Welfare consequences for people with epilepsy and their partners: A matched nationwide study in Denmark

Living with epilepsy in adolescence and young adulthood transitioning from pediatric to adult hospital services: A systematic review and meta-synthesis of qualitative studies

BACKGROUND

Transition is characterized by developing greater self-identity and growing independence, but adolescents dealing with chronic illnesses encounter health-related and situational changes during transition. Despite the many suggestions made in recent years, the shift from pediatric to adult care continues to pose difficulties for adolescents and young adults with epilepsy (AWE). The holistic perspective of AWE's experiences and needs during transition is not as well understood.

AIM

To synthesize the qualitative evidence related to AWE's experiences and needs transitioning from pediatric to adult hospital care.

METHODS

This systematic review adhered to the rigorous Joanna Briggs methodology for qualitative evidence synthesis. A comprehensive search was conducted across multiple databases, including PubMed, CINAHL, Scopus, Embase, PsycINFO, and ProQuest Dissertations & Theses Global, from their inception to April 2024. The findings were critically appraised and aggregated using meta-synthesis.

RESULTS

The search yielded a total of 3,985 studies, and twenty-one were included in the review. Two of the included studies were undertaken in a program where a transition clinic was established. The meta-synthesis reveals that the transition experience of AWE is more than a change from one clinic to another and is interwoven into a pattern of developmental, health-illness, situational, and organizational transition issues. Five synthesized findings were developed: 1) Feeling different from others and striving to address the impact of epilepsy in everyday life; 2) the transition from pediatric to adult care - a problematic intersection point; 3) the family's role - support or parental overprotectiveness 4) seeking knowledge and being familiar with epilepsy supported by healthcare professionals and technologies, and 5) development of independence and responsibility through involvement and support from healthcare professionals and parents.

CONCLUSION

During the transition from pediatric to adult hospital care, AWEs encounter a loss of familiarity, increased responsibility, and feelings of not belonging. Therefore, it is essential to create an environment where they can thrive beyond the limitations of their illness. Understanding, acceptance, and inclusivity should characterize this environment to support AWEs in facilitating the development of responsibility, independence, and confidence as they navigate transitions.

Being an adolescent with epilepsy during the transition from pediatric to adult hospital care: A qualitative descriptive study

BACKGROUND

The transition from pediatric to adult care is challenging for adolescent patients despite numerous recommendations in recent decades. However, the perspective of the patients is sparsely investigated.

AIM

To explore the experiences and needs of adolescents with epilepsy (AWE) during the transition from pediatric to adult hospital care.

METHODS

We conducted 15 semi-structured interviews with AWEs aged 13-20 years and 10 h of field observations of consultations. Interviews were audio-recorded, transcribed, anonymized, and entered into NVivo (version 12, QSR International) with the transcribed field notes. Data were analyzed using systematic text condensation.

RESULTS

Three themes were identified: (1) Navigating epilepsy in everyday life; (2) The difficult balance between concealment and openness about epilepsy; and (3) Being seen as an individual and not an illness. AWEs' needs in transition are closely associated with their experiences and perceptions of illness, treatment, consultations, and seizures. Notably, AWEs reveal a significant concern about being overlooked beyond their medical condition in appointments.

CONCLUSIONS

This study highlights the vulnerability and challenges of AWEs transitioning to adult care. Overall, AWEs seek understanding, acceptance, and autonomy in managing their epilepsy and transitioning to adult care. Their experiences underscore the importance of holistic support and communication in healthcare settings. A concerted effort from healthcare professionals (HCP) is necessary to foster the recognition of AWEs as individuals with distinct personalities, needs, and capabilities.

The economic burden of diseases in the Nordic countries: A systematic review

BACKGROUND

Economic burden studies can provide insights into the drivers leading to increasing healthcare costs. It can also provide a more holistic view of how diseases impact the welfare of patients and their families. Having concrete estimates of the economic burden across multiple diseases can help policymakers determine which diseases are economically more burdensome. This study aimed to review and summarise comprehensively economic burden studies across multiple diseases in the Nordic countries between 2000 and 2020.

METHODS

According to the 2020 PRISMA statement, a systematic literature review was conducted in PubMed, CINAHL, Academic Search Premier and Global Health databases using key terms related to the economic burden of any disease in Denmark, Finland, Greenland, Iceland, Norway and Sweden. Grey literature was also reviewed.

