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Abstract
Three neuromodulation therapies, all using implanted device and electrodes, have been
approved to treat adults with drug-resistant focal epilepsy, namely, the vagus nerve
stimulation in 1995, deep brain stimulation of the anterior nucleus of the thalamus
(ANT-DBS) in 2018 (2010 in Europe), and responsive neurostimulation (RNS) in 2014.
Indications for VNS have more recently extended to children down to age of 4. Limited or
anecdotal data are available in other epilepsy syndromes and refractory/super-refractory
status epilepticus. Overall, neuromodulation therapies are palliative, with only a
minority of patients achieving long-term seizure freedom, justifying favoring such
treatments in patients who are not good candidates for curative epilepsy surgery. About
half of patients implanted with VNS, ANT-DBS, and RNS have 50% or greater reduction in
seizures, with long-term data suggesting increased efficacy over time. Besides their
impact on seizure frequency, neuromodulation therapies are associated with various
benefits and drawbacks in comparison to antiseizure drugs. Yet, we lack high-level
evidence to best position each neuromodulation therapy in the treatment pathways of
persons with difficult-to-treat epilepsy.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lara E. Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Raspin C, Shankar R, Barion F, Pollit V, Murphy J, Sawyer L, Danielson V. An economic evaluation of vagus nerve stimulation as an adjunctive treatment to anti-seizure medications for the treatment of drug-resistant epilepsy in England. J Med Econ 2021; 24:1037-1051. [PMID: 34348576 DOI: 10.1080/13696998.2021.1964306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Anti-seizure medications (ASMs) are commonly used to prevent recurring epileptic seizures, but around a third of people with epilepsy fail to achieve an adequate response. Vagus nerve stimulation (VNS) is clinically recommended for people with drug-resistant epilepsy (DRE) who are not suitable for surgery, but the cost-effectiveness of the intervention has not recently been evaluated. The study objective is to estimate costs and quality-adjusted life-years (QALYs) associated with using VNS as an adjunct to ongoing ASM therapy, compared to the strategy of using only ASMs in the treatment of people with DRE, from an English National Health Service perspective. METHODS A cohort state transition model was developed in Microsoft Excel to simulate costs and QALYs of the VNS + ASM and ASM only strategies. Patients could transition between five health states, using a 3-month cycle length. Health states were defined by an expected percentage reduction in seizure frequency, derived from randomized control trial data. Costs included the VNS device as well as its installation, setup, and removal; ASM therapy; adverse events associated with VNS (dyspnea, hoarseness, and cough); and health-state costs associated with epilepsy including hospitalizations, emergency department visits, neurologist visits, and primary care visits. A range of sensitivity analyses, including probabilistic sensitivity analysis, were run to assess the impact of parameter and structural uncertainty. RESULTS In the base case, VNS + ASM had an estimated incremental cost-effectiveness ratio (ICER) of £17,771 per QALY gained compared to ASMs alone. The cost-effective ICER was driven by relative reductions in expected seizure frequency and the differences in health care resource use associated therewith. Sensitivity analyses found that the amount of resource use per epilepsy-related health state was a key driver of the cost component. CONCLUSIONS VNS is expected to be a cost-effective intervention in the treatment of DRE in the English National Health Service.
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Affiliation(s)
| | - Rohit Shankar
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
- Cornwall Partnership NHS Foundation Trust, Bodmin, UK
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Health Technology Assessment Report on Vagus Nerve Stimulation in Drug-Resistant Epilepsy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176150. [PMID: 32847092 PMCID: PMC7504285 DOI: 10.3390/ijerph17176150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 07/31/2020] [Accepted: 08/13/2020] [Indexed: 01/12/2023]
Abstract
Background: Vagus nerve stimulation (VNS) is a palliative treatment for medical intractable epileptic syndromes not eligible for resective surgery. Health technology assessment (HTA) represents a modern approach to the analysis of technologies used for healthcare. The purpose of this study is to assess the clinical, organizational, financial, and economic impact of VNS therapy in drug-resistant epilepsies and to establish the congruity between costs incurred and health service reimbursement. Methods: The present study used an HTA approach. It is based on an extensive detailed bibliographic search on databases (Medline, Pubmed, Embase and Cochrane, sites of scientific societies and institutional sites). The HTA study includes the following issues: (a) social impact and costs of the disease; (b) VNS eligibility and clinical results; (c) quality of life (QoL) after VNS therapy; (d) economic impact and productivity regained after VNS; and (e) costs of VNS. Results: Literature data indicate VNS as an effective treatment with a potential positive impact on social aspects and on quality of life. The diagnosis-related group (DRG) financing, both on national and regional levels, does not cover the cost of the medical device. There was an evident insufficient coverage of the DRG compared to the full cost of implanting the device. Conclusions: VNS is a palliative treatment for reducing seizure frequency and intensity. Despite its economic cost, VNS should improve patients’ quality of life and reduce care needs.
