From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (S.R.S.); Department of Quantitative Health Sciences (M.W.K., B.L.U.), Department of Neurological Surgery (M.S.), and Epilepsy Center (L.J.), Cleveland Clinic; and Department of Population and Quantitative Health Sciences (M.E.S.), Case Western Reserve University, Cleveland, OH.
Neurology. 2020 Sep 8;95(10):e1404-e1416. doi: 10.1212/WNL.0000000000010185. Epub 2020 Jul 8.
Surgery is an effective but costly treatment for many patients with drug-resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, surgery is cost-effective compared to medical management for patients deemed surgical candidates and whether surgical evaluation is cost-effective for patients with DR-TLE in general.
We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use second-order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both health care and societal perspectives, including direct health care costs (e.g., surgery, antiepileptic drugs) and indirect costs (e.g., lost earnings by patients and care providers.) We compare the incremental cost-effectiveness ratio to societal willingness to pay (∼$100,000 per quality-adjusted life-year [QALY]) to determine whether surgery is cost-effective.
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 vs 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in patients with DR-TLE even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost-effective within 3 years, and 89% of simulations favor surgery over the lifetime horizon.
For surgically eligible patients with DR-TLE, surgery is cost-effective. For patients with DR-TLE in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. Patients with DR-TLE should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.
手术是许多耐药性颞叶癫痫（DR-TLE）患者的有效但昂贵的治疗方法。我们旨在评估在美国，对于被认为是手术候选者的患者，手术是否比药物治疗更具成本效益，以及对于一般的 DR-TLE 患者，手术评估是否具有成本效益。
我们使用半马尔可夫模型来评估手术和手术评估在终身范围内的成本效益。我们使用二阶蒙特卡罗模拟进行概率敏感性分析，以估计模型输出的变化。我们采用医疗保健和社会观点，包括直接医疗保健成本（例如手术、抗癫痫药物）和间接成本（例如患者和护理人员的收入损失）。我们将增量成本效益比与社会愿意支付的价格（约每质量调整生命年 10 万美元[QALY]）进行比较，以确定手术是否具有成本效益。
由于在长期内具有成本节约（32.8 万美元对 42.3 万美元）和更有效的效果（16.6 对 13.6 QALY），手术相对于药物治疗在有手术资格的患者中具有成本效益。在 DR-TLE 患者中，即使被认为是手术候选者的概率仅为 5%，手术评估也具有成本效益。从社会角度来看，手术在 3 年内具有成本效益，89%的模拟结果支持在整个生命周期内进行手术。
对于有手术资格的 DR-TLE 患者，手术具有成本效益。对于一般的 DR-TLE 患者，手术评估（和可能随后的手术）具有成本效益。基于成本效益，DR-TLE 患者应毫不犹豫地接受手术评估。