RESULTS

A total of 10,050 potential titles and abstracts were identified and screened, and 254 full-text papers that met the inclusion criteria were evaluated by two independent reviewers. Of these, 119 articles were included in a qualitative synthesis. Twenty-nine had clearly defined comparison groups, thus able to attribute the costs to the disease. Large variations concerning methodology and cost components were noted. Across diseases, the economic burden ranged from EUR 1668 per patient annually for chronic obstructive pulmonary disease to EUR 93,041 for multiple sclerosis. However, estimates varied widely, even within each disease.

CONCLUSIONS

Our review highlights the need for more comparable economic burden studies. Future studies should focus on applying robust methodology and homogeneous cost-reporting methods to inform policymakers about which diseases are economically more burdensome.

Health inequities and societal costs for patients with fibromyalgia and their spouses: a Danish cohort study

OBJECTIVE

To assess the burden of illness of people with fibromyalgia (FM) and their spouses compared with selected match populations in Denmark.

METHODS

Population-based, cohort case-control study using data from Danish registries from 1994 to 2021. Individuals with an FM diagnosis were identified from the National Patient Register (2008-2019) and randomly matched to a 1:4 general population comparator. Spouses or persons co-living with subjects with FM at the time of diagnosis were compared with matched comparator spouses. Healthcare and societal costs, socioeconomic status and occurrence of comorbidities were evaluated for subjects with FM, spouses and controls.

RESULTS

9712 subjects with FM (94.9% females, mean age 50 years) and 5946 spouses were included. At year of diagnosis, subjects with FM had significantly more comorbidities compared with controls, including significantly more comorbid rheumatic disorders. The highest risk at the time of FM diagnosis was a comorbid diagnosis of ankylosing spondylitis (OR 7.0, 95% CI 4.9 to 10.0). Significantly more comorbidities were also observed in spouses. Subjects with FM and spouses had higher healthcare and public transfer costs and lower income from employment at all timepoints. Loss of income from employment in subjects with FM occurred years before establishment of the FM diagnosis. The employment rate after diagnosis was 22%. 10 years after the FM diagnosis, 50% received disability pension as compared with 11% of matched controls. The observed net average increased societal cost for subjects with FM amounted to €27 193 per patient-year after diagnosis.

CONCLUSION

FM has major health and socioeconomic consequences for patients, their partners and society and call for improved healthcare strategies matching patients' needs.

Usage and impact of patient-reported outcomes in epilepsy

BACKGROUND

The use of patient-reported outcomes (PRO) in clinical practice is gaining increasing attention. This study aimed to provide a critical assessment of the current state-of-the-art and beliefs about the use of PRO in the management of people with epilepsy across some European countries.

METHODS

Structured interviews were conducted with European experts to collect insights about (I) the personal experience with PRO; (II) the value and impact of PRO in the decision-making process at the national level; and (III) the interest for and use of PRO by national health authorities.

RESULTS

Nine neurologists (Austria, Belgium, Czechia, Denmark, France, Greece, Italy, Poland, and United Kingdom), three health economists (Portugal, Romania, and Sweden), and one epidemiologist (Slovakia) participated. They all stated that PRO are collected at their own countries in the context of clinical trials and/or specific projects. During everyday clinical practice, PRO are collected routinely/almost routinely in Austria and Sweden and only at the discretion of the treating physicians in Czechia, Denmark, France, Greece, and Portugal. There was complete consensus about the favorable impact that the PRO can have in terms of clinical outcomes, healthcare resources utilization, and general patient satisfaction. Only participants from Portugal and Sweden answered that the PRO are perceived as very important by the National Health Authorities of their respective countries.

CONCLUSIONS

Differences exist in attitudes and perspectives about PRO in epilepsy across Europe. An active plan is warranted to harmonize the measurement of PRO and ensure they can be relevant to people with epilepsy and health services.

Patient-reported outcome measures as determinants for the utilization of health care among outpatients with epilepsy: a prognostic cohort study

BACKGROUND

Patient-reported outcome (PRO) measures can inform clinical decision making and planning of treatment in the health care system. The aim of this study was to examine whether patient-reported health domains influence the use of health care services in outpatients with epilepsy.

METHODS

This was a prognostic cohort study of 2,426 epilepsy outpatients referred to PRO-based follow-up at the Department of Neurology, Aarhus University Hospital, Denmark. Patients filled out a questionnaire covering health literacy areas, self-efficacy, well-being and general health. The main outcome was a record of contact to the epilepsy outpatient clinic, inpatient ward and/or emergency room within 1 year, retrieved from health register data. Associations were analysed by multivariable binomial logistic regression.

