Clinical Evaluation of Digital Therapeutics: Present and Future

Digital Therapeutics in China: Comprehensive Review

BACKGROUND

Digital therapeutics (DTx) are software-driven interventions that provide personalized, evidence-based treatments for various medical conditions. China's rapid technological adoption, large population, and supportive government policies position it as a potential global leader in DTx. However, challenges remain in clinical trial standardization, regulatory approval, product development, and reimbursement models. A comprehensive assessment of clinical evidence, commercialization trends, and regulatory frameworks is essential for understanding China's evolving DTx ecosystem and its global implications.

OBJECTIVE

This study systematically reviews and analyzes the DTx landscape in China, focusing on clinical trials, commercial products, regulatory frameworks, and pricing and reimbursement models. The findings provide insights for countries aiming to develop, regulate, and integrate DTx solutions into health care systems.

METHODS

This comprehensive review integrates multiple methodological approaches to examine different aspects of the DTx ecosystem in China. We conducted a systematic review and meta-analysis to evaluate clinical trials, searching PubMed, Google Scholar, IEEE, Web of Science, and ScienceDirect until July 2024. Meta-analyses used random-effects models, reporting results as standardized mean differences (SMDs) and 95% CIs. For commercial products, a scoping review using the National Medical Products Administration database was performed. Regulatory policies were systematically identified through a manual review of official government sources, while pricing and reimbursement models were analyzed through a comprehensive assessment of public and private insurance policies, government initiatives, and commercial pathways.

RESULTS

: A total of 96 clinical trials on DTx in China were identified, with cognitive disorders (n=21, 22%) and diabetes (n=20, 21%) being the most frequently studied, followed by cardiovascular diseases (n=8, 8%), sleeping disorders (n=6, 6%), and smoking cessation (n=6, 6%). Meta-analysis for diabetes DTx showed a trend toward improved hemoglobin A1c levels in digital intervention groups compared to controls (SMD -0.96, 95% CI -2.03 to 0.11) but did not reach statistical significance (I²=97%). Meta-analysis for cognitive disorder DTx showed significant improvement in global cognitive function in DTx-treated participants (SMD 0.65, 95% CI 0.37-0.94), despite notable heterogeneity (I²=71.7%). The commercial landscape analysis identified 97 active DTx solutions, primarily targeting cognitive impairment (38 companies), ophthalmic diseases (30 companies), and respiratory diseases (5 companies). The regulatory review highlighted China's reliance on general medical device policies under the National Medical Products Administration rather than DTx-specific regulations, with emerging regional innovation policies supporting industry growth. Pricing analysis revealed diverse reimbursement models, including value-based pricing, private insurance partnerships, and government-facilitated programs.

CONCLUSIONS

China has made substantial progress in DTx development but still faces challenges in clinical trial standardization, regulatory approval, and reimbursement. Key factors driving DTx adoption include targeted indications, standardized clinical trials, streamlined regulation, and diversified pricing models. China's experience provides valuable lessons for other countries with emerging digital health ecosystems as they develop DTx research, regulations, and integration strategies.

TRIAL REGISTRATION

PROSPERO CRD42024615584; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024615584.

Digital Therapeutic Combining Hypnosis and Diaphragmatic Breathing Intervention for Functional Abdominal Bloating: A Feasibility Study

INTRODUCTION

Abdominal bloating is a difficult symptom to treat. Hypnotherapy and diaphragmatic intervention have separately shown benefit on bloating in prior work but have not been united into a single intervention. We aimed to obtain data on the potential therapeutic impact of a novel audio-recorded bloating treatment for bloating integrating hypnosis and diaphragmatic breathing, with proposed synergistic effect.

