Digital Therapeutic Care Apps With Decision-Support Interventions for People With Low Back Pain in Germany: Cost-Effectiveness Analysis

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

Cost-effectiveness analysis of digital therapeutics for home-based cardiac rehabilitation for patients with chronic heart failure: model development and data analysis

BACKGROUND

In recent years, numerous guidelines and expert consensus have recommended the inclusion of digital technologies and products in cardiac rehabilitation. Digital therapeutics (DTx) is an evidence-based medicine that uses digital means for data collection and monitoring of indicators to control and optimize the treatment, management, and prevention of disease.

OBJECTIVE

This study collected and reviewed real-world data and built a model using health economics assessment methods to analyze the potential cost-effectiveness of DTx applied to home-based cardiac rehabilitation for patients with chronic heart failure. From the perspective of medical and health decision-makers, the economic value of DTx is evaluated prospectively to provide the basis and reference for the application decision and promotion of DTx.

METHODS

Markov models were constructed to simulate the outcomes of DTx for home-based cardiac rehabilitation (DT group) compared to conventional home-based cardiac rehabilitation (CH group) in patients with chronic heart failure. The model input parameters were clinical indicators and cost data. Outcome indicators were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). The robustness of the evaluation methods and results was tested using sensitivity analyses. Clinical indicators, cost data, and health utility values were obtained from real-world data, including clinical study data, published literature, and public website information.

RESULTS

The Markov model simulated a time span of 10 years, with a cycle set at one month, for 120 cycles. The results showed that the per capita cost of the CH group was 38,442.11 CNY/year, with a QALY of 0.7196 per person per year. The per capita cost of the DT group was 42,300.26 CNY/year, with a QALY of 0.81687 per person per year. The ICER per person was 39,663.5 CNY/QALY each year, which was below the willingness-to-pay threshold of 85,698 CNY (China's GDP per capita in 2022).

CONCLUSIONS

DTx for home-based cardiac rehabilitation is an extremely cost-effective rehabilitation option compared with conventional home-based cardiac rehabilitation. DTx for home-based cardiac rehabilitation is potentially valuable from the perspective of healthcare decision-makers.

Economic Evaluation Associated With Clinical-Grade Mobile App-Based Digital Therapeutic Interventions: Systematic Review

BACKGROUND

Digital therapeutics (DTx), a class of software-based clinical interventions, are promising new technologies that can potentially prevent, manage, or treat a spectrum of medical disorders and diseases as well as deliver unprecedented portability for patients and scalability for health care providers. Their adoption and implementation were accelerated by the need for remote care during the COVID-19 pandemic, and awareness about their utility has rapidly grown among providers, payers, and regulators. Despite this, relatively little is known about the capacity of DTx to provide economic value in care.

OBJECTIVE

This study aimed to systematically review and summarize the published evidence regarding the cost-effectiveness of clinical-grade mobile app-based DTx and explore the factors affecting such evaluations.

METHODS

A systematic review of economic evaluations of clinical-grade mobile app-based DTx was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Major electronic databases, including PubMed, Cochrane Library, and Web of Science, were searched for eligible studies published from inception to October 28, 2022. Two independent reviewers evaluated the eligibility of all the retrieved articles for inclusion in the review. Methodological quality and risk of bias were assessed for each included study.

RESULTS

A total of 18 studies were included in this review. Of the 18 studies, 7 (39%) were nonrandomized study-based economic evaluations, 6 (33%) were model-based evaluations, and 5 (28%) were randomized clinical trial-based evaluations. The DTx intervention subject to assessment was found to be cost-effective in 12 (67%) studies, cost saving in 5 (28%) studies, and cost-effective in 1 (6%) study in only 1 of the 3 countries where it was being deployed in the final study. Qualitative deficiencies in methodology and substantial potential for bias, including risks of performance bias and selection bias in participant recruitment, were identified in several included studies.

CONCLUSIONS

This systematic review supports the thesis that DTx interventions offer potential economic benefits. However, DTx economic analyses conducted to date exhibit important methodological shortcomings that must be addressed in future evaluations to reduce the uncertainty surrounding the widespread adoption of DTx interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022358616; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022358616.

Technologies in Home-Based Digital Rehabilitation: Scoping Review

BACKGROUND

Due to growing pressure on the health care system, a shift in rehabilitation to home settings is essential. However, efficient support for home-based rehabilitation is lacking. The COVID-19 pandemic has further exacerbated these challenges and has affected individuals and health care professionals during rehabilitation. Digital rehabilitation (DR) could support home-based rehabilitation. To develop and implement DR solutions that meet clients' needs and ease the growing pressure on the health care system, it is necessary to provide an overview of existing, relevant, and future solutions shaping the constantly evolving market of technologies for home-based DR.

OBJECTIVE

In this scoping review, we aimed to identify digital technologies for home-based DR, predict new or emerging DR trends, and report on the influences of the COVID-19 pandemic on DR.

