The costs of childhood epilepsy in Italy: comparative findings from three health care settings

Epilepsy-Related Direct Medical and Direct Non-Medical Cost in Adult Patients Living with Epilepsy at a Tertiary Neurology Center in Rwanda

Objective

Up to one in four patients living with epilepsy (PwE) mentions financial constraints as a reason for loss to follow-up at the Ndera tertiary neuropsychiatry hospital. Therefore, we evaluated the annual direct medical cost (DMC) and direct non-medical cost (DnMC) of epilepsy and calculated costs assuming different follow-up frequency.

Materials and Methods

DMC data were obtained from a descriptive retrospective study of medical records, pharmacy dispensation and hospital logs of PwE, following their initial consultation in 2018 and who adhered to the normal clinical practice of monthly consultations for one year. DnMC data were collected through structured interviews of PwE in a cross-sectional cohort in August 2020. DnMC included biomedical care costs (eg, transportation, hospitality) and non-biomedical costs (traditional healer visits). We report weighted means for total costs, health insurance costs, and out-of-pocket costs (OoP).

Results

Mean annual total cost was 389.4 US$, of which 226.2 US$ was covered by the Rwandan Health Insurance co-payment for DMC and 163.2 US$ was OoP paid by patients. Mean weighted annual DMC (n = 55) was 248.9 US$. Mean weighted annual DMC for medical consultations and antiseizure medication accounted for 30.7 US$ and 161.7 US$, respectively. Based on structured interviews (n = 69), mean weighted annual DnMC for biomedical care was 73.0 US$. Mean DnMC for traditional healer care was 67.6 US$. Weighted annual total OoP was 163.2 US$ or 20% of the GDP per capita. OoP consisted of 14% DMC co-payment, 45% biomedical DnMC, and 41% traditional healer DnMC.

Conclusion

Epilepsy-related costs at a tertiary center are an important economic burden for PwE and Rwandan Health Insurance. Biomedical and traditional healer DnMC constitute 86% of total OoP. Future prospective studies should evaluate outcomes and costs of reduced visit frequency, indirect costs, and costs of comorbidities.

Health Care System Costs Associated With Surgery and Medical Therapy for Children With Drug-Resistant Epilepsy in Ontario

BACKGROUND AND OBJECTIVES

Improvement in seizure control after epilepsy surgery could lead to lower health care resource use and costs, but it is uncertain whether this could offset the high costs related to surgery. This study aimed to evaluate phase-specific and cumulative long-term health care costs of surgery compared to medical therapy in children with drug-resistant epilepsy from the health care payer perspective.

METHODS

Children who were evaluated for epilepsy surgery and treated with surgery or medical therapy from 2003 to 2018 at the Hospital for Sick Children in Toronto were identified from chart review and linked to their health administrative databases in Ontario, Canada. Inverse probability of treatment weighting with stabilized weights was used to balance the baseline covariates between the 2 groups. Patients were assigned to presurgery, surgery, short-term (first 2 years), intermediate-term (2-5 years), and long-term (>5 years) postsurgery care phases on the basis of treatment trajectory. Phase-specific and cumulative long-term health care costs were evaluated. Costs were converted from Canadian to US dollars year 2018 value.

RESULTS

There were 372 surgical and 258 medical patients. Costs were higher in surgical than medical patients for presurgery (3 and 39 weeks), surgery, and short-term care phase, and the attributable costs of surgery per 7 patient-days were $1,602 (95% CI $1,438-$1,785), $172 (95% CI $147-$185), $19,819 (95% CI $18,822-$20,932), and $28 (95% CI $22-$32), respectively. Costs were lower in surgical patients for intermediate- and long-term care phase, and the attributable costs were -$72 (95% CI -$124 to -$35) and -$94 (95% CI -$129 to -$63), respectively. In surgical patients, costs were highest for surgery followed by presurgery care phase, with hospitalizations accounting for the highest cost component. In medical patients, costs increased gradually from presurgery to long-term care phase. Cumulative costs were higher for surgical than medical patients in the first 7 years after surgery, but from 8 years on, costs were lower for surgical patients.

DISCUSSION

This study demonstrated the long-term economic benefits of epilepsy surgery compared to medical therapy for the health care system with the use of real-world data, which would justify the high costs of surgery. The results will support future economic evaluation comparing minimally invasive treatment such as laser therapy to surgery.

