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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.
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.
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.
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.
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.
The rate of chronic health conditions (CHCs) in children and adolescents (eg, asthma, diabetes) has doubled in the past 20 years [
Taking daily medications is a challenge irrespective of the frequency, formulation, or patient’s age. There are possible differences in adherence barriers across chronic conditions, such as disease-specific treatment regimens and monitoring requirements. However, evidence from a recent systematic review suggests that among adolescents with chronic conditions, most perceived barriers are not unique to a specific disease state [
Adolescents have adopted communication technology such as cellular phones, the Internet, and social networking at a rapid rate across levels of social position and status [
The effect of technology-based interventions on health care costs in adolescents with CHCs may go beyond the direct cost savings associated with medication adherence and related health outcomes. These interventions may facilitate efficient health care operations (eg, fewer missed clinic, screening, or laboratory monitoring appointments), increased access to high-quality care (eg, timely referrals to other services for consultations), and potential cost savings of labor. Therefore, economic evaluation of technology-based interventions can contribute to a better understanding of the scalability, sustainability, and benefits of broader investment of such technology tools. Economic data may also raise considerations for third-party reimbursement should interventions prove to be effective in improving health outcomes in this population. The objectives of this systematic review are to (1) conduct an economic evaluation (cost effectiveness and cost-utility analyses) of text-messaging and smartphone-based interventions that focus on improving medication adherence in adolescents with CHCs and (2) determine whether the incremental benefit gained from using such interventions is enough to justify the additional cost required to adopt, develop, and maintain the intervention.
The authors collaborated with a librarian who developed the search strategies and from July to September 2015 ran searches in the following databases: PubMed MEDLINE, Embase (embase.com), Cochrane Central Register of Controlled Trials (CENTRAL) on the Wiley platform, Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO), PsycINFO (EBSCO), Web of Science, Center for Review and Dissemination (CRD); and Inspec (EBSCO). Further searches were run in November 2015 using the following sources: ProQuest dissertations, Scopus, ClinicalTrials.gov, World Health Organization clinical trials, Controlled-Trials.org, Institute for Electrical and Electronics Engineers (IEEE) Xplore, and Google Scholar. Search strategies for all databases except MEDLINE were adapted from the PubMed MEDLINE strategy. All databases were searched back to 1995 with no language limits applied. The search strategy looked for all articles on text messaging, phones, mobile apps, and portable software combined with adherence or compliance, and search terms related to child, pediatric, adolescent, and youth.
The inclusion criteria were as follows: (1) adolescents (12-24 years old) with a CHC that requires long-term daily or weekly medications for 12 months or longer [
We developed a standardized form for data extraction from the final included articles, adjusted for this particular study. Data items in the extraction form included the following: first author's name; publication year; country; CHC; participant ages; study design; duration of intervention and follow-up; components of technology intervention (text messaging or smartphone apps); adherence measures and rates; disease-related outcomes; theoretical framework; and economic outcomes including cost effectiveness and/or cost-utility data (eg, cost components of each intervention), incremental cost-effectiveness ratios (ICERs), quality adjusted life years (QALYs), and sensitivity analyses. We planned to evaluate the quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach [
The initial search retrieved 1137 records from the main electronic databases (PubMed, Embase, PsycINFO, CINAHL, CENTRAL, Web of Science, Inspec, CRD, and IEEE Xplore). We identified an additional 286 records from the gray literature and hand search of the bibliography of other systematic reviews. After removal of the duplicates, 1118 original articles remained (
Flow of studies through the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Creary et al were able to achieve a significant improvement in hydroxyurea adherence rates (93.3%) among children and adolescents with sickle cell disease by using mobile DOT [