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Jennum P, Hastrup LH, Ibsen R, Kjellberg J, Simonsen E. Welfare consequences for people diagnosed with attention deficit hyperactivity disorder (ADHD): A matched nationwide study in Denmark. Eur Neuropsychopharmacol 2020; 37:29-38. [PMID: 32682821 DOI: 10.1016/j.euroneuro.2020.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 03/18/2020] [Accepted: 04/23/2020] [Indexed: 12/18/2022]
Abstract
There is insufficient data regarding the excess direct and indirect costs associated with attention deficit hyperactivity disorder (ADHD). Using the Danish National Patient Registry (2002-2016), we identified 83,613 people of any age with a diagnosis of ADHD or who were using central-acting medication against ADHD (primarily methylphenidate, with at least two prescriptions) and matched them to 334,446 control individuals. Additionally, 18,959 partners of patients aged ≥18 years with ADHD were identified, and compared with 74,032 control partners. Direct costs were based on data from the Danish Ministry of Health. Information about the use and costs of drugs were obtained from the Danish Medicines Agency. The frequencies of visits and hospitalizations, and costs of general practice were derived from data from the National Health Security. Indirect costs were obtained from Coherent Social Statistics. The average annual health care costs for people with ADHD and their partners were, respectively, €2636 and €477 higher than those of the matched controls. A greater percentage of people with ADHD and their partners compared with respective control subjects received social services (sick pay or disability pension). Those with ADHD had a lower income from employment than did controls for equivalent periods up to five years before the first diagnosis of ADHD. The additional direct and indirect annual costs (for those aged ≥18 years) including transfers of ADHD compared with controls were €23,072 for people with ADHD and €7,997 for their partners. ADHD has substantial socioeconomic consequences for individual patients, their partners and society.
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Affiliation(s)
- Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Faculty of Health Sciences, University of Copenhagen, Rigshospitalet, DK 2600 Glostrup, Copenhagen, Denmark.
| | | | | | - Jakob Kjellberg
- VIVE - The Danish Center for Social Science Research, Copenhagen, Denmark.
| | - Erik Simonsen
- Psychiatric Research Unit, Psychiatry, Region Zealand, Denmark; Department of Clinical Medicine, Faculty of Medical and health Sciences, University of Copenhagen, Denmark.
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Brodtkorb E, Samsonsen C, Jørgensen JV, Helde G. Epilepsy patients with and without perceived benefit from vagus nerve stimulation: A long-term observational single center study. Seizure 2019; 72:28-32. [DOI: 10.1016/j.seizure.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/27/2019] [Accepted: 09/08/2019] [Indexed: 11/27/2022] Open
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Kopciuch D, Barciszewska A, Fliciński J, Paczkowska A, Winczewska‐Wiktor A, Jankowski R, Steinborn B, Nowakowska E. Economic and clinical evaluation of vagus nerve stimulation therapy. Acta Neurol Scand 2019; 140:244-251. [PMID: 31165476 DOI: 10.1111/ane.13137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/13/2019] [Accepted: 06/03/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The medical and social care of drug-resistant epilepsy (DRE) entails significant costs. Approximately 30 to 40 percent of patients with DRE who underwent vagus nerve stimulator (VNS) implantation achieve an above 50 percent reduction in seizure frequency. The study objective was to analyze the effect of VNS on clinical effects improvement and therapy cost reduction in patients with DRE over a 2-year follow-up period. The second purpose of the study was to compare average costs of VNS treatment of patients with DRE in selected countries, taking into account the purchasing power parity. MATERIALS AND METHODS The study included all the patients who had VNS implanted at our department between 2014 and 2018. Data on clinical events and medical costs were collected prospectively and obtained from medical documentation. We also reviewed relevant literature on costs of VNS therapy in patients with DRE from the last 18 years. RESULTS Resource utilization and epilepsy-related events were reduced during the follow-up period compared to the baseline. Average total cost was estimated at EUR 7703.59 in year 1 and at EUR 7108.38 in year 2 following VNS implantation. Average direct costs of VNS treatment of patients with DRE over the last 18 years varied between the countries and ranged from EUR 24 790.43 in the United States to EUR 64.84 in the United Kingdom. CONCLUSION Vagus nerve stimulator is a cost-effective therapy yielding measurable clinical and therapeutic outcomes over the long term. Moreover, the analysis contained in this review highlights the poor consensus of methodological approaches.