The global cost of epilepsy: A systematic review and extrapolation

OBJECTIVE

Global action for epilepsy requires information on the cost of epilepsy, which is currently unknown for most countries and regions of the world. To address this knowledge gap, the International League Against Epilepsy Commission on Epidemiology formed the Global Cost of Epilepsy Task Force.

METHODS

We completed a systematic search of the epilepsy cost-of-illness literature and identified studies that provided a comprehensive set of direct health care and/or indirect costs, followed standard methods of case identification and cost estimation, and used data on a representative population or subpopulation of people with epilepsy. Country-specific costs per person with epilepsy were extracted and adjusted to generate an average cost per person in 2019 US dollars. For countries with no cost data, estimates were imputed based on average costs per person of similar income countries with data. Per person costs for each country were then applied to data on the prevalence of epilepsy from the Global Burden of Disease collaboration adjusted for the treatment gap.

RESULTS

One hundred one cost-of-illness studies were included in the direct health care cost database, 74 from North America or Western Europe. Thirteen studies were used in the indirect cost database, eight from North America or Western Europe. The average annual cost per person with epilepsy in 2019 ranged from $204 in low-income countries to $11 432 in high-income countries based on this highly skewed database. The total cost of epilepsy, applying per person costs to the estimated 52.51 million people in the world with epilepsy and adjusting for the treatment gap, was $119.27 billion.

SIGNIFICANCE

Based on a summary and extrapolations of this limited database, the global cost of epilepsy is substantial and highly concentrated in countries with well-developed health care systems, higher wages and income, limited treatment gaps, and a relatively small percentage of the epilepsy population.

Economic burden of epilepsy in children: A population-based matched cohort study in Canada

OBJECTIVE

The economic burden of childhood epilepsy to the health care system remains poorly understood. This study aimed to determine phase-specific and cumulative long-term health care costs in children with epilepsy (CWE) from the health care payer perspective.

METHODS

This cohort study utilized linked health administrative databases in Ontario, Canada. Incident childhood epilepsy cases were identified from January 1, 2003 to June 30, 2017. CWE were matched to children without epilepsy (CWOE) on age, sex, rurality, socioeconomic status, and comorbidities, and assigned prediagnosis, initial, ongoing, and final care phase based on clinical trajectory. Phase-specific, 1-year and 5-year cumulative health care costs, attributable costs of epilepsy, and distribution of costs across different ages were evaluated.

RESULTS

A total of 24 411 CWE were matched to CWOE. The costs were higher for prediagnosis and initial care than ongoing care in CWE. Hospitalization was the main cost component. The costs of prediagnosis, initial, and ongoing care were higher in CWE than CWOE, with the attributable costs at $490 (95% confidence interval [CI] = $352-$616), $1322 (95% CI = $1247-$1402), and $305 (95% CI = $276-$333) per 30 patient-days, respectively. Final care costs were lower in CWE than CWOE, with attributable costs at -$2515 (95% CI = -$6288 to $961) per 30 patient-days. One-year and 5-year cumulative costs were higher in CWE ($14 776 [95% CI = $13 994-$15 546] and $39 261 [95% CI = $37 132-$41 293], respectively) than CWOE ($6152 [95% CI = $5587-$6768] and $15 598 [95% CI = $14 291-$17 006], respectively). The total health care costs were highest in the first year of life in CWE for prediagnosis, initial, and ongoing care.

SIGNIFICANCE

Health care costs varied along the continuum of epilepsy care, and were mainly driven by hospitalization costs. The findings identified avenues for remediation, such as enhancing care around the time of epilepsy diagnosis and better care coordination for epilepsy and comorbidities, to reduce hospitalization costs and the economic burden of epilepsy care.

Influence of patient, caregiver, and family factors on unmet healthcare needs in children with drug-resistant epilepsy undergoing epilepsy surgery evaluation

OBJECTIVE

The aim of this study was to assess whether patient, caregiver, and family factors correlate with unmet healthcare needs in children with drug-resistant epilepsy (DRE) who were evaluated for epilepsy surgery.

METHODS

Caregivers of children with DRE completed questions on unmet healthcare needs, including physical and mental needs. Patient (demographic, seizure severity, and comorbidities), caregiver (sociodemographics, depression, and anxiety), and family (family functioning, resources, and demands) factors were evaluated. A series of bivariable regression was conducted to assess the associations with unmet needs (overall, physical, and mental needs), followed by multivariable regression.

