To the best of our knowledge, this is the first cost-effectiveness study performed for a telemedical DMP for heart failure in the context of the Austrian health care system and the first at all in a real-world setting outside of a randomized controlled trial. The principal finding of this 1-year retrospective cohort study is that HerzMobil Tirol, a 3-month telemedicine-assisted transitional care service in patient with advanced heart failure, is highly cost-effective and improves health outcomes when compared with UC.

The present economic evaluation builds on data on the superior effectiveness of HMT, that is, reduction in heart failure hospitalization and mortality that were previously published [11]. The cost-effectiveness that largely offset the increased cost of the DMP occurred during follow-up as a result of a decrease in worsening HF and fewer deaths.

HMT resulted in an average of 42 additional hospital-free life days, 40 additional life days, and 0.12 avoided hospitalizations per person compared with usual care. The mean DPM costs for HMT were 1916 EUR per person. Hospital costs per day and patient were comparable between groups (€ 555 vs € 561). Mean HF-rehospitalization costs per patient were 5551 EUR in HMT and 6943 EUR in the UC arm. Total costs per person including DMP costs in HMT were on average 523 EUR higher than the costs in UC leading to an ICER of 4773 EUR per life-year gained outside the hospital.

Based on the results and bootstrap sampling, these results appear to be robust, showing that the HMT-based strategy was a more than acceptable cost-effectiveness trade-off in most bootstrap simulations and even dominant (cost savings, i.e., lower costs and better health outcomes) in 14.4% of simulations.

Sensitivity analyses showed a cost-saving effect of HMT when non-HF-related costs in six patients were replaced by the average costs in the HMT and UC groups and when these patients with non-HF-related hospital costs were completely removed from analyses. No random sample has shown that HMT is dominated by UC, i.e. more expensive and less effective.

The fact that HMT is cost-effective in the conservative base-case analysis and even cost-saving in the sensitivity analysis emphasizes the usefulness of DMPs, also from the perspective of the payers and the impact on the healthcare budget.

In Austria, there is no explicit threshold for an intervention to be considered cost-effective. In the international context, for example, in the USA and the UK, thresholds ranging from 50,000 USD per QALY gained to 150,000 USD per QALY gained and above have been reported [21, 22]. HMT can thus be considered as very cost-effective compared to usual care.

In general, telemedicine interventions in HF are relatively heterogenous, making a comparison difficult [9, 23]. Structured telephone support and telemonitoring for HF patients were found to reduce all-cause mortality and HF-related hospitalization [24,25,26,27]. Although only a few studies reported cost savings from economic evaluation as their primary aim [10, 28], most of the reports point in the same direction of potentially cost savings. In these studies, savings resulted almost entirely from reductions in hospital admissions, while other costs were comparable in intervention and control groups.

TIM-HF2, the largest trial to date with a comprehensive cost-effectiveness analysis demonstrating superior clinical effectiveness as well as relevant cost savings, is not conceptually exactly comparable to HMT, but nevertheless represents an important benchmark [10]. In the TIM-HF2 study, which did not include patients in the vulnerable transition phase, noninvasive remote patient management (RPM) was compared with usual care. The study included an HF patient education program followed by monthly patient telephone interviews with a study duration of 12 months and a follow-up period of up to 393 days after study onset. The RPM in TIM-HF2 [10] was cost-saving with average health-care costs per patient year of 14,412 EUR in the RPM group and 17,537 EUR in the UC group based on 339.08 days alive and out of hospital in the RPM versus 332.25 in the usual care group. The improved health outcome of 6 days alive and out of hospital was lower compared to 42 days gained in HMT. The total costs in TIM-HF2 included additional cost items such as non-HF-hospital stays, medication, and rehabilitation, and they are, therefore, considerably higher compared with HMT. The difference of unplanned HF hospitalizations in RPM versus usual care was − 522.65 EUR and for unplanned cardiovascular hospitalizations − 4,520.21 EUR.

