An economic evaluation of surgery for temporal lobe epilepsy

doi:10.1016/0896-6974(95)00039-G

Journal of Epilepsy

Volume 8, Issue 3, August 1995, Pages 227-235

Journal of Epilepsy

https://doi.org/10.1016/0896-6974(95)00039-G Get rights and content

Abstract

We wished to determine whether surgery in adults with difficult to control temporal lobe epilepsy (TLE) is more effective and less costly than medical therapy. We evaluated the costs and consequences of surgical versus medical treatment of TLE, using decision-analysis modeling and an intention-to-treat approach. Data on outcome probabilities and resource utilization were obtained from critical appraisal of the literature, local experience, a panel of experts, and community patient survey. Surgically treating 100 patients for 35 years results in 57 seizure-free patients and a cost of $8,117,911. Medically treating 100 patients results in 12 seizure-free patients and a cost of $10,741,425. Surgery required a larger initial expenditure than medical treatment ($2,775,640 vs. $856,970), but cost-time curves intersect at 8.5 years and surgery remained cheaper thereafter. Results were unchanged by extensive sensitivity analyses. The major determinant of surgical dominance is its greater effectiveness (seizure-free rate) as compared with medical treatment. Surgery remained less costly, with concurrent effectiveness rates >41 and <30%, respectively, for surgical and medical treatment. Available evidence indicates that TLE surgery is more effective and cheaper than medical treatment, a win-win situation. However, adequately designed, controlled trials are necessary to determine more accurately and comprehensively the effectiveness of each therapeutic alternative.

References (66)

W.T. Blume et al.
Effectiveness of temporal lobectomy measured by yearly follow-up and multivariate analysis
J Epilepsy
(1994)
T.J. Rosenbaum et al.
Subdural electrode recordings for seizure focus localization
J Epilepsy
(1989)
T.P. Klassen et al.
Economic evaluation of intravenous immune globulin therapy for Kawasaki syndrome
J Pediatr
(1993)
S. Birch et al.
Cost effectiveness/utility analysis: do current decision rules lead us to where we want to be?
J Health Econ
(1992)
D.G. Froberg et al.
Methodology for measuring healthstate preferences—IV: progress and a research agenda
J Clin Epidemiol
(1989)
T.C. Chalmers et al.
Historical vs. randomized controls for clinical trials
Controlled Clin Trials
(1980)
N.D. Grace et al.
The present status of portal hypertension in cirrhosis
Gastroenterology
(1966)
D.H. Eddy
Three battles to watch in the 1990's
JAMA
(1993)
V. Horsley Sir
Brain surgery
Br Med J
(1886)
E.A. Rodin
The prognosis of patients with epilepsy
(1968)

W.A. Hauser et al.

Incidence, prevalence, time trends of convulsive disorders in Rochester, Minnesota: a community survey

A.A. Ward

Surgery of epilepsy—overview

E. Wyllie

Clinical outcome after complete or partial cortical resection for intractable epilepsy

Neurology

(1987)

T.S. Walczak et al.

Anterior temporal lobectomy for complex partial seizures: evaluation, results, and long term follow-up in 100 cases

Neurology

(1990)

J.M. Van Buren

Surgery of temporal lobe epilepsy

T.B. Rasmussen

Surgical treatment of complex partial seizures: results, lessons and problems

Epilepsia

(1983)

B. Guldvog et al.

Surgical versus medical treatment for epilepsy. 1. Outcome related to survival, seizures, and neurologic deficit

Epilepsia

(1991)

W. Feindel et al.

Temporal lobectomy with amygdalectomy and minimal hippocampal resection: review of 100 cases

Can J Neurol Sci

(1991)

J. Engel

Update on surgical treatment of the epilepsies

R.D. Elwes et al.

Outcome following resective surgery for temporal lobe epilepsy: a prospective follow-up study of 102 consecutive cases

J Neurol Neurosurg Psychiatry

(1991)

J.S. Duncan et al.

Seizure characteristics, pathology, and outcome after temporal lobectomy

Neurology

(1987)

C.B. Dodrill et al.

Multidisciplinary prediction of seizure relief from cortical resection surgery

Ann Neurol

(1986)

K.G. Davies et al.

Temporal lobectomy for intractable epilepsy: experience with 58 cases over 21 years

Br J Neurosurg

(1993)

L.D. Cahan

Surgery for epilepsy: a review

Acta Neurol Scand

(1986)

R.J. Porter et al.

Reply

Ann Neurol

(1989)

NIH Consensus Panel

Surgery for epilepsy

W.T. Blume

Epilepsy Unit Brochure

(1990)

Department of Clinical Epidemiology and Biostatistics, McMaster University

How to read clinical journals. VII. To understand an economic evaluation

Can Med Assoc J

(1984)

Department of Clinical Epidemiology and Biostatistics, McMaster University

How to read clinical journals. VII. To understand an economic evaluation

Can Med Assoc J

(1984)

M.F. Drummond et al.

Methods for the economic evaluation of health care programmes

R.H. Mattson et al.

