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Guo J, Wang Z, van 't Klooster MA, Van Der Salm SM, Leijten FS, Braun KP, Zijlmans M. Seizure Outcome After Intraoperative Electrocorticography-Tailored Epilepsy Surgery: A Systematic Review and Meta-Analysis. Neurology 2024; 102:e209430. [PMID: 38768406 PMCID: PMC11175635 DOI: 10.1212/wnl.0000000000209430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 03/12/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Tailoring epilepsy surgery using intraoperative electrocorticography (ioECoG) has been debated, and modest number of epilepsy surgery centers apply this diagnostic method. We assessed the current evidence to use ioECoG-tailored epilepsy surgery for improving postsurgical outcome. METHODS PubMed and Embase were searched for original studies reporting on ≥10 cases who underwent ioECoG-tailored surgery for epilepsy, with a follow-up of at least 6 months. We used a random-effects model to calculate the overall rate of patients achieving favorable seizure outcome (FSO), defined as Engel class I, ILAE class 1, or seizure-free status. Meta-regression was used to investigate potential sources of heterogeneity. We calculated the odds ratio (OR) for estimating variables on FSO:ioECoG vs non-ioECoG-tailored surgery (if included studies contained patients with non-ioECoG-tailored surgery), ioECoG-tailored epilepsy surgery in children vs adults, temporal (TL) vs extratemporal lobe (eTL), MRI-positive vs MRI-negative, and complete vs incomplete resection of tissue that generated interictal epileptiform discharges (IEDs). A Bayesian network meta-analysis was conducted for underlying pathologies. We assessed the evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). RESULTS Eighty-three studies (82 observational studies, 1 trial) comprising 3,631 patients with ioECoG-tailored surgery were included. The overall pooled rate of patients who attained FSO after ioECoG-tailored surgery was 74% (95% CI 71-77) with significant heterogeneity, which was predominantly attributed to pathologies and seizure outcome classifications. Twenty-two studies contained non-ioECoG-tailored surgeries. IoECoG-tailored surgeries reached a higher rate of FSO than non-ioECoG-tailored surgeries (OR 2.10 [95% CI 1.37-3.24]; p < 0.01; very low certainty). Complete resection of tissue that displayed IEDs in ioECoG predicted FSO better compared with incomplete resection (OR 3.04 [1.76-5.25]; p < 0.01; low certainty). We found insignificant difference in FSO after ioECoG-tailored surgery in children vs adults, TL vs eTL, or MRI-positive vs MRI-negative. The network meta-analysis showed that the odds of FSO was lower for malformations of cortical development than for tumors (OR 0.47 95% credible interval 0.25-0.87). DISCUSSION Although limited by low-quality evidence, our meta-analysis shows a relatively good surgical outcome (74% FSO) after epilepsy surgery with ioECoG, especially in tumors, with better outcome for ioECoG-tailored surgeries in studies describing both and better outcome after complete removal of IED areas.
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Affiliation(s)
- Jiaojiao Guo
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Ziyi Wang
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Maryse A van 't Klooster
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Sandra M Van Der Salm
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Frans S Leijten
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Kees P Braun
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
| | - Maeike Zijlmans
- From the Department of Neurology and Neurosurgery (J.G., Z.W., M.A.K., S.M.V.D.S., F.S.L., K.P.B., M.Z.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Part of ERN EpiCARE; and Stichting Epilepsie Instellingen Nederland (SEIN) (M.Z.), the Netherlands
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Lipska I, Di Bidino R, Niewada M, Nemeth B, Bochenek T, Kukla M, Więckowska B, Sobczak A, Iłowiecka K, Zemplenyi A, Martelli N, Martin T, Filiniuk O, Kosyachenko K, Sucu R, Piniazhko O, Zaliska O, Avdeyev A, Shanazarov N, von Pinoci M, Hren R. Overcoming Barriers in Hospital-Based Health Technology Assessment (HB-HTA): International Expert Panel Consensus. Healthcare (Basel) 2024; 12:889. [PMID: 38727447 PMCID: PMC11083158 DOI: 10.3390/healthcare12090889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
The purpose of this article is to investigate the common facilitators and barriers associated with the implementation of hospital-based health technology assessment (HB-HTA) across diverse hospital settings in seven countries. Through a two-round Delphi study, insights were gathered from a panel of 15 HTA specialists from France, Hungary, Italy, Kazakhstan, Poland, Switzerland, and Ukraine. Experts initially conducted a comprehensive review of the HB-HTA implementation in their respective countries, identifying the barriers and facilitators through descriptive analysis. Subsequently, panel experts ranked these identified barriers and facilitators on a seven-point Likert scale. A median agreement score ≥ 6 and interquartile range (IQR) ≤ 1 was accepted as reaching a consensus. Out of the 12 statements categorized as external and internal barriers and facilitators, the expert panel reached consensus on six statements (two barriers and four facilitators). The external barrier, which achieved consensus, was the lack of the formal recognition of the role of HB-HTA in national or regional legislations. The internal barrier reaching consensus was the limited availability of human resources dedicated to HB-HTA. This qualitative study indicates that HB-HTA still has progress to make before being formally accepted and integrated across most countries, although by building on the facilitating factors we identified there may be an opportunity for the implementation of internationally developed strategies to strengthen HB-HTA practices.
