King J T, Sperling M R, Justice A C, O'Connor M J
Department of Veterans Affairs Medical Center, Department of Neurosurgery, Case Western Reserve University and University Hospitals, Cleveland, Ohio 44106, USA.
J Neurosurg. 1997 Jul;87(1):20-8. doi: 10.3171/jns.1997.87.1.0020.
Patients with medically intractable temporal lobe epilepsy are potential candidates for anterior temporal lobectomy (ATL), in which epileptogenic temporal lobe tissue is localized and surgically removed. This surgical approach can eliminate or drastically reduce seizures in the majority of patients. The authors used a decision-analysis model to examine the cost-effectiveness of a surgical evaluation and treatment protocol for medically intractable temporal lobe epilepsy. This model compared a cohort treated with the new protocol with a continuation of their immediate preoperative medical management and projected these differences over the patient's lifetime. The Markov model incorporated postoperative seizure status, patient quality of life, death from surgical and natural causes, discounting, and the direct medical costs associated with outpatient evaluation, hospitalization, surgery, antiepileptic drugs, and lifetime outpatient treatment. The intent-to-treat analysis included patients who underwent evaluation but were not eligible for ATL. Sensitivity analyses were also performed on the variables in the model. Data from the baseline model indicated that evaluation for ATL provided an average of 1.1 additional quality-adjusted life years (QALYs) compared with continued medical management, at an additional cost of $29,800. Combining the clinical and economic outcomes yielded a cost-effectiveness ratio of $27,200 per QALY. This value is comparable to other accepted medical or surgical interventions, such as total knee arthroplasty ($16,700/QALY) or coronary artery balloon angioplasty ($40,800/QALY). Sensitivity analyses demonstrate that the results are critically dependent on postoperative seizure status and improvement in quality of life. Although further work is necessary to quantify the improvement in quality of life after epilepsy surgery better, the present data indicate that ATL for treatment of intractable temporal lobe epilepsy is a cost-effective use of medical resources.
药物治疗难以控制的颞叶癫痫患者是前颞叶切除术（ATL）的潜在候选者，在该手术中，致痫性颞叶组织被定位并通过手术切除。这种手术方法可以消除或大幅减少大多数患者的癫痫发作。作者使用决策分析模型来检验药物治疗难以控制的颞叶癫痫的手术评估和治疗方案的成本效益。该模型将接受新方案治疗的队列与继续术前即时药物治疗的队列进行比较，并预测患者一生中的这些差异。马尔可夫模型纳入了术后癫痫发作状态、患者生活质量、手术和自然原因导致的死亡、贴现以及与门诊评估、住院、手术、抗癫痫药物和终身门诊治疗相关的直接医疗费用。意向性治疗分析包括接受评估但不符合ATL条件的患者。还对模型中的变量进行了敏感性分析。基线模型的数据表明，与继续药物治疗相比，ATL评估平均可增加1.1个质量调整生命年（QALY），额外成本为29,800美元。综合临床和经济结果得出的成本效益比为每QALY 27,200美元。该值与其他公认的医疗或手术干预措施相当，如全膝关节置换术（16,700美元/QALY）或冠状动脉球囊血管成形术（40,800美元/QALY）。敏感性分析表明，结果严重依赖于术后癫痫发作状态和生活质量的改善。尽管需要进一步开展工作以更好地量化癫痫手术后生活质量的改善情况，但目前的数据表明，ATL治疗难治性颞叶癫痫是一种具有成本效益的医疗资源利用方式。
