The cost--effectiveness of unilateral magnetic resonance--guided focused ultrasound in comparison with unilateral deep brain stimulation for the treatment of medically refractory essential tremor in England

Objectives: This study aims to ascertain the cost-effectiveness of magnetic resonance--guided focused ultrasound (MRgFUS) for the treatment of medically refractory Essential Tremor (mrET) in England. Essential Tremor (ET) is the most common movement disorder affecting approximately 1 million in the UK causing considerable societal impact affecting patients, carers and the wider healthservice. Medical treatment has mixed efficacy, with approximately 25-55% of ET medication refractory. Deep brain stimulation (DBS) is a proven neurosurgical treatment; however, the risks of surgery and anaesthesia mean some patients are ineligible. MRgFUS is an emerging noninvasive technique that causes tremor suppression by thermal ablation of tremor--sensitive brain tissue. Several international clinical trials have demonstrated MRgFUS is safe and clinically effective; however, to--date no cost--effectiveness study has been performed in Europe. Methods: A Markov model was used to assess two subpopulations of mrET - those eligible and those ineligible for neurosurgery - in the context specific to England and its healthcare system. For those eligible for neurosurgery, MRgFUS was compared to DBS, the current standard treatment. For those ineligible for neurosurgery, MRgFUS was compared to treatment with medication alone. The model calculated the Incremental cost--effectiveness ratio (ICER) with appropriate sensitivity and scenario analyses. Results: For those eligible for neurosurgery: In the model base case, the MRgFUS was economically dominant compared to DBS; MRgFUS was less costly (19,779 pound vs 62,348) pound and more effective generating 0.03 additional quality--adjusted life--years (QALYs) per patient (3.71 vs 3.68) over the 5--year time horizon. over the 5--year time horizon. For those ineligible for neurosurgery: In the model base case, MRgFUS cost over 16,000 pound per patient more than medication alone (19,779 pound vs 62,348) pound but yielded 0.77 additional QALYs per patient(3.71 vs 2.95), producing an incremental cost--effectiveness ratio (ICER) of 20,851 pound per QALY. This ICER of 20,851 pound per QALY falls within the National Institute for Clinical Excellence's (NICE) willingness to pay threshold (WTP) of 20,000-30,000 demonstrating the cost--effectiveness profile of MRgFUS. Conclusion: This study demonstrates the favourable cost-effectiveness profile of MRgFUS for the treatment of mrET in England; in both patients suitable and not suitable for neurosurgery. Advances in knowledge: The introduction of MRgFUS as a widely available ET treatment in UK is currently undergoing the necessary stages of regulatory approval. As the first European study, these favourable cost--effectiveness outcomes (notably the model base case ICER falling within NICE's WTP) can provide a basis for future commissioning of brain MRgFUS treatments in the UK, Europe and globally.