Conservative management, surgery and radiosurgery for treatment of vestibular schwannomas: a model-based approach to cost-effectiveness

Objective To undertake a cost-effectiveness analysis comparing conservative management, surgery and radiosurgery for treating small-to-medium (1-20mm)-sized vestibular schwannomas. DesignModel-based economic evaluation using individual-level data from a Birmingham-based longitudinal patient database and from published sources. Both a decision tree and state-transition (Markov) model were developed, from an National Health Service (NHS) perspective. Sensitivity analyses were also carried out. SettingSecondary care treatment for patients with small-to-medium-sized vestibular schwannomas. ParticipantsThree hypothetical cohorts of adult patients receiving conservative management, radiosurgery or surgery treatment, aged 58years as starting age within model. Main outcome measuresCost-effectiveness based on cost per quality-adjusted life year (QALY). ResultsConservative management is the preferred strategy for the treatment of small-to-medium-sized vestibular schwannomas. Conservative management is both cheaper (-722 and -2764) pound and more effective (0.136 and 0.554 quality-adjusted life years) than both radiosurgery and surgery, respectively. A conservative strategy can therefore be considered as highly cost-effective. This result is sensitive to the assumed quality-of-life parameters in the model. Sensitivity analysis suggests that the probability of a conservative strategy being the most cost-effective approach compared with surgery and radiosurgery at a willingness to pay of 20000 pound/quality-adjusted life year gained is 80% and 55%, respectively. ConclusionsA conservative approach is the preferred strategy for treatment of small-to-medium vestibular schwannomas. This result is sensitive to quality-of-life values used in the analysis. More research is required to assess the impact of treatment upon patients' health-related quality of life over time.