The aim of this review is to identify economic evidence and approaches used in evaluation of early-life interventions to promote healthy eating in the first 1000 days in community, education, and home settings and establish evidence gaps.

Five databases and 5 websites were searched using key words. Findings are presented using a narrative synthesis.

Home, education, and community settings

Pregnant women, infants and young children 0-2 years old

Economic evaluations presenting costs and consequences published in English peer-reviewed journals were selected. Overall, the 24 included studies demonstrated mixed quality. Based on CHEERS 2022, titles, comparators, and outcomes were commonly reported, whereas health economic analysis plan (HEAP), heterogeneity, and uncertainty were least reported. Four studies stated the analytical perspectives with clear decision contexts, making the results useful in decision-making. Several studies had a time horizon of 1 year or shorter with unclear decision-context. Four studies presented relatively transparent methods, with the interpretation of results from cost-utility analyses being informative for decision-making.

This review identified consistent methodological challenges in the economic evaluation of early-life nutrition interventions. Comparators were inconsistently defined, with the varied definition of ‘standard care’ across studies and settings, limiting comparability and decision relevance. Furthermore, most studies adopted short time horizons, often one year (or shorter), limiting the ability to capture longer-term outcomes such as obesity, educational attainment, and life-course health impacts. Chosen outcomes were narrow, focusing on immediate health outcomes without consideration of broader or downstream effects. In addition, socioeconomic characteristics or exploring differential effects across population groups were rarely reported in the included studies. Addressing these identified issues require more robust and transparent approaches to economic evaluation. Incorporating a HEAP as an integral part of a study protocol ensures that key methodological elements (such as the economic question, PICO, analytical perspectives, time horizons, the approaches to handling uncertainties, and decision contexts) are pre-specified and aligned with decision contexts to support evidence-based decision-making.

A novel transdiagnostic blended Ecological Momentary Intervention (EMI) for improving self-esteem in youth who experienced childhood adversity has shown beneficial effects. However, evidence on the cost-effectiveness of SELFIE and EMIs overall is lacking.

In this RCT-based economic evaluation, participants aged 12–26 years with low self-esteem (<26 on the Rosenberg Self-Esteem Scale [RSES]) and experienced childhood adversity were recruited from specialized mental health services and the general population and randomly allocated to CAU (control condition) or CAU + SELFIE (experimental condition). The Trimbos/iMTA Questionnaire for Costs Associated with Psychiatric Illness (TiC-P), the RSES, and EQ-5D-5L were assessed at baseline, post-intervention, and 6-, 18-, and 24-month follow-up. Incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, and acceptability curves, were generated. Sensitivity and subgroup analyses assessed robustness.

From a societal perspective, the ICER presented €1,219 per improved point of self-esteem, and the ICUR presented €53,986 per QALY gained. The probability of cost-effectiveness was 26% at a willingness-to-pay (WTP) threshold of €20,000/QALY and 49% at €50,000/QALY. At €50,000/QALY, the probability of cost-effectiveness was 77% from a healthcare perspective (ICUR €15,671/QALY gained) and 87% for participants recruited from specialized mental health services (ICUR €–14,567/QALY gained).

At the societal level, the SELFIE intervention exceeded the WTP threshold. Tests for robustness showed higher probabilities of cost-effectiveness from a healthcare perspective, likely reflecting the absence of educational productivity loss costs in the societal perspective, and in youth recruited from specialized mental health services. The innovative field of blended EMIs yields encouraging first results, urging more cost-effectiveness research.

The choice between transcatheter and surgical pulmonary valve replacement for young adults with repaired tetralogy of Fallot who develop significant pulmonary valve insufficiency is challenging. Decision analytic modelling may be used to simulate long-term outcomes and suggest influential clinical thresholds for decision-making. A Markov model was constructed to compare the 5-year outcomes for a hypothetical cohort of 18-year-old patients.