RESULTS

Of the 86 children with DRE, 32 (37.2%) reported having overall unmet healthcare needs, 21 (24.4%) have unmet physical, and 13 (15.1%) have unmet mental healthcare needs. Multivariable regression showed that the odds of overall unmet needs in children were higher in patients with higher depressive symptoms (odds ratio [OR] = 1.7, p = 0.03), and caregivers who were unemployed (OR = 3.8, p = 0.008). The odds of unmet physical needs in children were higher among patients with higher depressive symptoms (OR = 2.0, p = 0.02), caregivers who were older (OR = 1.1, p = 0.02), and caregivers who were unemployed (OR = 6.5, p = 0.008). There were no significant correlates between patient, caregiver, and family factors with unmet mental needs (all p > 0.05).

INTERPRETATION

Children with DRE were at risk for not receiving needed healthcare. Patient factors such as patient depressive symptoms, and caregiver factors such as caregivers' age and employment status were associated with unmet needs. Identifying the predictors of unmet healthcare needs is a necessary step in addressing unmet needs in this population with DRE.

Treatment-Related Costs of Childhood Epilepsy in Mainland China: A Preliminary Study in a Tertiary Pediatric Epilepsy Center

This study aimed to investigate the treatment-related annual cost of childhood epilepsy and its related factors in mainland China. A total of 244 cases were collected at the outpatient clinics of Peking University First Hospital Pediatrics from April 2010 to August 2013. The median annual epilepsy treatment-related costs per patient were estimated to be RMB7822 (US$1160), accounting for 43.72% (median) of urban residents' disposable income in China. Those who lived far away or with uncontrolled seizures yielded much higher costs. This study concluded that the treatment of children with epilepsy produces a heavy burden on both families and society in mainland China. The constitution ratio of antiepileptic drugs and travel expenses are much higher than those of other countries. Adjusting medical insurance coverage, balancing medical resource distribution, and taking good control of seizures might be effective in reducing the economic burden of childhood epilepsy in China.

Effect of Epilepsy on Families, Communities, and Society

The effect of epilepsy extends beyond those with the diagnosis and impacts families, communities and society. Caregiver and sibling quality of life is often negatively affected by frequent seizures, comorbid behavioral and sleep disorders and stigma surrounding the diagnosis. Furthermore, the negative effects can be magnified by individual coping styles and resources available to families of those with epilepsy. Beyond the family and immediate caregivers, epilepsy affects local communities by drawing additional resources from education systems. The direct costs of caring for an individual with epilepsy and the indirect costs associated with decreased productivity place financial strain on individuals and health care systems throughout the world. This review details factors affecting family and caregiver quality of life and provides several approaches through which health care providers may address these concerns. Furthermore, we examine the financial effect of epilepsy on society and review emerging strategies to lessen health care use for individuals with epilepsy.

The direct costs of epilepsy in Russia. A prospective cost-of-illness study from a single center in Moscow

OBJECTIVE

The objective of this study was to investigate prospectively the direct costs of epilepsy in Russia, taking a patient perspective and a bottom-up approach.

METHODS

The study was conducted in adolescents and adults with epilepsy seen in the ambulatory services of a city hospital in Moscow. Patients were assigned to different prognostic categories: newly diagnosed epilepsy; epilepsy in remission for 2+years; epilepsy in remission for <2years or with occasional seizures; active, nondrug-resistant epilepsy; drug-resistant epilepsy; and drug-resistant epilepsy in surgical candidates. Patients were followed prospectively for 12months. Demographic and clinical features at admission were collected and correlated with costs. Cost estimates were based on the Russian National Health Service perspective and its implementation in Moscow. Cost items included drugs and laboratory/instrumental tests. The costs per patient were calculated for the entire sample and for each prognostic category separately. Univariate and multivariate analyses were performed.

RESULTS

Included were 738 patients (393 men, 345 women aged 14-85years). The median annual cost/patient was €955 (IQR 521-2134; range 51-10,904). The median cost of drugs was €643 (IQR 288-1866; range 0-9960), and the median cost of laboratory/instrumental testing was €202 (IQR 160-270; range 20-1217). Mean costs varied across prognostic categories ranging from €782 in newly diagnosed patients to €3777 in patients with drug-resistant epilepsy. Mean (SD) hospital costs ranged from €646.7 (109.0) in patients with occasional seizures to €950.0 (28.3) in surgical candidates. Independent predictors of total costs were younger age at diagnosis, disability status, generalized seizures, multiple seizure types, seizure severity, and etiology.

SIGNIFICANCE

The cost of epilepsy in Moscow varies significantly depending on disease characteristics and response to drug treatment.

