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U.S. patients with drug-resistant temporal lobe epilepsy (DR-TLE) should be referred for evaluation for epilepsy surgery “without hesitation,” concludes a new model-based analysis of surgery cost effectiveness from Cleveland Clinic researchers.
The study, published in Neurology, revealed two main findings:
- TLE surgery is cost-effective relative to continued medical management in the U.S. among adult patients who are determined to be surgical candidates.
- Surgical evaluation is cost-effective in patients with DR-TLE in the U.S. even if a patient’s probability of being deemed a surgical candidate is as low as five percent.
“The clinical effectiveness of epilepsy surgery for well-selected patients with pharmacoresistant temporal lobe epilepsy has been well established, but surgery remains an underutilized treatment option, in part because it is viewed as costly,” said the study’s senior investigator, Lara Jehi, MD, Cleveland Clinic’s chief research information officer and research director for the Epilepsy Center.
“We have demonstrated, however, that compared with continued medical management, epilepsy surgery is actually cost-saving in the long run for patients already determined to be good surgical candidates. We also found that, at a population level, even when a patient with DR-TLE is not known to qualify for epilepsy surgery, referral for a surgical evaluation to assess the patient’s surgical candidacy remains the most cost effective management option.”
The study was performed using a Markov decision-analytic model, where the primary analysis assessed whether surgery was cost effective relative to continued medical management in adults with DR-TLE deemed to be surgical candidates and the secondary analysis assessed the cost-effectiveness of evaluation for epilepsy surgery among adults diagnosed with DR-TLE. Each analysis was done using a lifetime horizon.
Both healthcare and societal perspectives were used, with the former including direct healthcare costs, such as the cost of surgery and anti-epileptic drugs, and the latter including direct costs plus indirect costs, like lost earnings. Cost-effectiveness was evaluated by determining whether the strategy of interest (surgery or surgical evaluation) was more effective and less costly than the alternative or if it was more effective but more costly.
The analyses were based on data from Cleveland Clinic and from a meta-analysis of published literature involving patients with DR-TLE, where drug resistance was defined as having continued seizures despite adequate trials of at least two appropriately chosen anti-epileptic drugs. “Parameter estimates were derived from pooled estimates from multiple component studies,” explained Michael Kattan, PhD, chair of Lerner Research Institute’s Department of Quantitative Health Sciences and co-author on the study. Costs were adjusted to 2019 U.S. dollar equivalents.
Main takeaways for clinicians
While conceding that their study carries the limitations of any cost-effectiveness analysis using pooled data and multiple assumptions, the researchers note that it is a much-needed assessment of a pressing research question. The study is the first cost-effectiveness analysis of epilepsy surgery in the U.S. in more than two decades, and the applicability of analyses from other nations is highly limited by dramatic differences in these nations’ healthcare cost structures.
“In contrast to traditional reluctance to refer patients for surgical evaluation due to concern over up-front costs, our findings suggest that a referral-based strategy is actually the cost-effective approach for patients with drug-resistant temporal lobe epilepsy, said Dr. Jehi. “The cost of surgical evaluation is absolutely reasonable, even in patients with a low likelihood of being deemed a surgical candidate. In patients who have a high chance of surgical eligibility, evaluation is likely to be cost-saving.”
Dr. Kattan, an expert in personalized medical risk prediction models, noted that a key next step for research in this area is to develop cost-effectiveness prediction models that can be customized to individual patient profiles.
“In the meantime, our findings strengthen the growing case for widespread consideration of surgery for patients with medically refractory temporal lobe epilepsy. The up-front cost of surgical evaluation is undeniably smaller than the price ultimately paid by patients, society and our healthcare system with an unchallenged strategy restricted to medications alone,” said Dr. Jehi.
Article adapted from Consult QD.