A Markov model was constructed to simulate 10,000 hypothetical patients undergoing either transcatheter pulmonary valve replacement or surgical pulmonary valve replacement. Model inputs were abstracted from contemporary literature on the 5-year horizon. Outputs were used to derive an incremental cost-effectiveness ratio. Sensitivity and threshold analyses were performed to identify factors that would hypothetically change management.

From modelling, surgical pulmonary valve replacement had superior survival, lower incidence of endocarditis, and lower reintervention rate compared to transcatheter pulmonary valve replacement at 5 years. Surgical pulmonary valve replacement yielded lower cumulative postprocedural costs ($10,767 versus $14,528) and greater quality-adjusted life years (3.16 versus 3.12 QALYs) than transcatheter pulmonary valve replacement. The calculated incremental cost-effectiveness ratio (−88,743$/QALY) identified surgical pulmonary valve replacement as the preferred strategy at baseline. Sensitivity analysis demonstrated that transcatheter pulmonary valve replacement would be the preferred strategy if either the post-transcatheter pulmonary valve replacement endocarditis rate or the post-transcatheter pulmonary valve replacement surgical reintervention rate were reduced to 0%/month.

Comprehensive modelling of diverse outcomes showed that surgical pulmonary valve replacement had superior mid-term cost-effectiveness outcomes compared to transcatheter pulmonary valve replacement for young adults with repaired tetralogy of Fallot and pulmonary valve regurgitation. Sensitivity analysis found that the prevalence of post-transcatheter pulmonary valve replacement endocarditis and post-transcatheter pulmonary valve replacement surgical reintervention were influential outcomes for centres to consider when choosing between these strategies.

Behavioural interventions can be delivered via online school canteens to improve healthy purchasing for students. However, no evaluations of the cost or cost-effectiveness of online canteen interventions have been conducted. The objective was to conduct a cost and cost-effectiveness analysis of implementing an online school canteen intervention to improve healthy purchasing.

The ‘Click & Crunch’ cluster randomised controlled trial was conducted in seventeen Australian primary schools.

Eight control schools (848 students) received the standard online canteen. Nine intervention schools (1359 students) received a behavioural intervention delivered through the online canteen.

Incremental cost-effectiveness ratios (ICER) were calculated for the cost per student to achieve (1) a unit decrease in the mean energy (kJ) content and (2) a percentage increase in the mean proportion of healthier ‘Everyday’ items purchased in their online lunch orders (from a health service and societal perspective).

It costs AUD$568 per school (range $343–$806) to implement. The ICER for mean energy content was AUD$0·06 and AUD$0·46 for mean proportion of ‘Everyday’ foods (from a health perspective). At a willingness to pay of AUD$0·20 and AUD$1·20 per student, the intervention would have a 95 % and 99 % probability of being cost-effective for the energy (kJ) content and proportion of ‘Everyday’ items, respectively.

‘Click & Crunch’ has the potential to be a cost-effective intervention to reduce the energy content and increase the proportion of ‘Everyday’ items from primary school online canteen lunch orders.

Individuals with severe mental illnesses (SMIs) experience anxiety that impairs functioning and quality of life. This cluster randomized trial evaluated exposure-based cognitive behavioral therapy (ebCBT) integrated into assertive community treatment (ACT) teams to reduce anxiety.

Fifteen ACT teams were allocated to ebCBT + ACT (k = 8, n = 50) or ACT-only (k = 7, n = 43). The intervention followed four steps: situation identification, four-component analysis (behavior, cognition, emotion, physical symptoms), psychoeducation, and graded exposure. Staff received 50 h training and bimonthly supervision over 12 months. Co-primary outcomes were trait and social anxiety; secondary outcomes were psychiatric symptoms, functioning, quality of life, and recovery.

The ebCBT + ACT group showed significant improvements in State–Trait Anxiety Inventory–Trait scores at 12 months (AMD = −5.30, 95% CI = −8.71 to −1.90, p = 0.002, d = −0.64) and 18 months (AMD = −7.22, 95% CI = −12.1 to −2.34, p = 0.004, d = −0.60). Brief Fear of Negative Evaluation scores showed near-significant improvement at 18 months (AMD = −3.70, 95% CI = −7.44 to 0.04, p = 0.052, d = −0.40). Secondary outcomes, including global functioning, recovery, and quality of life, also improved. Cost-effectiveness analyses indicated favorable cost-effectiveness for anxiety outcomes.

