Five-Year Cost-Effectiveness Analysis of Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization Versus Ventriculoperitoneal Shunting in Postinfectious Hydrocephalus in a Low-Income Setting

BACKGROUND AND OBJECTIVES: For over 2 decades, an emerging body of data has established endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) as a viable option in the treatment of postinfectious hydrocephalus (PIH) in low-resource settings with similar outcomes to the previous standard of care, ventriculoperitoneal shunting (VPS). However, given the costly equipment, ETV/CPC may be perceived as a more expensive alternative in an already resource-constrained environment. To date, no substantive analysis has been performed examining the cost-effectiveness of ETV/CPC vs VPS in the treatment of PIH. The aim of this study was to determine whether ETV/CPC was cost-effective compared with VPS in a low-income setting. METHODS: A post hoc analysis was performed on a 100-patient cohort of Ugandan infants with PIH from an intention-to-treat randomized controlled trial (ClinicalTrials.gov number, NCT01936272). Cost-effectiveness was measured as a ratio of incremental cost per disability adjusted life years (DALYs) averted. DALYs were assigned to health states observed over 5 years, including postoperative complications, readmissions, reoperations, and death. Costs were reflective of patient-level hospital financial records. An incremental cost-effectiveness ratio was calculated to evaluate the relative difference in cost and effectiveness between the 2 surgical interventions. The willingness-to-pay threshold was defined at 100% of the Ugandan gross domestic product per capita. RESULTS: In our base-case, VPS cost $735 United States Dollar (USD) and incurred 0.74 DALYs, whereas ETV/CPC cost $641 USD and incurred 0.77 DALYs. This resulted in an incremental cost-effectiveness ratio of $3477 USD per DALY averted by VPS. Sensitivity analysis demonstrated ETV/CPC to be cost-effective in 63% of simulated scenarios, with key points of uncertainty around complication risks and procedure costs. CONCLUSION: At the willingness-to-pay threshold, VPS was not considered cost-effective relative to ETV/CPC. This work adds to the growing body of literature in support of ETV/CPC as a preferred approach to the surgical management of PIH, especially in resource-constrained settings.