France is undergoing a profound demographic transition marked by a growing older adult population. As of 2024, 10% of the population, equivalent to 7 million individuals, is aged ≥75 years, and this number is expected to rise to 16% by 2050, representing 12 million individuals [1,2].

Chronic diseases are highly prevalent among older adults in France, with 91% of individuals aged ≥75 years presenting at least 1 chronic condition or ongoing treatment. Multimorbidity is also a defining feature of aging: 47% of men and 36% of women aged ≥75 years live with 2 or more chronic diseases, and up to 26% of men and 17% of women in this age group have 3 or more chronic diseases [3]. Aging also significantly increases the risk of loss of independence. Although most older adults remain autonomous until late in life, the share of older adults receiving the French “Allocation Personnalisée d’Autonomie,” a marker of dependency, rises from 2% among adults aged 70 to 74 years to approximately 50% among those aged 90 to 94 years and to three-quarters among those aged ≥95 years [4]. Finally, increasing age is accompanied by increased risks of social isolation, particularly among women. More than half of women aged 85 years live alone, compared to just 25% of men [4].

These demographic shifts place immense pressure on France’s health care infrastructure, which is already strained by shortages of geriatricians and a declining number of general practitioners (GPs). The result is a fragmented and reactive health care system, where emergency departments (EDs) and inpatient services often serve as the default response to complex geriatric needs. Approximately 40% of those aged ≥80 years in France are hospitalized annually, with an average duration of approximately 25 days per patient. It is estimated that more than 30% of these hospitalizations could have been avoided, with similar figures for ED visits [5,6]. These trends underline the urgent need for scalable, home-based care solutions tailored to the evolving needs of an aging, increasingly dependent population.

Remote monitoring systems (RMSs) have gained international traction as a promising solution for managing older patients with chronic and complex health needs. Existing RMSs vary widely in structure and technology but generally include combinations of wearable sensors, mobile health apps, and care coordination frameworks [7-14]. These RMSs are typically multidisciplinary, involving nurses, hospital physicians, geriatricians, and GPs, often with social support services integrated. Most of these RMSs have demonstrated reductions in hospitalizations and emergency visits [9-11,13,14].

Launched in 2019, the Vigie-Age framework is a multidisciplinary hospital-community initiative designed to provide comprehensive, coordinated care for older adults with multiple chronic conditions. Its primary objectives are to enhance quality of life and reduce avoidable hospitalizations through better continuity of care. This framework includes EPOCA, an RMS that is a human-centered connected telemedicine solution offering secure and continuous home support for complex older patients (with multiple comorbidities, loss of autonomy, and/or dependency). It is built around a 24×7 tele-monitoring platform that enables real-time clinical oversight, rapid response to health deterioration, and seamless coordination among health care professionals. The system integrates two core technological components: (1) connected devices, such as a wristband, for transmitting health data or emergency alerts, and (2) a centralized RMS coordination hub staffed by trained nurses and physicians, who engage directly with patients and caregivers when needed. Hospital geriatricians or GPs play a central role in the framework, offering ongoing medical supervision via tele-consultations and tele-expertise and maintaining active communication with community health care teams. In parallel, community-based nurses conduct regular home visits, monitor patient conditions, and deliver essential care services.

Vigie-Age has been included in the French “Article 51” experimental framework launched in 2018 to promote innovation in health care delivery and financing. Article 51 enables pilot studies of interventions that aim to improve care coordination, efficiency, and patient outcomes through new organizational models and payment structures. These pilots are evaluated for their clinical impact, economic sustainability, and potential for national scale-up, providing valuable data.

This study aimed to assess the cost-effectiveness of the Vigie-Age framework, including the EPOCA RMS, compared to standard of care (SOC), focusing on reductions in hospitalizations, emergency visits, and overall health care costs and using real-world data from the Article 51 evaluation of the Vigie-Age framework.

The results of the cost-effectiveness and budget impact models, including projections on hospitalizations, ED visits, and direct and indirect costs, are presented in Table 2.

Over a lifetime horizon, accounting for background mortality, the model estimated an undiscounted average survival of 1.8 years per patient, with an average duration in the EPOCA program of 8.1 months. During this period, patients in the EPOCA arm experienced an average of 2.8 ED visits and 4.2 hospitalizations, compared to 6.1 ED visits and 7.8 hospitalizations in the SOC arm, representing reductions of 54% and 46%, respectively. The decrease in hospitalizations translated into a reduction in the total number of hospital days, from 55.6 days in the SOC arm to 30.6 days in the EPOCA arm.

From the collective perspective, the undiscounted total cost per patient was estimated at €29,165 in the EPOCA arm, compared to €39,929 in the SOC arm. This difference was driven primarily by reductions in hospitalization (€13,924 in savings) and ED visit costs (€543 in savings), partially offset by an increase of €853 in outpatient care costs. After incorporating the program cost (€2,850), the net savings amounted to €10,764 per patient. Similar cost savings were observed under the NHI perspective, with total savings of €7,430 per patient. These included €10,964 in reduced hospitalization costs, €170 in ED savings, and an €853 increase in outpatient costs, with program costs assumed equal across perspectives. Importantly, EPOCA remained cost-saving even when applying the higher intervention cost of €4,441 used in sensitivity analyses.

