Evaluating the Cost Effectiveness of Tele-Rehabilitation: A Systematic Review of Randomized Clinical Trials

Seyyedeh Fatemeh Mousavi Baigi; Atefeh Sadat Mousavi; Khalil Kimiafar; Masomeh Sarbaz

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Evaluating the cost effectiveness of tele-rehabilitation: A systematic review of randomized clinical trials

Seyyedeh Fatemeh Mousavi Baigi¹; Atefeh Sadat Mousavi²; Khalil Kimiafar³; Masomeh Sarbaz³*

1. MSc Student of Health Information Technology, Department of Medical Records and Health Information Technology, Faculty of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran, 2. MSc in Health Information Technology, Department of Medical Records and Health Information Technology, Faculty of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran, 3. Associate Professor, Department of Medical Records and Health Information Technology, Faculty of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran

Correspondence: *. Corresponding author: Masomeh Sarbaz, Associate Professor, Department of Medical Records and Health Information Technology, Faculty of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Introduction: Despite the epidemic of COVID-19, the current budget constraints of governments do not allow to increase the budget of conventional rehabilitation programs. As a result, there is a growing need for cost-effective alternative strategies such as tele-rehabilitation. Therefore, the purpose of this study was a systematic review of randomized clinical trial studies to evaluate the cost-effectiveness of tele-rehabilitation.

Material and Methods: A systematic review, without time limit, was searched by searching for keywords in the title, abstract and keywords of studies in the authoritative scientific databases Embase, Web of Science, Scopus, and PubMed on November 24, 2021. Randomized and controlled trial studies that used the tele-rehabilitation approach as an intervention in the study and evaluated it in terms of cost-effectiveness were considered as inclusion criteria. Eligibility criteria were screened independently by two researchers. In order to evaluate the quality of the input studies to this study, the JBI quality evaluation checklist for randomized controlled trials was used. The same checklist was used to extract the data. The data elements in this checklist included the title of the publication, year of publication, country, number of participants, duration of intervention, technology-based approach, study population, study objectives and main findings of the study.

Results: A total of 11 articles with inclusion criteria were included in the study. There was no significant bias in the studies and all studies had the quality of inclusion in our study. The tele-rehabilitation approaches and health conditions evaluated in the studies were largely different. In 45% of the studies, tele-rehabilitation interventions reported a significant improvement in the outcomes and clinical effects in the tele-rehabilitation group versus the control group (face-to-face visit). In 64% of the studies, tele-rehabilitation interventions were more cost effective than traditional rehabilitation interventions. However, in 36% of the studies, no significant difference was observed in the amount of money spent between the control and intervention groups. In addition, in 4 studies, no significant improvement in quality in the adjusted years was reported.

Conclusion: The evidence from this study shows that tele-rehabilitation services and care for the general public are more cost effective than face-to-face rehabilitation services. It is suggested that future studies to maximize the potential of tele-rehabilitation focus on improving patients' access to rehabilitation services and removing barriers to tele-rehabilitation.

Received: 2022 March 6; Accepted: 2022 June 20

FHD. 2022 Jun 25; 11(1): 118

doi: 10.30699/fhi.v11i1.368

Keywords: Key Words Tele-Rehabilitation, Cost Effectiveness, Systematic Review.

INTRODUCTION

In recent decades, following the upward trend of aging and the increase of chronic diseases, the need for rehabilitation services has increased throughout the world, especially in low- and middle-income countries [1-6]. Worldwide, more than 1,600 million adults aged 15 to 64 have conditions that could benefit them from rehabilitation in 2019 [1].

At present, the need for rehabilitation has not been largely met. In some low- and middle-income countries, more than 50 percent of people do not receive the rehabilitation services they need. Rehabilitation services in 60-70% of countries have been disrupted due to the COVID-19 epidemic [7, 8]. In addition, despite the COVID-19 epidemic, current government budget constraints do not allow for increased funding for conventional rehabilitation programs. As a result, there is a growing need for cost-effective alternative strategies such as the use of technologies to provide telemedicine services such as telemedicine. Currently, the use of technology in health care systems has significantly increased access to health care services worldwide [9].

