Direct medical costs of refractory epilepsy incurred by three different treatment modalities: a prospective assessment

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

BACKGROUND AND PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Burden of illness in people with medically refractory epilepsy who suffer from daily to weekly seizures: 12-month follow-up of participants in the EPISODE study

BACKGROUND

A small group of people with epilepsy suffers from frequent seizures despite the available pharmacological and non-pharmacological interventions. The impact of epilepsy on these people extends beyond health-related quality of life (HRQoL), impacting a person's broader well-being and ability to participate in society. This study describes the burden of medically refractory epilepsy in people who suffer from daily to weekly seizures, in terms of HRQoL, well-being, and societal costs.

METHODS

Data from the EPISODE study on (cost-) effectiveness of seizure dogs for adults with severe medically refractory epilepsy were used, collected in 25 patients during the first 12 months before they were partnered with a certified seizure dog. Data comprised seizure diaries covering 365 days and five three-monthly surveys, including the EQ-5D-5L, QOLIE-31-P, and ICECAP-A to measure HRQoL and well-being. A societal perspective was applied to estimate costs using the iMCQ and iPCQ questionnaires about healthcare use, informal care, and productivity losses.

RESULTS

Daily seizure frequency and survey data were collected in 25 patients. A minimum of 114 observations was available for each instrument included in the survey. A total of 80% of participants experienced seizures on three or more days per week, with a median ranging from 1 to 17 seizures per seizure day. The mean EQ-5D-5L utility score was 0.682 (SD 0.235), which is considerably lower than the age-adjusted general population average. The mean QOLIE-31-P and ICECAP-A scores were 55.8 (SD 14.0) and 0.746 (SD 0.172), respectively. The average annual total cost amounted to €39,956 (range €3,804-€132,64). Informal care accounted for the largest share of costs (50%); those who received informal care reported, on average, 26 h per week (SD 30).

CONCLUSIONS

Severe medically refractory epilepsy is associated with a considerable burden of illness at the patient and societal level. People with this condition have significantly reduced HRQoL and well-being and are limited in their ability to work while having substantial medical costs and a strong dependency on informal care.

The role of vagus nerve stimulation in genetic etiologies of drug-resistant epilepsy: a meta-analysis

OBJECTIVE

Drug-resistant epilepsy (DRE) affects many children. Vagus nerve stimulation (VNS) may improve seizure control; however, its role in children with genetic etiologies of epilepsy is not well described. The authors systematically reviewed the literature to examine the effectiveness of VNS in this cohort.

METHODS

In January 2021, the authors performed a systematic review of the PubMed/MEDLINE, SCOPUS/Embase, Cochrane, and Web of Science databases to investigate the impact of VNS on seizure outcomes in children with genetic etiologies of epilepsy. Primary outcomes included seizure freedom rate, ≥ 90% seizure reduction rate, and ≥ 50% seizure reduction rate. Secondary outcomes were seizure severity and quality of life (QOL), including cognitive, functional, and behavioral outcomes. A random-effects meta-analysis was performed.

RESULTS

The authors identified 125 articles, of which 47 with 216 nonduplicate patients were analyzed. Common diagnoses were Dravet syndrome (DS) (92/216 patients [42.6%]) and tuberous sclerosis complex (TSC) (63/216 [29.2%]). Seizure freedom was not reported in any patient with DS; the pooled proportion (95% CI) of patients with ≥ 50% seizure reduction was 41% (21%-58%). Secondary cognitive outcomes of VNS were variable in DS patients, but these patients demonstrated benefits in seizure duration and status epilepticus. In TSC patients, the pooled (95% CI) seizure freedom rate was 40% (12%-71%), ≥ 90% seizure reduction rate was 31% (8%-56%), and ≥ 50% reduction rate was 68% (48%-91%). Regarding the secondary outcomes of VNS in TSC patients, several studies reported decreased seizure severity and improved QOL outcomes. There was limited evidence regarding the use of VNS to treat patients with other genetic etiologies of epilepsy, such as mitochondrial disease, Rett syndrome, Doose syndrome, Landau-Kleffner syndrome, Aicardi syndrome, Angelman syndrome, ring chromosome 20 syndrome, and lissencephaly; variable responses were reported in a limited number of cases.

CONCLUSIONS

The authors conducted a systematic review of VNS outcomes in children with genetic etiologies of DRE. Among the most studied conditions, patients with TSC had substantial seizure reduction and improvements in QOL, whereas those with DS had less robust seizure reduction. Increased testing, diagnosis, and long-term follow-up studies are necessary to better characterize VNS response in these children.

Hospital costs associated with vagus nerve stimulation and medical treatment in pediatric patients with refractory epilepsy

Objectives

Refractory epilepsy is a diagnosis of recurrent seizures that requires multiple resources for optimal chronic management. The disease negatively impacts the lives of affected patients and families and poses an economic burden to the health care system. This study compares hospital costs between pediatric patients treated with antiseizure medications (ASMs) only and ASMs plus vagus nerve stimulation (VNS).

Methods

Patients 0–17 years of age who were diagnosed with refractory epilepsy between January 1, 2011 and December 31, 2016, were identified from the Children's Hospital Association's Pediatric Health Information System (PHIS) database. Patients treated with ASMs only or ASMs plus VNS were included in the study and were followed 1 year prior and 2 years after meeting pre‐determined criteria for refractory epilepsy. The difference‐in‐difference (DID) approach along with the two‐part model was used to compare the changes in mean hospital costs captured in the PHIS database over time between the two cohorts.