METHODS

Patients with nonorganic bowel disorders with predominant bloating symptoms completed a digitally delivered 7-session audio-recorded hypnotherapy program without clinician involvement. The intervention combined bloating-targeted hypnotic suggestions and guided diaphragmatic breathing delivered under hypnosis, and was supplemented with interval self-guided breathing exercises. Participants completed online REDCap assessments at baseline, midtreatment, at end of treatment, and 3-month follow-up, evaluating symptom severity, gastrointestinal symptom-specific anxiety, overall anxiety/depression, and quality of life. Outcomes were assessed in an intention-to-treat manner with repeated measures analysis of variances (ANOVAs) with Bonferroni-adjusted pairwise post hoc tests.

RESULTS

Of 23 patients who started treatment, 22 (95.6%) completed follow-up. Bloating severity on Irritable Bowel Syndrome-Symptom Severity Scale and Patient Assessment of Upper Gastrointestinal Symptom Severity Index showed reduction in bloating with large effect sizes (Cohen d of ∼0.8) at the end of treatment, as did Visceral Sensitivity Index bloating-related anxiety. At the end of treatment, 16 patients (69.6%) were Irritable Bowel Syndrome-Symptom Severity Scale treatment responders (≥30% symptom reduction) on bloating and 17 (73.9%) on overall bowel symptom severity. Anxiety, depression, and quality-of-life scores were unchanged. Outcome measures were fully maintained at the 3-month follow-up.

DISCUSSION

Results suggest the therapeutic utility of a new cost-effective self-administered bloating intervention. A randomized controlled trial is planned to confirm these therapeutic effects.

Designing and developing a prescription digital therapeutic for at-home heart rate variability biofeedback to support and enhance patient outcomes in post-traumatic stress disorder treatment

Post-traumatic stress disorder (PTSD) is a psychiatric condition producing considerable distress, dysfunction, and impairment in affected individuals. While various forms of psychotherapy are commonly utilized in PTSD treatment, the known neurological pathologies associated with PTSD are insufficiently addressed by these conventional approaches. Heart rate variability biofeedback (HRV-BFB) is a promising tool for correcting autonomic dysfunction in PTSD, with subsequent changes in clinically significant outcome measures. This paper outlines a systematic approach for the development, distribution, and implementation of a prescription at-home HRV-BFB digital therapeutic. We provide recommendations for evidence-generation strategies and propose appropriate regulatory pathways within existing frameworks. Widespread access to HRV-BFB could potentially reduce the distress, disability, and healthcare burden associated with PTSD. Promoting HRV-BFB as a primary intervention could also serve to reduce the stigma associated with "mental" illness and increase health literacy regarding the neuroimmune impacts of psychosocial factors. These processes might in turn improve treatment-seeking, adherence, and supported self-management of these conditions.

Adoption of Digital Therapeutics in Europe

Digital therapeutics (DTx) are an emerging medical therapy comprising evidence-based interventions that are regulatory approved for patient use, or are under development, for a variety of medical conditions, including hypertension, cancer, substance use disorders and mental disorders. DTx have significant potential to reduce the overall burden on healthcare systems and offer potential economic benefits. There is currently no specific legal regulation on DTx in the EU. Although European countries have similar approaches to digital health solutions, the adoption of DTx varies across the continent. The aim of this narrative review is to discuss the levels of adoption of DTx in Europe, and to explore possible strategies to improve adoption, with the goal of higher rates of adoption, and more consistent use of DTx across the continent. The article discusses the regulatory and reimbursement landscape across Europe; validation requirements for DTx, and the importance of co-design and an ecosystem-centric approach in the development of DTx. Also considered are drivers of adoption and prescription practices for DTx, as well as patient perspectives on these therapeutics. The article explores potential factors that may contribute to low rates of DTx adoption in Europe, including lack of harmonisation in regulatory requirements and reimbursement; sociodemographic factors; health status; ethical concerns; challenges surrounding the use and validation of AI; knowledge and awareness among healthcare professionals (HCPs) and patients, and data standards and interoperability. Efforts to improve rates of access to DTx and adoption of these therapeutics across Europe are described. Finally, a framework for improved uptake of DTx in Europe is proposed.

