Bilateral Deep Brain Stimulation is the Procedure to Beat for Advanced Parkinson Disease: A Meta-Analytic, Cost-Effective Threshold Analysis for Focused Ultrasound

Abstract

Background: Parkinson disease (PD) impairs daily functioning for an increasing number of patients and has a growing national economic burden. Deep brain stimulation (DBS) may be the most broadly accepted procedural intervention for PD, but cost-effectiveness has not been established. Moreover, magnetic resonance image-guided focused ultrasound (FUS) is an emerging incisionless, ablative treatment that could potentially be safer and even more cost-effective.

Objective: To (1) quantify the utility (functional disability metric) imparted by DBS and radiofrequency ablation (RF), (2) compare cost-effectiveness of DBS and RF, and (3) establish a preliminary success threshold at which FUS would be cost-effective compared to these procedures.

Methods: We performed a meta-analysis of articles (1998-2018) of DBS and RF targeting the globus pallidus or subthalamic nucleus in PD patients and calculated utility using pooled Unified Parkinson Disease Rating Scale motor (UPDRS-3) scores and adverse events incidences. We calculated Medicare reimbursements for each treatment as a proxy for societal cost.

Results: Over a 22-mo mean follow-up period, bilateral DBS imparted the most utility (0.423 quality-adjusted life-years added) compared to (in order of best to worst) bilateral RF, unilateral DBS, and unilateral RF, and was the most cost-effective (expected cost: $32 095 ± $594) over a 22-mo mean follow-up. Based on this benchmark, FUS would need to impart UPDRS-3 reductions of ∼16% and ∼33% to be the most cost-effective treatment over 2- and 5-yr periods, respectively.

Conclusion: Bilateral DBS imparts the most utility and cost-effectiveness for PD. If our established success threshold is met, FUS ablation could dominate bilateral DBS's cost-effectiveness from a societal cost perspective.

Keywords: Cost-effectiveness; Deep brain stimulation; Magnetic resonance guided focused ultrasound; Quality of life; Radiofrequency ablation; Utility.

Graphical Abstract

FIGURE 1.

Decision-analytic model to calculate benefits, harms, health-related utility, expected costs, and cost-effectiveness resulting from current surgical treatments of PD.

FIGURE 2.

PRISMA diagram of included articles.

FIGURE 3.

Scatterplot demonstrating UPDRS-3 reduction by treatment type and over publication time. DBS studies were significantly newer than RF studies, though publication year was not associated with UPDRS-3 reduction. Size of data point represents number of patients in the study.

FIGURE 4.

Scatterplots demonstrating UPDRS-3 reduction by target over follow-up length. A, Off-medication. UPDRS-3 reduction decreased over time, and STN provided greater benefit than GPi. B, On-medication. STN and GPi provided equivalent benefit. Size of data point represents number of patients in the study. Note: axis scales are different in A and B.

FIGURE 5.

Scatterplot demonstrating UPDRS-3 reduction for bilateral vs unilateral, over baseline UPDRS-3 scores. Bilateral treatment provided greater efficacy than unilateral treatment. There was no association between baseline score and efficacy outcome or baseline score and bilateral vs unilateral. Size of data point represents number of patients in the study.

FIGURE 6.

Cost-effectiveness acceptability curve. Bilateral DBS is consistently the most cost-effective treatment at willingness-to-pay thresholds at and above $20,000.

FIGURE 7.

Sensitivity analysis demonstrating the UPDRS-3 OFF % reduction that FUS would have to meet in order to be more cost-effective than bilateral at various ICER values. A, 2-yr timescale. B, 5-yr timescale.

FIGURE 8.

Plot demonstrating how changes in the AE incidence and UPDRS-3% reduction of FUS affect its cost-effectiveness, over a 2-yr period. Blue shaded areas demonstrate scenarios where bilateral DBS is the most cost-effective option (if adhering to the societal $50 000 willingness-to-pay threshold). Purple shaded areas indicate scenarios where FUS is the more cost-effective option.

FIGURE 9.

Tornado diagram demonstrating effect of varying FUS AE incidence and disutility as well as cost and efficacy on the overall ICER of bilateral DBS compared to FUS (an ICER less than $50 000 supports DBS as more cost-effective, whereas an ICER greater than $50 000 supports FUS as more cost-effective). Red bars demonstrate the effects of an increase in the variable value and blue bars indicate the effects of a decrease in the variable value.