In contrast to TIM-HF2, where the team was available 24/7 for 12 months to review RPM data, in HMT, comprehensive care by network physicians and HF nurses was provided only during office hours and for 3 months. Despite the longer supervision in TIM-HF2, the intervention costs in TIM-HF2 were 503 EUR less than in our study (RPM 1,414 EUR, HMT 1,916 EUR). This was mostly due to 25% higher personnel costs for running HMT compared to TIM-HF2. In contrast to TIM-HF2, HMT included home visits by heart failure nurses and a flat rate for the resident physicians. The relative costs for technical infrastructure (150 EUR [8%] vs. 85 EUR [6%]) and for patients measuring devices (357 EUR [19%] vs 226 E’UR [16%]) were higher in HMT where equipment logistics and reprocessing were included in the HMT equipment costs.

Taking all these differences into account, an ICER of € 4773 calculated in HMT is quite comparable to the cost savings of € 1758 per patient year in TIM-HF2.

HerzMobil Tirol is established in routine healthcare for advanced HF in the province of Tyrol, Austria. To the best of our knowledge, the present study is the first economic evaluation of a telemedicine-based transitional care program outside of a clinical study, meaning that “all-comers” rather than carefully selected study participants in a controlled setting were included. The present results demonstrate that the cost-effectiveness data collected in clinical trials are replicable in routine clinical practice.

However, as all empirical real-world economic evaluations, our study has several limitations.

First, the analysis only considered a 1-year time horizon of the clinical follow-up and may, therefore, reflect only partial (short-term) clinical and economic benefits of the DMP program [29]. Results may further improve with long-term effectiveness results of HMT. Such an analysis would require decision-analytic modeling using further assumptions [30].

Second, we did only partly apply weighted end points to synthesize information on quality and quantity of life by calculating hospital-free survival. We did not use utilities to calculate quality-adjusted life years (QALY) due to limited information on disease-specific quality of life or utility measures. However, in TIM-HF2, outcomes related to survival days and hospitalizations were consistent with QALY outcomes [11]. We opted for the partially weighted long-term outcome of hospital-free survival and did not focus on further time to event analyses as the primary outcome, as there are also substantial costs after the first event. However, from a clinical perspective, such analyses could be performed in the future.

Third, nonmedical resources (e.g., transportation to the hospital, patient time) were not considered. This likely biased our results against HMT because the inclusion of transportation costs or productivity loss for caring relatives would likely even decrease the incremental total costs of HMT in the base-case analysis. Also, productivity losses were not considered since most of the patients were already retired.

Fourth, in this retrospective analysis, resource use was not evaluated in the outpatient care setting. For simplification, it was assumed that medical treatment, rehabilitation, etc. were similar in both groups. In TIM-HF2, no substantial difference was found in medication and outpatient costs between groups. Rehabilitation costs were significantly higher in the DMP group for individuals who received rehabilitation, but there was no significant difference in the rehabilitation costs averaged for all individuals in both arms.

Fifth, the costs for the disease management program were based on projections of costs when HMT will be implemented across Tyrol. Due to the scalability of the base infrastructure (coordination and IT infrastructure), approximately 18% of the base costs per year will decrease with more patient cases managed year.

Sixth, since less than 5% of patients refused to participate in HMT, an overly optimistic assessment of the effectiveness of the program due to the exclusion of unstable or disinterested patients can largely be excluded. Inequalities in the baseline characteristics due to the retrospective nature of the study were balanced by multivariate testing and subgroup analyses [11].

Seventh, one-off costs for the software application were not taken into account, as HMT was already introduced in 2012. As these costs are very low at around €20,000 and are spread over all future patient years, they do not influence the cost-effectiveness in any relevant way, but must be taken into account when planning the budget for the installation of a DMP.

Our empirical real-world study results can be used for further health and budget impact analyses as well as for decision analytic models assessing longer time horizons. Further research in health technology assessment should assess further aspects beyond effectiveness and cost-effectiveness such as the equity impact influenced by equal access for more patients if telemedicine is used in DMPs. Although we believe that this study shows robust results in favor of the DMP as a very cost-effective or even cost-saving option, future research could identify further predictors (i.e., effect modifiers) that allow a more individualized assessment of which patients benefit most and which subgroup offers the greatest cost savings.