Cost-effectiveness of the ketogenic diet and vagus nerve stimulation for the treatment of children with intractable epilepsy

Reina J A de Kinderen; Debby Postulart; Albert P Aldenkamp; Silvia M A A Evers; Danielle A J E Lambrechts; Anton J A de Louw; Marian H J M Majoie; Janneke P C Grutters

doi:10.1016/j.eplepsyres.2014.12.005

Cost-effectiveness of the ketogenic diet and vagus nerve stimulation for the treatment of children with intractable epilepsy

Epilepsy Res. 2015 Feb:110:119-31. doi: 10.1016/j.eplepsyres.2014.12.005. Epub 2014 Dec 13.

Authors

Reina J A de Kinderen¹, Debby Postulart², Albert P Aldenkamp³, Silvia M A A Evers⁴, Danielle A J E Lambrechts⁵, Anton J A de Louw⁶, Marian H J M Majoie⁷, Janneke P C Grutters⁸

Affiliations

¹ Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands; MHENS School of Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands. Electronic address: Reina.dekinderen@maastrichtuniversity.nl.
² Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands. Electronic address: debby.postulart@gmail.com.
³ Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands; MHENS School of Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands; Department of Behavioral Sciences, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands; ACE Academic Center for Epileptology, Kempenhaeghe/Maastricht University Medical Center, Heeze/Maastricht, The Netherlands; Faculty of Electrical Engineering, University of Technology, Eindhoven, The Netherlands. Electronic address: aldenkampB@kempenhaeghe.nl.
⁴ Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; Trimbos Institute, National Institute of Mental Health and Addiction, Utrecht, The Netherlands. Electronic address: s.evers@maastrichtuniversity.nl.
⁵ Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands; ACE Academic Center for Epileptology, Kempenhaeghe/Maastricht University Medical Center, Heeze/Maastricht, The Netherlands; Department of Neurology, Academic Center for Epileptology Kempenhaeghe, Heeze, The Netherlands. Electronic address: D.lambrechts@kempenhaeghe.nl.
⁶ Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands; ACE Academic Center for Epileptology, Kempenhaeghe/Maastricht University Medical Center, Heeze/Maastricht, The Netherlands; Department of Neurology, Academic Center for Epileptology Kempenhaeghe, Heeze, The Netherlands. Electronic address: louwA@kempenhaeghe.nl.
⁷ Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands; ACE Academic Center for Epileptology, Kempenhaeghe/Maastricht University Medical Center, Heeze/Maastricht, The Netherlands; Department of Neurology, Academic Center for Epileptology Kempenhaeghe, Heeze, The Netherlands. Electronic address: MajoieM@kempenhaeghe.nl.
⁸ Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands. Electronic address: Janneke.grutters@radboudumc.nl.

PMID: 25616464
DOI: 10.1016/j.eplepsyres.2014.12.005

Abstract

Purpose: The objective of this study was to estimate the expected cost-utility and cost-effectiveness of the ketogenic diet (KD), vague nerve stimulation (VNS) and care as usual (CAU), using a decision analytic model with a 5-year time horizon.

Methods: A Markov decision analytical model was constructed to estimate the incremental costs, quality-adjusted life years (QALYs) and successfully treated patient (i.e. 50% or more seizure reduction) of the treatment strategies KD, VNS and CAU, from a health care perspective. The base case considered children with intractable epilepsy (i.e. two or more antiepileptic drugs had failed) aged between 1 and 18 years. Data were derived from literature and expert meetings. Deterministic and probabilistic sensitivity analyses were performed.

Results: Our results suggest that KD is more effective and less costly, and thus cost-effective compared with VNS, after 12 months. However, compared to CAU, neither KD nor VNS are cost-effective options, they are both more effective but also more expensive (€346,899 and €641,068 per QALY, respectively). At 5 years, VNS is cost-effective compared with KD and CAU (€11,378 and €68,489 per QALY, respectively) and has a 51% probability of being cost-effective at a ceiling ratio of €80,000 per QALY.

Conclusions: Our results suggest that on average the benefits of KD and VNS fail to outweigh the costs of the therapies. However, these treatment options should not be ignored in the treatment for intractable epilepsy in individual or specific groups of patients. There is a great need for high quality comparative studies with large patient samples which allow for subgroup analyses, long-term follow-up periods and outcome measures that measure effects beyond seizure frequency (e.g. quality of life). When this new evidence becomes available, reassessment of the cost-effectiveness of KD and VNS in children with intractable epilepsy should be carried out.

Keywords: Economic evaluation; Intractable epilepsy; Ketogenic diet; Modeling; QALY; Vagus nerve stimulation.

Publication types

Comparative Study
Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Child
Child, Preschool
Cost-Benefit Analysis
Diet, Ketogenic / economics*
Epilepsy / economics*
Epilepsy / therapy*
Humans
Infant
Markov Chains
Models, Econometric
Quality-Adjusted Life Years
Vagus Nerve Stimulation / economics*