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Vasey MJ, Tai XY, Thorpe J, Jones GD, Ashby S, Hallab A, Ding D, Andraus M, Dugan P, Perucca P, Costello DJ, French JA, O'Brien TJ, Depondt C, Andrade DM, Sengupta R, Datta A, Delanty N, Jette N, Newton CR, Brodie MJ, Devinsky O, Cross JH, Sander JW, Hanna J, Besag FMC, Sen A. The impact of COVID-19 on people with epilepsy: Global results from the coronavirus and epilepsy study. Epilepsia Open 2024; 9:1931-1947. [PMID: 39225433 PMCID: PMC11450608 DOI: 10.1002/epi4.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 07/25/2024] [Accepted: 08/09/2024] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVE To characterize the experience of people with epilepsy and aligned healthcare workers (HCWs) during the first 18 months of the COVID-19 pandemic and compare experiences in high-income countries (HICs) with non-HICs. METHODS Separate surveys for people with epilepsy and HCWs were distributed online in April 2020. Responses were collected to September 2021. Data were collected for COVID-19 infections, the effect of COVID-related restrictions, access to specialist help for epilepsy (people with epilepsy), and the impact of the pandemic on work productivity (HCWs). The frequency of responses for non-HICs and HICs were compared using non-parametric Chi-square tests. RESULTS Two thousand one hundred and five individuals with epilepsy from 53 countries and 392 HCWs from 26 countries provided data. The same proportion of people with epilepsy in non-HICs and HICs reported COVID-19 infection (7%). Those in HICs were more likely to report that COVID-19 measures had affected their health (32% vs. 23%; p < 0.001). There was no difference between non-HICs and HICs in the proportion who reported difficulty in obtaining help for epilepsy. HCWs in non-HICs were more likely to report COVID-19 infection than those in HICs (18% vs 6%; p = 0.001) and that their clinical work had been affected by concerns about contracting COVID-19, lack of personal protective equipment, and the impact of the pandemic on mental health (all p < 0.001). Compared to pre-pandemic practices, there was a significant shift to remote consultations in both non-HICs and HICs (p < 0.001). SIGNIFICANCE While the frequency of COVID-19 infection was relatively low in these data from early in the pandemic, our findings suggest broader health consequences and an increased psychosocial burden, particularly among HCWs in non-HICs. Planning for future pandemics should prioritize mental healthcare alongside ensuring access to essential epilepsy services and expanding and enhancing access to remote consultations. PLAIN LANGUAGE SUMMARY We asked people with epilepsy about the effects of COVID-19 on their health and healthcare. We wanted to compare responses from people in high-income countries and other countries. We found that people in high-income countries and other countries had similar levels of difficulty in getting help for their epilepsy. People in high-income countries were more likely to say that their general health had been affected. Healthcare workers in non-high-income settings were more likely to have contracted COVID-19 and have the care they deliver affected by the pandemic. Across all settings, COVID-19 associated with a large shift to remote consultations.
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Affiliation(s)
| | - Xin You Tai
- Nuffield Department of Clinical Neurosciences, Oxford Epilepsy Research GroupUniversity of OxfordOxfordUK
| | - Jennifer Thorpe
- Nuffield Department of Clinical Neurosciences, Oxford Epilepsy Research GroupUniversity of OxfordOxfordUK
| | - Gabriel Davis Jones
- Nuffield Department of Clinical Neurosciences, Oxford Epilepsy Research GroupUniversity of OxfordOxfordUK
| | | | - Asma Hallab
- Charité—Universitätsmedizin BerlinCorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Biologie Intégrative et Physiologie – Neurosciences Cellulaires et Intégrées, Faculté des Sciences et IngénierieSorbonne UniversitéParisFrance
| | - Ding Ding
- Institute of NeurologyFudan University Huashan HospitalShanghaiChina
| | - Maria Andraus
- Department of Internal Medicine, Faculty of Medicine & Neurology and Neurophysiology Services, Deolindo Couto Institute of NeurologyUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazil
| | - Patricia Dugan
- Department of NeurologyNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Piero Perucca
- Department of Medicine (Austin Health), Epilepsy Research CentreThe University of MelbourneMelbourneVictoriaAustralia
- Department of Neurology, Bladin‐Berkovic Comprehensive Epilepsy ProgramAustin HealthMelbourneVictoriaAustralia
- Department of Neuroscience, School of Translational Medicine, The Alfred HospitalMonash UniversityMelbourneVictoriaAustralia
- Departments of Medicine and NeurologyThe Royal Melbourne Hospital, The University of MelbourneMelbourneVictoriaAustralia
| | - Daniel J. Costello
- Epilepsy Service, Cork University Hospital & College of Medicine and HealthUniversity College CorkCorkIreland
| | | | - Terence J. O'Brien
- Department of Neuroscience, School of Translational Medicine, The Alfred HospitalMonash UniversityMelbourneVictoriaAustralia
| | - Chantal Depondt
- Department of Neurology, CUB Erasme HospitalHôpital Universitaire de Bruxelles—Université Libre de BruxellesBrusselsBelgium
| | - Danielle M. Andrade
- Division of Neurology, Adult Epilepsy Genetics Program, Toronto Western HospitalUniversity of TorontoTorontoOntarioCanada
| | | | | | - Norman Delanty
- School of Pharmacy and Biomolecular Sciences, Beaumont Hospital, FutureNeuro Research CentreRoyal College of Surgeons in IrelandDublinIreland
| | - Nathalie Jette
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada
| | - Charles R. Newton
- Nuffield Department of Clinical Neurosciences, Oxford Epilepsy Research GroupUniversity of OxfordOxfordUK
- Department of PsychiatryUniversity of OxfordOxfordUK
| | | | - Orrin Devinsky
- Department of NeurologyNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - J. Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child HealthLondonUK
- Young EpilepsyLingfieldUK
| | - Josemir W. Sander
- UCL Queen Square Institute of NeurologyLondonUK
- Stichting Epilepsie Instellingen Nederland (SEIN)HeemstedeThe Netherlands
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | | | - Frank M. C. Besag
- East London NHS Foundation TrustBedfordUK
- UCL School of PharmacyLondonUK
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Arjune Sen
- Nuffield Department of Clinical Neurosciences, Oxford Epilepsy Research GroupUniversity of OxfordOxfordUK
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Reyes A, Prabhakaran D, Banegas MP, Shih JJ, Iragui-Madoz VJ, Almane DN, Ferguson L, Jones JE, Busch RM, Hermann BP, McDonald CR. Individual- and community-level social determinants of health are associated with cognition in older adults with focal epilepsy. Epilepsy Behav 2024; 158:109927. [PMID: 38970893 DOI: 10.1016/j.yebeh.2024.109927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE Epilepsy is associated with significant health disparities, including access to specialized care and adverse outcomes that have been associated with several social determinants of health (SDOH). We sought to examine the relationship between individual- and community-level SDOH and cognitive outcomes in older adults with epilepsy. MATERIALS AND METHODS We collected clinical, SDOH, and neuropsychological data in 57 older adults with epilepsy. Individual-level SDOH included patient factors (quality of education, income, insurance, marital status) and early-life environmental factors (parental education and occupation, childhood employment). Neighborhood deprivation was measured with the Area Deprivation Index (ADI). Stepwise regressions were conducted to examine the independent contribution of individual-level SDOH to cognitive performance, and Spearman rho correlations were conducted to examine the relationship between ADI and cognitive performance. The SDOH profiles of patients who met the criteria for cognitive impairment were examined. RESULTS After controlling for clinical variables, patient factors (public health insurance, poorer quality of education) and early-life environmental factors (lower mother's education, lower father's and mother's occupational complexity, history of childhood employment) were significant predictors of lower performance on measures of global cognition, verbal learning and memory, processing speed, and executive function. Higher ADI values (greater disadvantage) were associated with lower scores on global cognitive measures, verbal learning and memory, and executive function. Patients who met criteria for cognitive impairment had, on average, a greater number of adverse SDOH, including lower household incomes and father's education, and higher ADI values compared to those who were cognitively intact. CONCLUSION We provide new evidence of the role of individual- and community-level SDOH on cognitive outcomes in older adults with epilepsy. This emerging literature highlights the need to examine SDOH beyond epilepsy-related clinical factors. These data could inform the development of interventions focused on increasing access to epilepsy care, education, and resources and promoting brain and cognitive health within the most at-risk communities.
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Affiliation(s)
- Anny Reyes
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, San Diego, CA, USA.
| | - Divya Prabhakaran
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, San Diego, CA, USA
| | - Matthew P Banegas
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, San Diego, CA, USA
| | - Jerry J Shih
- Department of Neuroscience, University of California, San Diego, San Diego, CA, USA
| | | | - Dace N Almane
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, USA
| | - Lisa Ferguson
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jana E Jones
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, USA
| | - Robyn M Busch
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce P Hermann
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, USA
| | - Carrie R McDonald
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
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Kamitaki BK, Maniar S, Rambhatla R, Gao K, Cantor JC, Choi H, Bover Manderski MT. Health insurance and transportation barriers impact access to epilepsy care in the United States. Epilepsy Res 2024; 205:107424. [PMID: 39121695 DOI: 10.1016/j.eplepsyres.2024.107424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/25/2024] [Accepted: 08/05/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE Inconsistent access to healthcare for people with epilepsy results in reduced adherence to antiseizure medications, increased seizure frequency, and fewer appropriate referrals for epilepsy surgery. Identifying and addressing factors that impede access to care should consequently improve patient outcomes. We hypothesized that health insurance and transportation affect access to outpatient neurology care for adults living with epilepsy in the United States (US). METHODS We conducted a retrospective cross-sectional study of US adults with active epilepsy surveyed via the National Health Interview Survey (NHIS) in 2015 and 2017. We established whether patients reported seeing a neurologist in the past year and used multiple logistic regression to determine whether health insurance status and transportation access were associated with this outcome. RESULTS We identified 735 respondents from 2015 and 2017, representing an estimated 2.98 million US adults with active epilepsy. After adjusting for socioeconomic and seizure-related co-variates, we found that a lack of health insurance coverage was associated with no epilepsy care in the past year (adjusted odds ratio [aOR] 0.22; 95 % confidence interval [CI]: 0.09 - 0.54). Delayed care due to inadequate transportation (aOR 0.42; 95 % CI: 0.19 - 0.93) also resulted in reduced patient access to a neurologist. CONCLUSION Due to the inherent nature of their condition, people with epilepsy are less likely to have employer-sponsored health insurance or consistent driving privileges. Yet, these factors also impact patient access to neurological care. We must address transportation and insurance barriers through long-term investment and partnership between community, healthcare, and government stakeholders.
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Affiliation(s)
- Brad K Kamitaki
- Rutgers-Robert Wood Johnson Medical School, Department of Neurology, 125 Paterson Street, Suite 6200, New Brunswick, NJ 08901, USA.
| | - Shelly Maniar
- Rutgers-Robert Wood Johnson Medical School, Department of Neurology, 125 Paterson Street, Suite 6200, New Brunswick, NJ 08901, USA.
| | - Raaga Rambhatla
- Rutgers-Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA.
| | - Kelly Gao
- Rutgers-Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA.
| | - Joel C Cantor
- Rutgers University, Center for State Health Policy, 112 Paterson Street, 5th Floor, New Brunswick, NJ 08901, USA.
| | - Hyunmi Choi
- Columbia University, Department of Neurology, 710 West 168th Street, 7th Floor, New York, NY 10032, USA.
| | - Michelle T Bover Manderski
- Rutgers School of Public Health, Department of Biostatistics and Epidemiology, 683 Hoes Lanes West, Piscataway, NJ 08854, USA; Rutgers Institute for Nicotine and Tobacco Studies, 303 George Street, Suite 500, New Brunswick, NJ 08901, USA.
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Guignet M, Steve White H, Novotny EJ, Benedict Nwogu I, Zaraa S, Stergachis A, Ems D, Bacci JL. Community Pharmacist-Centered training program improves confidence in delivering epilepsy care. Epilepsy Behav 2024; 158:109933. [PMID: 38970894 DOI: 10.1016/j.yebeh.2024.109933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/11/2024] [Accepted: 06/29/2024] [Indexed: 07/08/2024]
Abstract
RATIONALE Incorporating pharmacists into interdisciplinary healthcare teams can improve patient outcomes across disease states; however, there is little evidence describing pharmacists' contributions to epilepsy care. Previous research from our group revealed that community pharmacists are well positioned to serve as patient advocates, monitor medications, and provide education for people living with epilepsy. However, pharmacists would like to receive additional training in epilepsy management. Advanced training in neurology is not a practical approach for community pharmacists who engage daily with patients having a variety of conditions and medications. OBJECTIVE To develop and evaluate a flexible, community pharmacist-centered training program to improve both confidence and competence in delivering epilepsy care. METHODS The training program consisted of five 1-hour, self-paced online modules and two 90-minute synchronous virtual sessions. Topics included the classification of the epilepsies, comorbid conditions, antiseizure medicine (ASM) therapy, special populations (pregnancy, people of childbearing potential, older adults), seizure emergencies, and sudden unexpected death in epilepsy (SUDEP), as well as social determinants of health. The training program was delivered over 6 weeks to pharmacists located at two community pharmacies in Washington State. Learning was assessed using a pre- and post-training questionnaire containing questions that evaluated knowledge and confidence in the training material. RESULTS The training program did not significantly change pharmacists' mastery of the material. However, the pharmacists' confidence in delivering the material significantly improved in 14 of the 16 areas that were evaluated. Pharmacists' mastery and confidence were strongest in areas around ASM management, SUDEP and seizure emergencies, people of child-bearing potential and older adults with epilepsy, and comorbidities, whereas social health disparities in epilepsy care remained an area that required further training. CONCLUSION Our findings support the idea that community pharmacists are well positioned with the knowledge to play an important role in epilepsy care. However, dedicated training tailored to community pharmacists' needs may improve their confidence in providing such care.
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Affiliation(s)
- Michelle Guignet
- Center for Epilepsy Drug Discovery, School of Pharmacy, Department of Pharmacy, University of Washington, 1959 NE Pacific Street, Box 357630, Seattle, WA, 98195, USA.
| | - H Steve White
- Center for Epilepsy Drug Discovery, School of Pharmacy, Department of Pharmacy, University of Washington, 1959 NE Pacific Street, Box 357630, Seattle, WA, 98195, USA.
| | - Edward J Novotny
- Department of Neurology and Pediatrics, University of Washington, 1959 NE Pacific St, RR-650, Seattle, WA 98195, USA; Seattle Children's Hospital, Seattle, WA Neurology M/S MB.7.420, 4800 Sandpoint Way, NE, Seattle, WA 98105, USA.
| | - Ifechukwu Benedict Nwogu
- Department of Pharmacy, School of Pharmacy, University of Washington, 1959 NE Pacific Street, Box 357630, Seattle, WA, 98195, USA.
| | - Sabra Zaraa
- Department of Pharmacy, School of Pharmacy, University of Washington, 1959 NE Pacific Street, Box 357630, Seattle, WA, 98195, USA.
| | - Andy Stergachis
- Department of Pharmacy, School of Pharmacy, University of Washington, 1959 NE Pacific Street, Box 357630, Seattle, WA, 98195, USA; School of Public Health, University of Washington, Hans Rosling Center for Population Health, 3980 15(th) Ave NE, Seattle, WA 98195, USA.
| | - Derek Ems
- UCB Pharma, 1950 Lake Park Drive, Smyrna, GA 30080, USA.
| | - Jennifer L Bacci
- Department of Pharmacy, School of Pharmacy, University of Washington, 1959 NE Pacific Street, Box 357630, Seattle, WA, 98195, USA.
