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September 08, 2020; 95 (10) Article

Cost-effectiveness of surgery for drug-resistant temporal lobe epilepsy in the US

Shehryar R. Sheikh, View ORCID ProfileMichael W. Kattan, Michael Steinmetz, Mendel E. Singer, Belinda L. Udeh, Lara Jehi
First published July 8, 2020, DOI: https://doi.org/10.1212/WNL.0000000000010185
Shehryar R. Sheikh
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.
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Michael W. Kattan
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.
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  • ORCID record for Michael W. Kattan
Michael Steinmetz
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.
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Mendel E. Singer
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.
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Belinda L. Udeh
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.
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Lara Jehi
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.
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Cost-effectiveness of surgery for drug-resistant temporal lobe epilepsy in the US
Shehryar R. Sheikh, Michael W. Kattan, Michael Steinmetz, Mendel E. Singer, Belinda L. Udeh, Lara Jehi
Neurology Sep 2020, 95 (10) e1404-e1416; DOI: 10.1212/WNL.0000000000010185

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Abstract

Objective 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.

Methods 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.

Results 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.

Conclusion 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.

Glossary

ASM=
antiseizure medications;
DR-TLE=
drug-resistant temporal lobe epilepsy;
ICER=
incremental cost-effectiveness ratio;
QALY=
quality-adjusted life-year;
WTP=
willingness to pay

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 417

  • Podcast: NPub.org/wtj0x0

  • Received June 21, 2019.
  • Accepted in final form March 16, 2020.
  • © 2020 American Academy of Neurology
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