gms | German Medical Science

Background and state of research: The provision of specialized, professionally coordinated, and interdisciplinary care is relevant for the treatment of transgender and gender diverse (TGD) people diagnosed with gender incongruence/gender dysphoria. In rural areas outside the metropolitan regions, however, trans health care structures are rarely adequate or within reach. In order to improve trans health care for TGD people, an interdisciplinary, internet-based transgender health care program (i²TransHealth) has been developed.

Research question and objectives, hypothesis: The aim of this study was to determine the cost-effectiveness of i²TransHealth for treatment-seeking TGD people in rural regions of northern Germany with no or insufficient trans health care structures from a societal perspective.

Method: This study was conducted alongside a randomized-controlled trial comparing the effectiveness of i²TransHealth with a waiting list. The i²TransHealth treatment consisted of a telehealth-based e-health intervention including 1:1 chat with study therapists in combination with outpatient physician care when needed. As health effect measures, quality-adjusted life years (QALYs) were calculated based on the EQ-5D-5L index, and response to treatment based on the BSI-18 global severity index was used. Health care service utilization was assessed using service receipt inventories. The cost-effectiveness of i²TransHealth compared to a waiting list was assessed using the adjusted incremental cost-effectiveness ratio (ICER) based on seemingly unrelated regressions. Furthermore, the uncertainty of the ICER was assessed using cost-effectiveness planes and cost-effectiveness acceptability curves.

Results: Participants in the intervention group (IG; n = 90) and the control group (CG; n = 84) were on average aged 27 years. The mean QALYs of participants in the IG and CG were both 0.28 during the 4-month follow-up period. With 23.02%, participants in the IG had higher response to treatment compared to participants in the CG (9.21%, p = 0.011). The mean 4-month total costs were higher among the participants in the IG (+1390 €, p = 0.001). The corresponding ICER of i²TransHealth was 254,021 € per additional QALY, and 10,786 € per response to treatment, respectively. The corresponding probability of cost-effectiveness of i²TransHealth was 20% at a WTP of 150,000 € per additional QALY and 75% at a WTP of 15,000 € per additional response to treatment.

Discussion: From a societal perspective, i²TransHealth was unlikely to be cost-effective, even at high WTP per additional QALY. However, the comparison of i²TransHealth with a waiting list could have led to a distortion of the results with regard to health care service utilization. When considering additional response to treatment as health effect measure, the probability of cost-effectiveness of i²TransHealth could be high depending on the WTP.

Implication for care: Especially for rural areas, the combination of access to an internet-based health care program as well as trans-informed primary care physicians might be an easy to implement and affordable, yet not proven cost-effective, way to improve trans health care related to transition.

Funding: Innovationsfonds/Versorgungsforschung; 01NVF17051