Indication-based analysis of patient outcomes following deep brain stimulation surgery.

BACKGROUND: While considered a safe operation, deep brain stimulation (DBS) has been associated with various morbidities. We assessed differences in postsurgical complication rates in patients undergoing the most common types of neurostimulation surgery. METHODS: The National Readmission Database (NRD) was queried to identify patients undergoing neurostimulation placement with the diagnosis of Parkinson disease (PD), epilepsy, dystonia, or essential tremor (ET). Demographics and complications, including infection, pneumonia, and neurostimulator revision, were queried for each cohort and compiled. Readmissions were assessed in 30-, 90-, and 180-day intervals. We implemented nearest-neighbor propensity score matching to control for demographic and sample size differences between groups. RESULTS: We identified 3230 patients with Parkinson disease, 1289 with essential tremor, 965 with epilepsy, and 221 with dystonia. Following propensity score matching, 221 patients remained in each cohort. Readmission rates 30-days after hospital discharge for PD patients (15.5 %) were significantly greater than those for ET (7.8 %) and seizure patients (4.4 %). Pneumonia was reported for PD (1.6 %), seizure (3.3 %) and dystonia (1.7 %) patients but not individuals ET. No PD patients were readmitted at 30-days due to dysphagia while individuals treated for ET (6.5 %), seizure (1.6 %) and dystonia (5.2 %) were. DBS-revision surgery was performed for 11.48 % of PD, 6.52 % of ET, 1.64 % of seizure and 6.90 % of dystonia patients within 30-days of hospital discharge. CONCLUSION: 30-day readmission rates vary significantly between indications, with patients receiving DBS for PD having the highest rates. Further longitudinal studies are required to describe drivers of variation in postoperative outcomes following DBS surgery for different indications.

Long-Term Specialized Physical Therapy in Cervical Dystonia: Outcomes of a Randomized Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of a specialized physical therapy (SPT) program on disability in cervical dystonia (CD) compared to regular physical therapy (RPT). DESIGN: A single-blinded randomized controlled trial. SETTING: This study was performed by a physical therapist in a primary health care setting. Measurements were performed at baseline, 6 and 12 months in the botulinum toxin (BoNT) outpatient clinic of the neurology department. PARTICIPANTS: Patients with primary CD and stable on BoNT treatment for 1 year (N=96). MAIN OUTCOME MEASURES: The primary outcome was disability assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Secondary outcomes were pain, anxiety, depression, quality of life (QOL), and health related costs over 12 months. RESULTS: A total of 72 participants (30 men, 42 women) finished the study: 40 received SPT, 32 RPT. No significant between group differences were found after 12 months of treatment (P=.326). Over these 12 months both groups improved significantly (P<.001) on the TWSTRS disability scale compared to baseline (SPT 1.7 points, RPT 1.0 points). Short Form 36 (SF-36) General Health Perceptions (P=.046) and self-perceived improvement (P=.007) showed significantly larger improvements after 12 months in favor of SPT. Total health related costs after 12 months were $1373±556 for SPT compared to $1614±917 for RPT. CONCLUSION: SPT revealed no significant differences compared to RPT after 12 months of treatment on the TWSTRS disability scale. Both groups showed similar improvements compared to baseline. Positive results in the SPT group were higher patient perceived effects and general health perception. Treatment costs were lower in the SPT group. With lower costs and similar effects, the SPT program seems to be the preferred program to treat CD.

Internal Pulse Generators in Deep Brain Stimulation: Rechargeable or Not?

OBJECTIVE: Deep brain stimulation (DBS) is a cost-effective strategy for the treatment of different neurologic disorders. However, DBS procedures are associated with high costs of implantation and replacement of the internal pulse generator (IPG). Different manufacturers propose the use of rechargeable IPGs. The objective of this study is to compare the implantation costs of nonrechargeable IPGs versus the estimated costs of rechargeable IPGs in different categories of patients to evaluate if an economic advantage for the health care system could be derived. METHODS: The study looked at 149 patients who underwent a surgical procedure for IPG replacement. In a hypothetical scenario, rechargeable IPGs were implanted instead of nonrechargeable IPGs at the time of DBS system implantation. Another scenario was outlined in a perspective period of time, corresponding to the patients' life expectancy. Costs were calculated, and inferential analysis was performed. RESULTS: A savings of €234,194, including the cost of management of complications, was calculated during a follow-up period of 7.9 years. In a comprehensive life expectancy period of 47 years, a savings of €5,918,188 would be obtained (P < 0.05). Long-term group data point out that a relevant savings would be expected from implantation of rechargeable IPGs in dystonic patients (P < 0.05) and patients with Parkinson disease (P < 0.05), and a savings is projected to occur in other categories of patients (P < 0.05). CONCLUSIONS: Implantation of rechargeable IPGs presents clinical advantages compared with nonrechargeable devices. A huge economic savings can be realized with the implantation of rechargeable IPGs in categories of patients implanted with IPGs for DBS.

