Global Economic Evaluation of the Reported Costs of Deep Brain Stimulation

INTRODUCTION

Despite the known benefits of deep brain stimulation (DBS), the cost of the procedure can limit access and can vary widely. Our aim was to conduct a systematic review of the reported costs associated with DBS, as well as the variability in reporting cost-associated factors to ultimately increase patient access to this therapy.

METHODS

A systematic review of the literature for cost of DBS treatment was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and Embase databases were queried. Olsen & Associates (OANDA) was used to convert all reported rates to USD. Cost was corrected for inflation using the US Bureau of Labor Statistics Inflation Calculator, correcting to April 2022.

RESULTS

Twenty-six articles on the cost of DBS surgery from 2001 to 2021 were included. The median number of patients across studies was 193, the mean reported age was 60.5 ± 5.6 years, and median female prevalence was 38.9%. The inflation- and currency-adjusted mean cost of the DBS device was USD 21,496.07 ± USD 8,944.16, the cost of surgery alone was USD 14,685.22 ± USD 8,479.66, the total cost of surgery was USD 40,942.85 ± USD 17,987.43, and the total cost of treatment until 1 year of follow-up was USD 47,632.27 ± USD 23,067.08. There were no differences in costs observed across surgical indication or country.

CONCLUSION

Our report describes the large variation in DBS costs and the manner of reporting costs. The current lack of standardization impedes productive discourse as comparisons are hindered by both geographic and chronological variations. Emphasis should be put on standardized reporting and analysis of reimbursement costs to better assess the variability of DBS-associated costs in order to make this procedure more cost-effective and address areas for improvement to increase patient access to DBS.

Post-trial access in implanted neural device research: Device maintenance, abandonment, and cost

BACKGROUND

Clinical trial participants who benefit from experimental neural devices for the treatment of debilitating and otherwise treatment-resistant conditions are generally not ensured continued access to effective therapy or maintenance of devices at the conclusion of trials.

OBJECTIVE/HYPOTHESIS

Post-trial obligations have been extensively examined in the context of drug trials, but there has been little empirical examination of stakeholder perspectives regarding these obligations in the rapidly growing field of neural device research.

METHODS

This study examined the perspectives of 44 stakeholders (i.e., 23 researchers and 21 patient-participants) involved in implantable neural device trials.

RESULTS

Researchers were concerned about current post-trial management, identified barriers like cost, and suggested ways to improve the system. Many patient-participants were unaware of whether they would have post-trial access, but most thought they should keep devices if beneficial, and agreed with researchers that more should be done to help them keep and maintain these neural devices.

CONCLUSION

To our knowledge, this is the first in-depth examination of researcher perspectives regarding continued access to experimental neural devices and only the second such examination of patient-participant perspectives. These data can help inform future ethical and policy decisions about post-trial access to implantable neurotechnology.

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.

Early subthalamic nucleus deep brain stimulation in Parkinson's disease reduces long-term medication costs

INTRODUCTION

Subthalamic nucleus (STN) deep brain stimulation (DBS) is recognized as a safe and effective treatment in mid- and advanced-staged Parkinson's disease (PD) that decreases the need for PD medications and their associated costs. This study reports medication costs from the only clinical trial to evaluate DBS in patients with early-stage PD and projects costs through advanced-stage disease.

METHODS

The DBS in early-stage PD pilot was a prospective, single-blind clinical trial that randomized 30 patients with early-stage PD 1:1 to receive bilateral STN-DBS plus optimal drug therapy (ODT) or ODT alone. Subjects who completed the trial participated in an observational follow-up study and were evaluated annually for five years after randomization. PD medication data collected at each study visit were used to calculate and project medication costs (n = 28).

RESULTS

Five-year cumulative medication cost reduction with early DBS+ODT was $28,246. Mean annual medication cost for early DBS+ODT subjects was 2.4 times lower than early ODT subjects (β = 2.4, 95%CI:1.5-3.7, p = 0.0004). Early DBS+ODT is projected to reduce cumulative medication costs by $104,958 over 15 years of disease duration.

CONCLUSION

DBS in early-stage PD may provide long-term medication cost reduction compared to standard care.

