Cost-Effectiveness of an Interdisciplinary, Internet-Based Transgender Health Care Program in Germany: Economic Evaluation Alongside a Randomized Controlled Trial.

Background: The provision of specialized, professionally coordinated, and interdisciplinary care is relevant for the care of transgender and gender diverse (TGD) people diagnosed with gender incongruence or gender dysphoria. In remote areas outside the metropolitan regions, however, transgender health care structures are rarely adequate or within reach. In order to improve transgender health care for TGD people, an interdisciplinary, internet-based transgender health care program (i²TransHealth) has been developed. Objective: The aim of this study was to determine the cost-effectiveness of i²TransHealth for TGD people from remote areas with no or insufficient transgender health care structures either exploring their gender identity or being in an early phase of transition from a societal perspective. Methods: This study was conducted alongside a randomized controlled trial comparing the effectiveness of i²TransHealth with a waiting list. The i²TransHealth intervention consisted of a telehealth-based eHealth intervention including one-to-one chat conversations with study therapists in combination with office-based regular care provided by general physicians and psychiatrists when needed. As health effect measures, quality-adjusted life years (QALYs) were calculated based on the EuroQol 5-dimension 5-level index, and reliable improvement on the Global Severity Index of the Brief Symptom Inventory-18 (BSI-18 GSI) was used. Health care service usage was assessed using service receipt inventories. The cost-effectiveness of i²TransHealth compared with 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=88) and the control group (CG; n=80) were on average aged 26 and 27 years, respectively. The mean QALYs of participants in the IG and CG were both 0.28 (SE 0.00) during the 4-month follow-up period. With 23.02%, participants in the IG had statistically significantly higher reliable improvement on the BSI-18 GSI compared with participants in the CG (9.21%, P=.01). The mean 4-month total costs were statistically significantly higher among the participants in the IG (+€1390, P=.002; a currency exchange rate of €1=US $1.14 was applicable as of December 31, 2020). The corresponding ICER of i²TransHealth was €254,021 per additional QALY, and €10,786 per additional reliable improvement on the BSI-18 GSI, respectively. The corresponding probability of cost-effectiveness of i²TransHealth was 20% at a willingness-to-pay (WTP) of €150,000 per additional QALY and 75% at a WTP of €15,000 per additional reliable improvement on the BSI-18 GSI. Conclusions: 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 usage. When considering additional reliable improvement on the BSI-18 GSI as health effect measure, the probability of cost-effectiveness of i²TransHealth is unclear depending on the WTP.