Economic evaluations of videoconference and telephone consultations in primary care: A systematic review

Abstract

Introduction

Telehealth services using videoconference and telephone modalities have been increasing exponentially in primary care since the coronavirus pandemic. The challenge now is ensuring that these services remain sustainable. This review investigates the cost-effectiveness of videoconference and telephone consultations in primary care settings, by summarizing the available published evidence.

Methods

A systematic search of PubMed, Embase, Scopus, and CINAHL databases was used to identify articles published from January 2000 to July 2020, using keyword synonyms for telehealth, primary care, and economic evaluation. Databases were searched, and title, abstract, and full-text reviews were conducted. Article reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

Results

Twenty articles were selected for inclusion, with 12 describing telephone triage services, seven describing telehealth substitution services, and one describing another telehealth service in primary care. These services were delivered by nurses, doctors, and allied health clinicians. Of the 20 included studies, 11 used cost analyses, five used cost-minimization analyses, and four used one or more methods, including either a cost–consequence analysis, a cost–utility analysis, or a cost-effectiveness analysis.

Conclusions

Telephone and videoconference consultations in primary care were cost-effective to the health system when deemed clinically appropriate, clinician when time was used efficiently, and when overall demand on health services was reduced. The societal benefits of telehealth consultations should be considered an important part of telehealth planning and should influence funding reform decisions for telehealth services in primary care.

Keywords

Telehealth telemedicine economic primary care systematic review

Introduction

Telehealth is the delivery of a healthcare service from a distance. Common telehealth modalities include videoconference, store-and-forward, and remote monitoring. The benefits of telehealth are well reported and include improved access to care, reduced need for travel, and better continuity of care.^1–3 Despite these benefits, the routine uptake of telehealth by health services prior to the coronavirus (COVID-19) pandemic was slow and fragmented.⁴ Telehealth use has increased globally since COVID-19 because it obviates the need for direct physical contact.^5–9 Payers, including governments and health insurers, responded to this need by funding telehealth (i.e. videoconference and telephone consultations) in a similar way to in-person (traditional) consultations.^1,10–12 In primary care, videoconference and telephone consultations have been reimbursed to reduce the risk of COVID-19 transmission.^1,13 Primary care is generally an individual's first encounter with the health system and includes general practitioner (GP) or family physician services, nurse-led clinics, or other multidisciplinary services.¹⁴ Many of these clinicians are now routinely using videoconference and telephone modalities to provide patient care.

Videoconference and telephone consultations in primary care settings have grown exponentially during the pandemic; the challenge now is ensuring the sustainability of telehealth as a business-as-usual service post-pandemic.⁹ A viable telehealth service requires funding to support infrastructure and personnel costs. To assist decision-makers with telehealth funding choices, evaluations summarizing the economic evidence for videoconference and telephone consultations are required. Economic evaluations should consider both the costs and consequences (or benefits) of a service to determine if it is cost-effective.¹⁵ Consequences are quantified by measuring the effectiveness of a service, either through a clinical outcome or utility value, such as the quality-adjusted life year (QALY).^15,16 Previous research has investigated the safety and effectiveness of telehealth in primary care^17–20; however, there is limited literature on the economic evaluation of telehealth of any kind in primary care. This review aims to investigate the cost-effectiveness of videoconference and telephone consultations in primary care settings, by summarizing the available published evidence.

Methods

This systematic review was conducted in accordance with the published protocol in the International Prospective Register of Systematic Reviews (ID CRD42020205098).²¹

Search strategy and article screening

The Boolean searches of PubMed, EMBASE, Scopus, and CINAHL databases were conducted using keyword synonyms for telehealth, primary care, and economic evaluation (Supplementary File S1). COVID-19 was included as a search term in case telehealth was investigated in this context. The comprehensiveness of results was guaranteed by hand-searching reference lists of returned articles. Duplicates were removed, titles and abstracts were screened for eligibility, and articles were read in full text by two reviewers (KD and CM). Any conflicts were revised by a third reviewer (CS) to reach consensus for the final included articles.

Eligibility criteria

The search strategy included articles published in English from January 2000 to July 2020.

Included studies reported on:

telehealth services integrated in primary care settings (services must be connected with local clinics or providers);

videoconference consultations, telephone triage, and telephone consultations;

comparisons between telehealth and usual care (i.e. usually an in-person consultation);

economic outcomes of telehealth.

Excluded studies reported on:

alternative telehealth modalities (remote monitoring or store-and-forward);

telehealth in secondary, tertiary, or quaternary care settings;

telehealth consultations involving a specialist;

telehealth not integrated into primary care (e.g. national government help line).