Ketogenic Diet Decreases Emergency Room Visits and Hospitalizations Related to Epilepsy

Background. Approximately, one-third of patients with epilepsy are refractory to pharmacological treatment which mandates extensive medical care and imposes significant economic burden on patients and their societies. This study intends to assess the impact of the treatment with ketogenic diet (KD) on reducing seizure-related emergency room visits and hospitalizations in children with refractory epilepsy. Methods. This is a retrospective review of children treated with the KD in one tertiary center. We compared a 12 months' period prior to KD with 12 months after the diet was started in regard to the number of emergency department (ED) visits, hospitalizations, and hospital days as well as their associated charges. Results. 37 patients (57% males) were included. Their ages at time of KD initiation were (4.0 ± 2.78) years. Twelve months after the KD initiation, the total number of ED visits was reduced by 36% with a significant decrease of associated charges (p = 0.038). The number of hospital admissions was reduced by 40% and the number of hospital days was reduced by 39%. The cumulative charges showed net cost savings after 9 months when compared to the prediet baseline. Conclusion. In children with refractory epilepsy, treatment with the ketogenic diet reduces the number of ED visits and hospitalizations and their corresponding costs.

Vaccinating Italian infants with a new multicomponent vaccine (Bexsero®) against meningococcal B disease: A cost-effectiveness analysis

The European Medicines Agency has approved a multicomponent serogroup B meningococcal vaccine (Bexsero®) for use in individuals of 2 months of age and older. A cost-effectiveness analysis (CEA) from the societal and Italian National Health Service perspectives was performed in order to evaluate the impact of vaccinating Italian infants less than 1 y of age with Bexsero®, as opposed to non-vaccination. The analysis was carried out by means of Excel Version 2011 and the TreeAge Pro® software Version 2012. Two basal scenarios that differed in terms of disease incidence (official and estimated data to correct for underreporting) were considered. In the basal scenarios, we considered a primary vaccination cycle with 4 doses (at 2, 4, 6 and 12 months of age) and 1 booster dose at the age of 11 y, the societal perspective and no cost for death. Sensitivity analyses were carried out in which crucial variables were changed over probable ranges. In Italy, on the basis of official data on disease incidence, vaccination with Bexsero® could prevent 82.97 cases and 5.61 deaths in each birth cohort, while these figures proved to be three times higher on considering the estimated incidence. The results of the CEA showed that the Incremental Cost Effectiveness Ratio (ICER) per QALY was €109,762 in the basal scenario if official data on disease incidence are considered and €26,599 if estimated data are considered. The tornado diagram indicated that the most influential factor on ICER was the incidence of disease. The probability of sequelae, the cost of the vaccine and vaccine effectiveness also had an impact. Our results suggest that vaccinating infants in Italy with Bexsero® has the ability to significantly reduce meningococcal disease and, if the probable underestimation of disease incidence is considered, routine vaccination is advisable.

The economic impact of epilepsy: a systematic review

BACKGROUND

In this review we aimed to determine the economic impact of epilepsy and factors associated with costs to individuals and health systems.

METHODS

A narrative systematic review of incidence and case series studies with prospective consecutive patient recruitment and economic outcomes published before July 2014 were retrieved from Medline, Embase and PsycInfo.

RESULTS

Of 322 studies reviewed, 22 studies met the inclusion criteria and 14 were from high income country settings. The total costs associated with epilepsy varied significantly in relation to the duration and severity of the condition, response to treatment, and health care setting. Where assessed, 'out of pocket' costs and productivity losses were found to create substantial burden on households which may be offset by health insurance. However, populations covered ostensibly for the upfront costs of care can still bear a significant economic burden.

CONCLUSIONS

Epilepsy poses a substantial economic burden for health systems and individuals and their families. There is uncertainty over the degree to which private health insurance or social health insurance coverage provides adequate protection from the costs of epilepsy. Future research is required to examine the role of different models of care and insurance programs in protecting against economic hardship for this condition, particularly in low and middle income settings.

Costs and Clinical Outcomes of Epilepsy Surgery in Children With Drug-Resistant Epilepsy

PURPOSE

Approximately 20% of children with epilepsy are drug-resistant, incurring considerable costs. Epilepsy surgery has been shown to be an effective intervention in this population. This study provides an initial look at the costs associated with surgical management of children with drug-resistant epilepsy as compared with medical management alone.

