The cost-effectiveness of STN surgery

Subthalamic nucleus stimulation (STN) is an expensive neurosurgical treatment, but it offers a return on investment within 2.2 years when subsequent savings in healthcare expenditure are taken into account.French investigators assessing the clinical effects and economic cost of STN calculated that the cost of the procedure is €36 904 per patient. However, the six-month healthcare costs for PD patients decreased from €10 087 ± 4 887 before surgery to €1 673 ± 2 111 after surgery, and the authors point out, "Given the savings in healthcare expenditure obtained in a 6 month period, the cost of the procedure would allow a return on investment over 2.2 years. Thus, we may consider that STN stimulation is cost effective..."The cost of the surgery takes into account a stay in hospital of 4 - 5 days for confirmation of surgical indication, the surgery itself, hospitalisation for surgery (18 - 31 days), cost of equipment, cost of all consultations or hospitalisations for postoperative adjustments, and cost of drug therapy during the first postoperative year. Healthcare costs before and after the operation included hospitalisations, outpatient visits, auxiliary care, and antiparkinsonian medication. The cost savings after surgery were largely attributable to the reduction in the need for antidopaminergic medication, particularly subcutaneous apomorphine.The calculations did not take into account the cost of replacing the neurostimulator, which the investigators estimated is around €15 000 every five years. In addition, long-term disabling symptoms such as dementia and postural instability were not considered. However, the authors say that the results of their study are valid for at least five years, since the major benefit on motor function is largely maintained over this period. They add that further studies are warranted to determine longer-term costs.The investigators also assessed factors that predicted patients who would most benefit from surgery. They report, "We found that the best predictive factor for surgery induced benefit was a low preoperative on-period motor score, whatever its severity during off periods. Therefore, the most suitable candidates for STN stimulation should exhibit an excellent on-period motor function, even if off-period motor disability or levodopa induced dyskinesias are severe."Reference...