Early Repetitive Transcranial Magnetic Stimulation Exerts Neuroprotective Effects and Improves Motor Functions in Hemiparkinsonian Rats

Repetitive transcranial magnetic stimulation (rTMS) is a popular noninvasive technique for modulating motor cortical plasticity and has therapeutic potential for the treatment of Parkinson's disease (PD). However, the therapeutic benefits and related mechanisms of rTMS in PD are still uncertain. Accordingly, preclinical animal research is helpful for enabling translational research to explore an effective therapeutic strategy and for better understanding the underlying mechanisms. Therefore, the current study was designed to identify the therapeutic effects of rTMS on hemiparkinsonian rats. A hemiparkinsonian rat model, induced by unilateral injection of 6-hydroxydopamine (6-OHDA), was applied to evaluate the therapeutic potential of rTMS in motor functions and neuroprotective effect of dopaminergic neurons. Following early and long-term rTMS intervention with an intermittent theta burst stimulation (iTBS) paradigm (starting 24 h post-6-OHDA lesion, 1 session/day, 7 days/week, for a total of 4 weeks) in awake hemiparkinsonian rats, the effects of rTMS on the performance in detailed functional behavioral tests, including video-based gait analysis, the bar test for akinesia, apomorphine-induced rotational analysis, and tests of the degeneration level of dopaminergic neurons, were identified. We found that four weeks of rTMS intervention significantly reduced the aggravation of PD-related symptoms post-6-OHDA lesion. Immunohistochemically, the results showed that tyrosine hydroxylase- (TH-) positive neurons in the substantia nigra pars compacta (SNpc) and fibers in the striatum were significantly preserved in the rTMS treatment group. These findings suggest that early and long-term rTMS with the iTBS paradigm exerts neuroprotective effects and mitigates motor impairments in a hemiparkinsonian rat model. These results further highlight the potential therapeutic effects of rTMS and confirm that long-term rTMS treatment might have clinical relevance and usefulness as an additional treatment approach in individuals with PD.

Parkinson's disease advanced therapies - A systematic review: More unanswered questions than guidance

In advanced Parkinson's disease (PD), therapeutic interventions include device-aided therapies such as continuous subcutaneous apomorphine infusion (CSAI), levodopa-carbidopa intestinal gel (LCIG) infusion, and deep brain stimulation (DBS). We reappraised the evidence guiding the decision of appropriate device-aided therapies in advanced PD, and systematically reviewed the literature (including ongoing clinical trials) comparing CSAI, LCIG, DBS in terms of efficacy and cost-effectiveness, with particular consideration to possible conflicts of interests. Of 14,980 documents screened, sixteen were included (4 and 13 studies examining efficacy and cost-effectiveness, respectively). LCIG and DBS showed higher efficacy compared to best medical therapy (BMT). DBS was more expensive than BMT and LCIG. Lifetime costs of CSAI were lower of those of DBS, and DBS lifetime costs were lower than those of LCIG. The majority of studies (11 out of 16) showed direct or indirect sponsorship from pharmaceutical or device companies. Only one ongoing clinical trial comparing LCIG with DBS was found. Device-aided therapies address unmet needs in advanced PD. LCIG and DBS are superior to BMT in head-to-head studies; however, initial and lifetime costs should be considered when choosing those therapies. Guidelines to assist clinicians and patients to choose device-aided therapies, free from conflict of interests, are required.

Pediatric Deep Brain Stimulation for Dystonia: Current State and Ethical Considerations

Dystonia is a movement disorder that can have a debilitating impact on motor functions and quality of life. There are 250,000 cases in the United States, most with childhood onset. Due to the limited effectiveness and side effects of available treatments, pediatric deep brain stimulation (pDBS) has emerged as an intervention for refractory dystonia. However, there is limited clinical and neuroethics research in this area of clinical practice. This paper examines whether it is ethically justified to offer pDBS to children with refractory dystonia. Given the favorable risk-benefit profile, it is concluded that offering pDBS is ethically justified for certain etiologies of dystonia, but it is less clear for others. In addition, various ethical and policy concerns are discussed, which need to be addressed to optimize the practice of offering pDBS for dystonia. Strategies are proposed to help address these concerns as pDBS continues to expand.

TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation

BACKGROUND

Chronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation.

OBJECTIVE

This paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA.

METHODS

We are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans' clinical outcomes and travel burdens and costs.

RESULTS

This program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310).

CONCLUSIONS

Evaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20139.

Cost-Effectiveness of Deep Brain Stimulation With Movement Disorders: A Systematic Review

Background

Movement disorders (MDs) are increasingly being managed with deep brain stimulation (DBS). High-quality economic evaluations (EEs) are necessary to evaluate the cost-effectiveness of DBS. We conducted a systematic review of published EEs of the treatment of MDs with DBS. The review compares and contrasts the reported incremental cost-effectiveness ratios (ICERs) and methodology employed by trial-based evaluations (TBEs) and model-based evaluations (MBEs).

Methods

MeSH and search terms relevant to "MDs," "DBS," and "EEs" were used to search biomedical and economics databases. Studies that used a comparative design to evaluate DBS, including before-after studies, were included. Quality and reporting assessments were conducted independently by 2 authors. Seventeen studies that targeted Parkinson's disease (PD), dystonia, and essential tremor (ET), met our selection criteria.

Results

Mean scores for methodological and reporting quality were 73% and 76%, respectively. The ICERs for DBS compared with best medical therapy to treat PD patients obtained from MBEs had a lower mean and range compared with those obtained from TBEs ($55,461-$735,192 per quality-adjusted life-year [QALY] vs. $9,301-$65,111 per QALY). Pre-post ICER for DBS to treat dystonia was $64,742 per QALY. DBS was not cost-effective in treating ET compared with focused-ultrasound surgery. Cost-effectiveness outcomes were sensitive to assumptions in health utilities, surgical costs, battery life-span, model time horizons, and the discount rate.

Conclusions

The infrequent use of randomized, controlled trials to evaluate DBS efficacy, the paucity of data reporting the long-term effectiveness and/or utility of DBS, and the uncertainty surrounding cost data limit our ability to report cost-effectiveness summaries that are robust.

Parkinson's disease: Mechanisms, translational models and management strategies

Parkinson's disease is a progressive neurodegenerative disorder. The classical motor symptoms include resting tremors, bradykinesia, rigidity and postural instability and are accompanied by the loss of dopaminergic neurons and Lewy pathology. Diminished neurotransmitter level, oxidative stress, mitochondrial dysfunction and perturbed protein homeostasis over time worsen the disease manifestations in elderly people. Current management strategies aim to provide symptomatic relief and to slow down the disease progression. However, no pharmacological breakthrough has been made to protect dopaminergic neurons and associated motor circuitry components. Deep brain stimulation, stem cells-derived dopaminergic neurons transplantation, gene editing and gene transfer remain promising approaches for the potential management of neurodegenerative disease. Toxin or genetically induced rodent models replicating Parkinson's disease pathology are of high predictive value for translational research. This review addresses the current understanding, management strategies and the Parkinson's disease models for translational research. Preclinical research may provide powerful tools to quest the potential therapeutic and neuroprotective compounds for dopaminergic neurons and hence possible cure for the Parkinson's disease.

Economic Evaluation of Interventions in Parkinson's Disease: A Systematic Literature Review

BACKGROUND

Parkinson's disease (PD) management comprises of drug treatments, surgery, and physical activity/occupational therapies to relieve PD's symptoms. The aim of this study is twofold; first, to appraise recent economic evaluation studies on PD management in order to update the existing knowledge; and second, to facilitate decision making on PD management by assessing the cost-effectiveness of all types of PD interventions.