Embedding ebCBT within ACT services may reduce anxiety-related fear and avoidance and enhance recovery-related outcomes in individuals with SMI. These findings support the feasibility and clinical value of integrating structured psychological interventions into intensive community-based outreach services.

To model the potential value for money of implementing proposed unhealthy food advertising restrictions on Western Australian (WA) transport-owned assets to prevent obesity-related diseases.

A cost–benefit analysis using a societal perspective was undertaken to model the policy intervention over a 30-year time horizon. The effectiveness of the intervention was based on a similar policy implemented in the United Kingdom by Transport for London, adapted to the WA context. The ACE-Obesity Policy model, a validated multi-state lifetable Markov model, was used to assess the expected health (quantified as health-adjusted life years (HALY)) and economic outcomes of the intervention’s impact on unhealthy food consumption. The potential costs of policy development and monitoring and revenue impacts on government and industry (outdoor advertising companies) were included in the modelled analysis.

Western Australia.

Greater Perth population.

The cost of implementing the policy was estimated at A$28 million (95 % uncertainty intervals (UI): $23, $35), 71 % borne by the government and the remaining by outdoor advertisers. A mean population weight reduction of 0·58 kg (95 % UI: 0·28, 0·90) was estimated, which translated to 5906 health-adjusted life years gained (95 % UI: 2750, 9084) with a monetary value of A$1374 million (95 % UI: $642, $2112). Eight percent of the monetised benefits were attributed to healthcare cost savings, while 92 % were associated with monetised health gains. The intervention was estimated to generate a net-present value of $1346 million (95 % UI: $614, $2082) and benefit–cost ratio of 50 (95 % UI: 23, 81).

Policy to restrict advertising of unhealthy foods on WA transport-owned assets is likely to represent excellent value for money.

Depression screening in primary care has been widely discussed, but its economic implications have remained largely unexplored. The GET.FEEDBACK.GP randomised controlled trial evaluated feedback interventions after depression screening in primary care. The study arms were (a) feedback provided to the general practitioner; (b) feedback to both the patient and the treating general practitioner; and (c) a control group without feedback. Analysis of clinical effectiveness revealed that feedback interventions were not associated with decreased depression severity. Their economic implications were the subject of this study.

To evaluate the economic impact of general-practitioner- and patient-targeted feedback following depression screening for adults in German primary care.

A cost-effectiveness analysis from a societal perspective of feedback interventions after depression screening with a time horizon of 12 months was conducted. Direct and indirect costs were estimated. Quality-adjusted life years were calculated on the basis of the EQ-5D-5L, and incremental cost-effectiveness ratios and cost-effectiveness acceptability curves based on the net monetary benefit were constructed. Sensitivity analyses and post hoc explorative subpopulation analyses were performed. Trial registration: ClinicalTrials.gov, NCT03988985.

In total, 987 participants who screened positive for at least moderate depression were included. Feedback provision was not significantly associated with changes in costs or quality-adjusted life years during follow-up. Cost-effectiveness probabilities of feedback interventions were lower than 50% compared with no feedback. Higher cost-effectiveness probabilities were observed in patients whose suspected depression was confirmed 1 month post-screening and in those with previous depression.

The analysed feedback interventions cannot be considered to be cost-effective for the investigated population. Patient-targeted feedback was potentially cost-effective for subpopulations, particularly patients with a later confirmed depression diagnosis; this requires further research.

AVATAR therapy, a digitally supported intervention, utilises avatars to promote recovery in people who experience distressing auditory hallucinations. This approach was recently evaluated in a multicentre randomised controlled trial comparing brief (AV-BRF) and extended (AV-EXT) forms of therapy with treatment as usual (TAU). There was evidence for the effectiveness of therapy, particularly for AV-EXT. However, value for money needs to be assessed.