Data extraction and data synthesis

Data were extracted from the included studies by one reviewer (KD) and cross-checked by another reviewer (CS). Extracted data included study characteristics, service model descriptions, type of economic evaluations, and key economic findings. Telehealth service models were classified as: “triage,” where telehealth was used for remote patient assessment; “substitution,” where a telehealth consultation directly substituted an in-person consultation; and “other service,” which did not fit into these categories. Triage services prioritized care or determined need for treatment and were staffed by clinical personnel who could provide self-management advice to patients if an in-person consultation was not required. Economic evaluations were characterized as: a cost analysis (CA), a cost-minimization analysis (CMA), a cost-effectiveness analysis (CEA), a cost–utility analysis (CUA) or a cost–consequence analysis (CCA). The further descriptions of these analysis types are provided (Table 1). The economic findings were synthesized narratively and categorized by service model description. Meta-analysis was not completed due to the inappropriateness of combining economic outcomes between different patient populations, countries, and health systems. All costs and price years were adjusted to 2020 US$ using price deflators for GDP and purchasing price parities for GDP.²²

Table 1.

Description of economic analysis types.

Analysis type	Description
CA	A CA only compares the costs of alternative services and does not measure the clinical effectiveness outcomes of comparative services.
CMA	A CMA compares the costs of services, but unlike a CA, it assumes that the effectiveness for comparative services is equivalent, justifying sole focus on cost comparison.^15,16
CEA	A CEA assesses both costs and consequences, where consequences are measured by units of chosen clinical effectiveness (e.g. disease-specific measure like blood pressure). A CEA seeks to calculate a single figure to represent service differences, presented as a cost per increment of effectiveness.
CUA	A CUA assesses both costs and consequences, where consequences are measured by a utility measure (e.g. quality-adjusted life year). A CUA seeks to calculate a single figure to represent service differences.
CCA	A CCA presents costs and consequences (i.e. effectiveness outcomes) in a disaggregated format to allow decision-makers to assess their value independently.¹⁶

CA: cost analysis; CCA: cost–consequence analysis; CEA: cost-effectiveness analysis; CMA: cost-minimization analysis; CUA: cost–utility analysis.

Quality assessment

The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to assess the quality of each article.²³ Each article was assigned a value out of 24 points, with higher scores indicating more complete reporting.²³ CHEERS items include economic principles such as perspective, time horizon, discounting, effectiveness measurement, assumptions, and incremental cost and outcomes.²³ Final quality scores were reported as percentages; the denominator was adjusted accordingly if any items were irrelevant to an analysis. All articles were scored by one reviewer (KD), and a random sample (20%) of the articles was cross-checked by another reviewer (CS) for quality assessment.

Results

Study selection

Twenty articles were included in this review. The screening and selection process is summarized in Figure 1.^24–43

Figure 1.

Article identification, screening, and inclusion process. Modeled according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) protocol.

Study characteristics

Telehealth was provided to primary care patients with musculoskeletal problems,^26,34 asthma,^25,35,39 acute respiratory illnesses,³³ depression,³⁸ diabetes,⁴¹ and other clinical conditions. Studies reflected telehealth in five countries, with most originating in the United Kingdom (50%) (Table 2). Five studies (25%) conducted a CMA, 11 (55%) conducted a CA, and four (20%) assessed costs and effectiveness by conducting one or more methods of a CCA (n = 2), a CUA (n = 2), and a CEA (n = 2). Telehealth services were delivered by nurses,^{24,25,27,28,30–32,35,37,39,42,43} doctors,^24,29,33,36 physiotherapists,^26,34 psychologists,³⁸ and counselors.⁴⁰ Clinicians were often reported as clinically experienced,^{25–28,30,34,35,37,43} and some received telehealth training.^{24,26,27,39,40}

Table 2.

Study characteristics.

