title: Cost-utility analysis of competing treatment strategies for drug-resistant epilepsy in children with Tuberous Sclerosis Complex.
abstract: The management of drug-resistant epilepsy in children with Tuberous Sclerosis Complex (TSC) is challenging because of the multitude of treatment options, wide range of associated costs, and uncertainty of seizure outcomes. The most cost-effective approach for children whose epilepsy has failed to improve with first-line medical therapy is uncertain.
  
  
  
  A review of MEDLINE from 1990 to 2015 was conducted. A cost-utility analysis, from a third-party payer perspective, was performed for children with drug-resistant epilepsy that had failed to improve with 2 antiseizure drugs (ASDs) and that was amenable to resective epilepsy surgery, across a time-horizon of 5years. Four strategies were included: (1) resective epilepsy surgery, (2) vagus nerve stimulator (VNS) implantation, (3) ketogenic diet, and (4) addition of a third ASD (specifically, carbamazepine). The incremental cost per quality-adjusted life year (QALY) gained was analyzed.
  
  
  
  Given a willingness-to-pay (WTP) of $100,000 per QALY, the addition of a third ASD ($6600 for a gain of 4.14 QALYs) was the most cost-effective treatment strategy. In a secondary analysis, if the child whose epilepsy had failed to improve with 3 ASDs, ketogenic diet, addition of a fourth ASD, and resective epilepsy surgery were incrementally cost-effective treatment strategies. Vagus nerve stimulator implantation was more expensive yet less effective than alternative strategies and should not be prioritized.
  
  
  
  The addition of a third ASD is a universally cost-effective treatment option in the management of children with drug-resistant epilepsy that has failed to improve with 2 ASDs. For children whose epilepsy has failed to improve with 3 ASDs, the most cost-effective treatment depends on the health-care resources available reflected by the WTP.
authors: Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA; Brain Research Institute, University of California Los Angeles, Los Angeles, CA, USA. Electronic address: afallah@mednet.ucla.edu.
authors: Aria
authors: A
authors: Fallah
authors: Division of Pediatric Neurosurgery, Department of Surgery, University of Montreal, Montreal, QC, Canada.
authors: Alexander G
authors: AG
authors: Weil
authors: Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Biostatistics and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors: Shelly
authors: S
authors: Wang
authors: Division of Pediatric Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
authors: Evan
authors: E
authors: Lewis
authors: Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA; Department of Neurology, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
authors: Christine B
authors: CB
authors: Baca
authors: Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA; Brain Research Institute, University of California Los Angeles, Los Angeles, CA, USA.
authors: Gary W
authors: GW
authors: Mathern
mesh_terms: D000927:Anticonvulsants / Q000191:economics / Q000627:therapeutic use; D002220:Carbamazepine / Q000191:economics / Q000627:therapeutic use; D002648:Child; D003362:Cost-Benefit Analysis; D055423:Diet, Ketogenic / Q000191:economics*; D000069279:Drug Resistant Epilepsy / Q000191:economics / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D017048:Health Care Costs; D006801:Humans; D012189:Retrospective Studies; D012919:Social Behavior; D016896:Treatment Outcome; D014402:Tuberous Sclerosis / Q000150:complications*; D055536:Vagus Nerve Stimulation / Q000191:economics*
chemical_list: D000927:Anticonvulsants; D002220:Carbamazepine
keywords: Antiseizure drugs; Epilepsy; Ketogenic diet; Resective surgery; Seizures; Tuberous Sclerosis Complex; Vagal nerve stimulator