Results

One thousand one hundred thirteen patients treated with ASMs plus VNS and 3471 patients treated with ASMs only were included. At a follow‐up time of 2 years, for the ASMs‐only cohort, the adjusted all‐cause and epilepsy‐related mean annual total costs increased by $14 715 (95% confidence interval [CI]: $12 375–$17 055) and $18 437 (95% CI: $15 978–$20 896), respectively. By comparison, the adjusted all‐cause and epilepsy‐related mean annual total costs of the ASMs plus VNS cohort increased by $12 838 (95% CI: $8171–$17 505) and $15 183 (95% CI: $10 253–$20 113), respectively. Compared to ASMs only, ASMs plus VNS generated a cost savings of $3254 for epilepsy‐related annual costs per year after the index date.

Significance

Compared to ASMs alone, ASMs plus VNS is a treatment modality associated with lower annual hospital costs over time. Our study shows that VNS is a cost‐beneficial treatment for a national cohort of pediatric patients with refractory epilepsy.

Efficacy and safety of VNS therapy or continued medication management for treatment of adults with drug-resistant epilepsy: systematic review and meta-analysis

Vagus nerve stimulation (VNS) Therapy® is an adjunctive neurostimulation treatment for people with drug-resistant epilepsy (DRE) who are unwilling to undergo resective surgery, have had unsuccessful surgery or are unsuitable for surgery. A systematic review and meta-analysis were conducted to determine the treatment effects of VNS Therapy as an adjunct to anti-seizure medications (ASMs) for the management of adults with DRE. A literature search was performed in August 2020 of the Medline®, Medline® Epub Ahead of Print, Embase, and the Cochrane library databases. Outcomes examined included reduction in seizure frequency, seizure freedom, ASM load, discontinuations, and serious adverse events (SAEs). Comparators included best medical practice, ASMs, low-stimulation or sham VNS Therapy. Four RCTs and six comparative observational studies were identified for inclusion. Against comparators, individuals treated with VNS had a significantly better odds of experiencing a ≥ 50% reduction in seizure frequency (OR: 2.27 [95% CI 1.47, 3.51]; p = 0.0002), a ≥ 75% reduction in seizure frequency (OR: 3.56 [95% CI 1.59, 7.98]; p = 0.002) and a reduced risk for increased ASM load (risk ratio: 0.36 [95% CI 0.21, 0.62]; p = 0.0002). There was no difference in the odds of discontinuation or the rate of SAEs between VNS versus comparators. This meta-analysis demonstrated the benefits of VNS Therapy in people with DRE, which included improvement in seizure frequency without an increase in the rate of SAEs or discontinuations, thereby supporting the consideration of VNS Therapy for people who are not responding to ASMs and those unsuitable or unwilling to undergo surgery.

An economic evaluation of vagus nerve stimulation as an adjunctive treatment to anti-seizure medications for the treatment of drug-resistant epilepsy in England

INTRODUCTION

Anti-seizure medications (ASMs) are commonly used to prevent recurring epileptic seizures, but around a third of people with epilepsy fail to achieve an adequate response. Vagus nerve stimulation (VNS) is clinically recommended for people with drug-resistant epilepsy (DRE) who are not suitable for surgery, but the cost-effectiveness of the intervention has not recently been evaluated. The study objective is to estimate costs and quality-adjusted life-years (QALYs) associated with using VNS as an adjunct to ongoing ASM therapy, compared to the strategy of using only ASMs in the treatment of people with DRE, from an English National Health Service perspective.

METHODS

A cohort state transition model was developed in Microsoft Excel to simulate costs and QALYs of the VNS + ASM and ASM only strategies. Patients could transition between five health states, using a 3-month cycle length. Health states were defined by an expected percentage reduction in seizure frequency, derived from randomized control trial data. Costs included the VNS device as well as its installation, setup, and removal; ASM therapy; adverse events associated with VNS (dyspnea, hoarseness, and cough); and health-state costs associated with epilepsy including hospitalizations, emergency department visits, neurologist visits, and primary care visits. A range of sensitivity analyses, including probabilistic sensitivity analysis, were run to assess the impact of parameter and structural uncertainty.

RESULTS

In the base case, VNS + ASM had an estimated incremental cost-effectiveness ratio (ICER) of £17,771 per QALY gained compared to ASMs alone. The cost-effective ICER was driven by relative reductions in expected seizure frequency and the differences in health care resource use associated therewith. Sensitivity analyses found that the amount of resource use per epilepsy-related health state was a key driver of the cost component.

CONCLUSIONS

VNS is expected to be a cost-effective intervention in the treatment of DRE in the English National Health Service.

Vagus nerve stimulation in patients with therapy-resistant generalized epilepsy

BACKGROUND

For patients with generalized epilepsy who do not respond to antiseizure medications, the therapeutic options are limited. Vagus nerve stimulation (VNS) is a treatment mainly approved for therapy-resistant focal epilepsy. There is limited information on the use of VNS on generalized epilepsies, including Lennox-Gastaut Syndrome (LGS) and genetic generalized epilepsy (GGE).

METHODS

We identified patients with a diagnosis of generalized epilepsy (including LGS and GGE), who underwent VNS implantation at the London Health Sciences Centre and Western University, London, Ontario, since this treatment became available in Canada in 1997 until July 2018. We assessed response to the treatment, including admissions to hospital and complications.

