Endoscopic Third Ventriculostomy and Choroid Plexus Cauterization (ETV+CPC) versus Ventriculoperitoneal Shunt (VPS) for the Treatment of Infant Hydrocephalus: A Cost-effectiveness Analysis

Introduction: As ETV+CPC has been adopted more globally, uncertainly exists as to whether infants should be offered ETV+CPC versus shunt as the initial treatment for hydrocephalus.

Objectives
To conduct a cost-effectiveness analysis that determines whether the quality-of-life benefit outweighs the associated healthcare costs when comparing ETV+CPC to shunt.

Methods: A probabilistic Markov model was constructed from the healthcare payer perspective which compared ETV+CPC with shunt as the index treatment. Model clinical inputs (ex. infection, revision, and mortality rates) were derived from the Hydrocephalus Clinical Research Network prospective registry and costs were estimated from systematic review of the literature as well as local healthcare costing data. Health utilities were derived from a systematic literature review and used to calculate quality-adjusted-life-years (QALY). The model used 1-week cycle lengths and was run for 520 cycles, with the assumption that after 10 years all the potential differences in costs and QALYs were realized.

Results: In the base case, the mean difference in costs and QALYs between ETV+CPC and shunt were $434 (3499) and 0.031 (0.030) respectively. ETV+CPC was cost-effective compared to shunt at all willingness-to-pay thresholds above $12,500 per QALY. At a threshold of $50,000 per QALY, the expected added value to the healthcare system by offering ETV+CPC as the primary treatment was $1,098 (3800) per patient after 10 years of follow-up. Additionally, ETV+CPC remained cost-effective compared to shunt as long as the ETV+CPC failure rate was less than 75%. The difference in utility between patients successfully treated with ETV+CPC and shunt was found to be a major driver in net monetary benefit.

Conclusion : Based on the best evidence available to date, ETV+CPC is cost-effective compared to shunt as the initial treatment of infant hydrocephalus. The paucity of health utility data for each treatment is the weakness of the model and should be the emphasis of further research.