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Tantillo GB, Sullivan-Baca E, Rehman R, López MR, Haneef Z. Health care utilization of Hispanic/Latino veterans with epilepsy: A national population-based study. Epilepsia 2024; 65:1668-1678. [PMID: 38557951 DOI: 10.1111/epi.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Hispanic/Latino people with epilepsy are a growing population that has been understudied in clinical epilepsy research. U.S. veterans are at a higher risk of epilepsy due to greater exposures including traumatic brain injury. Hispanic/Latino Veterans with Epilepsy (HL-VWEs) represent a growing population; however the treatment utilization patterns of this population have been vastly understudied. METHODS HL-VWE were identified from administrative databases during fiscal year 2019. Variables compared between Hispanic and non-Hispanic VWEs included demographics, rurality, service era, utilization of clinical services/investigations, and service-connected injury. Chi-square and Student's t tests were used for comparisons. RESULTS Among 56 556 VWEs, 3247 (5.7%) were HL. HL-VWEs were younger (59.2 vs 63.2 years; p < .01) and more commonly urban-dwelling (81.6% vs 63.2%, p < .01) compared to non-HL-VWEs. They were also more likely to have served in recent missions such as the Persian Gulf War and post- 9/11 wars (p < .01). HL-VWEs had a higher utilization of all neurology services examined including neurology clinic visits, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, electroencephalography (EEG), epilepsy monitoring, and comprehensive epilepsy care (p < .01 for all). HL-VWEs were more likely to visit an emergency room or have seizure-related hospitalizations (p < .01). HL-VWEs were more likely to have a service-connected disability greater or equal to 50% (p < .01). SIGNIFICANCE This study is one of the largest cohorts examining HL-VWEs. We found higher utilization of services in neurology, epilepsy, and neuroimaging by HL-VWEs. HL-VWE are younger, more commonly urban-dwelling, and more likely to have served during recent combat periods and have higher amounts of service-connected disability. Given that the proportion of Hispanic veterans is projected to rise over time, more research is needed to provide the best interventions and mitigate the long-term impact of epilepsy on this diverse patient group.
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Affiliation(s)
| | - Erin Sullivan-Baca
- Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Houston VA Medical Center, Houston, Texas, USA
| | - Rizwana Rehman
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
- Durham VA Medical Center, Durham, North Carolina, USA
| | - María Raquel López
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
- University of Miami Medical Center, Miami, Florida, USA
| | - Zulfi Haneef
- Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Houston VA Medical Center, Houston, Texas, USA
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
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Seneviratne NU, Ho SY, Correa DJ. Surveying neurologist perspectives and knowledge of epilepsy surgery to identify barriers to surgery referral. Epilepsia Open 2024; 9:960-968. [PMID: 38446338 PMCID: PMC11145599 DOI: 10.1002/epi4.12925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE Epilepsy surgery is an effective means of treating medically refractory epilepsy (MRE), but it remains underused. We aimed to analyze the perspectives and knowledge of referring neurologists in the New York metropolitan area, who serve a large epilepsy population. METHODS We adapted a previous Canadian survey by Roberts et al. (2015), adding questions regarding demographic descriptors, insurance coverage, training and practice details, and perceived social barriers for patients. We surveyed neurologists directly affiliated with Montefiore Medical Center and those referring to Montefiore's Comprehensive Epilepsy Center. Participants had 10 weeks to fill out an online Qualtrics survey with weekly reminders. RESULTS Of 117 neurologists contacted, 51 eligible neurologists completed the survey (63.8% Montefiore, 35.0% referring group). A high proportion of the results were from epilepsy-trained individuals (41.2%) and neurologists who graduated residency ≤19 years ago (80.4%). 80.4% of respondents felt that epilepsy surgery is safe, but only 56.9% would refer a patient for surgical workup after two failed trials of anti-seizure medications. Epileptologists and providers with a larger volume of epilepsy patients and electroencephalogram readings had better knowledge of the epilepsy surgery workup guidelines. When asked to rank social barriers to patients receiving surgery, participants were most concerned about lack of social support, financial insecurity, and a patient's dual role as a caregiver. SIGNIFICANCE Our study suggests continued reluctance of neurologists regarding epilepsy surgery, and deficiencies in the knowledge and adherence to the recommended guidelines. In the context of prior studies, these results showed improved understanding of the definition of MRE (80.4%) and an increased likelihood to refer eligible patients as early as possible (78.4%) in line with current consensus recommendations. The finding that epilepsy-trained and more epilepsy/electroencephalogram-facing neurologists showed better understanding of the guidelines suggests that increased education efforts should be targeted at non-epileptologists. PLAIN LANGUAGE SUMMARY Our study asked New York City doctors about their approach to epilepsy surgery. Many do not consider it as early as they could in treatment plans. The doctors with extra epilepsy training were better at knowing when to consider surgery.
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Affiliation(s)
| | - Sophey Y. Ho
- Mount Sinai Health SystemNew York CityNew YorkUSA
| | - Daniel J. Correa
- Saul R. Korey Department of NeurologyAlbert Einstein College of MedicineBronxNew YorkUSA
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Xie K, Ojemann WKS, Gallagher RS, Shinohara RT, Lucas A, Hill CE, Hamilton RH, Johnson KB, Roth D, Litt B, Ellis CA. Disparities in seizure outcomes revealed by large language models. J Am Med Inform Assoc 2024; 31:1348-1355. [PMID: 38481027 PMCID: PMC11105138 DOI: 10.1093/jamia/ocae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVE Large-language models (LLMs) can potentially revolutionize health care delivery and research, but risk propagating existing biases or introducing new ones. In epilepsy, social determinants of health are associated with disparities in care access, but their impact on seizure outcomes among those with access remains unclear. Here we (1) evaluated our validated, epilepsy-specific LLM for intrinsic bias, and (2) used LLM-extracted seizure outcomes to determine if different demographic groups have different seizure outcomes. MATERIALS AND METHODS We tested our LLM for differences and equivalences in prediction accuracy and confidence across demographic groups defined by race, ethnicity, sex, income, and health insurance, using manually annotated notes. Next, we used LLM-classified seizure freedom at each office visit to test for demographic outcome disparities, using univariable and multivariable analyses. RESULTS We analyzed 84 675 clinic visits from 25 612 unique patients seen at our epilepsy center. We found little evidence of bias in the prediction accuracy or confidence of outcome classifications across demographic groups. Multivariable analysis indicated worse seizure outcomes for female patients (OR 1.33, P ≤ .001), those with public insurance (OR 1.53, P ≤ .001), and those from lower-income zip codes (OR ≥1.22, P ≤ .007). Black patients had worse outcomes than White patients in univariable but not multivariable analysis (OR 1.03, P = .66). CONCLUSION We found little evidence that our LLM was intrinsically biased against any demographic group. Seizure freedom extracted by LLM revealed disparities in seizure outcomes across several demographic groups. These findings quantify the critical need to reduce disparities in the care of people with epilepsy.
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Affiliation(s)
- Kevin Xie
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, United States
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - William K S Ojemann
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, United States
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Ryan S Gallagher
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Russell T Shinohara
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Alfredo Lucas
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, United States
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Chloé E Hill
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, United States
| | - Roy H Hamilton
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Kevin B Johnson
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Dan Roth
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Brian Litt
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, United States
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Colin A Ellis
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, United States
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Gotlieb E, Agarwal P, Blank LJ, Kwon CS, Muxfeldt M, Young JJ, Jette N. Disparities in Teleneurology Use in Medicaid Beneficiaries With Epilepsy by Practice Setting: Promoting Health Equity in Academic Centers. Neurology 2024; 102:e209348. [PMID: 38608210 PMCID: PMC11175647 DOI: 10.1212/wnl.0000000000209348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/13/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Medicaid beneficiaries in many American academic medical centers can receive care in a separate facility than those not covered by Medicaid. We aimed to identify possible disparities in care by evaluating the association between facility type (integrated faculty practice or Medicaid-only outpatient clinic) and telehealth utilization in people with epilepsy. METHODS We performed retrospective analyses using structured data from the Mount Sinai Health System electronic medical record data from January 2003 to August 2021. We identified people of all ages with epilepsy who were followed by an epileptologist after January 3, 2018, using a validated ICD-9-CM/10-CM coded case definition. We evaluated associations between practice setting and telehealth utilization, an outcome measure that captures the evolving delivery of neurologic care in a post-coronavirus disease 2019 era, using multivariable logistic regression. RESULTS We identified 4,586 people with epilepsy seen by an epileptologist, including Medicaid beneficiaries in the Medicaid outpatient clinic (N = 387), Medicaid beneficiaries in the faculty practice after integration (N = 723), and non-Medicaid beneficiaries (N = 3,476). Patients not insured by Medicaid were significantly older (average age 40 years vs 29 in persons seen in Medicaid-only outpatient clinic and 28.5 in persons insured with Medicaid seen in faculty practice [p < 0.0001]). Medicaid beneficiaries were more likely to have drug-resistant epilepsy (DRE), with 51.94% of people seen in Medicaid-only outpatient clinic, 41.63% of Medicaid beneficiaries seen in faculty practice, and 37.2% of non-Medicaid beneficiaries having DRE (p < 0.0001). Medicaid outpatient clinic patients were less likely to have telehealth visits (phone or video); 81.65% of patients in the Medicaid outpatient clinic having no telehealth visits vs 71.78% of Medicaid beneficiaries in the faculty practice and 70.89% of non-Medicaid beneficiaries (p < 0.0001). In an adjusted logistic regression analysis, Medicaid beneficiaries had lower odds (0.61; 95% CI 0.46-0.81) of using teleneurology compared with all patients seen in faculty practice (p = 0.0005). DISCUSSION Compared with the Medicaid-only outpatient clinic, we found higher telehealth utilization in the integrated faculty practice with no difference by insurance status (Medicaid vs other). Integrated care may be associated with better health care delivery in people with epilepsy; thus, future research should examine its impact on other epilepsy-related outcomes.
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Affiliation(s)
- Evelyn Gotlieb
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Parul Agarwal
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Leah J Blank
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Churl-Su Kwon
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Maria Muxfeldt
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - James J Young
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
| | - Nathalie Jette
- From the Departments of Neurology (L.J.B., M.M., J.J.Y., N.J.), Population Health Science (P.A., L.J.B., N.J.), and Policy and Institute for Healthcare Delivery Science (P.A., L.J.B., N.J.), Icahn School of Medicine at Mount Sinai (E.G., P.A.), New York; Departments of Neurology, Neurosurgery, and Epidemiology, and the Gertrude H. Sergievsky Center (C.-S.K.), Columbia University, New York, NY; and Department of Clinical Neurosciences (N.J.), University of Calgary, AB, Canada
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Miller JS, Oladele F, McAfee D, Adereti CO, Theodore WH, Akinsoji EO. Disparities in Epilepsy Diagnosis and Management in High-Income Countries: A Review of the Literature. Neurol Clin Pract 2024; 14:e200259. [PMID: 38585438 PMCID: PMC10996906 DOI: 10.1212/cpj.0000000000200259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/20/2023] [Indexed: 04/09/2024]
Abstract
Purpose of Review Currently, an estimated 3.4 million people in the United States live with epilepsy. Previous studies have identified health disparities associated with race/ethnicity, socioeconomic status (SES), sex, insurance status, and age in this population. However, there has been a dearth of research addressing these disparities. We performed a literature review of articles published between 2010 and 2020 pertaining to health disparities in people with epilepsy (PWE), identified key factors that contribute to gaps in their care, and discussed possible solutions. Recent Findings Health disparities in prevalence, treatment access, time to diagnosis, health care delivery and engagement, and clinical outcomes were identified among individuals who were either of low SES, rural-based, uninsured/underinsured, older patients, patients of color, or female sex. Summary Disparities in care for PWE continue to persist. Greater priority should be placed on addressing these gaps intricately tied to sociodemographic factors. Reforms to mitigate health disparities in PWE are necessary for timely diagnosis, effective treatment, and positive long-term outcomes.
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Affiliation(s)
- Joseph S Miller
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Folake Oladele
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Darrian McAfee
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Christopher O Adereti
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - William H Theodore
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Elizabeth O Akinsoji
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
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Lado FA, Ahrens SM, Riker E, Muh CR, Richardson RM, Gray J, Small B, Lewis SZ, Schofield TJ, Clarke DF, Hopp JL, Lee RR, Salpekar JA, Arnold ST. Guidelines for Specialized Epilepsy Centers: Executive Summary of the Report of the National Association of Epilepsy Centers Guideline Panel. Neurology 2024; 102:e208087. [PMID: 38306606 PMCID: PMC10962912 DOI: 10.1212/wnl.0000000000208087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/26/2023] [Indexed: 02/04/2024] Open
Abstract
The National Association of Epilepsy Centers first published the guidelines for epilepsy centers in 1990, which were last updated in 2010. Since that update, epilepsy care and the science of guideline development have advanced significantly, including the importance of incorporating a diversity of stakeholder perspectives such as those of patients and their caregivers. Currently, despite extensive published data examining the efficacy of treatments and diagnostic testing for epilepsy, there remain significant gaps in data identifying the essential services needed for a comprehensive epilepsy center and the optimal manner for their delivery. The trustworthy consensus-based statements (TCBS) process produces unbiased, scientifically valid guidelines through a transparent process that incorporates available evidence and expert opinion. A systematic literature search returned 5937 relevant studies from which 197 articles were retained for data extraction. A panel of 41 stakeholders with diverse expertise evaluated this evidence and drafted recommendations following the TCBS process. The panel reached consensus on 52 recommendations covering services provided by specialized epilepsy centers in both the inpatient and outpatient settings in major topic areas including epilepsy monitoring unit care, surgery, neuroimaging, neuropsychology, genetics, and outpatient care. Recommendations were informed by the evidence review and reflect the consensus of a broad panel of expert opinions.
