Digital tools for epilepsy: Opportunities and barriers

High precision in epileptic seizure self-reporting with an app diary

People with epilepsy frequently under- or inaccurately report their seizures, which poses a challenge for evaluating their treatment. The introduction of epilepsy health apps provides a novel approach that could improve seizure documentation. This study assessed the documentation performance of an app-based seizure diary and a conventional paper seizure diary. At two tertiary epilepsy centers patients were asked to use one of two offered methods to report their seizures (paper or app diary) during their stay in the epilepsy monitoring unit. The performances of both methods were assessed based on the gold standard of video-EEG annotations. In total 89 adults (54 paper and 35 app users) with focal epilepsy were included in the analysis, of which 58 (33 paper and 25 app users) experienced at least one seizure and made at least one seizure diary entry. We observed a high precision of 85.7% for the app group, whereas the paper group's precision was lower due to overreporting (66.9%). Sensitivity was similar for both methods. Our findings imply that performance of seizure self-reporting is patient-dependent but is more precise for patients who are willing to use digital apps. This may be relevant for treatment decisions and future clinical trial design.

A multicenter randomized controlled feasibility trial of a digital self-management intervention for adults with epilepsy

OBJECTIVE

Self-management interventions may enhance health-related quality of life (HRQoL) in epilepsy. However, several barriers often impair their implementation in the real world. Digital interventions may help to overcome some of these barriers. Considering this, the Helpilepsy Plus Prototype was developed as a prototype smartphone-delivered self-care treatment program for adults with epilepsy.

METHODS

The 12-week Helpilepsy Plus Prototype was evaluated through a randomized controlled feasibility trial with a waiting-list control (WLC) group. Outcome measurement at baseline and at 12 weeks assessed adherence to the prototype intervention and changes in epilepsy-related outcomes. The primary endpoint was patient autonomy measured with EASE, and secondary endpoints included HRQoL measured with QOLIE-31, health literacy measured with HLQ, anxiety, and depression symptoms measured with HADS. Semi-structured interviews were conducted with a heterogeneous sample of participants to assess user-friendliness and usefulness. The prototype program was delivered through the Neuroventis Platform (Neuroventis, BV, Overijse, Belgium), a certified medical device (under EU/MDD Class I, and EU/MDR grace period).

RESULTS

Ninety-two patients were included (46 in the intervention group, 46 in WLC). Most participants (63%, 58/92 women, median age 30 years) had pharmacoresistant epilepsy (61%, 56/92). Only 22% of participants (10/46) in the intervention group completed at least half of all intervention sessions. No significant differences between the intervention group and WLC were observed. Although there was a larger proportion of patients in the intervention group with meaningful improvements in HRQoL compared to WLC (19/46 versus 11/46), the difference was not significant (p = 0.119). Qualitative feedback showed that participants would appreciate more personalization, such as adaptation of the content to their current epilepsy knowledge level, a more interactive interface, shorter text sections, and interaction through reminders and notifications.

SIGNIFICANCE

Digital interventions should allow sufficient scope for personalization and interaction to increase patient engagement and enable benefits from self-care apps. Feedback loops allow the participatory development of tailored interventions.

PLAIN LANGUAGE SUMMARY

In this study, we investigated the effectiveness of an app-based self-help intervention. Study participants were either randomly assigned to a group that had access to the app or a group that received access to the app after the end of the study. Although a larger proportion of participants in the intervention group showed a relevant improvement in quality of life, the difference between the two groups was not statistically significant. Less than one-fifth of participants in the intervention group attended at least half of all intervention sessions; patient feedback showed that patients required more personalization and interactive options.

Mobile Health Application for Seizure Management: A Human-Systems Integration Approach

OBJECTIVE

The study aims to develop a mHealth application for seizure management based on the human system integration (HSI) approach.

BACKGROUND

Unmet healthcare needs among people with epilepsy continue to exist despite the advancement in healthcare technology. Current seizure management methods are found to be ineffective. Therefore, a more efficient strategy such as mHealth technology is necessary to aid seizure management.