In terms of health outcomes, the EPOCA arm was associated with 1.30 discounted QALYs compared to 1.26 QALYs in the SOC arm, a gain of 0.04 QALYs, primarily attributable to reduced hospitalizations and associated improvements in quality of life. Discounted total costs were €24,683 for EPOCA and €31,792 for SOC from the NHI perspective, yielding net savings of €7,108. Given that EPOCA resulted in both lower costs and improved outcomes, it was considered a dominant strategy compared to SOC. Similar conclusions were observed in the collective perspective, with €10,329 in total cost savings. EPOCA remained dominant at the higher intervention cost of €4,441 in both perspectives.

Sensitivity analyses considering no benefit or waning benefit of EPOCA after the end of the intervention did not change the conclusion, with EPOCA remaining a dominant strategy (Table 3). Deterministic sensitivity analysis (Figure 1) identified the average cost of hospitalization as the most influential parameter in the NHI perspective and the mean age at inclusion and the cost of hospitalization as the most influential parameters in the collective perspective. However, even under lower hospitalization cost scenarios, EPOCA remained cost-saving or cost-neutral, confirming the robustness of the model’s conclusions across parameter ranges.

PSA (Figure 2) further supported these findings. From the collective perspective, EPOCA had a 90% probability of being the dominant strategy and a 95% probability of being cost-effective at a willingness-to-pay threshold of €30,000 per QALY. From the NHI perspective, these probabilities were 80% and 87%, respectively.

This cost-effectiveness analysis shows that the EPOCA RMS could be associated with a reduction in avoidable hospitalizations and ED visits in frail, polypathological older adults. Over a modeled lifetime horizon, EPOCA was associated with a 54% reduction in ED visits and a 46% reduction in hospitalizations, resulting in a 25-day decrease in cumulative hospital stay per patient. These reductions were associated with cost savings of €10,764 per patient from the collective perspective and €7430 from the French payer (NHI) perspective. Notably, even under conservative assumptions for the program costs and in sensitivity analyses, EPOCA remained a dominant strategy, offering better outcomes at lower costs.

These results are consistent with the Article 51 pilot study and real-world data from retrospective observational studies of the EPOCA system [24]. In both hospital-led and GP-led implementations, EPOCA was associated with sharp declines in hospitalizations (−48% to −57%), ED visits (−48% to −62%), and hospital stay duration (−49% to −63%) within just 1 year of follow-up.

International evidence supports the observed outcomes of EPOCA. Similar RMSs have demonstrated reductions in hospital use, with relative risk reductions of up to 57%, 28% in unplanned hospitalizations, and 33% in ED visits [7,9-11,13,25]. EPOCA appears to achieve higher magnitudes of effect, possibly due to its integration into a comprehensive care coordination model involving both hospital and community actors, including nurses, GPs, and geriatricians. Additionally, unlike some RMSs, which may inadvertently increase ED use due to overalerting [10], EPOCA’s design emphasizes triage, anticipatory care, and direct intervention, which could contribute to a true reduction in ED burden. In terms of cost-effectiveness, international evidence also supports the outcomes observed in this study. Previous evaluations of RMSs have reported per-patient savings ranging from approximately €1000 to €2800 [11,26,27], including program costs, which are on the lower end of the €7400 to €10,800 in net savings estimated in this analysis.

These findings have several important implications for health policy. First, EPOCA’s suggested effectiveness in both clinical and economic dimensions supports its integration into national care pathways for older adults. Second, the program’s potential net savings from the NHI perspective support the case for full reimbursement, particularly in light of demographic aging and increasing chronic disease prevalence. Moreover, EPOCA responds to systemic challenges faced by the French health care system: high hospitalization rates among older adults, underresourced primary care, and fragmented coordination between community-based and hospital-based care. By reducing hospital reliance and enabling safe, structured home care, EPOCA could contribute directly to system efficiency and sustainability.

Despite these promising findings, several limitations must be acknowledged. First, the base data from the Vigie-Age Article 51 pilot study involved limited follow-up, requiring extrapolation through Markov modeling. Although sensitivity analyses and waning assumptions confirmed the robustness of the results, longer-term and clinical trial data will be necessary to validate projections. Additionally, because the effectiveness inputs were based on a pre-post comparison without a control group, biases such as regression to the mean and time-varying confounding may have influenced the results. Although the observed differences are likely too large to be entirely due to bias, smaller differences could affect conclusions. Second, there was significant variability in available hospitalization costs, potentially impacting cost estimates. Third, outpatient cost data were partially incomplete, particularly for nonreimbursed services, which may have led to conservative cost assumptions. Fourth, the disutility values relied on data from heart failure patients [19], which may not be directly applicable to the population used in the model since no more closely matching source was found. Nevertheless, 73% of those in the Vigie-Age Article 51 study presented cardiovascular risk factors, and heart failure hospitalization occurred frequently. Finally, although the program likely reduces caregiver burden through improved coordination and reduced crisis care, these effects were not directly measured and warrant further investigation.

In conclusion, based on currently limited real-world evidence from the Vigie-Age study, this modeling study suggests that the EPOCA RMS may be a cost-effective intervention for managing older patients at high risk of hospitalization. It could not only reduce acute care use but also improve quality-adjusted life expectancy and lower total health care costs. From the NHI perspective, the budget impact may be neutral to favorable. Supported by real-world implementation data and consistent with international best practices, EPOCA has strong potential for national scale-up. Embedding such models within France’s older adult care infrastructure could enhance care quality, reduce hospital pressure, and better address the needs of a rapidly aging population. These results will need to be confirmed with clinical trial results.