Deep brain stimulation for dystonia: patient selection and outcomes.

In a literature survey, 341 patients with primary and 109 with secondary dystonias treated with deep brain stimulation (DBS) of the internal segment of the globus pallidus (GPi) were identified. In general, the outcomes for primary dystonias were more favourable compared to the secondary forms. For some secondary dystonias--like tardive dystonia, myoclonus-dystonia (M-D), NBIA (PANK2), the outcome was very good. Only for the primary generalized dystonias, the efficacy of GPi-DBS has been confirmed in randomised controlled trials. Predictors of outcome are the experience and dedication of the stereotactic team, the selection of patients--the diagnosis and pre-operative screening--and the quality of the post-operative care. Predictors of negative outcome are long duration of the disease--with contractures or scoliosis--and concomitant symptoms like spasticity and cerebellar dysfunction. More studies are required to establish the role of GPi-DBS in the treatment of secondary dystonias.

Utilization and perceived effectiveness of complementary and alternative medicine in patients with dystonia.

The use of complementary and alternative medicine (CAM) is increasing worldwide, especially by patients with chronic diseases. To date, no data are available about utilization and perceived effectiveness of CAM in patients with dystonia. A questionnaire survey on utilization and costs of CAM was completed by 180 members of the German Dystonia Society, a patient advocate group. In total, 131 dystonia patients (73%) were current or former users of CAM, 55 patients used CAM in addition to botulinum toxin A injections, and 86 patients had experience with three or more CAM methods. The options used most widely were acupuncture (56%), relaxation techniques (44%), homeopathy (27%), and massages (26%). Among users of specific CAM methods, breathing therapy, Feldenkrais, massages, and relaxation techniques were perceived as most effective. On average, patients spent 1,513 Euro on CAM without reimbursement. There was no correlation between costs and perceived effectiveness of different methods. In line with other studies on chronically ill patients, our results show that dystonia patients frequently utilize CAM methods, often in addition to conventional treatment. There is a growing need to evaluate scientifically the effect of CAM methods on symptom severity and quality of life in dystonia, to prevent utilization of costly and ineffective CAM treatments.

[Costs of drug treatment of neurologic diseases: Parkinson disease, dystonia, epilepsy]. / Kosten der medikamentösen Behandlung neurologischer Erkrankungen: Morbus Parkinson, Dystonie, Epilepsie.

AIM: The costs of drug treatment were evaluated for Parkinson's disease, focal dystonias and epilepsy. METHODS: Retrospective analysis over a period of 12 months of 785 patients who visited regularly a neurological out-patient department. RESULTS: Drug treatment caused a mean annual expenditure of DM 3,920.- (US-($) 2590, pounds 1690) for Parkinson's disease (n = 409), DM 3,620.- (US-($) 2390; pounds 1550) for focal dystonias (n = 140) and DM 660.- (US-($) 435, pounds 280) for hemifacial spasm (n = 35) per patient.- In Parkinson's disease costs are dependent on the extent of the disease, the type involved and the presence or absence of motor fluctuations. In Hoehn and Yahr stage I we calculated costs of DM 2,230.- (US-($) 1470; pounds 960), in contrast to DM 11,870.- (US-($) 7830; pounds 5100) in Hoehn and Yahr stage V. The occurrence of fluctuations in motor ability increased annual costs to DM 6,010.- (US-($) 3970, pounds 2580); patients' treatment without motor fluctuations was cheaper (DM 2,700.-; US-($) 1780, pounds 1160).- The annual treatment costs of focal dystonias and facial hemispasm varied due to the location of the involuntary movement and the extent of symptoms: DM 4,900.- (US-($) 3300; pounds 2100) were calculated for the treatment of cervical dystonias, DM 1,480.- (US-($) 930; pounds 600) for the treatment of blepharo-spasm (oromandibular dystonia: DM 1,710.-; US-($) 1200; pounds 800) and DM 600.- (US-($) 470; pounds 300) for the treatment of facial hemispasm.- The drug treatment of epilepsy caused mean costs of DM 1,740.- (US-($) 1160; pounds 750) per year. There were marked differences concerning the different epileptic syndromes and types of seizure. CONCLUSION: Costs of drug treatment varied considerably in the three diseases depending on the course, the type and the different forms of the respective disease.