METHODS

A systematic search for studies published between 2010 and 2018 was conducted. The inclusion and exclusion of the articles were based on criteria relevant to population, intervention, comparison, outcomes, and study design (PICO). The reporting quality of the articles was assessed according to Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

Twenty-eight articles were included, 10 of which were evaluations of drug treatments, 10 deep brain stimulation (DBS), and eight physical/occupational therapies. Among early-stage treatments, Ti Ji dominated all physical activity interventions; however, its cost-effectiveness should be further explored in relation to its duration, intensity, and frequency. Multidisciplinary interventions of joint medical and nonmedical therapies provided slightly better health outcomes for the same costs. In advanced PD patients, adjunct drug treatments could become more cost-effective if introduced during early PD and, although DBS was more cost-effective than adjunct drug therapies, the results were time-bound.

CONCLUSIONS

Conditionally, certain PD interventions are cost-effective. However, PD progression differs in each patient; thus, the cost-effectiveness of individually tailored combinations of interventions that could provide more time in less severe disease states and improve patients' and caregivers' quality of life, should be further explored.

Automated Deep Brain Stimulation Programming for Tremor

Deep brain stimulation (DBS) programming, the systematic selection of fixed electrical stimulation parameters that deliver maximal therapeutic benefit while limiting side effects, poses several challenges in the treatment of movement disorders. DBS programming requires the expertise of trained neurologists or nurses who assess patient symptoms according to standardized clinical rating scales and use patient reports of DBS-related side effects to adjust stimulation parameters and optimize therapy. In this paper, we describe and validate an automated software platform for DBS programming for tremor associated with Parkinson's disease and essential tremor. DBS parameters are changed automatically through a direct computer interface with implanted neurostimulators. Each tested DBS setting is ranked according to its effect on tremor, which is assessed using smartwatch inertial measurement unit data, and side effects, which are reported through a user interface. Blinded neurologist assessments showed the automated programming method performed at least as well as clinician mediated programming in selecting the optimal settings for tremor therapy. This proof of concept study describes a novel DBS programming paradigm that may improve programming efficiency and outcomes, increase access to programming outside specialty clinics, and aid in the development of adaptive and closed-loop DBS strategies.

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.

Closing the Loop on Deep Brain Stimulation for Treatment-Resistant Depression

Major depressive episodes are the largest cause of psychiatric disability, and can often resist treatment with medication and psychotherapy. Advances in the understanding of the neural circuit basis of depression, combined with the success of deep brain stimulation (DBS) in movement disorders, spurred several groups to test DBS for treatment-resistant depression. Multiple brain sites have now been stimulated in open-label and blinded studies. Initial open-label results were dramatic, but follow-on controlled/blinded clinical trials produced inconsistent results, with both successes and failures to meet endpoints. Data from follow-on studies suggest that this is because DBS in these trials was not targeted to achieve physiologic responses. We review these results within a technology-lifecycle framework, in which these early trial “failures” are a natural consequence of over-enthusiasm for an immature technology. That framework predicts that from this “valley of disillusionment,” DBS may be nearing a “slope of enlightenment.” Specifically, by combining recent mechanistic insights and the maturing technology of brain-computer interfaces (BCI), the next generation of trials will be better able to target pathophysiology. Key to that will be the development of closed-loop systems that semi-autonomously alter stimulation strategies based on a patient's individual phenotype. Such next-generation DBS approaches hold great promise for improving psychiatric care.

Orexin Directly Enhances the Excitability of Globus Pallidus Internus Neurons in Rat by Co-activating OX1 and OX2 Receptors

Orexin, released from the hypothalamus, has been implicated in various basic non-somatic functions including feeding, the sleep-wakefulness cycle, emotion, and cognition. However, the role of orexin in somatic motor control is still little known. Here, using whole-cell patch clamp recording and immunostaining, we investigated the effect and the underlying receptor mechanism of orexin-A on neurons in the globus pallidus internus (GPi), a critical structure in the basal ganglia and an effective target for deep brain stimulation therapy. Our results showed that orexin-A induced direct postsynaptic excitation of GPi neurons in a concentration-dependent manner. The orexin-A-induced excitation was mediated via co-activation of both OX1 and OX2 receptors. Furthermore, the immunostaining results showed that OX1 and OX2 receptors were co-localized in the same GPi neurons. These results suggest that the central orexinergic system actively modulates the motor functions of the basal ganglia via direct innervation on GPi neurons and presumably participates in somatic-non-somatic integration.

