Cost-effectiveness of treatments in neurological diseases

Professor Dyfrig Hughes and colleagues at the Centre for Health Economics and Medicines Evaluation, School of Health Sciences, have recently published the results of three clinical trials of interventions in epilepsy and sciatica.

The Standard and New Antiepileptic Drugs (SANAD II) trials, led by Professor Tony Marson of the University of Liverpool, compared a range of antiepileptic drugs for how well they control seizures, their general tolerability and their cost-effectiveness, to assess whether newer drugs should be recommended as first-line treatments. This involved 1,510 participants, who were followed-up for up to six years.

The findings, published in the leading medical journal, The Lancet, conclude that valproate is still the best first choice for generalised epilepsy, while lamotrigine remains the best first-line drug for focal epilepsy. 

Dr Catrin Plumpton and Professor Dyfrig Hughes assessed the cost-effectiveness of each treatment, and calculated that for generalised epilepsy, valproate was more effective and less expensive overall compared to levetiracetam. For patients with focal epilepsy, lamotrigine was cost-effective compared with levetiracetam and zonisamide.

Dyfrig commented: "Our economic assessments support the clinical results in that treatments which were less effective were also not cost-effective. These findings should lead to a change in clinical practice, away from levetiracetam which has been widely used as a treatment of first choice.” 

The NERVES clinical trial, led by Dr Martin Wilby at the Walton Neurological Centre, compared the clinical effectiveness and cost-effectiveness of surgery with a steroid injection – admininstered into the lower back, between the spine and spinal cord – in patients with sciatica caused by a ‘slipped disc’. 163 patients were recruited between 2015 and 2017. The results, published in Lancet Rheumatology, indicated that while there was no significant differences in clinical outcomes, surgery was unlikely to be a cost-effective alternative to steroid injection. Eifiona Wood, Dr Dan Hill-McManus and Professor Dyfrig Hughes estimated that the cost-effectiveness ratio exceeded the threshold applied by the National Institute for Health and Care Excellence (NICE) when judging the value of healthcare interventions.

Dyfrig commented: “The results of the NERVES trial are expected to influence the the way in which patients with sciatica are managed in hospital settings. Surgery is not a cost-effective option for patients who are eligible for a steroid spinal injection. These results highlight the importance of considering economic outcomes in supporting decisions on the best use of health care resources.” 

The SANAD II and NERVES trials were funded by the National Institute for Health Research Health Technology Assessment Programme.
eferences:
Marson A, Burnside G, Appleton R, Smith D, Leach JP, Sills G, Tudur-Smith C, Plumpton C, Hughes DA, Williamson P, Baker GA, Balabanova S, Taylor C, Brown R, Hindley D, Howell S, Maguire M, Mohanraj R, Smith PE; SANAD II collaborators. The SANAD II study of the effectiveness and cost-effectiveness of valproate versus levetiracetam for newly diagnosed generalised and unclassifiable epilepsy: an open-label, non-inferiority, multicentre, phase 4, randomised controlled trial. Lancet. 2021 Apr 10;397(10282):1375-1386.
Marson A, Burnside G, Appleton R, Smith D, Leach JP, Sills G, Tudur-Smith C, Plumpton C, Hughes DA, Williamson P, Baker GA, Balabanova S, Taylor C, Brown R, Hindley D, Howell S, Maguire M, Mohanraj R, Smith PE; SANAD II collaborators. The SANAD II study of the effectiveness and cost-effectiveness of levetiracetam, zonisamide, or lamotrigine for newly diagnosed focal epilepsy: an open-label, non-inferiority, multicentre, phase 4, randomised controlled trial. Lancet. 2021 Apr 10;397(10282):1363-1374.
Wilby MJ, Best A, Wood E, Burnside G, Bedson E, Short H, Wheatley D, Hill-McManus D, Sharma M, Clark S, Baranidharan G, Price C, Mannion R, Hutchinson PJ, Hughes D, Marson AG, Williamson, P. A Randomised Controlled Trial of Surgical Microdiscectomy versus Trans-foraminal Epidural Steroid Injection for sciatica of up to 1 year; the NERVES trial. The Lancet Rheumatology 26 Jan 2021.

Publication date: 21 April 2021