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Affiliation(s)
- Iga Lipska
- Health Policy Institute, 00-819 Warsaw, Poland; (I.L.); (A.S.); (K.I.)
- Medical Department, Academy of Applied Medical and Social Sciences, 82-300 Elbląg, Poland
- Hospital-Based Health Technology Assessment Interest Group, Health Technology Assessment International, Edmonton, AB T6H 5P9, Canada; (M.K.); (R.S.)
| | - Rossella Di Bidino
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
- Health Graduate School of Health Economics and Management (ALTEMS), Università Cattolica Del Sacro Cuore, 00168 Rome, Italy
| | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Bertalan Nemeth
- Syreon Research Institute, 1142 Budapest, Hungary; (B.N.); (A.Z.)
| | - Tomasz Bochenek
- Department of Nutrition and Drug Research, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, 31-126 Krakow, Poland;
| | - Monika Kukla
- Hospital-Based Health Technology Assessment Interest Group, Health Technology Assessment International, Edmonton, AB T6H 5P9, Canada; (M.K.); (R.S.)
| | - Barbara Więckowska
- Social Insurance Department, Warsaw School of Economics, 02-554 Warsaw, Poland;
| | - Alicja Sobczak
- Health Policy Institute, 00-819 Warsaw, Poland; (I.L.); (A.S.); (K.I.)
| | | | - Antal Zemplenyi
- Syreon Research Institute, 1142 Budapest, Hungary; (B.N.); (A.Z.)
- Center for Health Technology Assessment and Pharmacoeconomics Research, Faculty of Pharmacy, University of Pécs, 7624 Pécs, Hungary
| | - Nicolas Martelli
- Pharmacy Department, Georges Pompidou European Hospital, 75015 Paris, France; (N.M.); (T.M.)
- Faculty of Pharmacy, Université Paris-Saclay, GRADES, 91190 Orsay, France
| | - Tess Martin
- Pharmacy Department, Georges Pompidou European Hospital, 75015 Paris, France; (N.M.); (T.M.)
- Faculty of Pharmacy, Université Paris-Saclay, GRADES, 91190 Orsay, France
| | - Olena Filiniuk
- Safe, Affordable, and Effective Medicines for Ukrainians (SAFEMed) Activity, Management Sciences for Health, 02000 Kyiv, Ukraine;
| | - Kostyantyn Kosyachenko
- Department of Management and Economy of Pharmacy, Bogomolets National Medical University, 01601 Kyiv, Ukraine;
| | - Rabia Sucu
- Hospital-Based Health Technology Assessment Interest Group, Health Technology Assessment International, Edmonton, AB T6H 5P9, Canada; (M.K.); (R.S.)
| | - Oresta Piniazhko
- Department of Health Technology Assessment, State Expert Center, Ministry of Health of Ukraine, 01021 Kyiv, Ukraine;
- Department of Management and Economy of Pharmacy, Medicine Technology and Pharmacoeconomics, Faculty of Postgraduate Education, Danylo Halytsky Lviv National Medical University, 79010 Lviv, Ukraine;
| | - Olha Zaliska
- Department of Management and Economy of Pharmacy, Medicine Technology and Pharmacoeconomics, Faculty of Postgraduate Education, Danylo Halytsky Lviv National Medical University, 79010 Lviv, Ukraine;
| | - Andrey Avdeyev
- Medical Center Hospital of the President’s Affairs Administration of the Republic of Kazakhstan, Astana 010000, Kazakhstan; (A.A.); (N.S.)
