Health resource utilization among US veterans with psychogenic nonepileptic seizures: A comparison before and after video-EEG monitoring

Health care utilization of Hispanic/Latino veterans with epilepsy: A national population-based study

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.

Cross-sectional evaluation of health resource use in patients with functional neurological disorders referred to a tertiary neuroscience centre

Introduction

Functional neurological disorder (FND) is a common cause of referral to neurology services. FND has been shown to lead to significant healthcare resource use and is associated with significant disability, comorbidity and distress. This leads to substantial direct, indirect and intangible costs to the patient and society.

Methods

We recruited consecutive patients with FND referred to a tertiary FND specialist clinic. We assessed health and social care resource use in the 6 months preceding their consultation through a modified version of the Client Service Receipt Inventory in the form of a postal questionnaire. The total cost was estimated by combining the number and frequency of health resource use with standard national unit costs. We also assessed indirect costs such as informal care and loss of income.

Results

We collected data on 118 subjects. Patients with comorbid anxiety or depression had higher costs in the preceding 6 months, as did patients who had a longer duration of FND symptoms. Indirect costs were higher than the already substantial direct costs and a large proportion of patients with FND were receiving government support.

Conclusion

This study highlights the high cost of FND to both patients and health systems. Adequate reform of the patient pathway and reorganisation of services to make diagnoses and initiate treatment more quickly would likely reduce these costs.

Improvements in Montreal Cognitive Assessment scores after neurobehavioral therapy in adults with functional (nonepileptic) seizures and traumatic brain injury

Cognitive functioning impacts clinical symptoms, treatment response, and quality of life in adults with functional/nonepileptic seizures (FS/NES), but no study to date examines effects of behavioral FS/NES treatment on cognition in these patients. We hypothesized that there would be a reduction in cognitive symptoms in participants with FS/NES and traumatic brain injury (TBI) following neurobehavioral therapy (NBT). We also hypothesized that select seizure-related, medication, subjective cognitive, and mental health symptoms would be negatively correlated with improvements in cognitive performance after NBT. Participants were 37 adults with TBI + FS/NES and 35 adults with TBI only, recruited from medical centers in the northeastern or southeastern U.S. TBI + FS/NES participants completed a 12 session NBT intervention, and TBI without seizures participants were not treated. All participants completed pre-post assessments of cognition (Montreal Cognitive Assessment [MoCA]) and baseline sociodemographic factors and mental health symptoms. Pre-post MoCA scores increased significantly in TBI + FS/NES participants (28/37 [75.7%] improved) but not in TBI comparisons (10/35 [28.6%] improved). Language, memory, and visuospatial/executive functions, but not attention, improved over time in the TBI + FS/NES group. Gains in cognition were concentrated in those TBI + FS/NES participants with likely baseline cognitive impairments (MoCA total score <26), and 9/17 of these participants moved from the "impaired" range at baseline (<26) to the "intact" range at endpoint (≥26). Lastly, participants taking fewer medications and reporting lower subjective cognitive difficulties at baseline showed larger pre-post MoCA total score improvements. Overall, results from this study suggest the potential for positive change in cognition in FS/NES and co-occurring TBI using evidence-based psychotherapy.

Economic Cost of Functional Neurologic Disorders: A Systematic Review

BACKGROUND AND OBJECTIVES

Functional neurologic disorder (FND) represents genuine involuntary neurologic symptoms and signs including seizures, weakness, and sensory disturbance, which have characteristic clinical features, and represent a problem of voluntary control and perception despite normal basic structure of the nervous system. The historical view of FND as a diagnosis of exclusion can lead to unnecessary health care resource utilization and high direct and indirect economic costs. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess these economic costs and to assess for any cost-effective treatments.

METHODS

We searched electronic databases (PubMed, PsycInfo, MEDLINE, EMBASE, and the National Health Service Economic Evaluations Database of the University of York) for original, primary research publications between inception of the databases and April 8, 2022. A hand search of conference abstracts was also conducted. Key search terms included "functional neurologic disorder," "conversion disorder," and "functional seizures." Reviews, case reports, case series, and qualitative studies were excluded. We performed a descriptive and qualitative thematic analysis of the resulting studies.

