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Venkatraman V, Futch BG, Bartlett A, Yang LZ, Lee HJ, Shofty B, Parente BA, Lad SP, Williamson TL, Rahimpour S. Disparities in Access to Deep Brain Stimulation and Responsive Neurostimulation Approaches to Drug-Resistant Epilepsy. Neuromodulation 2024; 27:792-799. [PMID: 38159098 PMCID: PMC11193492 DOI: 10.1016/j.neurom.2023.11.007] [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: 05/28/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Epilepsy affects 1% to 2% of the global population, and those who are resistant to medical treatment may be candidates for neuromodulation. In select populations, brain stimulation approaches including deep brain stimulation (DBS) and responsive neurostimulation (RNS) are used. Although studies have shown that patients from Black, Hispanic, lower income, and rural communities have less access to epilepsy care and have lower rates of epilepsy surgery, disparities in the use of brain stimulation for epilepsy treatment are currently not known. MATERIALS AND METHODS We queried the US National Inpatient Sample data base from January 1, 2014 to December 31, 2019 for all patients discharged with an International Classification of Diseases (ICD) Ninth Revision or ICD Tenth Revision diagnosis of drug-resistant epilepsy. Among these patients discharged, the rates of brain stimulation treatment, including DBS and RNS, were reported in each subgroup of race, ethnicity, and insurance. To generate national estimates, all analyses were weighted. RESULTS A total of 237,895 patients discharged with drug-resistant epilepsy were identified, of whom 4,925 (2.1%) received brain stimulation treatment for drug-resistant epilepsy. Black patients (n = 420, 0.9%, odds ratio [OR] = 0.51, 95% CI [0.40, 0.64]) were less likely to receive brain stimulation treatment than were White patients (n = 3300, 2.4%). There was no significant difference between Asian (n = 105, 2.3%, OR = 0.80, 95% CI [0.53, 1.33]) and Hispanic (n = 655, 2.6%, OR = 0.95, 95% CI [0.77, 1.17]) patients and White patients. No significant difference was observed between female (n = 2515, 2.1%, OR = 1.02, 95% CI [0.89, 1.17]) and male (n = 2410, 2.0%) patients either. Patients with Medicare (n = 1150, 1.2%, OR = 0.69, 95% CI [0.57, 0.84]) or Medicaid (n = 1150, 1.8%, OR = 0.52, 95% CI [0.44, 0.62]) were less likely to receive brain stimulation treatment than were those with private insurance as the primary payer (n = 2370, 3.9%). CONCLUSIONS We discovered significant disparities in the use of brain stimulation treatments for drug-resistant epilepsy based on race and insurance status. More research will be required to determine the cause of these disparities.
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Affiliation(s)
- Vishal Venkatraman
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Brittany G Futch
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Alyssa Bartlett
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Lexie Z Yang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Ben Shofty
- Department of Neurosurgery, University of Utah Health, Salt Lake City, UT, USA
| | - Beth A Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | - Shervin Rahimpour
- Department of Neurosurgery, University of Utah Health, Salt Lake City, UT, USA.