Telemedicine and telehealth are widely used as a supplement or alternative to consulting physicians to prevent, treat, or improve a patient's condition. Tele-rehabilitation refers to the provision of rehabilitation services with the help of communication and information technologies. This may involve a variety of forms of technology, such as telephony, Internet-based communications, virtual reality applications, or a combination of other forms of computer systems and technologies. Such technologies, when used for preventive, curative, rehabilitation services as well as outcome monitoring, as a means of providing guidelines and solutions to address rehabilitation issues. Tele-rehabilitation creates opportunities to reduce the rising costs of health care in a new and effective way [9, 10].

However, technology is not a one-size-fits-all solution, but relies on the innovative ideas and creative capacities of providers to ensure that their use is optimally sustained [9]. Because telemedicine is a rapidly evolving discipline, there is a need to analyze clinical outcomes and the costs associated with telemedicine. Cost Analysis - The benefit of a complex analysis is that it needs to examine the current state of the cost of care in the area and then compare it to the expected cost of developing the system to provide similar care with similar or improved outcomes [11]. Numerous studies have shown the effectiveness and cost-effectiveness of telecare and telemonitoring services [12-14].

Considering that cost-effectiveness studies in tele-rehabilitation include different and heterogeneous results and the lack of a systematic review in the last decade to examine the cost-effectiveness of tele-rehabilitation systems in a comprehensive and comprehensive approach prevents the development of an overview of developers. And health policymakers to these systems. Therefore, the purpose of this study was a systematic review of randomized clinical trial studies to evaluate the cost-effectiveness of tele-rehabilitation.

MATERIAL AND METHODS

This systematic review is based on PRISMA 2020 guidelines [15, 16]; To report the evidence from the input studies to this systematic review. The text was searched on November 24, 2021 in PubMed, Embase, Scopus and Web of Science databases (Table 1).

Table 1. Search Strategy

Database	Search strategy
PubMed	("Cost-Benefit Analysis"[MeSH Terms] AND "Telerehabilitation"[MeSH Terms]) OR (("Cost-Benefit Analysis"[Title/Abstract] OR "Cost Effectiveness"[Title/Abstract] OR "Economic Evaluation"[Title/Abstract] OR "Cost Benefit"[Title/Abstract] OR "Cost and Benefit"[Title/Abstract] OR "Cost-Utility Analysis"[Title/Abstract]) AND ("Telerehabilitation"[Title/Abstract] OR "Tele-rehabilitation"[Title/Abstract] OR "Tele-rehabilitation"[Title/Abstract] OR "Virtual Rehabilitation"[Title/Abstract] "Virtual Rehabilitation"[Title/Abstract]))
Scopus	TITLE-ABS-KEY (("Cost-Benefit Analysis" OR "Cost Effectiveness" OR "Economic Evaluation" OR "Cost Benefit" OR "Cost and Benefit" OR "Cost-Utility Analysis") AND ("Telerehabilitation" OR "Tele-rehabilitation" OR "Tele-rehabilitation" OR "Virtual Rehabilitation"))
Web of Science	TS= ("Cost-Benefit Analysis" OR "Cost Effectiveness" OR "Economic Evaluation" OR "Cost Benefit" OR "Cost and Benefit" OR "Cost-Utility Analysis") AND TS= ("Telerehabilitation" OR "Tele-rehabilitation" OR "Tele-rehabilitation" OR "Virtual Rehabilitation")
Embase	('Cost-Benefit Analysis':ti,ab,kw OR 'Cost Effectiveness':ti,ab,kw OR 'Economic Evaluation':ti,ab,kw OR 'Cost Benefit':ti,ab,kw OR 'Cost and Benefit':ti,ab,kw OR 'Cost-Utility Analysis':ti,ab,kw) AND ('Telerehabilitation':ti,ab,kw OR 'Tele-rehabilitation':ti,ab,kw OR 'Tele-rehabilitation':ti,ab,kw OR 'Virtual Rehabilitation':ti,ab,kw))

This review was limited to randomized and controlled trials so that we could evaluate the studies with the highest quality of evidence. We also did not filter in the study population or the type of tele-rehabilitation technology so that we would not miss articles on the cost-effectiveness of tele-rehabilitation interventions. All articles were removed from the collection of collected texts and duplicate articles were removed from this review. Titles and abstracts were screened independently based on eligibility criteria. Articles that did not meet the inclusion criteria were excluded from this review. Complete texts were then retrieved and screened by two separate researchers based on eligibility criteria. Disagreements between researchers were resolved through discussion.