The role of deep brain stimulation in Parkinson's disease: an overview and update on new developments

Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by the loss of neuronal dopamine production in the brain. Oral therapies primarily augment the dopaminergic pathway. As the disease progresses, more continuous delivery of therapy is commonly needed. Deep brain stimulation (DBS) has become an effective therapy option for several different neurologic and psychiatric conditions, including PD. It currently has US Food and Drug Administration approval for PD and essential tremor, as well as a humanitarian device exception for dystonia and obsessive-compulsive disorder. For PD treatment, it is currently approved specifically for those patients suffering from complications of pharmacotherapy, including motor fluctuations or dyskinesias, and a disease process of at least 4 years of duration. Studies have demonstrated superiority of DBS and medical management compared to medical management alone in selected PD patients. Optimal patient selection criteria, choice of target, and programming methods for PD and the other indications for DBS are important topics that continue to be explored and remain works in progress. In addition, new hardware options, such as different types of leads, and different software options have recently become available, increasing the potential for greater efficacy and/or reduced side effects. This review gives an overview of therapeutic management in PD, specifically highlighting DBS and some of the recent changes with surgical therapy.

Economic Analysis of Deep Brain Stimulation in Parkinson Disease: Systematic Review of the Literature

BACKGROUND

Parkinson disease (PD) is a chronic multifaceted neurodegenerative disorder of adult onset that affects quality of life and places a burden on patients, caregivers, and society. In early disease, dopaminergic therapy improves motor symptoms, but as the disease progresses, symptoms tend to increase in frequency and severity, even with best medical treatment (BMT). Deep brain stimulation (DBS) becomes an option for certain patients, but cost becomes an important issue.

OBJECTIVE

We performed a systematic review of the literature of economic studies of the use of DBS in patients with PD, including costs studies or economic evaluations expressed as cost per improvement in quality life, decrease in dose of pharmacological treatments, and the decrease of caregiver burden.

METHODS

We reviewed the following databases: Medline/PubMed, Embase, Cochrane Database of Systematic Reviews, LILACS, Cochrane Central Register of Controlled Trials, WHO International Clinical Trials Registry Platform ICTRP portal and ClinicalTrials.gov from 1980 to 2015. Costs have been converted or adjusted to 2016 US dollars (US$).

RESULTS

Nine studies were identified. The average cost of DBS for a patient with PD in 5 years is US$186,244. The quality-adjusted life year was higher in DBS compared with BMT after at least 2 years of treatment, with an average incremental cost utility ratio of US$41,932 per additional quality-adjusted life year gained. Costs in the first year are higher with DBS because of direct costs related to the surgical procedure, the device, and the more frequent controls. Studies show better results with a longer time horizon (up to 5 years).

CONCLUSION

DBS is a cost-effective intervention for patients with advanced PD, but it has a high initial cost compared with BMT. However, DBS reduces pharmacologic treatment costs and should also reduce direct, indirect, and social costs of PD on the long term.

Cost analysis of awake versus asleep deep brain stimulation: a single academic health center experience

OBJECT

The objective of this study was to compare the cost of deep brain stimulation (DBS) performed awake versus asleep at a single US academic health center and to compare costs across the University HealthSystem Consortium (UHC) Clinical Database.

METHODS

Inpatient and outpatient demographic and hospital financial data for patients receiving a neurostimulator lead implant (from the first quarter of 2009 to the second quarter of 2014) were collected and analyzed. Inpatient charges included those associated with International Classification of Diseases, Ninth Revision (ICD-9) procedure code 0293 (implantation or replacement of intracranial neurostimulator lead). Outpatient charges included all preoperative charges ≤ 30 days prior to implant and all postoperative charges ≤ 30 days after implant. The cost of care based on reported charges and a cost-to-charge ratio was estimated. The UHC database was queried (January 2011 to March 2014) with the same ICD-9 code. Procedure cost data across like hospitals (27 UHC hospitals) conducting similar DBS procedures were compared.

