Economics of Migraine Surgery Compared to Biologic Therapy - a Markov Analysis
Pooja S. Yesantharao, MS1, Erica B Lee, MS1, Kevin M Klifto, PharmD1, A. Lee Dellon, MD, PhD2 and Sashank K Reddy, MD, PhD3,4, (1)Johns Hopkins University School of Medicine, Baltimore, MD, (2)Plastic Surgery, Johns Hopkins University, Baltimore, MD, (3)Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, (4)Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD
INTRODUCTION: Chronic migraine (CM) is a common and debilitating neurological condition. Novel treatment options have recently been described for the prophylactic management of CM refractory to first-line oral agents. These include injectable biologic drugs such as calcitonin gene-related peptide (CGRP) antagonists (erenumab) and botulinum toxin (onabotulinumtoxinA), and surgical management including peripheral neurolysis or neurectomy. Given the expense of these modalities, it is important to understand their expected benefits . This study examined the cost-utility of surgery versus biologic therapies in management of refractory CM.
MATERIALS AND METHODS: This was a cost-utility analysis comparing surgical therapy to erenumab and onabotulinumtoxinA 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 cost-effectiveness from both societal and payer perspectives.
RESULTS: Migraine surgery was associated with a 0.02 increase in QALYs per patient when compared to erenumab, and a 0.03 increase in QALYs per patient when compared to onabotulinumtoxinA. In terms of direct costs (i.e. payer perspective), migraine surgery resulted in a decrease in cost of $19337 when compared to erenumab and a decrease in cost of $12639 when compared to onabotulinumtoxinA. Thus, surgery was a dominant strategy compared to both erenumab and onabotulinumtoxinA. In terms of indirect costs (i.e. societal perspective), migraine surgery resulted in a decrease in cost of $553 when compared to erenumab and a decrease in cost of $470 when compared to onabotulinumtoxinA. Thus, surgery was again the dominant strategy. Multiple scenario analyses were completed to more-comprehensively evaluate cost-effectiveness. In one scenario, we extended the time horizon to 5 years, 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.2 In this scenario, surgery failed to be a dominant strategy over erenumab or onabotulinumtoxinA, due to increased costs per QALY gained as a result of revision procedures.
CONCLUSIONS: In this cost-effectiveness analysis, we demonstrated that surgical deactivation of migraine trigger sites may pose a cost-effective approach to the treatment of refractory chronic migraine in adults, when compared to erenumab or long-term onabotulinumtoxinA injections. However, upon scenario analyses, we found that when considering revision surgery requirements in patients, as well as associated health outcomes, migraine surgery was no longer the dominant strategy.
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