Cost-effectiveness of stereotactic laser ablation (SLA) for brain tumors

Figures & data

Figure 1. (PRISMA) Preferred reporting items for systematic reviews and meta-analysis flow diagram of the search strategy and study selection. GBM: glioblastoma; LITT: laser interstitial thermal therapy.

Table 1. Important terms and definitions used in health economics studies.

Definitions:
Cost Effectiveness Analysis (CEA) [20]	CEA examines the relative costs and health related outcomes of one or more interventions. It compares two interventions by estimating the cost to gain a unit of health outcome such as quality adjusted life years (QALY), life years gained (LYG).
Quality Adjusted Life Years (QALY) [21,22,23]	A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. QALY is calculated as ‘years of life × utility value’, where utility value (quality of life) is 1 for perfect health, 0.5 for bedridden and 0 for dead.
Life Years Gained (LYG)	It is the additional survival of a person in years as a result of receiving the treatment.
Incremental Cost Effectiveness Ratio (ICER) [24,25]	ICER provides a ratio of extra cost per extra unit of health effect. It is calculated by difference in costs of two interventions divided by the differences in their health effect.
Cost to Charge ratio [26]	It is the ratio of the hospital’s total allowable Medicare cost to its total gross charges.
Bundled Payment of Care Improvement (BPCI) [17,27]	BPCI program by Medicare evaluates treatments over extended bundles of care and pays for them. These extended bundles of care include rehabilitation care, nursing home care, home healthcare.
Willingness to Pay (WTP) [28]	WTP is the maximum amount that the payer would agree to pay for availing a treatment. This is used in a cost benefit analysis to valuate the health benefit in financial terms.

Table 2. Salient features and comparison of the two included studies.

Study	Leuthardt 2016 [17]	Voigt 2016 [18]
Country	US	US
Setting	University Hospital	Computational modeling
Study design	Retrospective economic evaluation	Cost-effectiveness economic modeling
Use of actual cost data	Yes	No; Medicare and reimbursement cost data
Focus	Economic aspect of patient outcomes  in relation to location of discharge	Cost-effectiveness of LITT (SLA) vs combined existing treatments (as per NCCN guidelines)
DRGs	[25,26]	[23,25,26]
Treatment groups	1. LITT (SLA) (n = 27) 2. Craniotomy (n = 340)	1. LITT (SLA) 2. Current treatments:  a) Craniotomy ± gliadel wafers  b) Biopsy only
Study population	1. Primary brain cancer 2. Metastatic brain cancer	High-grade glioma  (eloquent, deep-seated lesions)
Findings	LITT (SLA) vs craniotomy  (acute vs post-care costs): 1. Primary brain cancer MD = –US$1669, p = 0.62 2. Difficult to access lesions (primary) MD = –US$4179, p = 0.22 3. Metastatic brain cancer MD = –US$6522, p = 0.02	LITT (SLA) vs current treatments: Cost effectiveness ratio: CER = –US$29,340/LYG OS = +3.07 months
Time horizon	Peri and post-operative period  (including discharge to other sites)	Initial procedure until death  (including complications, rehabilitation costs)
Cost modeling	–	Yes; Decision tree/Markov model; Monte Carlo simulations
ICER	–	Yes; cost/LYG

DRG: Diagnosis Related Group; NCCN: National Comprehensive Cancer Network, MD: median difference; LITT: Laser Interstitial Thermal Therapy; SLA: Stereotactic Laser Ablation; LYG: Life Years Gained; ICER: Incremental Cost Effectiveness Ratio [17,18].

Figure 2. Median difference in acute care costs (in US $) including procedure costs and post-operative care by tumor type between Brain SLA vs craniotomy. SLA: stereotactic laser ablation; DTA: difficult to access lesions [17].

Figure 3. Comparison of base case between SLA and other treatments on outcomes of overall survival (in months) and cost (in US$). In parenthesis is mentioned the willingness to pay amount (in US$) [18]. Other treatments include craniotomy (with or without carmustine wafer) and biopsy. LYG: life years gained; SLA: stereotactic laser ablation; OS: overall survival.

Figure 4. Average length of stay (LOS) in Brain SLA, craniotomy (with or without carmustine /gliadel wafers) and biopsy groups in the two included studies [17,18].

Figure 5. Incidence of discharge to sites other than home like skilled nursing facility, inpatient rehabilitation facility and home healthcare. SLA: stereotactic laser ablation [17].

Figure 6. Flowchart demonstrating direct and indirect costs segmentation.

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