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Affiliation(s)
- Fred A Lado
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Stephanie M Ahrens
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Ellen Riker
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Carrie R Muh
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - R Mark Richardson
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Johanna Gray
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Barbara Small
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Sandra Z Lewis
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Thomas J Schofield
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Dave F Clarke
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Jennifer L Hopp
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Roland R Lee
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Jay A Salpekar
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Susan T Arnold
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
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Balzekas I, Richardson JP, Lorence I, Lundstrom BN, Worrell GA, Sharp RR. Qualitative Analysis of Decision to Pursue Electrical Brain Stimulation by Patients With Drug-Resistant Epilepsy and Their Caregivers. Neurol Clin Pract 2024; 14:e200245. [PMID: 38585236 PMCID: PMC10996908 DOI: 10.1212/cpj.0000000000200245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/01/2023] [Indexed: 04/09/2024]
Abstract
Background and Objectives To understand why patients with drug-resistant epilepsy (DRE) pursue invasive electrical brain stimulation (EBS). Methods We interviewed patients with DRE (n = 20) and their caregivers about their experiences in pursuing EBS approximately 1 year post device implant. Inductive analysis was applied to identify key motivating factors. Results The cohort included participants aged from teens to 50s with deep brain stimulation, vagus nerve stimulation, responsive neurostimulation, and chronic subthreshold cortical stimulation. Patients' motivations included (1) improved quality of life (2) intolerability of antiseizure medications, (3) desperation, and (4) patient-family dynamics. Both patients and caregivers described a desire to alleviate burdens of the other. Patient apprehensions about EBS focused on invasiveness and the presence of electrodes in the brain. Previous experiences with invasive monitoring and the ability to see hardware in person during clinical visits influenced patients' comfort in proceeding with EBS. Despite realistic expectations for modest and delayed benefits, patients held out hope for an exceptionally positive outcome. Discussion Our findings describe the motivations and decision-making process for patients with DRE who pursue invasive EBS. Patients balance feelings of desperation, personal goals, frustration with medication side effects, fears about surgery, and potential pressure from concerned caregivers. These factors together with the sense that patients have exhausted therapeutic alternatives may explain the limited decisional ambivalence observed in this cohort. These themes highlight opportunities for epilepsy care teams to support patient decision-making processes.
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Affiliation(s)
- Irena Balzekas
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Jordan P Richardson
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Isabella Lorence
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Brian Nils Lundstrom
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Gregory A Worrell
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Richard R Sharp
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
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12
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Ghebrehiwet M, Cox K, Nees D, Dunford B, Jacobsen SM, Bacani R, Vassar M. Inequities in Epilepsy: A Scoping Review. Neurol Clin Pract 2023; 13:e200211. [PMID: 37795499 PMCID: PMC10547471 DOI: 10.1212/cpj.0000000000200211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/21/2023] [Indexed: 10/06/2023]
Abstract
Objectives The objective of this study was to complete a scoping review of current literature surrounding health inequities in epilepsy while providing recommendations for future research. Methods During July 2022, we searched MEDLINE and Ovid Embase to find published articles pertaining to epilepsy and health inequities. Initially, authors received training. Authors then screened, and data were extracted in a masked duplicate manner. Studies published within the time frame of 2011-2021 in all countries were deemed appropriate. We screened 5,325 studies for titles and abstracts and then 56 studies for full text. We evaluated the inequities of race/ethnicity, sex or gender, income, occupation status, education level, under-resourced/rural population, and LGBTQ+. To summarize the data and descriptive statistics of our study, we used Stata 17.0 (StataCorp, LLC, College Station, TX). Results We obtained a sample size of 45 studies for study inclusion. The most reported health inequities were income (18/45, 40.0%), under-resourced/rural population (15/45, 33.3%), and race/ethnicity (15/45, 33.3%). The least reported health inequity was LGBTQ+ (0/45, 0.0%). Discussion The findings of our study suggest that gaps exist in literature concerning epilepsy and inequities. The inequities of income status, under-resourced/rural population, and race/ethnicity were examined the most, while LGBTQ+, occupation status, and sex or gender were examined the least. With the ultimate goal of more equitable and patient-centered care in mind, it is vital that future studies endeavor to fill in these determined gaps.
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Affiliation(s)
- Merhawit Ghebrehiwet
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Katherine Cox
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Danya Nees
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Bryan Dunford
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Samuel M Jacobsen
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Rigel Bacani
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Matt Vassar
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
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Gotlieb EG, Blank L, Willis AW, Agarwal P, Jette N. Health equity integrated epilepsy care and research: A narrative review. Epilepsia 2023; 64:2878-2890. [PMID: 37725065 DOI: 10.1111/epi.17728] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND With the unanimous approval of the Intersectoral Global Action Plan on epilepsy and other neurological disorders by the World Health Organization in May 2022, there are strong imperatives to work towards equitable neurological care. AIMS Using epilepsy as an entry point to other neurologic conditions, we discuss disparities faced by marginalized groups including racial/ethnic minorities, Americans living in rural communities, and Americans with low socioeconomic status. MATERIALS AND METHODS The National Institute on Minority Health Disparities Research Framework (NIMHD) was used to conduct a narrative review through a health equity lens to create an adapted framework for epilepsy and propose approaches to working towards equitable epilepsy and neurological care. RESULTS In this narrative review, we identified priority populations (racial and ethnic minority, rural-residing, and low socioeconomic status persons with epilepsy) and outcomes (likelihood to see a neurologist, be prescribed antiseizure medications, undergo epilepsy surgery, and be hospitalized) to explore disparities in epilepsy and guide our focused literature search using PubMed. In an adapted NIMHD framework, we examined individual, interpersonal, community, and societal level contributors to health disparities across five domains: (1) behavioral, (2) physical/built environment, (3) sociocultural, (4) environment, and (5) healthcare system. We take a health equity approach to propose initiatives that target modifiable factors that impact disparities and advocate for sustainable change for priority populations. DISCUSSION To improve equity, healthcare providers and relevant societal stakeholders can advocate for improved care coordination, referrals for epilepsy surgery, access to care, health informatics interventions, and education (i.e., to providers, patients, and communities). More broadly, stakeholders can advocate for reforms in medical education, and in the American health insurance landscape. CONCLUSIONS Equitable healthcare should be a priority in neurological care.
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Affiliation(s)
- Evelyn G Gotlieb
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Leah Blank
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population, Health Science and Policy and Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Allison W Willis
- Departments of Neurology and Biostatistics, Epidemiology and Informatics, University of Pennsylvania
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Parul Agarwal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population, Health Science and Policy and Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jette
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population, Health Science and Policy and Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Xie K, Ojemann WKS, Gallagher RS, Lucas A, Hill CE, Hamilton RH, Johnson KB, Roth D, Litt B, Ellis CA. Disparities in seizure outcomes revealed by large language models. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.20.23295842. [PMID: 37790442 PMCID: PMC10543059 DOI: 10.1101/2023.09.20.23295842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Objective Large-language models (LLMs) in healthcare have the potential to propagate existing biases or introduce new ones. For people with epilepsy, social determinants of health are associated with disparities in access to care, but their impact on seizure outcomes among those with access to specialty care remains unclear. Here we (1) evaluated our validated, epilepsy-specific LLM for intrinsic bias, and (2) used LLM-extracted seizure outcomes to test the hypothesis that different demographic groups have different seizure outcomes. Methods First, we tested our LLM for intrinsic bias in the form of differential performance in demographic groups by race, ethnicity, sex, income, and health insurance in manually annotated notes. Next, we used LLM-classified seizure freedom at each office visit to test for outcome disparities in the same demographic groups, using univariable and multivariable analyses. Results We analyzed 84,675 clinic visits from 25,612 patients seen at our epilepsy center 2005-2022. We found no differences in the accuracy, or positive or negative class balance of outcome classifications across demographic groups. Multivariable analysis indicated worse seizure outcomes for female patients (OR 1.33, p = 3×10-8), those with public insurance (OR 1.53, p = 2×10-13), and those from lower-income zip codes (OR ≥ 1.22, p ≤ 6.6×10-3). Black patients had worse outcomes than White patients in univariable but not multivariable analysis (OR 1.03, p = 0.66). Significance We found no evidence that our LLM was intrinsically biased against any demographic group. Seizure freedom extracted by LLM revealed disparities in seizure outcomes across several demographic groups. These findings highlight the critical need to reduce disparities in the care of people with epilepsy.
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Affiliation(s)
- Kevin Xie
- University of Pennsylvania, Dept. of Bioengineering, Philadelphia, PA, USA
- University of Pennsylvania, Center for Neuroengineering and Therapeutics, Philadelphia, PA, USA
| | - William K S Ojemann
- University of Pennsylvania, Dept. of Bioengineering, Philadelphia, PA, USA
- University of Pennsylvania, Center for Neuroengineering and Therapeutics, Philadelphia, PA, USA
| | - Ryan S Gallagher
- University of Pennsylvania, Center for Neuroengineering and Therapeutics, Philadelphia, PA, USA
- University of Pennsylvania, Dept. of Neurology, Philadelphia, PA, USA
| | - Alfredo Lucas
- University of Pennsylvania, Dept. of Bioengineering, Philadelphia, PA, USA
- University of Pennsylvania, Center for Neuroengineering and Therapeutics, Philadelphia, PA, USA
- University of Pennsylvania, Dept. of Neurology, Philadelphia, PA, USA
| | - Chloé E Hill
- University of Michigan, Dept. of Neurology, Ann Arbor, MI, USA
| | - Roy H Hamilton
- University of Pennsylvania, Dept. of Neurology, Philadelphia, PA, USA
| | - Kevin B Johnson
- University of Pennsylvania, Dept. of Bioengineering, Philadelphia, PA, USA
- University of Pennsylvania, Dept. Of Biostatistics, Epidemiology and Informatics, Philadelphia, PA USA
- University of Pennsylvania, Dept. of Computer and Information Science, Philadelphia, PA, USA
- University of Pennsylvania, Dept. of Pediatrics, Philadelphia, PA, USA
| | - Dan Roth
- University of Pennsylvania, Dept. of Computer and Information Science, Philadelphia, PA, USA
| | - Brian Litt
- University of Pennsylvania, Dept. of Bioengineering, Philadelphia, PA, USA
- University of Pennsylvania, Center for Neuroengineering and Therapeutics, Philadelphia, PA, USA
- University of Pennsylvania, Dept. of Neurology, Philadelphia, PA, USA
| | - Colin A Ellis
- University of Pennsylvania, Center for Neuroengineering and Therapeutics, Philadelphia, PA, USA
- University of Pennsylvania, Dept. of Neurology, Philadelphia, PA, USA
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15
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Chu DY, Adluru N, Nair VA, Choi T, Adluru A, Garcia-Ramos C, Dabbs K, Mathis J, Nencka AS, Gundlach C, Conant L, Binder JR, Meyerand ME, Alexander AL, Struck AF, Hermann B, Prabhakaran V. Association of neighborhood deprivation with white matter connectome abnormalities in temporal lobe epilepsy. Epilepsia 2023; 64:2484-2498. [PMID: 37376741 PMCID: PMC10530287 DOI: 10.1111/epi.17702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE Social determinants of health, including the effects of neighborhood disadvantage, impact epilepsy prevalence, treatment, and outcomes. This study characterized the association between aberrant white matter connectivity in temporal lobe epilepsy (TLE) and disadvantage using a US census-based neighborhood disadvantage metric, the Area Deprivation Index (ADI), derived from measures of income, education, employment, and housing quality. METHODS Participants including 74 TLE patients (47 male, mean age = 39.2 years) and 45 healthy controls (27 male, mean age = 31.9 years) from the Epilepsy Connectome Project were classified into ADI-defined low and high disadvantage groups. Graph theoretic metrics were applied to multishell connectome diffusion-weighted imaging (DWI) measurements to derive 162 × 162 structural connectivity matrices (SCMs). The SCMs were harmonized using neuroCombat to account for interscanner differences. Threshold-free network-based statistics were used for analysis, and findings were correlated with ADI quintile metrics. A decrease in cross-sectional area (CSA) indicates reduced white matter integrity. RESULTS Sex- and age-adjusted CSA in TLE groups was significantly reduced compared to controls regardless of disadvantage status, revealing discrete aberrant white matter tract connectivity abnormalities in addition to apparent differences in graph measures of connectivity and network-based statistics. When comparing broadly defined disadvantaged TLE groups, differences were at trend level. Sensitivity analyses of ADI quintile extremes revealed significantly lower CSA in the most compared to least disadvantaged TLE group. SIGNIFICANCE Our findings demonstrate (1) the general impact of TLE on DWI connectome status is larger than the association with neighborhood disadvantage; however, (2) neighborhood disadvantage, indexed by ADI, revealed modest relationships with white matter structure and integrity on sensitivity analysis in TLE. Further studies are needed to explore this relationship and determine whether the white matter relationship with ADI is driven by social drift or environmental influences on brain development. Understanding the etiology and course of the disadvantage-brain integrity relationship may serve to inform care, management, and policy for patients.
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Affiliation(s)
- Daniel Y Chu
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nagesh Adluru
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Veena A Nair
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Timothy Choi
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Anusha Adluru
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Camille Garcia-Ramos
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kevin Dabbs
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jedidiah Mathis
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew S Nencka
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Carson Gundlach
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lisa Conant
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeffrey R Binder
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary E Meyerand
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Andrew L Alexander
- Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- William S. Middleton Veterans Hospital, Madison, Wisconsin, USA
| | - Bruce Hermann
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Vivek Prabhakaran
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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16
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Hill CE, Lin CC, Terman SW, Zahuranec D, Parent JM, Skolarus LE, Burke JF. Predictors of referral for long-term EEG monitoring for Medicare beneficiaries with drug-resistant epilepsy. Epilepsia Open 2023; 8:1096-1110. [PMID: 37423646 PMCID: PMC10472378 DOI: 10.1002/epi4.12789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE For people with drug-resistant epilepsy, the use of epilepsy surgery is low despite favorable odds of seizure freedom. To better understand surgery utilization, we explored factors associated with inpatient long-term EEG monitoring (LTM), the first step of the presurgical pathway. METHODS Using 2001-2018 Medicare files, we identified patients with incident drug-resistant epilepsy using validated criteria of ≥2 distinct antiseizure medication (ASM) prescriptions and ≥1 drug-resistant epilepsy encounter among patients with ≥2 years pre- and ≥1 year post-diagnosis Medicare enrollment. We used multilevel logistic regression to evaluate associations between LTM and patient, provider, and geographic factors. We then analyzed neurologist-diagnosed patients to further evaluate provider/environmental characteristics. RESULTS Of 12 044 patients with incident drug-resistant epilepsy diagnosis identified, 2% underwent surgery. Most (68%) were diagnosed by a neurologist. In total, 19% underwent LTM near/after drug-resistant epilepsy diagnosis; another 4% only underwent LTM much prior to diagnosis. Patient factors most strongly predicting LTM were age <65 (adjusted odds ratio 1.5 [95% confidence interval 1.3-1.8]), focal epilepsy (1.6 [1.4-1.9]), psychogenic non-epileptic spells diagnosis (1.6 [1.1-2.5]) prior hospitalization (1.7, [1.5-2]), and epilepsy center proximity (1.6 [1.3-1.9]). Additional predictors included female gender, Medicare/Medicaid non-dual eligibility, certain comorbidities, physician specialties, regional neurologist density, and prior LTM. Among neurologist-diagnosed patients, neurologist <10 years from graduation, near an epilepsy center, or epilepsy-specialized increased LTM likelihood (1.5 [1.3-1.9], 2.1 [1.8-2.5], 2.6 [2.1-3.1], respectively). In this model, 37% of variation in LTM completion near/after diagnosis was explained by individual neurologist practice and/or environment rather than measurable patient factors (intraclass correlation coefficient 0.37). SIGNIFICANCE A small proportion of Medicare beneficiaries with drug-resistant epilepsy completed LTM, a proxy for epilepsy surgery referral. While some patient factors and access measures predicted LTM, non-patient factors explained a sizable proportion of variance in LTM completion. To increase surgery utilization, these data suggest initiatives targeting better support of neurologist referral.