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Affiliation(s)
- Dorota Kopciuch
- Department of Pharmacoeconomics and Social Pharmacy Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
| | - Anna‐Maria Barciszewska
- Department of Neurosurgery and Neurotraumatology Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
- Department of Neurosurgery and Neurotraumatology Heliodor Swiecicki Clinical Hospital in Poznań Poznań Poland
| | - Jędrzej Fliciński
- Department of Developmental Neurology Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
| | - Anna Paczkowska
- Department of Pharmacoeconomics and Social Pharmacy Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
| | - Anna Winczewska‐Wiktor
- Department of Developmental Neurology Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
| | - Roman Jankowski
- Department of Neurosurgery and Neurotraumatology Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
- Department of Neurosurgery and Neurotraumatology Heliodor Swiecicki Clinical Hospital in Poznań Poznań Poland
| | - Barbara Steinborn
- Department of Developmental Neurology Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
| | - Elżbieta Nowakowska
- Department of Pharmacoeconomics and Social Pharmacy Karol Marcinkowski University of Medical Sciences in Poznań Poznań Poland
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Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark. Epilepsy Behav 2019; 98:59-65. [PMID: 31299534 DOI: 10.1016/j.yebeh.2019.06.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/09/2019] [Accepted: 06/11/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures. METHODS From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics. RESULTS A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners. SIGNIFICANCE Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.
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Kavčič A, Kajdič N, Rener-Primec Z, Krajnc N, Žgur T. Efficacy and tolerability of vagus nerve stimulation therapy (VNS) in Slovenian epilepsy patients: younger age and shorter duration of epilepsy might result in better outcome. Acta Clin Croat 2019; 58:255-264. [PMID: 31819321 PMCID: PMC6884381 DOI: 10.20471/acc.2019.58.02.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
To review the outcome of vagus nerve stimulation (VNS) therapy in all implanted Slovenian patients with drug-resistant epilepsy, data on 48 patients implanted between 2001 and 2015 were obtained retrospectively from medical records. The outcome was assessed in 2016. Out of 48 patients, 39 responded at follow up. The seizure frequency was reduced in 18 (46.2%) patients; 13 (33.3%) of them reported ≥50% reduction after 12 months of therapy. The responder rate was higher among patients implanted before the age of six years. Ictal severity decreased in 22 (56.4%), seizure duration in 19 (48.7%) and post-ictal recovery time in 22 (56.4%) patients. Favorable effects on the quality of life (QOL) were improved alertness in 33.3%, concentration in 41.0%, energy and mood in 38.5%, and memory in 17.9% of patients. Reduced seizure burden and improved QOL were more often observed in patients implanted at a younger age. Shorter duration of epilepsy was significantly associated with QOL improvement. Adverse effects were transient. Overall positive effects showed VNS to be a safe, well-tolerated and effective adjunctive treatment in most severe drug-resistant epilepsy patients. Implantation at a younger age and shorter duration of epilepsy before implantation could be important predictors of better outcome.
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Affiliation(s)
| | - Nina Kajdič
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Zvonka Rener-Primec
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Natalija Krajnc
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tomaž Žgur
- 1Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 2Department of Child, Adolescent and Developmental Neurology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; 3Department of Pediatrics, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia; 4Department of Clinical Neurophysiology, Medical Centre Ljubljana, Ljubljana, Slovenia
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Welfare consequences for people with epilepsy and their partners: A matched nationwide study in Denmark. Seizure 2017; 49:17-24. [DOI: 10.1016/j.seizure.2017.05.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 12/14/2022] Open
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