Comparison of carbamazepine, phenobarbital, phenytoin and primidone in partial and secondarily generalized tonic-clonic seizures

N Engl J Med

(1985)

R.M. Dasheiff

Epilepsy surgery: is it an effective treatment?

Ann Neurol

(1989)

J. Dean et al.

Valproate monotherapy in thirty patients with partial seizures

Epilepsia

(1988)

Cited by (53)

Cost of pre-surgical evaluation for epilepsy surgery: A single-center experience
2022, Epilepsy Research
To estimate the cost and time taken to evaluate adults with drug-resistant focal epilepsy for potentially curative surgery.
We reviewed data on 100 consecutive individuals at a tertiary referral center evaluated for epilepsy surgery in 2017. The time elapsed between referral and either surgery or a definitive decision not to progress was measured. National Health Service tariffs applicable to our setting were used to estimate the total cost of evaluation for individuals following different routes through the pre-surgical pathway. After surgery, self-reported seizure freedom rates were obtained from each individual to assess the approximate cost of pre-surgical evaluation per additional person seizure-free.
Of 100 individuals evaluated, 27 had surgery, 63 had a definitive decision not to have surgery, and ten were awaiting further investigations. The median duration of the pre-surgical evaluation was 29.7 months (IQR 18.6–44.1 months), with a median cost per person of £9138 (IQR £6984–£14,868). Those who proceeded to Stage Two investigations (including fluorodeoxyglucose positron emission tomography, ictal single-photon emission computerized tomography and intracranial electroencephalography) had a higher cost and extended evaluation length. After a median of 3.1 (IQR 2.3–3.7) years, 15/27 people who had surgery were seizure-free. This equated to an approximate cost of £123,500 spent per additional person seizure-free.
Pre-surgical evaluation is long and costly, particularly for those who require icEEG. For those with drug-resistant focal epilepsy, surgery is, however, associated with a greater chance of seizure freedom. The suitability and risk-benefit ratio of surgery should be considered at each step of the pre-surgical pathway.
Cost-effectiveness analysis of epilepsy surgery in children and adolescents with drug resistant focal epilepsy at three years in a tertiary care epilepsy center in Thailand
2020, Journal of Clinical Neuroscience
Epilepsy surgery is proven as a cost-effective treatment in developed countries, especially in adults with drug resistant epilepsy (DRE). This study is aimed to demonstrate the cost-effectiveness of epilepsy surgery in children and adolescents with DRE at three years compared with those who were eligible for surgery but received medical treatment. This study was conducted from January 2014 to December 2018. Clinical data were obtained from a retrospective chart review. Direct medical costs, including epilepsy surgery, inpatient and outpatient treatment were retrieved from the finance department. Direct non-medical costs were collected from the family interview. The effectiveness was determined by percent seizure reduction and quality of life assessed by EQ-5D scores. Decision tree analysis using TreeAge Pro® 2018 was deployed to determine the cost-effectiveness. Seventeen patients had epilepsy surgery and 19 were in the medical group. Seizure freedom was noted in 52% and 16% in the surgical and medical groups, respectively. Incremental cost-effectiveness ratio (ICER) was 743,040 THB (22,793 USD) per 1 QALY and 3302 THB (101 USD) per 1% seizure reduction. The study did not demonstrate cost-effectiveness of epilepsy surgery in the short term compared with Thailand’s threshold (160,000 THB (4908 USD) per 1 QALY). Epilepsy surgery may be cost-effective if evaluated beyond three years.
Epilepsy surgery in low- and middle-income countries: A scoping review
2019, Epilepsy and Behavior
Citation Excerpt :
In view of the high burden of epilepsy in LMIC, it is debated whether surgery may be a cost-effective long-term investment that may benefit more people in the long run [188]. Studies evaluating the costs of surgical versus medical treatment observed that although surgical treatment requires a large initial expenditure, it was superior because of the greater seizure-free rate, with the long term cost-analysis favoring surgery as the cost–time curves intersect in a few years [189–191]. These cost-analyses comparing medical and surgical therapy of epilepsy should be interpreted with caution since the cost of surgery and benefit gained by seizure reduction are not linear and that measuring just the reduction in seizure frequency in the short-term is inadequate to compare costs.
Epilepsy surgery is an important treatment option for people with drug-resistant epilepsy. Surgical procedures for epilepsy are underutilized worldwide, but it is far worse in low- and middle-income countries (LMIC), and it is less clear as to what extent people with drug-resistant epilepsy receive such treatment at all. Here, we review the existing evidence for the availability and outcome of epilepsy surgery in LMIC and discuss some challenges and priority.
We used an accepted six-stage methodological framework for scoping reviews as a guide. We searched PubMed, Embase, Global Health Archives, Index Medicus for South East Asia Region (IMSEAR), Index Medicus for Eastern Mediterranean Region (IMEMR), Latin American & Caribbean Health Sciences Literature (LILACS), African Journal Online (AJOL), and African Index Medicus (AIM) to identify the relevant literature.
We retrieved 148 articles on epilepsy surgery from 31 countries representing 22% of the 143 LMIC. Epilepsy surgery appears established in some of these centers in Asia and Latin America while some are in their embryonic stage reporting procedures in a small cohort performed mostly by motivated neurosurgeons. The commonest surgical procedure reported was temporal lobectomies. The postoperative seizure-free rates and quality of life (QOL) are comparable with those in the high-income countries (HIC). Some models have shown that epilepsy surgery can be performed within a resource-limited setting through collaboration with international partners and through the use of information and communications technology (ICT). The cost of surgery is a fraction of what is available in HIC.
This review has demonstrated the availability of epilepsy surgery in a few LMIC. The information available is inadequate to make any reasonable conclusion of its existence as routine practice. Collaborations with international partners can provide an opportunity to bring high–quality academic training and technological transfer directly to surgeons working in these regions and should be encouraged.
Comparing the effects of cortical resection and vagus nerve stimulation in patients with nonlesional extratemporal epilepsy
2013, Epilepsy and Behavior
The main purpose of this retrospective study was to compare the effects of resective surgery (RESgr—26 patients) and vagus nerve stimulation (VNSgr—35 patients) on seizure frequency (2 and 5 years after surgery) in patients with nonlesional extratemporal epilepsy (NLexTLE). We analyzed hospital admission costs directly associated with epilepsy (HACE) in both groups at the same follow-up. The decrease in seizure frequency from the preoperative levels, in both VNSgr and RESgr, was statistically significant (p < 0.001). The seizure frequency reduction did not differ significantly between the follow-up visits for either group (p = 0.221 at 2 years and 0.218 at 5 years). A significantly higher number of Engel I and Engel I + II patients were found in RESgr than in VNSgr at both follow-up visits (p = 0.04 and 0.007, respectively). Using McHugh classification, we did not find statistically significant differences between both groups at both follow-up visits. Hospital admission costs directly associated with epilepsy/patient/year in both RESgr and VNSgr dropped significantly at 2- and 5-year follow-up visit and this reduction was not statistically different between RESgr and VNSgr (p = 0.232).
Both VNS and resective surgery cause comparably significant seizure reduction in NLexTLE. Resective surgery leads to a greater number of patients with excellent postoperative outcome (Engel I + II). The HACE reduction is statistically comparable between both groups.
Epilepsy surgery in developing countries
2012, Handbook of Clinical Neurology
Citation Excerpt :
In the USA, the estimated payback time for epilepsy surgery is approximately 6 years (Gumnit, 2001). Whereas the Canadian study (Wiebe and Gafni, 1995) comprised both intracranial and noninvasive presurgical evaluations, the USA figures apply particularly to noninvasive, not complicated temporal lobe resections. This figure is important because it is estimated that approximately 60% of all epilepsy surgeries needed in developing countries at this point require no intracranial or complex evaluation.
Cost-effectiveness of pediatric epilepsy surgery compared to medical treatment in children with intractable epilepsy
2011, Epilepsy Research
Citation Excerpt :
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.
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.
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.
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.
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.