RESULTS

A total of 46 patients were included in this study with a history of therapy-resistant generalized epilepsy. The mean age at implantation was 24 years (interquartile range [IQR] = 17.8-31 years), significantly younger in the LGS group (p = 0.02) and 50% (n = 23) were female. The most common etiologies were GGE in 37% (n = 17) and LGS in 63% (n = 29). Median follow-up since VNS implantation was 63 months (IQR: 31-112.8 months). Of the LGS group 41.7% (n = 12) of patients had an overall seizure reduction of 50% or more, and 64.7% (n = 11) in the GGE group without statistical significance between the groups. The best response in seizure reduction was seen in generalized tonic-clonic seizures, with a significant reduction in the GGE group (p = 0.043). There was a reduction of seizure-related hospital admissions from 91.3% (N = 42) preimplantation, to 43.5% (N = 20) postimplantation (p < 0.05). The frequency of side effects due to the stimulation was almost equal in both groups (62.1% in LGS and 64.7% in GGE).

CONCLUSIONS

Vagus nerve stimulation should be considered as a treatment in patients with therapy-resistant generalized epilepsy, especially in cases with GGE.

Health Technology Assessment Report on Vagus Nerve Stimulation in Drug-Resistant Epilepsy

Background: Vagus nerve stimulation (VNS) is a palliative treatment for medical intractable epileptic syndromes not eligible for resective surgery. Health technology assessment (HTA) represents a modern approach to the analysis of technologies used for healthcare. The purpose of this study is to assess the clinical, organizational, financial, and economic impact of VNS therapy in drug-resistant epilepsies and to establish the congruity between costs incurred and health service reimbursement. Methods: The present study used an HTA approach. It is based on an extensive detailed bibliographic search on databases (Medline, Pubmed, Embase and Cochrane, sites of scientific societies and institutional sites). The HTA study includes the following issues: (a) social impact and costs of the disease; (b) VNS eligibility and clinical results; (c) quality of life (QoL) after VNS therapy; (d) economic impact and productivity regained after VNS; and (e) costs of VNS. Results: Literature data indicate VNS as an effective treatment with a potential positive impact on social aspects and on quality of life. The diagnosis-related group (DRG) financing, both on national and regional levels, does not cover the cost of the medical device. There was an evident insufficient coverage of the DRG compared to the full cost of implanting the device. Conclusions: VNS is a palliative treatment for reducing seizure frequency and intensity. Despite its economic cost, VNS should improve patients’ quality of life and reduce care needs.

Vagus Nerve Stimulation versus Responsive Neurostimulator System in Patients with Temporal Lobe Epilepsy

INTRODUCTION

Patients with medically refractory temporal lobe epilepsy (TLE) are candidates for neuromodulation procedures. While vagus nerve stimulation (VNS) was historically the procedure of choice for this condition, the responsive neurostimulation system (RNS) has come into favor for its more targeted approach. While both VNS and RNS have been reported as efficacious treatments for TLE, the outcomes of these 2 procedures have not been directly compared. This study aims to compare outcomes following VNS versus RNS for TLE.

METHODS

We retrospectively reviewed the records of all patients with TLE who underwent VNS or RNS placement at our institution from 2003 to 2018. The primary outcome was change in seizure frequency. Other outcomes included Engel score, change in anti-epileptic medications, and complications.

RESULTS

Twenty-three patients met inclusion criteria; 11 underwent VNS and 12 underwent RNS. At baseline, the 2 groups were statistically similar regarding age at surgery, epilepsy duration, and preoperative seizure frequency. At last follow-up, both groups displayed reduced seizure frequency (mean reduction of 46.3% for the VNS group and 58.1% for the RNS group, p = 0.49). Responder rate, Engel score, and change in medications were statistically similar between groups. Compared to 0.0% of the VNS group, 13.3% of the RNS group experienced infection requiring re-operation.

CONCLUSION

Despite their different mechanisms, VNS and RNS resulted in similar response rates for patients with TLE. We suggest that VNS should not be excluded as a treatment for patients with medically refractory TLE who are not candidates for resective or ablative procedures.

Vagus nerve stimulation (VNS) therapy update

Epilepsy affects millions of people worldwide. Approximately one-third have pharmacoresistant epilepsy, and of these, the majority are not candidates for epilepsy surgery. Vagus nerve stimulation (VNS) therapy has been an option to treat pharmacoresistant seizures for 30 years. In this update, we will review the clinical data that support the device's efficacy in children, adolescents, and adults. We will also review its side-effect profile, quality of life and cost benefits, and the impact the device has on sudden unexpected death in epilepsy (SUDEP). We will then discuss candidate selection and provide guidance on dosing and future models. Vagus nerve stimulation therapy is an effective treatment for many seizure types and epilepsy syndromes with a predictable and benign side-effect profile that supports its role as the most commonly prescribed device to treat pharmacoresistant epilepsy. "This article is part of the Supplement issue Neurostimulation for Epilepsy."