To compare separately the cost utility of the brief and extended forms of AVATAR therapy with TAU.

In a three-arm randomised controlled trial the use of health services was measured, and costs (2021/2022; pounds sterling) calculated from a health and social care perspective over a 28-week follow-up period. Quality-adjusted life years (QALYs; derived from the 5-level version of the EuroQol 5-Dimension questionnaire) were combined with costs.

AV-BRF resulted in extra costs of £319 (95% CI, −£1558 to £2496), and AV-EXT in lower costs of £1965 (95% CI, −£1912 to £1519), compared with TAU. Over the follow-up, AV-BRF resulted in 0.0159 (95% CI, −0.0103 to 0.0422) and AV-EXT in 0.0173 (95% CI, −0.0049 to 0.0395) more QALYs than TAU. The cost per QALY for AV-BRF compared with TAU was £20 016, while AV-EXT dominated TAU (lower costs and more QALYs).

Neither version of AVATAR had a substantial impact on QALYs. However, AV-EXT did result in reduced care costs − albeit not statistically significant − and was potentially cost-effective compared with TAU. AV-BRF had an incremental cost-effectiveness ratio that indicated lower potential cost-effectiveness. These findings are uncertain, but could still inform decision-making regarding interventions in this field.

Generalized myasthenia gravis (gMG) is a chronic neuromuscular disease that causes muscle weakness and fatigue, severely impairing quality of life. Efgartigimod is a novel drug that is recently approved for treatment of acetylcholine receptor antibody-positive (AChR-Ab+) gMG patients in Canada. In clinical practice, it is expected to be used in AChR-Ab+ gMG patients who continue to experience symptoms despite conventional therapy and primarily replace chronic immunoglobulins.

A Markov model was developed to estimate costs and benefits (measured as quality-adjusted life years [QALYs]) of efgartigimod and chronic immunoglobulins for AChR-Ab+ gMG patients. The analysis was conducted from the perspective of the Canadian publicly funded healthcare system over a lifetime horizon. The model comprised six health states based on Myasthenia Gravis Activities of Daily Living (MG-ADL) scores: MG-ADL < 5, MG-ADL 5–7, MG-ADL 8–9, MG-ADL ≥ 10, myasthenic crisis or death. Health state transition probabilities were estimated from the ADAPT and ADAPT+ studies, plus a network meta-analysis that compared efgartigimod against chronic immunoglobulins. The MyRealWorld MG study informed utility values. Modeled costs included treatment and administration, disease monitoring, complications from chronic corticosteroid use, exacerbation/crisis management, adverse events and end-of-life care.

Over a lifetime horizon, efgartigimod and chronic immunoglobulins were predicted to have total discounted QALYs of 16.80 and 13.35 and total discounted costs of $1,913,294 and $2,170,315, respectively. Efgartigimod dominated chronic immunoglobulins with incremental QALYs of 3.45 and cost savings of $257,020.

Efgartigimod provides greater benefit in terms of lower costs than chronic immunoglobulins for AChR-Ab+ gMG patients in Canada.

Loneliness is associated with several physical and mental health problems, yet its costs to the healthcare system remain unclear.

The current study aimed to review literature on the health and social care impacts of loneliness, and review economic evaluations of loneliness interventions.

We conducted a systematic review of studies published from 2008 to April 2025 by searching five bibliographic databases, grey literature and reference lists of systematic reviews. Studies estimating health and social care cost/expenditure, and on health resource utilisation, were included to assess the impact of loneliness on the health system. Return on investment, social return on investment and cost-effectiveness evaluations were included to assess the economic impact of loneliness interventions. We conducted quality appraisal and narrative synthesis of results.

We included 53 studies. Eight estimated the healthcare cost/expenditure of loneliness, 33 reported healthcare resource use and 19 were economic evaluations of interventions. Findings relating to the cost/expenditure of loneliness and service use were inconsistent: some studies reported excess costs/expenditure and service use, whereas others found lower costs/expenditure and service use. Economic evaluation studies indicated that loneliness interventions can be cost-effective, but were not consistently cost-saving or effective in reducing loneliness.