Co-Creation in the Development of Digital Therapeutics: A Narrative Review

Digital therapeutics (DTx) are transforming healthcare delivery through personalised, evidence-based interventions that offer a cost-effective approach to health management. However, their widespread adoption faces significant barriers including privacy concerns, usability issues, and integration challenges within healthcare systems. This review assesses the current evidence on DTx, with a particular focus on the role of co-creation in enhancing design and usability. A narrative review was conducted to identify studies exploring co-creation in DTx development. Three studies were selected for in-depth analysis, demonstrating that co-creation processes significantly improve the usability and effectiveness of DTx interventions. Findings underscore challenges in DTx implementation, including complex regulatory processes, digital inequality, high development costs, and difficulties in integrating with existing healthcare systems. Despite the existence of discrete examples of co-creation in DTx and its acknowledged value in the healthcare domain, systematic research in this field remains markedly limited. Future studies should prioritise establishing best practises for co-creation, with particular emphasis on methods to enhance data privacy and security, standardisation protocols, and patient engagement strategies to optimise DTx adoption and effectiveness. This review contributes to the growing body of literature on DTx by highlighting the potential of co-creation while also identifying critical areas for future research.

Comparison of Product Features and Clinical Trial Designs for the DTx Products with the Indication of Insomnia Authorized by Regulatory Authorities

BACKGROUND

Digital therapeutics (DTx) have attracted attention as the substitutes or add-ons to conventional pharmacotherapy and the number of DTx products authorized with the regulatory reviews of the clinical evidence is increasing. Insomnia is one of the major targets of the DTx due to the benefit from cognitive behavioral interventions and several products have been launched in the market with regulatory reviews. However, common features of the products and the clinical evidence required by each regulatory agency have not been investigated.

METHODS

In this study, we identified the DTx products with the primary indication of insomnia authorized with regulatory reviews of clinical evidence by literature and website searches, and investigated the common features of the products and of the study designs for the pivotal clinical trials.

RESULTS

The total of 6 DTx products were identified. The components of cognitive behavioral therapy for insomnia (CBT-I) were identified as common features of the products. All the pivotal clinical trials were randomized, parallel-group, blind studies against insomnia patients. No products have been authorized in multiple countries regardless of the similarity of the features of the products and of the study designs for the pivotal clinical trials.

CONCLUSIONS

Our study revealed that the components of CBT-I and gold standard design in pivotal clinical trials were adopted in all the DTx products for insomnia authorized with reviews of clinical evidence. At the same time, our findings suggest the needs of internationally harmonized regulatory review and authorization system to facilitate the early patient access to the promising DTx products.

From palm to practice: prescription digital therapeutics for mental and brain health at the National Institutes of Health

Prescription Digital Therapeutics (PDTs) are emerging as promising tools for treating and managing mental and brain health conditions within the context of daily life. This commentary distinguishes PDTs from other Software as Medical Devices (SaMD) and explores their integration into mental and brain health treatments. We focus on research programs and support from the National Institutes of Health (NIH), discussing PDT research supported by the NIH's National Institute on Child Health and Development (NICHD), National Institute of Mental Health (NIMH), and National Institute on Aging (NIA). We present a hierarchical natural language processing topic analysis of NIH-funded digital therapeutics research projects. We delineate the PDT landscape across different mental and brain health disorders while highlighting opportunities and challenges. Additionally, we discuss the research foundation for PDTs, the unique therapeutic approaches they employ, and potential strategies to improve their validity, reliability, safety, and effectiveness. Finally, we address the research and collaborations necessary to propel the field forward, ultimately enhancing patient care through innovative digital health solutions.

Predicting Long-Term Engagement in mHealth Apps: Comparative Study of Engagement Indices

BACKGROUND

Digital health care apps, including digital therapeutics, have the potential to increase accessibility and improve patient engagement by overcoming the limitations of traditional facility-based medical treatments. However, there are no established tools capable of quantitatively measuring long-term engagement at present.

