title: Cost-effectiveness of telehealth for patients with depression: evidence from the Healthlines randomised controlled trial.
abstract: BACKGROUND
  Depression is a prevalent long-term condition that is associated with substantial resource use. Telehealth may offer a cost-effective means of supporting the management of people with depression.
  
  
  OBJECTIVE
  To investigate the cost-effectiveness of a telehealth intervention ('Healthlines') for patients with depression.
  
  
  METHODS
  A prospective patient-level economic evaluation conducted alongside a randomised controlled trial. Patients were recruited through primary care, and the intervention was delivered via a telehealth service. Participants with a confirmed diagnosis of depression and PHQ-9 score ≥10 were recruited from 43 English general practices. A series of up to 10 scripted, theory-led, telephone encounters with health information advisers supported participants to effect a behaviour change, use online resources, optimise medication and improve adherence. The intervention was delivered alongside usual care and was designed to support rather than duplicate primary care. Cost-effectiveness from a combined health and social care perspective was measured by net monetary benefit at the end of 12 months of follow-up, calculated from incremental cost and incremental quality-adjusted life years (QALYs). Cost-consequence analysis included cost of lost productivity, participant out-of-pocket expenditure and the clinical outcome.
  
  
  RESULTS
  A total of 609 participants were randomised - 307 to receive the Healthlines intervention plus usual care and 302 to receive usual care alone. Forty-five per cent of participants had missing quality of life data, 41% had missing cost data and 51% of participants had missing data on either cost or utility, or both. Multiple imputation was used for the base-case analysis. The intervention was associated with incremental mean per-patient National Health Service/personal social services cost of £168 (95% CI £43 to £294) and an incremental QALY gain of 0.001 (95% CI -0.023 to 0.026). The incremental cost-effectiveness ratio was £132 630. Net monetary benefit at a cost-effectiveness threshold of £20 000 was -£143 (95% CI -£164 to -£122) and the probability of the intervention being cost-effective at this threshold value was 0.30. Productivity costs were higher in the intervention arm, but out-of-pocket expenses were lower.
  
  
  CONCLUSIONS
  The Healthlines service was acceptable to patients as a means of condition management, and response to treatment after 4 months was higher for participants randomised to the intervention. However, the positive average intervention effect size was modest, and incremental costs were high relative to a small incremental QALY gain at 12 months. The intervention is not likely to be cost-effective in its current form.
  
  
  BACKGROUND
  None.
  © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.
authors.affiliation: DPhil, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Padraig
authors.initials: P
authors.lastname: Dixon
authors.affiliation: PhD, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Sandra
authors.initials: S
authors.lastname: Hollinghurst
authors.affiliation: PhD, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Louisa
authors.initials: L
authors.lastname: Edwards
authors.affiliation: PhD, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Clare
authors.initials: C
authors.lastname: Thomas
authors.affiliation: MPH, Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Alexis
authors.initials: A
authors.lastname: Foster
authors.affiliation: PhD, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Ben
authors.initials: B
authors.lastname: Davies
authors.affiliation: MSc, Bristol Randomised Trials Collaboration (BRTC), School of Social and Community Medicine, University of Bristol, Bristol, UK.
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authors.initials: D
authors.lastname: Gaunt
authors.affiliation: PhD, Bristol Randomised Trials Collaboration (BRTC), School of Social and Community Medicine, University of Bristol, Bristol, UK; Nottingham Clinical Trials Unit, Faculty of Medicine & Health Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
authors.forename: Alan A
authors.initials: AA
authors.lastname: Montgomery
authors.affiliation: MD, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.
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authors.lastname: Salisbury