| | - Nasrulla Shanazarov
- Medical Center Hospital of the President’s Affairs Administration of the Republic of Kazakhstan, Astana 010000, Kazakhstan; (A.A.); (N.S.)
| | - Marina von Pinoci
- Care Quality Division, Hôpitaux Universitaires de Genève, 1211 Geneva, Switzerland;
| | - Rok Hren
- Syreon Research Institute, 1142 Budapest, Hungary; (B.N.); (A.Z.)
- Institute of Mathematics, Physics, and Mechanics, 1000 Ljubljana, Slovenia
- Faculty of Mathematics and Physics, University of Ljubljana, 1000 Ljubljana, Slovenia
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Liker MA, Sanger TD, MacLean JA, Nataraj J, Arguelles E, Krieger M, Robison A, Olaya J. Stereotactic Awake Basal Ganglia Electrophysiological Recording and Stimulation (SABERS): A Novel Staged Procedure for Personalized Targeting of Deep Brain Stimulation in Pediatric Movement and Neuropsychiatric Disorders. J Child Neurol 2024; 39:33-44. [PMID: 38409793 DOI: 10.1177/08830738231224057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Selection of targets for deep brain stimulation (DBS) has been based on clinical experience, but inconsistent and unpredictable outcomes have limited its use in patients with heterogeneous or rare disorders. In this large case series, a novel staged procedure for neurophysiological assessment from 8 to 12 temporary depth electrodes is used to select targets for neuromodulation that are tailored to each patient's functional needs. Thirty children and young adults underwent deep brain stimulation target evaluation with the new procedure: Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation (SABERS). Testing is performed in an inpatient neuromodulation monitoring unit over 5-7 days, and results guide the decision to proceed and the choice of targets for permanent deep brain stimulation implantation. Results were evaluated 3-6 months postoperatively with the Burke-Fahn-Marsden Dystonia Rating Scale and the Barry-Albright Dystonia Scale. Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation testing allowed modulation to be tailored to specific neurologic deficits in a heterogeneous population, including subjects with primary dystonia, secondary dystonia, and Tourette syndrome. All but one subject were implanted with 4 permanent deep brain stimulation leads. Results showed significant improvement on both scales at postoperative follow-up. No significant adverse events occurred. Use of the Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation protocol with evaluation in the neuromodulation monitoring unit is feasible and results in significant patient benefit compared with previously published results in these populations. This new technique supports a significant expansion of functional neurosurgery to predict effective stimulation targets in a wide range of disorders of brain function, including those for which the optimal target is not yet known.
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Affiliation(s)
- Mark A Liker
- Divison of Neurosurgery, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Terence D Sanger
- Samueli School of Engineering, University of California Irvine, Irvine, CA, USA
- Research Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, CA, USA
- Department of Neurology, Children's Hospital of Orange County, Orange, CA, USA
| | - Jennifer A MacLean
- Research Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurology, Children's Hospital of Orange County, Orange, CA, USA
| | - Jaya Nataraj
- Samueli School of Engineering, University of California Irvine, Irvine, CA, USA
| | - Enrique Arguelles
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Mark Krieger
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Aaron Robison
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Joffre Olaya
- Divison of Neurosurgery, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurological Surgery, School of Medicine, University of California Irvine, Irvine, CA, USA
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Piazza MG, Smith KJ, Abel TJ. Influence of New Technologies on the Cost-Effectiveness of Invasive Monitoring in Epilepsy Surgery. World Neurosurg 2023; 180:231-232. [PMID: 37838164 DOI: 10.1016/j.wneu.2023.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Affiliation(s)
- Martin G Piazza
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth J Smith
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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5
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Ngan Kee N, Foster E, Marquina C, Tan A, Pang SST, O'Brien TJ, Kwan P, Jackson GD, Chen Z, Ademi Z. Systematic Review of Cost-Effectiveness Analysis for Surgical and Neurostimulation Treatments for Drug-Resistant Epilepsy in Adults. Neurology 2023; 100:e1866-e1877. [PMID: 36927880 PMCID: PMC10159768 DOI: 10.1212/wnl.0000000000207137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/18/2023] [Indexed: 03/18/2023] Open
Abstract
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.
