Cost-effectiveness analysis of a telemedicine network for acute neurological care in northeast Germany (ANNOTeM)

Background: Expert neurological care in rural areas remains a major challenge and contributes to disparities in outcomes after acute neurological emergencies. To address this gap, the ANNOTeM project established a comprehensive, digitally enabled "hub-and-spoke" telemedicine network connecting academic neurology centers with regional hospitals in northeast Germany, providing 24/7 remote expertise, standardized operating procedures, and digital quality management. Methods: This prospective pre and post implementation study used statutory health insurance claims to compare patient outcomes and costs for acute neurological emergencies across 11 ANNOTeM network hospitals vs. 11 matched non-network hospitals (all hospitals were localized in rural regions). The analysis included all consecutively hospitalized adults with ICD-10 coded acute neurological disorders. The primary clinical endpoint was the composite of 90-day mortality, new need for outpatient or nursing home care. Health economic evaluation included direct medical, non-medical, and indirect costs from the insurer's perspective. Results: Following network implementation, the rate of the primary outcome decreased in ANNOTeM hospitals (33.8% vs. 35.9%; unadjusted absolute difference: -2.1%; adjusted absolute difference: -3.2%; aHR 0.89, 95% CI: 0.79-0.99), with no improvement in control hospitals (40.7% vs. 42.5%; aHR 1.04, 95% CI: 0.85-1.15). Mean 90-day total costs per patient rose modestly from €11,938 to €12,252 (+2.6%, non-significant). Non-network hospitals showed a similar non-significant cost increase. The cost per avoided adverse composite outcome was €14,968 (unadjusted). Conclusion: Implementing a digitally integrated teleneurology network was associated with improved patient outcomes without substantial increases in per-patient costs. These results support the economic sustainability and transformative potential of innovative, network-based telemedicine systems for acute neurological care in underserved, rural regions.