MR-Guided Focused Ultrasound Versus Radiofrequency Capsulotomy for Treatment-Refractory Obsessive-Compulsive Disorder: A Cost-Effectiveness Threshold Analysis
2019
Meta-analytic techniques support neuroablation as a promising therapy for treatment-refractory obsessive-compulsive disorder (OCD). This technique appears to offer a more favorable complication rate and higher utility than
deep brain stimulation. Moreover, these pooled findings suggest that bilateral radiofrequency (RF)
capsulotomyhas marginally greater efficacy than stereotactic
radiosurgeryor cingulotomy. MR-guided focused ultrasound (MRgFUS)
capsulotomyis an emerging approach with a potentially more favorable profile than radiofrequency ablation and
radiosurgery, with preliminary data suggesting safety and efficacy. As a clinical trial is being developed, our study examined the cost and clinical parameters necessary for MRgFUS
capsulotomyto be a more cost-effective alternative to RF
capsulotomy. A decision analytical model of MRgFUS with RF
capsulotomyfor OCD was performed using outcome parameters of 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. Effectiveness was defined as the degree to which MRgFUS lowered Y-BOCS score. Given that MRgFUS is a new therapy for OCD with scant published data, theoretical risks of MRgFUS
capsulotomywere derived from published
essential tremoroutcomes. Sensitivity analysis yielded cost, effectiveness, and complication rates as critical MRgFUS parameters defining the cost-effectiveness threshold. Literature search identified eight publications (162 subjects). The average reduction of preoperative Y-BOCS score was 56.6% after RF
capsulotomywith a 22.6% improvement in utility, a measure of quality of life. 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, including neurological and neurobehavioral changes, in the other 14.8% of cases did not incur further costs, although they impacted utility.
Rollbackanalysis of RF
capsulotomyyielded an expected effectiveness of 0.212
quality-adjusted life years/year at an average cost of $24,099. Compared to RF
capsulotomy, MRgFUS was more cost-effective under a range of possible cost and complication rates. While further study will be required, MRgFUS lacks many of the inherent risks associated with more invasive modalities and has potential as a safe and cost-effective treatment for OCD.
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