Changing the neurology policy landscape in the United States: Misconceptions and facts about epilepsy

Epilepsy has a relatively high prevalence, and diagnosis and treatment are often challenging. Seizure freedom without significant side effects is the ultimate goal for both physicians and patients, but not always achievable. In those cases, the treatment goals of patients and providers may differ. In the United States, many clinicians continue to prescribe older AEDs, even though newer AEDs have a more desirable safety and tolerability profile, fewer drug-drug interactions, and are associated with lower epilepsy-related hospital visits. Newer AEDs are more commonly prescribed by neurologists and epilepsy center physicians, highlighting the importance of access to specialty care. We report that antiepileptic drugs are not the dominant cost driver for patients with epilepsy and costs are considerably higher in patients with uncontrolled epilepsy. Poor drug adherence is considered a main cause of unsuccessful epilepsy treatment and is associated with increases in inpatient and emergency department admissions and related costs. Interventions and educational programs are needed to address the reasons for nonadherence. Coverage policies placing a higher cost burden on patients with epilepsy lead to lower treatment adherence, which can result in higher future health care spending. Epilepsy is lagging behind other neurological conditions in terms of funding and treatment innovation. Increased investment in epilepsy research may be particularly beneficial given current funding levels and the high prevalence of epilepsy.

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 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.

Vagus nerve stimulation therapy for treatment-resistant epilepsy: a 15-year experience at a single institution

OBJECTIVE

Treatment-resistant epilepsy (TRE) occurs in 20-30% of patients. The goal of this study is to assess the efficacy and safety of vagus nerve stimulation (VNS) in this group of patients, including adult and pediatric populations and several off-label indications.

METHODS

This is a retrospective review of 59 consecutive patients in whom 60 VNS devices were implanted at a single institution during a 15-year period. Patients were evaluated in the Multidisciplinary Epilepsy Committee and complete presurgical workup was performed. The series included indications not approved by the FDA, such as children under 12 years of age, pregnancy and right-sided VNS. Performing the procedure on an out-patient basis was recently adopted, minimizing hospital length of stay.

RESULTS

There were 42 adults and 17 children (14 under 12 years of age) and the mean age at implantation was 26 years. Duration of VNS therapy ranged from 6 months to 9 years. For the entire cohort, the mean percentage seizure reduction was 31.37%. Twenty patients (34.48%) were considered responders (seizure reduction ≥50%); 7 patients (12.06%) had seizure reduction of ≥75% and 2 patients had seizure control of ≥90% (3.4%). The patient in whom right-sided VNS was implanted achieved the same reduction in seizure burden and the patient who became pregnant could reduce antiepileptic drugs dosage, without complications. Side-effects were mild and there were no permanent nerve injuries. One patient died in the follow-up due to psychiatric disorders previously known.

CONCLUSIONS

VNS is a safe and effective palliative treatment for TRE patients. There are an increasing number of indications and further randomized trials would potentially expand the number of patients who may benefit from it. A multidisciplinary team is crucial for a complete preoperative evaluation and selection of the optimal candidates for the treatment.

Epilepsy: closing the loop for patients with epilepsy

In a long-term clinical trial, a responsive neurostimulation system was shown to reduce seizures and improve quality of life in patients with drug-resistant epilepsy. Furthermore, these effects persisted over an extended time period. Will neurostimulation close the treatment gap for patients with refractory epilepsy?

Quality of Life and Memory after Vagus Nerve Stimulator Implantation for Epilepsy

Objective:

This prospective, case control study evaluates quality of life (QOL), depressive affect, and memory outcomes of epilepsy patients implanted with a vagus nerve stimulator (VNS).

Methods:

Three groups of patients with epilepsy underwent assessment on two occasions: 1) patients with a VNS were tested before and 12 months after implantation (n = 16); 2) patients who underwent cerebral resective surgery were tested pre- and post-operatively (n = 10); and 3) patients under medical management (n = 9). Group means were compared on the QOLIE-89, Geriatric Depression Scale, Wechsler Memory Scale - III, and the Memory Observation Questionnaire. Secondary analyses calculated the reliable change index, providing information on change beyond measurement error and chance.

Results:

Mean ratings of QOL, depression, and memory complaints and objective memory scores remained stable or improved in all the groups. The QOL improved more after cerebral resective surgery than VNS or medication controls, but the VNS and medication control groups did not differ. In the VNS group, QOL was not related to seizure reduction. The percentage of cases showing real change in memory was equivalent across groups, except in one of eight indices (i.e., verbal recognition memory).

Conclusions:

This first case controlled design found that vagus nerve stimulation as an adjunctive therapy for seizure control did not change QOL, depressive affect, or objective memory scores over one-year more so than medical management alone. We point out the need for larger case control, non-industry funded investigations.

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.

A patient-level meta-analysis of studies evaluating vagus nerve stimulation therapy for treatment-resistant depression

Objective

To compare response and remission rates in depressed patients with chronic treatment-resistant depression (TRD) treated with vagus nerve stimulation (VNS) Therapy^® plus treatment as usual (VNS + TAU) or TAU alone in a meta-analysis using Bayesian hierarchical models.

Data sources and study selection

Six outpatient, multicenter, clinical trials that have evaluated VNS + TAU or TAU in TRD, including two single-arm studies of VNS + TAU (n = 60 and n = 74), a randomized study of VNS + TAU versus TAU (n = 235), a randomized study of VNS + TAU comparing different VNS stimulation intensities (n = 331), a nonrandomized registry of VNS + TAU versus TAU (n = 636), and a single-arm study of TAU (n = 124) to provide longer-term, control data for comparison with VNS-treated patients.