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Affiliation(s)
- Chloe E. Hill
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Chun Chieh Lin
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
- Department of NeurologyThe Ohio State UniversityColumbusOhioUSA
| | - Samuel W. Terman
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Darin Zahuranec
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Jack M. Parent
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | | | - James F. Burke
- Department of NeurologyThe Ohio State UniversityColumbusOhioUSA
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Goenka A, Fonseca LD, Kumar G. Demographic and geographic variations in the access time of pediatric patients presenting with staring spells. Epilepsy Behav 2023; 145:109299. [PMID: 37336135 DOI: 10.1016/j.yebeh.2023.109299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To assess the demographic and geographic variations in access time - defined as years between the date of symptom onset and initial date of neurological care - in pediatric patients presenting with staring spells. MATERIALS AND METHODS We conducted a secondary analysis of a retrospective chart review study from 2011 to 2021. A total of 1,353 staring spell patients, aged 0 to 17.9 years, were analyzed for age, sex, race/ethnicity, insurance, county, average county annual per capita personal income, and access time. RESULTS Patients aged 0-2.9 years had the shortest median access time of 0.3 years, compared to 1.2 years in patients aged 3-12.9 years and 1.0 year in patients aged 13-17.9 years. Statistically significant differences were seen based on race/ethnicity and insurance with White patients having shorter access time of 0.5 years compared to Black patients with 1.0 year and self-pay patients having the shortest access time of 0.4 years compared to patients with private insurance (0.7 years). Warren County had the largest annual per capita personal income of $65,855 and access time of 0.5 years compared to Preble county with the least annual per capita personal income of $45,016 and access time of 1.1 years. CONCLUSION Demographic parameters of age, race/ethnicity, insurance, and annual county per capita personal income appeared to be associated with access time to initial neurological care in patients with staring spells. These associations need to be investigated further to ensure timely access to neurological care and to ensure equity in health care.
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Affiliation(s)
- Ajay Goenka
- Department of Neurology, Dayton Children's Hospital, Dayton, OH, USA; Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
| | - Laura D Fonseca
- Department of Neurology, Dayton Children's Hospital, Dayton, OH, USA.
| | - Gogi Kumar
- Department of Neurology, Dayton Children's Hospital, Dayton, OH, USA; Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
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18
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Jenkins C, Cabrera A, Goldenholz DM, Losey T, Baker NA, Estes M, Casassa CM. Gaps in care following first time seizure in an underserved region: A retrospective analysis. Seizure 2023; 108:96-101. [PMID: 37146517 PMCID: PMC10213122 DOI: 10.1016/j.seizure.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/07/2023] Open
Abstract
PURPOSE This study investigated the characteristics of patients presenting with the first-time seizure (FTS) and whether neurology follow-up occurred in a medically underserved area. METHODS A retrospective study of adults with a FTS discharged from the Emergency Department (ED) at Loma Linda University between January 1, 2017 and December 31, 2018 was performed. The primary outcome was days from the ED visit to the first neurology visit. Secondary outcomes included repeat ED visits, percentage of patients who had specialty assessment in one year, type of neurologist seen, and percentage lost to follow-up. RESULTS Of the 1327 patients screened, 753 encounters met criteria for manual review, and after exclusion criteria were applied, 66 unique encounters were eligible. Only 30% of FTS patients followed up with a neurologist. The median duration for neurology follow-up was 92 days (range=5-1180). After initial ED visit, 20% of follow-up patients were diagnosed with epilepsy within 189 days, and 20% of patients re-presented to the ED with recurrent seizures while awaiting their initial neurology appointment. Reasons for lack of follow-up included: referral issues, missed appointments, and shortage of available neurologists. CONCLUSION This study highlights the significant treatment gap that a first-time seizure clinic (FTSC) could fill in underserved communities. FTSC may reduce the morbidity and mortality associated with untreated recurrent seizures.
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Affiliation(s)
| | - Andrew Cabrera
- Loma Linda School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA.
| | - Daniel M Goldenholz
- Division of Epilepsy, Department of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
| | - Travis Losey
- Department of Neurology, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Nancy A Baker
- Department of Neurology, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Molly Estes
- Department of Emergency Medicine, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Charles M Casassa
- Department of Neurology, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
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Suen CG, Wood AJ, Burke JF, Betjemann JP, Guterman EL. Hospital EEG Capability and Associations With Interhospital Transfer in Status Epilepticus. Neurol Clin Pract 2023; 13:e200143. [PMID: 37064585 PMCID: PMC10101704 DOI: 10.1212/cpj.0000000000200143] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/06/2023] [Indexed: 03/18/2023]
Abstract
Background and Objectives EEG is widely recommended for status epilepticus (SE) management. However, EEG access and use across the United States is poorly characterized. We aimed to evaluate changes in inpatient EEG access over time and whether availability of EEG is associated with interhospital transfers for patients hospitalized with SE. Methods We performed a cross-sectional study using data available in the National Inpatient Sample data set from 2012 to 2018. We identified hospitals that used continuous or routine EEG during at least 1 seizure-related hospitalization in a given year using ICD-9 and ICD-10 procedure codes and defined these hospitals as EEG capable. We examined annual change in the proportion of hospitals that were EEG capable during the study period, compared characteristics of hospitals that were EEG capable with those that were not, and fit multivariable logistic regression models to determine whether hospital EEG capability was associated with likelihood of interhospital transfer. Results Among 4,550 hospitals in 2018, 1,241 (27.3%) were EEG capable. Of these, 1,188 hospitals (95.7%) were in urban settings. From 2012 to 2018, the proportion of hospitals that were EEG capable increased in urban settings (30.5%-41.1%, Mann-Kendall [M-K] test p < 0.001) and decreased in rural settings (4.0%-3.2%, M-K p = 0.026). Among 130,580 patients hospitalized with SE, 80,725 (61.8%) presented directly to an EEG-capable hospital. However, EEG use during hospitalization varied from 8% to 98%. Initial admission to a hospital without EEG capability was associated with 22% increased likelihood of interhospital transfer (adjusted RR 1.22, [95% CI, 1.09-1.37]; p < 0.01). Among those hospitalized at an EEG-capable hospital, patients admitted to hospitals in the lowest quintile of EEG volume were more than 2 times more likely to undergo interhospital transfer (adjusted RR 2.22, [95% CI 1.65-2.93]; p < 0.001). Discussion A minority of hospitals are EEG capable yet care for most patients with SE. Inpatient EEG use, however, varies widely among EEG-capable hospitals, and lack of inpatient EEG access is associated with interhospital transfer. Given the high incidence and cost of SE, there is a need to better understand the importance and use of EEG in this patient population to further organize inpatient epilepsy systems of care to optimize outcomes.
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Affiliation(s)
- Catherine G Suen
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - Andrew J Wood
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - James F Burke
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - John P Betjemann
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - Elan L Guterman
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
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20
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Hsieh JK, Pucci FG, Sundar SJ, Kondylis E, Sharma A, Sheikh SR, Vegh D, Moosa AN, Gupta A, Najm I, Rammo R, Bingaman W, Jehi L. Beyond seizure freedom: Dissecting long-term seizure control after surgical resection for drug-resistant epilepsy. Epilepsia 2023; 64:103-113. [PMID: 36281562 PMCID: PMC10100416 DOI: 10.1111/epi.17445] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE This study was undertaken to better understand the long-term palliative and disease-modifying effects of surgical resection beyond seizure freedom, including frequency reduction and both late recurrence and remission, in patients with drug-resistant epilepsy. METHODS This retrospective database-driven cohort study included all patients with >9 years of follow-up at a single high-volume epilepsy center. We included patients who underwent lobectomy, multilobar resection, or lesionectomies for drug-resistant epilepsy; we excluded patients who underwent hemispherectomies. Our main outcomes were (1) reduction in frequency of disabling seizures (at 6 months, each year up to 9 years postoperatively, and at last follow-up), (2) achievement of seizure remission (>6 months, >1 year, and longest duration), and (3) seizure freedom at last follow-up. RESULTS We included 251 patients; 234 (93.2%) achieved 6 months and 232 (92.4%) experienced 1 year of seizure freedom. Of these, the average period of seizure freedom was 10.3 years. A total of 182 (72.5%) patients were seizure-free at last follow-up (defined as >1 year without seizures), with a median 11.9 years since remission. For patients not completely seizure-free, the mean seizure frequency reduction at each time point was 76.2%, and ranged from 66.6% to 85.0%. Patients decreased their number of antiseizure medications on average by .58, and 53 (21.2%) patients were on no antiseizure medication at last follow-up. Nearly half (47.1%) of those seizure-free at last follow-up were not seizure-free immediately postoperatively. SIGNIFICANCE Patients who continue to have seizures after resection often have considerable reductions in seizure frequency, and many are able to achieve seizure freedom in a delayed manner.
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Affiliation(s)
- Jason K. Hsieh
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Francesco G. Pucci
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Swetha J. Sundar
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Efstathios Kondylis
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Akshay Sharma
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Shehryar R. Sheikh
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Deborah Vegh
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Ahsan N. Moosa
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Ajay Gupta
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Imad Najm
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Richard Rammo
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - William Bingaman
- Department of Neurosurgery, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Lara Jehi
- Charles Shor Epilepsy Center, Neurological InstituteCleveland Clinic FoundationClevelandOhioUSA
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Bensken WP, Alberti PM, Khan OI, Williams SM, Stange KC, Vaca GFB, Jobst BC, Sajatovic M, Koroukian SM. A framework for health equity in people living with epilepsy. Epilepsy Res 2022; 188:107038. [PMID: 36332544 PMCID: PMC9797034 DOI: 10.1016/j.eplepsyres.2022.107038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/22/2022] [Accepted: 10/17/2022] [Indexed: 12/31/2022]
Abstract
Epilepsy is a disease where disparities and inequities in risk and outcomes are complex and multifactorial. While most epilepsy research to date has identified several key areas of disparities, we set out to provide a multilevel life course model of epilepsy development, diagnosis, treatment, and outcomes to highlight how these disparities represent true inequities. Our piece also presents three hypothetical cases that highlight how the solutions to address inequities may vary across the lifespan. We then identify four key domains (structural, socio-cultural, health care, and physiological) that contribute to the persistence of inequities in epilepsy risk and outcomes in the United States. Each of these domains, and their core components in the context of epilepsy, are reviewed and discussed. Further, we highlight the connection between domains and key areas of intervention to strive towards health equity. The goal of this work is to highlight these domains while also providing epilepsy researchers and clinicians with broader context of how their work fits into health equity.
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Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA.
| | - Philip M Alberti
- AAMC Center for Health Justice, Association of American Medical Colleges, Washington, DC, USA
| | - Omar I Khan
- Epilepsy Center of Excellence, Baltimore VA Medical Center US Department of Veterans Affairs, Baltimore, MD, USA
| | - Scott M Williams
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department of Genetics and Genome Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Kurt C Stange
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Center for Community Health Integration, Departments of Family Medicine & Community Health, and Sociology Case Western Reserve University, Cleveland, OH, USA
| | - Guadalupe Fernandez-Baca Vaca
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Barbara C Jobst
- Department of Neurology, Geisel School of Medicine Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Martha Sajatovic
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department Psychiatry, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
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22
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Kamitaki BK, Zhang P, Master A, Adler S, Jain S, Thomas-Hawkins C, Lin H, Cantor JC, Choi H. Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey. Epilepsy Behav 2022; 136:108923. [PMID: 36166877 DOI: 10.1016/j.yebeh.2022.108923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/21/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.
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Affiliation(s)
- Brad K Kamitaki
- Rutgers-Robert Wood Johnson Medical School, Department of Neurology, 125 Paterson Street, Suite 6200, New Brunswick, NJ 08901, USA.
| | - Pengfei Zhang
- Rutgers-Robert Wood Johnson Medical School, Department of Neurology, 125 Paterson Street, Suite 6200, New Brunswick, NJ 08901, USA
| | - Aditi Master
- Rutgers-Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Shoshana Adler
- Rutgers-Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Saloni Jain
- Rutgers-Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Charlotte Thomas-Hawkins
- Rutgers University School of Nursing, Division of Nursing Science, 180 University Ave, Newark, NJ 07102, USA
| | - Haiqun Lin
- Rutgers University School of Nursing, Division of Nursing Science, 180 University Ave, Newark, NJ 07102, USA
| | - Joel C Cantor
- Rutgers University, Center for State Health Policy, 112 Paterson Street, 5th Floor, New Brunswick, NJ 08901, USA
| | - Hyunmi Choi
- Columbia University, Department of Neurology, 710 West 168(th) Street, 7(th) Floor, New York, NY 10032, USA
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23
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Kandregula S, Terrell D, Beyl R, Freelin A, Guthikonda B, Notarianni C, Toms J. Racial and socioeconomic disparities in the advanced treatment of medically intractable pediatric epilepsy. Neurosurg Focus 2022; 53:E2. [DOI: 10.3171/2022.7.focus22338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/21/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE
Racial and ethnic disparities in healthcare have gained significant importance since the Institute of Medicine published its report on disparities in healthcare. There is a lack of evidence on how race and ethnicity affect access to advanced treatment of pediatric medically intractable epilepsy. In this context, the authors analyzed the latest Kids’ Inpatient Database (KID) for racial/ethnic disparities in access to surgical treatment of epilepsy.
METHODS
The authors queried the KID for the years 2016 and 2019 for the diagnosis of medically intractable epilepsy.
