A cost-effectiveness analysis of anterior temporal lobectomy for intractable temporal lobe epilepsy

Remote effects of temporal lobe epilepsy surgery: Long-term morphological changes after surgical resection

OBJECTIVE

Epilepsy surgery is an effective treatment for drug-resistant patients. However, how different surgical approaches affect long-term brain structure remains poorly characterized. Here, we present a semiautomated method for quantifying structural changes after epilepsy surgery and compare the remote structural effects of two approaches, anterior temporal lobectomy (ATL), and selective amygdalohippocampectomy (SAH).

METHODS

We studied 36 temporal lobe epilepsy patients who underwent resective surgery (ATL = 22, SAH = 14). All patients received same-scanner MR imaging preoperatively and postoperatively (mean 2 years). To analyze postoperative structural changes, we segmented the resection zone and modified the Advanced Normalization Tools (ANTs) longitudinal cortical pipeline to account for resections. We compared global and regional annualized cortical thinning between surgical treatments.

RESULTS

Across procedures, there was significant cortical thinning in the ipsilateral insula, fusiform, pericalcarine, and several temporal lobe regions outside the resection zone as well as the contralateral hippocampus. Additionally, increased postoperative cortical thickness was seen in the supramarginal gyrus. Patients treated with ATL exhibited greater annualized cortical thinning compared with SAH cases (ATL: -0.08 ± 0.11 mm per year, SAH: -0.01 ± 0.02 mm per year, t = 2.99, P = 0.006). There were focal postoperative differences between the two treatment groups in the ipsilateral insula (P = 0.039, corrected). Annualized cortical thinning rates correlated with preoperative cortical thickness (r = 0.60, P < 0.001) and had weaker associations with age at surgery (r = -0.33, P = 0.051) and disease duration (r = -0.42, P = 0.058).

SIGNIFICANCE

Our evidence suggests that selective procedures are associated with less cortical thinning and that earlier surgical intervention may reduce long-term impacts on brain structure.

Systematic Review of Cost-Effectiveness Analysis for Surgical and Neurostimulation Treatments for Drug-Resistant Epilepsy in Adults

BACKGROUND AND OBJECTIVES

Surgical and neurostimulator treatments are effective for reducing seizure burden in selected individuals living with drug-resistant epilepsy (DRE). We aimed to determine the presence and key model determinants for cost-effectiveness of these interventions, compared with medical management alone, to assist with decisions about resource allocation.

METHODS

A systematic literature search was conducted on June 1, 2022, using MEDLINE, EMBASE, the NHS Economic Evaluation Database, and the Cost-Effectiveness Analysis database. Included studies were economic evaluations in adult DRE cohorts, comparing surgical and neurostimulator treatments (vagus nerve stimulation [VNS], responsive neurostimulation [RNS], and deep brain stimulation [DBS]) vs medical management alone and reporting cost-benefit analysis, cost-utility, or cost-effectiveness. Exclusion criteria were studies with pediatric cohorts and those published in a language other than English. Three independent reviewers screened, extracted, and assessed data against the Consolidated Health Economic Evaluation Reporting Standards checklist, and a fourth reviewer adjudicated discrepancies.

RESULTS

Ten studies met inclusion criteria. Seven studies evaluated epilepsy surgery, and 3 evaluated neurostimulation treatments. All relevant studies established that epilepsy surgery is a cost-effective intervention compared with medical management alone, for quality-adjusted life-years and seizure freedom at 2 and 5 years. All relevant studies found neurostimulator treatments to be potentially cost-effective. The incremental cost-effectiveness ratio (ICER), with lower ICER indicating greater cost-effectiveness, was reported for 9 studies and varied between GBP £3,013 and US $61,333. Cost adaptation revealed ICERs from US $170 to US $121,726. Key model determinants included, but were not limited to, improved surgical outcomes and quality of life, reduced surgical and presurgical evaluation costs, higher rates of surgical eligibility after referral and evaluation, epilepsy subtype, less expensive neurostimulator devices with improved longevity, and cost analysis strategy used in the analysis.

DISCUSSION

There is consistent evidence that epilepsy surgery is a cost-effective treatment of eligible candidates with DRE. Limited evidence suggests that VNS, RNS, and DBS may be cost-effective therapies for DRE, although more health economic evaluations alongside prospective clinical trials are needed to validate these findings.

STUDY REGISTRATION INFORMATION

PROSPERO CRD42021278436.

Cost-effectiveness of surgical treatment compared to medical treatment in patients with drug-refractory epilepsy: A systematic review

BACKGROUND AND PURPOSE

Approximately 30% of epilepsy patients develop a drug-refractory epilepsy, that is, seizures cannot be controlled with antiepileptic drugs. Surgery has been evaluated as an effective but costly form of treatment. The aim of this systematic review is to synthesize the available evidence on the cost-effectiveness of surgical treatment compared to medical treatment for these patients.

METHOD

A systematic literature search was performed in MEDLINE, Embase, PsycINFO, Cochrane Library and the National Health Service Economic Evaluation Database until September 2022. Title, abstract and full-text screening were conducted by two researchers. Original studies published in English or German analyzing the cost-effectiveness of surgical compared to medical treatment were included. Study characteristics, effectiveness measures, costs and incremental cost-effectiveness ratios (ICERs) were extracted. The quality of studies was assessed using the Drummond checklist.

RESULTS

Fourteen studies were included. Most studies evaluated surgery as cost-effective. The ICER per patient seizure free ranged from dominant to purchasing power parity US dollars (PPP-USD) 479,275. The ICER per 1% seizure reduction ranged from PPP-USD 227 to PPP-USD 342. The ICER per year without seizures was PPP-USD 4202 and the ICER per quality-adjusted life-year ranged from dominant to PPP-USD 90,874. The studies varied greatly in their methodology and time horizon.

CONCLUSION

Surgical treatment is cost-effective compared to medical treatment, especially when a lifetime horizon is adopted. It is concluded that all disease-specific costs should be considered over a long period when assessing the cost-effectiveness of epilepsy treatment. From an economic perspective, efforts should be made to improve access to surgical treatment for patients with drug-refractory epilepsy.

Cost-effectiveness analysis of responsive neurostimulation for drug-resistant focal onset epilepsy

OBJECTIVE

We evaluated the incremental cost-effectiveness of responsive neurostimulation (RNS) therapy for management of medically refractory focal onset seizures compared to pharmacotherapy alone.

METHODS

We created and analyzed a decision model for treatment with RNS therapy versus pharmacotherapy using a semi-Markov process. We adopted a public payer perspective and used the maximum duration of 9 years in the RNS long-term follow-up study as the time horizon. We used seizure frequency data to model changes in quality of life and estimated the impact of RNS therapy on the annual direct costs of epilepsy care. The model also included expected mortality, adverse events, and costs related to system implantation, programming, and replacement. We interpreted our results against societal willingness-to-pay thresholds of $50 000, $100 000, and $200 000 per quality-adjusted life year (QALY).

RESULTS

Based on three different calculated utility value estimates, the incremental cost-effectiveness ratio (ICER) for RNS therapy (with continued pharmacotherapy) compared to pharmacotherapy alone ranged between $28 825 and $46 596. Multiple sensitivity analyses yielded ICERs often below $50 000 per QALY and consistently below $100 000/QALY.