METHOD

The needs identification phase involved identifying the user requirements by interviewing 10 stakeholders and conducting thematic analysis and needs interpretation technique. In the solution identification phase, the system requirements were derived using various human-centered design and systems engineering approaches and were evaluated through quality function deployment to determine design targets. For the design and evaluation phase, the design targets were reflected in the app through the iterative prototyping process, and the interface and functional design were evaluated by seven human factors and ergonomics experts and four stakeholders, respectively.

RESULTS

Three primary needs and ten user requirements were derived from the needs identification phase. Ten out of fifteen system requirements were selected as design targets to be included in the final prototype. Results of the evaluation showed that the interface design of the proposed app showed superior usability compared to a competitor app and that the app functions were beneficial for the stakeholders.

CONCLUSION

The mHealth app designed through the HSI framework showed good potential in addressing the main issues in seizure management.

APPLICATION

The mHealth app design methodology based on the HSI approach can be applied to the design of small-scale systems in various domains.

Digital health applications in the self-management of epilepsy-A survey on patients' perspective

OBJECTIVE

Digital health applications can be prescribed since 2019 in Germany, which is likely to facilitate a broad use of epilepsy self-management applications, possibly directly connected to clinical systems via telematics infrastructures. This article reports on patients' interest in digital support for epilepsy self-management, influencing factors and patients' knowledge about digitization of health care in Germany.

METHODS

This work is based on self-reported data from 115 people with epilepsy participating in an anonymous online survey with a total of 54 questions covering several topics, including sociodemographics and epilepsy manifestation, use of technology in general and for treatment support, training programs, affinity for technology, knowledge on the digital infrastructure in Germany, and self-efficacy in dealing with chronic illness. The self-constructed questionnaire uses existing instruments like TA-EG, SES6G, and Hoffmeyer-Zlotnik sociodemographic questionnaire. To analyze the knowledge about digitalization in health care, a combination of self-assessment and knowledge quiz was used. The analysis was performed using descriptive methods and inferential statistics (t-test, reliability analysis, and correlations).

RESULTS

Participants were most interested in seizure alerting and documentation with the possibility to share documentation with physicians. The analysis of technology affinity showed medium enthusiasm, with positively perceived consequences being rated higher than the negatively perceived consequences of technology use. Knowledge on national health infrastructures was mediocre and training on this was judged to be essential and desired. Furthermore, a significant correlation was found between interest in use and affinity for technology (enthusiasm for technology [r = 0.29; P = 0.00]) and positively perceived consequences of technology (r = 0.33; P = 0.00).

SIGNIFICANCE

Our results underline the high relevance of digital solutions for patients and the importance of individual training opportunities in digital health literacy, thereby enabling patients to decide competently for or against offered digital solutions.

Understanding Contexts and Challenges of Information Management for Epilepsy Care

Epilepsy is a common chronic neurological disease. People with epilepsy (PWE) and their caregivers face several challenges related to their epilepsy management, including quality of care, care coordination, side effects, and stigma management. The sociotechnical issues of the information management contexts and challenges for epilepsy care may be mitigated through effective information management. We conducted 4 focus groups with 5 PWE and 7 caregivers to explore how they manage epilepsy-related information and the challenges they encountered. Primary issues include challenges of finding the right information, complexities of tracking and monitoring data, and limited information sharing. We provide a framework that encompasses three attributes - individual epilepsy symptoms and health conditions, information complexity, and circumstantial constraints. We suggest future design implications to mitigate these challenges and improve epilepsy information management and care coordination.

MEW network self-management program characteristics and lessons learned through the RE-AIM framework

RATIONALE

The promotion of evidence-based self-management support for people living with chronic conditions such as epilepsy is a public health priority. Epilepsy self-management encompasses three general areas: (1) treatment management, (2) seizure management, and (3) lifestyle management. Interventions focusing on self-management have increased quality of life and adherence to treatment. This study assesses and synthesizes the Managing Epilepsy Well Network (MEWN) program implementation experiences using the RE-AIM framework. This research informs the quality and rigor of MEWN program dissemination and implementation efforts to assess whether these programs are being implemented and their scalability.