Studies were included in the study if they met all the inclusion criteria: 1) Randomized clinical trial studies that used tele-rehabilitation versus traditional rehabilitation methods (face-to-face visits) and evaluated in terms of cost-effectiveness. 2) The full text of the articles was available in English.

On the other hand, exclusion criteria include: 1) studies including books, review articles, letters, studies in the form of letters to the editor and conference summaries; 2) Lack of availability of the full text in English; 3) Lack of relevance of the title, abstract or full text of the articles for the purpose of reading. The same checklist was used to extract the data. The data elements in this checklist included the title of the publication, year of publication, country, number of participants, duration of intervention, technology-based approach and the population studied, study objectives and main findings of the study.

In order to evaluate the quality of studies entering this study, the JBI quality evaluation checklist for randomized controlled trials was used [17]. This checklist consisted of 13 questions to evaluate the quality of studies. If the answer to a question was yes, he would get a score of 1 and otherwise a score of zero; therefore, the maximum quality evaluation score that each study could achieve was 13. Studies with a score less than 7 were excluded from this study.

RESULTS

The process of identifying and selecting studies based on PRISMA diagrams is shown in Figure 1. A total of 467 related documents were selected for review. After reviewing the articles and eliminating duplicate studies (197 articles), 270 articles were obtained and their screening was evaluated based on the titles and abstracts of the article. At the end of the review, 200 articles that had nothing to do with the purpose of this study were deleted. Then, 70 articles were selected to review their full text, of which 59 articles were deleted and finally 11 main articles were included in the study.

[Figure ID: F1] Figure 1. Diagram of the search process and study selection

The results of evaluating the quality of articles in Table 2 show that there was no significant bias in the studies and all studies had the quality of inclusion in our study.

Table 2. Summary of article quality evaluation using JBI evaluation checklist

Score	13	12	11	10	9	8	7	6	5	4	3	2	1	Reference
11	Yes	Yes	Yes	Yes	No	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	[18]
8	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	No	Yes	No	Yes	[19]
8	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	No	Yes	No	Yes	[20]
10	Yes	Yes	Yes	Yes	No	Yes	Yes	No	Yes	No	Yes	Yes	Yes	[21]
11	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	[22]
10	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	No	No	Yes	Yes	Yes	[13]
8	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	No	Yes	No	Yes	[6]
8	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	No	Yes	No	Yes	[23]
10	Yes	Yes	Yes	Yes	No	Yes	Yes	No	Yes	No	Yes	Yes	Yes	[24]
9	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	No	Yes	Yes	Yes	[25]
9	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	No	Yes	Yes	Yes	[26]

The characteristics of all the studies included are reported in Tables 3 and 4. Of the 11 incoming studies, three (27%) were in Australia [19, 22, 24], two (18%) in Denmark [18, 26], two in the United States [6, 25] and other studies in Belgium [20], Spain [21], Nigeria [13] and Poland [23]. The number of participants in each study ranged from 30 [21] to 516 [25] and included a total of 1479 participants. The duration of intervention in each study ranged from 6 weeks [24] to 12 months [6].

Approaches and health implications in tele-rehabilitation

Tele-rehabilitation approaches and health conditions evaluated in the studies were largely different, including wireless technology based on remote health monitor in chronic obstructive pulmonary disease (COPD), teleconferencing based online video conferencing. In patients with heart failure [19], a comprehensive rehabilitation program based on motion sensor in heart patients [20], virtual reality (VR) in restoring the balance of people with hemiparesis after stroke [21], tele-rehabilitation platform and Monitoring exercise in coronary heart disease [22] tele-rehabilitation (app, call, DVD) in people with chronic nonspecific low back pain [13], environmental equipment and remote control of vital signs in veterans [6], Remedial rehabilitation Combined cycle in heart failure patients [23], participatory tele-rehabilitation (contact and DVD) in advanced stage cancer patients [25], telemedicine-based rehabilitation program in cardiac patients [26].