Data extraction

A systematic review of individual patient-level data based on the intent-to-treat principle, including all patients who contributed more than one post-baseline visit. Response was based on the Montgomery–Åsberg Depression Rating Scale (MADRS) and the Clinical Global Impressions scale’s Improvement subscale (CGI-I), as these were the two clinician-rated measures common across all or most studies. Remission was based on the MADRS.

Results

Outcomes were compared from baseline up to 96 weeks of treatment with VNS + TAU (n = 1035) versus TAU (n = 425). The MADRS response rate for VNS + TAU at 12, 24, 48, and 96 weeks were 12%, 18%, 28%, and 32% versus 4%, 7%, 12%, and 14% for TAU. The MADRS remission rate for VNS + TAU at 12, 24, 48, and 96 weeks were 3%, 5%, 10%, and 14% versus 1%, 1%, 2%, and 4%, for TAU. Adjunctive VNS Therapy was associated with a greater likelihood of response (odds ratio [OR] = 3.19, 95% confidence interval [CI]: 2.12, 4.66) and remission (OR = 4.99, CI: 2.93, 7.76), compared with TAU. For patients who had responded to VNS + TAU at 24 weeks, sustained response was more likely at 48 weeks (OR = 1.98, CI: 1.34, 3.01) and at 96 weeks (OR = 3.42, CI: 1.78, 7.31). Similar results were observed for CGI-I response.

Conclusion

For patients with chronic TRD, VNS + TAU has greater response and remission rates that are more likely to persist than TAU.

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-effectiveness of adding-on new antiepileptic drugs to conventional regimens in controlling intractable seizures in children

BACKGROUND AND PURPOSE OF THE STUDY

Intractable seizures are a subgroup of epileptic disorders challenging the physicians' skills to become controlled. Showing resistance towards common pharmacotherapy, they demand newer antiepileptic drugs acquired at higher costs. 0.06% of children around the world are estimated to suffer from epilepsy and its consequences. The aim of the present study has been to evaluate the cost-effectiveness of these drugs in the treatment of intractable seizures in children.

METHODS

Clinical and cost data were collected from medical and cost records preserved at a neurologist office and a referral pharmacy respectively. Based on the new AED which are accessible in Iran, regimens were categorized into eight groups. The first group consisting of conventional AEDs was considered as comparator and the effectiveness of other groups was compared with it. Incremental Cost-effectiveness Ratio (ICER) of adding-on each new antiepileptic drug was calculated in terms of Rials per consequence (Rls/consq) and compared with each other. Furthermore ICER of the regimens was compared with the GDP per capita (Gross Domestic Product) of the year (2010).

RESULTS

the ICER of the adding-on regimens range from negative values for Gabapentin, Levetiracetam and Zonisamide to low values for Lamotrigine (~ 6.4 million Rials/consequence [mil Rls/consq]) and Oxcarbazepine (~7.7 mil Rls/consq) and followed by high values for Topiramate (~21 mil Rls/consq) and Vigabatrin (~43.7 mil Rls/consq) considering the three months of remaining on regimen. By increasing the limit of remaining time to six months, the previously mentioned regimens persist on negative values. However Oxcarbazepine (~28.7 mil Rls/consq) and Lamotrigine (~13.8 mil Rls/consq) show a steep increase. Topiramate (~23.6 mil Rls/consq) displays a less change. Opposite to other regimens, the ICER value of Vigabatrin (~17.26 mil Rls/consq) has shown an important increase.

MAJOR CONCLUSIONS

Adding-on new antiepileptics to conventional regimens are cost-effective and justified considering the GDP per capita.

Vagus nerve stimulation for epilepsy: the notre-dame hospital experience

PURPOSE

Retrospective study assessing the efficacy and tolerability of vagus nerve stimulation (VNS) for the treatment of refractory epilepsy at Notre-Dame Hospital.

METHODOLOGY

Chart review of all adult epileptic patients treated by VNS with ≥ 1 year follow-up. Responders were defined as patients with ≥ 50% reduction of baseline seizure frequency.

RESULTS

Thirty-four patients (14M; mean age = 29.9 yrs) received a VNS. Sub-pectoralis implantation (n = 25) was more frequent than subcutaneous (n = 9). Most patients suffered from intractable partial epilepsy. After 6 months, 12 months, 24 months, and 36 months, 14/34 patients (41%), 16/34 patients (47%), 17/30 patients (57%) and 12/20 patients (60%) respectively were responders. Two patients (6%) became seizure-free. Complications related to implantation were minor: eight cases of limited cervical hypoesthesia, two minor scar infections and one Horner syndrome. Adverse events (voice hoarseness, throat paresthesia, coughing) related to stimulation were generally mild and tended to wane over time. However, a reduction in seizure frequency did not translate into a reduction in medication, as only 9% of responders had less antiepileptic medication at last follow-up compared to baseline.

CONCLUSION

VNS as practiced at Notre-Dame hospital is an efficacious and safe treatment for refractory epilepsy. Quotas allotted to epilepsy centers in the province of Quebec should be lifted or increased to allow more patients to benefit from this therapeutic device.