PROCEDURES

In a retrospective cohort study of children with drug-resistant epilepsy referred for possible surgical intervention, we compared direct costs of those treated surgically versus those offered surgery but managed medically instead. We also assessed the difference in seizure frequency between the two groups.

FINDINGS

There were 94 total patients, 78 (83%) in the surgical group and 16 (17%) in the medical group. The median (25th-75th percentile) cost of the epilepsy surgery hospitalization was $118,400 ($101,900-$143,800). Total median annual follow-up costs, not including the cost of surgical hospitalization, were not significantly different between the two groups at 1- or 2-year follow-up. However, the surgical patients who were seizure-free at 1-year follow-up, and those that remained seizure-free at 2-year follow-up, had significantly lower costs compared with the medical group ($8000 versus $16,200, P = 0.04 and $4300 versus $7600, P = 0.05, respectively). The surgical group had significantly fewer seizures compared with the medical group at 1-year follow-up.

CONCLUSIONS

Although epilepsy surgery is expensive and the overall costs of surgical and medical management are similar in the first 2 years, patients who achieved seizure freedom after surgery had lower costs compared with those treated medically.

Costs of epilepsy and cost-driving factors in children, adolescents, and their caregivers in Germany

OBJECTIVE

To provide first data on the cost of epilepsy and cost-driving factors in children, adolescents, and their caregivers in Germany.

METHODS

A population-based, cross-sectional sample of consecutive children and adolescents with epilepsy was evaluated in the states of Hessen and Schleswig-Holstein (total of 8.796 million inhabitants) in all health care sectors in 2011. Data on socioeconomic status, course of epilepsy, and direct and indirect costs were recorded using patient questionnaires.

RESULTS

We collected data from 489 children and adolescents (mean age ± SD 10.4 ± 4.2 years, range 0.5-17.8 years; 264 [54.0%] male) who were treated by neuropediatricians (n = 253; 51.7%), at centers for social pediatrics ("Sozialpaediatrische Zentren," n = 110, 22.5%) and epilepsy centers (n = 126; 25.8%). Total direct costs summed up to €1,619 ± €4,375 per participant and 3-month period. Direct medical costs were due mainly to hospitalization (47.8%, €774 ± €3,595 per 3 months), anticonvulsants (13.2%, €213 ± €363), and ancillary treatment (9.1%, €147 ± €344). The total indirect costs amounted to €1,231 ± €2,830 in mothers and to €83 ± €593 in fathers; 17.4% (n = 85) of mothers and 0.6% (n = 3) of fathers reduced their working hours or quit work because of their child's epilepsy. Independent cost-driving factors were younger age, symptomatic cause, and polytherapy with anticonvulsants. Older age, active epilepsy, symptomatic cause, and polytherapy were independent predictors of higher antiepileptic drug (AED) costs, whereas younger age, longer epilepsy duration, symptomatic cause, disability, and parental depression were independent predictors for higher indirect costs.

SIGNIFICANCE

Treatment of children and adolescents with epilepsy is associated with high direct costs due to frequent inpatient admissions and high indirect costs due to productivity losses in mothers. Direct costs are age-dependent and higher in patients with symptomatic epilepsy and polytherapy. Indirect costs are higher in the presence of a child's disability and parental depression.

Evaluation of health-care utilization in patients with Dravet syndrome and on adjunctive treatment with stiripentol and clobazam

Dravet syndrome (DS) is a rare, severe childhood epilepsy syndrome that imposes a substantial burden on patients and their caregivers. This study evaluated health-care utilization over a 2-year period in patients with DS at an outpatient clinic of a German epilepsy center. Data on the course of epilepsy, anticonvulsant treatment, and direct costs were recorded using the electronic seizure diary Epivista and patients' files. We enrolled 13 patients with DS (6 females, mean age: 12.3±7.5 years) between 2007 and 2010 and evaluated them during a 1-year baseline. All patients had drug-resistant epilepsy and their seizures failed to improve with a mean number of 6.7±3.4 anticonvulsants. They had an overall mean seizure frequency of 102.1 seizures per year (median: 31, range: 3-538) with 43.2 GTCSs per year (median: 14, range: 0-228). We estimated the annual total direct costs at €6506±3974 (range: €1174-11,783) per patient with hospitalization (68.9% of total direct costs) as the major cost factor ahead of costs for anticonvulsants (24.0%). For the 1-year follow-up period, less severely affected patients were continued on conventional anticonvulsants (n=4) or switched to adjunctive treatment with stiripentol and clobazam (n=9). In the latter group, six patients (67%) were long-term responders, with between 25% and 100% seizure reduction with respect to either GTCSs or the overall seizure frequency. This reduction in seizure frequency was associated with a shift in the distribution of cost components towards higher medication costs and decreased hospitalization costs. The total direct costs increased by 42.7%, mainly due to the newly introduced stiripentol, with an annual cost of €6610. This study showed that direct costs of patients with DS were above the average European costs of drug-resistant epilepsy in children. Treatment with new anticonvulsants resulted in reduction of seizures and inpatient admissions.