RESULTS

A total of 2,017 patients responded to the questionnaire and 1,961 were included in the final analyses. An outpatient contact was more likely among patients with very low health literacy ('social support'): odds ratio (OR) 1.5 (95% CI: 1.1-2.1), very low and low self-efficacy: OR 1.7 (95% CI: 1.2-2.3) and OR 1.4 (95% CI: 1.0-1.8), low and medium well-being: OR 2.2 (95% CI: 1.6-3.0) and OR 1.4 (95% CI: 1.1-1.9), and patients rating their general health as fair: OR 2.8 (95% CI: 1.7-4.6). Inpatient contact and emergency room contact were associated with the health domains of self-efficacy and general health.

CONCLUSIONS

PRO questionnaire data indicated that patients with low health literacy ("social support"), well-being, self-efficacy and self-rated general health had an increased use of health care services at 1 year.These results suggest that PRO measures may provide useful information in relation to the possibility of proactive efforts and prevention of disease-related issues and to help identify efficiency options regarding resource utilization.

Teaching distinguishing semiological features improves diagnostic accuracy of seizure-like events by emergency physicians

Background

Misdiagnosis of seizure-like events (SLE) in emergency situations is common. Here, we evaluate whether a single, video-based lesson highlighting distinguishing semiological features can improve the diagnostic accuracy of emergency physicians for epileptic seizures (ES), psychogenic non-epileptic seizures (PNES) and syncopes (SY).

Methods

40 emergency physicians (24 anesthetists, nine surgeons and seven internal medicine specialists by primary specialty) participated in a prospective trial on the diagnostic accuracy of SLE. They assessed video-displayed SLE at two time points: before and after a lecture on distinguishing semiological features. In the lecture, semiological features were demonstrated using patient videos, some were acted by the instructor in addition. The increase in correct diagnoses and recognition of distinguishing semiological features were analyzed.

Results

Before the lesson, 45% of 200 SLE-ratings were correct: 15% of SY (n = 40), 30% of PNES (n = 40), 59% of ES (n = 120, focal to bilateral tonic–clonic seizures (FBTCS) 87.5% (n = 40), focal impaired aware seizures (FIAS) 45% (n = 80)). Semiology teaching increased both the rate of correct diagnoses of SLE to overall 79% (p < 0.001) (ES 91% (p < 0.001), FBCTS 98% (n.s.), FIAS 88% (p < 0.001), PNES 88% (p < 0.001), SY 35% (p < 0.001)), and the number of recognized distinguishing semiological features. We identified several semiological features with high entity specific positive predictive values (> 0.8).

Conclusions

A single 45-min video-based lesson highlighting distinguishing semiological features improves the diagnostic accuracy of ES, PNES and SY by emergency physicians. We expect that including this aspect into the curriculum of emergency physicians will lead to better individual patient treatment in pre-hospital medicine and more appropriate subsequent use of clinical resources.

Estimates of epilepsy prevalence, psychiatric co-morbidity and cost

PURPOSE

This study estimated epilepsy prevalence, psychiatric co-morbidity and annual costs associated with epilepsy.

METHODS

We used Danish national health registers to identify persons diagnosed with epilepsy and psychiatric disorders, and persons using antiseizure medication and persons using drugs for psychiatric disorders. We calculated the prevalence of epilepsy and co-morbid psychiatric disorders in Denmark on December 31, 2016, using information on epilepsy and psychiatric disorders based on combinations of hospital contacts and use of antiseizure and psychoactive medication. Further, direct and indirect annual costs associated with epilepsy were calculated using individual-level data from a range of socioeconomic registers.

RESULTS

There were 5,044,367 persons alive and living in Denmark on December 31, 2016, including 33,628 persons with at least one hospital contact with epilepsy in the previous five years (epilepsy prevalence 0.67% (0.69% males; 0.65% females)). Among these persons with epilepsy, we identified 12,562 (37.4%) persons with a psychiatric disorder or use of drugs used for psychiatric disorders as compared with 801,052 (15.9%) persons in the general population. The estimated total annual individual net costs associated with epilepsy was €30,683. Compared with prevalence estimates on December 31, 2006, the prevalence of epilepsy on December 31, 2016, was slightly higher in the older population and slightly lower in children CONCLUSIONS: Population estimates from national registers provide epilepsy prevalence estimates of approximately 0.6-0.7% - similar to previous reviews of epilepsy prevalence. In addition, the national sample allowed idenitfication of high prevalence of psychiatric disorders and high societal costs associated with epielspy.

