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Patient Selection for Deep Brain Stimulation in Parkinson’s Disease

NOMINATED TOPIC | May 31, 2022
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1. What is the decision or change (e.g. clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

Patient selection for deep brain stimulation in Parkinson’s disease.

2. Why are you struggling with this issue?

There are no existing guidelines for the pre-operative process for DBS in PD in the Americas, but a German group developed evidence-based quality indicators for DBS in PD: Haas K, Stangl S, Steigerwald F, et al. Development of evidence-based quality indicators for deep brain stimulation in patients with Parkinson's disease and first year experience of implementation of a nation-wide registry. Parkinsonism & related disorders. 2019;60:3-9.

The incidence of PD in the United States doubled between 1997 and 2017, with an estimated that there will be 1.64 million cases by 2037.1,2 While symptomatic pharmacotherapeutics are effective, DBS is recognized as a treatment of choice for PD patients with OFF-fluctuations and certain specific medication-refractory symptoms such as tremor.3,4 Unfortunately, DBS practices in terms of candidate selection, pre-operative evaluation and target selection vary widely.5 This greatly affects consistent assessment of DBS on patient outcomes.

Postoperative sequelae such as cognitive impairment6,7, impulsivity8,9, or balance impairment may be related to baseline factors.10-13 Given that neuropsychiatric and balance deficits are some of the most costly parkinsonian symptoms driving healthcare utilization (ref needed), rigorous screening of DBS candidacy to minimize these outcomes would impact individual and health system resources. Finally, there is some concern that financial incentives may lead some towards substandard practices.14 Efficacy of DBS is highly dependent on the strength of preoperative candidacy.

References

  1. Feigin VL, Vos T, Alahdab F, et al. Burden of Neurological Disorders Across the US From 1990-2017: A Global Burden of Disease Study. JAMA neurology. 2021;78(2):165-176.
  2. Yang W, Hamilton JL, Kopil C, Beck JC. Current and projected future economic burden of Parkinson's disease in the U.S. 2020;6:15.
  3. Fox SH, Katzenschlager R, Lim SY, et al. The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the motor symptoms of Parkinson's disease. Movement disorders : official journal of the Movement Disorder Society. 2011;26 Suppl 3:S2-41.
  4. Ferreira JJ, Katzenschlager R, Bloem BR, et al. Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson's disease. European journal of neurology. 2013;20(1):5-15.
  5. Mahajan A, Butala A, Okun MS, Mari Z, Mills KA. Global Variability in Deep Brain Stimulation Practices for Parkinson's Disease. Frontiers in human neuroscience. 2021;15:667035.
  6. Rothlind JC, York MK, Carlson K, et al. Neuropsychological changes following deep brain stimulation surgery for Parkinson's disease: comparisons of treatment at pallidal and subthalamic targets versus best medical therapy. Journal of neurology, neurosurgery, and psychiatry. 2015;86(6):622-629.
  7. Cernera S, Okun MS, Gunduz A. A Review of Cognitive Outcomes Across Movement Disorder Patients Undergoing Deep Brain Stimulation. Frontiers in neurology. 2019;10:419.
  8. Ballanger B, van Eimeren T, Moro E, et al. Stimulation of the subthalamic nucleus and impulsivity: release your horses. Annals of neurology. 2009;66(6):817-824.
  9. Frank MJ, Samanta J, Moustafa AA, Sherman SJ. Hold your horses: impulsivity, deep brain stimulation, and medication in parkinsonism. Science. 2007;318(5854):1309-1312.
  10. Yin Z, Bai Y, Zou L, et al. Balance response to levodopa predicts balance improvement after bilateral subthalamic nucleus deep brain stimulation in Parkinson's disease. NPJ Parkinson's disease. 2021;7(1):47.
  11. Smeding HM, Speelman JD, Huizenga HM, Schuurman PR, Schmand B. Predictors of cognitive and psychosocial outcome after STN DBS in Parkinson's Disease. Journal of neurology, neurosurgery, and psychiatry. 2011;82(7):754-760.
  12. Yágüez L, Costello A, Moriarty J, et al. Cognitive predictors of cognitive change following bilateral subthalamic nucleus deep brain stimulation in Parkinson's disease. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2014;21(3):445-450.
  13. Mills KA, Donohue K, Swaminathan A, Leoutsakos JM, Smith G, Brandt J. Neuropsychological predictors of patient-reported cognitive decline after deep brain stimulation in Parkinson's disease. Journal of clinical and experimental neuropsychology. 2019;41(3):219-228.
  14. Mari Z. Billing anomaly in PD: Exploiting DBS in the US fee-for-service reimbursement model. Parkinsonism and Related Disorders October 2020;Vol. 79, Supplement 1(e1-e126 (e50), A176).

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

While DBS surgery can be highly effective for the treatment of motor fluctuations in Parkinson’s disease15 and is being considered earlier in the disease course16, efficacy is highly dependent on the strength of preoperative candidacy. However, is a costly and complex approach, with input from a multi-disciplinary team including neurologist, neurosurgeon, neuropsychologist and ideally, a physical therapist and social worker. Post-operative outcomes are linked to the initial evaluation by a multidisciplinary team.17 As such, an inconsistent process contributes to poor, yet costly outcomes. A guideline guiding pre-operative evaluation will add reliability to the pr ocess, thus contributing to good, replicable patient outcomes.

References

  1. Follett KA, Weaver FM, Stern M, et al. Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med. 2010;362(22):2077-2091.
  2. Schuepbach WM, Rau J, Knudsen K, et al. Neurostimulation for Parkinson's disease with early motor complications. N Engl J Med. 2013;368(7):610-622.
  3. Abboud H, Mehanna R, Machado A, et al. Comprehensive, Multidisciplinary Deep Brain Stimulation Screening for Parkinson Patients: No Room for "Short Cuts". Movement disorders clinical practice. 2014;1(4):336-341.

4. When do you need the evidence report?

Tue, 03/28/2023

5. What will you do with the evidence report?

The American Academy of Neurology may use this SR to develop guideline recommendation statements pending SR findings.

Optional Information About You

What is your role or perspective? Specialty Society Guideline and Measure Development Staff

If you are you making a suggestion on behalf of an organization, please state the name of the organization American Academy of Neurology

May we contact you if we have questions about your nomination? Yes

Page last reviewed December 2022
Page originally created May 2022

Internet Citation: Patient Selection for Deep Brain Stimulation in Parkinson’s Disease. Content last reviewed December 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/get-involved/nominated-topics/patient-selection

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