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.

Clinical outcomes, quality of life, and costs associated with implantation of vagus nerve stimulation therapy in pediatric patients with drug-resistant epilepsy

BACKGROUND

VNS (Vagus Nerve Stimulation Therapy) is approved in the USA to treat refractory epilepsy as adjunctive to antiepileptic drugs (AEDs) in patients ≥12 years with complex partial seizures.

AIMS

To evaluate clinical outcomes, quality-adjusted life years (QALY), and costs associated with VNS in pediatric patients with drug-resistant epilepsy in a real-world setting.

METHODS

A retrospective analysis was conducted using Medicaid data (USA). Patients had ≥1 neurologist visits with epilepsy diagnosis (ICD-9 345.xx, 780.3x), ≥1 procedure claims for VNS implantation, ≥1 AEDs, ≥6-months of Pre- and Post-VNS continuous enrollment. Pre-VNS period was 6-months and Post-VNS period extended from implantation until device removal, death, Medicaid disenrollment, or study end (up to 3 years). Incidence rate ratios (IRR) and costs ($2010) were estimated. QALYs were estimated using number of seizure-related events.

RESULTS

For patients 1-11 years old (N = 238), hospitalizations and emergency room visits were reduced Post-VNS vs. Pre-VNS (adjusted IRR = 0.73 [95% CI: 0.61-0.88] and 0.74 [95% CI: 0.65-0.83], respectively). Average total healthcare costs were lower Post-VNS vs. Pre-VNS ($18,437 vs. $18,839 quarterly [adjusted p = 0.052]). For patients 12-17 years old (N = 207), hospitalizations and status epilepticus events were reduced Post-VNS vs. Pre-VNS (adjusted IRR = 0.43 [95% CI: 0.34-0.54] and 0.25 [95% CI: 0.16-0.39], respectively). Average total healthcare costs were lower Post-VNS vs. Pre-VNS period ($14,546 vs. $19,695 quarterly [adjusted p = 0.002]). Lifetime QALY gain after VNS was 5.96 (patients 1-11 years) and 4.82 years (patients 12-17 years).

CONCLUSIONS

VNS in pediatric patients is associated with decreased resource use and epilepsy-related events, cost savings, and QALY gain.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Economic analysis of newer antiepileptic drugs

In the last 20 years, several second-generation antiepileptic drugs (AEDs) have been marketed. These newer drugs are expensive and have no established superiority over the first-generation compounds in terms of efficacy when used as monotherapy. A systematic review of economic studies dealing with the newer AEDs has been performed to put these drugs in a wider perspective. A number of economic analysis studies of second-generation AEDs have examined these compounds as monotherapy or adjunctive therapy. Almost all monotherapy studies showed newer AEDs as having similar effectiveness but significantly higher acquisition costs than first-generation drugs. The evidence from adjunctive therapy studies was more conflicting. Lamotrigine appeared to be a cost-effective drug when higher thresholds were used, or when savings were defined by the cost of surgery. Levetiracetam also appeared to be cost effective when the costs of surgical investigation were discounted.In a decision model that included quantification of the uncertainty associated with the decision regarding the cost effectiveness of AEDs, second-generation drugs used as monotherapy for newly diagnosed partial epilepsy produced similar benefits but were more expensive than older drugs. The newer AEDs were more effective but more expensive than existing monotherapies in patients with refractory partial epilepsy, but may be cost effective at higher thresholds, and continue to be cost effective in patients responding to the assigned drug. In patients with newly diagnosed generalized epilepsy, valproate was more cost effective than lamotrigine.The results of current economic studies are difficult to assess and compare because of a number of methodological drawbacks. Future studies should be implemented using a standardized approach to define the costs and outcomes of representative cohorts of patients with newly diagnosed epilepsy recruited from different countries and followed prospectively.

Estimating the cost of epilepsy in Europe: a review with economic modeling

PURPOSE

Based on available epidemiologic, health economic, and international population statistics literature, the cost of epilepsy in Europe was estimated.

