1. Costs of Neurostimulation Can We Afford The Therapy in 2020? Krishna Kumar MBBS MS FRCS(C) Member Ord. of Canada, Saskatchewan Ord. of Merit Clinical Professor of Neurosurgery Department of Neurosurgery Regina Canada Syed Rizvi MD Department of Neurology University of Saskatchewan Regina Canada

2. Disclosures Act as a consultant for Medtronic Inc. And Boston Scientific. Have received research grants from Medtronic Inc. Disclosures

3. Policymakers require evidence of comparative cost-effectiveness in order to continue to make funding decisions To make the case for neurostimulation we use SCS as a prototype This presentation illustrates the long-term cost- effectiveness of SCS compared with CMM as projected for the year 2020 Introduction

4. 1. National Institute of Arthritis and Musculoskeletal Skin Diseases website. News and Events Page. ghttp://www.niams.nih.gov/ne/highlights/spotlight/2006/back_pain_study.htm. 2.Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. 2011. 3.Darrell J. Gaskin, Patrick Richard. The Economic Costs of Pain in the United States. The Journal of Pain, 2012; 13 (8): 715 DOI: 10.1016/j.jpain.2012.03.009 Projected

5. Disclosures To evaluate the cost impact of SCS against CMM over time we will project costs for 4 commonly encountered chronic pain syndromes: FBSS (Failed Back Surgery Syndrome) CRPS (Complex Regional Pain Syndrome) PAD (Peripheral Arterial Disease) RAP (Refractory Angina Pectoris) Introduction

6. Methods Markov model developed to evaluate the cost-effectiveness of SCS versus CMM Model inputs derived from 313 patients Costs and outcomes followed in six-month cycles Health effects expressed as quality-adjusted life years (QALYs) gained Costs and effects were evaluated over an 8-year time horizon (2012-2020) and discounted at 3.5% per annum Methods

7. Cost-effectiveness was identified by deterministic and probabilistic sensitivity analysis (50,000 Monte-Carlo iterations) Outcome measures presented: Cost Effectiveness (EQ-5D) Incremental cost-effectiveness ratio (ICER) Incremental net monetary benefit (INMB) Acceptability of treatment (CEAC) Expected value of perfect information (EVPI) Strategy selection frequency Methods

8. Judging Cost-effectiveness: Willingness-to-Pay (WTP) USA and Canada: $50,000 / QALY 1, 2 United Kingdom: £20,000- £30,000 / QALY 3 Willingness to Pay: Judging Cost-effectiveness 1 Braithwaite RS, Meltzer DO, King JT Jr, Leslie D, Roberts MS. Med Care 2008; 46(4): 343-5. 2 King JT Jr, Tsevat J, Lave JR, Roberts MS. Med Decis Making 2005; 25(6): 667–677. 3 Devlin N, Parkin D. Health Economics 2004; 13(5): 437-452.

9. Markov Model Treatment Options SCS Trial SCS Trial CMM Success Optimal Health State Suboptimal Health State CMM Optimal Health State Suboptimal Health State Failure Implant Death TreeAge Pro 2011 (TreeAge Software Inc., Williamstown MA)

11. Results

12. Costs, Effectiveness, and ICERs associated with SCS+CMM and CMM StrategySCS+CMMCMM FBSS Cost (CAN$)$89,094 $ 82,654 Effectiveness (QALY)3.062.18 ICER (cost per QALY gained)$7,318 CRPS Cost (CAN$) $ 105,049 $ 91,968 Effectiveness (QALY)1.823.18 ICER (cost per QALY gained)$9,618 PAD Cost (CAN$) $ 96,113 $ 88,017 Effectiveness (QALY)1.652.76 ICER (cost per QALY gained)$7,294 RAP Cost (CAN$) $ 99,043 $ 110,932 Effectiveness (QALY)1.673.13 ICER (cost per QALY gained)$8,143

13. Similar diagram for other pain pathologies Incremental Cost-Effectiveness Ratio Deterministic Sensitivity Analysis: Tornado Diagram for FBSS

14. Probabilistic Sensitivity Analysis: ICER Scatter plot for FBSS

15. Incremental Net Monetary Benefit of SCS over CMM

16. Cost-Effectiveness Acceptability Curve: SCS over CMM

17. Strategy Selection Frequency Based on a simulation of 50,000

18. Reliability of the Model: Expected Value of Perfect Information (EVPI)

19. Comparative Study of Rechargeable and Non-rechargeable IPG

20. Conclusion Based on our projections SCS will remain a cost-effective therapy in the management of neuropathic and ischemic pain in the year 2020 SCS provided a positive INMB over CMM at WTP thresholds ≥ $7,000 per QALY The probability of SCS providing a cost-effective alternative to CMM ranged from 74-95%, depending on pathology and WTP The rechargeable IPG is more cost-effective if the lifespan of a non-rechargeable IPG ≤ 4.25 years