Surgery is a cost-effective treatment for drug-resistant epilepsy, with limited evidence suggesting that VNS, RNS, and DBS are too.

In patients with drug-resistant epilepsy (DRE) considered surgically eligible, epilepsy surgery is shown to be a more cost-effective treatment than standard medical management. These are the findings of a systematic review published in Neurology.

Patients with DRE experience “continued seizures despite adequate trials of two or more antiseizure medications.” The early use of effective treatment strategies is critical in this population since DRE is associated with much of the epilepsy-related burden worldwide. Although the use of epilepsy surgery has demonstrated superiority to medical therapy alone in certain groups with DRE, epilepsy surgical procedures remain underutilized.

For the study, researchers sought to establish the presence of and key model determinants of the cost-effectiveness of surgical and neurostimulator treatments for patients with DRE, compared with medical management alone, in an effort to help channel resource allocation.

Researchers conducted a literature search of relevant studies published in international peer-reviewed journals and included studies based on the following criteria: a target population comprised adults ≥18 years of age with DRE; intervention of interest was epilepsy surgery, vagus nerve stimulation (VNS), deep brain stimulation (DBS), or responsive neurostimulation (RNS); and comparator of interest was continued use of antiseizure medication.

There is consistent evidence that epilepsy surgery is a cost-effective treatment for eligible candidates with DRE.

Primary outcomes evaluated included health care costs, quality-adjusted life-years (QALYs), years of life lived (YOLLs), and years of life saved (YOLS).

Researchers used the incremental cost-effectiveness ratio (ICER) to compare the primary outcomes. A lower ICER was indicative of greater cost-effectiveness.

A total of 10 studies fulfilled the eligibility criteria, 7 of which assessed epilepsy surgery and 3 of which evaluated neurostimulation therapies. Of the 10 studies, 8 reported on cost-utility analyses with QALY as the outcome, whereas 2 were cost-effectiveness evaluations in which seizure freedom was the outcome. In all 10 studies, standard medical management with antiseizure medications alone was the comparator.

Researchers found that in all 7 studies in which epilepsy surgery was evaluated, it was reported to be a cost-effective intervention, with 3 of the studies implying it to be a dominant strategy. In 2 studies, VNS was shown to be either cost-effective or potentially cost-effective, 1 study demonstrated that DBS was potentially cost-effective, and 1 study showed that RNS “very likely falls within the range of cost-effectiveness.”

To determine the confidence of their conclusions, the researchers performed sensitivity analyses. According to the base case probabilistic sensitivity analysis, the probability of the results being cost-effective were from 84.0% to 99.7% for epilepsy surgery and from 1.0% to 99.7% for neurostimulator treatments.

Researchers found that epilepsy surgery is a cost-effective intervention compared with medical management alone, in terms of QALYs, as well as 2-year and 5-year freedom from seizures. ICER, which was reported for 9 of the 10 studies, varied between GBP £3013 and US $61,133. Based on cost adaptation, ICERs ranged from US $170 to US $121,726.

Study limitations included the lack of restrictions put in place on publication data. Further, only English publications were included in the current analysis. Additionally, there are few randomized, controlled trials on epilepsy surgery available in the literature.

Researchers concluded that “There is consistent evidence that epilepsy surgery is a cost-effective treatment for eligible candidates with DRE. Limited evidence suggests that VNS, RNS, and DBS may be cost-effective therapies for DRE, although more health economic evaluations alongside prospective clinical trials are needed to validate these findings.”