title: Cost-effectiveness of focused ultrasound, radiosurgery, and DBS for essential tremor.
abstract: BACKGROUND
  Essential tremor remains a very common yet medically refractory condition. A recent phase 3 study demonstrated that magnetic resonance-guided focused ultrasound thalamotomy significantly improved upper limb tremor. The objectives of this study were to assess this novel therapy's cost-effectiveness compared with existing procedural options.
  
  
  METHODS
  Literature searches of magnetic resonance-guided focused ultrasound thalamotomy, DBS, and stereotactic radiosurgery for essential tremor were performed. Pre- and postoperative tremor-related disability scores were collected from 32 studies involving 83 magnetic resonance-guided focused ultrasound thalamotomies, 615 DBSs, and 260 stereotactic radiosurgery cases. Utility, defined as quality of life and derived from percent change in functional disability, was calculated; Medicare reimbursement was employed as a proxy for societal cost. Medicare reimbursement rates are not established for magnetic resonance-guided focused ultrasound thalamotomy for essential tremor; therefore, reimbursements were estimated to be approximately equivalent to stereotactic radiosurgery to assess a cost threshold. A decision analysis model was constructed to examine the most cost-effective option for essential tremor, implementing meta-analytic techniques.
  
  
  RESULTS
  Magnetic resonance-guided focused ultrasound thalamotomy resulted in significantly higher utility scores compared with DBS (P < 0.001) or stereotactic radiosurgery (P < 0.001). Projected costs of magnetic resonance-guided focused ultrasound thalamotomy were significantly less than DBS (P < 0.001), but not significantly different from radiosurgery.
  
  
  CONCLUSIONS
  Magnetic resonance-guided focused ultrasound thalamotomy is cost-effective for tremor compared with DBS and stereotactic radiosurgery and more effective than both. Even if longer follow-up finds changes in effectiveness or costs, focused ultrasound thalamotomy will likely remain competitive with both alternatives. © 2017 International Parkinson and Movement Disorder Society.
authors.affiliation: Department of Neurosurgery, Stanford, California, USA.
authors.forename: Vinod K
authors.initials: VK
authors.lastname: Ravikumar
authors.affiliation: Department of Neurosurgery, Stanford, California, USA.
authors.forename: Jonathon J
authors.initials: JJ
authors.lastname: Parker
authors.affiliation: Department of Neurosurgery, Stanford, California, USA.
authors.forename: Traci S
authors.initials: TS
authors.lastname: Hornbeck
authors.affiliation: Department of Neurology, Stanford, California, USA.
authors.forename: Veronica E
authors.initials: VE
authors.lastname: Santini
authors.affiliation: Department of Radiology, Stanford University, Stanford, California, USA.
authors.forename: Kim Butts
authors.initials: KB
authors.lastname: Pauly
authors.affiliation: Department of Radiology, Stanford University, Stanford, California, USA.
authors.forename: Max
authors.initials: M
authors.lastname: Wintermark
authors.affiliation: Department of Radiology, Stanford University, Stanford, California, USA.
authors.forename: Pejman
authors.initials: P
authors.lastname: Ghanouni
authors.affiliation: Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Sherman C
authors.initials: SC
authors.lastname: Stein
authors.affiliation: Department of Neurosurgery, Stanford, California, USA.
authors.forename: Casey H
authors.initials: CH
authors.lastname: Halpern
mesh_terms: D000368:Aged; D002986:Clinical Trials as Topic / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D016206:Databases, Bibliographic / Q000706:statistics & numerical data; D046690:Deep Brain Stimulation / Q000191:economics / Q000379:methods*; D020329:Essential Tremor / Q000000981:diagnostic imaging / Q000191:economics / Q000628:therapy; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery / Q000191:economics / Q000379:methods*; D012189:Retrospective Studies; D014463:Ultrasonography / Q000191:economics / Q000379:methods*
keywords: cost-effectiveness; deep brain stimulation; essential tremor; focused ultrasound; radiosurgery