SIGNIFICANCE

Modeling based on 9 years of available data demonstrates that RNS therapy for medically refractory epilepsy very likely falls within the range of cost-effectiveness, depending on method of utility estimation, variability in model inputs, and willingness-to-pay threshold. Several factors favor improved cost-effectiveness in the future. Given the increasing focus on delivering cost-effective care, we hope that this analysis will help inform clinical decision-making for this surgical option for refractory epilepsy.

Seizure and neuropsychological outcomes in a large series of selective amygdalohippocampectomies with a minimally invasive subtemporal approach

OBJECTIVE

Debate continues over proper surgical treatment for mesial temporal lobe epilepsy (MTLE). Few large comprehensive studies exist that have examined outcomes for the subtemporal selective amygdalohippocampectomy (sSAH) approach. This study describes a minimally invasive technique for sSAH and examines seizure and neuropsychological outcomes in a large series of patients who underwent sSAH for MTLE.

METHODS

Data for 152 patients (94 women, 61.8%; 58 men, 38.2%) who underwent sSAH performed by a single surgeon were retrospectively reviewed. The sSAH technique involves a small, minimally invasive opening and preserves the anterolateral temporal lobe and the temporal stem.

RESULTS

All patients in the study had at least 1 year of follow-up (mean [SD] 4.52 [2.57] years), of whom 57.9% (88/152) had Engel class I seizure outcomes. Of the patients with at least 2 years of follow-up (mean [SD] 5.2 [2.36] years), 56.5% (70/124) had Engel class I seizure outcomes. Preoperative and postoperative neuropsychological test results indicated no significant change in intelligence, verbal comprehension, perceptual reasoning, attention and processing, cognitive flexibility, visuospatial memory, or mood. There was a significant change in word retrieval regardless of the side of surgery and a significant change in verbal memory in patients who underwent dominant-side resection (p < 0.05). Complication rates were low, with a 1.3% (2/152) permanent morbidity rate and 0.0% mortality rate.

CONCLUSIONS

This study reports a large series of patients who have undergone sSAH, with a comprehensive presentation of a minimally invasive technique. The sSAH approach described in this study appears to be a safe, effective, minimally invasive technique for the treatment of MTLE.

Community health workers to improve adherence to anti-seizure medication in rural South Africa: Is it cost-effective?

OBJECTIVE

Epilepsy is a common, chronic neurological disorder that disproportionately affects individuals living in low- and middle-income countries (LMICs), where the treatment gap remains high and adherence to medication remains low. Community health workers (CHWs) have been shown to be effective at improving adherence to chronic medications, yet no study assessing the costs of CHWs in epilepsy management has been reported.

METHODS

Using a Markov model with age- and sex-varying transition probabilities, we determined whether deploying CHWs to improve epilepsy treatment adherence in rural South Africa would be cost-effective. Data were derived using published studies from rural South Africa. Official statistics and international disability weights provided cost and health state values, respectively, and health gains were measured using quality adjusted life years (QALYs).

RESULTS

The intervention was estimated at International Dollars ($) 123 250 per annum per sub-district community and cost $1494 and $1857 per QALY gained for males and females, respectively. Assuming a costlier intervention and lower effectiveness, cost per QALY was still less than South Africa's Gross Domestic Product per capita of $13 215, the cost-effectiveness threshold applied.

SIGNIFICANCE

CHWs would be cost-effective and the intervention dominated even when costs and effects of the intervention were unfavorably varied. Health system re-engineering currently underway in South Africa identifies CHWs as vital links in primary health care, thereby ensuring sustainability of the intervention. Further research on understanding local health state utility values and cost-effectiveness thresholds could further inform the current model, and undertaking the proposed intervention would provide better estimates of its efficacy on reducing the epilepsy treatment gap in rural South Africa.

Cost-effectiveness analysis of epilepsy surgery in children and adolescents with drug resistant focal epilepsy at three years in a tertiary care epilepsy center in Thailand

Epilepsy surgery is proven as a cost-effective treatment in developed countries, especially in adults with drug resistant epilepsy (DRE). This study is aimed to demonstrate the cost-effectiveness of epilepsy surgery in children and adolescents with DRE at three years compared with those who were eligible for surgery but received medical treatment. This study was conducted from January 2014 to December 2018. Clinical data were obtained from a retrospective chart review. Direct medical costs, including epilepsy surgery, inpatient and outpatient treatment were retrieved from the finance department. Direct non-medical costs were collected from the family interview. The effectiveness was determined by percent seizure reduction and quality of life assessed by EQ-5D scores. Decision tree analysis using TreeAge Pro® 2018 was deployed to determine the cost-effectiveness. Seventeen patients had epilepsy surgery and 19 were in the medical group. Seizure freedom was noted in 52% and 16% in the surgical and medical groups, respectively. Incremental cost-effectiveness ratio (ICER) was 743,040 THB (22,793 USD) per 1 QALY and 3302 THB (101 USD) per 1% seizure reduction. The study did not demonstrate cost-effectiveness of epilepsy surgery in the short term compared with Thailand's threshold (160,000 THB (4908 USD) per 1 QALY). Epilepsy surgery may be cost-effective if evaluated beyond three years.

An Initial Cost-Effectiveness Analysis of Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Epilepsy Surgery

INTRODUCTION

Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new technology that provides a clinically efficacious and minimally invasive alternative to conventional microsurgical resection. However, little data exist on how costs compare to traditional open surgery. The goal of this paper is to investigate the cost-effectiveness of MRgLITT in the treatment of pediatric epilepsy.

METHODS

We retrospectively analyzed the medical records of pediatric patients who underwent MRgLITT via the Visualase® thermal therapy system (Medtronic, Inc., Minneapolis, MN, USA) between December 2013 and September 2017. Direct costs associated with preoperative, operative, and follow-up care were extracted. Benefit was calculated in quality-adjusted life years (QALYs), and the cost-effectiveness was derived from the discounted total direct costs over QALY. Sensitivity analysis on 4 variables was utilized to assess the validity of our results.

RESULTS

Twelve consecutive pediatric patients with medically refractory epilepsy underwent MRgLITT procedures. At the last postoperative follow-up, 8 patients were seizure free (Engel I, 66.7%), 2 demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). The average cumulative discounted QALY was 2.11 over the lifetime of a patient. Adjusting for inflation, MRgLITT procedures had a cost-effectiveness of USD 22,211 per QALY. Our sensitivity analysis of cost variables is robust and supports the procedure to be cost--effective.

CONCLUSION

Our data suggests that MRgLITT may be a cost-effective alternative to traditional surgical resection in pediatric epilepsy surgery.

Early economic evaluation of MRI-guided laser interstitial thermal therapy (MRgLITT) and epilepsy surgery for mesial temporal lobe epilepsy

Background

MRI-guided laser interstitial thermal therapy (MRgLITT) is a new minimally invasive treatment for temporal lobe epilepsy (TLE), with limited effectiveness data. It is unknown if the cost savings associated with shorter hospitalization could offset the high equipment cost of MRgLITT. We examined the cost-utility of MRgLITT versus surgery for TLE from healthcare payer perspective, and the value of additional research to inform policy decision on MRgLITT.