Care in Europe after presenting to the emergency department with a seizure; Position paper and insights from the European Audit of Seizure Management in Hospitals (EuroNASH)

BACKGROUND

This position paper makes recommendations following an audit of care provided to people presenting with a seizure to Emergency Departments (ED) in Europe.

METHODS

Participating countries were asked to include 5 hospitals agreeing to identify 50 consecutive seizure patients presenting to their ED between 1 August 2016 and 31 August 2017. Anonymous data were collected to web database. Where quoted, percentages are mean site values and ranges are 10^th to 90^th centile.

RESULTS

Data were collected on 2204 ED visits (47 sites, up to 6 per country, across 15 countries): 1270 (58%) known epilepsy, 299 (14%) previous blackouts but no epilepsy diagnosis, 634 (29%) with a first seizure. Wide variability was identified for most variables. Of those with known epilepsy, 41.2% (range 26.2% to 59.6%) attended ED in the previous 12 months, but only 64.7% (range 37.2% to 79.8%) had seen an epilepsy specialist in the previous 12 months. 67.7% (range 34.0% to 100%) were admitted; 53.1% to a neurology ward (range 0.0% to 88.9%). Only 37.5% first seizure patients (range 0.0% to 71.4%) were given advice about driving.

CONCLUSIONS

and recommendations We recommend that in Europe we: Agree guidance on the management and onward referral of those presenting to the ED with a seizure. Create a referral process that can be easily implemented. Ensure that the seizure services receive referrals and see the patients within a short time period. Develop and implement a simple system to allow continuous monitoring of key indices of epilepsy care.

Trends in resource utilization and cost of illness in patients with active epilepsy in Germany from 2003 to 2020

OBJECTIVE

To calculate epilepsy-related direct, indirect, and total costs in adult patients with active epilepsy (ongoing unprovoked seizures) in Germany and to analyze cost components and dynamics compared to previous studies from 2003, 2008 and 2013. This analysis was part of the Epi2020 study.

METHODS

Direct and indirect costs related to epilepsy were calculated with a multicenter survey using an established and validated questionnaire with a bottom-up design and human capital approach over a 3-month period in late 2020. Epilepsy-specific costs in the German health care sector from 2003, 2008 and 2013 were corrected for inflation to allow for a valid comparison.

RESULTS

Data on the disease-specific costs for 253 patients in 2020 were analyzed. The mean total costs were calculated at € 5,551 (± € 5,805; median: € 2,611; range: € 274 to € 21,667) per three months, comprising mean direct costs of € 1,861 (± € 1,905; median: € 1,276; range: € 327 to € 13,158) and mean indirect costs of € 3,690 (± € 5,298; median: € 0; range: € 0 to € 11,925). The main direct costs components were hospitalization (42.4%), anti-seizure medication (42.2%) and outpatient care (6.2%). Productivity losses due to early retirement (53.6%), part-time work or unemployment (30.8%) and seizure-related off-days (15.6%) were the main reasons for indirect costs. However, compared to 2013, there was no significant increase of direct costs (-10.0%), and indirect costs significantly increased (p<0.028, +35.1%), resulting in a significant increase in total epilepsy-related costs (p<0.047, +20.2%). Compared to the 2013 study population, a significant increase of cost of illness could be observed (p=0.047).

SIGNIFICANCE

The present study shows that disease-related costs in adult patients with active epilepsy increased from 2013 to 2020. As direct costs have remained constant, this increase is attributable to an increase in indirect costs. These findings highlight the impact of productivity loss caused by early retirement, unemployment, working time reduction and seizure-related days off.

The effect of epilepsy surgery on productivity: A systematic review and meta-analysis

OBJECTIVES

An important but understudied benefit of resective epilepsy surgery is improvement in productivity; that is, people's ability to contribute to society through participation in the workforce and in unpaid roles such as carer duties. Here, we aimed to evaluate productivity in adults with drug-resistant epilepsy (DRE) pre- and post-resective epilepsy surgery, and to explore the factors that positively influence productivity outcomes.

METHODS

We conducted a systematic review and meta-analysis using four electronic databases: Medline (Ovid), EMBASE (Ovid), EBM Reviews - Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Library. All studies over the past 30 years reporting on pre- and post-resective epilepsy surgical outcomes in adults with DRE were eligible for inclusion. Meta-analysis was performed to assess the post-surgery change in employment outcomes.