RESULTS

Two hundred eleven DBS procedures (53 awake and 158 asleep) were performed at a single US academic health center during the study period. The average patient age ( ± SD) was 65 ± 9 years old and 39% of patients were female. The most common primary diagnosis was Parkinson’s disease (61.1%) followed by essential and other forms of tremor (36%). Overall average DBS procedure cost was $39,152 ± $5340. Asleep DBS cost $38,850 ± $4830, which was not significantly different than the awake DBS cost of $40,052 ± $6604. The standard deviation for asleep DBS was significantly lower (p ≤ 0.05). In 2013, the median cost for a neurostimulator implant lead was $34,052 at UHC-affiliated hospitals that performed at least 5 procedures a year. At Oregon Health & Science University, the median cost was $17,150 and the observed single academic health center cost for a neurostimulator lead implant was less than the expected cost (ratio 0.97).

CONCLUSIONS

In this single academic medical center cost analysis, DBS performed asleep was associated with a lower cost variation relative to the awake procedure. Furthermore, costs compared favorably to UHC-affiliated hospitals. While asleep DBS is not yet standard practice, this center exclusively performs asleep DBS at a lower cost than comparable institutions.

Deep brain stimulation for obesity: rationale and approach to trial design

Obesity is one of the most serious public health concerns in the US. While bariatric surgery has been shown to be successful for treatment of morbid obesity for those who have undergone unsuccessful behavioral modification, its associated risks and rates of relapse are not insignificant. There exists a neurological basis for the binge-like feeding behavior observed in morbid obesity that is believed to be due to dysregulation of the reward circuitry. The authors present a review of the evidence of the neuroanatomical basis for obesity, the potential neural targets for deep brain stimulation (DBS), as well as a rationale for DBS and future trial design. Identification of an appropriate patient population that would most likely benefit from this type of therapy is essential. There are also significant cost and ethical considerations for such a neuromodulatory intervention designed to alter maladaptive behavior. Finally, the authors present a consolidated set of inclusion criteria and study end points that should serve as the basis for any trial of DBS for obesity.

Comparison of Bilateral vs. Staged Unilateral Deep Brain Stimulation (DBS) in Parkinson's Disease in Patients Under 70 Years of Age

OBJECTIVE

The most popular surgical method for deep brain stimulation (DBS) in Parkinson's disease (PD) is simultaneous bilateral DBS. However, some centers conduct a staged unilateral approach advocating that reduced continuous intraoperative time reduces postoperative complications, thus justifying the cost of a second operative session. To test these assumptions, we performed a retrospective analysis of the Truven Health MarketScan® Database.

METHODS

Using the MarketScan Database, we retrospectively analyzed patients that underwent simultaneous bilateral or staged unilateral DBS between 2000 and 2009. The main outcome measures were 90-day postoperative complication rates, number of reprogramming hours one year following procedure, and annualized healthcare cost. The outcome measures were compared between cohorts using multivariate regressions controlling for appropriate covariates.

RESULTS

A total of 713 patients that underwent DBS between 2000 and 2009 met inclusion criteria for the study. Of these patients, 556 underwent simultaneous bilateral DBS and 157 received staged unilateral DBS. No statistically significant differences were found between groups in the rate of infection (simultaneous: 4.3% vs. staged: 7.0%; p = 0.178), pneumonia (3.1% vs. 5.7%; p = 0.283), hemorrhage (2.9% vs. 2.5%; p = 0.844), pulmonary embolism (0.5% vs. 1.3%), and device-related complications (0.5% vs. 0.0%). Patients in the staged cohort had a higher rate of lead revision in 90 days (3.2% vs. 12.7%; RR = 3.07; p < 0.001). The staged cohort had a higher mean (SD) number of reprogramming hours within one year of procedure (6.0 ± 5.7 vs. 7.8 ± 8.1; RR = 1.17; p < 0.001). No significant difference was found between the mean (SD) annualized payments between the cohorts ($86,100 ± $94,700 vs. $102,100 ± $121,500; p = 0.148).

CONCLUSION

Our study did not find a significant difference between 90-day postoperative complication rates or annualized cost between the staged and simultaneous cohorts. Thus, we believe that it is important to consider other factors when deciding between the staged and simultaneous DBS. Such factors include patient convenience and the laterality of symptoms.