Methods

We developed a microsimulation model to evaluate quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) of MRgLITT versus surgery in TLE, assuming life-time horizon and 1.5% discount rate. Model inputs were derived from the literature. We conducted threshold and sensitivity analyses to examine parameter uncertainties, and expected value of partial perfect information analyses to evaluate the expected monetary benefit of eliminating uncertainty on probabilities associated with MRgLITT.

Results

MRgLITT yielded 0.08 more QALYs and cost $7,821 higher than surgery, with ICER of $94,350/QALY. Influential parameters that could change model outcomes include probabilities of becoming seizure-free from disabling seizures state and returning to disabling seizures from seizure-free state 5 years after surgery and MRgLITT, cost of MRgLITT disposable equipment, and utilities of disabling seizures and seizure-free states of surgery and MRgLITT. The cost-effectiveness acceptability curve showed surgery was preferred in more than 50% of iterations. The expected monetary benefit of eliminating uncertainty for probabilities associated with MRgLITT was higher than for utilities associated with MRgLITT.

Conclusions

MRgLITT resulted in more QALYs gained and higher costs compared to surgery in the base-case. The model was sensitive to variations in the cost of MRgLITT disposable equipment. There is value in conducting more research to reduce uncertainty on the probabilities and utilities of MRgLITT, but priority should be given to research focusing on improving the precision of estimates on effectiveness of MRgLITT.

Surgical outcomes for medically intractable epilepsy in low- and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to describe the current state of epilepsy surgery and establish estimates of seizure outcomes following surgery for medically intractable epilepsy (MIE) in low- and middle-income countries (LMICs).

METHODS

The MEDLINE and Embase databases were searched without publication date restriction. This search was supplemented by a manual screen of key epilepsy and neurosurgical journals (January 2005 to December 2016). Studies that reported outcomes for at least 10 patients of any age undergoing surgery for MIE in LMICs over a defined follow-up period were included. A meta-analysis with a random-effects model was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. Pooled estimates of seizure freedom and favorable seizure outcomes following anterior temporal lobectomy with or without amygdalohippocampectomy (ATL ± AH) were reported.

RESULTS

Twenty studies were selected, of which 16 were from Asian centers. The average age at surgery in all studies was less than 30 years, and the average preoperative duration of epilepsy ranged from 3 to 16.1 years. Mesial temporal sclerosis accounted for 437 of 951 described pathologies, and 1294 of the 1773 procedures were ATL ± AH. Based on 7 studies (646 patients) the pooled seizure freedom estimate following ATL ± AH was 68% (95% CI 55%-82%). Based on 8 studies (1096 patients), the pooled estimate for favorable seizure outcomes was 79% (95% CI 74%-85%).

CONCLUSIONS

Surgery for MIE in LMICs shows a high percentage of seizure freedom and favorable outcomes. These findings call for a concerted global effort to improve timely access to surgery for MIE patients in these regions, including investments aimed at refining existing and establishing additional centers.

Cost-effectiveness of epileptic surgery compared with medical treatment in children with drug-resistant epilepsy

BACKGROUND

Epilepsy surgery is an alternative to continued antiepileptic drugs (AEDs) in children with drug-resistant epilepsy (DRE).

OBJECTIVE

The objective of the study was to measure, model, and compare the medical costs and impacts on health-related quality of life (HRQL) of epilepsy surgery versus continued medical treatment with AEDs in children with DRE.

METHODS

A decision analytic model was created to estimate the cost-effectiveness of epilepsy surgery relative to continued medical treatment with AEDs. The model was based on costing and effectiveness data collected from 105 children with DRE who were operated on at the Royal Children's Hospital, Melbourne, Australia. The mean cost of conducting epilepsy surgery was AU$ 61,417 per person. Effectiveness of continued medical treatment was sourced from best available literature. In the absence of published utility values for pediatric patients with epilepsy and ethical approval to contact patients directly, HRQL was estimated by four clinicians using the Child Health Utility 9 Dimension (CHU9D). Outcome measures were seizure freedom and quality-adjusted life years (QALYs).

RESULTS

The costs over 7.6 years of follow-up were AU$ 219,297 for the surgical treatment group compared with AU$ 170,583 for the medical treatment group. The incremental cost-effectiveness ratio (ICER) for surgically vs medical treatment was AU$ 76,538 per additional patient attaining seizure freedom and AU$ 75,541 per additional QALY gained.

CONCLUSION

Epilepsy surgery resulted in a greater reduction of seizures and improvement in HRQL but was more expensive than continued medical treatment with AEDs. Including benefits outside of a healthcare perspective would likely lead to a more compelling cost-effective argument.

Direct and indirect costs associated with stereotactic radiosurgery or open surgery for medial temporal lobe epilepsy: Results from the ROSE trial

OBJECTIVE

To determine whether a less-invasive approach to surgery for medically refractory temporal lobe epilepsy is associated with lower health care costs and costs of lost productivity over time, compared to open surgery.

METHODS

We compared direct medical costs and indirect productivity costs associated with treatment with stereotactic radiosurgery (SRS) or anterior temporal lobectomy (ATL) in the ROSE (Radiosurgery or Open Surgery for Epilepsy) trial. Health care use was abstracted from hospital bills, the study database, and diaries in which participants recorded health care use and time lost from work while seeking care. Costs of use were calculated using a Medicare costing approach used in a prior study of the costs of ATL. The power of many analyses was limited by the sample size and data skewing.

RESULTS

Combined treatment and follow-up costs (in thousands of US dollars) did not differ between SRS (n = 20, mean = $76.6, 95% confidence interval [CI] = 50.7-115.6) and ATL (n = 18, mean = $79.0, 95% CI = 60.09-103.8). Indirect costs also did not differ. More ATL than SRS participants were free of consciousness-impairing seizures in each year of follow-up (all P < 0.05). Costs declined following ATL (P = 0.005). Costs tended to increase over the first 18 months following SRS (P = 0.17) and declined thereafter (P = 0.06). This mostly reflected hospitalizations for SRS-related adverse events in the second year of follow-up.

SIGNIFICANCE

Lower initial costs of SRS for medial temporal lobe epilepsy were largely offset by hospitalization costs related to adverse events later in the course of follow-up. Future studies of less-invasive alternatives to ATL will need to assess adverse events and major costs systematically and prospectively to understand the economic implications of adopting these technologies.

Survey of epilepsy and seizure awareness in Manitoba: An evaluation

BACKGROUND

Epilepsy and seizure awareness is gradually improving across Canada. With the strategic proposal for a Comprehensive Epilepsy Program in Manitoba (including formation of a new Pediatric Epilepsy Monitoring Unit (EMU)), a provincial strategy has been recommended outlining a path towards improved access to epilepsy care. We sought to qualify the current state of clinician knowledge and comfort towards diagnosis and management of this condition.

METHODS

A qualitative online survey (Survey of Epilepsy and Seizure Awareness in Manitoba: An Evaluation (SESAME)), comprised of 36 short-answer questions, was delivered to primary care and specialist physicians in Manitoba.

