Reduced long-term cost and increased patient satisfaction with rechargeable implantable pulse generators for deep brain stimulation

Cost-effectiveness and threshold analysis of deep brain stimulation vs. treatment-as-usual for treatment-resistant depression

Treatment-resistant depression (TRD) affects approximately 2.8 million people in the U.S. with estimated annual healthcare costs of $43.8 billion. Deep brain stimulation (DBS) is currently an investigational intervention for TRD. We used a decision-analytic model to compare cost-effectiveness of DBS to treatment-as-usual (TAU) for TRD. Because this therapy is not FDA approved or in common use, our goal was to establish an effectiveness threshold that trials would need to demonstrate for this therapy to be cost-effective. Remission and complication rates were determined from review of relevant studies. We used published utility scores to reflect quality of life after treatment. Medicare reimbursement rates and health economics data were used to approximate costs. We performed Monte Carlo (MC) simulations and probabilistic sensitivity analyses to estimate incremental cost-effectiveness ratios (ICER; USD/quality-adjusted life year [QALY]) at a 5-year time horizon. Cost-effectiveness was defined using willingness-to-pay (WTP) thresholds of $100,000/QALY and $50,000/QALY for moderate and definitive cost-effectiveness, respectively. We included 274 patients across 16 studies from 2009-2021 who underwent DBS for TRD and had ≥12 months follow-up in our model inputs. From a healthcare sector perspective, DBS using non-rechargeable devices (DBS-pc) would require 55% and 85% remission, while DBS using rechargeable devices (DBS-rc) would require 11% and 19% remission for moderate and definitive cost-effectiveness, respectively. From a societal perspective, DBS-pc would require 35% and 46% remission, while DBS-rc would require 8% and 10% remission for moderate and definitive cost-effectiveness, respectively. DBS-pc will unlikely be cost-effective at any time horizon without transformative improvements in battery longevity. If remission rates ≥8-19% are achieved, DBS-rc will likely be more cost-effective than TAU for TRD, with further increasing cost-effectiveness beyond 5 years.

Movement disorder Deep brain stimulation Hybridization: Patient and caregiver outcomes

Background and Objectives

Deep brain stimulation (DBS) is a well-established surgical treatment for certain movement disorders and involves the implantation of brain electrodes connected to implantable pulse generators (IPGs). As more device manufacturers have entered the market, some IPG technology has been designed to be compatible with brain electrodes from other manufacturers, which has facilitated the hybridization of implant technology. The aim of this study was to assess the benefits of hybridization of non-rechargeable, constant voltage IPGs to rechargeable, constant current IPGs.

Methods

A list of DBS movement disorder patients who had their non-rechargeable, constant voltage IPGs replaced with rechargeable, constant current IPGs from a different manufacturer was compiled. Structured surveys of these patients, and their caregivers when applicable, were undertaken to determine both patient and caregiver satisfaction in this DBS hybridization strategy.

Results

Eighteen patients met inclusion criteria and twelve patients or their caregivers completed the structured survey (67% response rate). Nine patients had Parkinson's disease (75%), three had essential tremor (25%). Nine (75%) were converted from bilateral single-channel IPGs, and three (25%) were converted from a unilateral dual-channel IPGs. Overall, 92% of patients and caregivers surveyed reported improvement or no change in their symptoms, 92% reported a decrease or no change in their medication requirements, and 92% report they are satisfied or very satisfied with their IPG hybridization and would recommend the surgery to similar patients. There were no immediate surgical complications.

Conclusion

In this series of movement disorder DBS patients, surgery was safe and patient and caregiver satisfaction were high with a hybridization of non-rechargeable, constant voltage IPGs to rechargeable, constant current IPGs.

Essential Tremor - Deep Brain Stimulation vs. Focused Ultrasound

INTRODUCTION

Essential Tremor (ET) is one of the most common tremor syndromes typically presented as action tremor, affecting mainly the upper limbs. In at least 30-50% of patients, tremor interferes with quality of life, does not respond to first-line therapies and/or intolerable adverse effects may occur. Therefore, surgery may be considered.