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Leinonen MK, Igland J, Dreier JW, Alvestad S, Cohen JM, Gilhus NE, Gissler M, Sun Y, Tomson T, Zoega H, Vegrim HM, Christensen J, Bjørk MH. Socioeconomic differences in use of antiseizure medication in pregnancies with maternal epilepsy: A population-based study from Nordic universal health care systems. Epilepsia 2024. [PMID: 38804650 DOI: 10.1111/epi.18022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Research points to disparities in disease burden and access to medical care in epilepsy. We studied the association between socioeconomic status (SES) and antiseizure medication (ASM) use in pregnancies with maternal epilepsy. METHODS We conducted a cross-sectional study consisting of 21 130 pregnancies with maternal epilepsy identified from Nordic registers during 2006-2017. SES indicators included cohabitation status, migrant background, educational attainment, and household income. Main outcomes were the proportion and patterns of ASM use from 90 days before pregnancy to birth. We applied multiple imputation to handle SES variables with 2%-4% missingness. We estimated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using modified Poisson regression with the highest SES category as reference. RESULTS Mothers with the highest education and the highest income quintile used ASMs least frequently (56% and 53%, respectively). We observed increased risks of ASM discontinuation prior to or during the first trimester for low SES. The risk estimates varied depending on the SES indicator from aRR = 1.27 for low income (95% CI: 1.03-1.57) to aRR = 1.66 for low education (95% CI: 1.30-2.13). Migrant background was associated with ASM initiation after the first trimester (aRR 2.17; 95% CI 1.88-2.52). Low education was associated with the use of valproate during pregnancy in monotherapy (aRR 1.70; 95% CI 1.29-2.24) and in polytherapy (aRR 2.65; 95% CI 1.66-4.21). Low education was also associated with a 37% to 39% increased risk of switching from one ASM to another depending on the ASM used. For the other SES indicators, aRRs of switching varied from 1.16 (foreign origin; 95% CI 1.08-1.26) to 1.26 (not married or cohabiting; 95% CI 1.17-1.36). SIGNIFICANCE Low SES was associated with riskier patterns of ASM use: discontinuation, late initiation, and switching during pregnancy. These findings may reflect unplanned pregnancies, disparities in access to preconception counseling, and suboptimal care.
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Affiliation(s)
- Maarit K Leinonen
- Finnish Institute for Health and Welfare, Knowledge Brokers, Helsinki, Finland
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
| | - Jannicke Igland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Julie Werenberg Dreier
- National Centre for Register-Based Research, Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Silje Alvestad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Epilepsy, Member of the ERN EpiCARE, Oslo University Hospital, Oslo, Norway
| | - Jacqueline M Cohen
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Knowledge Brokers, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Yuelian Sun
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Helga Zoega
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Håkon M Vegrim
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
- National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marte-Helene Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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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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Alcala-Zermeno JL, Fureman B, Grzeskowiak CL, Potnis O, Taveras M, Logan MW, Rybacki D, Friedman D, Lowenstein D, Kuzniecky R, French J. Racial disparities in the utilization of invasive neuromodulation devices for the treatment of drug-resistant focal epilepsy. Epilepsia 2024; 65:e61-e66. [PMID: 38506370 DOI: 10.1111/epi.17961] [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: 12/19/2023] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 03/21/2024]
Abstract
Racial disparities affect multiple dimensions of epilepsy care including epilepsy surgery. This study aims to further explore these disparities by determining the utilization of invasive neuromodulation devices according to race and ethnicity in a multicenter study of patients living with focal drug-resistant epilepsy (DRE). We performed a post hoc analysis of the Human Epilepsy Project 2 (HEP2) data. HEP2 is a prospective study of patients living with focal DRE involving 10 sites distributed across the United States. There were no statistical differences in the racial distribution of the study population compared to the US population using census data except for patients reporting more than one race. Of 154 patients enrolled in HEP2, 55 (36%) underwent invasive neuromodulation for DRE management at some point in the course of their epilepsy. Of those, 36 (71%) were patients who identified as White. Patients were significantly less likely to have a device if they identified solely as Black/African American than if they did not (odds ratio = .21, 95% confidence interval = .05-.96, p = .03). Invasive neuromodulation for management of DRE is underutilized in the Black/African American population, indicating a new facet of racial disparities in epilepsy care.
