Cost-Effectiveness of Virtual Emergency Care Models: A Systematic Review (Preprint)

<sec> <title>BACKGROUND</title> Virtual care technologies have rapidly expanded in emergency medicine, particularly accelerated by the COVID-19 pandemic. However, comprehensive economic evaluations of their cost-effectiveness remain fragmented across different clinical applications and healthcare settings, creating uncertainty for policymakers and healthcare administrators considering implementation. </sec> <sec> <title>OBJECTIVE</title> This study aimed to systematically review and synthesize evidence on the cost-effectiveness of virtual emergency care models compared to traditional in-person emergency care across diverse clinical conditions, populations, and healthcare settings. </sec> <sec> <title>METHODS</title> We conducted a systematic review following PRISMA guidelines, searching eight electronic databases (PubMed, Embase, Scopus, Web of Science, CINAHL, Cochrane Library, MEDLINE, PsycINFO) from inception to February 2025. We included full economic evaluations (cost-effectiveness, cost-utility, cost-benefit, or cost-minimization analyses) comparing virtual emergency care interventions to usual care. Two reviewers independently screened studies, extracted data, and assessed quality using the Drummond checklist and Consensus Health Economic Criteria (CHEC) list. Evidence certainty was evaluated using GRADE methodology. Given heterogeneity in interventions and methods, we conducted a narrative synthesis organized by virtual care modality and clinical application. </sec> <sec> <title>RESULTS</title> From 5,817 identified references, 12 studies met inclusion criteria, representing diverse virtual care modalities across five countries (United States, Australia, Italy, Canada, Haiti). All studies demonstrated that virtual emergency care was either cost-saving or cost-effective compared to usual care. Video consultation was the most common modality (10/12 studies), achieving 31-73% reduction in patient transfers and cost savings of US $105-$5,118 per encounter. Five studies (50%) found virtual care to be dominant (both less costly and more effective). Incremental cost-effectiveness ratios ranged from €990 to $108,363 per quality-adjusted life year (QALY), with most falling below accepted willingness-to-pay thresholds. Transfer avoidance was the primary economic driver, particularly in rural settings. Quality assessment revealed high methodological rigor (mean Drummond score: 92.9%; mean CHEC score: 95.4%). Using GRADE methodology, we found high certainty evidence for cost-effectiveness outcomes, moderate certainty for transfer reduction and quality of life improvements, and low certainty for emergency department length of stay and mortality benefits. </sec> <sec> <title>CONCLUSIONS</title> Virtual emergency care demonstrates strong and consistent cost-effectiveness across diverse clinical conditions, populations, and healthcare settings. The evidence particularly supports implementation for stroke care, pediatric emergencies, and rural/remote populations where transfer avoidance drives substantial economic benefits. All evaluated modalities, from sophisticated video consultation systems to simple telephone-based services, achieved favorable economic outcomes, suggesting technology should match context rather than maximize sophistication. These findings provide robust economic justification for expanding virtual emergency care access and removing regulatory barriers. As healthcare systems face mounting pressures from aging populations, workforce shortages, and budget constraints, virtual emergency care offers a proven strategy for improving access and quality while reducing costs. </sec> <sec> <title>CLINICALTRIAL</title> PROSPERO CRD42025648202 </sec>