Introduction: Meta-analytic techniques recently supported neuroablation as a promising therapy for treatment-refractory obsessive-compulsive disorder (OCD) with a more favorable complication rate than deep brain stimulation. Moreover, these pooled findings suggested that bilateral radiofrequency (RF) capsulotomy had marginally greater efficacy than unilateral ablation, stereotactic radiosurgery, and cingulotomy. MR-guided focused ultrasound (MRgFUS) capsulotomy is an emerging therapy for OCD, with preliminary data suggesting safety and efficacy. Thus, we sought to determine the cost and clinical parameters necessary for MRgFUS capsulotomy to be a viable alternative to RF capsulotomy.
Methods: We created a decision analytical model of MRgFUS with RF capsulotomy for OCD. Outcome parameters included percent surgical improvement in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score, complications, and side effects. The analysis compared measured societal costs, derived from Medicare reimbursement rates, and effectiveness, based on published RF data. Theoretical risks of MRgFUS capsulotomy were based on published essential tremor outcomes. Sensitivity analysis yielded cost, effectiveness, and complication rate as critical MRgFUS parameters defining the cost-effectiveness threshold.
Results: Literature search identified eight publications (162 subjects). The average reduction of preoperative Y-BOCS score was 56.6% after RF capsulotomy, with a 22.6% improvement in utility. Complications occurred in 16.2% of RF cases. In 1.42% of cases, complications were considered acute-perioperative and incurred additional hospitalization cost. The adverse events in the other 14.8% of cases did not incur further costs, although they impacted utility. Rollback analysis of RF capsulotomy yielded an expected effectiveness of 0.212 QALYs/year at an average cost of $24,099. MRgFUS capsulotomy was more cost-effective under a range of possible cost and complication rates (Figure 1).
Conclusions: MRgFUS capsulotomy lacks many of the inherent risks associated with more invasive modalities and has potential to be a safe and cost-effective treatment for OCD. Future trials should directly assess outcomes for this emerging indication against established neurosurgical OCD therapies.
Patient Care: Our study helps define the range of possible cost and complication rates under which MRgFUS capsulotomy is a safe and cost-effective treatment for OCD. These findings will directly inform future clinical trials investigating the use of MRgFUS capsulotomy for treatment-refractory OCD.
Learning Objectives: By the conclusion of this session, participants should be able to: (1) describe the importance of MRgFUS versus RF capsulotomy for treatment-refractory obsessive-compulsive disorder, (2) discuss, in small groups, the relative cost-effectiveness of these therapies, and (3) identify effective neurosurgical treatment strategies for patients with OCD.
References: Brown LT, Mikell CB, Youngerman BE, Zhang Y, McKhann GM 2nd, Sheth SA. Dorsal anterior cingulotomy and anterior capsulotomy for severe, refractory obsessive-compulsive disorder: a systematic review of observational studies. J Neurosurg. 2016 Jan;124(1):77-89
Jung HH, Kim SJ, Roh D, Chang JG, Chang WS, Kweon EJ, Kim CH, Chang JW. Bilateral thermal capsulotomy with MR-guided focused ultrasound for patients with treatment-refractory obsessive-compulsive disorder: a proof-of-concept study. Mol Psychiatry. 2015 Oct;20(10): 1205-11.
Kumar KK, Appelboom G, Lamsam L, Williams NR, Bhati MT, Stein SC, Halpern CH. Comparative Effectiveness of Neuroablation and Deep Brain Stimulation for Treatment-Resistant Obsessive-Compulsive Disorder: A Meta-Analytic Study. 2018. Under Review.