RESULTS

The search resulted in a total of 3,244 studies. Sixteen studies were included after screening and exclusion of duplicates. These included the following: cost-of-illness (COI) studies that were conducted alongside cohort studies without intervention and those that included a comparator group, for example, another neurologic disorder (n = 4); COI studies that were conducted alongside cohort studies without intervention and those that did not include a comparator group (n = 4); economic evaluations of interventions that were either pre-post cohort studies (n = 6) or randomized controlled trials (n = 2). Of these, 5 studies assessed active interventions, and 3 studies assessed costs before and after a definitive diagnosis of FND. Studies showed an excess annual cost associated with FND (range $4,964-$86,722 2021 US dollars), which consisted of both direct and large indirect costs. Studies showed promise that interventions, including provision of a definitive diagnosis, could reduce this cost (range 9%-90.7%). No cost-effective treatments were identified. Study comparison was limited by study design and location heterogeneity.

DISCUSSION

FND is associated with a significant use of health care resources, resulting in economic costs to both the patient and the taxpayer and intangible losses. Interventions, including accurate diagnosis, seem to offer an avenue toward reducing these costs.

A retrospective study of the correlation between duration of monitoring in the epilepsy monitoring unit and diagnostic yield

OBJECTIVE

Long-term video-electroencephalographic (LTVEM) monitoring is a valuable tool in the evaluation of paroxysmal clinical events. However, vEEG itself is costly. Hence, we aimed to establish if longer duration of monitoring (DOM) is associated with higher diagnostic yield.

METHOD

A retrospective review of patients admitted into the epilepsy monitoring unit (EMU) for the diagnostic evaluation of paroxysmal events was performed. Patients' demographic, clinical characteristics, and vEEG data were analyzed. In the cohort of patients with DOM > 7 days, the reasons for prolonged DOM were identified and the differences in clinical characteristics and vEEG data between conclusive and inconclusive studies were analyzed.

RESULT

A total of 501 patients were included. Four hundred and thirty-six (87 %) patients had conclusive studies. Of these patients, 67.9 % patients with conclusive studies received diagnosis within the first 7 days of monitoring with the highest on day 7. The likelihood of conclusive studies decreased beyond 7 days. A total of 175 had DOM > 7 days, of which 140 (80 %) had conclusive studies. In the cohort with DOM > 7 days, patients with previous abnormal routine EEG, previous vEEG monitoring, first event recorded before day 5 of admission and ≥1 events recorded during vEEG monitoring were more likely to have conclusive studies. The most common reason for prolonging DOM beyond 7 days was to adequately record multiple semiologically distinctive events (76 %).

CONCLUSION

Our study supports that longer DOM is associated with an increase in diagnostic yield. More than one-third of our cohort were monitored beyond 7 days with majority (80 %) being conclusive. Our findings may guide clinicians in planning the DOM and predicting the likelihood of conclusive vEEG studies in patients with prolonged DOM based on the clinical characteristics and vEEG data.

Predictive value of video alone in diagnosis of epileptic vs paroxysmal nonepileptic events in children

OBJECTIVE

Previous studies examined the use of video-based diagnosis and the predictive value of videos for differentiation of epileptic seizures (ES) from paroxysmal nonepileptic events (PNEE) in the adult population. However, there are no such published studies strictly on the pediatric population. Using video-EEG diagnosis as a gold standard, we aimed to determine the diagnostic predictive value of videos of habitual events with or without additional clinical data in differentiating the PNEE from ES in children.

METHODS

Consecutive admissions to our epilepsy monitoring unit between June 2020 and December 2020 were analyzed for events of interest. Four child neurologists blinded to the patient's diagnosis formulated a diagnostic impression based upon the review of the video alone and again after having access to basic clinical information, in addition to the video. Features of the video which helped to make a diagnosis were identified by the reviewers as a part of a survey.

RESULTS

A total of 54 patients were included (ES n = 24, PNEE n = 30). Diagnostic accuracy was calculated for each reviewer and combined across all the ratings. Diagnostic accuracy by video alone was 74.5% (sensitivity 80.8%, specificity 66.7%). Providing reviewers with basic clinical information in addition to the videos significantly improved diagnostic accuracy compared to viewing the videos alone. Inter-rater reliability between four reviewers based on the video alone showed moderate agreement (κ = 0.51) and unchanged when additional clinical data were presented (κ = 0.51). The ES group was significantly more likely to demonstrate changes in facial expression, generalized stiffening, repetitive eye blinks, and eye deviation when compared with the PNEE group, which was more likely to display bilateral myoclonic jerking.

CONCLUSIONS

Video review of habitual events by Child Neurologists may be helpful in reliably distinguishing ES from PNEE in children, even without included clinical information.

Diagnosis and management of functional neurological disorder

Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.

Economic Costs of Delayed Diagnosis of Functional Motor Disorders: Preliminary Results From a Cohort of Patients of a Specialized Clinic

Background: Functional motor disorders (FMDs) are prevalent and highly disabling conditions in young adults that can result in reduced independence. Despite advances in diagnosis and treatment, the economic burden of FMDs is largely unknown.

