A Markov Analysis of Surgical versus Medical Management of Chronic Migraines
Year: 2021
Type: article
Abstract: PURPOSE: Refractory chronic migraine (CM) is a common and debilitating neurological condition, affecting over 8 million people in the United States. It is associated with billions of dollars in lost productivity annually. Novel medical (anti-calcitonin gene-related peptide antibodies, or erenumab) and surgical treatment modalities have emerged for CM in recent years. Given the substantial economic burden of CM, it is not sufficient to simply understand clinical outcomes: it is also critical to study the cost-utility of CM treatment, especially in refractory cases. Although prior studies have demonstrated the cost-utility of migraine surgery over long-term onabotulinumtoxinA injections, no one has investigated the cost-utility of migraine surgery versus medical management of CM with erenumab. The current study examined the cost-utility of surgical versus medical management of refractory CM. METHODS: This was a cost-utility analysis comparing surgical therapy to erenumab in adults with refractory CM. The primary model outcomes were the incremental cost-effectiveness ratio (ICER), which is represented in terms of cost per quality-adjusted life year (QALY) gained. Hybrid Monte Carlo patient simulation and Markov cohort modeling were used to study the cost-effectiveness from both societal (indirect costs—time lost from work, productivity lost, etc.) and payer perspectives (direct costs—costs of care, cost of medication, facility fees, etc.). RESULTS: Migraine surgery was associated with a 0.2 increase in QALYs per patient when compared with erenumab. In terms of direct costs (ie, payer perspective), migraine surgery resulted in a decrease in cost of $19,337 when compared with erenumab. Thus, surgery was a dominant strategy compared with erenumab given that it reduced global costs and improved patient-reported outcomes. In terms of indirect costs (ie, societal perspective), migraine surgery resulted in a decrease in cost of $470 when compared with erenumab. Thus, surgery was again the dominant strategy as it reduced indirect costs and improved patient outcomes in comparison with erenumab. Multiple scenario analyses were completed to more-comprehensively evaluate cost-effectiveness. In one scenario, we extended the time horizon of the model, and we assumed that 12% of patients undergoing migraine surgery required revision surgery within five years of the initial procedure, based on published results by Guyuron et al. Even in this scenario, surgery remained the dominant strategy over erenumab, as global direct and indirect costs considering revision procedures were still less than costs associated with lifetime utilization of erenumab. Sensitivity analyses demonstrated that surgery was cost-effective compared with erenumab when patients required medical therapy for at least 1 year. CONCLUSIONS: Given that migraine surgery and erenumab each have their respective benefits and limitations, it is important to specifically understand the relative cost-utility of these two treatment modalities for refractory CM. Our model suggests that surgical deactivation of migraine trigger sites may pose a cost-effective approach to treating refractory CM in adults. This is especially the case when patients are anticipated to require medical therapy with erenumab for more than 1 year. Understanding when it is cost-effective to perform migraine surgery may help expand coverage and access for those patients who can specifically benefit from this therapy.
Institution: Stanford University
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,195
OpenAlex ID: W4286917345