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Affiliation(s)
- Juan Luis Alcala-Zermeno
- Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brandy Fureman
- Research and New Therapies, Epilepsy Foundation, Bowie, Maryland, USA
| | | | - Ojas Potnis
- Research and New Therapies, Epilepsy Foundation, Bowie, Maryland, USA
| | - Maria Taveras
- Department of Neurology, Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
| | - Margaret W Logan
- Research and New Therapies, Epilepsy Foundation, Bowie, Maryland, USA
| | - Delanie Rybacki
- Research and New Therapies, Epilepsy Foundation, Bowie, Maryland, USA
| | - Daniel Friedman
- Department of Neurology, Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
| | - Daniel Lowenstein
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Ruben Kuzniecky
- Department of Neurology, Zucker Hofstra School of Medicine, Northwell Health, New York, New York, USA
| | - Jacqueline French
- Research and New Therapies, Epilepsy Foundation, Bowie, Maryland, USA
- Department of Neurology, Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
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Abath CB, Gupta N, Hadjinicolaou A, Donatelli S, Singh A, Merchant S, Ryan ME, Soby M, Ryan C, Nelson AK, Maldonado Pacheco JE, Zhang B, Williams DN, Yuskaitis CJ, Harini C. Delays to care in infantile epileptic spasms syndrome: Racial and ethnic inequities. Epilepsia 2024; 65:107-114. [PMID: 37953072 DOI: 10.1111/epi.17827] [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: 05/30/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE Non-Hispanic (NH) Black children are less likely to receive a standard treatment course for infantile epileptic spasms syndrome (IESS) than White/NH children at pediatric tertiary care epilepsy centers in the United States. However, if inequities exist in time to diagnosis is unknown. Diagnostic delays as little as 1 week can be associated with worse developmental outcomes. METHODS Diagnostic delays were evaluated in a retrospective cohort of 100 children with new onset IESS between January 2019 and May 2022. RESULTS Children with Black, Indigenous, and People of Color (BIPOC) caregivers were more likely to experience clinically significant delays in referral from first provider to neurologist, when compared to White/NH children, even after controlling for other demographic and clinical variables (odds ratio = 4.98, confidence interval = 1.24-19.94, p = .023). SIGNIFICANCE Disproportionate diagnostic delays place BIPOC children at risk of adverse developmental and epilepsy outcomes. Further interventional prospective and qualitative studies are needed to address inequities in care.
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Affiliation(s)
- Christina Briscoe Abath
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nishtha Gupta
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Stephanie Donatelli
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Avantika Singh
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabrina Merchant
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Morgan E Ryan
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meghann Soby
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christopher Ryan
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Adrianne Katrina Nelson
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - John E Maldonado Pacheco
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Bo Zhang
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David N Williams
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christopher J Yuskaitis
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Chellamani Harini
- Department of Neurology, Comprehensive Epilepsy Program, Division of Epilepsy, Boston Children's Hospital, Boston, Massachusetts, USA
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7
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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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Howard SD, Campbell PA, Montgomery CT, Tomlinson SB, Ojukwu DI, Chen HI, Chin MH. Effect of Race and Insurance Type on Access to, and Outcomes of, Epilepsy Surgery: A Literature Review. World Neurosurg 2023; 178:202-212.e2. [PMID: 37543199 DOI: 10.1016/j.wneu.2023.07.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Despite higher rates of seizure freedom, a large proportion of patients with medically refractory seizures who could benefit from epilepsy surgery do not receive surgical treatment. This literature review describes the association of race and insurance status with epilepsy surgery access and outcomes. METHODS Searches in Scopus and PubMed databases related to disparities in epilepsy surgery were conducted. The inclusion criteria consisted of data that could be used to compare epilepsy surgery patient access and outcomes by insurance or race in the United States. Two independent reviewers determined article eligibility. RESULTS Of the 289 studies reviewed, 26 were included. Most of the studies were retrospective cohort studies (23 of 26) and national admissions database studies (13 of 26). Of the 17 studies that evaluated epilepsy surgery patient demographics, 11 showed that Black patients were less likely to receive surgery than were White patients or had an increased time to surgery from seizure onset. Nine studies showed that patients with private insurance were more likely to undergo epilepsy surgery and have shorter time to surgery compared with patients with public insurance. No significant association was found between the seizure recurrence rate after surgery with insurance or race. CONCLUSIONS Black patients and patients with public insurance are receiving epilepsy surgery at lower rates after a prolonged waiting period compared with other patients with medically refractory epilepsy. These results are consistent across the current reported literature. Future efforts should focus on additional characterization and potential causes of these disparities to develop successful interventions.