AREAS COVERED

In this review, the authors discuss and compare unilateral ventral intermedius nucleus deep brain stimulation (VIM DBS) and bilateral DBS with Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy, which comprises focused acoustic energy generating ablation under real-time MRI guidance. Discussion includes their impact on tremor reduction and their potential complications. Finally, the authors provide their expert opinion.

EXPERT OPINION

DBS is adjustable, potentially reversible and allows bilateral treatments; however, it is invasive requires hardware implantation, and has higher surgical risks. Instead, MRgFUS is less invasive, less expensive, and requires no hardware maintenance. Beyond these technical differences, the decision should also involve the patient, family, and caregivers.

Sacral neuromodulation: Rechargeable versus non-rechargeable device. What would the patient preferences be in France?

AIMS

Sacral neuromodulation (SNM) is a minimally invasive technique that provides effective treatment for the management of refractory overactive bladder (OAB), non-obstructive urinary retention (NOUR), and fecal incontinence (FI). This study assessed patient preferences between the currently available non-rechargeable SNM device and a new, full-body magnetic resonance imaging (MRI)-safe, smaller, rechargeable device.

METHODS

An online cross-sectional survey was conducted among French OAB, NOUR, FI patients, recruited via a market research vendor. To assess their preferences, patients were asked to indicate their level of agreement with 10 statements regarding the size of the device, its rechargeability, and the role of MRI using a 6-item Likert scale. A descriptive statistical analysis was performed.

RESULTS

In all, 95 patients (68% women), mean age 50 years, were included in the study: 51% were treated for OAB; 44% received an oral treatment and 28% had SNM. Overall, 71% of the 95 patients indicated a preference for the new device; 75% considered that recharging the device would not impact their lifestyle; 74% believed that the smaller size of the rechargeable device would facilitate their choice to be treated with SNM; 80% found full-body MRI compatibility important.

CONCLUSIONS

Most patients may prefer the new rechargeable SNM device over the current "standard". Compatibility with full-body MRI and the smaller device size seemed the key features of the newer device that would influence their choice of being treated with SNM. Future national and international recommendations should consider a shared decision-making process between the physician and the patient.

LEVEL OF EVIDENCE: 4

Deep brain stimulation of fornix for memory improvement in Alzheimer's disease: A critical review

Memory reflects the brain function in encoding, storage and retrieval of the data or information, which is a fundamental ability for any live organism. The development of approaches to improve memory attracts much attention due to the underlying mechanistic insight and therapeutic potential to treat neurodegenerative diseases with memory loss, such as Alzheimer's disease (AD). Deep brain stimulation (DBS), a reversible, adjustable, and non-ablative therapy, has been shown to be safe and effective in many clinical trials for neurodegenerative and neuropsychiatric disorders. Among all potential regions with access to invasive electrodes, fornix is considered as it is the major afferent and efferent connection of the hippocampus known to be closely associated with learning and memory. Indeed, clinical trials have demonstrated that fornix DBS globally improved cognitive function in a subset of patients with AD, indicating fornix can serve as a potential target for neurosurgical intervention in treating memory impairment in AD. The present review aims to provide a better understanding of recent progresses in the application of fornix DBS for ameliorating memory impairments in AD patients.

Developments in Deep Brain Stimulators for Successful Aging Towards Smart Devices—An Overview

This work provides an overview of the present state-of-the-art in the development of deep brain Deep Brain Stimulation (DBS) and how such devices alleviate motor and cognitive disorders for a successful aging. This work reviews chronic diseases that are addressable via DBS, reporting also the treatment efficacies. The underlying mechanism for DBS is also reported. A discussion on hardware developments focusing on DBS control paradigms is included specifically the open- and closed-loop “smart” control implementations. Furthermore, developments towards a “smart” DBS, while considering the design challenges, current state of the art, and constraints, are also presented. This work also showcased different methods, using ambient energy scavenging, that offer alternative solutions to prolong the battery life of the DBS device. These are geared towards a low maintenance, semi-autonomous, and less disruptive device to be used by the elderly patient suffering from motor and cognitive disorders.