Objective: This pilot retrospective study provides a real-world overview of the economic costs related to delayed diagnosis of FMDs from a cohort of patients of a specialized clinic in Italy, based on Italian healthcare costs.

Methods: Sociodemographic data, clinical history, healthcare service utilization, and associated direct costs were collected for a period of up to 5 years before a definite diagnosis of FMDs in 40 patients.

Results: The mean time lag between the onset of FMDs symptoms and diagnosis was 6.63 years (±8.57). The mean annual use of recourses per patient was three specialist visits (95% CI 2.4–3.4) and three diagnostic examinations (95% CI 2.2–3.6) that made up a total of six investigations and over seven (95% CI 5.5–9.7) rehabilitation contacts per year per patient were used before a diagnosis of FMDs was established. In more than 50% of the cases, patients had been hospitalized or made an ER visit at least once before receiving the correct diagnosis. The average annual costs for delayed diagnosis, taking into account only direct healthcare costs (without medications), was about €2,302 (CI 95% €1,570–2,830) per patient [€1,524 covered by the NHS (CI 95% €1,214–1,834) and € 778 by the patient (CI 95% €606–960)]. Hospitalization accounted for €916 (CI 95% €670–1,160) per patient per year, followed by rehabilitation €493 (CI 95% €345–641) and diagnostic tests € 387 (CI 95% €314–460).

Conclusion: These preliminary results shed some light on the high healthcare services volume and direct healthcare costs from clinic to clinic for visits, unnecessary tests, and prescribed treatments in a real-world overview from a cohort of patients of a specialized clinic in Italy. It may represent a starting point for future studies to statistically test and quantify cost reduction after implementing appropriate healthcare pathways.

Functional seizures are not less important than epilepsy

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People with functional seizures often suffer from psychiatric comorbidities.

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People with FS report detrimental effects on social aspects of their lives.

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FS are associated with a considerable direct and indirect economic burden.

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FS have increased rates of mortality compared to healthy controls.

Functional seizures (FS) are frequently encountered in neurology clinics, often affect young adults, and have significant negative impacts on many aspects of a person’s life. In the current narrative review, we searched the literature regarding some of the consequences of FS (i.e., psychiatric comorbidities, social consequences, costs that are associated with the condition, cognitive impairment in patients with FS, the quality of life of the people with FS, and the increased risk of mortality that is associated with FS). Evidence shows that FS have significant negative consequences, comparable in their magnitude to those affecting patients with epilepsy. The clinical and scientific communities should take steps to address these consequences through clinical care and research that prioritizes, facilitates, and expedites evidence-based diagnosis and treatment for FS.

Home video prediction of epileptic vs. nonepileptic seizures in US veterans

OBJECTIVE

Using video-EEG (v-EEG) diagnosis as a gold standard, we assessed the predictive diagnostic value of home videos of spells with or without additional limited demographic data in US veterans referred for evaluation of epilepsy. Veterans, in particular, stand to benefit from improved diagnostic tools given higher rates of PNES and limited accessibility to care.

METHODS

This was a prospective, blinded diagnostic accuracy study in adults conducted at the Houston VA Medical Center from 12/2015-06/2019. Patients with a definitive diagnosis of epileptic seizures (ES), psychogenic nonepileptic seizures (PNES), or physiologic nonepileptic events (PhysNEE) from v-EEG monitoring were asked to submit home videos. Four board-certified epileptologists blinded to the original diagnosis formulated a diagnostic impression based upon the home video review alone and video plus limited demographic data.

RESULTS

Fifty patients (30 males; mean age 47.7 years) submitted home videos. Of these, 14 had ES, 33 had PNES, and three had PhysNEE diagnosed by v-EEG. The diagnostic accuracy by video alone was 88.0%, with a sensitivity of 83.9% and specificity of 89.6%. Providing raters with basic patient demographic information in addition to the home videos did not significantly improve diagnostic accuracy when comparing to reviewing the videos alone. Inter-rater agreement between four raters based on video was moderate with both videos alone (kappa = 0.59) and video plus limited demographic data (kappa = 0.60).

SIGNIFICANCE

This study demonstrated that home videos of paroxysmal events could be an important tool in reliably diagnosing ES vs. PNES in veterans referred for evaluation of epilepsy when interpreted by experts. A moderate inter-rater reliability was observed in this study.