OBJECTIVE

This study aimed to evaluate an existing engagement index (EI) in a commercial health management app for long-term use and compare it with a newly developed EI.

METHODS

Participants were recruited from cancer survivors enrolled in a randomized controlled trial that evaluated the impact of mobile health apps on recovery. Of these patients, 240 were included in the study and randomly assigned to the Noom app (Noom Inc). The newly developed EI was compared with the existing EI, and a long-term use analysis was conducted. Furthermore, the new EI was evaluated based on adapted measurements from the Web Matrix Visitor Index, focusing on click depth, recency, and loyalty indices.

RESULTS

The newly developed EI model outperformed the existing EI model in terms of predicting EI of a 6- to 9-month period based on the EI of a 3- to 6-month period. The existing model had a mean squared error of 0.096, a root mean squared error of 0.310, and an R2 of 0.053. Meanwhile, the newly developed EI models showed improved performance, with the best one achieving a mean squared error of 0.025, root mean squared error of 0.157, and R2 of 0.610. The existing EI exhibited significant associations: the click depth index (hazard ratio [HR] 0.49, 95% CI 0.29-0.84; P<.001) and loyalty index (HR 0.17, 95% CI 0.09-0.31; P<.001) were significantly associated with improved survival, whereas the recency index exhibited no significant association (HR 1.30, 95% CI 1.70-2.42; P=.41). Among the new EI models, the EI with a menu combination of menus available in the app's free version yielded the most promising result. Furthermore, it exhibited significant associations with the loyalty index (HR 0.32, 95% CI 0.16-0.62; P<.001) and the recency index (HR 0.47, 95% CI 0.30-0.75; P<.001).

CONCLUSIONS

The newly developed EI model outperformed the existing model in terms of the prediction of long-term user engagement and compliance in a mobile health app context. We emphasized the importance of log data and suggested avenues for future research to address the subjectivity of the EI and incorporate a broader range of indices for comprehensive evaluation.

The Revolution of Digital Therapeutics (DTx) in the Pharmaceutical Industry and Their Quality Impacts

An increasing number of developments and trends are driving the expansion of the digital therapeutics (DTx) market in the pharmaceutical industry. Digital therapeutics are therapies intended to treat, diagnose, and prevent diseases by using patient-directed clinically assessed software applications, which can optimize the effectiveness and delivery of healthcare. These digital innovations became important as the world changed, particularly during the coronavirus pandemic. Nowadays pharma companies are getting more comfortable with the idea of digital therapies. The majority of pharmaceutical companies are examining how to incorporate pharmaceuticals and digital therapies into their treatment regimens, leveraging digital tools to enhance patient outcomes and streamline healthcare delivery. A thorough overview of the most recent technological advancements in the creation of digital therapies shows particular technologies that are essential to the market's future growth. Moreover, the evaluation of digital therapeutics by clinical trial and real-world data is outlined. The critical quality attributes of DTx products and the challenges, including data management issues and regulatory obstacles, which make the creation, approval, and marketing of customized medicines more difficult, are covered in this review article. Overall, pharma companies are venturing into the world of digital therapeutics while acknowledging the limitations of the emerging field.

Comparing the Efficacy of Digital and In-Person Weight Loss Interventions for Patients with Obesity and Glycemic Disorders: Evidence from a Randomized Non-Inferiority Trial

Digital weight loss interventions present a viable and cost-effective alternative to traditional therapy. However, further evidence is needed to establish the equal effectiveness of both approaches. This randomized controlled non-inferiority trial aimed to compare the effects of an intensive in-person weight loss intervention program with Vitadio digital therapy. One hundred patients with obesity and diagnosed with type 2 diabetes, prediabetes, or insulin resistance were enrolled and randomly assigned to one of the two treatment groups. Over a 6-month period, the control group received five in-person consultations with a physician who specialized in obesity treatment, a dietitian and/or a nutrition nurse, while the intervention group followed the digital program based on a multimodal therapeutic approach. The extent of weight loss was assessed and compared between the groups. Additionally, changes in body composition and metabolic parameters for the digital intervention group were analyzed. The study results demonstrated comparable effectiveness of both treatments for weight reduction. The positive effects of Vitadio were further evidenced by favorable changes in body composition and lipid metabolism and improved glycemic control in the intervention group. These findings suggest that Vitadio is an effective tool for assisting patients with managing obesity and preventing diabetes progression.