METHODS

The study data were derived from a MEWN Self-management Program Survey conducted with currently active MEWN researchers through an online survey and review of program publications and archival documents. Survey data were obtained from either the principal investigator or study team for the UPLIFT, HOBSCOTCH, SMART, MINDSET, TIME, and PACES programs. The survey questionnaire included 6 sections consisting of 68 questions and focused on the RE-AIM dimensions and respondent characteristics. The RE-AIM dimensions included: (1) Reach, (2) Effectiveness, (3) Adoption (number of and type of adopting sites), (4) Implementation (retention rate, barriers to implementation), and (5) Maintenance.

RESULTS

Across the MEWN programs, participation (44-120 individuals) and delivery methods (community, clinic, or asynchronous; group or individual) ranged with most programs predominantly reaching White or African American participants. Common program outcome measures included clinical outcomes (e.g., depression, quality of life, seizure frequency) and indicators of self-management behaviors (e.g., problem-solving; self-efficacy). Initial efficacy trials suggested programs were effective in changing some of their targeted outcomes (effectiveness). Most programs were implemented in clinical settings and several programs are being replicated or adapted to different geographical (e.g., urban, rural, suburban) or demographic (e.g., race, age) settings (adoption). Program delivery methods involved a mixture of program staff, peer educators, and researchers. Implementation enabling factors included partnerships with local epilepsy organizations and the inclusion of peer educators. Retention rates for all programs averaged 83.6%. Internal barriers included recruitment and lack of sufficient resources for participants. External barriers included clinical staff buy-in, staffing, and insufficient funding for support staff. Despite uncertain funding, all programs offered next steps to sustain their initiatives such as packaging their programs, initiating adoption with regional organizations, and supporting organizational readiness (maintenance). Dissemination efforts included partnering with other organizations, provision of training and technical assistance, and partnering with national organizations on grant opportunities to scale up existing programs.

CONCLUSION

These data showcase the impact of the MEWN self-management interventions on health and quality of life. These programs are employing training, readiness assessment, technical assistance, and development of partnerships to increase program scalability. Finally, program adaptations are being conducted to expand the interventions to other populations to address health inequalities. The lessons learned are critical for other interventions attempting to increase the translation of their programs to other settings.

Latent class analysis of eHealth behaviors among adults with epilepsy

OBJECTIVE

The objective of this study was to determine the proportions of uptake and factors associated with electronic health (eHealth) behaviors among adults with epilepsy.

METHODS

The 2013, 2015, and 2017 National Health Interview Surveys were analyzed. We assessed the proportions of use of five domains of eHealth in those with epilepsy: looked up health information on the internet, filled a prescription on the internet, scheduled a medical appointment on the internet, communicated with a health care provider via email, and used chat groups to learn about health topics. Multivariate logistic regressions were conducted to identify factors associated with any eHealth behaviors among those with active epilepsy. Latent class analysis was performed to identify underlying patterns of eHealth activity. Survey participants were classified into three discrete classes: (1) frequent, (2) infrequent, and (3) nonusers of eHealth. Multinomial logistic regression was performed to identify factors associated with frequency of eHealth use.

RESULTS

There were 1770 adults with epilepsy, of whom 65.87% had at least one eHealth behavior in the prior year. By domain, 62.61% looked up health information on the internet, 15.81% filled a prescription on the internet, 14.95% scheduled a medical appointment on the internet, 17.20% communicated with a health care provider via email, and 8.27% used chat groups to learn about health topics. Among those with active epilepsy, female sex, more frequent computer usage, and internet usage were associated with any eHealth behavior. Female sex and frequent computer use were associated with frequent eHealth use as compared to nonusers.

SIGNIFICANCE

A majority of persons with epilepsy were found to use at least one form of eHealth. Various technological and demographic factors were associated with eHealth behaviors. Individuals with lower eHealth behaviors should be provided with targeted interventions that address barriers to the adoption of these technologies.