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Affiliation(s)
- Susanna D Howard
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Paige-Ashley Campbell
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Canada T Montgomery
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samuel B Tomlinson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Disep I Ojukwu
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - H Isaac Chen
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Marshall H Chin
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA
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10
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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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11
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Pellinen J. Treatment gaps in epilepsy. FRONTIERS IN EPIDEMIOLOGY 2022; 2:976039. [PMID: 38455298 PMCID: PMC10910960 DOI: 10.3389/fepid.2022.976039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/18/2022] [Indexed: 03/09/2024]
Abstract
Over 50 million people around the world have epilepsy, and yet, epilepsy recognition and access to care are ongoing issues. Nearly 80% of people with epilepsy live in low-and middle-income countries and face the greatest barriers to quality care. However, there are substantial disparities in care within different communities in high-income countries as well. Across the world, under-recognition of seizures continues to be an issue, leading to diagnostic and treatment delays. This stems from issues surrounding stigma, public education, basic access to care, as well as healthcare worker education. In different regions, people may face language barriers, economic barriers, and technological barriers to timely diagnosis and treatment. Even once diagnosed, people with epilepsy often face gaps in optimal seizure control with the use of antiseizure medications. Additionally, nearly one-third of people with epilepsy may be candidates for epilepsy surgery, and many either do not have access to surgical centers or are not referred for surgical evaluation. Even those who do often experience delays in care. The purpose of this review is to highlight barriers to care for people with epilepsy, including issues surrounding seizure recognition, diagnosis of epilepsy, and the initiation and optimization of treatment.
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12
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Cramer SW, Do TH, Palzer EF, Naik A, Rice AL, Novy SG, Hanson JT, Piazza AN, Howard MA, Huling JD, Chen CC, McGovern RA. Persistent Racial Disparities in Deep Brain Stimulation for Parkinson's Disease. Ann Neurol 2022; 92:246-254. [PMID: 35439848 PMCID: PMC9546407 DOI: 10.1002/ana.26378] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022]
Abstract
We sought to determine whether racial and socioeconomic disparities in the utilization of deep brain stimulation (DBS) for Parkinson's disease (PD) have improved over time. We examined DBS utilization and analyzed factors associated with placement of DBS. The odds of DBS placement increased across the study period, whereas White patients with PD were 5 times more likely than Black patients to undergo DBS. Individuals, regardless of racial background, with 2 or more comorbidities were 14 times less likely to undergo DBS. Privately insured patients were 1.6 times more likely to undergo DBS. Despite increasing DBS utilization, significant disparities persist in access to DBS. ANN NEUROL 2022;92:246–254
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Affiliation(s)
- Samuel W Cramer
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | - Truong H Do
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | - Elise F Palzer
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, IL
| | | | | | - Jacob T Hanson
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | | | | | - Jared D Huling
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN
| | - Robert A McGovern
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN.,Division of Neurosurgery, Minneapolis VA Health Care System, Minneapolis, MN
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13
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Baumer FM, Mytinger JR, Neville K, Briscoe Abath C, Gutierrez CA, Numis AL, Harini C, He Z, Hussain SA, Berg AT, Chu CJ, Gaillard WD, Loddenkemper T, Pasupuleti A, Samanata D, Singh RK, Singhal NS, Wusthoff CJ, Wirrell EC, Yozawitz E, Knupp KG, Shellhaas RA, Grinspan ZM. Inequities in therapy for infantile spasms: a call to action. Ann Neurol 2022; 92:32-44. [PMID: 35388521 DOI: 10.1002/ana.26363] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/22/2022] [Accepted: 03/15/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine whether selection of treatment for children with infantile spasms (IS) varies by race/ethnicity. METHODS The prospective US National Infantile Spasms Consortium database includes children with IS treated from 2012-2018. We examined the relationship between race/ethnicity and receipt of standard IS therapy (prednisolone, adrenocorticotropic hormone, vigabatrin), adjusting for demographic and clinical variables using logistic regression. Our primary outcome was treatment course, which considered therapy prescribed for the first and, when needed, the second IS treatment together. RESULTS Of 555 children, 324 (58%) were Non-Hispanic white, 55 (10%) Non-Hispanic Black, 24 (4%) Non-Hispanic Asian, 80 (14%) Hispanic, and 72 (13%) Other/Unknown. Most (398, 72%) received a standard treatment course. Insurance type, geographic location, history of prematurity, prior seizures, developmental delay or regression, abnormal head circumference, hypsarrhythmia, and IS etiologies were associated with standard therapy. In adjusted models, Non-Hispanic Black children had lower odds of receiving a standard treatment course compared with Non-Hispanic white children (OR 0.42, 95% CI 0.20-0.89, p = 0.02). Adjusted models also showed that children with public (vs. private) insurance had lower odds of receiving standard therapy for treatment 1 (OR 0.42, CI 0.21-0.84, p = 0.01). INTERPRETATION Non-Hispanic Black children were more often treated with non-standard IS therapies than Non-Hispanic white children. Likewise, children with public (vs. private) insurance were less likely to receive standard therapies. Investigating drivers of inequities, and understanding the impact of racism on treatment decisions, are critical next steps to improve care for patients with IS. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fiona M Baumer
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, Palo Alto, CA
| | - John R Mytinger
- Department of Pediatrics, Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Kerri Neville
- Department of Pediatrics, Division of Pediatric Neurology, University of Michigan (Michigan Medicine), Ann Arbor, MI
| | - Christina Briscoe Abath
- Department of Child Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Camilo A Gutierrez
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD
| | - Adam L Numis
- Department of Neurology, Division of Epilepsy, University of California San Francisco, San Francisco, CA
| | - Chellamani Harini
- Department of Child Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Zihuai He
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, Palo Alto, CA
| | - Shaun A Hussain
- Department of Pediatrics, Division of Pediatric Neurology, University of California, Los Angeles, CA
| | - Anne T Berg
- Ann & Robert H. Lurie Children's Hospital of Chicago and Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Catherine J Chu
- Department of Neurology, Divisions of Child Neurology and Neurophysiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Tobias Loddenkemper
- Department of Child Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Debopam Samanata
- Division of Child Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, AR
| | - Rani K Singh
- Department of Pediatrics, Atrium Health-Levine Children's, Charlotte, NC
| | - Nilika S Singhal
- Department of Neurology, Division of Epilepsy, University of California San Francisco, San Francisco, CA
| | - Courtney J Wusthoff
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, Palo Alto, CA
| | - Elaine C Wirrell
- Department of Neurology, Divisions of Epilepsy and Child and Adolescent Neurology, Mayo Clinic, Rochester, MN
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology of the Saul R Korey Department of Neurology and Department of Pediatrics, Montefiore Medical Center, NY
| | - Kelly G Knupp
- Department of Pediatrics, New York-Presbyterian Komansky Children's Hospital, Weill Cornell Medicine, New York, NY
| | - Renée A Shellhaas
- Department of Pediatrics, Division of Pediatric Neurology, University of Michigan (Michigan Medicine), Ann Arbor, MI
| | - Zachary M Grinspan
- Department of Pediatrics and Neurology, University of Colorado, Aurora, CO.,Department of Healthcare Policy & Research, New York-Presbyterian Komansky Children's Hospital, Weill Cornell Medicine, New York, NY
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14
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Abstract
PURPOSE OF REVIEW Epilepsy is a common, chronic neurologic disease with continued disparities in care. The COVID-19 pandemic and recent social movements have drawn greater attention to social determinants of health and our progress (or lack thereof) toward delivering more equitable care. RECENT FINDINGS Recent studies continue to document racial and economic disparities in diagnosis, treatment, and overall care of epilepsy and associated conditions. Notably, an increasing number of studies are attempting to design healthcare pathways and other interventions to improve access and equity in epilepsy care. SUMMARY The present literature highlights the importance of identifying and addressing the particular needs of vulnerable persons with epilepsy. Practitioners and researchers should continue to develop interventions aimed at improving care for all patients and, crucially, measure the impact of their changes to ensure that any interventions are truly advancing health equity.