Implementing a digital solution for patients with migraine-Developing a methodology for comparing digitally delivered treatment with conventional treatment: A study protocol

Migraine is one of the most frequent and expensive neurological disease in the world. Non-pharmacological and digitally administered treatment options have long been used in the treatment of chronic pain and mental illness. Digital solutions increase the patients' possibilities of receiving evidence-based treatment even when conventional treatment options are limited. The main goal of the study is to assess the efficacy of interdisciplinary digital interventions compared to conventional treatment. The maximum number of participants in this multi-centre, open-label, prospective, randomized study is 600, divided into eight treatment groups. The participants will take part in either a conventional or a digital intervention, performing various tests and interdisciplinary tasks. The primary outcome is expected to be a reduction in the number of headache days. We also undertake to measure various other headache-related burdens as a secondary outcome. The sample size, digital interventions not conducted via video calls, the lack of human connection, limited intervention program, and the conducting of studies only in digitally sophisticated countries are all significant limitations. However, we believe that digitally mediated treatment options are at least as effective as traditional treatment options while also allowing for a significantly higher patient throughput. The future of chronic disease treatment is remote monitoring and high-quality digitally mediated interventions.The study is approved by the Ethics Committee of the University of Tartu for Human Research (Permission No. 315T-17, 10.08.2020) and is registered at ClinicalTrials.gov: NTC05458817 (14.07.2022).

Exploring the potential of digital therapeutics: An assessment of progress and promise

Digital therapeutics (DTx), a burgeoning subset of digital health solutions, has garnered considerable attention in recent times. These cutting-edge therapeutic interventions employ diverse technologies, powered by software algorithms, to treat, manage, and prevent a wide array of diseases and disorders. Although DTx shows significant promise as an integral component of medical care, its widespread integration is still in the preliminary stages. This limited adoption can be largely attributed to the scarcity of comprehensive research that delves into DTx's scope, including its technological underpinnings, potential application areas, and challenges-namely, regulatory hurdles and modest physician uptake. This review aims to bridge this knowledge gap by offering an in-depth overview of DTx products' value to both patients and clinicians. It evaluates the current state of maturity of DTx applications driven by digital technologies and investigates the obstacles that developers and regulators encounter in the market introduction phase.

Digital health technologies and artificial intelligence in cardiovascular clinical trials: A landscape of the European space

The recent pandemic ushered in a marked surge in the adoption of digital health technologies (DHTs), necessitating remote approaches aiming to safeguard both patient and healthcare provider well-being. These technologies encompass an array of terms, including e-health, m-health, telemedicine, wearables, sensors, smartphone apps, digital therapeutics, virtual and augmented reality, and artificial intelligence (AI). Notably, some DHTs employed in critical healthcare decisions may transition into the realm of medical devices, subjecting them to more stringent regulatory scrutiny. Consequently, it is imperative to understand the validation processes of these technologies within clinical studies. Our study summarizes an extensive examination of clinical trials focusing on cardiovascular (CV) diseases and digital health (DH) interventions, with particular attention to those incorporating elements of AI. A dataset comprising 107 eligible trials, registered on clinicaltrials.gov and International Clinical Trials Registry Platform (ICTRP) databases until 19 June 2023, forms the basis of our investigation. We focused on clinical trials employing DHTs in the European context, revealing a diverse landscape of interventions. Devices constitute the predominant category (45.8%), followed by behavioral interventions (17.8%). Within the CV domain, trials predominantly span pivotal or confirmatory phases, with a notable presence of smaller feasibility and exploratory studies. Notably, a majority of trials exhibit randomized, parallel assignment designs. When analyzing the multifaceted landscape of trial outcomes, we identified various categories such as physiological and functional measures, diagnostic accuracy, CV events and mortality, patient outcomes, quality of life, treatment adherence and effectiveness, quality of hospital processes, and usability/feasibility measures. Furthermore, we delve into a subset of 15 studies employing AI and machine learning, describing various study design features, intended purposes and the validation strategies employed. In summary, we aimed to elucidate the diverse applications, study design features, and objectives of the evolving CV-related DHT clinical trials field.