Clinical and economic impact of vagus nerve stimulation therapy in patients with drug-resistant epilepsy

We evaluated long-term medical and economic benefits of vagus nerve stimulation (VNS) therapy in drug-resistant epilepsy. A pre-post analysis was conducted using multistate Medicaid data (January 1997-June 2009). One thousand six hundred fifty-five patients with one or more neurologist visits with epilepsy diagnoses (ICD-9 345.xx, 780.3, or 780.39), one or more procedures for vagus nerve stimulator implantation, one or more antiepileptic drugs (AEDs), and 6 or more months of continuous Medicaid enrollment pre- and post-VNS were selected. The pre-VNS period was 6 months. The post-VNS period extended from implantation to device removal, death, Medicaid disenrollment, or study end (up to 3 years). Incidence rate ratios (IRRs) and cost differences ($2009) were estimated. Mean age was 29.4 years. Hospitalizations decreased post-VNS compared with pre-VNS (adjusted IRR=0.59, P<0.001). Grand mal status events decreased post-VNS compared with pre-VNS (adjusted IRR=0.79, P<0.001). Average total health care costs were lower post-VNS than pre-VNS ($18,550 vs $19,945 quarterly, P<0.001). VNS is associated with decreased resource utilization and epilepsy-related clinical events and net cost savings after 1.5 years.

Neurostimulation: vagus nerve stimulation and beyond

Patients with medically intractable epilepsy who are not candidates for epilepsy surgery could benefit from neurostimulation. At this time, vagus nerve stimulation (VNS) therapy is the only Food and Drug Administation-approved neurostimulation modality; it has been shown to be efficacious and just as well tolerated in children and adolescents as in adults. Notwithstanding the initial cost of the device and implantation, VNS therapy has been shown to be a cost-effective treatment, reducing direct medical costs and improving health-related quality of life measures. Deep brain stimulation of various brain regions, especially the anterior nucleus of the thalamus and responsive neurostimulation, also appear effective but are not yet approved for clinical use. Repetitive transcranial magnetic stimulation, which is also in early clinical development, is promising and could become available in the not too distant future.

Antiepileptic drug monotherapy: the initial approach in epilepsy management

Antiepileptic drug (AED) monotherapy is the preferred initial management approach in epilepsy care, since most patients may be successfully managed with the first or second monotherapy utilized. This article reviews the rationale and evidence supporting preferential use of monotherapy when possible and guidelines for initiating and successfully employing AED monotherapy. Suggested approaches to consider when patients fail monotherapy include substituting a new AED monotherapy, initiating chronic maintenance AED polytherapy, or pursuit of non-pharmacologic treatments such as epilepsy surgery or vagus nerve stimulation. Reducing AED polytherapy to monotherapy frequently reduces the burden of adverse effects and may also improve seizure control. AED monotherapy remains the optimal approach for managing most patients with epilepsy.

Truly "rational" polytherapy: maximizing efficacy and minimizing drug interactions, drug load, and adverse effects

While several newer AEDs have study data that support monotherapy usage, most possess FDA indications for adjunctive treatment of partial onset seizures, leading to their initial (and often persistent) clinical use as adjunctive polytherapy for patients with refractory epilepsy. This review considers a practical approach to the appropriate role for polytherapy in epilepsy, presents the evidence for AED polytherapy, reviews the mythic but practically reasonable concept of "rational polytherapy," and concludes with practical strategies for avoiding and employing polytherapy in clinical practice. The appropriate indications for AED polytherapy include transitional polytherapy during titration of a new adjunctive AED toward monotherapy or long-term maintenance AED polytherapy in medically refractory epilepsy.

Management of vagal nerve stimulator infections: do they need to be removed?

OBJECT

Vagal nerve stimulators (VNSs) have been used successfully to treat medically refractory epilepsy. Although their efficacy is well established, appropriate management of infections is less clearly defined. In the authors' experience, patients who have gained a benefit from VNS implantation have been reluctant to have the device removed. The authors therefore sought conservative management options to salvage infected VNS systems.

METHODS

The authors performed a retrospective review of 191 (93 female and 98 male) consecutive patients in whom VNS systems were placed between 2000 and 2007.

RESULTS

They identified 10 infections (5.2%). In 9 of 10 patients the cultured organism was Staphylococcus aureus. Three (30%) of 10 patients underwent early removal (within 1 month) of the VNS as the initial treatment. The remaining 7 patients were initially treated with antibiotics. Two (28.6%) of these patients were successfully treated using antibiotics without VNS removal. Patients in whom conservative treatment failed were given cephalexin as first-line antibiotic treatment. All patients recovered completely regardless of treatment regimen.

CONCLUSIONS

This study confirms the low rate of infection associated with VNS placement and suggests that, in the case of infection, treatment without removal is a viable option. However, the authors' data suggest that oral antibiotics are not the best first-line therapy.

Estimating the potential savings with vagus nerve stimulation for treatment-resistant depression: a payer perspective

OBJECTIVE

To provide a formula estimating potential reductions in healthcare utilization costs with adjunctive vagus nerve stimulation (VNS Therapy) in treatment-resistant depression (TRD).

METHODS

This payer-perspective formula incorporates costs of treatment as usual for TRD patients from a published analysis of the MarketScan private payer claims database and the 2004 Medicare 5% standard analytic file. Estimated remission and response rates are from the published VNS pilot and pivotal studies. Costs were converted to 2008 US dollars per the US Bureau of Labor Statistics medical care costs, consumer price index. Device and implantation costs were calculated at $28,336.