RESULTS

One hundred and eight subjects responded across varying medical disciplines. One hundred and one (93.5%) had previously managed patients with epilepsy, and 87 (80.6%) had previously ordered an electroencephalogram (EEG). A total of 63 (59.4%) had referred to a neurologist, with a lower proportion (30, 28.3%) referring specifically to an epileptologist. Only 36 respondents (33.3%) had heard of the International League Against Epilepsy (ILAE) guidelines. A total of 61 (56.5%) were unaware of invasive EEG techniques. Most (85, 78.7%) understood a role for surgery in treating epilepsy, with 12 (11.1%) unaware of surgical therapies beyond vagal nerve stimulation (VNS). Finally, less than half (44.2%) had heard about the Comprehensive Epilepsy Program in Manitoba, with nearly two-thirds (62.8%) indicating that they would like to have more information on epilepsy management.

CONCLUSIONS

The SESAME successfully identified strong awareness towards epilepsy, with identifiable lapses in knowledge that will benefit from a formal provincial-wide educational curriculum.

Systematic review of health economic studies in cranial neurosurgery

OBJECTIVE As the cost of health care continues to increase, there is a growing emphasis on evaluating the relative economic value of treatment options to guide resource allocation. The objective of this systematic review was to evaluate the current evidence regarding the cost-effectiveness of cranial neurosurgery procedures. METHODS The authors performed a systematic review of the literature using PubMed, EMBASE, and the Cochrane Library, focusing on themes of economic evaluation and cranial neurosurgery following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Included studies were publications of cost-effectiveness analysis or cost-utility analysis between 1995 and 2017 in which health utility outcomes in life years (LYs), quality-adjusted life years (QALYs), or disability-adjusted life years (DALYs) were used. Three independent reviewers conducted the study appraisal, data abstraction, and quality assessment, with differences resolved by consensus discussion. RESULTS In total, 3485 citations were reviewed, with 53 studies meeting the inclusion criteria. Of those, 34 studies were published in the last 5 years. The most common subspecialty focus was cerebrovascular (32%), followed by neurooncology (26%) and functional neurosurgery (24%). Twenty-eight (53%) studies, using a willingness to pay threshold of US$50,000 per QALY or LY, found a specific surgical treatment to be cost-effective. In addition, there were 11 (21%) studies that found a specific surgical option to be economically dominant (both cost saving and having superior outcome), including endovascular thrombectomy for acute ischemic stroke, epilepsy surgery for drug-refractory epilepsy, and endoscopic pituitary tumor resection. CONCLUSIONS There is an increasing number of cost-effectiveness studies in cranial neurosurgery, especially within the last 5 years. Although there are numerous procedures, such as endovascular thrombectomy for acute ischemic stroke, that have been conclusively proven to be cost-effective, there remain promising interventions in current practice that have yet to meet cost-effectiveness thresholds.

An initial cost-effectiveness analysis of intraoperative magnetic resonance imaging (iMRI) in pediatric epilepsy surgery

PURPOSE

Previous studies have illustrated the clinical utility of the addition of intraoperative magnetic resonance imaging (iMRI) to conventional microsurgical resection. While iMRI requires initial capital cost investment, long-term reduction in costly follow-up management and reoperation costs may prove economically efficacious. The objective of this study is to investigate the cost-effectiveness of the addition of iMRI utilization versus conventional microsurgical techniques in focal cortical dysplasia (FCD) resection in pediatric patients with medically refractory epilepsy.

METHODS

We retrospectively reviewed the medical records of pediatric subjects who underwent surgical resection of FCD at the Children's National Health System between March 2005 and April 2015. Patients were assigned to one of three cohorts: iMRI-assisted resection, conventional resection with iMRI-assisted reoperation, or conventional resection. Direct costs included preoperative, operative, postoperative, long-term follow-up, and antiepileptic drug (AED) costs. The cost-effectiveness was calculated as the sum total of all direct medical costs over the quality-adjusted life years (QALYs). We also performed sensitivity analysis on numerous variables to assess the validity of our results.

RESULTS

Fifty-six consecutive pediatric patients underwent resective surgery for medically intractable FCD. Ten patients underwent iMRI-assisted resection; 7 underwent conventional resection followed by iMRI-assisted reoperation; 39 patients underwent conventional microsurgical resection. Taken over the lifetime of the patient, the cumulative discounted QALY of patients in the iMRI-assisted resection cohort was about 2.91 years, versus 2.61 years in the conventional resection with iMRI-assisted reoperation cohort, and 1.76 years for the conventional resection cohort. Adjusting for inflation, iMRI-assisted surgeries have a cost-effectiveness ratio of $16,179 per QALY, versus $28,514 per QALY for the conventional resection with iMRI-assisted reoperation cohort, and $49,960 per QALY for the conventional resection cohort. Sensitivity analysis demonstrated that no one single variable significantly altered cost-effectiveness across all three cohorts compared to the baseline results.

CONCLUSION

The addition of iMRI to conventional microsurgical techniques for resection of FCD in pediatric patients with intractable epilepsy resulted in increased seizure freedom and reduction in long-term direct medical costs compared to conventional surgeries. Our data suggests that iMRI may be a cost-effective addition to the surgical armamentarium for epilepsy surgery.

Shunt surgery in idiopathic normal pressure hydrocephalus is cost-effective-a cost utility analysis

Background

The objective was to evaluate the cost-effectiveness of shunt surgery in patients with idiopathic normal pressure hydrocephalus (iNPH).

Methods

Health-related quality of life was evaluated before and 6 months after surgery using the EQ-5D-3 L (EuroQOL group five-dimensions health survey) in 30 patients (median age, 71 years; range, 65–89 years) diagnosed with iNPH. The costs associated with shunt surgery were assessed by a detailed survey with interviews and extraction of register data concerning the cost of hospital care, primary care, residential care, home-care service and informal care. The cost of untreated patients was derived from the cost of dementia disorders in Sweden in 2012, as reported by the National Board of Health and Welfare. The cost effectiveness analysis used a decision-analytic Markov model. We used a societal perspective and a lifelong time horizon to estimate costs and effects. One-way sensitivity analysis and probabilistic sensitivity analysis were carried out to test the robustness of the model.

Results

The shunt surgery model as the standard treatment in iNPH resulted in a gain of 2.2 life years and 1.7 quality-adjusted life years (QALY), along with an incremental cost per patient of €7,500/QALY. The sensitivity analysis showed that the results were not sensitive to changes in uncertain parameters or assumptions.

Conclusions

Shunt surgery in iNPH, an underdiagnosed condition severely impairing elderly patients, is not only an effective medical treatment, it is also cost-effective, adding 2.2 additional life years and 1.7 QALYs at a low cost, a remarkable gain for an individual aged around 70 years.

Medical versus surgical treatment of prolactinomas: an analysis of treatment outcomes

INTRODUCTION

Prolactinomas are unique tumors that may go into both hormonal and radiographic remission with dopamine agonist therapy or transsphenoidal surgery. Regardless of modality, the goals of therapy remain the same: (1) biochemical remission, including reduction of prolactin and normalization of sex hormones; (2) radiographic tumor control, with a range including prevention of tumor growth, tumor regression, or complete tumor resolution; (3) resolution of preoperative symptoms, including those that are hormonal or neurologic; and (4) prevention of new hypopituitarism or new neurologic symptoms.

