Bridging the Gap between Evidence and Practice for Adults with Medically Refractory Temporal Lobe Epilepsy: Is a Change in Funding Policy Needed to Stimulate a Shift in Practice?
Table 1
Characteristics of included and excluded studies, following full-text review.
MRE adults with presumed TLE (hypothetical cohort of 100 patients in each alternative option)
Preliminary resource consumption Survey of 33 representative local patients Confirmation of resource use Expert panel Perioperative costs Cohort of 30 consecutive local patients (1993 Cdn) Physician costs Provincial fee schedule (1992 Cdn)
Clinical outcome probability estimates, Literature search, local experience, and expert panel
N/A
Surgery is cost-effective $895,119/seizure-free patient with BMT versus $142,419/seizure-free patient with surgery Surgery dominates BMT at around 8-9 years
Hospital costs Cost/charge ratios from local finance department (1994 USD) Outpatient investigations/physician costs Medicare fee schedule (1994 USD) AED cost Local bulk acquisition cost (1994 USD)
One-year seizure status, Cohort of 51 local patients Postoperative mortality, Review of the literature and local data Nonsurgical mortality, Review of the literature QALYs, Review of the literature
N/A
ATL is preferred for MRE (ICUR of surgery = $27,200/QALY)
Medical services Local hospital and providers plus review of the literature (1995 USD) Surgical evaluation Based on select cohort of 25 local patients (1991–1993 USD) Surgical complication costs Based on postoperative hematoma costs of 2 patients in larger operative cohort of 150 patients (1991–1993 USD) Follow-up costs Lifetime estimate, using local unit costs (year not clear) AED costs Hospital pharmacy costs based on average AED dosage (year not clear)
Clinical event probabilities, Review of the literature QALY, Review of the literature
N/A
ATL is preferred for MRE (MCUR of surgery = $15,581/QALY)
280 adults with MRE thought to be surgical candidates (not necessarily TLE)
Hospital costs Published fees (2004 Euros) Outpatient costs Published professional fees (2004 Euros) Direct, nonmedical costs Estimated from mode of transportation, distances, and transport fees (2003 Euros), elicited from patients Indirect costs Working days lost, elicited from patients
Seizure freedom rates, Review of outcomes for 280 patients in study Transition probabilities, Review of the literature Mortality rates, General population data Quality of life, Questionnaires administered to patients in study
National PHRC (1998) and Pfizer
Surgery is cost-effective in medium-term projections (productivity not considered) ICER of surgery at 5 years: ~1,900 Euros/seizure-free year Surgery is cost-effective at around 7-8 years postoperatively (ICER becomes 0, direct costs only)
(b) Studies that were NOT included in final analysis
A Comparison of Surgical and Medical Costs for Refractory Epilepsy
Epilepsia
This was a cost analysis to assess the impact of incorporating direct and indirect costs
(i) Surgery is cost-effective (ii) Reduction of direct costs occurs in the long term (>10 years) (iii) Income gains more significant to society than payers; therefore, societal perspective is necessary