Author, publication year (country)	Analysis type	Study method for evaluation	N	Clinician/service type	Service and comparator details	Author determined cost-effectiveness
Campbell et al., 2014 (United Kingdom)	CCA	Cluster RCT	20,990 patients from 42 practices	Nurse or GP/triage	Compared nurse telephone triage, GP telephone triage, and usual care (patient management as usual after consultation request) for patients seeking same-day consultations in general practice	Decision-maker to decide; 28-day costs for primary outcome contacts (i.e. within-practice consultations of any mode, OOH consultations, walk-in centre contacts, A&E visits) were similar for nurse triage, GP triage, and usual care
Gruffydd-Jones et al., 2005 (United Kingdom)	CMA*	Open RCT	194 patients	Nurse/triage	Compared nurse telephone triage to usual clinic care (in-person consultations) for asthma reviews in general practice	Yes, telephone triage is equally effective and less costly than usual care for conducting asthma reviews
Mallet et al., 2007 (United Kingdom)	CMA	Prospective cohort study	194 patients	Physiotherapist/triage	Compared physiotherapy self-referral with telephone triage to usual care (GP referral for in-person consultations) for general practice MSK patients	Yes, telephone triage provided by physiotherapists was feasible, cost-effective, and offered comparable care to the usual GP-referral pathway
Marklund et al., 2007 (Sweden)	CA	Observational Study	362 patients	Nurse/triage	Compared telephone nurse triage service to usual care (no triage service) in primary care	Yes, having a telephone nurse triage service in primary care may lead to cost savings from referral to appropriate levels of care
Navartil-Strawn et al., 2014 (United States)	CA*	Observational study	132,509 calls (patient number unknown)	Nurse/triage	Compared patients who were compliant with nurse telephone triage recommendations, to patients who were non-compliant to recommendations	Yes, compliance with nurse telephone triage recommendations resulted in lower average health care expenditures compared to non-compliance to nurse triage recommendations
Newbould et al., 2017 (United Kingdom)	CA*	Observational study	147 practices (patient number unknown)	GP/triage	Compared GP telephone triage “telephone-first approach” to usual care (booked in for in-person GP consultations)	No, there was no evidence that GP telephone triage would save costs or reduce ED visits compared to usual care (no GP triage prior to in-person consultations)
Richard et al., 2002 (United Kingdom)	CA*	Experimental study	4685 patients	Nurse/triage	Compared nurse telephone triage to usual care (i.e. patients fitted into extra in-person GP appointments) for patients requesting same-day appointments in general practice	No, nurse telephone triage did not reduce costs per patient for managing same day appointments compared to usual care in general practice settings
O’Connell et al., 2001 (United States)	CA*	Observational study	25,426 patients and >10,000 calls	Nurse/triage	Compared nurse telephone triage service to usual care (no telephone triage service) for primary care patients	Yes, nurse telephone triage appeared cost-effective, improving access to advice and resulting in the appropriate use of medical services
Cariello et al., 2003 (United States)	CA*	Observational study	300 patients and 1893 calls	Nurse/triage	Compared a nurse telephone triage (with decision support) service to usual care (no telephone triage service)	Yes, nurse telephone triage for primary care patients can result in significant financial savings for the health care system
Lattimer et al., 2000 (United Kingdom)	CA	RCT	>14,000 calls (patient number unknown)	Nurse/triage	Compared nurse telephone triage to usual care (no addition of nurse triage service) in OOH general practice	Yes, nurse telephone triage in OOH general practice settings may reduce costs by reducing the demand for ED admissions
Moth et al., 2013 (Denmark)	CA*	Simulation scenario study	634,978 calls (patient number unknown)	GP or nurse/triage	Compared GP telephone triage to nurse telephone triage in OOH primary care service	Decision-maker to decide; cost savings of substituting GPs for nurses are dependent on a range of factors
Richards et al., 2004 (United Kingdom)	CA*	Cluster RCT	4703 patients	Nurse/triage	Compared off-site nurse triage (NHS direct) to on-site nurse triage for patients requesting same-day appointments in general practice	Decision-maker to decide; off-site nurse triage was more costly than on-site practice nurse triage for managing same-day appointment requests
Ashwood et al., 2017 (United States)	CA*	Case–control study	981 patients	Physicians/ Substitution	Compared telehealth consultations (telephone or videoconference) by physicians to usual in-person consultations for primary care patients with acute respiratory illnesses	No, telehealth consultations increased net annual spending compared to usual care; however, telehealth can increase access to care and convenience
Hollinghurst et al., 2013 (United Kingdom)	CCA/CUA	RCT	2249 patients	Physiotherapist/substitution	Compared physiotherapist telephone consultations to usual care (patients placed on waiting list for in-person physiotherapy) for primary care patients with MSK problems	Yes, physiotherapist telephone consultations are cost-effective with careful management of staff time, consideration of scale of operation, and flexibility; telephone provided slightly greater QALY benefits at small cost increase
Pinnock et al., 2005 (United Kingdom)	CMA*	RCT	278 patients	Nurse/substitution	Compared nurse telephone consultations to nurse in-person consults for asthma reviews in general practice	Yes, nurse telephone consultations were cost-effective compared to nurse in-person consultations for conducting asthma reviews
Eichler et al., 2010 (Switzerland)	CA	Observational study	469 patients	GP/substitution	Compared GP telephone consultations, home-visit consultations, and in-person consultations in a GP OOH service	Yes, GPs can provide OOH care where telephone consultations are less costly than practice or home visit consultations
Kafali et al., 2014 (United States)	CEA	RCT	257 patients	Psychologist/substitution	Compared a telephone CBT, in-person CBT, and usual care (no CBT); also directly compared telephone CBT to in-person CBT for primary care patients with depression	Yes, telephone CBT by psychologists was more cost-effective than in-person CBT by psychologists for depression, when effectiveness was measured by improvement in Patient Health Questionnaire (PHQ-9) scores
Pinnock et al., 2007 (United Kingdom)	CMA*	RCT	509 consults (patient number unknown)	Nurse/substitution	Compared nurse asthma review service by telephone or in-person mode to usual care (maintained existing reviews per clinical need) in general practice	Yes, offering telephone asthma reviews cost-effectively increased asthma review rates with no detriment to asthma morbidity
Richter et al., 2015 (United States)	CMA*	RCT	566 patients	Counselor/substitution	Compared telephone consultations to videoconference consultations for smoking cessation counselling in primary care	Yes, telephone consultations for smoking cessation counselling were significantly less expensive than videoconference consultations
Hollenbeak et al., 2016 (United States)	CEA/CUA	RCT	257 patients	Primary care clinicians/other	Compared individual call group call via telephone mode to deliver lifestyle intervention for diabetes patients in a primary care	Yes, CC was cost-effective compared to IC for delivering a diabetes intervention in terms of cost per clinical measures; No, CC was not cost-effective compared to IC in terms of QALYs