Introduction to use of an acute seizure action plan for seizure clusters and guidance for implementation

It is important for patients with epilepsy and their caregivers, including care partners, to understand the patient's seizure clusters and what to do when they occur. In many instances, seizure clusters are unique to each patient. The knowledge gained from understanding a patient's seizure cluster or seizure pattern provides a foundation for taking prompt action to prevent worsening to prolonged seizures, status epilepticus, and potentially death. Seizure action plans (SAPs), which are similar to the disease-related treatment action plans for other conditions, can be developed by a health care provider (HCP) in conjunction with the patient with epilepsy and/or caregivers, and SAPs are specifically customized for the individual patient and his or her seizure management. However, the current literature lacks unified guidance on how to design SAPs that will help prepare patients and caregivers for rapidly determining and initiating appropriate treatment of acute seizure emergencies in the community and at home. Here, we examine the current usage and value of SAPs for pediatric and adult patients with epilepsy, and we introduce the concept of the acute SAP (ASAP) for use specifically during seizure emergencies, such as seizure clusters. This type of standardized, simplified, and customized plan can rapidly and concisely provide patients and caregivers with a practical protocol to treat a seizure cluster consistently, appropriately, and in a timely manner. Details on potential content and formats of ASAPs are provided. Following this is a discussion of barriers to ASAP use that may affect HCPs or patients and caregivers, including lack of standardization, relevance, and personalization and pitfalls associated with technology. This leads into a discussion of guidance for developing, implementing, and updating ASAPs that suggests ways to address the barriers and ensure that the ASAP is best suited to the patient's needs.

Use of Health-Related Apps and Telehealth in Adults with Epilepsy in Germany: A Multicenter Cohort Study

Background: Telehealth can improve the treatment of chronic disorders, such as epilepsy. Telehealth prevalence and use increased during the coronavirus disease 2019 (COVID-19) pandemic. However, familiarity with and use of telehealth and health-related mobile applications (apps) by persons with epilepsy remain unknown. Methods: We investigated telehealth use, demographics, and clinical variables within the multicenter Epi2020 cross-sectional study. Between October and December 2020, adults with epilepsy completed a validated questionnaire, including individual questions regarding knowledge and use of apps and telehealth. Results: Of 476 included individuals (58.2% women; mean age 40.2 ± 15.4 years), 41.6% reported using health-related apps. Health apps were used more frequently (pedometer 32.1%, exercise app 17.6%) than medical apps (health insurance 15.1%, menstrual apps 12.2%) or apps designed for epilepsy (medication reminders 10.3%, seizure calendars 4.6%). Few used seizure detectors (i.e., apps as medical devices 1.9%) or mobile health devices (fitness bracelet 11.3%). A majority (60.9%) had heard the term telehealth, 78.6% of whom had a positive view. However, only 28.6% had a concrete idea of telehealth, and only 16.6% reported personal experience with telehealth. A majority (55%) would attend a teleconsultation follow-up, and 41.2% would in a medical emergency. Data privacy and availability were considered equally important by 50.8%, 21.8% considered data privacy more important, and 20.2% considered data availability more important. Current health-related app use was independently associated with younger age (p = 0.003), higher education (p < 0.001), and subjective COVID-19-related challenges (p = 0.002). Persistent seizure occurrence (vs. seizure freedom ≥12 months) did not affect willingness to use teleconsultations on multivariable logistic regression analysis. Conclusions: Despite positive telehealth views, few persons with epilepsy in Germany are familiar with specific apps or services. Socioeconomic factors influence telehealth use more than baseline epilepsy characteristics. Telehealth education and services should target socioeconomically disadvantaged individuals to reduce the digital care gap. German Clinical Trials Register (DRKS00022024; Universal Trial Number: U1111-1252-5331).

The Promise of Digital Self-Management: A Reflection about the Effects of Patient-Targeted e-Health Tools on Self-Management and Wellbeing

Increasingly, people have direct access to e-Health resources such as health information on the Internet, personal health portals, and wearable self-management applications, which have the potential to reinforce the simultaneously growing focus on self-management and wellbeing. To examine these relationships, we searched using keywords self-management, patient-targeting e-Health tools, and health as wellbeing. Direct access to the health information on the Internet or diagnostic apps on a smartphone can help people to self-manage health issues, but also leads to uncertainty, stress, and avoidance. Uncertainties relate to the quality of information and to use and misuse of information. Most self-management support programs focus on medical management. The relationship between self-management and wellbeing is not straightforward. While the influence of stress and negative social emotions on self-management is recognized as an important cause of the negative spiral, empirical research on this topic is limited to health literacy studies. Evidence on health apps showed positive effects on specific actions and symptoms and potential for increasing awareness and ownership by people. Effects on more complex behaviors such as participation cannot be established. This review discovers relatively unknown and understudied angles and perspectives about the relationship between e-Health, self-management, and wellbeing.