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Affiliation(s)
- Leah J Blank
- Department of Neurology Division of Health Outcomes and Knowledge Translation, Department of Population Health Science and Policy, Division of Health Outcomes and Knowledge Translation, New York, New York, USA
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15
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Tang OY, Pugacheva A, Bajaj AI, Rivera Perla KM, Weil RJ, Toms SA. The National Inpatient Sample: A Primer for Neurosurgical Big Data Research and Systematic Review. World Neurosurg 2022; 162:e198-e217. [PMID: 35247618 DOI: 10.1016/j.wneu.2022.02.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The National Inpatient Sample - the largest all-payer inpatient database in the United States - is an important instrument for big data analysis of neurosurgical inquiries. However, earlier research has determined that many NIS studies are limited by common methodological pitfalls. In this study, we provide the first primer of NIS methodological procedures in the setting of neurosurgical research and review all published neurosurgical studies utilizing the NIS. METHODS We designed a protocol for neurosurgical big data research using the NIS, based on the authors' subject matter expertise, NIS documentation, and input and verification from the Healthcare Cost and Utilization Project. We subsequently used a comprehensive search strategy to identify all neurosurgical studies utilizing the NIS in the PubMed and MEDLINE, Embase, and Web of Science databases from inception to August 2021. Studies underwent qualitative categorization (years of the NIS studied, neurosurgical subspecialty, age group, and thematic focus of study objective) and analysis of longitudinal trends. RESULTS We identified a canonical, four-step protocol for NIS analysis: study population selection, defining additional clinical variables, identification and coding of outcomes, and statistical analysis. Methodological nuances discussed include identifying neurosurgery-specific admissions, addressing missing data, calculating additional severity and hospital-specific metrics, coding perioperative complications, and applying survey weights to make nationwide estimates. Inherent database limitations and common pitfalls of NIS studies discussed include lack of disease process-specific variables and data following the index admission, inability to calculate certain hospital-specific variables after 2011, performing state-level analyses, conflating hospitalization charges and costs, and not following proper statistical methodology for performing survey-weighted regression. In a systematic review, we identified 647 neurosurgical studies utilizing the NIS. While almost 60% of studies were published after 2015, <10% of studies analyzed NIS data after 2015. The average sample size of studies was 507,352 patients (standard deviation=2,739,900). Most studies analyzed cranial procedures (58.1%) and adults (68.1%). The most prevalent topic areas analyzed were surgical outcome trends (35.7%) and health policy and economics (17.8%), while patient disparities (9.4%) and surgeon or hospital volume (6.6%) were the least studied. CONCLUSIONS We present a standardized methodology to analyze the NIS, systematically review the state of the NIS neurosurgical literature, suggest potential future directions for neurosurgical big data inquiries, and outline recommendations to improve the design of future neurosurgical data instruments.
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Affiliation(s)
- Oliver Y Tang
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Alisa Pugacheva
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Ankush I Bajaj
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Krissia M Rivera Perla
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Robert J Weil
- Southcoast Brain & Spine, Southcoast Health, Dartmouth, MA, USA
| | - Steven A Toms
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA.
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