Deep Brain Stimulation (DBS)
Health Technology Assessment Committee Recommendations¹
- Given deep-brain stimulation (DBS) is more clinically and cost-effective than DUODOPA for patients with advanced Parkinson’s disease, access to DBS should be improved.
- There is a large unmet need for DBS in patients with advanced Parkinson’s disease in BC. An opportunity exists to increase patient access to DBS through collaboration between Vancouver Coastal Health and Fraser Health Authorities, and should be pursued via the Lower Mainland Surgical Group.
Health Technology Assessment Committee Findings
- Direct comparisons between DBS and DUODOPA were limited to two retrospective observational studies of lower quality that reported small sample sizes and were subject to a high risk of selection bias. Indirect comparisons of DBS and DUODOPA were limited to five parallel RCTs of good quality. Observational studies included one 15-month study of 40 patients and one 5 year study involving 60 patients.
- The 15 month study did not find significant differences between DUODOPA and DBS in all four Unified Parkinson’s Disease Rating Scales (UPDRS), but the follow-up period for this study was short. The 5-year observational study involving 60 patients found DBS to be significantly more effective at improving symptoms of troublesome dyskinesia, but found the two modalities to be comparable in other UPDRS subscales. An indirect comparison of RCT studies demonstrated that patients receiving DBS experienced significant improvement in UPDRS III, IV and daily ON time without troublesome dyskinesia when compared to DUODOPA. Indirect RCT comparisons also demonstrated that DBS patients gained an additional average of 2.2 hours of daily ON time without troublesome dyskinesia when compared to DUODOPA.
- Effective treatment for advanced PD greatly improves the quality of life of those living with the disease by improving physical and cognitive abilities, reducing the risk of serious injuries, and enhancing social connections and relationships.
- Treatment of advanced PD with DBS, as compared to DUODOPA, is much more cost-effective at a wide range of willingness-to-pay values per quality adjusted life year. The cost per quality adjusted life year (QALY) for DBS is $66,102, compared to the cost of DUODOPA which is $177,814 per QALY. The total cost over ten years to treat a patient with DBS is $228,053. The total cost over ten years to treat a patient with DUODOPA is $537,000. In order to have the same cost-effectiveness profile as DBS, a 78% reduction in the cost of DUODOPA would be required.
- Current capacity for DBS surgery is substantially below demand for treatment, resulting in an average wait-time of 3-4 years. Addressing the backlog demand for DBS surgeries or DUODOPA will require approximately 152 primary surgeries per year (either DBS surgeries or PEG-J implants for DUODOPA) for the next four years, and a capacity of 92 surgeries annually thereafter to keep wait times below 1 year.
- Implementation of either treatment procedure to all eligible patients across British Columbia would require an increase in specialized clinic services for the long-term management and post-operative care for patients, improved capacity to perform surgeries, and attracting, training and retaining qualified surgeons to perform the procedure.
- Currently in BC, one functional neurosurgeon is contracted to provide DBS surgeries under an alternative payment plan. Clinician and health authority stakeholders stated that the current MSP fee schedule for DBS is unattractive given the length of the procedure.