Revolutionizing clinical trials: the role of AI in accelerating medical breakthroughs

Clinical trials are the essential assessment for safe, reliable, and effective drug development. Data-related limitations, extensive manual efforts, remote patient monitoring, and the complexity of traditional clinical trials on patients drive the application of Artificial Intelligence (AI) in medical and healthcare organisations. For expeditious and streamlined clinical trials, a personalised AI solution is the best utilisation. AI provides broad utility options through structured, standardised, and digitally driven elements in medical research. The clinical trials are a time-consuming process with patient recruitment, enrolment, frequent monitoring, and medical adherence and retention. With an AI-powered tool, the automated data can be generated and managed for the trial lifecycle with all the records of the medical history of the patient as patient-centric AI. AI can intelligently interpret the data, feed downstream systems, and automatically fill out the required analysis report. This article explains how AI has revolutionised innovative ways of collecting data, biosimulation, and early disease diagnosis for clinical trials and overcomes the challenges more precisely through cost and time reduction, improved efficiency, and improved drug development research with less need for rework. The future implications of AI to accelerate clinical trials are important in medical research because of its fast output and overall utility.

Assessing the Potential Risks of Digital Therapeutics (DTX): The DTX Risk Assessment Canvas

MOTIVATION

Digital therapeutics (DTX), i.e., health interventions that are provided through digital means, are increasingly available for use; in some countries, physicians can even prescribe selected DTX following a reimbursement by health insurances. This results in an increasing need for methodologies to consider and monitor DTX's negative consequences, their risks to patient safety, and possible adverse events. However, it is completely unknown which aspects should be subject to surveillance given the missing experiences with the tools and their negative impacts.

OBJECTIVE

Our aim is to develop a tool-the DTX Risk Assessment Canvas-that enables researchers, developers, and practitioners to reflect on the negative consequences of DTX in a participatory process.

METHOD

Taking the well-established business model canvas as a starting point, we identified relevant aspects to be considered in a risk assessment of a DTX. The aspects or building blocks of the canvas were constructed in a two-way process: first, we defined the aspects relevant for discussing and reflecting on how a DTX might bring negative consequences and risks for its users by considering ISO/TS 82304-2, the scientific literature, and by reviewing existing DTX and their listed adverse effects. The resulting aspects were grouped into thematic blocks and the canvas was created. Second, six experts in health informatics and mental health provided feedback and tested the understandability of the initial canvas by individually applying it to a DTX of their choice. Based on their feedback, the canvas was modified.

RESULTS

The DTX Risk Assessment Canvas is organized into 15 thematic blocks which are in turn grouped into three thematic groups considering the DTX itself, the users of the DTX, and the effects of the DTX. For each thematic block, questions have been formulated to guide the user of the canvas in reflecting on the single aspects. Conclusions: The DTX Risk Assessment Canvas is a tool to reflect the negative consequences and risks of a DTX by discussing different thematic blocks that together constitute a comprehensive interpretation of a DTX regarding possible risks. Applied during the DTX design and development phase, it can help in implementing countermeasures for mitigation or means for their monitoring.