RESULTS
A total of 29,292 patients were included in the sample. Of these patients, 8.9% (n = 2610) underwent surgical treatment/invasive monitoring. The mean ages in the surgical treatment and nonsurgical treatment groups were 11.73 years (SD 5.75 years) and 9.5 years (SD 6.16 years), respectively. The most common insurance in the surgical group was private/commercial (55.9%) and Medicaid in the nonsurgical group (47.7%) (p < 0.001). White patients accounted for the most common population in both groups, followed by Hispanic patients. African American patients made up 7.9% in the surgical treatment group compared with 12.9% in the nonsurgical group. African American (41.1%) and Hispanic (29.9%) patients had higher rates of emergency department (ED) utilization compared with the White population (24.6%). After adjusting for all covariates, the odds of surgical treatment increased with increasing age (OR 1.06, 95% CI 1.053–1.067; p < 0.001). African American race (OR 0.513, 95% CI 0.443–0.605; p < 0.001), Hispanic ethnicity (OR 0.681, 95% CI 0.612–0.758; p < 0.001), and other races (OR 0.789, 95% CI 0.689–0.903; p = 0.006) had lower surgical treatment odds compared with the White population. Medicaid/Medicare was associated with lower surgical treatment odds than private/commercial insurance (OR 0.603, 0.554–0.657; p < 0.001). Interaction analysis revealed that African American (OR 0.708, 95% CI 0.569–0.880; p = 0.001) and Hispanic (OR 0.671, 95% CI 0.556–0.809; p < 0.001) populations with private insurance had lower surgical treatment odds than White populations with private insurance. Similarly, African American patients, Hispanic patients, and patients of other races with nonprivate insurance also had lower surgical treatment odds than their White counterparts after adjusting for all other covariates.
CONCLUSIONS
Based on the KID, African American and Hispanic populations had lower surgical treatment rates than their White counterparts, with higher utilization of the ED for pediatric medically intractable epilepsy.
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Affiliation(s)
| | | | - Robbie Beyl
- Department of Statistics, Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - Anne Freelin
- Department of Neurosurgery, LSU Health Shreveport; and
| | | | | | - Jamie Toms
- Department of Neurosurgery, LSU Health Shreveport; and
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Hatoum R, Nathoo-Khedri N, Shlobin NA, Wang A, Weil AG, Fallah A. Barriers to Epilepsy Surgery in Pediatric Patients: A Scoping Review. Seizure 2022; 102:83-95. [DOI: 10.1016/j.seizure.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/05/2022] [Accepted: 08/31/2022] [Indexed: 11/25/2022] Open
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Tian N, Kobau R, Zack MM, Greenlund KJ. Barriers to and Disparities in Access to Health Care Among Adults Aged ≥18 Years with Epilepsy - United States, 2015 and 2017. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2022; 71:697-702. [PMID: 35617131 PMCID: PMC9153461 DOI: 10.15585/mmwr.mm7121a1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Niu Tian
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Rosemarie Kobau
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Matthew M Zack
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Kurt J Greenlund
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
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Gorbea MS. The Promise of Regenerative Medicine and Applications of Human Induced Pluripotent Stem Cells (iPSC) in Attenuating Current Racial Disparities in Epilepsy Therapeutics. AJOB Neurosci 2022; 13:135-137. [PMID: 35324397 DOI: 10.1080/21507740.2022.2048729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Terman SW, Kerr WT, Aubert CE, Hill CE, Marcum ZA, Burke JF. Adherence to Antiseizure vs Other Medications Among US Medicare Beneficiaries With and Without Epilepsy. Neurology 2022; 98:e427-e436. [PMID: 34893556 PMCID: PMC8793102 DOI: 10.1212/wnl.0000000000013119] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/16/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The objectives of this study were to compare adherence to antiseizure medications (ASMs) vs non-ASMs among individuals with epilepsy, to assess the degree to which variation in adherence is due to differences between individuals vs between medication classes among individuals with epilepsy, and to compare adherence in individuals with vs without epilepsy. METHODS This was a retrospective cohort study using Medicare. We included beneficiaries with epilepsy (≥1 ASM, plus ICD-9-CM diagnostic codes) and a 20% random sample without epilepsy. Adherence for each medication class was measured by the proportion of days covered (PDC) in 2013 to 2015. We used Spearman correlation coefficients, Cohen κ statistics, and multilevel logistic regressions. RESULTS There were 83,819 beneficiaries with epilepsy. Spearman correlation coefficients between ASM PDCs and each of the 5 non-ASM PDCs ranged from 0.44 to 0.50; Cohen κ ranged from 0.33 to 0.38; and within-person differences between the PDC of each ASM minus the PDC of each non-ASM were all statistically significant (p < 0.01), although median differences were all very close to 0. Fifty-four percent of variation in adherence across medications was due to differences between individuals. Adjusted predicted probabilities of adherence were as follows: ASMs 74% (95% confidence interval [CI] 73%-74%), proton pump inhibitors 74% (95% CI 74%-74%), antihypertensives 77% (95% CI 77%-78%), selective serotonin reuptake inhibitors 77% (95% CI 77%-78%), statins 78% (95% CI 78%-79%), and levothyroxine 82% (95% CI 81%-82%). Adjusted predicted probabilities of adherence to non-ASMs were 80% (95% CI 80%-81%) for beneficiaries with epilepsy vs 77% (95% CI 77%-77%) for beneficiaries without epilepsy. DISCUSSION Among individuals with epilepsy, ASM adherence and non-ASM adherence were moderately correlated, half of the variation in adherence was due to between-person rather than between-medication differences, adjusted adherence was slightly lower for ASMs than several non-ASMs, and epilepsy was associated with a quite small increase in adherence to non-ASMs. Nonadherence to ASMs may provide an important cue to the clinician to inquire about adherence to other potentially life-prolonging medications as well. Although efforts should focus on improving ASM adherence, patient-level rather than purely medication-specific behaviors are also critical to consider when developing interventions to optimize adherence.
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Affiliation(s)
- Samuel W Terman
- From the Department of Neurology (S.W.T., W.T.K., C.E.H., J.F.B.), and Institute for Healthcare Policy and Innovation (S.W.T., C.E.H., J.F.B.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of General Internal Medicine (C.E.A.), Bern University Hospital, and Institute of Primary Health Care (BIHAM) (C.E.A.), University of Bern, Switzerland; and Department of Pharmacy (Z.A.M.), School of Pharmacy, University of Washington, Seattle.
| | - Wesley T Kerr
- From the Department of Neurology (S.W.T., W.T.K., C.E.H., J.F.B.), and Institute for Healthcare Policy and Innovation (S.W.T., C.E.H., J.F.B.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of General Internal Medicine (C.E.A.), Bern University Hospital, and Institute of Primary Health Care (BIHAM) (C.E.A.), University of Bern, Switzerland; and Department of Pharmacy (Z.A.M.), School of Pharmacy, University of Washington, Seattle
| | - Carole E Aubert
- From the Department of Neurology (S.W.T., W.T.K., C.E.H., J.F.B.), and Institute for Healthcare Policy and Innovation (S.W.T., C.E.H., J.F.B.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of General Internal Medicine (C.E.A.), Bern University Hospital, and Institute of Primary Health Care (BIHAM) (C.E.A.), University of Bern, Switzerland; and Department of Pharmacy (Z.A.M.), School of Pharmacy, University of Washington, Seattle
| | - Chloe E Hill
- From the Department of Neurology (S.W.T., W.T.K., C.E.H., J.F.B.), and Institute for Healthcare Policy and Innovation (S.W.T., C.E.H., J.F.B.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of General Internal Medicine (C.E.A.), Bern University Hospital, and Institute of Primary Health Care (BIHAM) (C.E.A.), University of Bern, Switzerland; and Department of Pharmacy (Z.A.M.), School of Pharmacy, University of Washington, Seattle
| | - Zachary A Marcum
- From the Department of Neurology (S.W.T., W.T.K., C.E.H., J.F.B.), and Institute for Healthcare Policy and Innovation (S.W.T., C.E.H., J.F.B.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of General Internal Medicine (C.E.A.), Bern University Hospital, and Institute of Primary Health Care (BIHAM) (C.E.A.), University of Bern, Switzerland; and Department of Pharmacy (Z.A.M.), School of Pharmacy, University of Washington, Seattle
| | - James F Burke
- From the Department of Neurology (S.W.T., W.T.K., C.E.H., J.F.B.), and Institute for Healthcare Policy and Innovation (S.W.T., C.E.H., J.F.B.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of General Internal Medicine (C.E.A.), Bern University Hospital, and Institute of Primary Health Care (BIHAM) (C.E.A.), University of Bern, Switzerland; and Department of Pharmacy (Z.A.M.), School of Pharmacy, University of Washington, Seattle
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28
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Gutierrez-Colina AM, Wetter SE, Mara CA, Guilfoyle S, Modi AC. Racial Disparities in Medication Adherence Barriers: Pediatric Epilepsy as an Exemplar. J Pediatr Psychol 2022; 47:620-630. [PMID: 35024854 PMCID: PMC9172841 DOI: 10.1093/jpepsy/jsac001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To evaluate how racial disparities in medication adherence barriers relate to key clinical outcomes (i.e., seizure control and adherence) in pediatric epilepsy and to identify the most critical barriers in determining health outcomes in Black youth and White youth. METHODS This observational study included a sample of youth aged 2-17 years with epilepsy obtained by combining data from four different studies. A total of 226 caregivers and 43 adolescents reported on adherence barriers. An electronic monitor was used to measure adherence to the primary antiepileptic drug. Racial disparities in individual barriers were examined. The relative importance of different types of barriers in determining clinical outcomes was evaluated in both Black and White youth. RESULTS Adherence barriers, including running out of medications, access to pharmacies, competing demands, and difficulty swallowing, disproportionally affected Black children with epilepsy compared to White children. System- and community-level barriers emerged as the most important in determining seizure outcomes among Black youth. Both system- and individual-level barriers, on the other hand, were important for adherence outcomes. CONCLUSIONS System- and community-level barriers, as opposed to individual-level barriers, are more highly endorsed by Black families compared to White families. These barriers are also the most critical in driving seizure outcomes among Black youth. There is a critical need to shift from a primary focus on individual-level barriers to an approach that deliberately targets larger systemic barriers to reduce the existing adherence and health disparities that affect Black children with pediatric conditions.
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Affiliation(s)
- Ana M Gutierrez-Colina
- Correspondence concerning this article should be addressed to Avani C. Modi, PhD, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave. (MLC 7039-Adherence Center), Cincinnati, OH 45229, USA. E-mail:
| | - Sara E Wetter
- Department of Clinical & Health Psychology, University of Florida, USA
| | - Constance A Mara
- Center for Adherence and Self-Management, Cincinnati Children’s Hospital Medical Center, USA
| | - Shanna Guilfoyle
- Center for Adherence and Self-Management, Cincinnati Children’s Hospital Medical Center, USA
| | - Avani C Modi
- Center for Adherence and Self-Management, Cincinnati Children’s Hospital Medical Center, USA
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29
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Oberdhan D, Bacci E, Hill JN, Palsgrove A, Hareendran A. Developing a Conceptual Disease Model of Patient Experiences and Identifying Patient-Reported Clinical Outcome Assessments for Use in Trials of Treatments for Focal Onset Seizures. Neuropsychiatr Dis Treat 2022; 18:611-631. [PMID: 35345602 PMCID: PMC8957350 DOI: 10.2147/ndt.s354031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/09/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To identify concepts important to understanding the experiences of adults with focal onset seizures (FOS) and evaluate clinical outcome assessments (COAs) for measuring these concepts in clinical trials of treatments for FOS. METHODS A search of published qualitative research, clinical trials, and approved product labels for FOS treatments was performed to develop a conceptual disease model (CDM) of patients' experience of living with FOS. Concepts of interest (COI) were selected, and a second literature search was conducted to identify COAs measuring these concepts. Ten COAs were selected and reviewed to document their development process, evidence of measurement properties, and methods for interpreting change scores using criteria proposed in regulatory guidelines for patient-reported outcomes to support label claims. RESULTS Concepts identified from the published literature (13 articles, 1 conference abstract), 24 clinical trials, and 8 product labels were included in a novel CDM. Impacts on physical, cognitive, and social and emotional function were chosen as COI for evaluating treatment outcomes for FOS; the additional concept of social support and coping strategies was chosen to understand patients' lived experiences. From 51 unique COAs identified, 10 were selected based on their potential coverage of the COI; some symptom severity and health-related quality of life (HRQoL) COAs covered multiple COI. Of these 10, 8 COAs evaluated impacts/limitations on physical function, 8 measured social and emotional impacts, and 5 assessed social support and coping strategies. While most assessments had gaps in evidence validating their measurement properties, 2 COAs measuring symptom severity and 1 COA measuring HRQoL had evidence confirming their potential utility in clinical trials to support label claims. CONCLUSION This research provides insights into the experience of patients with FOS and identifies COAs that measure concepts considered to support endpoints in clinical trials for FOS.
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Affiliation(s)
- Dorothee Oberdhan
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
| | | | | | - Andrew Palsgrove
- Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD, USA
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Bernstein J, Kashyap S, Kortz MW, Zakhary B, Takayanagi A, Toor H, Savla P, Wacker MR, Ananda A, Miulli D. Utilization of epilepsy surgery in the United States: A study of the National Inpatient Sample investigating the roles of race, socioeconomic status, and insurance. Surg Neurol Int 2021; 12:546. [PMID: 34877032 PMCID: PMC8645483 DOI: 10.25259/sni_824_2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/11/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Epilepsy is estimated to affect 70 million people worldwide and is medically refractory in 30% of cases. Methods: This is a retrospective cross-sectional study using a US database from 2012 to 2014 to identify patients aged ≥18 years admitted to the hospital with epilepsy as the primary diagnosis. The sampled population was weighted using Healthcare Cost and Utilization Project guidelines. Procedural ICD-9 codes were utilized to stratify the sampled population into two cohorts: resective surgery and implantation or stimulation procedure. Results: Query of the database yielded 152,925 inpatients, of which 8535 patients underwent surgical intervention. The nonprocedural group consisted of 76,000 White patients (52.6%) and 28,390 Black patients (19.7%) while the procedural group comprised 5550 White patients (64%) and 730 Black patients (8.6%) (P < 0.001). Patients with Medicare were half as likely to receive a surgical procedure (14.8% vs. 28.4%) while patients with private insurance were twice as likely to receive a procedure (53.4% vs. 29.3%), both were statistically significant (P < 0.01). Those in the lowest median household income quartile by zip code (<$40,000) were 68% less likely to receive a procedure (21.5% vs. 31.4%) while the highest income quartile was 133% more likely to receive a procedure (26.1% vs. 19.5%). Patients from rural and urban nonteaching hospitals were, by a wide margin, less likely to receive a surgical procedure. Conclusion: We demonstrate an area of need and significant improvement at institutions that have the resources and capability to perform epilepsy surgery. The data show that institutions may not be performing enough epilepsy surgery as a result of racial and socioeconomic bias. Admissions for epilepsy continue to increase without a similar trend for epilepsy surgery despite its documented effectiveness. Race, socioeconomic status, and insurance all represent significant barriers in access to epilepsy surgery. The barriers can be remedied by improving referral patterns and implementing cost-effective measures to improve inpatient epilepsy services in rural and nonteaching hospitals.