A journey into the unknown: An ethnographic examination of drug-resistant epilepsy treatment and management in the United States

Patients often recognize unmet needs that can improve patient-provider experiences in disease treatment management. These needs are rarely captured and may be hard to quantify in difficult-to-treat disease states such as drug-resistant epilepsy (DRE). To further understand challenges living with and managing DRE, a team of medical anthropologists conducted ethnographic field assessments with patients to qualitatively understand their experience with DRE across the United States. In addition, healthcare provider assessments were conducted in community clinics and Comprehensive Epilepsy Centers to further uncover patient-provider treatment gaps. We identified four distinct stages of the treatment and management journey defined by patients' perceived control over their epilepsy: Gripped in the Panic Zone, Diligently Tracking to Plan, Riding a Rollercoaster in the Dark, and Reframing Priorities to Redefine Treatment Success. We found that patients sought resources to streamline communication with their care team, enhanced education on treatment options beyond medications, and long-term resources to protect against a decline in control over managing their epilepsy once drug-resistant. Likewise, treatment management optimization strategies are provided to improve current DRE standard of care with respect to identified patient-provider gaps. These include the use of digital disease management tools, standardizing neuropsychiatrists into patients' initial care team, and introducing surgical and non-pharmacological treatment options upon epilepsy and DRE diagnoses, respectively. This ethnographic study uncovers numerous patient-provider gaps, thereby presenting a conceptual framework to advance DRE treatment. Further Incentivization from professional societies and healthcare systems to support standardization of the treatment optimization strategies provided herein into clinical practice is needed.

Impact of mobile health application on data collection and self-management of epilepsy

Recent advances in mobile health have enabled health data collection, which includes seizure and medication tracking and epilepsy self-management. We developed a mobile epilepsy management application, integrated with a hospital electronic health record (EHR). In this prospective clinical trial, we assessed whether the mobile application provides quality healthcare data compared to conventional clinic visits, and enhances epilepsy self-management for patients with epilepsy. The study population includes patients with epilepsy (ages 15 years and older) and caregivers for children with epilepsy. Participants were provided access to the application for 90 days. We compared healthcare data collected from the mobile application with data obtained from clinic visits. The healthcare data included seizure records, seizure triggering factors, medication adherence rate, profiles of adverse events resulting from anti-seizure medication (ASM), and comorbidity screenings. In addition, we conducted baseline and follow-up questionnaires after the 90-day period to evaluate how this mobile application improved epilepsy knowledge and self-efficacy in seizure management. Data of 99 participants (18 patients with epilepsy and 81 caregivers) were analyzed. Among 24 individuals who had seizures, we obtained detailed seizure records from 13 individuals through clinic visits and for 18 from the application. Aside from the 6 individuals who reported their medication adherence during clinic visitation, half of the study participants had adherence rates of over 70%, as monitored through the application. However, the adherence rates were not reliable due to high variability. Twenty-three individuals reported 59 adverse reactions on the application, whereas 21 individuals reported 24 adverse reactions during clinic visits. We collected comorbidity data from 4 individuals during clinic visits. In comparison, 64 participants underwent comorbidity self-screening on the application, and 2 of them were referred to neuropsychiatric services. Compared to rare/non-users, app users demonstrated significant improvement in epilepsy knowledge score (p < 0.001) and self-efficacy score (p = 0.038). In conclusion, mobile health technology would help patients and caregivers to record their healthcare data and aid in self-management. Mobile health technology would provide an influential clinical validity in epilepsy care when users engage and actively maintain records on the application.

Usefulness, limitations, and parental opinion about teleconsultation for rare pediatric epilepsies

AIM

Evaluation of the usefulness and the parental opinion about teleconsultation (TC) for rare pediatric epilepsies.