AREAS COVERED

In the following review, we performed a search of the literature using keywords 'prolactinoma,' 'dopamine agonist,' 'surgery,' 'cost-effectiveness,' 'recurrence,' and 'complication' to compare the relative merits of medical versus surgical therapy for prolactinoma, including special circumstances such as cystic tumors, pregnant patients, and the cost-effectiveness of different strategies.

EXPERT COMMENTARY

Medical therapy can offer a cure, but surgery provides an important adjunct to patients with resistance or intolerance to dopamine agonists, and offers excellent outcomes including when combined with continued postoperative medical therapy. Further head to head comparisons will benefit patients and practitioners weighing the relative risks and benefits of medical and surgical intervention, including the issue of their relative cost-effectiveness.

The application of preoperative computed tomography angiogram for hemispherectomy

Hemispherectomy is an established neurosurgical procedure for unilateral refractory epilepsy . Even though the surgical approach has evolved greatly, prevention of catastrophic intraoperative bleeding is a challenge. It is important that surgeons know the abnormal blood vessel before surgery. Herein, we report our experience with two patients in whom computed tomographic angiography (CTA) was used in the preoperative evaluation for hemispherectomy. CTA allowed for precise anatomical delineation of the hemispheric vascular abnormalities. Preoperative CTA showed that the specific cerebral arteries and their branches ipsilateral to the lesion were slender. Elaborate preoperative planning for the surgical approach helped prevent catastrophic intraoperative bleeding. Favorable outcomes were achieved in both children. CTA appears to confer a considerable advantage in the preoperative vascular and anatomical delineation in patients scheduled for hemispherectomy. To our knowledge, this is the first report about the application of CTA for hemispherectomy preoperative planning.

Laser Interstitial Thermal Therapy for Mesial Temporal Lobe Epilepsy

Approximately one-third of patients with epilepsy do not achieve adequate seizure control through medical management alone. Mesial temporal lobe epilepsy (MTLE) is one of the most common forms of medically refractory epilepsy referred for surgical management. Stereotactic laser amygdalohippocampotomy using magnetic resonance-guided laser interstitial thermal therapy (MRg-LITT) is an important emerging therapy for MTLE. Initial published reports support MRg-LITT as a less invasive surgical option with a shorter hospital stay and fewer neurocognitive side effects compared with craniotomy for anterior temporal lobectomy with amygdalohippocampectomy and selective amygdalohippocampectomy. We provide a historical overview of laser interstitial thermal therapy development and the technological advancements that led to the currently available commercial systems. Current applications of MRg-LITT for MTLE, reported outcomes, and technical issues of the surgical procedure are reviewed. Although initial reports indicate that stereotactic laser amygdalohippocampotomy may be a safe and effective therapy for medically refractory MTLE, further research is required to establish its long-term effectiveness and its cost/benefit profile.

Long-term reduction of health care costs and utilization after epilepsy surgery

OBJECTIVE

To assess long-term direct medical costs, health care utilization, and mortality following resective surgery in persons with uncontrolled epilepsy.

METHODS

Retrospective longitudinal cohort study of Medicaid beneficiaries with epilepsy from 2000 to 2008. The study population included 7,835 persons with uncontrolled focal epilepsy ages 18-64 years, with an average follow-up time of 5 years. Of these, 135 received surgery during the study period. To account for selection bias, we used risk-set optimal pairwise matching on a time-varying propensity score, and inverse probability of treatment weighting. Repeated measures generalized linear models were used to model utilization and cost outcomes. Cox proportional hazard was used to model survival.

RESULTS

The mean direct medical cost difference between the surgical group and control group was $6,806 after risk-set matching. The incidence rate ratio of inpatient, emergency room, and outpatient utilization was lower among the surgical group in both unadjusted and adjusted analyses. There was no significant difference in mortality after adjustment. Among surgical cases, mean annual costs per subject were on average $6,484 lower, and all utilization measures were lower after surgery compared to before.

SIGNIFICANCE

Subjects that underwent epilepsy surgery had lower direct medical care costs and health care utilization. These findings support that epilepsy surgery yields substantial health care cost savings.

Bridging the Gap between Evidence and Practice for Adults with Medically Refractory Temporal Lobe Epilepsy: Is a Change in Funding Policy Needed to Stimulate a Shift in Practice?

Objective. Surgery for medically refractory epilepsy (MRE) in adults has been shown to be effective but underutilized. Comprehensive health economic evaluations of surgery compared with continued medical management are limited. Policy changes may be necessary to influence practice shift. Methods. A critical review of the literature on health economic analyses for adults with MRE was conducted. The MEDLINE, EMBASE, CENTRAL, CRD, and EconLit databases were searched using relevant subject headings and keywords pertaining to adults, epilepsy, and health economic evaluations. The screening was conducted independently and in duplicate. Results. Four studies were identified (1 Canadian, 2 American, and 1 French). Two were cost-utility analyses and 2 were cost-effectiveness evaluations. Only one was conducted after the effectiveness of surgery was established through a randomized trial. All suggested surgery to be favorable in the medium to long term (7-8 years and beyond). The reduction of medication use was the major cost-saving parameter in favor of surgery. Conclusions. Although updated evaluations that are more generalizable across settings are necessary, surgery appears to be a favorable option from a health economic perspective. Given the limited success of knowledge translation endeavours, funder-level policy changes such as quality-based purchasing may be necessary to induce a shift in practice.

Neurologists' knowledge of and attitudes toward epilepsy surgery: a national survey

OBJECTIVES

In the current study, we aim to assess potential neurologist-related barriers to epilepsy surgery among Canadian neurologists.

METHODS

A 29-item, pilot-tested questionnaire was mailed to all neurologists registered to practice in Canada. Survey items included the following: (1) type of medical practice, (2) perceptions of surgical risks and benefits, (3) knowledge of existing practice guidelines, and (4) barriers to surgery for patients with epilepsy. Neurologists who did not complete the questionnaire after the initial mailing were contacted a second time by e-mail, fax, or telephone. After this reminder, the survey was mailed a second time to any remaining nonresponders.

RESULTS

In total, 425 of 796 neurologists returned the questionnaire (response rate 53.5%). Respondents included 327 neurologists who followed patients with epilepsy in their practice. More than half (56.6%) of neurologists required patients to be drug-resistant and to have at least one seizure per year before considering surgery, and nearly half (48.6%) failed to correctly define drug-resistant epilepsy. More than 75% of neurologists identified inadequate health care resources as the greatest barrier to surgery for patients with epilepsy.

CONCLUSIONS

A substantial proportion of Canadian neurologists are unaware of recommended standards of practice for epilepsy surgery. Access also appears to be a significant barrier to epilepsy surgery and surgical evaluation. As a result, we are concerned that patients with epilepsy are receiving inadequate care. A greater emphasis must be placed on knowledge dissemination and ensuring that the infrastructure and personnel are in place to allow patients to have timely access to this evidence-based treatment.