RESULTS

From the MarketScan and pooled outcomes data (VNS pilot and pivotal studies), potential per patient savings (hospitalization directly and indirectly related to depression) was $2974 at 5 years of device life, $23,539 at 8 years (moderate cost reduction scenario); $12,914 at 5 years, $40,935 at 8 years (optimistic scenario). Corresponding break-even device life was 4.57 and 3.62 years, respectively. From the Medicare file and pooled outcomes, potential per patient savings (inpatient and outpatient directly and indirectly related to depression) was $8358 at 5 years of device life, $32,385 at 8 years (moderate scenario); $19,837 at 5 years, $52,473 at 8 years (optimistic scenario). Corresponding break-even device life was 3.96 and 3.18 years, respectively.

CONCLUSIONS

The formula allows an evaluation of expected reductions in healthcare costs as a function of input cost variables, efficacy rates, and benefit scenarios. Cited costs differ relative to care settings, diagnostic principles, and procedural volume. This formula can help assess moderate-to-longer-term economic benefits of VNS for a particular institution. Results suggested that potential reductions in healthcare costs with VNS for TRD may be substantial. Break-even device life for the scenarios presented ranges between 2.3 and 5.7 years.

Vagus nerve stimulation therapy for pharmacoresistant epilepsy: effect on health care utilization

We retrospectively analyzed the effects of vagus nerve stimulation (VNS) therapy on utilization of medical services by 138 patients in a large staff-model health maintenance organization. We compared average quarterly rates for 12 months before device implantation with quarterly rates during 48 months of follow-up. Wilcoxon matched-pairs signed-ranks tests comparing pre-VNS with post-VNS utilization rates showed statistically significant reductions in numbers of emergency department visits, hospitalizations, and hospital lengths of stay, beginning with the first quarter after implantation (P<0.05 for all post-implantation quarters for these three aspects). For the first two quarters after implantation, the average number of outpatient visits was significantly greater than the pre-implant quarterly average (quarter 1: P<0.0001; quarter 2: P=0.0067), but the average was 12.2% less by the fourth quarter of the first year after implantation and significantly less beginning with the first quarter of the second year (P=0.0017) and continuing through the end of the study (P<0.0001 for all subsequent quarters). A comparison of time spent on epilepsy-related tasks during the year before implantation with the year after implantation also revealed significant decreases in the average number of days on which patients could not work because of health-related concerns, from 3.67 to 1.04 days (P=0.002, paired Student's t test) and the average time spent caring for health problems, from 352.6 to 136.1 minutes per week (P<0.001). VNS therapy had a positive effect on both the utilization of health care services and the time spent on epilepsy-related tasks for these patients with pharmacoresistant epilepsy.

Opinion of Belgian neurologists on antiepileptic drugs: Belgian Study on Epilepsy Treatment (BESET)

OBJECTIVES

To describe the choice of treatment in adult patients with epilepsy in Belgium, to detect the presence or absence of consensus among neurologists in epilepsy treatment, and to analyze the gaps between current guidelines and prescriptions.

MATERIALS AND METHODS

Hundred Belgian neurologists were systematically interviewed between May and June 2003 using a structured questionnaire (modified Rand method).

RESULTS

Initial monotherapy was the preferred treatment strategy. Valproate was the first choice in idiopathic generalized epilepsy (IGE) and carbamazepine in focal epilepsy (FE). The new antiepileptic drugs (AED) were usually recommended in second-line. However, in special treatment situations, they were considered first-line, e.g., lamotrigine in case of women of childbearing age.

CONCLUSIONS

Neurologists reached consensus for most questions on epilepsy treatment. In 2003, monotherapy with valproate and carbamazepine was the common treatment strategy in Belgium, whereas lamotrigine and to a lesser extent levetiracetam, topiramate, and oxcarbazepine were predominantly prescribed in second-line. This is in agreement with the recently published UK epilepsy guidelines but not in agreement, however, with the US guidelines, that for new onset epilepsy, new and old drugs are equally effective. Belgian neurologists, except for some special situations still prefer old drugs as first line.

Direct and Indirect Costs of Refractory Epilepsy in a Tertiary Epilepsy Center in Germany

PURPOSE

There are only few studies on the costs of epilepsy in Germany. Therefore, we performed a pilot study to estimate the direct and indirect costs of refractory epilepsy in a German epilepsy center.

METHODS

A "prevalence-based," cross-sectional convenience sample of adults with active epilepsy attending the outpatient clinic of our tertiary epilepsy center was evaluated. Seizure-free patients and patients presenting with their first seizure were excluded. Direct and indirect costs were prospectively recorded over a three-month period using questionnaires and a patient diary. Cost driving factors were identified.

RESULTS

One hundred one patients were included (40.7+/-15.2 years; disease duration: 18.1+/-15.3 years; 6 patients had focal epilepsy with simple partial seizures only, 28 with complex partial seizures, 43 with secondarily generalized tonic-clonic seizures; 20 had idiopathic generalized epilepsy with generalized tonic-clonic seizures). The total costs of epilepsy per patient were in average euro 2610+/-4200 over the three-month period. Direct cost contributed 39% to the total costs. Costs of anticonvulsant medication were the main contributor to the direct costs while indirect costs were caused mainly by losses due to early retirement. Cost driving factors included higher seizure frequency, longer disease duration, ictal falls, and situationally inappropriate complex behavior during or after the seizure.

CONCLUSIONS

Indirect costs were higher than direct costs in adult patients with active epilepsy attending a German epilepsy center. Medication contributed the most to the direct costs and early retirement was the main factor for the indirect costs. The costs of poorly controlled epilepsy in this German study were above average of the European costs of epilepsy.

