Response to Journal Club: Surgical Management of Trigeminal Neuralgia: Use and Cost-Effectiveness From an Analysis of the Medicare Claims Database.

T he authors appreciate Drs Mazur and Ravindra’s very detailed analysis of our article. which points out in a very systematic way all the strengths and weaknesses of our study. We respect their concluding remarks: “the results of this study are hypothesis generating at best, but the evidence is not strong enough to guide surgical decision making. . .” but would like to briefly discuss the second half of this same sentence: “. . .or alter health service delivery for TN.” The picture that we have portrayed of the different surgical treatments for trigeminal neuralgia (TN), relies on peer-reviewed scientific studies including some of the most commonly cited references in the field that were all included and discussed in recent reviews of the literature. Those are the studies routinely used by practitioners to discuss the risks and benefits of each treatment option. The use of billing data to discuss treatment utilization might not be the most accurate, but it is currently the best available source of information, often used by government, trade groups, and advocacy groups to promote their respective arguments. There are certainly a multitude of reasons why a specific treatment is chosen for 1 individual patient, and such a decision is the result of careful consideration of the pros and cons of each option within the privileged doctor-patient relationship. Nevertheless, given the current economic environment, there is a growing need to justify such a decision with accurate outcome data and to demonstrate that any additional investment in the patient’s health correlates with improved outcome in comparison with a less onerous option. In the case of TN, our study confirms that microvascular decompression, despite being the most expensive treatment, provides the best outcome of all 3 modalities. Its use as treatment of choice for medically refractory neuralgia can therefore be justified from a medical and economic perspective. It would bemuch harder to explain the choice of stereotactic radiosurgery as the second most commonly utilized treatment with the currently available data on efficacy and cost that make it 11 times less cost-effective than the alternative percutaneous rhizotomy, a surgical option that provides similar pain relief at a significantly lesser cost. We agree with Mazur and Ravindra that a financial analysis should include all financial aspects of the treatment, including all indirect costs such as time away from work. Nevertheless, it is very unlikely that any sensitivity analysis would reverse an 11-fold difference in cost-effectiveness such as the one that separates stereotactic radiosurgery from percutaneous stereotaxic rhizotomy. Unless the neurosurgical community is able to clearly demonstrate the value of stereotactic radiosurgery (defined by the equation quality cost ), it is conceivable that insurers could, in the future, deny payment for radiosurgical treatment in favor of percutaneous stereotaxic rhizotomy. In summary, we believe that our article should alter the way health services are delivered for TN in the sense that individual practitioners should be aware of their value choice and be very careful to explicitly justify why a less cost-effective treatment is chosen for a particular patient. In the current health care delivery model, the person who chooses the treatment and the person who benefits from the treatment are not the entity that covers the cost of the treatment. Such amodel puts the burden of proving the soundness of the treatment choice on the shoulders of those who make the choice and those who benefit from the choice. Treatments that cannot demonstrate an added value might 1 day be denied by insurance companies on the basis that a less expensive option achieves the same result. The problem of assessing the value of different treatmentmodalities is generating a lot of attention as the Affordable Care Act is scrutinized and maybe modified. Other high-cost medical specialties such as oncology have created dedicated task forces to investigate the value (or lack thereof) of different treatments and provide arguments to justify (or deny) their use. Our article will Siviero Agazzi, MD, MBA*