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

Abstract

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.

Neurostimulation in people with drug‐resistant epilepsy: Systematic review and meta‐analysis from the ILAE Surgical Therapies Commission

“…Some studies have recently shown interesting results concerning the cost-effectiveness of RNS compared to pharmacotherapy alone. 64 It is be important to conduct similar studies in all modalities. Recent validated scores, like the Epilepsy Satisfaction Questionnaire (ESSQ- 19), have put more emphasis on the psychosocial domain while considering the side-effects of a brain intervention.…”

“…Moreover, additional cost‐effectiveness studies are needed to guide treatment decisions and resource allocation. Some studies have recently shown interesting results concerning the cost‐effectiveness of RNS compared to pharmacotherapy alone 64 . It is be important to conduct similar studies in all modalities.…”

Can responsive deep brain stimulation be a cost‐effective treatment for severe obesity?

“…Our analysis revealed that if rDBS provides a BMI reduction of at least 13.7 to 15.2 kg/m 2 over a 5‐year period, it would be more cost‐effective compared with LRYGB. Our complication rates were estimated from the largest published responsive neurostimulation series (in epilepsy) (26,27), which matches the rates of real‐world data (39), but, even with complication rates increased to 10% artificially, the overall rDBS average treatment cost was fairly stable. Moreover, utility due to adverse events did not change when using DBS data for obsessive‐compulsive disorder, which represents a different device but more similar brain target to obesity.…”

“…These complications represent those associated with the treatment modality (e.g., infection, skin erosion, lead fracture) rather than those associated with a specific brain target. We searched PubMed for the largest published series (included 256 patients followed over 7 years (26,27)) to calculate per year adverse event incidences as done in a past analysis (28). Additionally, to provide a robust estimate of adverse events, given that the epilepsy studies target cortical rather than deep brain regions, we conducted a sensitivity analysis using published DBS studies for obsessivecompulsive disorder, which represents a similar target used in the rDBS trial.…”

Early cost–utility analysis of genetically guided therapy for patients with drug‐resistant epilepsy

“…There is also scope for extending the comparators to include neuromodulation options for drug-resistant epilepsy not amenable to surgical intervention, such as vagus nerve stimulation (VNS), [28][29][30][31] anterior nucleus of the thalamus deep brain stimulation, and responsive neurostimulation. [32][33][34][35] VNS 36 and responsive neurostimulation therapy 37 have been found to be cost-effective. As a good proportion of patients with drug-resistant epilepsy benefit from neuromodulation, an assessment of relative cost-effectiveness in the era of genomic sequencing may be warranted for patients with certain epilepsy types.…”