Past, Present, and Future of Deep Brain Stimulation: Hardware, Software, Imaging, Physiology and Novel Approaches

Deep brain stimulation (DBS) has advanced treatment options for a variety of neurologic and neuropsychiatric conditions. As the technology for DBS continues to progress, treatment efficacy will continue to improve and disease indications will expand. Hardware advances such as longer-lasting batteries will reduce the frequency of battery replacement and segmented leads will facilitate improvements in the effectiveness of stimulation and have the potential to minimize stimulation side effects. Targeting advances such as specialized imaging sequences and "connectomics" will facilitate improved accuracy for lead positioning and trajectory planning. Software advances such as closed-loop stimulation and remote programming will enable DBS to be a more personalized and accessible technology. The future of DBS continues to be promising and holds the potential to further improve quality of life. In this review we will address the past, present and future of DBS.

Implantable Pulse Generators for Deep Brain Stimulation: Challenges, Complications, and Strategies for Practicality and Longevity

Deep brain stimulation (DBS) represents an important treatment modality for movement disorders and other circuitopathies. Despite their miniaturization and increasing sophistication, DBS systems share a common set of components of which the implantable pulse generator (IPG) is the core power supply and programmable element. Here we provide an overview of key hardware and software specifications of commercially available IPG systems such as rechargeability, MRI compatibility, electrode configuration, pulse delivery, IPG case architecture, and local field potential sensing. We present evidence-based approaches to mitigate hardware complications, of which infection represents the most important factor. Strategies correlating positively with decreased complications include antibiotic impregnation and co-administration and other surgical considerations during IPG implantation such as the use of tack-up sutures and smaller profile devices.Strategies aimed at maximizing battery longevity include patient-related elements such as reliability of IPG recharging or consistency of nightly device shutoff, and device-specific such as parameter delivery, choice of lead configuration, implantation location, and careful selection of electrode materials to minimize impedance mismatch. Finally, experimental DBS systems such as ultrasound, magnetoelectric nanoparticles, and near-infrared that use extracorporeal powered neuromodulation strategies are described as potential future directions for minimally invasive treatment.

Fixed-Life or Rechargeable Battery for Deep Brain Stimulation: Preference and Satisfaction in Chinese Patients With Parkinson's Disease

Introduction: DBS is a widely used therapy for PD. There is now a choice between fixed-life implantable pulse generators (IPGs) and rechargeable IPGs, each having advantages and disadvantages. This study aimed to evaluate the preference and satisfaction of Chinese patients with Parkinson's disease (PD) who were treated with deep brain stimulation (DBS). Materials and Methods: Two hundred and twenty PD patients were treated with DBS and completed a self-reported questionnaire to assess their long-term satisfaction and experience with the type of battery they had chosen and the key factors affecting these choices. The survey was performed online and double-checked for completeness and accuracy. Results: The median value of the postoperative duration was 18 months. The most popular way for patients to learn about DBS surgery was through media (79/220, 35.9%) including the Internet and television programs. In total, 87.3% of the DBS used rechargeable IPGs (r-IPG). The choice between rechargeable and non-rechargeable IPGs was significantly associated with affordability ( χ ( 1 ) 2 = 19.13, p < 0.001). Interestingly, the feature of remote programming significantly affected patients' choices between domestic and imported brands ( χ ( 1 ) 2 = 16.81, p < 0.001). 87.7% of the patients were satisfied with the stimulating effects as well as the implanted device itself. 40.6% of the patients with r-IPGs felt confident handling devices within 1 week after discharge. More than half of the patients checked their batteries every week. The mean interval for battery recharge was 4.3 days. 57.8% of the patients spent around 1 h recharging, and 71.4% of them recharged the battery independently. Conclusions: Most patients were satisfied with their choice of IPGs. The patients' economic status and the remote programming function of the device were the two most critical factors in their decision. The skill of recharging the IPG was easy to master for most patients.