METHODS

Europe was defined as the 25 European Union member countries, Iceland, Norway, and Switzerland. Guidelines for epidemiological studies on epilepsy were used for a case definition. A bottom-up prevalence-based cost-of-illness approach, the societal perspective for including the cost items, and the human capital approach as valuation principle for indirect costs were used. The cost estimates were based on selected studies with common methodology and valuation principles.

RESULTS

The estimated prevalence of epilepsy in Europe in 2004 was 4.3-7.8 per 1,000. The estimated total cost of the disease in Europe was euro15.5 billion in 2004, indirect cost being the single most dominant cost category (euro8.6 billion). Direct health care costs were euro2.8 billion, outpatient care comprising the largest part (euro1.3 billion). Direct nonmedical cost was euro4.2 billion. That of antiepileptic drugs was euro400 million. The total cost per case was euro2,000-11,500 and the estimated cost per European inhabitant was euro33.

CONCLUSIONS

Epilepsy is a relevant socioeconomic burden at individual, family, health services, and societal level in Europe. The greater proportion of such burden is outside the formal health care sector, antiepileptic drugs representing a smaller proportion. Lack of economic data from several European countries and other methodological limitations make this report an initial estimate of the cost of epilepsy in Europe. Prospective incidence cost-of-illness studies from well-defined populations and common methodology are encouraged.

A review of the costs of managing childhood epilepsy

Epilepsy is a chronic treatable condition for which new diagnostic tools and several new drugs and non-pharmacological treatments are now available. The cost profile of these options is assessed here through an overview of the available literature focusing on studies of childhood epilepsy. Several methodological problems arise when interpreting the results of economic studies in epilepsy, including the variability of the study population and costs items, the reliability of the sources of cost, the limitations of the methods of data collection and the deficiencies of the study designs, with reference to the measures of treatment benefits. International comparisons are then difficult because economic results cannot be compared on account of differences in monetary issues, clinical practice patterns and healthcare system frameworks. The economic aspects of epilepsy are different in children and adults. Differences are detectable in the incidence and expression of epileptic syndromes, social and emotional impact, availability of antiepileptic drugs, hospital admissions, diagnostic tests and referral to specialists, social assistants and other healthcare professionals. In addition, children have access to medical services only with the help of a caregiver, for whom there may be lost work days or under-employment. The mean annual cost per child with epilepsy was USD 1853 for controlled epilepsy and USD 4950 for uncontrolled epilepsy in a Spanish study performed in 1998 and the annual direct costs per child with epilepsy ranged from euro 844 for patients in remission to euro 3268 for patients with drug-resistant epilepsy in an Italian study done between 1996 and 1998. The Spanish study showed that direct costs are the major source of expenditure for children with epilepsy. These studies along with a number of other cost-of-illness studies in combined populations of adults and children showed that service use and costs increase with more severe forms of illness and seizure frequency, this being more marked in adults than in children. Moderate cost differences may be expected between children (higher) and adults (lower), particularly with reference to initial investigations. Costs of epilepsy are mostly explained by hospital admissions and drugs; in particular, drug costs tend to dominate in more well controlled epilepsy, while both hospital admissions and drugs are significant costs in less well controlled epilepsy. Newly diagnosed patients can incur significant hospital and diagnostic costs. Costs for epilepsy tend to be lower for patients cared for in general practice or outpatient settings than in hospital settings. Seizure control by drugs, ketogenic diet or surgery is associated with a significant reduction in the costs of epilepsy.

