Pediatric VNS Surgery: Pay Now or Pay More Later
By: MICHELE G. SULLIVAN, Clinical Psychiatry News Digital Network
12/20/11
BALTIMORE – "Pay now, save later" could be the motto in the case of vagus nerve stimulation surgery for young Medicaid patients who have intractable epilepsy.
In a study of 30-month outcomes in 445 children, vagus nerve stimulation (VNS) surgery had nearly paid for itself within a year, and began to save taxpayers money soon afterward, Dr. Sandra Helmers reported at the annual meeting of the American Epilepsy Society.
Dr. Sandra Helmers
http://www.clinicalpsychiatrynews.com/uploads/RTEmagicC_r78406ph_Helmers_Sandra_ATL.jpg.jpg
"When we looked at the annual costs of emergency department and hospitalization before and after VNS surgery, we found that the overall cost savings began in the fifth or sixth quarter after surgery," and continued to increase in succeeding quarters, said Dr. Helmers, a neurologist at Emory University Hospital and Clinic, Atlanta. "This is the way we need to look at these treatments, in terms of real-world outcomes in both health and finances."
She and her colleagues divided the group of children by age: patients aged 1-11 years (238) and patients aged 12-17 years (207). All were Medicaid recipients.
Among the younger group, the mean age at the time of surgery was 7 years. All had still been having seizures despite medical therapy. They had tried a mean of four antiepileptic drugs before surgery, and 63% were on polytherapy.
The mean age at the time of surgery in the older group was 15 years. They had tried a mean of four antiepileptic drugs before surgery, and 64% were on polytherapy.
The cost of the surgery ranged from about $20,000 to $30,000, which is "fairly high relative to the preimplant costs," Dr. Helmers said.
But it didn’t take long before the savings began to show, in terms of decreased hospital and ED visits, she said. In the first 6 months after the surgery, the younger patients were 27% less likely to have an ED visit and 26% less likely to have a hospital admission than they were in the prior 6 months. The surgery resulted in savings, but the overall costs were not quite statistically significant ($17,831 vs. $18,220 quarterly [P = .052]) in the 6 months before and after surgery.
During their 6-month postsurgery period, older patients were 57% less likely to go to the ED and 56% less likely to have a hospital admission. Average total health care costs were significantly lower in the 6 months after surgery than the 6 months before ($14,068 vs. $19,047 quarterly [P = .002]).
Although VNS surgery did positively affect hospitalizations, it did not significantly change the number of antiepileptic drugs the children took, Dr. Helmers noted. "We can’t really say anything about adding new medications, because these were refractory patients and for them, another trial of medicine typically does not give much benefit."
The findings are encouraging, because they show that the short-term expense of stabilizing children’s intractable epilepsy brings long-term savings.
"It is difficult for these children to get this intervention. Health insurance is the major barrier to good care for epilepsy. And if you don’t have insurance, you are unlikely to get this."
Policy makers need to know this kind of information, she said. "This pays off [in the United States] just as it has been shown to in other parts of the world. In our country we don’t use data like these to dictate policy – but that is coming. How that will play out in the future is something we still don’t know."
Dr. Helmers had no financial disclosures.
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Wednesday, December 28, 2011
Tuesday, December 20, 2011
Surgical revision of vagus nerve stimulation electrodes in children.
Otolaryngol Head Neck Surg. 2011 Jan;144(1):123-4.
Surgical revision of vagus nerve stimulation electrodes in children.
Source
University of Texas Medical School at Houston, Houston, Texas, USA.Abstract
Use of vagus nerve stimulation (VNS) has increased in the past decade, resulting in frequent revision cases for device failure. The authors report their series of children who underwent reimplantation of the VNS device after removal of old electrodes and leads. Patients with medically refractory seizures who underwent revision of VNS electrodes were included (n = 23). Twenty patients had high lead impedance and underwent removal of the device and replacement of the VNS electrodes during the same procedure. In 3 patients, electrodes and the device had been removed previously at an outside institution because of infection. None of the patients experienced any major complications. Mean operative time was 2.3 ± 0.9 hours. The reimplanted device worked well in all patients, and seizure control was similar to or better than that reported with the previous device. Thus, implantation of the VNS electrodes is reversible, and it appears that the electrodes can be removed or replaced safely if the device is not functioning properly.Vagal nerve stimulator infection: a lead-salvage protocol.
J Neurosurg Pediatr. 2011 Jun;7(6):671-5.
Vagal nerve stimulator infection: a lead-salvage protocol.
