Cost-effectiveness of pediatric epilepsy surgery compared to medical treatment in children with intractable epilepsy

https://doi.org/10.1016/j.eplepsyres.2011.01.005Get rights and content

Summary

Purpose

Due to differences in epilepsy types and surgery, economic evaluations of epilepsy treatment in adults cannot be extrapolated to children. We evaluated the cost-effectiveness of epilepsy surgery compared to medical treatment in children with intractable epilepsy.

Method

Decision tree analysis was used to evaluate the cost-effectiveness of surgery relative to medical management. Fifteen patients had surgery and 15 had medical treatment. Cost data included inpatient and outpatient costs for the period April 2007 to September 2009, physician fee, and medication costs. Outcome measure was percentage seizure reduction at one-year follow-up. Incremental cost-effectiveness ratio (ICER) was assessed. Sensitivity analysis was performed for different probabilities of surgical and medical treatment outcomes and costs, and surgical mortality or morbidity.

Results

More patients managed surgically experienced Engel class I and II outcomes compared to medical treatment at one-year follow-up. Base-case analysis yielded an ICER of $369 per patient for each percentage reduction in seizures for the surgery group relative to medical group. Sensitivity analysis showed robustness for the different probabilities tested.

Conclusion

Surgical treatment resulted in greater reduction in seizure frequency compared to medical therapy and was a cost-effective treatment option in children with intractable epilepsy who were evaluated for epilepsy surgery and subsequently underwent surgery compared to continuing medical therapy. However, larger sample size and long-term follow-up are needed to validate these findings.

Introduction

Epilepsy places a significant strain on the healthcare system, patients, and their families. Given the extended period pediatric patients will live with the disease, it is especially important to appreciate the costs of epilepsy in this population. Approximately 10–30% of patients with epilepsy are medically refractory (Berg et al., 2001, Farrell et al., 2006, Kwan and Brodie, 2000). Economic considerations are particularly important for patients with medically refractory epilepsy. Begley et al. (1994) reported 15% of patients who were most refractory accounted for >50% of the total costs of the illness. Jacoby et al. (1998) found that the cost correlated with the severity of epilepsy and intractable patients cost eightfold that of those with controlled epilepsy.

Surgical treatment may be beneficial in a carefully selected group of patients with medically refractory epilepsy. The success rates of epilepsy surgery are generally high, with 61–90% of surgical cases falling into Engel classes I and/or II following surgery (Benifla et al., 2006, Sinclair et al., 2003, Sinclair et al., 2004, Terra-Bustamante et al., 2005, Widjaja et al., 2008, Wyllie et al., 1998). The main goal of surgery is to reduce seizure frequency and therefore secondarily reduce the morbidity and mortality associated with epilepsy. Despite the higher cost of surgical treatment, it is expected that surgery would be more cost-effective than medical therapy. Using decision analysis to evaluate the cost effectiveness of anterior temporal lobectomy compared with medical management in medically intractable temporal lobe epilepsy, Langfitt (1997) found anterior temporal lobectomy was the more costly but more effective strategy and estimates of the cost effectiveness of anterior temporal lobectomy fall within generally acceptable range even accounting for uncertainties in the model. King et al. (1997) have also used a decision analysis model to evaluate the cost effectiveness of anterior temporal lobectomy for intractable temporal lobe epilepsy and found surgical treatment was more costly but provided an average of 1.1 additional quality-adjusted life years. Wiebe et al. (1995) have also found surgery required a larger initial expenditure than medical treatment but was more effective with a higher seizure-free rate as compared with medical treatment, with effectiveness rate of >41% and <30% for surgical and medical treatment respectively. They have also found extensive sensitivity analyses did not alter the results. All these studies have evaluated anterior temporal lobectomy in adults with temporal lobe epilepsy. Due to differences in the epileptogenic substrates responsible for epilepsy, the type of epilepsy surgery performed in children is different compared to adults. As hippocampal sclerosis is the most common epileptogenic substrate in adults with temporal lobe epilepsy, anterior temporal lobectomy is the most common surgical procedure carried out in the adult population with medically intractable epilepsy. However, in children, the epileptogenic substrate is more variable and extra-temporal lobe epilepsy is more common compared to adults, therefore resection of the epileptogenic cortex responsible for epilepsy is more commonly performed than anterior temporal lobectomy. For this reason, adult epilepsy economic evaluation results cannot be generalized to pediatric populations.

To our knowledge, only one economic evaluation of pediatric epilepsy surgery has been published to date, which found epilepsy surgery to be cost-effective (Keene and Ventureyra, 1999). The study by Keene et al. (Keene and Ventureyra, 1999) took a societal perspective over a 25-year time frame and compared epilepsy surgery without invasive monitoring to medical management, and found costs per patient 8% higher for the medical treatment group. Since invasive monitoring is frequently performed prior to surgical resection in many epilepsy surgery centers, costing of epilepsy surgery that does not include the cost of invasive monitoring may underestimate the cost of surgery. In this study, we evaluated the cost-effectiveness of pediatric epilepsy surgery compared to medical treatment in children with intractable epilepsy in the setting of a tertiary pediatric epilepsy center over a period of one year.

Section snippets

Perspective and approach to economic evaluation

A cost-effectiveness analysis was conducted to measure and compare the costs and health consequences of surgical and medical treatment for children with intractable epilepsy. Treatment effects were measured as change in seizure frequency. The direct medical costs of epilepsy treatment include inpatient care, outpatient care, and medication. The Canada Health Act's Annual Report for 2007–2008 states that provincial health ministries will incur the costs of medically necessary procedures and

Results

There was no significant difference in the mean age of the surgical and medical treatment groups (p > 0.05). The mean age of the surgical group was 8.9 years (range: 2.3–17 years) and the mean age of the medical group was 8.4 years (range: 5–14 years). There were no significant differences in the mean age at seizure onset and in the epilepsy duration in both groups (p > 0.05). The mean age at seizure onset in the surgical and medical groups was 2.6 years (range: 0.2–9 years) and 3.8 years (range:

Discussion

In this analysis, surgical management of pediatric epilepsy was both more expensive and more effective than medical management. Surgery was found to have an incremental cost-effectiveness ratio of $36,900 for seizure freedom at one-year follow-up relative to medical treatment, with a positive net monetary benefit at one-year following surgery. The higher initial costs of surgery were offset by its greater clinical effectiveness within one year of surgical treatment. These findings were

Acknowledgements

We thank Nicole E. Brown and May Seto for their contributions to this project.

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