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Affiliation(s)
- Jacob Bernstein
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Samir Kashyap
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Michael W Kortz
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Bishoy Zakhary
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Ariel Takayanagi
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Harjyot Toor
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Paras Savla
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Margaret R Wacker
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Ajay Ananda
- Department of Neurosurgery, Kaiser Sunset Medical Center, Los Angeles, California, United States
| | - Dan Miulli
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
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Beatty CW, Lockrow JP, Gedela S, Gehred A, Ostendorf AP. The Missed Value of Underutilizing Pediatric Epilepsy Surgery: A Systematic Review. Semin Pediatr Neurol 2021; 39:100917. [PMID: 34620465 DOI: 10.1016/j.spen.2021.100917] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
Pediatric epilepsy surgery is underutilized. Only 1%-11% of children with drug resistant epilepsy (DRE) undergo surgical treatment, or less than half of those estimated to benefit. We conducted a systematic review of articles published in PubMed, EMBASE, and Web of Science in order to study the factors related to surgery underutilization as well as the impact on both the individual and the healthcare system. Our review demonstrates multiple factors leading to underutilization, including family misconceptions about epilepsy surgery, lack of provider knowledge, as well as systemic health disparities. While the upfront cost of epilepsy surgery is significant, the long-term financial benefits and reduced health resource utilization tilt the economic advantage in favor of surgery in children with DRE. Additionally, timely interventions improve seizure and cognitive outcomes with low risk of complications. Further interventions are needed at the levels of family, provider, and the healthcare system to increase access to pediatric epilepsy surgery.
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Affiliation(s)
- Christopher W Beatty
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH
| | - Jason P Lockrow
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA
| | - Satyanarayana Gedela
- Emory University and Children's Healthcare of Atlanta, Division of Neurology, Department of Pediatrics, Atlanta, GA
| | - Alison Gehred
- Medical Library Division, Nationwide Children's Hospital, Columbus, OH
| | - Adam P Ostendorf
- The Ohio State University and Nationwide Children's Hospital, Division of Neurology, Department of Pediatrics, Columbus, OH.
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Underrepresented Populations in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100916. [PMID: 34620462 DOI: 10.1016/j.spen.2021.100916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Abstract
As awareness of pediatric epilepsy increases, accompanied by advancements in technology and research, it is important to identify certain types of patients that are overlooked for surgical management of epilepsy. Identifying these populations will allow us to study and elucidate the factors contributing to the underutilization and/or delayed application of surgical interventions. Demographically, African-American and Hispanic patients, as well as patients of certain Asian ethnicities, have relatively lower rates of undergoing epilepsy surgery than non-Hispanic and white patients. Among patients with epilepsy, those with higher odds of seizure-freedom following surgery are more likely to be referred for surgical evaluation by their neurologists, with the most common diagnosis being lesional focal epilepsy. However, patients with multifocal or generalized epilepsy, genetic etiologies, or normal (non-lesional) brain magnetic resonance imaging (MRI) are less likely be to referred for evaluation for resective surgery. With an increasing number of high-quality imaging modalities to help localize the epileptogenic zone as well as new techniques for both curative and palliative epilepsy surgery, there are very few populations of patients and/or types of epilepsy that should be precluded from evaluation to determine the suitability of epilepsy surgery. Ultimately, a clearer understanding of the populations who are underrepresented among those considered for epilepsy surgery, coupled with further study of the underlying reasons for this trend, will lead to less disparity in access to this critical treatment among patients with epilepsy.
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Guglielmi G, Eschbach KL, Alexander AL. Smaller Knife, Fewer Seizures? Recent Advances in Minimally Invasive Techniques in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100913. [PMID: 34620456 DOI: 10.1016/j.spen.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
Children with drug-resistant epilepsy are at high risk for developmental delay, increased mortality, psychiatric comorbidities, and requiring assistance with activities of daily living. Despite the advent of new and effective pharmacologic therapies, about one in 5 children will develop drug-resistant epilepsy, and most of these children continue to have seizures despite trials of other medication. Epilepsy surgery is often a safe and effective option which may offer seizure freedom or at least a significant reduction in seizure burden in many children. However, despite published evidence of safety and efficacy, epilepsy surgery remains underutilized in the pediatric population. Patient and family fears about the risks of surgery may contribute to this gap. Less invasive surgical techniques may be more palatable to children with epilepsy and their caregivers. In this review, we present recent advances in minimally invasive techniques for the surgical treatment of epilepsy as well as intriguing possibilities for the future. We describe the indications for, benefits of, and limits to minimally-invasive techniques including Stereo-encephalography, laser interstitial thermal ablation, deep brain stimulation, focused ultrasound, stereo-encephalography-guided radiofrequency ablation, endoscopic disconnections, and responsive neurostimulation.
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Affiliation(s)
- Gina Guglielmi
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Krista L Eschbach
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO
| | - Allyson L Alexander
- Graduate Medical Education, Neurological Surgery Residency, Carle BroMenn Medical Center, Normal IL; Section of Pediatric Neurology, Children's Hospital Colorado, Aurora CO; Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora CO; Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora CO; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora CO.
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Hamade YJ, Palzer EF, Helgeson ES, Hanson JT, Walczak TS, McGovern RA. Persistent racial and ethnic disparities as a potential source of epilepsy surgery underutilization: Analysis of large national datasets from 2006-2016. Epilepsy Res 2021; 176:106725. [PMID: 34304018 DOI: 10.1016/j.eplepsyres.2021.106725] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/10/2021] [Accepted: 07/13/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE High volume surgical epilepsy centers have reported a decrease in surgical resections and an increase in intracranial monitoring. Despite this increase in complexity, epilepsy surgery remains significantly underutilized. The goal of this study is to examine the utilization of and access to epilepsy surgery in the United States from 2006 to 2016. METHODS We used administrative datasets from the National Inpatient Sample (NIS) and Center for Medicare and Medicaid Services (CMS) to report national estimates of epilepsy surgery and changes in surgery types. We also examined disparities and barriers in access to epilepsy surgery. RESULTS Inpatient epilepsy admissions increased from 2.41 to 5.78 per 100,000 between 2006 and 2016, while surgical epilepsy admissions plateaued after 2011. Open resections comprised 75 % of all surgical cases from 2006 to 2011 then decreased each year to 50 % in 2016 with both temporal and extratemporal resections decreasing proportionally. Intracranial monitoring increased in the last two years of the study due to an increase in SEEG/depth electrode cases. The multivariate analysis showed that patients with Medicaid (OR 0.75, 95 % CI 0.67-0.83) and Medicare (OR 0.62, 95 % CI 0.54-0.70) were significantly less likely to undergo epilepsy surgery compared to those with private insurance. Black patients were less likely to undergo epilepsy surgery than White or Hispanic patients (OR 0.57, 95 % CI 0.49-0.67). No significant difference was found in epilepsy surgery rates after implementation of the Affordable Care Act (ACA) in 2014. CONCLUSION This study identifies recent trends in epilepsy surgical approaches and suggests that improving access to care does not necessarily address disparities present in the treatment of epilepsy patients who need surgical care.
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Affiliation(s)
- Youssef J Hamade
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN, 55455, United States.
| | - Elise F Palzer
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, United States
| | - Erika S Helgeson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, United States
| | - Jacob T Hanson
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN, 55455, United States
| | - Thaddeus S Walczak
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, 55455, United States
| | - Robert A McGovern
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN, 55455, United States
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Bensken WP, Navale SM, Andrew AS, Jobst BC, Sajatovic M, Koroukian SM. Markers of Quality Care for Newly Diagnosed People With Epilepsy on Medicaid. Med Care 2021; 59:588-596. [PMID: 33797505 PMCID: PMC8187271 DOI: 10.1097/mlr.0000000000001541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND For newly diagnosed people with epilepsy (PWE), proper treatment is important to improve outcomes, yet limited data exist on markers of quality care. OBJECTIVE Examine markers of quality care for newly diagnosed PWE. METHODS Using Medicaid claims data (2010-2014) for 15 states we identified adults 18-64 years of age diagnosed with incident epilepsy in 2012 or 2013. We built 5 sequential logistic regression models to evaluate: (1) seeing a neurologist; (2) diagnostic evaluation; (3) antiepileptic medication adherence; (4) serum drug levels checked; and (5) being in the top quartile of number of negative health events (NHEs). We adjusted for demographics, comorbidities, county-level factors, and the outcomes from all prior models. RESULTS Of 25,663 PWE, 37.3% saw a neurologist, with decreased odds for those of older age, those residing in counties with low-density of neurologists, and certain race/ethnicities; about 57% of PWE received at least 1 diagnostic test; and nearly 62% of PWE were adherent to their medication. The most common comorbidities were hypertension (37.1%) and psychoses (26.9%). PWE with comorbidities had higher odds of seeing a neurologist and to have NHEs. Substance use disorders were negatively associated with medication adherence and positively associated with high NHEs. CONCLUSIONS There are notable differences in demographics among people with incident epilepsy who do or do not see a neurologist. Differences in NHEs persist, even after controlling for neurologist care and diagnostic evaluation. Continued attention to these disparities and comorbidities is needed in the evaluation of newly diagnosed PWE.
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Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Suparna M Navale
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Angeline S Andrew
- Department of Neurology, Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Barbara C Jobst
- Department of Neurology, Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Martha Sajatovic
- Departments of Neurology and Psychiatry, University Hospitals Cleveland Medical Center and School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH
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Modi AC, Patel AD, Stevens J, Smith G, Huszti H, Guilfoyle SM, Mara CA, Schmidt M, Wagner JL. The psychosocial impact of COVID-19 within the first six months of the pandemic on youth with epilepsy and their caregivers. Epilepsy Behav 2021; 117:107855. [PMID: 33636530 PMCID: PMC8035246 DOI: 10.1016/j.yebeh.2021.107855] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We assessed the impact of COVID-19 on children with epilepsy and their families, focusing on epilepsy management, family routines, learning, and adherence to Centers for Disease Control and Prevention (CDC) pandemic guidelines (e.g., social distancing, mask wearing) within the first six months of the pandemic. Group differences in COVID-19 impact on families were also examined based on race and ethnicity, being medically and/or geographically underserved, and insurance status. METHODS Participants (n = 131) included children with epilepsy and their families from two clinical trials. The Impact of COVID-19 on Pediatric Epilepsy Management (ICPEM) measure was developed and administered to caregivers online from April 2020 to September 2020 across four large pediatric hospitals. Administration of the ICPEM occurred both during routine study assessments and an additional acute time point to obtain information early in the pandemic (e.g., April and May 2020). Descriptive statistics and t-tests were used for analyses. RESULTS Data indicate minor to moderate impact of COVID-19 on pediatric epilepsy management. Caregivers of children with epilepsy reported the most impact on education and social functioning. Adherence to CDC guidelines was reported to be high. Those having public insurance reported greater difficulties obtaining daily anti-seizure medications compared to those with private insurance. CONCLUSIONS This study presents important initial data regarding the impact of COVID-19 epilepsy management and daily functioning in children with epilepsy and their families. While the acute impact of COVID-19 restrictions appear to be mild to moderate, it is unclear what the long-term impact of the pandemic will be on families of children with epilepsy.
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Affiliation(s)
- Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, 3333 Burnet Ave., Cincinnati, OH 45229, United States,University of Cincinnati, College of Medicine, United States,Corresponding author at: Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Center for Treatment Adherence and Self-Management, University of Cincinnati, College of Medicine, 3333 Burnet Ave. MLC 7039, Cincinnati, OH 45229, United States
| | - Anup D. Patel
- Nationwide Children’s Hospital, 700 Children’s Drive, Near East Office Building, 3rd Floor, Columbus, OH 43205, United States,The Ohio State, Department of Pediatrics, 700 Children’s Drive, Near East Office Building, 3rd Floor, Columbus, OH 43205, United States
| | - Jack Stevens
- Nationwide Children’s Hospital, 700 Children’s Drive, Near East Office Building, 3rd Floor, Columbus, OH 43205, United States,The Ohio State, Department of Pediatrics, 700 Children’s Drive, Near East Office Building, 3rd Floor, Columbus, OH 43205, United States
| | - Gigi Smith
- College of Nursing, Medical University of South Carolina, Colcock Hall, 19 Bee St, MSC 002, Charleston, SC 29425, United States
| | - Heather Huszti
- Department of Pediatric Psychology, Children’s Hospital of Orange County, 1120 W La Veta Ave, Ste 470, Orange, CA 92868, United States
| | - Shanna M. Guilfoyle
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, 3333 Burnet Ave., Cincinnati, OH 45229, United States,University of Cincinnati, College of Medicine, United States
| | - Constance A. Mara
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, 3333 Burnet Ave., Cincinnati, OH 45229, United States,University of Cincinnati, College of Medicine, United States
| | - Matthew Schmidt
- College of Education, University of Florida, 2423 Normal Hall (2-206), PO Box 117048, Gainesville, FL 32611, United States
| | - Janelle L. Wagner
- College of Nursing, Medical University of South Carolina, Colcock Hall, 19 Bee St, MSC 002, Charleston, SC 29425, United States
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Kerr WT, Zhang X, Hill CE, Janio EA, Chau AM, Braesch CT, Le JM, Hori JM, Patel AB, Allas CH, Karimi AH, Dubey I, Sreenivasan SS, Gallardo NL, Bauirjan J, Hwang ES, Davis EC, D'Ambrosio SR, Al Banna M, Cho AY, Dewar SR, Engel J, Feusner JD, Stern JM. Epilepsy, dissociative seizures, and mixed: Associations with time to video-EEG. Seizure 2021; 86:116-122. [PMID: 33601302 PMCID: PMC7979505 DOI: 10.1016/j.seizure.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/23/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Video-electroencephalographic monitoring (VEM) is a core component to the diagnosis and evaluation of epilepsy and dissociative seizures (DS)-also known as functional or psychogenic seizures-but VEM evaluation often occurs later than recommended. To understand why delays occur, we compared how patient-reported clinical factors were associated with time from first seizure to VEM (TVEM) in patients with epilepsy, DS or mixed. METHODS We acquired data from 1245 consecutive patients with epilepsy, VEM-documented DS or mixed epilepsy and DS. We used multivariate log-normal regression with recursive feature elimination (RFE) to evaluate which of 76 clinical factors interacting with patients' diagnoses were associated with TVEM. RESULTS The mean and median TVEM were 14.6 years and 10 years, respectively (IQR 3-23 years). In the multivariate RFE model, the factors associated with longer TVEM in all patients included unemployment and not student status, more antiseizure medications (current and past), concussion, and ictal behavior suggestive of temporal lobe epilepsy. Average TVEM was shorter for DS than epilepsy, particularly for patients with depression, anxiety, migraines, and eye closure. Average TVEM was longer specifically for patients with DS taking more medications, more seizure types, non-metastatic cancer, and with other psychiatric comorbidities. CONCLUSIONS In all patients with seizures, trials of numerous antiseizure medications, unemployment and non-student status was associated with longer TVEM. These associations highlight a disconnect between International League Against Epilepsy practice parameters and observed referral patterns in epilepsy. In patients with dissociative seizures, some but not all factors classically associated with DS reduced TVEM.
