Objective: Surgery is an effective but costly treatment for many patients with drug resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, 1) surgery is cost-effective compared to medical management for patients deemed surgical candidates, 2) surgical evaluation is cost-effective for DR-TLE patients in general.

Methods: We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use 2^nd order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both healthcare and societal perspectives, including direct healthcare costs (e.g. surgery, AEDs) and indirect costs (e.g. lost earnings by patients and care providers.) We compare incremental cost-effectiveness ratio (ICER) to societal willingness-to-pay (~$100,000 per Quality Adjusted Life Year) to determine whether surgery is cost-effective.

Results: Epilepsy surgery is cost effective compared to medical management in surgically eligible patients by virtue of being cost saving ($328K vs. 423K) and more effective (16.6 QALY vs. 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in DR-TLE patients even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost effective within 3 years and 89% of simulations favor surgery over the lifetime horizon.

Conclusion: For surgically eligible DR-TLE patients, surgery is cost-effective. For DR-TLE patients in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. DR-TLE patients should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.