METHOD

One-month prospective survey of consecutive TCs. All clinics on site have been turned into TC in the context of COVID-19 pandemic. The physicians quoted all TCs while the parents expressed their opinion though an invitation for an online questionnaire.

RESULTS

We included 151 TCs (145 patients) among the 259 epilepsy TCs done during the study period. The parental questionnaire has been answered 105 times. The physicians felt confident to organize a TC for the next visit of 74.8% of the children, but some limits were identified such as the absence of physical examination, weight, and psychomotor development evaluation. The physicians felt more confident for a new TC in older patients (9.5 ± 5.5 years versus 5.3 ± 4.3 years) and in stable patients (73.8% confident for instable, 82.8% for stable). Parents were satisfied with TC feeling that it answered health issues in a better manner than a clinic pinpointing the gain of time and the absence of travel. However, half of them would prefer a clinic for the next appointment.

INTERPRETATION

Teleconsultation seems useful answering the patients' needs according to both physicians and families. Despite some limitations, it is most likely that TCs become a new part of the clinical activities in rare pediatric epilepsy centers.

Evaluation of a web-based virtual nursing intervention to support self-management among adults with epilepsy: A mixed-methods study

OBJECTIVE

A web-based intervention was developed to support epilepsy self-management. A mixed methods study was undertaken to evaluate the intervention's extent of utilization, acceptability and preliminary effects, and to assess user perception of it.

METHODS

First, a pilot parallel-group randomized controlled trial was conducted with a convenience sample of 75 adult with epilepsy who had Internet access allocated on a 1:1 ratio into an experimental group that received the intervention (experimental group (EG), n = 37) and a control group invited to consult epilepsy-related websites (control group (CG), n = 38). Self-management, knowledge, and quality of life (QoL) outcomes were measured at baseline and one and three months later. Descriptive statistics of extent of utilization and acceptability were computed. Linear mixed models were conducted to assess change in outcomes over time and between groups. Subsequently, an exploratory qualitative study was carried out with 15 EG participants. Qualitative data were subjected to thematic analysis.

RESULTS

Participants had a mean age of 40 years (range: 18-73), 45% were female, and mean time since diagnosis was 18 years (range: less than a year to 60 years). In the EG, 70% of the participants completed the intervention. Regarding acceptability, participants (n = 25) were satisfied overall (88%) and found content clear (92%) and the information reliable (100%). EG participants experienced greater improvement in QoL compared with CG participants, least-squares means (95% CI): 0.41 (0.06, 0.76). Three major themes emerged from the interviews (n = 15): intervention provides certain personal benefits; clinical content is of general interest but should be tailored; and intervention should target "new" patients early in the care trajectory.

DISCUSSION

The web-based intervention shows promise in terms of usefulness in enhancing QoL, and user experience showed that it is acceptable and helpful. It could constitute a complementary service in support of existing services for people with epilepsy and their families.

An Overview of Digital Health in the Transition of Pediatric to Adult Epilepsy Care

Children with epilepsy often have impairments in cognitive and behavioral functioning which may hinder socio-occupational well-being as they reach adulthood. Adolescents with epilepsy have the added worry of health problems while starting the transition from family-centered pediatric care into largely autonomous adult care. If this transition is not appropriately planned and resourced, it may result in medical mistrust, nonadherence, and worsening biopsychosocial health as an adult. In recent years, there has been increased availability of digital health solutions that may be used during this stark change in care and treating teams. The digital health landscape includes a wide variety of technologies meant to address challenges faced by patients, caregivers, medical professionals, and health care systems. These technologies include mobile health products and wearable devices (e.g., seizure monitors and trackers, smartphone passive data collection), digital therapeutics (e.g., cognitive/behavioral health management; digital speech–language therapy), telehealth services (e.g., teleneurology visits), and health information technology (e.g., electronic medical records with patient portals). Such digital health solutions may empower patients in their journey toward optimal brain health during the vulnerable period of pediatric to adult care transition. Further research is needed to validate and measure their impact on clinical outcomes, health economics, and quality of life.