Clinical characteristics of video-EEG patients: Limited utility of prolonging VEEG study duration beyond 5 days for spell classification

OBJECTIVE

The objective of the study was to identify the probability of establishing a diagnosis based on the duration of video-electroencephalogram (VEEG) monitoring. Additional aims were to determine whether there is a relationship between clinical characteristics of epilepsy monitoring unit (EMU) patients and VEEG results.

METHODS

We studied EMU length of stay and assessed the utility of prolonging studies in patients who had not yet received a diagnosis. Clinical characteristics in 212 consecutive patients admitted for scalp VEEG monitoring were recorded. We collected data including reason for admission, frequency of seizures/spells, gender, age, age at seizure onset, handedness, family history, history of neurologic disease, current and past antiepileptic drugs (AEDs), and prior work-up. Subjects were categorized into five diagnostic groups: epileptic seizures (Epi), nonepileptic events (NEE), mixed epileptic and nonepileptic events (Mixed), nonepileptic events from a physiologic cause (NEEP), and nondiagnostic study without results recorded (ND).

RESULTS

The most diagnoses were made during the first day of admission (45%), and by day 3, 82 patients remained without a diagnosis. On day 3, 25 of these patients (33%) received a diagnosis, on day 4, seven (22%) additional patients received a diagnosis, on day 5, 5 patients (35%) received a diagnosis, and by day 6, only one additional patient (11%) was given a diagnosis. Significant differences were found between diagnostic groups for admission reason, duration of EMU stay, age at seizure onset, duration of epilepsy, seizure frequency, and number of current and previously tried AEDs.

CONCLUSIONS

Our findings show that the majority of patients are diagnosed in the first 2 days of admission, and we found a limited benefit of prolonging nonsurgical inpatient VEEG studies beyond 5 days for spell/seizure classification. Additionally, patient demographics were significantly different for patients depending on VEEG diagnosis, which can help predict the utility of completing VEEG studies in individual patients.

Psychogenic nonepileptic seizures treated with psychotherapy: Long-term outcome on seizures and healthcare utilization

Psychogenic nonepileptic seizures (PNES) are known to be associated with significant costs of healthcare services. Here, we report the impact of psychotherapy on behavior surrounding healthcare utilization and the potential economic benefits associated with long-term seizure control.

METHODS

This retrospective study describes patients seen between 2010 and 2016 at the epilepsy clinic at Glostrup University Hospital in Denmark and offered a psychotherapeutic treatment program for PNES. Forty-two patients were interviewed about seizure outcome 12-24 months after psychotherapy, and the annual changes in healthcare utilization and associated costs of services provided in a period of 24 months before and up to 24 months after treatment were compared.

RESULTS

At 12-month follow-up, 83% of the patients had achieved above 50% reduction in seizures. The 24-month pretreatment costs compared with the 24-month posttreatment costs directly associated with seizures dropped by 95.8%, and total healthcare costs were reduced by 63%. Estimation of annual savings from the program comes to 1060 € per patient. An association was found between seizure rate and number of healthcare contacts.

CONCLUSION

This study adds to the evidence that psychotherapy is a cost-effective way of treating PNES. The economic benefits from this form of intervention appear not only to diminish costs directly associated with PNES, but also healthcare utilization in general.

Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark

OBJECTIVE

We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures.

METHODS

From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics.

RESULTS

A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners.

SIGNIFICANCE

Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.

A pilot study of reduction in healthcare costs following the application of intensive short-term dynamic psychotherapy for psychogenic nonepileptic seizures

PURPOSE

The purpose of this study was to examine preliminary evidence of intensive short-term dynamic psychotherapy (ISTDP) as a treatment option for psychogenic nonepileptic seizures (PNES) in terms of impact on healthcare costs, emotional wellbeing, and somatic symptoms.

METHOD

Drawn from a sample of patients treated in a tertiary psychiatric service over a nine-year period, this naturalistic pilot study compared within-group changes from pretreatment with each year up to three years posttreatment, in physician visits, physician costs, hospital admissions, and overall hospital costs.

RESULTS

Twenty-eight patients with PNES received ISTDP with average treatment duration of 3.6 sessions. Healthcare costs significantly reduced in follow-up compared with those in baseline, with patient costs falling below the healthy population means, and reductions in healthcare costs compared with those in baseline by 88% in year one, 90% in year two, and 81% in year three. This was accompanied by significant reductions in symptoms and interpersonal problems.

CONCLUSION

These preliminary findings indicate the potential for short-term and long-term healthcare savings and improvements in emotional wellbeing, for patients with PNES from the application of ISTDP. Further research evaluating the impact of ISTDP on seizure reduction and comparing this approach with control conditions is warranted.