An overview of PET neuroimaging

Over the past 35 years or so, PET brain imaging has allowed powerful and unique insights into brain function under normal conditions and in disease states. Initially, as PET instrumentation continued to develop, studies were focused on brain perfusion and glucose metabolism. This permitted refinement of brain imaging for important, non-oncologic clinical indications. The ability of PET to not only provide spatial localization of metabolic changes but also to accurately and consistently quantify their distribution proved valuable for applications in the clinical setting. Specifically, glucose metabolism brain imaging using (F-18) fluorodeoxyglucose continues to be invaluable for evaluating patients with intractable seizures for identifying seizure foci and operative planning. Cerebral glucose metabolism also contributes to diagnosis of neurodegenerative diseases that cause dementia. Alzheimer disease, dementia with Lewy bodies, and the several variants of frontotemporal lobar degeneration have differing typical patterns of hypometabolism. In Alzheimer disease, hypometabolism has furthermore been associated with poorer cognitive performance and ensuing cognitive and functional decline. As the field of radiochemistry evolved, novel radioligands including radiolabeled flumazenil, dopamine transporter ligands, nicotine receptor ligands, and others have allowed for further understanding of molecular changes in the brain associated with various diseases. Recently, PET brain imaging reached another milestone with the approval of (F-18) florbetapir imaging by the United States Federal Drug Administration for detection of amyloid plaque accumulation in brain, the major histopathologic hallmark of Alzheimer disease, and efforts have been made to define the clinical role of this imaging agent in the setting of the currently limited treatment options. Hopefully, this represents the first of many new radiopharmaceuticals that would allow improved diagnostic and prognostic information in these and other clinical applications, including Parkinson disease and traumatic brain injury.

Health Technology Assessment report on the presurgical evaluation and surgical treatment of drug-resistant epilepsy

PURPOSE

Epilepsy is a neurologic disorder with major social impact. Surgery is a valuable option in patients who are not responding to antiepileptic drugs. The literature reports demonstrate that a proportion ranging from 40 to 100% of patients with epilepsy achieve seizure remission after surgery. A presurgical evaluation (clinical and instrumental) must be performed in all patients with drug-resistant epilepsy to assess their suitability for surgical intervention. Health Technology Assessment (HTA) represents a modern approach to the analysis of technologies used for health care. HTA could be considered a bridge between science that produces evidence and the decisions that can be taken on the basis of that evidence at different levels of the health care system. The aim of this study is the HTA of epilepsy surgery including clinical, ethical, social, and economic features.

METHODS

The present study includes an analysis of the diagnostic and surgical workup performed at the Italian centers for the diagnosis and treatment of drug-resistant epilepsy (DRE). The study includes the following issues: (1) social, ethical impact, and costs of the disease; (2) clinical results, efficacy, and safety of surgery; (3) ethics and quality of life after surgery; and (4) economic impact and productivity regained after surgery. The cost of managing a patient with DRE included in the presurgical study was estimated by the bottom-up microcosting technique that starts from a detailed collection of data on consumption of resources and full costing. The phases analyzed were (1) noninvasive diagnostic workup; (2) neurosurgical intervention; and (3) follow-up.

KEY FINDINGS

The literature reports indicate epilepsy surgery as an effective treatment both on clinical results and on ethical, social, and quality of life aspects. The workup including the noninvasive presurgical study followed by surgery has a total cost of €20,827. Management of short-term follow-up increases the overhead to €22,291 at the first year, and then to €23,571 after 5 years. According to the estimates made in this survey, funding based on diagnosis-related group (DRG) tariff for the noninvasive diagnostic stage involving hospital admission is not remunerative in Italy either at regional or national levels. Effectively the difference between full cost and DRG has a delta of €3,402 and €2,537 respectively. The total cost of the presurgical, surgical, and follow-up evaluation is not remunerative for €10,554 (national data).

SIGNIFICANCE

Economic surveys in Italy have shown that surgery for DRE is an advantageous treatment from the standpoint of third-party payers and is cost-effective for society. DRE presurgical evaluation and surgery are not remunerative either at regional or national levels.

The economic burden of epilepsy in Korea, 2010

Objectives

The purposes of this study were to evaluate the prevalence of epilepsy and to estimate the cost of epilepsy in Korea, 2010.

Methods

This study used a prevalence based approach to calculate the cost of epilepsy. Claims data from the Korean national health insurance and data from the Korea health panel, the Korea National Statistical Office's records of causes of death, and labor statistics were used to estimate the cost of epilepsy. Patients were defined as those who were hospitalized or visited an outpatient clinic during 2010 with a diagnosis of epilepsy (International Classification of Diseases 10th revision codes G40-G41). Total costs of epilepsy included direct medical costs, direct non-medical cost and indirect costs.

Results

The annual prevalence of treated epilepsy was 228 per 100 000 population, and higher in men. The age-specific prevalence was highest for teenagers. The total economic burden of epilepsy was 536 billion Korean won (KW). Indirect cost (304 billion KW) was 1.3 times greater than direct cost (232 billion KW). By gender, the male (347 billion KW) were more burdened than the female (189 billion KW). The estimated cost in young age younger than 20 years old was 24.5% of the total burden of epilepsy.

Conclusions

A significant portion of the economic burden of epilepsy is borne by people in young age. To reduce the economic burden of epilepsy, effective prevention and treatment strategies are needed.

Comparing the effects of cortical resection and vagus nerve stimulation in patients with nonlesional extratemporal epilepsy

The main purpose of this retrospective study was to compare the effects of resective surgery (RESgr-26 patients) and vagus nerve stimulation (VNSgr-35 patients) on seizure frequency (2 and 5years after surgery) in patients with nonlesional extratemporal epilepsy (NLexTLE). We analyzed hospital admission costs directly associated with epilepsy (HACE) in both groups at the same follow-up. The decrease in seizure frequency from the preoperative levels, in both VNSgr and RESgr, was statistically significant (p<0.001). The seizure frequency reduction did not differ significantly between the follow-up visits for either group (p=0.221 at 2years and 0.218 at 5years). A significantly higher number of Engel I and Engel I+II patients were found in RESgr than in VNSgr at both follow-up visits (p=0.04 and 0.007, respectively). Using McHugh classification, we did not find statistically significant differences between both groups at both follow-up visits. Hospital admission costs directly associated with epilepsy/patient/year in both RESgr and VNSgr dropped significantly at 2- and 5-year follow-up visit and this reduction was not statistically different between RESgr and VNSgr (p=0.232). Both VNS and resective surgery cause comparably significant seizure reduction in NLexTLE. Resective surgery leads to a greater number of patients with excellent postoperative outcome (Engel I+II). The HACE reduction is statistically comparable between both groups.

Cost effectiveness of lacosamide in the adjunctive treatment of patients with refractory focal epilepsy in Belgium

OBJECTIVES

Lacosamide is an anti-epileptic drug, indicated as adjunctive therapy for patients with focal seizures with or without secondary generalization. This study aims to assess the cost effectiveness of standard anti-epileptic drug therapy plus lacosamide 300 mg/day compared with standard therapy alone from the perspective of the Belgian healthcare payer.