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Affiliation(s)
- Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States.
| | - Xingruo Zhang
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Chloe E Hill
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Emily A Janio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Andrea M Chau
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Chelsea T Braesch
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Justine M Le
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Jessica M Hori
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Akash B Patel
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Corinne H Allas
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Amir H Karimi
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Ishita Dubey
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Siddhika S Sreenivasan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Norma L Gallardo
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Janar Bauirjan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Eric S Hwang
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Emily C Davis
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Shannon R D'Ambrosio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Mona Al Banna
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Andrew Y Cho
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Sandra R Dewar
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jerome Engel
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States; Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Brain Research Institute, University of California Los Angeles, Los Angeles, CA, United States
| | - Jamie D Feusner
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - John M Stern
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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38
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Kerr WT, Zhang X, Hill CE, Janio EA, Chau AM, Braesch CT, Le JM, Hori JM, Patel AB, Allas CH, Karimi AH, Dubey I, Sreenivasan SS, Gallardo NL, Bauirjan J, Hwang ES, Davis EC, D'Ambrosio SR, Al Banna M, Cho AY, Dewar SR, Engel J, Feusner JD, Stern JM. Factors associated with delay to video-EEG in dissociative seizures. Seizure 2021; 86:155-160. [PMID: 33621828 DOI: 10.1016/j.seizure.2021.02.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/23/2021] [Accepted: 02/12/2021] [Indexed: 01/31/2023] Open
Abstract
PURPOSE While certain clinical factors suggest a diagnosis of dissociative seizures (DS), otherwise known as functional or psychogenic nonepileptic seizures (PNES), ictal video-electroencephalography monitoring (VEM) is the gold standard for diagnosis. Diagnostic delays were associated with worse quality of life and more seizures, even after treatment. To understand why diagnoses were delayed, we evaluated which factors were associated with delay to VEM. METHODS Using data from 341 consecutive patients with VEM-documented dissociative seizures, we used multivariate log-normal regression with recursive feature elimination (RFE) and multiple imputation of some missing data to evaluate which of 76 clinical factors were associated with time from first dissociative seizure to VEM. RESULTS The mean delay to VEM was 8.4 years (median 3 years, IQR 1-10 years). In the RFE multivariate model, the factors associated with longer delay to VEM included more past antiseizure medications (0.19 log-years/medication, standard error (SE) 0.05), more medications for other medical conditions (0.06 log-years/medication, SE 0.03), history of physical abuse (0.75 log-years, SE 0.27), and more seizure types (0.36 log-years/type, SE 0.11). Factors associated with shorter delay included active employment or student status (-1.05 log-years, SE 0.21) and higher seizure frequency (0.14 log-years/log[seizure/month], SE 0.06). CONCLUSIONS Patients with greater medical and seizure complexity had longer delays. Delays in multiple domains of healthcare can be common for victims of physical abuse. Unemployed and non-student patients may have had more barriers to access VEM. These results support earlier referral of complex cases to a comprehensive epilepsy center.
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Affiliation(s)
- Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States.
| | - Xingruo Zhang
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Chloe E Hill
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Emily A Janio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Andrea M Chau
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Chelsea T Braesch
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Justine M Le
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Jessica M Hori
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Akash B Patel
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Corinne H Allas
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Amir H Karimi
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Ishita Dubey
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Siddhika S Sreenivasan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Norma L Gallardo
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Janar Bauirjan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Eric S Hwang
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Emily C Davis
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Shannon R D'Ambrosio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Mona Al Banna
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Andrew Y Cho
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Sandra R Dewar
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jerome Engel
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States; Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Brain Research Institute, University of California Los Angeles, Los Angeles, CA, United States
| | - Jamie D Feusner
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - John M Stern
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Thorpe J, Ashby S, Hallab A, Ding D, Andraus M, Dugan P, Perucca P, Costello D, French JA, O'Brien TJ, Depondt C, Andrade DM, Sengupta R, Delanty N, Jette N, Newton CR, Brodie MJ, Devinsky O, Helen Cross J, Sander JW, Hanna J, Sen A. Evaluating risk to people with epilepsy during the COVID-19 pandemic: Preliminary findings from the COV-E study. Epilepsy Behav 2021; 115:107658. [PMID: 33341393 PMCID: PMC7698680 DOI: 10.1016/j.yebeh.2020.107658] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/22/2020] [Accepted: 11/22/2020] [Indexed: 01/21/2023]
Abstract
The COVID-19 pandemic has caused global anguish unparalleled in recent times. As cases rise, increased pressure on health services, combined with severe disruption to people's everyday lives, can adversely affect individuals living with chronic illnesses, including people with epilepsy. Stressors related to disruption to healthcare, finances, mental well-being, relationships, schooling, physical activity, and increased isolation could increase seizures and impair epilepsy self-management. We aim to understand the impact that COVID-19 has had on the health and well-being of people with epilepsy focusing on exposure to increased risk of seizures, associated comorbidity, and mortality. We designed two online surveys with one addressing people with epilepsy directly and the second for caregivers to report on behalf of a person with epilepsy. The survey is ongoing and has yielded 463 UK-based responses by the end of September 2020. Forty percent of respondents reported health changes during the pandemic (n = 185). Respondents cited a change in seizures (19%, n = 88), mental health difficulties (34%, n = 161), and sleep disruption (26%, n = 121) as the main reasons. Thirteen percent found it difficult to take medication on time. A third had difficulty accessing medical services (n = 154), with 8% having had an appointment canceled (n = 39). Only a small proportion reported having had discussions about epilepsy-related risks, such as safety precautions (16%, n = 74); mental health (29%, n = 134); sleep (30%, n = 140); and Sudden Unexpected Death in Epilepsy (SUDEP; 15%, n = 69) in the previous 12 months. These findings suggest that people with epilepsy are currently experiencing health changes, coupled with inadequate access to services. Also, there seems to be a history of poor risk communication in the months preceding the pandemic. As the UK witnesses a second COVID-19 wave, those involved in healthcare delivery must ensure optimal care is provided for people with chronic conditions, such as epilepsy, to ensure that avoidable morbidity and mortality is prevented during the pandemic, and beyond.
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Affiliation(s)
- Jennifer Thorpe
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK,SUDEP Action, 18 Newbury Street, Wantage, Oxfordshire OX12 8DA. UK
| | - Samantha Ashby
- SUDEP Action, 18 Newbury Street, Wantage, Oxfordshire OX12 8DA. UK
| | - Asma Hallab
- Department of Nuclear Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ding Ding
- Institute of Neurology, Fudan University Huashan Hospital, Shanghai, China
| | - Maria Andraus
- Department of Internal Medicine, Neurology Service, Epilepsy Program, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia Dugan
- Department of Neurology, NYU Grossman School of Medicine, USA
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, The Alfred Hospital, Monash University, Melbourne, Australia & Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Daniel Costello
- Epilepsy Service, Cork University Hospital & College of Medicine and Health, University College Cork, Ireland
| | | | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, The Alfred Hospital, Monash University, Melbourne, Australia & Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Chantal Depondt
- Department of Neurology, Hôpital Erasme – Université Libre de Bruxelles, Brussels, Belgium
| | - Danielle M. Andrade
- Adult Epilepsy Genetics Program, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | | | - Norman Delanty
- Beaumont Hospital, and School of Pharmacy and Biomolecular Sciences, FutureNeuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Charles R. Newton
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK,University Department of Psychiatry, University of Oxford, UK
| | - Martin J. Brodie
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, UK
| | - Orrin Devinsky
- Department of Neurology, NYU Grossman School of Medicine, USA
| | - J. Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK,Young Epilepsy, St Pier's Lane, Dormansland, Lingfield RH7 6P, UK
| | - Josemir W. Sander
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG & Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
| | - Jane Hanna
- SUDEP Action, 18 Newbury Street, Wantage, Oxfordshire OX12 8DA. UK
| | - Arjune Sen
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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Mehta D, Davis M, Epstein AJ, Wensel B, Grinnell T, Thach A, Williams GR. Comparative economic outcomes in patients with focal seizures initiating eslicarbazepine acetate versus brivaracetam as their first adjunctive ASD. J Med Econ 2021; 24:939-948. [PMID: 34311671 DOI: 10.1080/13696998.2021.1960682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS To study the association between initiation of first adjunctive therapy with eslicarbazepine acetate (ESL) vs. brivaracetam (BRV) on healthcare resource utilization (HCRU) and charges among patients with treated focal seizures (FS). MATERIALS AND METHODS Symphony Health's Integrated Dataverse (IDV) claims data (1 April 2015 to 30 June 2018) were used to identify two cohorts as first adjunctive therapy with ESL or BRV following a generic anti-seizure drug (ASD). The index date was the earliest claim for a new ESL or BRV prescription. Key inclusion criteria were only 1 generic ASD in the 12 months before the index date; ≥1 medical claim with an FS diagnosis. Unit of analysis was the 90-day person-time-block. Changes in HCRU and charges were assessed using a difference-in-differences framework. Both unadjusted and adjusted analyses were performed. The adjusted model utilized person-specific fixed effects and propensity score-based weighting to control for differences in baseline covariates. Bias-corrected bootstrap confidence intervals (CIs) were calculated for charge outcomes. RESULTS 208 and 137 patients initiated first adjunctive therapy with ESL (43.7 years, 51.9% female) or BRV (39.3 years, 51.8% female). Patients in the ESL cohort had numerically larger reductions in all-cause and FS-related inpatient hospitalizations and outpatient visits and FS-related emergency department visits. Compared to patients initiating BRV, patients treated with ESL had significantly larger reductions in total charges (-$3,446, CI: -$13,716, -$425), all-cause (-$3,166, CI: -$13,991, -$323) and FS-related (-$2,969, CI: -$21,547, -$842) medical charges, all-cause (-$3,397, CI: -$15,676, -$818) and FS-related (-$2,863, CI: -$19,707, -$787) outpatient charges, and non-ASD-related prescription charges (-$420, CI: -$1,058, -$78). LIMITATIONS Claims may be missing, or miscoded; outcomes may be influenced by variables not accounted for in the analysis; only information on submitted charges was included. CONCLUSIONS Among patients with FS, initiation of first adjunctive therapy with ESL was associated with significantly larger reductions in medical and non-ASD-related prescriptions charges compared to BRV.
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Affiliation(s)
| | | | | | - Brian Wensel
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | | | - Andrew Thach
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
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Anand SK, Macki M, Culver LG, Wasade VS, Hendren S, Schwalb JM. Patient navigation in epilepsy care. Epilepsy Behav 2020; 113:107530. [PMID: 33232897 DOI: 10.1016/j.yebeh.2020.107530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 12/20/2022]
Abstract
The concept of patient navigation was first introduced in 1989 by the American Cancer Society and was first implemented in 1990 by Dr. Harold Freeman in Harlem, NY. The role of a patient navigator (PN) is to coordinate care between the care team, the patient, and their family while also providing social support. In the last 30 years, patient navigation in oncological care has expanded internationally and has been shown to significantly improve patient care experience, especially in the United States cancer care system. Like oncology care, patients who require epilepsy care face socioeconomic and healthcare system barriers and are at significant risk of morbidity and mortality if their care needs are not met. Although shortcomings in epilepsy care are longstanding, the COVID-19 pandemic has exacerbated these issues as both patients and providers have reported significant delays in care secondary to the pandemic. Prior to the pandemic, preliminary studies had shown the potential efficacy of patient navigation in improving epilepsy care. Considering the evidence that such programs are helpful for severely disadvantaged cancer patients and in enhancing epilepsy care, we believe that professional societies should support and encourage PN programs for coordinated and comprehensive care for patients with epilepsy.
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Affiliation(s)
- Sharath Kumar Anand
- Wayne State University School of Medicine, 540 E Canfield St., Detroit, MI, USA.
| | - Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, USA
| | - Lauren G Culver
- Wayne State University School of Medicine, 540 E Canfield St., Detroit, MI, USA
| | - Vibhangini S Wasade
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, USA; Department of Neurology, Wayne State University School of Medicine, 540 E Canfield St., Detroit, MI, USA
| | - Samantha Hendren
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, USA; Center for Health Policy and Health Services Research, Henry Ford Health System, 2799 W Grand Blvd, Detroit MI 48202, USA
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Bonkowsky JL, deVeber G, Kosofsky BE. Pediatric Neurology Research in the Twenty-First Century: Status, Challenges, and Future Directions Post-COVID-19. Pediatr Neurol 2020; 113:2-12. [PMID: 32979654 DOI: 10.1016/j.pediatrneurol.2020.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND The year 2020 marked a fundamental shift in the pediatric neurology field. An impressive positive trajectory of advances in patient care and research faced sudden global disruptions by the coronavirus disease 2019 pandemic and by an international movement protesting racial, socioeconomic, and health disparities. The disruptions revealed obstacles and fragility within the pediatric neurology research mission. However, renewed commitment offers unique opportunities for the pediatric neurology research community to enhance and prioritize research directions for the coming decades. METHODS The Research Committee of the Child Neurology Society evaluated the challenges and opportunities facing the pediatric neurology research field, including reviewing published literature, synthesizing publically available data, and conducting a survey of pediatric neurologists. RESULTS We identified three priority domains for the research mission: funding levels, active guidance, and reducing disparities. Funding levels: to increase funding to match the burden of pediatric neurological disease; to tailor funding mechanisms and strategies to support clinical trial efforts unique to pediatric neurology; and to support investigators across their career trajectory. Active guidance: to optimize infrastructure and strategies, to leverage novel therapeutics, enhance data collection, and improve inclusion of children in clinical trials. Reducing disparities: to reduce health disparities in children with neurological disease, to develop proactive measures to enhance workforce diversity and inclusion, and increase avenues to balance work-life obligations for investigators. CONCLUSIONS In this uniquely challenging epoch, the pediatric neurology research community has a timely and important mission to re-engage the public and government, advancing the health of children with neurological conditions.