View all citing articles on Scopus

View full text

An economic evaluation of surgery for temporal lobe epilepsy

Abstract

J Epilepsy

J Epilepsy

J Pediatr

J Health Econ

J Clin Epidemiol

Controlled Clin Trials

Gastroenterology

Three battles to watch in the 1990's

JAMA

Brain surgery

Br Med J

The prognosis of patients with epilepsy

Incidence, prevalence, time trends of convulsive disorders in Rochester, Minnesota: a community survey

Surgery of epilepsy—overview

Clinical outcome after complete or partial cortical resection for intractable epilepsy

Neurology

Anterior temporal lobectomy for complex partial seizures: evaluation, results, and long term follow-up in 100 cases

Neurology

Surgery of temporal lobe epilepsy

Surgical treatment of complex partial seizures: results, lessons and problems

Epilepsia

Surgical versus medical treatment for epilepsy. 1. Outcome related to survival, seizures, and neurologic deficit

Epilepsia

Temporal lobectomy with amygdalectomy and minimal hippocampal resection: review of 100 cases

Can J Neurol Sci

Update on surgical treatment of the epilepsies

Outcome following resective surgery for temporal lobe epilepsy: a prospective follow-up study of 102 consecutive cases

J Neurol Neurosurg Psychiatry

Seizure characteristics, pathology, and outcome after temporal lobectomy

Neurology

Multidisciplinary prediction of seizure relief from cortical resection surgery

Ann Neurol

Temporal lobectomy for intractable epilepsy: experience with 58 cases over 21 years

Br J Neurosurg

Surgery for epilepsy: a review

Acta Neurol Scand

Reply

Ann Neurol

Surgery for epilepsy

Epilepsy Unit Brochure

How to read clinical journals. VII. To understand an economic evaluation

Can Med Assoc J

How to read clinical journals. VII. To understand an economic evaluation

Can Med Assoc J

Methods for the economic evaluation of health care programmes

Comparison of carbamazepine, phenobarbital, phenytoin and primidone in partial and secondarily generalized tonic-clonic seizures

N Engl J Med

Epilepsy surgery: is it an effective treatment?

Ann Neurol

Valproate monotherapy in thirty patients with partial seizures

Epilepsia