From the The Royal Melbourne Hospital (N.N.K., T.J.O.B., P.K.), Parkville; Department of Neuroscience (E.F., T.J.O.B., P.K., Z.C., Z.A.), Central Clinical School, Monash University, Melbourne; Department of Neurology (E.F., T.J.O.B., P.K., Z.C.), Alfred Health, Melbourne; School of Public Health and Preventive Medicine (C.M., P.K., Z.C., Z.A.), Monash University, Melbourne; Centre for Medicine Use and Safety (C.M., Z.A.), Monash University, Parkville; Faculty of Medicine, Nursing and Health Sciences (A.T., S.S.T.P.), Monash University, Clayton; Department of Medicine (T.J.O.B., P.K., G.D.J., Z.C.), The University of Melbourne, Parkville; Monash Institute of Medical Engineering (P.K.), Monash University, Clayton; Florey Institute of Neuroscience and Mental Health (G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia.
Neurology. 2023 May 2;100(18):e1866-e1877. doi: 10.1212/WNL.0000000000207137. Epub 2023 Mar 16.
Surgical and neurostimulator treatments are effective for reducing seizure burden in selected individuals living with drug-resistant epilepsy (DRE). We aimed to determine the presence and key model determinants for cost-effectiveness of these interventions, compared with medical management alone, to assist with decisions about resource allocation.
A systematic literature search was conducted on June 1, 2022, using MEDLINE, EMBASE, the NHS Economic Evaluation Database, and the Cost-Effectiveness Analysis database. Included studies were economic evaluations in adult DRE cohorts, comparing surgical and neurostimulator treatments (vagus nerve stimulation [VNS], responsive neurostimulation [RNS], and deep brain stimulation [DBS]) vs medical management alone and reporting cost-benefit analysis, cost-utility, or cost-effectiveness. Exclusion criteria were studies with pediatric cohorts and those published in a language other than English. Three independent reviewers screened, extracted, and assessed data against the Consolidated Health Economic Evaluation Reporting Standards checklist, and a fourth reviewer adjudicated discrepancies.
Ten studies met inclusion criteria. Seven studies evaluated epilepsy surgery, and 3 evaluated neurostimulation treatments. All relevant studies established that epilepsy surgery is a cost-effective intervention compared with medical management alone, for quality-adjusted life-years and seizure freedom at 2 and 5 years. All relevant studies found neurostimulator treatments to be potentially cost-effective. The incremental cost-effectiveness ratio (ICER), with lower ICER indicating greater cost-effectiveness, was reported for 9 studies and varied between GBP £3,013 and US $61,333. Cost adaptation revealed ICERs from US $170 to US $121,726. Key model determinants included, but were not limited to, improved surgical outcomes and quality of life, reduced surgical and presurgical evaluation costs, higher rates of surgical eligibility after referral and evaluation, epilepsy subtype, less expensive neurostimulator devices with improved longevity, and cost analysis strategy used in the analysis.
There is consistent evidence that epilepsy surgery is a cost-effective treatment of 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.
PROSPERO CRD42021278436.
对于药物难治性癫痫（DRE）患者，手术和神经刺激治疗可有效降低癫痫发作频率。本研究旨在确定与单纯药物治疗相比，这些干预措施的存在及其关键模型决定因素是否具有成本效益，以辅助资源配置决策。
2022 年 6 月 1 日，通过 MEDLINE、EMBASE、NHS 经济评估数据库和成本效益分析数据库进行了系统文献检索。纳入的研究为成年 DRE 队列的经济学评价，比较手术和神经刺激治疗（迷走神经刺激[VNS]、反应性神经刺激[RNS]和深部脑刺激[DBS]）与单纯药物治疗的成本效益分析、成本效用或成本效果。排除标准为儿科队列研究和非英语发表的研究。三位独立的审稿人根据合并健康经济评估报告标准清单筛选、提取和评估数据，第四位审稿人解决了差异。
符合纳入标准的研究有 10 项。7 项研究评估了癫痫手术，3 项研究评估了神经刺激治疗。所有相关研究均表明，与单纯药物治疗相比，癫痫手术是一种具有成本效益的干预措施，可提高 2 年和 5 年时的生活质量调整生命年和癫痫无发作率。所有相关研究均发现神经刺激治疗具有潜在的成本效益。9 项研究报告了增量成本效益比（ICER），ICER 越低表示成本效益越高，范围为 GBP £3013 至 US $61,333。成本适应性分析显示，ICER 从 US $170 至 US $121,726。关键模型决定因素包括但不限于手术结果和生活质量的改善、手术和术前评估成本的降低、转诊和评估后手术合格率的提高、癫痫亚型、寿命更长、价格更低的神经刺激设备以及分析中使用的成本分析策略。
有明确的证据表明，癫痫手术是治疗符合条件的 DRE 患者的一种具有成本效益的治疗方法。有限的证据表明，VNS、RNS 和 DBS 可能是 DRE 的具有成本效益的治疗方法，但需要更多的前瞻性临床试验和健康经济学评估来验证这些发现。
PROSPERO CRD42021278436。