Treatment of partial seizures in childhood : an overview

The treatment of partial seizures in children is based on the use of first generation and recently introduced antiepileptic drugs as well as nonpharmacological treatments such as the ketogenic diet, vagus nerve stimulation and surgical therapy. The present review discusses the efficacy and tolerability of different treatment options for partial seizures in childhood. Few adjunctive or monotherapy, placebo-controlled or comparative trials of the first-generation antiepileptic drugs and some of the more recently introduced antiepileptic drugs have been performed in children. This can be explained by the fact that it is only relatively recently (1989) that the International League against Epilepsy proposed that randomised, controlled trials be included among the required criteria for assessing the efficacy and tolerability of an antiepileptic agent. This led to controlled, comparative trials among older antiepileptic drugs (phenobarbital, phenytoin, carbamazepine and valproic acid), both in adults and in paediatric patients, being performed relatively 'late', based on when these drugs were first introduced. Carbamazepine and valproic acid may still be considered as first-line antiepileptic therapies for children with partial seizures. Phenobarbital and phenytoin are mostly considered as last choice drugs because of their adverse event profiles. The new generation of antiepileptic agents has added to the first- and second-line treatment options for paediatric partial seizures. To date, there are sufficient data to support the clinical use of some of the recently introduced antiepileptic drugs (e.g. oxcarbazepine, topiramate, gabapentin and lamotrigine) as adjunctive or first-line monotherapy. Because of the risk of visual field constriction with vigabatrin, the use of this drug is currently limited to patients refractory to other medications. Tiagabine, felbamate, levetiracetam and zonisamide have been shown to be effective in adults with partial seizures; however, at present there are not yet enough data on the efficacy of these drugs in children to support consideration of their use as either first-line or add-on therapy in this patient population, although controlled studies are expected shortly. Furthermore, the use of felbamate is considerably limited by rare, but severe, hepatic and haematological toxicity. Controlled trials for paediatric partial seizures are still lacking for the ketogenic diet and vagus nerve stimulation, though they may represent, in given patients, useful adjunctive alternative treatments for refractory partial seizures. In conclusion, further trials are needed to determine an optimal sequence of first- and second-line therapies and to establish whether other newer antiepileptic drugs merit consideration as initial therapy in children with partial seizures.

Direct Cost of Medical Management of Epilepsy among Adults in Italy: A Prospective Cost-of-Illness Study (EPICOS)

PURPOSE

To investigate the costs of epilepsy from a nationwide survey comparing adult patients included in different prognostic categories.

METHODS

A 12-month prospective observational study was conducted in 15 epilepsy centers from Northern, Central, and Southern Italy. The study population included a random sample of individuals aged 18 years and older with newly diagnosed (ND) epilepsy, seizure remission (R), occasional seizures (OS), active non-drug-resistant (NDR) seizures, drug-resistant (DR) seizures, or surgical candidates (SC). Estimates of the direct costs of care of epilepsy were based on the use of diagnostic examinations, laboratory tests, specialist consultations, hospital admissions, day-hospital days, and drugs, taking the Italian National Health Service perspective.

RESULTS

The sample included 631 patients (ND 62, R 158, OS 155, NDR 114, DR 128, and SC 14). The SC group had the highest total cost per patient (3,619 euros) followed by DR (2,190 euros), ND (976 euros), NDR (894 euros), OS (830 euros), and R (561 euros). For each epilepsy group, the main components of the total cost were drugs and hospital admissions. Drug costs increased from the R group to the DR group. The new antiepileptic drugs (AEDs) were the largest part of the cost of treatment.

CONCLUSIONS

The costs of epilepsy in referral patients vary significantly according to the time course of the disease and the response to treatment. Hospital admissions and drugs are the major sources of expenditure.

The costs of epilepsy in three different populations of patients with epilepsy

The purpose of this study was to estimate the costs of care in three different populations of patients with epilepsy (general practices (GP), University Hospital (UH), and Epilepsy Center (EC)), and to analyse the distribution of costs by type of services for each patient group. A cost diary was developed to obtain prospective information on epilepsy-attributable service use over a period of 3 months. Similar information over the previous 3 months was obtained from a cost questionnaire. In addition, a quality of life inventory (QOLIE-31) was used. Standard cost lists were applied for the valuation of the direct cost items. A sensitivity analysis was performed for certain cost items for which no reliable data were available. One hundred and sixteen patients with established epilepsy were included, and the mean costs per patient per month (in Euros) ranged from 52.08 to 357.63. Patients from GP appeared to have lower direct costs, spent less time in seeking or undergoing a treatment, and reported lower seizure frequencies and less severe seizure types than the patients from the other patient groups. Patients from the EC reported the highest productivity changes and unemployment rates and also had the lowest scores on the QOLIE-31. The cost items anti-epileptic drugs, hospital services, unpaid care, and transportation accounted for the majority of the total direct costs.

The economic cost of epilepsy: a review of the literature

Economic concerns are increasingly important in health system design, provider payment, and research funding decisions. Cost estimates are needed to provide insight into where the potential opportunities for cost-savings lie and to lay the groundwork for research to determine how to treat the disorder more effectively. The methods used by economists to estimate the direct and indirect costs of epilepsy are reviewed and results from studies in different countries are discussed. General patterns across patients with different types of conditions are reported. Gaps in the literature are identified and future research needs are assessed.