METHODS

The scoping review followed the framework of Arksey and O'Malley, with improvements made by Levac et al. A literature search was performed in PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library. The search spanned January 2015 to January 2022. A bibliometric analysis was performed to provide an overview of the included references, and a co-occurrence analysis identified the technologies for home-based DR. A full-text analysis of all included reviews filtered the trends for home-based DR. A gray literature search supplemented the results of the review analysis and revealed the influences of the COVID-19 pandemic on the development of DR.

RESULTS

A total of 2437 records were included in the bibliometric analysis and 95 in the full-text analysis, and 40 records were included as a result of the gray literature search. Sensors, robotic devices, gamification, virtual and augmented reality, and digital and mobile apps are already used in home-based DR; however, artificial intelligence and machine learning, exoskeletons, and digital and mobile apps represent new and emerging trends. Advantages and disadvantages were displayed for all technologies. The COVID-19 pandemic has led to an increased use of digital technologies as remote approaches but has not led to the development of new technologies.

CONCLUSIONS

Multiple tools are available and implemented for home-based DR; however, some technologies face limitations in the application of home-based rehabilitation. However, artificial intelligence and machine learning could be instrumental in redesigning rehabilitation and addressing future challenges of the health care system, and the rehabilitation sector in particular. The results show the need for feasible and effective approaches to implement DR that meet clients' needs and adhere to framework conditions, regardless of exceptional situations such as the COVID-19 pandemic.

Mapping Factors That Affect the Uptake of Digital Therapeutics Within Health Systems: Scoping Review

BACKGROUND

Digital therapeutics are patient-facing digital health interventions that can significantly alter the health care landscape. Despite digital therapeutics being used to successfully treat a range of conditions, their uptake in health systems remains limited. Understanding the full spectrum of uptake factors is essential to identify ways in which policy makers and providers can facilitate the adoption of effective digital therapeutics within a health system, as well as the steps developers can take to assist in the deployment of products.

OBJECTIVE

In this review, we aimed to map the most frequently discussed factors that determine the integration of digital therapeutics into health systems and practical use of digital therapeutics by patients and professionals.

METHODS

A scoping review was conducted in MEDLINE, Web of Science, Cochrane Database of Systematic Reviews, and Google Scholar. Relevant data were extracted and synthesized using a thematic analysis.

RESULTS

We identified 35,541 academic and 221 gray literature reports, with 244 (0.69%) included in the review, covering 35 countries. Overall, 85 factors that can impact the uptake of digital therapeutics were extracted and pooled into 5 categories: policy and system, patient characteristics, properties of digital therapeutics, characteristics of health professionals, and outcomes. The need for a regulatory framework for digital therapeutics was the most stated factor at the policy level. Demographic characteristics formed the most iterated patient-related factor, whereas digital literacy was considered the most important factor for health professionals. Among the properties of digital therapeutics, their interoperability across the broader health system was most emphasized. Finally, the ability to expand access to health care was the most frequently stated outcome measure.

CONCLUSIONS

The map of factors developed in this review offers a multistakeholder approach to recognizing the uptake factors of digital therapeutics in the health care pathway and provides an analytical tool for policy makers to assess their health system's readiness for digital therapeutics.

Economic Evaluation of Digital Therapeutic Care Apps for Unsupervised Treatment of Low Back Pain: Monte Carlo Simulation

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 €135.97 (a currency exchange rate of EUR €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 €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 €239.96 to €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.

Digital Therapeutics (DTx) Expand Multimodal Treatment Options for Chronic Low Back Pain: The Nexus of Precision Medicine, Patient Education, and Public Health

Digital therapeutics (DTx, software as a medical device) provide personalized treatments for chronic diseases and expand precision medicine beyond pharmacogenomics-based pharmacotherapies. In this perspective article, we describe how DTx for chronic low back pain (CLBP) can be integrated with pharmaceutical drugs (e.g., NSAIDs, opioids), physical therapy (PT), cognitive behavioral therapy (CBT), and patient empowerment. An example of an FDA-authorized DTx for CLBP is RelieVRx, a prescription virtual reality (VR) app that reduces pain severity as an adjunct treatment for moderate to severe low back pain. RelieVRx is an immersive VR system that delivers at-home pain management modalities, including relaxation, self-awareness, pain distraction, guided breathing, and patient education. The mechanism of action of DTx is aligned with recommendations from the American College of Physicians to use non-pharmacological modalities as the first-line therapy for CLBP. Herein, we discuss how DTx can provide multimodal therapy options integrating conventional treatments with exposome-responsive, just-in-time adaptive interventions (JITAI). Given the flexibility of software-based therapies to accommodate diverse digital content, we also suggest that music-induced analgesia can increase the clinical effectiveness of digital interventions for chronic pain. DTx offers opportunities to simultaneously address the chronic pain crisis and opioid epidemic while supporting patients and healthcare providers to improve therapy outcomes.

Cost-effectiveness analysis of digital therapeutics for home-based cardiac rehabilitation for patients with atrial fibrillation after catheter ablation

Background

In recent years, numerous guidelines and expert consensuses have recommended that digital technologies and products, such as digital therapeutics (DTx), be incorporated into cardiac rehabilitation (CR).

