A Comparative Cost-Consequence Analysis of Spinal Cord Stimulation and Magnetic Peripheral Nerve Stimulation for the Treatment of Painful Diabetic Peripheral Neuropathy in an Integrated Health System

Background: Painful diabetic peripheral neuropathy (PDN) is common, progressive, and often refractory to drugs. Two neuromodulation options now carry US Food and Drug Administration indications for PDN, implanted spinal cord stimulation (SCS) and noninvasive magnetic peripheral nerve stimulation (mPNS). This study compares what the two cost an integrated health system over three years and sets those costs beside the clinical results each has published. Methods: A deterministic cost-consequence model followed 100 patients for three years at Veterans Health Administration (VHA) contract prices: $27,000 for an SCS system and $350 per mPNS session, with 17 sessions in year 1 and up to 12 a year after that. SCS revision (34%) and explant (53%) prevalences, with their median timings of 16 and 39 months, came from a published 100-patient series and were spread across the horizon. A revision was costed as lead hardware. An explant was costed as removal of the device, with nothing purchased in its place. Patients who stopped either therapy stopped generating cost. One-way, threshold, scenario, and probabilistic sensitivity analyses were run. Reporting follows CHEERS 2022. Results: Device costs over three years were $2,882,250 for SCS and $910,000 for mPNS, a difference of $1,972,250, or $19,723 per patient, and a cost ratio of 3.17. The SCS system price and the mPNS session price drove the result. Explant prevalence had no effect on device cost. mPNS cost less in every scenario tested, including a pooled systematic-review explant rate (ratio 3.17), PDN trial explant rates (3.04), no mPNS attrition (2.01), and a five-year horizon with no attrition (1.28). The two therapies reach parity only if an SCS system costs less than about $8,500 or an mPNS session costs more than about $1,110 ($700 with no attrition). mPNS was cheaper in all 10,000 probabilistic simulations (median ratio 3.21; 95% interval 2.09 to 4.82). Three-month responder rates are of similar size (79% for 10 kHz SCS against conventional management; 72% for mPNS against sham at day 30, 70% to 81% at day 90) but come from trials of different design and were not treated as equivalent. Conclusion: For a health system buying at contract prices, mPNS costs roughly a third of SCS over three years, and no plausible change in the inputs closes the gap. Head-to-head trials with quality-of-life measurement are needed before anyone can say which therapy offers better value per quality-adjusted life year. On present evidence, offering mPNS before an implanted system is a reasonable position for shared decision-making. Keywords: painful diabetic neuropathy, spinal cord stimulation, magnetic peripheral nerve stimulation, cost-consequence analysis, sensitivity analysis, neuromodulation, veterans health administration