Clinical effects of tele-rehabilitation

In (5, 45%) of the tele-rehabilitation interventions studies, a significant improvement in the outcomes and clinical effects was reported in the tele-rehabilitation group versus the control group (face-to-face visit) [13, 18, 20-22]. However, in (3, 27%) of the studies, similar improvement in clinical effects was reported by both control (face-to-face) and intervention (remote saw technology) groups [19, 23, 26]. In all studies, the control group underwent traditional (face-to-face) rehabilitation; however, in one case, the intervention group studies (tele-rehabilitation) were used as an adjunct intervention alongside face-to-face rehabilitation sessions [20].

Cost Effectiveness in tele-rehabilitation

In (11, 64%) of the studies, tele-rehabilitation interventions were more cost effective than traditional rehabilitation interventions (face-to-face visits) [13, 18, 20, 21, 23, 25]. However, in (4, 36%) of the studies, no significant difference was observed in the amount of expenditure in the two groups of control and intervention [6, 19, 22, 26]. In addition, no significant improvement in quality adjusted years (QALY) was reported in 4 studies [19, 23, 24, 26]. In the study by Haesum et al., The costs of remote care equipment include training of health care professionals, logistics, time spent by health care professionals, costs of hospitalization, outpatient calls, contact with a general practitioner, contact with an emergency physician, and other services. It was initial and medication. The costs of training health care professionals included the time spent training and health care professionals with different hourly wage rates. The average incremental cost-effectiveness ratio in the south-east quarter of Denmark showed that tele-rehabilitation was less costly and more effective than the rehabilitation given to the control group (home exercise) [18].

Hwang et al. In their study presented a distance rehabilitation program (including 12 weeks of exercise and group training at home via online video conferencing versus a traditional clinic-based program. Health care costs in this study (including staff, equipment, and hospitalization) Re-hospitalized due to heart failure was extracted from the health system record and calculated in Australian dollars in 2013. The results of their study showed that the total cost of health care per participant in the tele-rehabilitation group was significantly lower (-1590). Dollars, however) during the 6 months, no significant difference was observed in the years of quality adjusted life between the two groups [19]. In the study by Lloréns et al., The major cost in traditional rehabilitation was the cost of transporting the clinic, while in tele-rehabilitation it was the cost of the hardware required for the virtual reality (VR) system. They report that under certain circumstances, VR-based tele-rehabilitation programs can save costs, which are mainly due to transportation services [21].

In the study by Maddison et al., Specialist pay was the highest rehabilitation costs based on tele-monitoring and training. In addition to wearable sensors, office rentals and smartphones were the main cost drivers; In contrast, sports equipment and facility/ utility/ rental were the biggest cost drivers for clinic-based rehabilitation [22]. However, Fatoye et al. cited the main sources of funding for tele-rehabilitation as telephone credit, use of Internet data throughout the project, and consulting costs. They found that tele-rehabilitation was approximately 50% cheaper than clinic-based rehabilitation [13]. In other studies, the main costs related to tele-rehabilitation are the costs of tele-rehabilitation equipment, including the cost of subscribing to post offices, iPads, software subscriptions, training DVDs, telephone calls, and traditional rehabilitation costs, including the cost of going to the clinic, the cost of visits and specialist counseling [24-26].

Table 3. Intervention time, number of participants, tele-rehabilitation approach/ target population and types of costs in 11 input studies

