Comparison of utilization and cost of healthcare services and pharmacotherapy following implantation of vagus nerve stimulation vs. responsive neurostimulation or deep brain stimulation for the treatment of drug-resistant epilepsy: analyses of a large United States healthcare claims database

Abstract

Aim

Vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) all are options for drug-resistant epilepsy (DRE). However, little is known about how the choice of neurostimulation impacts subsequent healthcare costs.

Materials and methods

We used a large US healthcare claims database to identify all patients with epilepsy who underwent neurostimulation between 2012 and 2019. Eligible patients were identified and stratified based on procedure received (VNS vs. RNS/DBS). VNS patients were matched by propensity scoring to RNS/DBS patients. Use and cost of healthcare resources and pharmacotherapy were ascertained over the 24-month period following neurostimulation, incorporating all-cause and epilepsy-related measures. Disease-related care was defined based on diagnoses of claims for medical care and relevant pharmacotherapies.

Results

Seven hundred and ninety-two patients met all selection criteria. VNS patients were younger, were prescribed a higher pre-index mean number of anti-seizure medications (ASMs), and had higher pre-index levels of use and cost of epilepsy-related healthcare services. We propensity matched 148 VNS patients to an equal number of RNS/DBS patients. One year following index date (inclusive), mean total all-cause healthcare costs were 50% lower among VNS patients than RNS/DBS patients, and mean epilepsy-related costs were 55% lower; corresponding decreases at the two-year mark were 41% and 48%, respectively.

Limitations

Some clinical variables, such as seizure frequency and severity, quality of life, and functional status were unavailable in the database, precluding our ability to comprehensively assess differences between devices. Administrative claims data are subject to billing code errors, inaccuracies, and missing data, resulting in possible misclassification and/or unmeasured confounding.

Conclusions

After matching, VNS was associated with significantly lower all-cause and epilepsy-related costs for the two-year period following implantation. All-cause and epilepsy-related costs remained statistically significantly lower for VNS even after costs of implantation were excluded.

PLAIN LANGUAGE SUMMARY

For some people with epilepsy, medications do not work very well. For these people, other treatment options exist. One such treatment is neurostimulation. There are three types of neurostimulators—vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS). All three devices are known to reduce seizures in patients who have tried several medications. However, it is not known how these devices impact the costs of care. We compared the use and costs of medical care over 2 years between patients who got VNS and those who got RNS/DBS. Before comparing the groups, we made sure that they were balanced. Patients who got VNS were less likely than patients who got RNS/DBS to go to the hospital during the follow-up period. Patients who got VNS also had lower healthcare costs than patients who got RNS/DBS during follow-up. These differences were seen for all medical care costs. These differences also were seen in the costs of care for epilepsy. Our results suggest that the use of VNS is associated with fewer hospitalizations than RNS/DBS, and also that use of VNS is associated with lower healthcare costs than RNS/DBS.

Keywords:

• Epilepsy
• seizure
• neuromodulation
• neurostimulation
• claims analysis
• administrative claims
• healthcare
• healthcare costs
• healthcare research
• healthcare resource utilization

JEL CLASSIFICATION CODES:

• I00
• I
• I19
• I1
• I

Transparency

Declaration of funding

This work was supported by LivaNova, PLC.

Declaration of financial/other relationships

Authors VD, JM, FB, and RL are paid employees and potential shareholders of LivaNova, a manufacturer of vagus nerve stimulation devices. Authors AB, QL, MS, and TV have served as paid consultants for LivaNova, as well as other pharma, biotech, and device companies, in their capacity as Evidera employees. Author SL has served as a consultant for LivaNova for scientific advisory, and as a speaker for a LivaNova webinar on access to care in epilepsy. Author LZ declares no conflicts of interest.

Author contributions

All authors listed meet the requirements for authorship, have been involved in all aspects of the study, believe that this manuscript adheres to ICMJE requirements, and have read and approved this final version of the manuscript and the authorship list. All authors had access to all the study data, take responsibility for the accuracy of the analysis, and had authority over manuscript preparation and the decision to submit the manuscript for publication.

Acknowledgements

The authors wish to thank the following individuals for their expertise and assistance throughout all aspects of our study: Carla Monacelli, Eliza Hagen, Ryan Verner, and Nicole Stamas.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.