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Meta-analytic techniques support neuroablation as a promising therapy for treatment-refractory obsessive-compulsive disorder (OCD)

Meta-analytic techniques support neuroablation as a promising therapy for treatment-refractory obsessive-compulsive disorder (OCD). OCD was performed using outcome parameters of percent surgical improvement in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score, complications, and side effects. The analysis compared measured societal costs, derived from Medicare reimbursement rates, and effectiveness, based on published RF data. Effectiveness was defined as the degree to which MRgFUS lowered Y-BOCS score. Given that MRgFUS is a new therapy for OCD with scant published data, theoretical risks of MRgFUS capsulotomy were derived from published essential tremor outcomes. Sensitivity analysis yielded cost, effectiveness, and complication rates as critical MRgFUS parameters defining the cost-effectiveness threshold. Literature search identified eight publications (162 subjects). The average reduction of preoperative Y-BOCS score was 56.6% after RF capsulotomy with a 22.6% improvement in utility, a measure of quality of life. Complications occurred in 16.2% of RF cases. In 1.42% of cases, complications were considered acute-perioperative and incurred additional hospitalization cost. The adverse events, including neurological and neurobehavioral changes, in the other 14.8% of cases did not incur further costs, although they impacted utility. Rollback analysis of RF capsulotomy yielded an expected effectiveness of 0.212 quality-adjusted life years/year at an average cost of $24,099. Compared to RF capsulotomy, MRgFUS was more cost-effective under a BI6727 (Volasertib) range of possible cost and complication rates. While further study will be required, MRgFUS lacks many of the inherent risks BI6727 (Volasertib) associated with more invasive modalities and has potential as a safe and cost-effective treatment for OCD. (%) /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ Mean utility /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ em SD /em /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ Utility reference /th /thead Surgery-relatedIntracranial hemorrhage1.421.000.75Danish et al. (2005)NeurologicalDecreased memory2.081.200.69Neumann et al. (1999)Cognitive decline1.421.000.8100.210Klein et al. (2001)Urinary incontinence0.710.710.660.13Castejon et al. (2015)Abulia, apathy4.261.700.6EstimatedNeurobehavioralAnxiety, related4.961.830.6040.017Endicott et al. (2007)Suicide0.710.7100Sox et al. (2013)Misc.0.710.710.8Estimated Open in a separate window em Incidence of operative complications of RF capsulotomy, along with the impact of each on utility and the relevant citation. OCD, obsessive-compulsive disorder; RF, radiofrequency /em . Table 2 Costs (2017 USD) of RF Capsulotomy and MRgFUS for OCD. thead th valign=”top” align=”left” rowspan=”1″ colspan=”1″ Treatment /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ CPT code /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ Professional reimbursement (USD) /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ DRG/APT/CPT (facility) code /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ Facility reimbursement (USD) /th th valign=”top” align=”center” colspan=”2″ rowspan=”1″ Total Reimbursement (USD) hr / /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ Mean /th th valign=”top” align=”center” rowspan=”1″ colspan=”1″ em SD /em /th /thead RF capsulotomy61735, 76377$1,72176377$32??No major complications24$22,197$23,950$2,970??Major complications23$32,898$34,651$4,297MRgFUS0398T, 77290, 61800$5,7881537, 5611, 5612, 5613, 5614$11,743$17,660$2,874 Open in a separate window em Compilation of treatment modality, CPT code, professional reimbursement (USD), facility code, facility reimbursement (USD), and total reimbursement for RF capsulotomy and MRgFUS. OCD, obsessive-compulsive disorder; MRgFUS, magnetic resonance guided focused ultrasound; RF, radiofrequency /em . Comparison of RF Capsulotomy to MRgFUS Because no larger MRgFUS series for OCD have been reported Nkx1-2 other than Jung et al., sensitivity analysis was necessary to make a head-to-head comparison of the two treatments. This sensitivity analysis examined cost, utility, and complications in determine cost-effectiveness threshold for MRgFUS and RF capsulotomy. Using this approach, analysis revealed MRgFUS as the more cost-effective neurosurgical intervention for OCD under a wide range of possible outcomes (Figure 1). Open in a BI6727 (Volasertib) separate window FIGURE 1 Decision tree comparing MgFUS and RF capsulotomy for treatment-refractory OCD. Possible outcomes of each BI6727 (Volasertib) treatment are listed. Acute complications of RF capsulotomy prolong hospital stays and increase costs. OCD, obsessive compulsive disorder; MRgFUS, magnetic resonance guided focused ultrasound; RF, radiofrequency. Discussion Obsessive-compulsive disorder is a chronic and often disabling condition affecting millions of people, and neurosurgical interventions help many who do not benefit from other treatments. The psychiatrist-neurosurgeon Jean Talairach first described and performed the capsulotomy in 1949, and since then numerous technologies have emerged to safely perform this surgery (Zanello et al., 2017). MRgFUS is one such technology and potentially a more viable and cost-effective alternative to RF capsulotomy. Using a decision-making analytical model under multiple parameters of complication rate and procedure cost, these findings support the cost-effectiveness of MRgFUS over RF capsulotomy (Figure 2). These findings rely on the calculated utility of RF capsulotomy as determined by published data.