CA: cost analysis; CBT: cognitive behavioral therapy; CCA: cost–consequence analysis; CEA: cost-effectiveness analysis; CMA: cost-minimization analysis; CUA: cost–utility analysis; n: number of participants; OOH: out-of-hours; QALY: quality-adjusted life years; RCT: randomized controlled trial; VC: videoconference.

*denoted by authors.

Studies described triage (n = 12, 60%), substitution (n = 7, 35%), and other telehealth services (n = 1, 5%). Triage services all used telephone to determine prioritized care or provide clinical advice to patients. One triage service compared GP to nurse telephone triage,⁴² and one compared off-site nurse (from external agency) to on-site (in-clinic) nurse telephone triage.⁴³ Decision support software was frequently used to support nurse triage recommendations.^{24,27,32,37,43} Most substitution services used telephone to substitute in-person care, with only two that used videoconference.^33,40 The one “other” telehealth service compared individual telephone calls to group calls.⁴¹ The reported benefits of telehealth were reduced waiting times, reduced travel, increased convenience, and accessible care.^{24,26,33–35,38}

Study quality reporting assessment

There was a wide spread of reporting quality when studies were assessed using the CHEERS checklist. Articles scored an average of 66% (SD = 15%, range 43–91%) on the checklist (Supplementary File S2). Low quality reporting was mostly due to CA studies, with nine scoring <70% and two scoring 70–79%. Lower scores were due to the poor reporting of effectiveness items (not applicable to CAs), perspective, discounting, uncertainty, and heterogeneity. No studies scored 100%; however, four scored between 80% and 89%, and one scored between 90% and 99%.

Economic findings

Telehealth triage services (n = 12)

Effective telehealth triage should direct patients to an appropriate service for their clinical condition or enable them to self-manage their condition without further care. Telehealth triage in primary care may provide economic benefits due to efficiencies gained in service use. Most studies investigated the effect of telephone triage on overall service use, such as emergency department (ED) admissions, which usually resulted in decreased costs to the health system.^{24,27–32,37} Four studies that examined nurse telephone triage reported that cost savings were due to the redirection of patients intending to use a higher level of care (e.g. ED) to a less costly and lower level of care (e.g. GP). These four studies used stated preference methods to estimate cost savings by comparing the patients’ intended action (as stated by them) to the actual clinician recommendation.^27,28,31,32 Another study investigated nurse telephone triage, reporting net yearly savings from reduced ED admissions and GP travel.³⁷ Conversely, two studies found opposite results, where GP triage did not reduce ED admissions,²⁹ and cost savings from shorter triage consultations were offset by costs in nursing staff, follow-up, and ED care.³⁰

Telephone triage enabled the prioritization of workload, diverting inappropriate same-day appointments to future routine appointments.³⁰ In a CCA study, no cost differences between GP triage, nurse triage, and in-person care were reported for primary care contacts within 28 days²⁴; instead, there was a redistribution of workload from in-person to triage care.²⁴ Two CMA studies found that telephone triage was cost-effective for asthma and physiotherapy patients, on the assumption that clinical outcomes were equivalent regardless of modality.^25,26 This was because of reduced consultation time and reduced missed appointments.^25,26 Two studies investigated different aspects of telephone triage, with one reporting that off-site nurses increased costs compared to on-site nurses because of longer consultations, fewer managed calls in a shift, and increased referral to doctors.⁴³ The other reported that the nurse substitution of GPs may increase costs because of subsequent GP care.⁴² Overall, three studies reported findings from a health system perspective,^24,25,37 while the remaining studies did not report a perspective (Table 3).

