The Value of Care in Parkinson’s Disease
DBS provided an additional 0.72 QALY over best medical treatment at an additional cost of US$35,000 (US$417,000 for best medical treatment and US$452,000 for DBS). This gave an incremental cost- effectiveness ratio of US$49,194 per QALY. The base case assumed a 30 % improvement in quality of life (QoL) with DBS and any improvement at this level or higher would make DBS a cost-effective option. If QoL improvements with DBS were <18 % versus best medical therapy, DBS would not be considered cost-effective (>US$100,000 per QALY) and improvements of 18–30 % would result in questionable cost-effectiveness.15
Cost-effectiveness of DBS would be achieved,
based on this analysis, if QoL is improved by >30 %, there are no significant complications and if the battery in the DBS unit lasts for >5 years. However, there were drawbacks to this analysis – most importantly, at the time of the study there was no adequate evaluation of QoL and the estimates of QoL were based on UPDRS scores; there was no distinction between DBS of the subthalamic nucleus (DBS-STN) and DBS of the globus pallidus pars interna (DBS-GPi); and clinical data were also insufficient in 2001, so a Delphi method was used to estimate efficacy.15
A subsequent comparison of DBS and best medical treatment estimated that DBS produced an approximately 23 % improvement in QoL in the first year after surgery.16
The cost of DBS (€18,456) was
partially offset by reduced drug costs (€3,799 in patients receiving DBS and €13,208 with best medical treatment) and other medical costs (€1,280 in patients receiving DBS and €4,017 with best medical treatment). A resulting cost-effectiveness ratio was calculated as €34,389 per QALY.16
The conclusion of the authors was that this
incremental cost-effectiveness ratio was “within appropriate limits to consider subthalamic stimulation as an efficient therapy”.16
In our group, we have conducted a cost-effectiveness comparison of DBS versus best medical treatment using a similar but more detailed model than previous studies (unpublished data). Our data indicate that DBS is not cost-effective in the first two years after surgery (incremental cost-effectiveness ratio of €408,607 per QALY and €68,499 per QALY in year one and two, respectively), but after five years or more, DBS is a cost-effective approach compared with best medical treatment (€25,205 per QALY after five years, €17,519 per QALY after 10 years and €12,039 per QALY after 20 years). However, it should be noted that there are limited data on the effects of DBS
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2. Wittchen HU, Jonsson B, Olesen J, Towards a better understanding of the size and burden and cost of brain disorders in Europe, Eur Neuropsychopharmacol, 2005;15:355–6.
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4. Wittchen HU, Jacobi F, Size and burden of mental disorders in Europe-a critical review and appraisal of 27 studies, Eur Neuropsychopharmacol, 2005;15:357–76.
5. Dorsey ER, Constantinescu R, Thompson JP, et al., Projected number of people with Parkinson disease in the most populous nations, 2005 through 2030, Neurology, 2007;68:384–6.
6. von Campenhausen S, Winter Y, Gasser J, et al., [Cost of illness and health service patterns in Morbus Parkinson in Austria], Wien Klin Wochenschr, 2009;121:574–82.
Cost data on PD in Europe are not as comprehensive as might be expected, but the burden of care is great and set to increase in the next 20 years. Effective treatment for PD is expensive and direct costs are high. These increase as the disease progresses, but cost data on therapies for advanced PD are sparse. Indeed, it is currently impossible to make rational decisions on the cost-effectiveness of the CDS therapies, Duodopa, APO and DBS. There are few studies of these three CDS therapies and no comparisons of the cost of each therapy. As the data set on efficacy and QoL of CDS treatments increases, it may become possible to do more detailed cost-effectiveness comparisons, and initial data do suggest that, in the long-term, DBS is cost-effective. n
7. Winter Y, von Campenhausen S, Brozova H, et al., Costs of Parkinson's disease in eastern Europe: a Czech cohort study, Parkinsonism Relat Disord, 2010;16:51–6.
8. Winter Y, von Campenhausen S, Popov G, et al., Costs of illness in a Russian cohort of patients with Parkinson's disease, Pharmacoeconomics, 2009;27:571–84.
9. von Campenhausen S, Winter Y, Silva AR, et al., Costs of illness and care in Parkinson's Disease: An evaluation in six countries, Eur Neuropsychopharmacol, 2010;21:180–91.
10. Aarsland D, Larsen JP, Tandberg E, Laake K, Predictors of nursing home placement in Parkinson's disease: a population-based, prospective study, J Am Geriatr Soc, 2000;48:938–42.
11. Goetz CG, Stebbins GT, Risk factors for nursing home placement in advanced Parkinson's disease, Neurology, 1993;43:2227–9.
12. Nyholm D, Nilsson Remahl AI, Dizdar N, et al., Duodenal levodopa infusion monotherapy vs oral polypharmacy in advanced Parkinson disease, Neurology, 2005;64:216–23.
13. Kristiansen IS, Bingefors K, Nyholm D, Isacson D, Short-term cost and health consequences of duodenal levodopa infusion in advanced Parkinson's disease in Sweden: an exploratory study, Appl Health Econ Health Policy, 2009;7:167–80.
14. Meissner W, Trottenberg T, Klaffke S, et al., [Apomorphine therapy versus deep brain stimulation. Clinical and economic aspects in patients with advanced Parkinson disease], Nervenarzt, 2001;72:924–7.
15. Tomaszewski KJ, Holloway RG, Deep brain stimulation in the treatment of Parkinson's disease: a cost-effectiveness analysis, Neurology, 2001;57:663–71.
16. Valldeoriola F, Morsi O, Tolosa E, et al., Prospective comparative study on cost-effectiveness of subthalamic stimulation and best medical treatment in advanced Parkinson's disease, Mov Disord, 2007;22:2183–91.
17. Munneke M, Nijkrake MJ, Keus SH, et al., Efficacy of community-based physiotherapy networks for patients with Parkinson's disease: a cluster-randomised trial, Lancet Neurol, 2010;9:46–54.
after 10 years and these long-term cost-effectiveness calculations used extrapolation from shorter-term data.
These data on DBS, although limited, do suggest that DBS is cost- effective, if using the World Health Organization definition, which is a cost-effectiveness ratio of €21,742–65,227 per QALY. In the UK, the NICE definition is somewhat stricter (€22,222–33,333 per QALY), but the most recent cost-effectiveness analyses of DBS also fall within this range. Unfortunately, there are no economic data to compare DBS with the other CDS therapies, and it is impossible to conclude on the cost-effectiveness of these other therapies.
It is important to acknowledge the role of non-pharmacological management of PD and, therefore, it is also important to consider the cost-effectiveness of such approaches. The recent ParkinsonNet trial of community-based physiotherapy included a cost-analysis.17 Although outcomes were not changed with physiotherapy and QoL was not significantly improved, costs were reduced by approximately 20 % (cost calculations included the cost of physiotherapy, medication, consultation, day-hospital rehabilitation, hospital admissions, home care, informal care and the productivity loss of the patient’s partner). If the cost-effectiveness ratio is calculated, physiotherapy cost is €39,600 per QALY. This would suggest that the cost-effectiveness of physiotherapy is marginal, but this trial ran for 24 weeks and it is possible that longer-term studies could provide more favourable outcomes and a more favourable cost per QALY.
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