Cost and Cost-Effectiveness of Digital Technologies for Support of Tuberculosis Treatment Adherence: A Systematic Review
Authors: Kafie Cedric , Mohamed Mona Salaheldin , Zary Miranda , Chilala Chimweta Ian , Bahukudumbi Shruti , Gore Genevieve , Foster Nicola , Fielding Katherine , Subbaraman Ramnath , Schwartzman Kevin 
Published: May 2024

ABSTRACTBackgroundDigital 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.MethodsA 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.ResultsOf 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.ConclusionDATs 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.KEY MESSAGESWhat is already known on this topicDigital adherence technologies (DATs) can provide a less intrusive, and potentially less resource-intensive way to monitor and support tuberculosis treatment adherence, as compared to traditional direct observation. To date, there is limited information about the cost and cost-effectiveness of these technologies in diverse care settings.What this study addsOur comprehensive review of available studies shows that some DATs like video-observed therapy can be cost-saving, particularly in higher-income countries, and especially when patient costs are considered.How this study might affect research, practice or policyWhile program savings related to some DATS will likely offset their initial costs in higher-income settings, more evidence is needed from lower-income settings where the TB burden is highest. Costing studies should also more rigorously account for all relevant costs, including those to patients.