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Affiliation(s)
- Nicholas Ngan Kee
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Emma Foster
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Clara Marquina
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Andy Tan
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Samantha S T Pang
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Terence J O'Brien
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Patrick Kwan
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Graeme D Jackson
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia
| | - Zhibin Chen
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia.
| | - Zanfina Ademi
- From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia.
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Kitschen A, Aleknonytė-Resch M, Sakalytė G, Diederich F. Cost-effectiveness of surgical treatment compared to medical treatment in patients with drug-refractory epilepsy: A systematic review. Eur J Neurol 2023; 30:749-761. [PMID: 36371643 DOI: 10.1111/ene.15632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Anne Kitschen
- Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Bremen, Germany
- Department of Philosophy, Politics and Economics, Witten/Herdecke University, Witten, Germany
| | - Milda Aleknonytė-Resch
- Department of Neurology, Kiel University, Kiel, Germany
- Institute of Medical Informatics and Statistics, Kiel University, Kiel, Germany
| | | | - Freya Diederich
- Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Bremen, Germany
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Abel TJ, Muthiah N, Hect JL, Gonzalez-Martinez J, Salehi A, Smyth MD, Smith KJ. Cost-effectiveness of invasive monitoring strategies in epilepsy surgery. J Neurosurg 2022:1-7. [PMID: 36585866 DOI: 10.3171/2022.11.jns221744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/17/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Drug-resistant epilepsy occurs in up to 40% of patients with epilepsy who may be considered for epilepsy surgery. For drug-resistant focal epilepsy, up to 50% of patients require invasive monitoring prior to surgery. Of the most common invasive monitoring strategies (subdural electrodes [SDEs] and stereo-electroencephalography [sEEG]), the most cost-effective strategy is unknown despite substantial differences in morbidity profiles. METHODS Using data collected from an internationally representative sample published in available systematic reviews and meta-analyses, this economic evaluation study employs a decision analysis model to simulate the risks and benefits of SDE and sEEG invasive monitoring strategies. In this model, patients faced differing risks of morbidity, mortality, resection, and seizure freedom depending on which invasive monitoring strategy they underwent. A range of cost values was obtained from a recently published single-center cost-utility analysis. The model considers a base case simulation of a characteristic patient with drug-resistant epilepsy using clinical parameters obtained from systematic reviews of invasive monitoring available in the literature. The main outcome measure was the probability of a positive outcome after invasive monitoring, which was defined as improvement in seizures without a complication. Cost-effectiveness was measured using an incremental cost-effectiveness ratio (ICER). RESULTS Invasive monitoring with sEEG had an increased cost of $274 and increased probability of effectiveness of 0.02 compared with SDEs, yielding an ICER of $12,630 per positive outcome obtained. Sensitivity analyses varied parameters widely and revealed consistent model results across the range of clinical parameters reported in the literature. One-way sensitivity analyses revealed that invasive monitoring strategy costs were the most influential parameter for model outcome. CONCLUSIONS In this analysis, based on available observational data and estimates of complication costs, invasive monitoring with either SDEs or sEEG was nearly equivalent in terms of cost-effectiveness.
