Patients with refractory temporal lobe epilepsy may be more inclined to opt for surgery when they understand the long-term cost effectiveness, as well as rates of increased seizure freedom and reduced seizure relapses.
Lara Jehi, MD
A study evaluating the cost of epilepsy surgery and surgical evaluation suggests that both the procedure and referral are cost-effective for eligible patients with drug-resistant temporal lobe epilepsy (DR-TLE).
Using a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon, investigators found that epilepsy surgery is cost effective compared to medical management in surgically eligible patients by virtue of being cost saving ($328,000 vs $423,000) and more effective (16.6 Quality Adjusted Life Year [QALY] vs. 13.6 QALY) than management in the long run. A single QALY represented a year of life in perfect health in the study.
The surgical evaluation for patients with DR-TLE remains cost-effective even if the probability of being deemed a surgical candidate as low as about 5%. Healthcare perspective costs showed that referral for surgery evaluation is estimated at $423,000 compared to $408,000 for those who continue medical management.
“What our study showed is that as long as a patient has drug-resistant epilepsy, they need to be referred for a surgical evaluation because it is cheaper to put them through testing and then figure out if they’re surgical candidates than it is to waste 10 to 20 years cycling through ineffective medication,” senior author Lara Jehi, MD, chief research officer, and epilepsy specialist, Cleveland Clinic, told NeurologyLive.
Jehi and colleagues measured how the incremental cost effectiveness ratio (ICER) changes over time for both models. For patients who are surgically eligible, surgery becomes cost effective within 3 to 4 years, dependent on societal or health care perspective. Additionally, for patients diagnosed with DR-TLE, referral for surgical evaluation becomes a cost-effective strategy for the cohort within 5 to 7 years.
Literature from previous studies factored into this assessment showed that seizure freedom was 71% probable in those who opted for surgery compared to 8% of those who continued medical management. Seizure relapse occurred in 25% of those on medical management compared to 5.6% between years 1—5 for those following surgery.
Jehi added, “There are a lot of fears out there. Some are justified but a lot are due to misinformation that may stop someone from even getting a referral. The biggest misconception though is that epilepsy surgery is riskier than the status quo.”
Cost-effectiveness was defined as meeting 1 of the following criteria: the strategy was more effective than the alternative and also reduced costs, or the strategy was more effective than the alternative, at a higher cost deemed “reasonable.”
Jehi and colleagues based their analysis off of existing literature concerning adult DR-TLE patients, as well as pooled estimates from multiple component studies with heterogeneity in the patient characteristics.
The primary analysis in Model 1 of the Markov decision-analytic model aimed to determine whether surgery was cost-effective compared to continued medical management in patients who had been deemed surgical candidates, while Model 2 aimed to determine whether it was cost-effective to evaluate patients with DR-TLE for surgery.
Aside from the outcome of electing surgery or continued medical management, the model factored in additional courses of treatment for patients. For patients who opt for surgery those included having either permanent major, peri-operative death, or no major complication. Those patients were then categorized as either free or not free of consciousness impairing seizures for a series of 1-year cycles till death.
Jehi and colleagues factored in clinical parameters, mortality tables, preference-based utility (quality of life) scores, healthcare costs, drug costs, and societal costs into the study. Analysis of drug costs of the medical regimens showed a significantly right-skewed distribution with a mean value of $21,772 per year and standard deviation (SD) of $19,144.
One-way sensitivity analysis that included all variables in the model revealed that surgery would not be cost-effective if the true probability of initial seizure freedom after surgery was less than 21%, true probability of relapse after initial surgical success was greater than 27%, patients age was greater than 97 years, cost of surgery was greater than 5 times the investigators estimated cost, or the true proportion of patients who were found eligible for surgery after initial referral was less than 5%.
“At the end of the day, I want to demystify everything behind epilepsy surgery. I want to tell patients and providers that if they’re going to take anything away from this study, it’s that a commitment to look into epilepsy surgery is not a commitment to get it done,” Jehi said.
Sheikh SR, Kattan MW, Steinmetz M, Singer ME, Udeh BL, Jehi L. Cost effectiveness of surgery for drug resistant temporal lobe epilepsy in the US. Neurology. Published online July 8, 2020. doi: 10/1212/WNL.0000000000010185