions themselves. [89]…”