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Affiliation(s)
- Taylor J Abel
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh.,Departments of2Bioengineering and
| | - Nallammai Muthiah
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Jasmine L Hect
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Jorge Gonzalez-Martinez
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh
| | - Afshin Salehi
- 3Department of Neurosurgery, University of Nebraska, Omaha, Nebraska; and
| | - Matthew D Smyth
- 4Department of Neurosurgery, Johns Hopkins All Children's Hospital, Tampa, Florida
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Willems LM, Hochbaum M, Zöllner JP, Schulz J, Menzler K, Langenbruch L, Kovac S, Knake S, von Podewils F, Hamacher M, Hamer HM, Reese JP, Frey K, Rosenow F, Strzelczyk A. Trends in resource utilization and cost of illness in patients with active epilepsy in Germany from 2003 to 2020. Epilepsia 2022; 63:1591-1602. [PMID: 35305026 DOI: 10.1111/epi.17229] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/26/2022] [Accepted: 03/16/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To calculate epilepsy-related direct, indirect, and total costs in adult patients with active epilepsy (ongoing unprovoked seizures) in Germany and to analyze cost components and dynamics compared to previous studies from 2003, 2008 and 2013. This analysis was part of the Epi2020 study. METHODS Direct and indirect costs related to epilepsy were calculated with a multicenter survey using an established and validated questionnaire with a bottom-up design and human capital approach over a 3-month period in late 2020. Epilepsy-specific costs in the German health care sector from 2003, 2008 and 2013 were corrected for inflation to allow for a valid comparison. RESULTS Data on the disease-specific costs for 253 patients in 2020 were analyzed. The mean total costs were calculated at € 5,551 (± € 5,805; median: € 2,611; range: € 274 to € 21,667) per three months, comprising mean direct costs of € 1,861 (± € 1,905; median: € 1,276; range: € 327 to € 13,158) and mean indirect costs of € 3,690 (± € 5,298; median: € 0; range: € 0 to € 11,925). The main direct costs components were hospitalization (42.4%), anti-seizure medication (42.2%) and outpatient care (6.2%). Productivity losses due to early retirement (53.6%), part-time work or unemployment (30.8%) and seizure-related off-days (15.6%) were the main reasons for indirect costs. However, compared to 2013, there was no significant increase of direct costs (-10.0%), and indirect costs significantly increased (p<0.028, +35.1%), resulting in a significant increase in total epilepsy-related costs (p<0.047, +20.2%). Compared to the 2013 study population, a significant increase of cost of illness could be observed (p=0.047). SIGNIFICANCE The present study shows that disease-related costs in adult patients with active epilepsy increased from 2013 to 2020. As direct costs have remained constant, this increase is attributable to an increase in indirect costs. These findings highlight the impact of productivity loss caused by early retirement, unemployment, working time reduction and seizure-related days off.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University, Frankfurt, Frankfurt am Main, Germany
| | - Maja Hochbaum
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University, Frankfurt, Frankfurt am Main, Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University, Frankfurt, Frankfurt am Main, Germany
| | - Juliane Schulz
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Katja Menzler
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Lisa Langenbruch
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University, Münster, Germany.,Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
| | - Stjepana Kovac
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University, Münster, Germany
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Felix von Podewils
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Mario Hamacher
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Hajo M Hamer
- Epilepsy Center and Department of Neurology, Friedrich-Alexander-University, Erlangen, Germany
| | - Jens-Peter Reese
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Katharina Frey
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University, Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University, Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University, Frankfurt, Frankfurt am Main, Germany
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Terman SW. Dollars and Sense: Cost-Effectiveness of Epilepsy Surgery. Epilepsy Curr 2021; 21:171-172. [PMID: 34867096 PMCID: PMC8609591 DOI: 10.1177/1535759721995191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cost Effectiveness of Surgery for Drug-Resistant Temporal Lobe Epilepsy in the US Neurology Sheikh SR, Kattan MW, Steinmetz M, Singer ME, Udeh BL, Jehi L. Neurology. 2020;95(1):e1404-e1416. doi:10.1212/WNL.0000000000010185 Objective: Surgery is an effective but costly treatment for many patients with drug-resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, surgery is cost-effective compared to medical management for patients deemed surgical candidates and whether surgical evaluation is cost-effective for patients with DR-TLE in general. Methods: We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use second-order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both health care and societal perspectives, including direct health care costs (eg, surgery, antiepileptic drugs) and indirect costs (eg, lost earnings by patients and care providers). We compare the incremental cost-effectiveness ratio to societal willingness to pay (∼US$100 000 per quality-adjusted life-year [QALY]) to determine whether surgery is cost-effective. Results: Epilepsy surgery is cost-effective compared to medical management in surgically eligible patients by virtue of being cost-saving (US$328 000 vs US$423 000) and more effective (16.6 vs 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in patients with DR-TLE even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost-effective within 3 years, and 89% of simulations favor surgery over the lifetime horizon. Conclusion: For surgically eligible patients with DR-TLE, surgery is cost-effective. For patients with DR-TLE in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. Patients with DR-TLE should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.
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