Table 3.

Economic analysis of selected studies.

Author, year	Discipline/modality	Perspective	Time horizon (weeks)	Was effectiveness evaluated?	Cost per patient	Main economic finding	Key conclusions for decision-makers
Campbell et al., 2014	GP or nurse/telephone	NHS (United Kingdom)	4	Yes, in terms of number and type of primary contacts in 28 days, patient safety, or satisfaction	$23.21 GP triage, $12.60 nurse triage	Mean 28-day cost estimates for primary outcome contacts were similar for usual care ($124.73), nurse triage ($125.18), and GP triage ($124.40)	• There was no difference in average costs between nurse triage, GP triage, and usual care • Triage changes the nature of workload, but does not reduces it
Gruffydd-Jones et al., 2005	Nurse/telephone	NHS (United Kingdom)	52	Yes, comparable outcomes in terms of asthma control (ACQ, mini AQLQ)	$421 telephone (95% CI: $419–$425) $668 in-person (95% CI: $662–$674)	Telephone triage can result in a 37% ($245) reduction in costs per patient than usual in-person care	• Telephone triage is a cost-effective method of care for asthma patients • Future studies are needed for pediatric patients with asthma
Mallet et al., 2014	Physiotherapist/telephone	Not reported	36	Yes, comparable outcomes previously demonstrated and described	$59.16 saved per telephone triage	Cost analysis projected annual saving of $137,081 to $202,194 if triage is expanded service-wide	• Telephone triage reduced waiting times and was cost-effective • Efficient administration support, stakeholder support, and a dedicated teams are necessary for success
Marklund et al., 2007	Nurse/telephone	Health system	0 (same day costs)	No	$10.36 triage call	Correct recommendations to an appropriate level of care led to cost savings; savings per call for recommending self-care was $98.38, PHC was $34.01, A&E was $31.07	• Advice given from triage can result in cost savings to the health system • Efficient triage may manage health resources more effectively
Navartil-Strawn et al., 2014	Nurse/telephone	Not reported	≈4 (30 days)	No	$373 saved for compliant callers compared to non-compliant callers.	Patient compliers that intended to visit ED, but were directed to lower care, had the highest savings; caller compliance led to reduced expenditure.	• Compliance with nurse recommendations resulted in low expenditures • Telephone triage helps guide patients to appropriate care
Newbould et al., 2017	GP/telephone	Not reported	52	No	Not reported	Median cost paid to support the change was $17,093; there was an overall increase in secondary care costs of $18,604 per 10,000 patients	• Considerable patient workload can be dealt with by telephone • No evidence for reduced ED visits • Large variations between practices
Richard et al., 2002	Nurse/telephone	Not reported	28	No	$46.05 usual care, $49.17 triage	Triage does not reduce overall costs per patient for managing same day appointments	• Triage saves were offset by increases in nursing, follow-up, OOH, and ED • Triage can smooth out unplanned GP workload
O’Connell et al., 2001	Nurse/telephone	Not reported	52	No	Not reported	The estimated return for every dollar invested in nurse triage service was $2.43	• Triage increased access to advice • Triage service was associated with the reduced utilization of ED services
Cariello et al., 2003	Nurse/telephone	Not reported	0 (same day costs)	No	Telehealth triage saved $81.13 per call	Telephone nurse triage resulted in a 38.6% reduction in cost (p < 0.001).	• Telephone nurse triage resulted in cost savings and may help avoid expensive visits
Lattimer et al., 2000	Nurse/telephone	NHS (United Kingdom)	52	No	Not reported	Telephone triage cost $181,164 p.a., but reduced other costs by $210,568	• Telephone triage may reduce costs by reducing ED admissions • GP practice costs decreased due to reduced travel to home visits
Ashwood et al., 2017	Physician/telephone or videoconference	Health system*	52	No	$88 telehealth $163 office visit $1940 ED visit	Telehealth visits were less costly than in-person visits; however, it led to increased spending of net $50.35 (95% CI: $11–$88) per person in telehealth user cohort.	• Telehealth is less expensive per episode than in-person visits • Strategies such as patient cost sharing or use in chronic diseases may increase the value of telehealth