Source
Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR 97239, USA.Abstract
OBJECT:
Vagal nerve stimulator (VNS) hardware infections are fraught with difficult management decisions. As with most implanted medical device-related infections, standard practice traditionally involves complete hardware removal, systemic antibiotic therapy, and subsequent reimplantation of the device. To avoid the potential morbidity of 2 repeat left carotid sheath surgical dissections, the authors have implemented a clinical protocol for managing VNS infections that involves generator removal and antibiotic therapy without lead removal.METHODS:
A prospective, single-surgeon database was compared with hospital billing records to identify patients who underwent primary implantation or reimplantation of a VNS lead, generator, or both, from January 2001 to May 2010, at Oregon Health & Science University. From these records, the authors identified patients with VNS hardware infections and characterized their management, using a lead salvage protocol.RESULTS:
In their review, the authors found a matching cohort of 206 children (age 3 months-17 years) who met the inclusion criteria. These children underwent 258 operations (including, in some children, multiple operations for generator end of life and/or lead malfunction). Six children experienced a single postimplantation infection (2.3% of the 258 operative cases), and no child experienced repeated infection. A lead-salvage protocol was used in 4 of 6 infected patients and was successful in 3 (75%), with clinical follow-up ranging from 10 months to 7.5 years. The fourth patient subsequently underwent lead removal and later reimplantation in standard fashion, with no adverse sequelae.CONCLUSIONS:
Vagal nerve stimulator lead salvage is a safe and potentially advantageous strategy in the management of VNS-related infection. Further study is necessary to validate appropriate patient selection, success rates, and risks of this approach.- PMID:
- 21631207
- [PubMed - indexed for MEDLINE]
Tuesday, December 13, 2011
Season's Greetings...
A brief video from Joyce and me to you and yours for a Happy Holiday Season including Joyce’s yearly update on her VNS Therapy. Be sure to turn up the volume to hear Joyce.
Herb
Tuesday, December 6, 2011
Systematic review and meta-analysis of vagus nerve stimulation in the treatment of depression: Variable results based on study designs.
Eur Psychiatry. 2011 Nov 30. [Epub ahead of print]
Systematic review and meta-analysis of vagus nerve stimulation in the treatment of depression: Variable results based on study designs.
Source
School of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain.Abstract
PURPOSE:
To determine the efficacy of vagus nerve stimulation (VNS) for treatment of depression.METHODS:
We conducted a systematic review and meta-analysis of analytical studies. Efficacy was evaluated according to severity of illness and percentage of responders.RESULTS:
We identified 687 references. Of these, 14 met the selection criteria and were included in the review. The meta-analysis of efficacy for uncontrolled studies showed a significant reduction in scores at the Hamilton Depression Rating Scale endpoint, and the percentage of responders was 31.8% ([23.2% to 41.8%], P<0.001). However, the randomised control trial which covered a sample of 235 patients with depression, reported no statistically significant differences between the active intervention and placebo groups (OR=1.61 [95%CI 0.72 to 3.62]; P=0.25). To study the cause of this heterogeneity, a meta-regression was performed. The adjusted coefficient of determination (R(2)(Adj)) was 0.84, which implies that an 84% variation in effect size across the studies was explained by baseline severity of depression (P<0.0001).CONCLUSION:
Currently, insufficient data are available to describe VNS as effective in the treatment of depression. In addition, it cannot be ruled out that the positive results observed in the uncontrolled studies might have been mainly due to a placebo effect.Copyright © 2011 Elsevier Masson SAS. All rights reserved.
Friday, December 2, 2011
Vagus nerve stimulation has a positive effect on mood in patients with refractory epilepsy.
Clin Neurol Neurosurg. 2011 Nov 28. [Epub ahead of print]
Vagus nerve stimulation has a positive effect on mood in patients with refractory epilepsy.
Source
Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands.Abstract
BACKGROUND:
Preliminary research on the efficacy of vagus nerve stimulation (VNS) indicated additional effects on neuropsychological variables like mood and quality of life (QOL).OBJECTIVES:
The objectives of this prospective longitudinal observational cohort study were to assess the effects of VNS on mood, QOL and cognition in patients with refractory epilepsy and to determine whether these effects occur dependent of seizure control.METHODS:
We included 41 patients with refractory epilepsy; treated with VNS as part of usual patient care. A neuropsychological battery was performed during baseline and repeated after 6 months of VNS in order to compare neuropsychological variables before and after VNS. All patients completed seizure diaries.RESULTS:
Significant improvements were observed for both mood and QOL after 6 months of VNS; based on the results in the POMS and QOLIE-89 questionnaires (p<0.05). There was no significant change in cognition. Mean percentage change in seizure frequency was -9.0%, while 20% of the patients achieved a seizure frequency reduction of 50% or more. No significant correlation was found between changes in seizure frequency and improvements in mood or QOL.CONCLUSIONS:
VNS is associated with improvements in both mood and QOL in patients with refractory epilepsy. Since these improvements appeared to be independent of seizure control, the results of this study indicate an additional antidepressant effect of VNS, which can be of extra value in view of the high co-morbidity of mood disturbances in patients with epilepsy.Copyright © 2011 Elsevier B.V. All rights reserved.
- PMID:
- 22130047
- [PubMed - as supplied by publisher]
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