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Affiliation(s)
- Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah.
| | - Gabrielle deVeber
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Barry E Kosofsky
- Department of Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, New York
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Shegog R, Begley C, Chong J, Sepulveda R, Addy R, Martin K, Rosales O, Halavacs N, Labiner D. MINDSET: Clinic-based decision support demonstrates longitudinal efficacy for increased epilepsy self-management adherence among Spanish speaking patients. Epilepsy Behav 2020; 113:107552. [PMID: 33242775 DOI: 10.1016/j.yebeh.2020.107552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND MINDSET, a bilingual (Eng./Span.) decision support tool was found feasible for facilitating goal-based epilepsy self-management (ESM) in the clinic. PURPOSE To evaluate the efficacy of MINDSET to increase ESM adherence among Hispanic patients. METHODS A RCT was conducted from August 2017 through January 2019. Spanish and English speaking Hispanic adult patients (n=94) with epilepsy in Arizona (n=53) and Texas (n=41) were randomly assigned within 6 neurology clinics to treatment (MINDSET plus Usual Care, hereafter referred to as MINDSET; n=46) and comparison (Usual Care Only; n=48) conditions. Self-reported self-management behavior (assessed through the Epilepsy Self-management scale) were categorized as adherent if performed 'usually' or 'always.' The proportion of adherence was compared between study conditions for 36 individual ESM behaviors and 5 ESM domains using Fischer's exact test. RESULTS The average time between visit 1 through 3 was 350+/-79 days with retention at 96.8%. Participants in the treatment condition had more college education and less unemployment. Self-management adherence improved across visits for all self-management behaviors irrespective of study condition. Compared to usual care MINDSET use led to greater ESM adherence for 86.1% behaviors (5 with statistical significance; p<0.05) and to significant improvement in the ESM domain of 'information management' (p<0.05). CONCLUSIONS Implementation of MINDSET within regular neurology visits may assist Hispanic adults with epilepsy to increase their adherence to ESM behaviors and maintain this adherence longitudinally. Replication with a broader demographic population of people with epilepsy is indicated.
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Affiliation(s)
- Ross Shegog
- University of Texas School of Public Health, Behavioral Science, Houston, TX, United States.
| | - Charles Begley
- University of Texas School of Public Health, Behavioral Science, Houston, TX, United States
| | - Jenny Chong
- University of Arizona, Department of Neurology, Tucson, AZ, United States
| | - Refugio Sepulveda
- University of Arizona, Department of Neurology, Tucson, AZ, United States
| | - Robert Addy
- University of Texas School of Public Health, Behavioral Science, Houston, TX, United States
| | - Kimberly Martin
- Epilepsy Foundation Central & South Texas, San Antonio, TX, United States
| | - Omar Rosales
- University of Texas School of Public Health, Behavioral Science, Houston, TX, United States
| | | | - David Labiner
- University of Arizona, Department of Neurology, Tucson, AZ, United States
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Clarke DF, Shah EG, Perkins FF. The Preoperative Evaluation of Drug-Resistant Epilepsy. Pediatr Neurol 2020; 112:78-83. [PMID: 32920308 DOI: 10.1016/j.pediatrneurol.2020.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 05/23/2020] [Accepted: 05/29/2020] [Indexed: 11/19/2022]
Abstract
Antiepileptic drugs afford good seizure control for approximately 70% of individuals with epilepsy. Epilepsy surgery is extremely helpful for appropriate individuals with drug resistance. Since antiquity, trephination was a crude and invasive technique to manage epilepsy. The late 1800s saw the advent of a more evidence-based approach with attempts to define seizure foci and determine areas of function. Seizure localization initially required direct brain stimulation during surgery before resection. Fortunately, improved knowledge of seizure semiology and advancements in preoperative investigations have enabled epilepsy specialists to better analyze the benefit of seizure reduction versus risk of functional harm. This preoperative phase and the investigative techniques used to analyze surgical candidacy will be discussed in this article.
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Affiliation(s)
- Dave F Clarke
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, Texas.
| | - Ekta G Shah
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Freedom F Perkins
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, Texas
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Kamitaki BK, Rishty S, Mani R, Wong S, Bateman LM, Thomas-Hawkins C, Cantor JC, Kleinman LC. Using ICD-10 codes to identify elective epilepsy monitoring unit admissions from administrative billing data: A validation study. Epilepsy Behav 2020; 111:107194. [PMID: 32534422 PMCID: PMC7286261 DOI: 10.1016/j.yebeh.2020.107194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/24/2020] [Indexed: 12/24/2022]
Abstract
Video-electroencephalogram (EEG) monitoring in the epilepsy monitoring unit (EMU) is essential for managing epilepsy and seizure mimics. Evaluation of care in the EMU would benefit from a validated code set capable of identifying EMU admissions from administrative databases comprised of large, diverse cohorts. We assessed the ability of code-based queries to parse EMU admissions from administrative billing records in a large academic medical center over a four-year period, 2016-2019. We applied prespecified queries for admissions coded as follows: 1) elective, 2) receiving video-EEG monitoring, and 3) including diagnoses typically required by major US healthcare payers for EMU admission. Sensitivity (Sn), specificity (Sp), and predictive value positive/negative (PVP, PVN) were determined. Two approaches were highly effective. Incorporating epilepsy, seizure, or seizure mimic codes as the admitting diagnosis (assigned at admission; Sn 96.3%, Sp 100.0%, PVP 98.3%, and PVN 100.0%) or the principal diagnosis (assigned after discharge; Sn 94.9%, Sp 100.0%, PVP 98.8%, and PVN 100.0%) identified elective adult EMU admissions with comparable reliability (p = 0.096). The addition of surgical procedure codes further separated EMU admissions for intracranial EEG monitoring. When applied to larger, more comprehensive datasets, these code-based queries should enhance our understanding of EMU utilization and access to care on a scalable basis.
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Affiliation(s)
- Brad K. Kamitaki
- Department of Neurology, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street Suite 6200, New Brunswick, NJ 08901, United States,Corresponding author at: 125 Paterson Street, Suite 6200, New Brunswick, NJ 08901, United States
| | - Shelly Rishty
- Department of Neurology, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street Suite 6200, New Brunswick, NJ 08901, United States
| | - Ram Mani
- Department of Neurology, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street Suite 6200, New Brunswick, NJ 08901, United States
| | - Stephen Wong
- Department of Neurology, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street Suite 6200, New Brunswick, NJ 08901, United States
| | - Lisa M. Bateman
- Department of Neurology, Columbia University Medical Center, 710 West 168th Street 7th Floor, New York, NY 10032, United States
| | - Charlotte Thomas-Hawkins
- Division of Nursing Science, School of Nursing, Rutgers University, 180 University Ave ACK 330, Newark, NJ 07102, United States
| | - Joel C. Cantor
- Center for State Health Policy, Rutgers University, 112 Paterson Street 5th Floor, New Brunswick, NJ 08901, United States
| | - Lawrence C. Kleinman
- Department of Pediatrics, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street 7th Floor, New Brunswick, NJ 08901, United States
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Abstract
A team of providers, researchers, patients, and families created a novel telehealth tool to improve communication across a variety of systems involved in pediatric epilepsy care. This tool facilitates in-home telemedicine appointments and saves costs for patients and hospital systems alike within the context of a population highly affected by health care disparities.
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47
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Poverty, insurance, and region as predictors of epilepsy treatment among US adults. Epilepsy Behav 2020; 107:107050. [PMID: 32294594 PMCID: PMC7242147 DOI: 10.1016/j.yebeh.2020.107050] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/17/2020] [Indexed: 11/20/2022]
Abstract
Disparities in epilepsy treatment have previously been reported. In the current study, we examine the role of socioeconomic status, health insurance, place of residence, and sociodemographic characteristics in past-year visit to a neurology or epilepsy provider and current use of antiseizure medications. Multiple years of data were compiled from the National Health Interview Surveys, Sample Adult Epilepsy Modules. The sample (n = 1655) included individuals 18 years and older who have been told by a doctor to have epilepsy or seizures. Independent variables included number of seizures in the past year, health insurance, poverty status, education, region, race/ethnicity, foreign-born status, age, and sex/gender. Two sets of weighted hierarchical logistic regression models were estimated predicting past-year epilepsy visit and current medication use. Accounting for recent seizure activity and other factors, uninsured and people residing outside of the Northeast were less likely to see an epilepsy provider, and people living in poverty were less likely to use medications, relative to their comparison groups. However, no racial/ethnic and nativity-based differences in specialty service or medication use were observed. Further research, including longitudinal studies of care trajectories and outcomes, are warranted to better understand healthcare needs of people with epilepsy, in particular treatment-resistant seizures, and to develop appropriate interventions at the policy, public health, and health system levels.
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Cihan E, Hesdorffer DC, Brandsoy M, Li L, Fowler DR, Graham JK, Karlovich M, Donner EJ, Devinsky O, Friedman D. Socioeconomic disparities in SUDEP in the US. Neurology 2020; 94:e2555-e2566. [PMID: 32327496 DOI: 10.1212/wnl.0000000000009463] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 12/05/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the impact of socioeconomic status (SES) on sudden unexpected death in epilepsy (SUDEP) rates. METHODS We queried all decedents presented for medico-legal investigation at 3 medical examiner (ME) offices across the country (New York City, Maryland, San Diego County) in 2009 to 2010 and 2014 to 2015. We identified all decedents for whom epilepsy/seizure was listed as cause/contributor to death or comorbid condition on the death certificate. We then reviewed all available reports. Decedents determined to have SUDEP were included for analysis. We used median income in the ZIP code of residence as a surrogate for SES. For each region, zip code regions were ranked by median household income and divided into quartiles based on total population for 2 time periods. Region-, age-, and income-adjusted epilepsy prevalence was estimated in each zip code. SUDEP rates in the highest and lowest SES quartiles were evaluated to determine disparity. Examined SUDEP rates in 2 time periods were also compared. RESULTS There were 159 and 43 SUDEP cases in the lowest and highest SES quartiles. ME-investigated SUDEP rate ratio between the lowest and highest SES quartiles was 2.6 (95% confidence interval [CI] 1.7-4.1, p < 0.0001) in 2009 to 2010 and 3.3 (95% CI 1.9-6.0, p < 0.0001) in 2014 to 2015. There was a significant decline in overall SUDEP rate between the 2 study periods (36% decrease, 95% CI 22%-48%, p < 0.0001). CONCLUSION ME-investigated SUDEP incidence was significantly higher in people with the lowest SES compared to the highest SES. The difference persisted over a 5-year period despite decreased overall SUDEP rates.
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Affiliation(s)
- Esma Cihan
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dale C Hesdorffer
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Brandsoy
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ling Li
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David R Fowler
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jason K Graham
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Karlovich
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth J Donner
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Orrin Devinsky
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daniel Friedman
- From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner's Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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49
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Grineski SE, Morales DX, Collins T, Wilkes J, Bonkowsky JL. Racial/Ethnic and Insurance Status Disparities in Distance Traveled to Access Children's Hospital Care for Severe Illness: the Case of Children with Leukodystrophies. J Racial Ethn Health Disparities 2020; 7:975-986. [PMID: 32095974 DOI: 10.1007/s40615-020-00722-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/15/2022]
Abstract
Families of children with special health care needs may travel substantial distances to access specialized health care. However, it is not known how race/ethnicity, insurance status, and access to disease-specific specialty care affect travel distances. This analysis examines patients aged 18 years or younger who were discharged from a Pediatric Health Information System (PHIS) children's hospital (n = 52) with a diagnosis of an inherited leukodystrophy between October 1, 2015, and September 30, 2018 (n = 950 patients). Leukodystrophies are rare but very serious neurological illnesses, with elevated mortality and morbidity rates. Bivariate and hierarchical generalized linear models reveal that white children, privately insured children, and children visiting leukodystrophy specialist centers travel farther for children's hospital care. These findings indicate that socially privileged families travel greater distances to obtain specialized health care, which could affect clinical outcomes.
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Affiliation(s)
- Sara E Grineski
- Department of Sociology, University of Utah, 480 S 1530 E. Room 0301, Salt Lake City, UT, 84112, USA.
| | - Danielle X Morales
- Department of Sociology and Anthropology, University of Texas at El Paso, 500 W University Ave, El Paso, TX, 79968, USA
| | - Timothy Collins
- Department of Geography, University of Utah, 260 South Central Campus Dr, Salt Lake City, UT, 84112, USA
| | - Jacob Wilkes
- Pediatric Analytics, Intermountain Healthcare, 295 Chipeta Way/Williams Building, Salt Lake City, UT, 84108, USA
| | - Joshua L Bonkowsky
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way/Williams Building, Salt Lake City, UT, 84108, USA
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Tetuan C, Axon DR, Bingham J, Boesen K, Lipsy R, Scovis N, Taylor AM, Warholak T, Lott BE, Leal S. Assessing the Effect of a Telepharmacist's Recommendations During an Integrated, Interprofessional Telehealth Appointment and Their Alignment with Quality Measures. J Manag Care Spec Pharm 2019; 25:1334-1339. [PMID: 31778622 PMCID: PMC10397946 DOI: 10.18553/jmcp.2019.25.12.1334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A growing provider shortage contributes to the widening gap in significant disparities that rural communities face. To expand access to care for rural-dwelling patients with epilepsy, a national nonprofit organization initiated an integrated, interprofessional telehealth program. OBJECTIVE To identify gaps in care based on a telepharmacist's recommendations and determine whether these recommendations aligned with Health Effectiveness Data Information Set (HEDIS) performance measures. METHODS A retrospective chart review was conducted for patients who had an appointment with an integrated interprofessional care team composed of an epileptologist, a social worker, registered nurses, and a pharmacist. This novel approach integrated provision of care by team members at geographically distinct remote locations. The pharmacist conducted comprehensive medical reviews via video conferencing and made recommendations to the epileptologist, primary care provider, and/or patient, as appropriate. The consultation was documented in the electronic health record (EHR). The pharmacist's recommendations were categorized as 1 of the 24 preselected HEDIS performance measures or as a non-HEDIS measure. The analysis used descriptive statistics to report patient demographics and pharmacist recommendations. RESULTS This study included 86 participants. 86 initial and 36 follow-up appointments were conducted between April 2016 and October 2017. The majority of patients were female (52%), with a mean age of 26.2 years (SD = 14.6, range 4-76) and were taking an average of 6.1 medications (SD = 3.6). 159 comorbidities or conditions were identified in the EHR along with 306 recommendations, for an average of 3.6 recommendations per patient (SD = 3.2). 41 (13.4%) recommendations aligned with preselected HEDIS measures, including medication management for depression (31.7%), hypertension (24.4%), asthma (9.8%), and comprehensive adult diabetes care (14.6%). The remaining 265 recommendations lacked sufficient documentation for categorization or failed to align with any targeted measure. CONCLUSIONS This retrospective analysis showed that only 13% of pharmacist recommendations aligned with HEDIS quality measures. While it demonstrates the added value of clinical pharmacists in novel telehealth approaches, future work is needed to develop strategies to increase the number of recommendations aligning with HEDIS measures that adhere to national consensus treatment guidelines via telepharmacist training and improved documentation. DISCLOSURES SinfoníaRx provided funding for this project through a grant to Warholak, Taylor, Axon, and Lott. Bingham, Boesen, Scovis, and Leal are employed by SinfoníaRx. Data from this study were presented at the American Society of Health-System Pharmacists Ambulatory Care Conference 2018; June 4, 2018; Denver, CO, and the Southwestern States Residency Conference 2018; June 15, 2018; Chandler, AZ.
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Affiliation(s)
- Christa Tetuan
- Medication Management Center, University of Arizona College of Pharmacy, Tucson
| | | | | | | | - Robert Lipsy
- Medication Management Center, University of Arizona College of Pharmacy, Tucson
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