Vagal nerve stimulation for refractory epilepsy in children: indications and experience at The Hospital for Sick Children

OBJECTIVES

The management of intractable epilepsy in children is a challenging problem. For those patients who do not respond to antiepileptic drugs and are not candidates for epilepsy surgery, vagal nerve stimulation (VNS), can be a viable alternative for reducing seizure frequency. We have reviewed the historical and clinical background of VNS treatment. We also include our experience at The Hospital for Sick Children in children who underwent VNS implantation.

METHODS

Forty-one children underwent VNS implantation for epilepsy over 6 years. After a mean follow-up of 31 months, 15 (38%) patients had a seizure frequency reduction of more than 90%. Fifteen (38%) children failed to respond to the VNS treatment. The device was removed in five children: in one, due to late infection; the other four could not tolerate the side effects of chronic VNS therapy. Two patients required reimplantation due to electrode failure. The most common side effects in our series were cough and vocal disturbances.

CONCLUSIONS

Our results show that VNS implantation can be a safe and effective alternative therapy for children with drug-resistant epilepsy who are not candidates for epilepsy surgery.

La stimulation du nerf vague dans le traitement de l’épilepsie

INTRODUCTION

Vagus nerve stimulation (VNS) is a non-pharmacological treatment for drug resistant epilepsy.

STATE OF ART

The good efficacy and tolerability of this device is now well established after several controlled studies, and more than 17000 people operated on in different countries. The physiology of VNS is not yet well known, and the potential mechanisms of action are reviewed. VNS seems to be as efficient as a new medication without some of the disadvantages (in case of pregnancy for example). SNV may have a beneficial effect for all kinds of drug-resistant epilepsy.

PERSPECTIVES

Better knowledge of the underlying anti-epileptic mechanisms may help to select the better responders to this expensive anti-epileptic tool.

Prescribing antiepileptic drugs: should patients be switched on the basis of cost?

To assess the costs of switching from one antiepileptic drug (AED) to another, all associated direct and indirect costs, not only drug acquisition costs, must be considered. The perspective of the healthcare system evaluated in cost-effectiveness analysis is of crucial importance. Multiple clinical factors can influence clinical decisions regarding switching AEDs. The economic cost of poorly controlled epilepsy is enormous and the most cost-effective intervention is an AED that provides total seizure control. Cost-minimisation studies have evaluated costs associated with various medications. If only efficacy and adverse events were considered, then the 'older' AEDs were generally more cost effective than the 'newer' AEDs. Most studies only examine very specific clinical situations and are not suitable for establishing general clinical recommendations. The pharmacoeconomics of AED choice is highly country specific. While switching to generic formulations is, in general, cost effective, some changes may be detrimental and more costly than remaining on the trade name preparation. For example, as a result of differences in bioavailability and possible loss of seizure control, changing patients to generic phenytoin and carbamazepine can be problematic. Fosphenytoin may only be cost effective in certain clinical situations compared with intravenous phenytoin. Seizure control should not be sacrificed on the basis of costs alone, as the major endpoint in treating epilepsy with AEDs is seizure control without adverse effects. Switching AEDs in clinical practice still depends on the individual clinical situation and choosing AED therapy solely on the basis of initial acquisition costs is unlikely to be cost effective in the long-term care of patients with epilepsy.

Clinical outcome of epilepsy surgery

PURPOSE OF REVIEW

The outcome from current surgical methods of treating drug-resistant epilepsy will be considered, looking at changes in classical resective surgery and new methodology being introduced in the functional treatment of these patients.

RECENT FINDINGS

There is now class I evidence that temporal lobe surgery is effective. Sophisticated and appropriate magnetic resonance imaging sequences, together with an assessment of the electroclinical syndrome, allow patients to be assessed for resective surgery. The concept of 'surgically remediable syndromes' determines the type of procedure that is effective for particular patients. Technical advances such as neuronavigation techniques and intra-operative magnetic resonance imaging have improved the effectiveness of these procedures. Other techniques of disconnection, such as multiple subpial transection, and stimulation both indirectly using the vagus nerve and directly using various intracranial targets, are currently effective and have potential for future development.

SUMMARY

This review will demonstrate that current surgical techniques are safe and effective in relieving drug-resistant epilepsy.

Lessons for neuropsychology from functional MRI in patients with epilepsy

This contribution aims to review the major findings of pre- and postsurgical functional magnetic resonance imaging (fMRI) in patients with refractory epilepsy from a neuropsychological perspective. We compared the contribution of fMRI with the intracarotid amytal procedure (IAP) with respect to functional mapping of language and memory in patients with therapy-resistant epilepsy. We conclude that using comprehensive language paradigms, fMRI has been able (1) to provide estimates of the degree of language lateralization including the degree of involvement of the nondominant hemisphere, (2) to provide information on the location of its activated network during expressive and receptive language, and (3) to help delineate eloquent language regions in the vicinity of the surgical target, thus preventing postoperative complications. The contribution of the frequently observed nondominant hemisphere activation to language should be explored and its clinical relevance determined. Evidence from fMRI studies is accumulating that reorganization of cognitive and motor function favors the activation of contralateral homotopic areas, although this process is far from understood. The exact functional contribution of atypical areas of activation should be investigated critically. In the presurgical evaluation process, detailed and reliable localization of language and memory functions of the individual patient is mandatory and should be the ultimate goal in the development of comprehensive clinical fMRI protocols.