Findings on the impact of loneliness on the healthcare system and economic evaluations of loneliness interventions were varied. Therefore, we cannot derive confident conclusions from this review. To address evidence gaps, future research relating to social care, younger populations, direct healthcare costs of loneliness and randomised controlled trials with long-term follow-ups should be prioritised.

Many patients with major depressive disorder (MDD) do not respond sufficiently to first-line treatments. Due to its biological and psychological mechanisms, exercise may enhance the effectiveness of other MDD treatments. In a pragmatic randomised superiority trial, we evaluated the clinical and cost-effectiveness of exercise therapy adjunct to guideline-concordant care as usual (CAU) for MDD in specialised mental health care.

MDD outpatients (N = 112; Mage = 37; 51% female) were randomized to CAU (96.9% psychotherapy, 59% pharmacotherapy) or CAU + EX (CAU plus 12 weeks of exercise therapy: one supervised and two home-based aerobic sessions/week). Depressive symptoms were assessed using the Inventory of Depressive Symptomatology-Self Report. Remission was evaluated during follow-up by blinded assessors using the Structured Clinical Interview for DSM-5. The economic evaluation followed a societal perspective.

Patients in the CAU + EX condition were significantly more likely than those in CAU to meet the exercise prescription; however, only 22% fully adhered to it. Depressive symptoms decreased from severe to moderate depression in both conditions, with no significant difference between the conditions on symptom reduction (b = −0.22, [−0.72, 0.29]) or remission rate (OR = 0.06, [−0.20, 0.32]). Evidence for cost-effectiveness was found in the per-protocol (≥ six supervised exercise sessions) but not in the intention-to-treat sample.

Adjunct exercise therapy does not provide additional clinical benefits or cost-effectiveness in specialized mental health care. Low adherence to the exercise prescription limits its potential. Cost-effectiveness may be achievable with higher adherence, warranting emphasis on strategies to improve adherence in this population.

Short-course regimens are currently explored to improve multidrug-resistant tuberculosis effects, reduce costs, as well as enhance patient adherence. Currently, we are determining the most cost-effective shorter regimen out of seven short-course regimens (6–9 months) to treat drug-resistant tuberculosis (DR-TB) compared to the current standard of care (SoC) 9- to 11-month regimen.

Cost-effectiveness of various short-course DR-TB treatment regimens, namely BEAT, BPaL, BPaLM, BPaLC, mBPaL1, mBPaL2, and mBPaL3, was compared to the current SoC in India. Decision tree model was used from a health system perspective. The information on various costs – such as preinvestigations, regimens, adverse drug reactions (ADRs) management, inpatient treatment – and on effect – such as clinical outcomes and ADRs – was collected from different published sources. It estimated costs, quality-adjusted life years, and incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were performed to validate outcomes against the willingness-to-pay threshold.

When all the short-course regimens were compared with the current SoC regimen, the ICERs were ₹5,385, ₹2,014, ₹2,008, ₹2,435, ₹1,462, ₹1,159, and ₹1,895 for BEAT, BPaL, BPaLM, BPaLC, mBPaL1, mBPaL2, and mBPaL3, respectively. Among the short-course regimens, mBPaL2 is the dominant strategy, and mBPaL1 has extended dominance. For all Bedaquiline-containing regimens, the cost of the drug is a crucial factor in determining cost effectiveness. The cost-effectiveness acceptability curve showed that all shorter regimens were 100 percent cost-effective.

The implementation of Bedaquiline-based regimen to treat DR-TB has become more effective, shorter in duration, and less burdensome to the health system.

Predictive biomarkers can identify patients who are more likely to respond to immunotherapy, which can guide treatment decisions. The objective of this study was to assess the potential value of predictive biomarkers in advanced NSCLC patients to guide the development of cost-effective biomarkers in this field.

A decision analytical model was constructed to compare theoretical new strategies with biomarkers to the current standard of care. The analysis was performed for three different patient groups based on PD-L1 status. Differences in health outcomes (QALYs) and costs were assessed between the current practice and these biomarker strategies.