Hollinghurst et al., 2013	Physiotherapist/telephone	Multiple (NHS United Kingdom, patient, partial societal)	24	Yes, in terms of QALYs and other clinical outcomes (e.g. SF-36v2)	$353 telephone $319 in-person (NHS perspective), in-person costs were $34 (95% CI: $67–$135) higher in in-person group	CCA: outcomes for telephone and usual care were similar; CUA: ICER was $5129 per QALY with a 0.88 probability of being cost effective at a WTP threshold of $35,504 (converted from £20,000)	• Physiotherapy telephone assessments may be cost-effective • Small differences in outcomes and costs for telephone versus usual care • Cost-effectiveness depends on the efficiency of physiotherapist time
Pinnock et al., 2005	Nurse/telephone	Health service	12	Yes, comparable outcomes previously demonstrated and described	$15.45 telephone $23.87 in-person	Telephone saved an average $8.42 (95% CI: $6.47–$10.40) per consultations and the total costs of providing the asthma review services were similar	• Telephone enabled a greater proportion of patients to be reviewed at no additional cost • Telephone improves access to care and reduced cost
Eichler et al., 2010	GP/telephone	Healthcare insurance company	0 (same day costs)	No	$207 home visit $118 practice visit $63 telephone visit	Telephone visits were less costly than practice or home visits and basic costs (consultations time) were the most important cost component	• GPs can treat ambulatory patients in OOH care using low cost measure • Diverse service models, integrated primary care with ED, and GP OOH care should be considered
Kafali et al., 2014	Psychologist/telephone	Partial societal	16	Yes, in terms of mental health outcomes (PHQ-9 and HSCL-20)	Telephone cost $593 less than in-person care	One score reduction in PHQ9 costs $751 less for telephone than in-person, “negative ICERS” for telephone compared to in-person results	• Telephone was more cost-effective for CBT than in-person consultations • Telephone CBT may lead to substantial savings
Pinnock et al., 2007	Nurse/telephone	Not reported	52	Yes, comparable outcomes previously demonstrated and described	$20.12 telephone $25.56 in-person $23.77 usual care	Cost per review for telephone option was lower than face-to-face service at mean difference of $5.44 (95% CI: $3.85–$7.02)	• Telephone reviews cost-effectively increased asthma review rates • Telephone improved access to care with no detriment to outcomes
Richter et al., 2015	Counselor/telephone or videoconference	Partial societal	4	Yes, comparable outcomes previously demonstrated and described	$61.79 telephone $54.58 video ITM (provider perspective)	Telephone was less costly than ITM from a societal perspective	• Telephone and ITM approaches should be combined • Telephone and ITM enabled patients to receive support in their homes
Moth et al., 2013	GP or nurse/telephone	Not reported	52	No	Not reported	Under optimal circumstances, nurse triage can decrease costs; however, it may lead to more face-to-face contacts, resulting in higher fees.	• Nurse triage may increase face-to-face contacts and higher GP fees • In an optimal scenario (e.g. lower demand for OOH services), nurse triage may decrease costs
Hollenbeak et al., 2016	Primary care clinicians/telephone	Partial societal	52	Yes, in terms of QALYs and other clinical outcomes (weight loss, BMI, waist circumference)	$3168 CC $3281 IC 0.635 QALYs CC 0.646 QALYs IC	ICER for CC versus IC was $10,349 per QALY with a 48% probability of being cost-effective at WTP of $111,886 (converted from $US 100,000) per QALY	• CC was cost-effective in terms of clinical measures, but not QALYs • Findings suggest that clinical effectiveness may be achieved with CC compared to IC
Richards et al., 2004	Nurse/telephone	Not reported	0 (same day costs)	No	On-site nurses saved $5.78 (95% CI: $1.77–$9.77) per triage call	Costs were greater for off-site nurses (NHS direct) than on-site nurses	• Off-site nurses managed fewer calls than on-site nurses and took longer • Off-site nurse triage was feasible but was more costly than on-site nurses • External triage services may be useful for smaller practices

BMI: body mass index; CC: conference call; CI: confidence interval; IC: individual call; OOH: out-of-hours care; WTP: willingness-to-pay.

