Authors: Abbas Rattani; Abbas Rattani; Michael Dewan; Chevis Shannon; John Wellons, III; Edith Kabachelor; Peter Ssenyonga, MD; Steven Schiff, MD, PhD; Abhaya Kulkarni, MD, PhD; Mark Shrime; Benjamin Warf, MD (Chicago, IL)
Evidence suggests ETV/CPC is equivalent to VPS as the initial treatment in regard to neurocognitive outcomes, brain growth, and treatment failure and complication rates at one year. However, the incremental cost effectiveness between the two strategies remains unknown. This is of particular importance for surgeons in low and middle-income countries (LMICs) where is found the greatest burden of PIH. We sought to identify the most cost-effective strategy in the treatment of PIH.
A post hoc cost-effectiveness analysis was performed on an intention-to-treat 100-patient cohort of infants presenting with PIH to a tertiary care hospital in Mbale, Uganda that had been randomized to receive ETV/CPC or VPS.
Cost and effectiveness values for ETV/CPC and VPS were $624.61 with 0.125 disability-adjusted life years (DALYs) and $674.71 with 0.121 respectively, where 0 is perfect health. The incremental cost associated with 1 additional unit of effectiveness was $11,133.32 per disability-adjusted life-year (DALY) with a net monetary benefit difference of $40.39— making ETV/CPC the optimal strategy at the willingness-to-pay threshold of $2,157.60/DALY for this Ugandan cohort. These findings were corroborated by our sensitivity analysis. Additionally, our model noted that shunt infection rates alone had to occur at a rate of < 1% in our base-case model to render VPS more cost-effective in Uganda.
Our study adds to the growing literature establishing ETV/CPC as a valuable approach in addressing the global burden of hydrocephalus. Despite ETV/CPC being slightly less effective in the first-year—as anticipated—and requiring a greater initial investment in non-disposable operable equipment in the first year, the overall ICER favors ETV/CPC as the intervention of choice in the treatment of PIH in this cohort. This is especially relevant in socioeconomic settings similar to Uganda where long-term shunt management is increasingly difficult.