Digital Therapeutics as a New Therapeutic Modality: A Review from the Perspective of Clinical Pharmacology

The promise of transforming digital technologies into treatments is what drives the development of digital therapeutics (DTx), generally known as software applications embedded within accessible technologies-such as smartphones-to treat, manage, or prevent a pathological condition. Whereas DTx solutions that successfully demonstrate effectiveness and safety could drastically improve the life of patients in multiple therapeutic areas, there is a general consensus that generating therapeutic evidence for DTx presents challenges and open questions. We believe there are three main areas where the application of clinical pharmacology principles from the drug development field could benefit DTx development: the characterization of the mechanism of action, the optimization of the intervention, and, finally, its dosing. We reviewed DTx studies to explore how the field is approaching these topics and to better characterize the challenges associated with them. This leads us to emphasize the role that the application of clinical pharmacology principles could play in the development of DTx and to advocate for a development approach that merges such principles from development of traditional therapeutics with important considerations from the highly attractive and fast-paced world of digital solutions.

Economic Evaluation Associated With Clinical-Grade Mobile App-Based Digital Therapeutic Interventions: Systematic Review

BACKGROUND

Digital therapeutics (DTx), a class of software-based clinical interventions, are promising new technologies that can potentially prevent, manage, or treat a spectrum of medical disorders and diseases as well as deliver unprecedented portability for patients and scalability for health care providers. Their adoption and implementation were accelerated by the need for remote care during the COVID-19 pandemic, and awareness about their utility has rapidly grown among providers, payers, and regulators. Despite this, relatively little is known about the capacity of DTx to provide economic value in care.

OBJECTIVE

This study aimed to systematically review and summarize the published evidence regarding the cost-effectiveness of clinical-grade mobile app-based DTx and explore the factors affecting such evaluations.

METHODS

A systematic review of economic evaluations of clinical-grade mobile app-based DTx was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Major electronic databases, including PubMed, Cochrane Library, and Web of Science, were searched for eligible studies published from inception to October 28, 2022. Two independent reviewers evaluated the eligibility of all the retrieved articles for inclusion in the review. Methodological quality and risk of bias were assessed for each included study.

RESULTS

A total of 18 studies were included in this review. Of the 18 studies, 7 (39%) were nonrandomized study-based economic evaluations, 6 (33%) were model-based evaluations, and 5 (28%) were randomized clinical trial-based evaluations. The DTx intervention subject to assessment was found to be cost-effective in 12 (67%) studies, cost saving in 5 (28%) studies, and cost-effective in 1 (6%) study in only 1 of the 3 countries where it was being deployed in the final study. Qualitative deficiencies in methodology and substantial potential for bias, including risks of performance bias and selection bias in participant recruitment, were identified in several included studies.

CONCLUSIONS

This systematic review supports the thesis that DTx interventions offer potential economic benefits. However, DTx economic analyses conducted to date exhibit important methodological shortcomings that must be addressed in future evaluations to reduce the uncertainty surrounding the widespread adoption of DTx interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022358616; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022358616.

Potential effectiveness of digital therapeutics specialized in executive functions as adjunctive treatment for clinical symptoms of attention-deficit/hyperactivity disorder: a feasibility study

Introduction

The role of digital therapeutics (DTx) in the effective management of attention deficit/hyperactivity disorder (ADHD) is beginning to gain clinical attention. Therefore, it is essential to verify their potential efficacy.

Method

We aimed to investigate the improvement in the clinical symptoms of ADHD by using DTx AimDT01 (NUROW) (AIMMED Co., Ltd., Seoul, Korea) specialized in executive functions. NUROW, which consists of Go/No-go Task- and N-Back/Updating-based training modules and a personalized adaptive algorithm system that adjusts the difficulty level according to the user's performance, was implemented on 30 Korean children with ADHD aged 6 to 12 years. The children were instructed to use the DTx for 15 min daily for 4 weeks. The Comprehensive attention test (CAT) and Childhood Behavior Checklist (CBCL) were used to assess the children at baseline and endpoint. In contrast, the ADHD-Rating Scale (ARS) and PsyToolkit were used weekly and followed up at 1 month, for any sustained effect. Repeated measures ANOVA was used to identify differences between the participants during visits, while t-tests and Wilcoxon signed-rank tests were used to identify changes before and after the DTx.