Fixed-Life or Rechargeable Batteries for Deep Brain Stimulation: Preference and Satisfaction Among Patients With Hyperkinetic Movement Disorders

Background: Deep brain stimulation (DBS) is an established treatment for hyperkinetic movement disorders. Patients undergoing DBS can choose between the use of a rechargeable or non-rechargeable battery for implanted pulse generators (IPG). Objectives: In this study, we aimed to evaluate patient preferences and satisfaction with rechargeable and non-rechargeable batteries for IPGs after undergoing DBS. Methods: Overall, 100 patients with hyperkinetic movement disorders (dystonia: 79, Tourette syndrome: 21) who had undergone DBS took a self-designed questionnaire to assess their satisfaction and experience with the type of battery they had chosen and the factors influencing their choice. Results: Of the participants, 87% were satisfied with the stimulating effects of the treatment as well as the implanted device; 76% had chosen rechargeable devices (r-IPGs), 71.4% of whom recharged the battery themselves. Economic factors were the main reason for choosing both r-IPG and non-rechargeable IPG (nr-IPG). The questionnaire revealed that 66% of the patients checked their r-IPG battery every week. The mean interval for battery recharge was 4.3 days. Conclusions: The majority of the patients were satisfied with their in-service-IPG, regardless of whether it was a r-IPG or nr-IPG. Affordability was the main factor influencing the choice of IPG. The majority of the patients were confident in recharging the battery of their r-IPG themselves; only 11% of patients experienced difficulties. Understanding the recharge process remains difficult for some patients and increasing the number of training sessions for the device may be helpful.

The utility of deep brain stimulation surgery for treating eating disorders: A systematic review

Background:

Deep brain stimulation (DBS) has demonstrated preliminary success as a treatment for neuropsychological disorders including obsessive-compulsive disorder and substance use disorder. This systematic review aims to assess the use of DBS in treating eating disorders (EDs) to determine its utility and the extent of adverse effects.

Methods:

A PubMed search following PRISMA guidelines was executed to find studies encompassing DBS as a treatment of ED. Outcomes were extracted from the literature and summarized while a review of quality was also performed.

Results:

From a search yielding 299 publications, 11 studies published between 2010 and 2020 were found to fit the inclusion criteria. Out of 53 patients who began with an abnormal BMI before treatment, 22 patients (41.5%) achieved normal BMI on follow-up. Significant neuropsychological improvement was seen in most patients as measured by neuropsychiatric testing and questionnaires.

Conclusion:

DBS as a treatment for ED may result in significant objective and psychological benefits. Further studies should aim to increase the sample size, standardize follow-up protocol, and standardize the neuropsychiatric tests used to determine psychological and physiological benefits.

Neuroimaging evaluation of deep brain stimulation in the treatment of representative neurodegenerative and neuropsychiatric disorders

Brain stimulation technology has become a viable modality of reversible interventions in the effective treatment of many neurological and psychiatric disorders. It is aimed to restore brain dysfunction by the targeted delivery of specific electronic signal within or outside the brain to modulate neural activity on local and circuit levels. Development of therapeutic approaches with brain stimulation goes in tandem with the use of neuroimaging methodology in every step of the way. Indeed, multimodality neuroimaging tools have played important roles in target identification, neurosurgical planning, placement of stimulators and post-operative confirmation. They have also been indispensable in pre-treatment screen to identify potential responders and in post-treatment to assess the modulation of brain circuitry in relation to clinical outcome measures. Studies in patients to date have elucidated novel neurobiological mechanisms underlying the neuropathogenesis, action of stimulations, brain responses and therapeutic efficacy. In this article, we review some applications of deep brain stimulation for the treatment of several diseases in the field of neurology and psychiatry. We highlight how the synergistic combination of brain stimulation and neuroimaging technology is posed to accelerate the development of symptomatic therapies and bring revolutionary advances in the domain of bioelectronic medicine.

Deep Brain Stimulation-Related Surgical Site Infections: A Systematic Review and Meta-Analysis

BACKGROUND

Over the last decades, the increased use of deep brain stimulation (DBS) has raised concerns about the potential adverse health effects of the treatment. Surgical site infections (SSIs) following an elective surgery remain a major challenge for neurosurgeons. Few studies have examined the prevalence and risk factors of DBS-related complications, particularly focusing on SSIs.