Omitting immunotherapy in NSCLC patients with a PD-L1 score < 1 percent or between 1 and 49 percent, and a negative biomarker test, could potentially reduce healthcare costs significantly a small loss in QALYs. In these groups, a biomarker test is potentially cost-effective as the incremental cost-effectiveness ratio largely exceeds a willingness-to-accept threshold of €80,000 saved per QALY lost. For patients with a PD-L1 score > 50 percent, a considerable QALY gain can potentially be realized by adding chemotherapy to patients with a negative biomarker test. However, this comes at a significant increase in costs and appears not to be cost-effective.

In general, predictive biomarkers seem to have the potential to increase the cost-effectiveness of treatment with immunotherapy in patients with advanced NSCLC. Optimal positioning of a biomarker depends on the weighing between health impact and costs.

Cognitive Behavioural Therapy for psychosis (CBTp) is an effective psychological treatment for Schizophrenia Spectrum and other psychotic Disorders (SSD). Despite guidelines recommending CBTp for all psychotic disorder patients, many SSD patients lack access to the treatment and little is known about its long-term cost-effectiveness. The aim of this study is to evaluate the cost-effectiveness of CBTp for the treatment of psychotic disorders through scenario analysis from a healthcare perspective.

Increased implementation of CBTp was evaluated using a real-world SSD population (N = 12,835) from the northern Netherlands (2010–2019). A patient-level model was used to simulate the long-term effects of rehospitalisation rate. We compared treatment as usual (TAU) with the same TAU plus hypothetical CBTp for all individuals not having received such in TAU, hence patients who received any CBTp sessions prior were excluded (N = 2,679). Outcomes considered were quality-adjusted life years gained and total costs of mental healthcare. Additional sensitivity and scenario analyses were performed to evaluate structural and parameter uncertainty.

TAU+CBTp was a cost-effective treatment in 61.2% of the simulations. The simulated net present values for QALY gains were 0.038, and for incremental costs were €492 per patient on average, resulting in an expected incremental cost-effectiveness ratio (ICER) of €12,947.

The evaluation shows that CBTp is likely a cost-effective treatment, although results were uncertain. These findings stress the importance of sufficient availability of CBTp for SSD patients. Making CBTp available for all eligible SSD patients may lead to substantial health gains for the SSD population and cost savings from the healthcare perspective in The Netherlands.

In the UK, around 1 in 4 adults over 65 years suffers from depression. Depression case finding followed by alerting patients and their general practioners (GPs) (screening + GP) is a promising strategy to facilitate depression management, but its cost-effectiveness remains unclear.

To investigate the cost-effectiveness of screening + GP compared with standard of care (SoC) in northern England.

Conducted alongside the CASCADE study, 1020 adults aged 65+ years were recruited. Participants with baseline Geriatric Depression Scale (GDS) ≥5 were allocated to the intervention arm and those >5 to SoC. Resource use and EQ-5D-5L data were collected at baseline and 6 months. Incremental cost-effectiveness ratio was calculated. Non-parametric bootstrapping was performed to capture sampling uncertainty. The results are presented using cost-effectiveness acceptability curves. Sensitivity analyses were conducted to assess the robustness of primary findings. Subgroup analyses were undertaken to examine the cost-effectiveness among participants with more comparable baseline characteristics across treatment groups.

Screening + GP incurred £37 more costs and 0.006 fewer quality-adjusted life years than SoC; the probability of the former being cost-effective was <5% at a £30 000 cost-effectiveness threshold. Sensitivity analyses confirmed the base-case findings. Subgroup analyses indicated that screening + GP was cost-effective when patients with baseline GDS 2–7, 3–6 and 4–5, respectively, were analysed.

Screening + GP was dominated by SoC in northern England. However, subgroup analyses suggested it could be cost-effective if patients with more balanced baseline characteristics were analysed. Economic evaluations alongside randomised controlled trials are warranted to validate these findings.