Telehealth substitution services (n = 7)

If telehealth is used to substitute in-person care, it should aim to produce comparable clinical outcomes or achieve additional benefits (e.g. reduced travel). Telehealth substitution may provide economic benefits if it is used in appropriate clinical scenarios and does not increase overall service use. A CCA/CUA study reported that physiotherapist telephone consultations cost slightly more than in-person consultations with slightly greater QALY benefits,³⁴ yielding an incremental cost-effectiveness ratio of $5129 per QALY from the health service perspective.³⁴ In a sensitivity analysis, it was demonstrated that higher savings would be achieved if physiotherapists spent more time on billable telehealth consultations than administrative tasks.³⁴ A CMA study reported that telephone asthma consultations were cost-effective compared with in-person consultations, from the health service perspective, because of reduced consultation times.³⁵ Similarly, another CMA study reported that telephone asthma consultations were cost-effective compared with in-person consultations because they were shorter and required less nurse time (no perspective reported).³⁹ Both CMA studies assumed that asthma-related outcomes were equivalent regardless of modality.

A study comparing home-visit, in-person, and telephone consultations by GPs reported that telephone reduced costs to the service provider.³⁶ Another study compared telephone cognitive behavioral therapy (CBT) to in-person CBT. Telephone was cost-effective from a partial societal perspective, because of reduced mental health service use, patient travel, and patient waiting time.³⁸ Telephone was also cost-effective compared with videoconference for a smoking cessation intervention from a partial societal perspective.⁴⁰ Higher costs for videoconference were largely due to clinic space costs.⁴⁰ One study reported that telephone and videoconference consultations for patients with acute respiratory illnesses increased overall service costs.³³ This was because of telehealth convenience, which resulted in additional health service use.³³ Overall, studies investigating substitution services used three CMAs,^35,39,40 two CAs,^33,36 one CEA,³⁸ and one CCA/CUA,³⁴ with only one study (CA)³³ reporting that telehealth was not cost-effective compared with in-person care (Table 3).

Other telehealth services (n = 1)

Other aspects of telehealth delivery are important to consider for potential avenues for cost savings. One CEA/CUA study compared telephone group calls to individual calls for a diabetes intervention, reporting that a group call was cost-effective from a partial societal perspective (patient gains are factored in) when clinical effectiveness measures were used (CEA).⁴¹ However, when QALYs were used to measure effectiveness (CUA), a group call was no longer cost-effective because of staff and technology costs.⁴¹

Discussion

The cost-effectiveness of telehealth services in primary care settings was found to be context dependent, contingent on changes in overall service use, and dependent on secondary care resource use. Implementation and operational costs (i.e. staff or consultation time) played an important role in determining telehealth cost-effectiveness. Of the 20 included studies, 13 reported telehealth as cost-effective, three reported telehealth as not cost-effective, one reported cost-effectiveness as decided by the decision-maker (CCA), and three reported cost-effectiveness as dependent on how telehealth was delivered (i.e. group vs individual call, nurse- vs GP-triage, and on- vs off-site nurses). These findings should be considered in light of study context, analysis type, and service model delivered. Of the 13 studies that reported cost-effective telehealth services, seven described telephone triage and six described telehealth substitution; six studies reported cost-effectiveness from a health system perspective, two from a partial societal perspective, and five without a perspective.

Integrating telehealth into primary care can be cost-effective for the health system when it reduces overall service use and secondary care resource use (e.g. ED admissions), especially when the same provider is bearing the cost for primary and secondary care services. Telephone triage saves costs if patients are successfully redirected from high-cost to low-cost acute care services, but not when the end result is an increase in service use or high-cost service access following triage. Telephone triage redistributed workload from in-person to telehealth modalities²⁴ and transferred appointment costs from inappropriate same-day appointments to routine appointments.³⁰ Therefore, telehealth can help prioritize care and change the nature of clinician workload, rather than affecting costs. Other studies have found that telehealth in primary care reduces secondary care resource use,^44–46 and although economic findings were not investigated, an economic impact can be inferred.

The efficient use of clinician time influenced the cost-effectiveness of telehealth in primary care. Telehealth resulted in shorter consultation times,^{25,30,35,36,39} which can reduce the marginal cost per consultation for the provider if fixed costs are assumed for the service.⁴⁷ However, longer consultations can improve patient care and satisfaction.⁴⁸ This emphasizes the importance of assessing costs and effectiveness (e.g. CEA) to ensure that economic benefits are achieved without compromising patient care. Provider costs for telehealth are not just reflected in consultation time, but in time spent on set-up and planning, and addressing technical issues. Increased savings were estimated if clinicians spent more time on telehealth consultations than administration tasks³⁴ or travel.³⁷ Therefore, telehealth could improve clinician productivity if this time is converted to clinical activities instead,^47,49 emphasizing the need for streamlined processes and reliable software.