Objective

The study aims to compare the cost-effectiveness of DTx for home-based CR (HBCR) with that of the conventional HBCR for patients with atrial fibrillation (AF) after catheter ablation in a real-world clinical setting.

Methods

Based on a single-center, prospective, blinded, randomized, parallel controlled trial of DTx-based HBCR for AF patients after catheter ablation, 100 AF patients undergoing catheter ablation were selected and randomized at a 1:1 ratio into a UC group (conventional HBCR) and DT group (DTx-based HBCR). The intervention lasted for 12 weeks. Medical cost data and clinical efficacy data (VO2max) were acquired from trial data. Effect data (QALYs, anxiety and depression status, health beliefs related to cardiovascular disease, and exercise self-efficacy) were obtained from a patient questionnaire. The cost-effectiveness analysis was conducted to assess the economic benefits of DTx-based HBCR versus conventional HBCR, and the robustness of the results was verified by sensitivity analysis.

Results

In the DT group (n = 49), the mean QALYs increased 0.119 ± 0.09, VO2max increased 9.3 ± 8.0 mL/(min*kg), anxiety, depression, health belief, and exercise self-efficacy had improved, and the total medical cost was 75,080.55 ± 19,746.62 CNY. In the UC group (n = 48), the mean QALYs increased 0.077 ± 0.06, VO2max increased 4.9 ± 6.6 mL/(min*kg), anxiety, depression, health belief, and exercise self-efficacy had improved, and the total medical cost was 73,972.66 ± 16,582.04 CNY. The difference in the medical cost was 1107.89 CNY, and the incremental cost-effectiveness ratio was 33,572.42 CNY/QALY, which was lower than the willingness-to-pay threshold of 85,698 CNY (China's per capita GDP in 2022).

Conclusion

DTx-based HBCR is more effective and cost-effective than conventional HBCR.

Cost-effectiveness of digital therapeutics for essential hypertension

Hypertension increases the risk of cardiovascular and other diseases. Lifestyle modification is a significant component of nonpharmacological treatments for hypertension. We previously reported the clinical efficacy of digital therapeutics (DTx) in the HERB-DH1 trial. However, there is still a lack of cost-effectiveness assessments evaluating the impact of prescription DTx. This study aimed to analyze the cost-effectiveness of using prescription DTx in treating hypertension. We developed a monthly cycle Markov model and conducted Monte Carlo simulations using the HERB-DH1 trial data to investigate quality-adjusted life-years (QALYs) and the cost of DTx for hypertension plus guideline-based lifestyle modification consultation treatment as usual (TAU), comparing DTx + TAU and TAU-only groups with a lifetime horizon. The model inputs were obtained from the HERB-DH1 trial, published or publicly available data, and expert assumptions. The incremental cost-effectiveness ratio (ICER) per QALY was used as the benchmark for cost-effectiveness. We performed probabilistic sensitivity analyses (PSAs) using the Monte Carlo simulation with two million sets. The DTx + TAU strategy produced 18.778 QALYs and was associated with ¥3,924,075 ($34,122) expected costs, compared with 18.686 QALYs and ¥3,813,358 ($33,160) generated by the TAU-only strategy over a lifetime horizon, resulting in an ICER of ¥1,199,880 ($10,434)/QALY gained for DTx + TAU. The monthly cost and attrition rate of DTx for hypertension have a significant impact on ICERs. In the PSA, the probability of the DTx arm being a cost-effective option was 87.8% at a threshold value of ¥5 million ($43,478)/QALY gained. In conclusion, the DTx + TAU strategy was more cost-effective than the TAU-only strategy.

Adjunct Digital Interventions Improve Opioid-Based Pain Management: Impact of Virtual Reality and Mobile Applications on Patient-Centered Pharmacy Care

Digital therapeutics (DTx, mobile medical apps, software as a medical device) are rapidly emerging as clinically effective treatments for diverse chronic diseases. For example, the Food and Drug Administration (FDA) has recently authorized a prescription virtual reality (VR) app for treatment of moderate to severe low back pain. The FDA has also approved an adjunct digital therapy in conjunction with buprenorphine for opioid use disorder, further illustrating opportunities to integrate digital therapeutics with pharmacotherapies. There are ongoing needs to disseminate knowledge about advances in digital interventions among health care professionals, policymakers, and the public at large. This mini-review summarizes accumulating clinical evidence of digital interventions delivered via virtual reality and mobile apps to improve opioid-based analgesia. We identified relevant randomized controlled trials (RCTs) using Embase and PubMed databases which reported pain scores with a validated pain scale (e.g., visual analog scales, graphic rating scale, numeric rating scale) and use of a digital intervention in conjunction with opiates. Among identified RCTs, the majority of studies reported improved pain scores in the digital intervention group, as compared to “treatment as usual” group. Our work suggests that VR and mobile apps can be used as adjunct digital therapies for pain management. We discuss these findings in the context of how digital health technologies can transform patient-centered pharmacy care.