Cost	Tele Rehabilitation Approach/ Target Population	Number of participants	Intervention time	Reference
Hospital admission Ambulatory contacts general practitioner contacts Emergency physician contacts Other primary services Medicine consumption Tele-home-care equipment	Wireless technology based on remote health monitor/ chronic obstructive pulmonary disease (COPD)	69	10 months	[18]
Exercise equipment Monitoring equipment Videoconferencing equipment Physiotherapist Nurse Other personnel Home visit Assessment Heart failure readmissions	Online video conferencing-based rehabilitation/ heart failure patients	53	6 months	[19]
Intervention costs: Standard cardiac rehabilitation, (the National Sickness and Invalidity Insurance Institution: RIZIV/INAMI) Standard cardiac rehabilitation (patient) Study nurse Accelerometer Web page service Info. brochure Health care costs: Cardiovascular rehospitalisation’s cost (RIZIV/INAMI) Cardiovascular rehospitalisation’s cost (patient) Specialist visit cost (RIZIV/INAMI) Specialist visit cost (patient) Diagnostics cost (RIZIV/INAMI) Diagnostics cost (patient)	Comprehensive motion rehabilitation program based on motion sensor / heart patients	140	3 months	[20]
Human resources: Physical therapy Monitoring Troubleshooting Round trips (n): Control Instrumentation: Laptop Kinect™ Internet access	Virtual reality (VR) in restoring balance in people with hemiparesis after stroke	30	5 months	[21]
Specialist salary Wearable sensors Office lease Smartphones Exercise equipment Facility lease/utilities	Tele-rehabilitation and Exercise Monitoring / Cardiovascular Disease Platform	162	3 months	[22]
SMS messages and reminder calls Compatible phones for the app Clinic visit Consultation fee Transportation and refreshment	App + Call + DVD/ tele-rehabilitation in People with Nonspecific Chronic Low Back Pain	47	2 m	[13]
Inpatient bed days of care Clinic visits Emergency room visits Nursing home care unit were totaled Veterans Administration- incurred expenses	Environmental equipment and remote vital sign control /veterans' tele-rehabilitation program	115	12 m	[6]
Diagnosis First week of hospitalization Final assessment Equipment Specialist advice	Combined tele-rehabilitation in patients with heart failure	126	9 weeks	[23]
Intervention physiotherapy sessions Additional physiotherapy sessions Direct physiotherapist time in minutes Intervention session costs (includes subscription fees) Additional sessions costs Patient time in minutes Carer time in minutesc Patient/Carer travel costs	IPad + software sharing / tele-rehabilitation in pelvic joint replacement patients	70	6 weeks	[24]
Instruction DVDs Elastic resistance bands Pedometers Fitness care manager call time Fitness care manager and pain care manager call time Pain care manager meeting Utilization Probability of hospitalization Hospital length of stay (days) Utilization Costs Cost of inpatient Hospital day	Call + DVD / Participatory tele-rehabilitation in advanced cancer patients	516	9 m	[25]
Costs of Tele dialog: Time (min) Staff time information to patients) Staff time (dialogue with patients) Visit at patient's home Collecting and cleaning devices Devices' cost: Rent of telemedicine devices (3 months) Rent of tablet Fitbit Ultra Activeheart.dk Cost of rehabilitation services: Contacts with Nurse Doctor Physiotherapist Dietician Psychologist Participations in team training Costs of healthcare services: Admissions Outpatient visits Contacts with: General Practitioner Emergency physician Transportation costs	Tele-dialogue / telemedicine rehabilitation program in heart patients	151	3 m	[26]

