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Deep brain stimulation for Parkinson disease – What does the short-term outcome analysis tell us?

      Deep brain stimulation (DBS) is the most successful surgical procedure for the treatment of advanced Parkinson's disease (PD) patients [
      • Hartmann C.J.
      • Fliegen S.
      • Groiss S.J.
      • Wojtecki L.
      • Schnitzler A.
      An update on best practice of deep brain stimulation in Parkinson's disease.
      ] when certain cardinal symptoms are insufficiently controlled with medications resulting in motor complications including excessive off time and dyskinesias. It has become the most significant treatment option for PD after levodopa. There is clear evidence of DBS superiority over continued best medical management of cardinal PD motor symptoms, motor complications, and overall quality of life in carefully selected PD patients [
      • Deuschl G.
      • Schade-Brittinger C.
      • Krack P.
      • Volkmann J.
      • Schafer H.
      • Botzel K.
      • Daniels C.
      • Deutschlander A.
      • Dillmann U.
      • Eisner W.
      • Gruber D.
      • Hamel W.
      • Herzog J.
      • Hilker R.
      • Klebe S.
      • Kloss M.
      • Koy J.
      • Krause M.
      • Kupsch A.
      • Lorenz D.
      • Lorenzl S.
      • Mehdorn H.M.
      • Moringlane J.R.
      • Oertel W.
      • Pinsker M.O.
      • Reichmann H.
      • Reuss A.
      • Schneider G.H.
      • Schnitzler A.
      • Steude U.
      • Sturm V.
      • Timmermann L.
      • Tronnier V.
      • Trottenberg T.
      • Wojtecki L.
      • Wolf E.
      • Poewe W.
      • Voges J.
      • German Parkinson Study Group N.S.
      A randomized trial of deep-brain stimulation for Parkinson's disease.
      ,
      • Weaver F.M.
      • Follett K.
      • Stern M.
      • Hur K.
      • Harris C.
      • Marks Jr., W.J.
      • Rothlind J.
      • Sagher O.
      • Reda D.
      • Moy C.S.
      • Pahwa R.
      • Burchiel K.
      • Hogarth P.
      • Lai E.C.
      • Duda J.E.
      • Holloway K.
      • Samii A.
      • Horn S.
      • Bronstein J.
      • Stoner G.
      • Heemskerk J.
      • Huang G.D.
      • Group CSPS
      Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial.
      ,
      • Williams A.
      • Gill S.
      • Varma T.
      • Jenkinson C.
      • Quinn N.
      • Mitchell R.
      • Scott R.
      • Ives N.
      • Rick C.
      • Daniels J.
      • Patel S.
      • Wheatley K.
      • Group P.S.C.
      Deep brain stimulation plus best medical therapy versus best medical therapy alone for advanced Parkinson's disease (PD SURG trial): a randomised, open-label trial.
      ]. Advances in new technology in the areas of electrode design, surgical approach and planning, novel programming techniques, and the emerging technologies of adaptive DBS and variable frequency stimulation will change the future landscape of DBS. In addition, DBS in PD is cost-effective [
      • Afentou N.
      • Jarl J.
      • Gerdtham U.G.
      • Saha S.
      Economic evaluation of interventions in Parkinson's disease: a systematic literature review.
      ,
      • Dams J.
      • Balzer-Geldsetzer M.
      • Siebert U.
      • Deuschl G.
      • Schuepbach W.M.
      • Krack P.
      • Timmermann L.
      • Schnitzler A.
      • Reese J.P.
      • Dodel R.
      • investigators E.
      Cost-effectiveness of neurostimulation in Parkinson's disease with early motor complications.
      ,
      • Pietzsch J.B.
      • Garner A.M.
      • Marks Jr., W.J.
      Cost-Effectiveness of deep brain stimulation for advanced Parkinson's disease in the United States.
      ]. However, it is not uncommon to see underutilization of DBS among PD patients who are ideal DBS candidates especially in women and those in lower socioeconomic classes [
      • Willis A.W.
      • Schootman M.
      • Kung N.
      • Wang X.Y.
      • Perlmutter J.S.
      • Racette B.A.
      Disparities in deep brain stimulation surgery among insured elders with Parkinson disease.
      ], potentially due to the perception and concerns related to surgical complications, although literature has shown that serious surgical complications of DBS are infrequent. For instance, multicenter studies have identified a 30-day perioperative mortality of 0.4% [
      • Kleiner-Fisman G.
      • Herzog J.
      • Fisman D.N.
      • Tamma F.
      • Lyons K.E.
      • Pahwa R.
      • Lang A.E.
      • Deuschl G.
      Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes.
      ,
      • Kenney C.
      • Simpson R.
      • Hunter C.
      • Ondo W.
      • Almaguer M.
      • Davidson A.
      • Jankovic J.
      Short-term and long-term safety of deep brain stimulation in the treatment of movement disorders.
      ] and permanent neurologic morbidity around 1% [
      • Voges J.
      • Hilker R.
      • Botzel K.
      • Kiening K.L.
      • Kloss M.
      • Kupsch A.
      • Schnitzler A.
      • Schneider G.H.
      • Steude U.
      • Deuschl G.
      • Pinsker M.O.
      Thirty days complication rate following surgery performed for deep-brain-stimulation.
      ]. However, one should be cautious in applying these randomized trials of multi- or single site study results, since there is a broad range of sites performing DBS, and potentially a wide heterogeneity in patient selection process. In addition, the procedures of DBS therapy and post-operative management are known to differ greatly amongst centers [
      • Ondo W.G.
      • Bronte-Stewart H.
      • Group D.B.S.S.
      The North American survey of placement and adjustment strategies for deep brain stimulation.
      ,
      • Abosch A.
      • Timmermann L.
      • Bartley S.
      • Rietkerk H.G.
      • Whiting D.
      • Connolly P.J.
      • Lanctin D.
      • Hariz M.I.
      An international survey of deep brain stimulation procedural steps.
      ]. Consequently, the short-term clinical outcomes and complications from DBS can vary significantly between centers. To analyze complications for surgical procedures, “operative mortality, complication rates, length of stay, readmission rates, patient satisfaction, functional health status, and other measures of health-related quality of life” are the important metrics [
      • Birkmeyer J.D.
      • Dimick J.B.
      • Birkmeyer N.J.
      Measuring the quality of surgical care: structure, process, or outcomes?.
      ]. However, given the heterogeneity of DBS practice, measuring all these metrics may not be practical. Therefore, using a standardized measure of surgical complications post-DBS implantation would help develop and better guide patient decision-making and counselling. In the U.S., 30-day hospital readmission rates for select medical conditions and surgical procedures have been used to monitor quality metrics. Hospital readmissions is considered a major target of healthcare reform. Using such a measure as a benchmark for DBS short term outcomes and complications, as well as healthcare utilization is feasible and can be very informative.

      Keywords

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