METHODS

The treatment pathway of a hypothetical cohort of 1000 patients over 2 years was simulated using a decision tree. Data about health state probabilities, seizure frequency and utility values were taken from lacosamide trials or from the literature. Effectiveness measures included the number of seizures avoided and the number of quality-adjusted life-years gained. Unit costs were taken from national references. Resource use was estimated by a panel of eight neurologists with extensive experience in epilepsy. The price year was 2008. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

Over a 24-month period, standard anti-epileptic drug therapy plus lacosamide led to a reduction of seven seizures, an increase of 0.038 quality-adjusted life-years and a cost decrease of &U20AC;3619 per patient compared with standard therapy alone. Using a willingness to pay of &U20AC;30 000 per quality-adjusted life-year, the net monetary benefit of standard anti-epileptic drug therapy plus lacosamide amounted to &U20AC;4754. The probability of standard anti-epileptic drug therapy plus lacosamide being cost effective was 97.3%, 99.8%, 99.9% and 100% at 6, 12 , 18 and 24 months, respectively.

CONCLUSION

In patients with difficult-to-treat epilepsy, standard anti-epileptic drug therapy plus lacosamide appears to be a cost-effective option in Belgium.

Determining surgical candidacy in temporal lobe epilepsy

Temporal lobe epilepsy (TLE) is the most common form of adult epilepsy that is amenable to surgical treatment. In the carefully selected patient, excellent seizure outcome can be achieved with minimal or no side effects from surgery. This may result in improved psychosocial functioning, achieving higher education, and maintaining or gaining employment. The objective of this paper is to discuss the surgical selection process of a patient with TLE. We define what constitutes a patient that has medically refractory TLE, describe the typical history and physical examination, and distinguish between mesial TLE and neocortical TLE. We then review the role of routine (ambulatory/sleep-deprived electroencephalography (EEG), video EEG, magnetic resonance imaging (MRI), neuropsychological testing, and Wada testing) and ancillary preoperative testing (positron emission tomography, single-photon emission computed tomography (SPECT), subtraction ictal SPECT correlated to MRI (SISCOM), magnetoencephalography, magnetic resonance spectroscopy, and functional MRI) in selecting surgical candidates. We describe the surgical options for resective epilepsy surgery in TLE and its commonly associated risks while highlighting some of the controversies. Lastly, we present teaching cases to illustrate the presurgical workup of patients with medically refractory TLE.

Ethical issues in surgical decision making concerning children with medically intractable epilepsy

The widespread inclusion of surgical strategies in the treatment of medically intractable epilepsy is largely justified by the medical and psychosocial burden of the illness. Performing these procedures in pediatric populations is associated with distinct challenges ranging from unique seizure etiologies to issues surrounding brain development and functional plasticity. As the trend toward more aggressive surgical intervention continues, the ethical foundation of current and emerging practices must be increasingly scrutinized. Here, we present the first article discussing ethical issues in the surgical management of medically intractable epilepsies in children. We discuss principles of informed consent, harm reduction, and justice in this vulnerable patient population. We also highlight the unique ethical challenge of surgical decision making concerning developmentally delayed children. The recognition of these issues is essential to providing patient-centered, responsible, and ethical care.

Quality of life and cost-effectiveness 1 year after total hip arthroplasty

Quality of life index (Quality Of Well-Being [QWB]) was used to calculate the costs per quality of well year (QWY) in total hip arthroplasty (THA) and compare it to other interventions. Ninety-eight primary and/or revision THA were reviewed. Patients had minimum 1-year follow-up. Quality of life index was used to calculate the costs per QWY in primary and revision THA. Preoperative QWB for primary THA was 0.52 ± 0.06 SD; revision was 0.53 ± 0.07 SD. The QWB change at 1 year for primary THA was 0.08 ± 0.13 SD; revision THA was 0.06 ± 0.14 SD. Calculated costs per QWY were $5572 for primary procedures and $10,775 for revision procedures. Cost-effectiveness of THA compares favorably with other surgical and medical interventions such as epilepsy ablation surgery and gastric bypass surgery.

Evaluation of Neuronavigation in Lesional and Non-Lesional Epilepsy Surgery

OBJECTIVE

For many patients, surgery for intractable epilepsy provides not only freedom or substantial relief from seizures, but also functional improvement and increased quality of life. Precise intraoperative localization of the underlying structural and functional processes is crucial in this regard. The aim of this study was to clinically evaluate whether neuronavigation leads to an improvement in the precision and safety of epilepsy surgery. In this paper, we also attempt to assess the navigation workstation as a platform for the integration of multimodal information (multimodal information guidance).

PATIENTS

Out of a series of 223 epilepsy surgery procedures, 140 were performed with the aid of neuronavigation. Patient and surgical data were prospectively collected.

METHODS

We used the neuronavigation device as a common platform to merge complementary information modalities. Correlation of anatomic and structural details with functional information contributed to the surgical script in non-lesional and localization-related epilepsy surgery. At least two different information modalities contributed to planning and surgical guidance in every patient. Immediately following the operative procedure, the surgeon answered a set of questions on the reasons for the application of neuronavigation, and the efficiency and safety of navigation. Detailed analysis of the location of the operative procedure, histopathological findings and outcome was performed.

RESULTS

The main benefits of neuronavigation in epilepsy surgery were precision of targeting even in small and deep-seated targets, safe manipulation in critical brain areas, accurate placement of electrodes, and correlation of electro-clinical information modalities with underlying structures. Furthermore, navigation provided individual tailoring of craniotomy and corticotomy. It was less reliable for verification of resection boundaries in the case of underlying glioma. Neuronavigational localization and its combination with image fusion and functional investigations greatly improved discussion within the epilepsy surgery team.

CONCLUSION

The neuronavigation concept proved its value in epilepsy surgery by linking anatomic, pathologic and functional data of the individual patient. Enhanced by the integration of multimodal information, neuronavigation significantly improved the available treatment options.

Global Cost-effectiveness of Cataract Surgery

OBJECTIVE

To determine the cost-effectiveness of cataract surgery worldwide and to compare it with the cost-effectiveness of comparable medical interventions.

DESIGN

Meta-analysis.

PARTICIPANTS

Approximately 12,000 eyes in the studies selected.

METHODS

Articles were identified by searching the literature using the phrase cataract surgery, in combination with the terms cost, cost-effectiveness, and cost-utility. Terms used for the comparable medical interventions search included epileptic surgery, hip arthroplasty, knee arthroplasty, carpal tunnel surgery, and defibrillator implantation. The search was restricted to the years 1995 through 2006. Cataract surgery costs were converted to 2004 United States dollars (US$). Cost-utility was calculated using: (1) costs discounted at 3% for 12 years with a discounted quality-adjusted life years (QALY) gain of 1.25 years, and (2) costs discounted at 3% for 5 years with a discounted QALY gain of 0.143 years. The Cataract Surgery Affordability Index (CSAI) for each country was calculated by dividing the cost of cataract surgery by the gross national income per capita for the year 2004.

MAIN OUTCOME MEASURES

Cost-utility in 2004 US$/QALY and affordability of cataract surgery relative to the United States.