Table 4. Summary of characteristics of input studies

Study result	Purpose of the study	References
The average incremental cost-effectiveness ratio in the south-east quarter of Denmark indicates that tele-rehabilitation is less costly and more effective than the rehabilitation given to the control group. The tele-rehabilitation program adds more value to money and saves on health care budgets. As a result, tele-rehabilitation programs are more cost-effective than conventional rehabilitation programs for COPD patients.	Cost-effectiveness analysis of the Danish TELEKAT project (tele care, chronically ill and integrated health care system)	[18]
Total health care costs were significantly lower ($ 1590) per participant in the tele-rehabilitation group. There was no significant difference in QALY between the two groups. Tele-rehabilitation of heart failure appears to be less costly for health care providers and as effective as traditional centre based rehabilitation.	Cost-effectiveness evaluation of an online rehabilitation program based on online video conferencing	[19]
Results The mean total cost per patient in the intervention group (Euro2156Euro126) was significantly lower than the control group (Euro2720 +/- Euro276) (p = 0.01). The cost-effectiveness increased QALY. The number of days lost due to cardiovascular readmission in the intervention group (0.33 15 0.15) was significantly less than the control group (0.79 20 0.20). Adding remote cardiac rehabilitation to conventional cardiac rehabilitation in the center provided Services are more effective and efficient than centre-based cardiac rehabilitation alone.	Evaluate the cost-effectiveness of a comprehensive remote cardiac rehabilitation program	[20]
First, VR-based tele-rehabilitation interventions significantly improved in both groups (control and home-based tele-rehabilitation group) from initial to final assessment at the leaf balance scale (eta (2) (p) = 0.68; P = 001), in the equilibrium subscales (eta (2) (p) = 0.24; P = .006) and gait (eta (2) (p) 0.57 = 0.001) evaluated the Tinetti axis function mobility and evaluated the Brunel equilibrium ( Control: chi (2) = 15.0; P = .002; Intervention: chi (2) = 21.9; P = .001). ). Clinical intervention cost more than tele-rehabilitation intervention ($ 654.72 per person).	Evaluating the Clinical Effectiveness of a Virtual Reality (VR) Rehabilitation Program in Restoring the Balance of People with Post-Stroke Hemiparesis Compared to an In-Clinical Program, Comparing Mental Experiences, and Comparing the Costs of Both Programs	[21]
Maximum oxygen uptake at 12 weeks was comparable in both groups and REMOTE-CR was lower than CBexCR (mean difference of adjusted mean REMOTE-CR-CBexCR (AMD) = 0.51 (95% CI-0.97 to 1.98) ml / kg / min. (p = 0.48) The costs of using hospital services were not statistically significant (NZD3459 / GBP1754 vs. NZD5464 / GBP2771, p = 0.20).	Comparison of the effects and costs of distance exercise-based cardiac rehabilitation (REMOTE-CR) with CBexCR-based programs in adults with coronary heart disease	[22]
REMOTE-CR is an effective and cost-effective alternative delivery model that can complement the overall utilization rate by increasing access and meeting participants' unique priorities as a complement to existing services.	Objective: Clinical evaluation and cost-effectiveness of tele-rehabilitation compared to clinic-based intervention for NCLBP patients with nonspecific chronic low back pain in Nigeria.	[13]
The average estimated cost of TBMT and CBMT interventions per person was 22,200 naira (US $ 61.7) and 38,200 naira (US $ 106), respectively. The QALY obtained was 0.085 for TBMT and 0.084 for CBMT. The TBMT arm was associated with an additional 0.001 QALY (95% confidence interval (CI): 0.001 to 0.002) per participant compared to the CBMT arm; Therefore, ICER showed that TBMT arm is less cost effective and more effective than CBMT arm. The findings of the study showed that tele-rehabilitation for NCLBP patients is cost effective. Due to the small number of participants in this study, further investigation of the effects and costs of interventions on a larger sample size is needed.	Veterans' tele-rehabilitation Program (LAMP) was evaluated for its effects on health care costs.	[6]
Using the actual costs collected for these analyzes, no significant difference in post-registration costs was observed between LAMP and MCG. For LAMP patients, the provision of adaptive equipment and environmental changes, in addition to intensive monitoring in patients' homes, led to an increase in post-intervention clinic visits with a reduction in hospital stays and nursing homes.	Cost-effectiveness of combined telemedicine rehabilitation compared to standard care in heart failure patients in Poland	[23]
Tele-rehabilitation is cost-effective compared to standard care, ie the additional costs are justified by the clinical effects obtained. The additional cost of achieving a year of healthy living, depending on the approach taken, is in the range of 58000-96000 QALY, which is clearly below the profitability threshold in Poland. The difference in QALY on the one-year horizon, although in favor of tele rehabilitation, was not noticeable.	Comparison of the cost-effectiveness of a tele-rehabilitation program offered remotely in patients' homes versus traditional care for patients with complete pelvic replacement after hospital discharge	[24]
The average estimated differences were observed in health care costs and QALYs obtained, but this difference was not significant. The average estimate of the difference in the cost of tele-rehabilitation compared to the presence was -28.90 dollars (-96.37 to $ 40.45), which is in favor of the tele-rehabilitation group. The estimated mean difference in QALYs obtained from tele-rehabilitation was -0.0025 (-0.0522 to 0.0217) compared to the presence. The mean difference in estimated time preferred less time for the tele-rehabilitation group (-4.69 to -3.74) hours. Tele-rehabilitation in the entire hip replacement population incurred similar costs and had similar effects to traditional care. Tele-rehabilitation significantly reduced time for patients and caregivers.	Determining the cost-effectiveness of a centralized remote care approach based on the CCM participatory care model for providing rehabilitation services to cancer patients was in the final stages of experiencing functional limitations.	[25]
In the total cost analysis, the total costs of hospitalization in both groups of tele-rehabilitation were significantly lower than the control group (P = 0.048).	Cost-Use Evaluation of a Remote Cardiac Rehabilitation Program	[26]

