Hinnovic » In an overburdened health care system, who will have access to DBS first? The challenges of resource allocation

In an overburdened health care system, who will have access to DBS first? The challenges of resource allocation

In an overburdened health care system, who will have access to DBS first?DBS costs tens of thousands of dollars per patient. Though a certain number of studies have shown its cost-effectiveness for Parkinson’s disorders (Bell et al, 2009, 581), it remains a large investment. Regulators, administrators and insurers may feel obliged to restrict the amount of DBS interventions performed, even more so if its use is significantly extended to psychiatric illnesses.

 

     
 

A number of studies (summarised in Bell et al, 2009: 581) have examined the costs associated to DBS in the treatment of patients with Parkinson’s Disorder (PD):

  1. Estimated over the 6 months before and after surgery, the total costs of PD were shown to decrease from 10 087 Euro to 1 673 Euro, mainly because of the decrease in medication (Fraix et al, 2006).

  2. Treatment costs in patients with PD followed up for 2 years after DBS implantation showed an increase of 32% in the first year of DBS therapy but a decrease of 54% in the second year when compared to preoperative expenses (Meissner et al, 2005).

  3. DBS has been shown to reduce pharmacological expenditures in PD from approximately 13 208 Euro to approximately 3 799 Euro in patients treated with alternative best medical treatment (Valldeoriola et al, 2007).

  4. The impact of DBS on health care expenditures in the treatment of psychiatric conditions is still unclear.

 
     

 

In fact, although DBS has been shown to have the potential for reducing treatment costs and pharmacological expenditures, this does not necessarily take into account potential economic gains made when patients see their functional capabilities improved. For several PD and psychiatric patients, a DBS procedure may also translate into going back to work. Unfortunately, because some aspects of cost-effectiveness may be difficult to quantify, health care systems may favour acute lifesaving interventions over functional ones. There is clearly a need for an analysis of the economic savings or gains provided by the DBS intervention.

 

If the investment DBS represents results in increased wait times or waiting lists, how will appropriate candidates for DBS be prioritized? Knowing that DBS is a last resort procedure, when all other treatments have failed, increased wait times and waiting lists raise important ethical issues from a patient’s or caregiver’s perspective. What if a potential candidate on the waiting list develops a comorbid condition which rules him/her out of the procedure? How do we make decisions about prioritizing access in refractory depressed patients who may have acute suicidal thoughts? There will clearly be a need for jurisdictions to clarify their resource allocation policies for DBS.

 

     
 

This text summarises the ethical issues related to deep brain stimulation, developed and discussed in an excellent publication by Emily Bell, Ghislaine Mathieu and Eric Racine. (2009). Preparing the ethical future of deep brain stimulation. Surgical Neurology, 72: 577-586. The summary has been approved by the first author.

 
     

Adapted by : Myriam Hivon, Ph.D.

 

REFERENCES

  • Bell E, Mathieu G, Racine E (2009). Preparing the ethical future of deep brain stimulation. Surgical Neurology, 72: 577-586.

  • Fraix V, Houeto JL, Lagrange C, et al. (2006) Clinical and economic results of bilateral subthalamic nucleus stimulation in Parkinson’s disease. J Neurol Neurosurg Psychiatry 77:443-9.

  • Meissner W, Schreiter D, Volkmann J, et al. (2005). Deep brain stimulation in late stage Parkinson’s disease: a retrospective cost analysis in Germany. J Neurol 252:218-23.

  • Valldeoriola F, Morsi O, Tolosa E, et al. (2007). Prospective comparative study on cost-effectiveness of subthalamic stimulation and best medical treatment in advanced Parkinson’s disease. Mov Disord 22: 2183-91.

 

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