The cost-effectiveness of telehealth likely depends on the clinical condition of primary care patients. Patients with acute respiratory illnesses found it more convenient to seek advice through telehealth,³³ which resulted in increased health system costs because of increased service use.³³ Therefore, telehealth may not be cost-effective for minor ailments, which can be self-managed. Telehealth was reported as cost-effective for the management of asthma,^35,39 musculoskeletal problems,^26,34 depression,³⁸ diabetes,⁴¹ and smoking cessation.⁴⁰ Chronic diseases, such as diabetes or asthma, have an immense economic burden on the health system because of costs for disease management and lost productivity from illness and death. Thus, primary care prevention and management are key in reducing long-term costs.⁵⁰ Telehealth can facilitate the ongoing care of chronic diseases that are often undertreated³³ and require regular monitoring.^51,52 Economic benefits from investment into these services may not be realized immediately as savings are likely gained in the future (due to reduced complications or improved management).

Missed appointments represent a cost burden on the health system by increasing the marginal cost of consultations provided by that service.^47,53 Telehealth can reduce failure to attend,²⁶ thereby decreasing unnecessary costs and ensuring that patients receive timely care, an aspect particularly important for primary care patients seeking advice for the first time. Implementation costs (e.g. infrastructure) can influence telehealth cost-effectiveness in the short term.^40,54 Other research has reported that cost savings from telehealth may not be recouped because of implementation or operational costs,⁵⁵ although this can be outweighed if service activity increases.⁵⁵ This demonstrates that telehealth may benefit from economies of scale, where increasing the scale of production decreases the marginal cost per consultation.^34,56–58 Asides from economic benefits, other more tangible telehealth benefits need to be acknowledged. Telehealth can reduce patient waiting times, increase convenience, and deliver more timely care. Considering this, partial societal perspectives often provide a broader cost estimation and more holistic approach to the benefits of telehealth.

Limitations

The conclusions are limited to the findings reported by included studies, where results are dependent on analysis type and reporting quality. Many studies failed to articulate an analysis perspective, making their assertions difficult to interpret. Sensitivity analysis, which measures the effect of fluctuating cost variations, was often not conducted even though this can help identify opportunities for economic improvement.⁵⁹ CA studies did not measure effectiveness, so the clinical impact of these services cannot be determined; some CAs used stated preference methods where there is no guarantee that patients will do what they stated. Furthermore, results were grouped by service model description, and not analysis type, because a majority of studies were CAs (i.e. limited CEAs and CUAs). These findings may be less applicable to videoconference, as only two studies investigated this modality. Earlier studies may not accurately reflect present situation, as telehealth costs may be reducing over time from more affordable ICT systems.

Implications for decision-makers

When the costs and effectiveness of telehealth are comparable to in-person care, it is an excellent contender for implementation given the societal benefits. Telehealth is not intended to replace all in-person care, and it is important to consider telehealth in the context of clinical requirements. Telehealth can save costs for the health system if overall service use is decreased, or in-person care is reduced. This knowledge is useful for decision-makers considering provider telehealth reimbursement.¹² However, telehealth implementation should be motivated by benefits outside cost savings, as it enables the delivery of multidisciplinary services and the expansion of primary care services (e.g. nurse triage).⁶⁰ The cost-effectiveness and reimbursement of telephone and videoconference consultations are likely to be different. Therefore, it is imperative that the cost-effectiveness of telephone and videoconference consultations is assessed separately to inform future telehealth funding reforms. Owing to the rapid uptake of telehealth since COVID-19,^6,9 investigating patient and clinician experiences may further help develop strategies for telehealth sustainability.

Conclusions

Videoconference and telephone consultations in primary care were cost-effective from a health system perspective when used in appropriate clinical situations, when clinician time was used efficiently, and when overall service use was reduced. The benefits of telehealth from a primary care perspective should consider the less tangible benefits, such as timely and accessible patient care, the promotion of multidisciplinary services, and opportunities to expand the capacity of the primary care sector. All these potential benefits are important for decision-makers considering the implementation and reimbursement of an integrated telehealth service.

Supplemental Material

sj-docx-1-jtt-10.1177_1357633X211043380 - Supplemental material for Economic evaluations of videoconference and telephone consultations in primary care: A systematic review

Supplemental material, sj-docx-1-jtt-10.1177_1357633X211043380 for Economic evaluations of videoconference and telephone consultations in primary care: A systematic review by Keshia R De Guzman, Centaine L Snoswell, Liam J Caffery, and Anthony C Smith in Journal of Telemedicine and Telecare

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Australian Government Research Training Program Scholarship.

ORCID iDs

Keshia R De Guzman

Centaine L Snoswell

Liam J Caffery

Anthony C Smith

Supplemental material

Supplemental material for this article is available online.

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