DISCUSSION

Despite the COVID-19 epidemic, current budget constraints do not allow for the increase in the budget of conventional rehabilitation programs. As a result, there is an increasing need for cost-effective alternative strategies such as tele-rehabilitation [20]. Tele-rehabilitation is one of the approaches that, with the help of patient education, monitoring and self-efficacy, identifies exacerbations in a timely manner and prevents patients from being hospitalized, thus reducing health costs [12]. Therefore, the purpose of this study was a systematic review of randomized clinical trial studies to evaluate the cost-effectiveness of tele-rehabilitation. The results of this study showed that in (5, 45%) of the studies of tele-rehabilitation interventions there is a significant improvement in the outcomes and clinical effects in the tele-rehabilitation group versus the control group (face-to-face visit) [13, 18, 20 -22]. In (11, 64%) of the studies, tele-rehabilitation interventions were more cost effective than traditional rehabilitation interventions (face-to-face visits) [13, 18, 20, 21, 23, 25]. However, in (4, 36%) of the studies, no significant difference was observed in the amount of expenditure in the two groups of control and intervention [6, 19, 22, 26]. In addition, in 4 of the studies, no significant improvement in quality adjusted years was reported [19, 23, 24, 26]. An RCT study in Australia found that total health care costs were significantly lower ($15,090) per participant in the tele-rehabilitation group [19]. RCT study In Belgium, the average total cost per patient in the tele-rehabilitation group (Euro 2156, Euro 126) was significantly lower than the control group (Euro 2720 +/- Euro276) [20]. The Spanish RCT study showed that rehabilitation in the clinic costs more than tele-rehabilitation intervention ($654.72 per person) [21]. However, the tele-rehabilitation approaches and health conditions evaluated in the studies were largely different. Previous studies have shown that tele-rehabilitation in heart patients shows good results in terms of feasibility, safety and effectiveness [20, 27, 28].

However, clinical trial studies with in-depth cost-benefit assessment are less common. Körtke et al. [29] were one of the first groups to report cost-effectiveness in a non-randomized controlled trial that evaluated a telephone guide to outpatient rehabilitation in cardiac surgery patients. They concluded that the total cost of a remote cardiac rehabilitation program is lower than conventional cardiac rehabilitation in a hospital. In their study, Lloréns and Nelson stated that the time spent by care professionals in the control group (face-to-face rehabilitation) was significantly longer than in the tele-rehabilitation group [21, 24]. However, Hwang et al. stated that a supervised training program based on patients' online video conferencing received similar contact times with health care professionals [19]. Frederix et al. reported that the number of missed appointments due to cardiovascular readmission in the intervention group was significantly (p=0.037) less than the control group [30]. Most studies have stated that the small number of participants and the small size of the community itself is an important factor in estimating costs, as purchasing equipment and infrastructure often requires a cost, and with a large number of participants the overall cost per person will be lower [13, 21, 22].

In addition, evidence from previous studies shows that tele-rehabilitation can be successful. For example, a systematic review reported the success rate of tele-rehabilitation in patients with a physical disability of 71% [30].

One of the limitations of this study was the wide variety of technologies used in tele-rehabilitation and different health conditions and evaluations in different years with different inflation rates. Evidence basis in feasibility study, impact and cost effectiveness of rehabilitation services. In addition, the keywords searched may not be sufficient and complete to obtain further studies, and some prominent and relevant studies may not be included in this study. Also, this study only included studies published in scientific journals and conference proceedings; therefore, it does not cover articles published in the gray literature.

CONCLUSION

Evidence from this study shows that tele-rehabilitation services and care are more cost-effective for the general public than face-to-face services. Considering that tele-rehabilitation interventions in reducing the time spent in providing services, reducing and eliminating the cost of transportation, provide self-efficacy in improving the condition of patients and considering that tele-rehabilitation in all clinical outcomes reported in control studies It is better or equal to traditional rehabilitation, so it is suggested that future studies focus on improving patients' access to rehabilitation services and removing barriers to tele-rehabilitation in order to maximize the potential for tele-rehabilitation.

AUTHOR’S CONTRIBUTION

All authors contributed to the literature review, design, data collection and analysis, drafting the manuscript, read and approved the final manuscript.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest regarding the publication of this study.

FINANCIAL DISCLOSURE

No financial interests related to the material of this manuscript have been declared.

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