Results

We included 27 participants with ADHD in this analysis. The ARS inattention (F = 4.080, p = 0.010), hyperactivity (F = 5.998. p < 0.001), and sum (F = 5.902, p < 0.001) significantly improved. After applying NUROW, internalized (t = -3.557, p = 0.001, 95% CI = -3.682--0.985), other (Z = -3.434, p = 0.001, effect size = -0.661), and sum scores (t = -3.081, p = 0.005, 95% CI = -10.126--2.022) were significantly changed in the CBCL. The overall effect was confirmed in the ARS sustained effect analysis even after 1 month of discontinuing the DTx intervention.

Discussion

According to caregivers, the findings indicate that DTx holds potential effect as an adjunctive treatment in children with ADHD, especially in subjective clinical symptoms. Future studies will require detailed development and application targeting specific clinical domains using DTx with sufficient sample sizes.Clinical trial registration: KCT0007579.

Digital therapeutics from bench to bedside

As a new therapeutic technique based on digital technology, the commercialization and clinical application of digital therapeutics (DTx) are increasing, and the demand for expansion to new clinical fields is remarkably high. However, the use of DTx as a general medical component is still ambiguous, and this ambiguity may be owing to a lack of consensus on a definition, in addition to insufficiencies in research and development, clinical trials, standardization of regulatory frameworks, and technological maturity. In this study, we conduct an in-depth investigation and analysis of definitions, clinical trials, commercial products, and the regulatory status related to DTx using published literature, ClinicalTrials.gov, and web pages of regulatory and private organizations in several countries. Subsequently, we suggest the necessity and considerations for international agreements on the definition and characteristics of DTx, focusing on the commercialization characteristics. In addition, we discuss the status and considerations of clinical research, key technology factors, and the direction of regulatory developments. In conclusion, for the successful settlement of DTx, real-world evidence-based validation should be strengthened by establishing a cooperative system between researchers, manufacturers, and governments, and there should be effective technologies and regulatory systems for overcoming engagement barriers of DTx.

Digital Intervention For The Management Of Alzheimer's Disease

Alzheimer's disease (AD) is a progressive, multifactorial, chronic, neurodegenerative disease with high prevalence and limited therapeutic options, making it a global health crisis. Being the most common cause of dementia, AD erodes the cognitive, functional, and social abilities of the individual and causes escalating medical and psychosocial needs. As yet, this disorder has no cure and current treatment options are palliative in nature. There is an urgent need for novel therapy to address this pressing challenge. Digital therapeutics (Dtx) is one such novel therapy that is gaining popularity globally. Dtx provides evidence based therapeutic interventions driven by internet and software, employing tools such as mobile devices, computers, videogames, apps, sensors, virtual reality aiding in the prevention, management, and treatment of ailments like neurological abnormalities and chronic diseases. Dtx acts as a supportive tool for the optimization of patient care, individualized treatment and improved health outcomes. Dtx uses visual, sound and other non-invasive approaches for instance-consistent therapy, reminiscence therapy, computerised cognitive training, semantic and phonological assistance devices, wearables and computer-assisted rehabilitation environment to find applications in Alzheimer's disease for improving memory, cognition, functional abilities and managing motor symptom. A few of the Dtx-based tools employed in AD include "Memory Matters", "AlzSense", "Alzheimer Assistant", "smart robotic dog", "Immersive virtual reality (iVR)" and the most current gamma stimulation. The purpose of this review is to summarize the current trends in digital health in AD and explore the benefits, challenges, and impediments of using Dtx as an adjunctive therapy for the management of AD.