Cost-Effectiveness of an E-Health Intervention to Improve Unhealthy Lifestyle Behaviors in Subfertile Women

Background: ‘Slimmer Zwanger’ is an e-health tool on the smartphone developed to improve the lifestyle behaviors of couples with a child wish, in order to increase the chance of pregnancy and improve pregnancy outcomes. The aim of this study was to assess the costs-effectiveness of coaching through e-health with the ‘Slimmer Zwanger‘ intervention in subfertile women. Decision analytic modeling was used to compare ‘Slimmer Zwanger’ to ‘do nothing’. Methods: Three models were developed and populated using survey data from the Erasmus Medical Centre and literature. The models reflected a range from intermediate to final outcomes. Outcome of model 1 is a reduction in unhealthy lifestyle behaviors, either in percentage of women achieving a complete healthy lifestyle, or a reduction in number of unhealthy lifestyle behaviors. The outcome of the second model was percentage of pregnancies achieved and of the third model percentage of healthy babies born. Costs, effects and incremental costs effectiveness ratio’s (ICER’s) were calculated from a health care and a societal perspective during a one year time horizon. Probabilistic sensitivity analyses were performed and results were represented in Cost Effectiveness Acceptability Curves (CEACs). Results: The percentage of women who achieved a completely healthy lifestyle was on average 3% higher when ‘Slimmer Zwanger’ was used than when nothing was done. In addition, women who used ‘Slimmer Zwanger’ had a lower number of unhealthy lifestyle behaviors. The probability that ‘Slimmer Zwanger’ is cost-effective compared to ‘do nothing’ is approximately 95% for the societal and 99% for the health care perspective, when a maximum acceptable cost effectiveness threshold of €1000 per reduction of one unheatlhy lifestyle behavior in subfertile women is used. Approximately 3% more pregnancies are expected in subfertile women when ‘Slimmer Zwanger’ is used than when nothing is done, with a mean additional costs of €-67 and €-362 from health care and societal point of view respectively. The probability that ‘Slimmer Zwanger’ is cost-effective compared to ‘do nothing’ in terms of pregnancies achieved is approximately 0.65 and 0.88 with a cost-effectiveness threshold of zero, for the health care and societal perspective respectively. Furthermore, on average 3.4% more healthy babies are expected to be born when ‘Slimmer Zwanger’ is used compared to ‘do nothing’. Incremental costs are expected to be €-196 (health care perspective) and €-477 (societal perspective). The probability that ‘Slimmer Zwanger’ is cost effective compared to ‘do nothing’ in terms of healthy babies born is approximately 0.75 for the health care- and 0.90 for the societal perspective, with a cost-effectiveness threshold of zero. Conclusion: ‘Slimmer Zwanger’ decreased the number of unhealthy lifestyle behaviors in subfertile women over a one year period. This resulted in a higher expected pregnancy probability and a higher expected probability of having a healthy baby. Due to high costs of fertility treatment and costs related to adverse pregnancy outcomes, and the relatively low costs of ‘Slimmer Zwanger’, there is a high probability that ‘Slimmer Zwanger’ is cost-effective compared to ‘do nothing ’. Moreover, there is a high probability that ‘Slimmer Zwanger’ is more effective and less costly compared with ‘do nothing’, which suggests that ‘Slimmer Zwanger’ is dominant over ‘do nothing’.