OBJECTIVES

We systematically searched published literature, up to June 2020, with no language restrictions.

MATERIALS AND METHODS

Eligible were studies that examined the prevalence of DBS-related SSIs, as well as studies that examined risk and preventive factors in relation to SSIs. We extracted information on study characteristics, follow-up, exposure and outcome assessment, effect estimate and sample size. Summary odds ratios (sOR) and 95% confidence intervals (CI) were calculated from random-effects meta-analyses; heterogeneity and small-study effects were also assessed.

RESULTS

We identified 66 eligible studies that included 12,258 participants from 27 countries. The summary prevalence of SSIs was estimated at 5.0% (95% CI: 4.0%-6.0%) with higher rates for dystonia (6.5%), as well as for newer indications of DBS, such as epilepsy (9.5%), Tourette syndrome (5.9%) and OCD (4.5%). Similar prevalence rates were found between early-onset and late-onset hardware infections. Among risk and preventive factors, the perioperative implementation of intra-wound vancomycin was associated with statistically significantly lower risk of SSIs (sOR: 0.26, 95% CI: 0.09-0.74). Heterogeneity was nonsignificant in most meta-analyses.

CONCLUSION

The present study confirms the still high prevalence of SSIs, especially for newer indications of DBS and provides evidence that preventive measures, such as the implementation of topical vancomycin, seem promising in reducing the risk of DBS-related SSIs. Large clinical trials are needed to confirm the efficacy and safety of such measures.

Outcomes of deep brain stimulation surgery for substance use disorder: a systematic review

Long has the standard of care for substance use disorder (SUD) been pharmacotherapy, psychotherapy, or rehabilitation with varying success. Deep brain stimulation (DBS) may have a beneficial reduction in the addiction-reward pathway. Recent studies have found reduced relapse and improvements in quality of life following DBS stimulation of the nucleus accumbens. We aim to identify positive outcomes and adverse effects to assess the viability of DBS as a treatment of addiction. A PubMed search following PRISMA guidelines was conducted to identify the entirety of reports reporting DBS as a treatment for SUD. Outcomes were extracted from the literature to be summarized, and a review of the quality of publications was also performed. From 2305 publications, 14 studies were found to fit the inclusion criteria published between 2007 and 2019. All studies targeted the nucleus accumbens (NAc) and remission rates at 6 months, 1 year, 2 years, and more than 6 years were 61% (20/33), 53% (17/32), 43% (14/30), and 50% (3/6), respectively. Not all studies detailed the stimulation settings or coordinates. The most common adverse effect across studies was a weight change of at least 2 kg. DBS shows potential as a long-term treatment of SUD in refractory patients. Further studies with controlled double-blind paradigms are needed for evaluation of the efficacy and safety of this treatment. Future studies should also investigate other brain regions for stimulation and optimal device stimulation parameters.

Update on Current Technologies for Deep Brain Stimulation in Parkinson's Disease

Deep brain stimulation (DBS) is becoming increasingly central in the treatment of patients with Parkinson's disease and other movement disorders. Recent developments in DBS lead and implantable pulse generator design provide increased flexibility for programming, potentially improving the therapeutic benefit of stimulation. Directional DBS leads may increase the therapeutic window of stimulation by providing a means of avoiding current spread to structures that might give rise to stimulation-related side effects. Similarly, control of current to individual contacts on a DBS lead allows for shaping of the electric field produced between multiple active contacts. The following review aims to describe the recent developments in DBS system technology and the features of each commercially available DBS system. The advantages of each system are reviewed, and general considerations for choosing the most appropriate system are discussed.