Health economic evaluation of technology-based interventions (eg, text messaging and smartphone apps) helps to highlight the added value of these interventions by addressing two important points: (1) whether the technology-based intervention used to improve medication adherence among adolescents with chronic conditions improves health outcomes relative to other existing interventions and (2) whether the incremental benefit gained from using the technology-based intervention is enough to justify the additional cost required to adopt, develop, and maintain the intervention. Data on ICERs per unit improvement in medication adherence, disease-related outcomes, and QALYs would inform health economic evaluation and aid in the development of a cost-effectiveness model to evaluate whether these improvements are worth the costs required to develop, maintain, and disseminate the intervention. Disease-related outcomes include disease-specific complications, mortality, and HRQOL. In addition, evaluation of health and social care costs are important to consider in relation to HRQOL. Health economic evaluation should include a comprehensive cost analysis of the development, maintenance, and dissemination of technology-based interventions. A cost-effectiveness model using a cost-utility analysis of technology-based interventions for improving patient outcomes could be measured in terms of ICER per unit improvement in disease-related outcomes or QALY gained compared to standard of care. The ICER per extra QALY generated by text-messaging or smartphone app interventions to improve medication adherence over standard of care can be calculated using the following equations:
• (costtext messaging - coststandard of care)/ (QALYtext messaging - QALYstandard of care)
• (costsmartphone app - coststandard of care)/ (QALYsmartphone app - QALYstandard of care)
• (costsmartphone app - costtext messaging)/ (QALYsmartphone app - QALYtext messaging)
In our study, we were not able to identify any articles that met all our predefined criteria. Only 4 articles described interventions with possible future cost saving but no formal economic evaluation. Deriving QALY for use in cost-utility analysis in pediatric populations is a challenging task with only a few child-specific preference-based measures available. There is no single preference-based utility measure that has been validated for children of all ages in different health states, including adolescents with chronic conditions [
Nonadherence to the recommended treatment is a widespread problem in pediatric CHCs. The increasing prevalence of CHCs coupled with management problems in pediatric populations present a barrier to optimal health. Self-management skills in adolescents and young adults are critical to maintain optimal adherence to their chronic medications, especially when they transition from pediatric to adult facilities with more expectations of self-care. Adolescent-centered interventions are needed to optimize their adherence to prescribed medication across CHCs, support the development of self-management skills, and enhance intervention uptake and long-term engagement while transitioning to self-care.
There has been a growing interest in the use of technology to improve medication adherence and self-management skills in the last few years. Similarly, there has been increased interest in the use of portable and easily accessible technology-based approaches to address health-related problems with an overall acceptability and feasibility for different health conditions. Among adults, evidence for the efficacy of text messaging to support medication adherence exists [
Despite the growing evidence of the efficacy of text-messaging and smartphone app interventions in improving medication adherence in adults with CHCs [
The majority of smartphone app initiatives have been pilot studies and the data generated from these studies are limited. In addition to efficacy and effectiveness data, economic evaluation is warranted. The cost to develop and maintain each intervention could be a barrier to the use of these interventions on a broader scale. Additionally, there is variability in patient access to preferred technologies. Formal economic evaluation of various interventions will help health care authorities determine whether the investment required to develop, maintain, and disseminate these interventions is worth the broader benefit, or lack thereof, experienced by patients with chronic conditions. Given the emerging evidence in the field of eHealth, future economic evaluations could consider broader inclusion criteria for different technology-based interventions.
In conclusion, we found no evidence to support the cost effectiveness of technology-based text-messaging and smartphone app interventions. The effect of such technology tools on health care costs in adolescents with CHCs can be beyond medication adherence. Technology-based interventions can facilitate increased operating efficiencies (eg, fewer missed clinic appointments), increased access to high-quality health services (eg, timely referrals to other services for consultations and self-management tools), and potential labor cost savings. Economic evaluation of technology-based interventions can contribute to a better and more evidence-based assessment of the scalability, sustainability, and benefits of broader investment of such technology tools and may raise considerations for third-party reimbursement should interventions prove to be effective in improving health outcomes in this population.
Database search strategies.
Cochrane Central Register of Controlled Trials
chronic health conditions
Cumulative Index to Nursing and Allied Health Literature
Center for Review and Dissemination
directly observed therapy
Grades of Recommendation, Assessment, Development, and Evaluation
health-related quality of life
incremental cost-effectiveness ratio
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
quality adjusted life years
None declared.