Cost-effectiveness of vagus nerve stimulation therapy for drug-resistant epilepsy across healthcare settings: a structured narrative review

Abstract

Abstract Drug-resistant epilepsy (DRE) is associated with substantial healthcare utilization, impaired quality of life (QOL), and considerable societal costs. Vagus nerve stimulation (VNS) has become an established adjunctive treatment for patients who are not suitable candidates for resective epilepsy surgery or who fail to achieve adequate seizure control with pharmacotherapy. This structured narrative review critically evaluates the current evidence on the cost-effectiveness of VNS in DRE. A comprehensive literature search was conducted across PubMed, Web of Science, Embase, Google Scholar, CNKI, and Wanfang Data, and 24 eligible studies comprising observational investigations, real-world database analyses, and economic modelling studies were included. The review synthesized evidence on direct medical costs, indirect societal costs, healthcare utilization, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs), while considering methodological characteristics including study design, modelling approach, time horizon, and healthcare perspective. Overall, many studies, particularly from high-income countries, suggest that although VNS requires substantial upfront costs related to device implantation, these costs may be partially offset time through reductions in seizure frequency, hospitalizations, emergency department visits, and other epilepsy-related healthcare utilization, with several analyses reporting favorable ICERs within accepted willingness-to-pay thresholds. However, considerable heterogeneity exists across the available evidence owing to differences in healthcare systems, reimbursement policies, patient populations, device pricing, modelling assumptions, economic perspectives, outcome measures, and study durations. Consequently, the reported economic outcomes are not directly comparable across settings and should be interpreted cautiously. Furthermore, most evidence originates from high-income countries, while data from middle- and low-income settings remain limited, and many economic evaluations rely on long-term model projections rather than extended real-world follow-up. Current evidence indicates that VNS may provide favorable long-term economic value for appropriately selected patients with DRE, but its cost-effectiveness is context dependent rather than universal. Future research should prioritize standardized economic evaluation methodologies, longer-term prospective studies, and region-specific cost analyses to improve the generalizability of findings and support evidence-based healthcare policy and reimbursement decisions.