The effect of fornix deep brain stimulation in brain diseases

Deep brain stimulation is used to alleviate symptoms of neurological and psychiatric disorders including Parkinson's disease, epilepsy, and obsessive-compulsive-disorder. Electrically stimulating limbic structures has been of great interest, and in particular, the region of the fornix. We conducted a systematic search for studies that reported clinical and preclinical outcomes of deep brain stimulation within the fornix up to July 2019. We identified 13 studies (7 clinical, 6 preclinical) that examined the effects of fornix stimulation in Alzheimer's disease (n = 9), traumatic brain injury (n = 2), Rett syndrome (n = 1), and temporal lobe epilepsy (n = 1). Overall, fornix stimulation can lead to decreased rates of cognitive decline (in humans), enhanced memory (in humans and animals), visuo-spatial memorization (in humans and animals), and improving verbal recollection (in humans). While the exact mechanisms of action are not completely understood, studies suggest fornix DBS to be involved with increased functional connectivity and neurotransmitter levels, as well as enhanced neuroplasticity.

Clinical Efficacy of Bilateral Deep Brain Stimulation Does Not Change After Implantable Pulse Generator Replacement but the Impedances Do: A Prospective Study

BACKGROUND

Deep brain stimulation (DBS) is an approved therapy option for movement disorders such as Parkinson's disease (PD), essential Tremor (ET), and dystonia. While current research focuses on rechargeable implantable pulse generators (IPGs), little is known about changes of the motor functions after IPG replacement and the consequences of additionally implanted hardware.

OBJECTIVE

To assess changes of the motor functions, the therapy impedances, and the total electric energy delivered (TEED) after elective IPG replacement.

METHODS

We prospectively acquired the data of 47 patients with PD, ET, and dystonia treated with bilateral DBS. Motor functions were rated prior to and after surgery using the revised Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III), the Fahn-Tolosa-Marin Tremor-Rating-Scale (FTM-TRS), and the Unified Dystonia Rating Scale (UDRS). Furthermore, the therapy impedances and TEED were assessed at the aforementioned times.

RESULTS

While preoperative motor scores were 48.32 ± 17.16 in PD, 39.71 ± 12.28 in ET, and 18.48 ± 16.30 in dystonia patients, postoperative scores were 47.84 ± 24.33, 32.86 ± 15.82, and 15.02 ± 15.17, respectively. Only in dystonia patients, motor scores significantly differed. Perioperative therapy impedance changes were 142.66 ± 105.35 Ω (Kinetra® to Activa® PC), -68.75 ± 43.05 Ω (Activa® PC to Activa® PC), and - 51.38 ± 38.75 Ω (Activa® PC to Activa® RC). Perioperative TEED changes were - 37.15 ± 38.87 μJ, 2.03 ± 35.91 μJ, and 12.39 ± 6.31 μJ in that first, second, and third group, respectively. Both the therapy impedances and TEED significantly differed between groups.

CONCLUSION

Although there were no statistically significant changes in the motor functions of all patients after elective IPG replacement, the therapy impedances were significantly higher and TEED was significantly lower after IPG replacement with concurrent Pocket Adapter implantation.

Dynamics of device-based treatments for Parkinson's disease in Germany from 2010 to 2017: application of continuous subcutaneous apomorphine, levodopa-carbidopa intestinal gel, and deep brain stimulation

Parkinson's disease (PD) is a very common extrapyramidal movement disorder and currently the world's fastest growing neurological disorder. In the course of disease progression, a majority of PD patients develop severe motor fluctuations which often cannot be adequately treated with common oral anti-Parkinsonian medications. With continuous subcutaneous apomorphine infusion (CSAI), levodopa-carbidopa intestinal gel infusion (LCIG), and deep brain stimulation (DBS), there exist three effective treatment options for advanced PD patients with motor fluctuations. In this study, we analyze the dynamics of implementation for these treatments in Germany over the years 2010-2017 based on the diagnosis-related group statistics and structured quality reports. All three intensified therapy measures are increasingly applied in Germany. The mean age of therapy implementation is rising and more male than female patients receive treatments. Although DBS is provided primarily in university hospitals with a caseload of at least two procedures per month, there exists a substantial proportion of DBS procedures which is conducted in hospitals with only a low caseload. Most of the drug pump implementations (CSAI and LCIG) are conducted in a large number of hospitals with an overall low case number. As we detect a strong rise of the implementation of these device-based therapies, it will be a challenging task to satisfy patient need and perpetuate high standards for these specialized procedures in the future.