RESULTS

Cost-utility values for cataract surgery (first eye) varied from $245 to $22,000/QALY in Western countries and from $9 to $1600 in developing countries. In developed countries, the cost-effectiveness of cataract surgery estimated by Choosing Interventions That Are Cost Effective ranged from, in international dollars (I$), I$730 to I$2400/disability-adjusted life years (DALY) averted, and I$90 to I$370/DALY averted in developing countries. The CSAI varied from 17% to 189% in developed countries and 29% to 133% in developing countries compared with the United States. The cost-utility of other comparable medical interventions was: epileptic surgery, $4000 to $20,000/QALY; hip arthroplasty, $2300 to $4800/QALY; knee arthroplasty, $6500 to $12,700/QALY; carpal tunnel surgery, $140 to $280/QALY; and defibrillator implantation, $700 to $23,000/QALY.

CONCLUSIONS

The cost-utility of cataract surgery varies substantially, depending how the benefit is assessed and on the duration of the assumed benefit. Cataract surgery is comparable in terms of cost-effectiveness to hip arthroplasty, is generally more cost-effective than either knee arthroplasty or defibrillator implantation, and is cost-effective when considered in absolute terms. The operation is considerably cheaper in Europe and Canada compared with the United States and is affordable in many developing countries, particularly India.

An unadjusted NNT was a moderately good predictor of health benefit

BACKGROUND AND OBJECTIVE

Whether the number needed to treat (NNT) is sufficiently precise to use in clinical practice remains unclear. We compared unadjusted NNTs to quality-adjusted life years (QALYs) gained, a more comprehensive measures of health benefit.

STUDY DESIGN AND SETTING

From a subset (n = 65) of a dataset of 228 cost-effectiveness analyses, we compared how well NNTs predicted clinically important QALY gains using correlation analysis, multivariable models and receiver-operator curve (ROC) analysis.

RESULTS

NNT was inversely correlated with QALY gains (P < .001); this relationship was affected by quality of life and life-expectancy gains of treatment (P <or= .04). The NNT is a moderately accurate predictor of treatments that provide large health benefits (area under ROC 0.74-0.81). For ruling out therapies with low QALY gains (threshold <or=0.125 to <or=0.5 QALYs), an NNT >15 had a sensitivity of 82% to 100%. For ruling in therapies with high QALY gains (threshold >or=0.125 to >or=0.5 QALYs), an NNT <or=5 had a specificity of 77%.

CONCLUSION

Using NNT thresholds of <or=5 and >15 to rule in and out therapies with large QALY gains may provide general guidance regarding the magnitude of health benefit.

Cost-utility analysis of vagus nerve stimulators for adults with medically refractory epilepsy

INTRODUCTION

The cost-utility of vagus nerve stimulator (VNS) devices for medically refractory epilepsy has yet to be estimated.

METHODS

Using a meta-analysis of randomised controlled trials of VNS, we estimate that six people require implantation in order for one person to experience a 50% reduction in seizure frequency. Costs averted from improved epilepsy control were ascertained from published literature. Values for health states were obtained from a series of 42 seizure clinic attenders using time trade-off techniques and the EQ-5D health status instrument. The cost per quality adjusted life year gained was estimated and the values obtained were tested in a sensitivity analysis.

RESULTS

Improved epilepsy control averted, on average, 745 pounds sterling health care costs per annum. People with epilepsy had great difficulty performing the time trade-off experiment, but those who managed to complete the task valued a 50% reduction in their own seizure frequency at 0.285 units. For a programme of six implants, the baseline model estimated the cost per quality adjusted life year gained at 28,849 pounds sterling. The most favourable estimate was equal to 4785 pounds sterling per quality adjusted life year gained, assuming that the number needed to treat was similar to published series in which one response was obtained for every three implants. The least favourable estimate was equal to 63,000 pounds sterling per quality adjusted life year gained, when EQ-5D utility values were used. The cost per quality adjusted life year gained was not sensitive to changes in length of stay, nor complication rates, but was significantly influenced by cost of device and device battery life expectancy.

CONCLUSION

There is not a strong economic argument against a programme of VNS implantation, although care should be taken to try and identify and treat those most likely to benefit.

Costs and benefits of intraoperative MR-guided brain tumor resection

We retrospectively compared the costs and benefits of brain tumor resection in the conventional operating room (cOR) with the interventional magnetic resonance (iMR) suite from 1993-1998. Comparisons were made for adults (diagnosis-related group (DRG) 001) and children (DRG 003) for length of stay (LOS), hospital charges and payments, hospital total direct and indirect costs, readmission rates, repeat resection (RR) interval, and net health outcome. Statistical analysis was with ANOVA, Dunnett's, and Bonferroni tests. For DRG 001, iMR LOS (3.7 days (d)) was 54.9% shorter than for cOR (8.2 d) for first resections (FR) (P < 0.001) and RR (6.0 vs. 8.7 d (31.0%), P < 0.05). IMR hospital charges were 12.2% lower ($4063) for FR and 4.1% lower ($922) for RR than for cOR. Total iMR hospital costs were 14.4% lower ($3415) than for cOR for FR and 3.3% lower ($723) than costs for RR. Cost-to-charge ratio (c/c) for FR was 69.6% (iMR) and 71.4% (cOR) and for RR 70.9% (iMR) and 71.1% (cOR). For DRG 003, iMR LOS (4.5 d) was shorter than for cOR (14.1 d, P < 0.001) for FR and for RR (8.0 vs. 13.3 d). IMR hospital charges were 43.8% lower than for cOR for FR (P < 0.05) and RR. The iMR costs were lower for FR (46.4%, P < 0.01) and RR (44.7%) than cOR. IMR c/c was 71.4% and 74.8% for cOR. For RR, the iMR c/c was 72.8% and 73.9% for cOR. No RR have followed iMR surgery. COR RR rate was 20% in adults and 30% in children. The mean time from iMR surgery was 11.3 months in adults and 18.0 in children. For the cOR, the mean time to RR was 9.3 months in adults and 13.3 in children. This data suggests that iMR surgery improves net health outcomes by reduced LOS, reduced RR, and reduced hospital charges and costs.

Cost-benefit analysis of universal tandem mass spectrometry for newborn screening

OBJECTIVE

To estimate potential costs and benefits of routinely using tandem mass spectrometry (MS/MS) to screen newborns for inborn errors of metabolism.

METHOD

Analysis of costs and benefits resulting from use of MS/MS in screening of 32 000 newborn infants using data from the Kaiser Permanente Medical Care Program of Northern California plus other published data.

SETTING

A large health maintenance organization.

RESULTS

In the base scenario, the cost per quality-adjusted life year saved by MS/MS screening was $5827; in the least favorable scenario, this cost was $11 419, and in the most favorable scenario, $736.

CONCLUSION

Costs per quality-adjusted life year saved by MS/MS screening for inborn errors of metabolism compare favorably with other mass screening programs, including those for breast and prostate cancer.

Economic evaluation of epilepsy treatment: a review of the literature

This article provides an overview of methods used and findings from economic analyses in epilepsy. Cost-effectiveness studies have evaluated different drugs for monotherapy and add-on therapy, and compared alternative treatment modalities for refractory epilepsy. The methodological characteristics of these studies are examined, and their results are compared and interpreted. Health outcome measures are defined and data sources described. Methods for assessing the direct and indirect costs, and/or cost savings, with a treatment's use, are explored. Directions for future research are identified and discussed.