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  • Focused Ultrasound Likely Dominates Deep Brain Stimulation and Stereotactic Radiosurgery for Medically-Refractory Essential Tremor: An Initial Decision and Cost-Effectiveness Analysis

    Final Number:
    2066

    Authors:
    Vinod Karthik Ravikumar BS; Jonathon Parker MD, PhD; Sherman C. Stein MD; Pejman Ghanouni MD, PhD; Casey H. Halpern MD

    Study Design:
    Other

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2016 Annual Meeting - Late Breaking Science

    Introduction: Essential Tremor (ET) is one of the most common neurologic conditions, and conservative measures are frequently suboptimal. Recent data from a multi-institution, randomized controlled clinical trial demonstrated that magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy improves upper limb tremor in medically refractory ET. This study assesses the cost-effectiveness of this novel therapy in comparison to existing procedural options.

    Methods: PubMed and Cochrane Library searches were performed for studies of MRgFUS, Deep Brain Stimulation (DBS), and Stereotactic Radiosurgery (SRS) for ET. Pre- and post-operative tremor-related disability scores were collected from 32 studies involving 83 MRgFUS, 615 DBS, and 260 SRS cases. Utility (defined as percent change in functional disability) was calculated, and Medicare reimbursements were collected as a proxy for societal cost. A decision and cost-effectiveness analysis was then constructed, implementing meta-analytic techniques.

    Results: MRgFUS thalamotomy resulted in significantly higher utility scores compared with DBS and SRS (p< 0.001). MRgFUS was also the most inexpensive procedure out of the three (p<0.001).

    Conclusions: Preliminary experience with MRgFUS for ET suggests that this novel therapeutic may be more effective than available alternatives and less costly for society. It thus is said to “dominate” DBS and SRS as a more cost-effective option for medically refractory ET. Our findings support further investigation of MRgFUS for ET, its FDA-approval, and broad adoption.

    Patient Care: This study is critical in helping to determine whether a novel therapeutic will be adopted for a patient population largely refractory to the current standard of care. Most studies that have been published in the literature, which thus far examine the efficacy of Focused Ultrasound in treating Essential Tremor, have small sample sizes and do not compare this novel treatment to the current medical and/or surgical options. Therefore, there is almost no context for how this new treatment performs and no means for adoption if this treatment does demonstrate high efficacy of treatment (i.e. no randomized trial comparing treatments for essential tremor exists). Our study, while not capable of replacing a randomized control trial, represents the best possible approximation of one.

    Learning Objectives: Numerical Valuations of Efficacy and Reimbursement for several interventions for Essential Tremor. Meta Analytic Techniques including Decision Tree Analysis, Monte Carlo Simulation, and ANOVA statistical analysis.

    References:

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