RESULTS

A total of 1005 titles and abstracts were reviewed. Seventeen studies, comprising 2056 unique patients, were suitable for the final quantitative synthesis and meta-analysis. Resective epilepsy surgery resulted in a 22% improvement in overall productivity (95% confidence interval [CI]: 1.07-1.40). The factors associated with increased post-surgery employment risk ratios were lower pre-surgical employment in the workforce (relative risk ratio [RRR] =0.34; 95% CI: 0.15-0.74), shorter follow-up duration (RRR = 0.95; 95% CI: 0.90-0.99), and lower mean age at time of surgery (RRR= 0.97; 95% CI: 0.94-0.99). The risk of bias of the included studies was assessed using Risk Of Bias In Non-randomised Studies - of Interventions and was low for most variables except "measurement of exposure."

SIGNIFICANCE

There is clear evidence that resective surgery in eligible surgical DRE patients results in improved productivity. Future work may include implementing a standardized method for collecting and reporting productivity in epilepsy cohorts and focusing on ways to reprioritize health care resource allocation to allow suitable candidates to access surgery earlier. This will ultimately benefit individuals with DRE, their families, our communities, and the wider health care system.

Seizure and social outcomes in patients with non-surgically treated temporal lobe epilepsy

OBJECTIVES

To investigate the seizure outcome with medical treatment in patients with temporal lobe epilepsy (TLE) and its associated factors. We also investigated the social outcome of the patients.

METHODS

This was a retrospective study of a prospectively built electronic database of patients with epilepsy. All patients with a diagnosis of TLE were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2019. In a phone call to the patients, at least 24 months after their diagnosis at our center, we investigated their current seizure control and social status.

RESULTS

Two hundred and twenty-two patients were studied; 101 patients (45.5%) were seizure free. A lower number of the prescribed drugs was the only factor with a significant association with the seizure-free outcome (Odds Ratio: 1.460; p = 0.001). At the time of the phone call, 76 patients (37.6%) reported having a college education, 103 patients (51%) were employed, 146 patients (72.3%) were married, and 81 patients (40%) reported driving a motor vehicle. The employment status, college education, and driving a motor vehicle were significantly associated with a seizure-free outcome status. The social achievements of the patients, who were partially responsive to medical therapy, were significantly worse than those who were seizure free.

CONCLUSION

Many patients with TLE may suffer from drug-resistant seizures. Ongoing seizures in these patients may affect their social lives substantially. Seizure reduction (not freedom) is not good enough to help the patients with TLE enjoy a healthy life with satisfactory social achievements.

Marital status in young adult patients with seizures: Epilepsy vs. functional seizures

OBJECTIVE

We investigated the marital status (married vs. none) among patients with seizures [i.e., epilepsy or functional seizures (FS)].

METHODS

This was a retrospective study of an electronic database of patients with seizures. All young adult patients, 18 to 45 years of age, with a diagnosis of either epilepsy or FS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. The two groups were matched for their age at diagnosis. Age at onset, sex, the marital status, and the final diagnosis were registered routinely.

RESULTS

During the study period, 194 patients with FS and 455 patients with epilepsy fulfilled the inclusion criteria. The rates of the married status were not significantly different between the two groups; 101 patients with FS (52%) and 204 PWE (45%) were married (p = 0.103). In the general population in Iran, 42,399,792 out of 66,421,989 (64%) of all people older than 16 years of age were married. This rate is significantly higher than the rate of the married status among patients with FS (p = 0.0006) and also those with epilepsy (p = 0.00001).

CONCLUSION

While the rates of the married status were not significantly different between PWE and those with FS, these rates were significantly lower than that in the general population in Iran. There are intriguing cross-cultural similarities and differences between our observations and those from other nations. These should be investigated in large multicenter international studies in the future.

Health, social, and economic consequences of rapid eye movement sleep behavior disorder: a controlled national study evaluating societal effects

STUDY OBJECTIVES

Parkinson's disease (PD) causes significant socioeconomic burdens. One of the strongest predictors of PD is rapid eye movement (REM) sleep behavior disorder (RBD; when there is no known other cause of RBD, referred to as idiopathic RBD [iRBD]), but there is no information about its factual welfare burden. We estimated the direct and indirect total costs of iRBD in a national sample of patients, based on a national register-based cohort study with matched controls.

METHODS

Using records from the Danish National Patient Registry, patient's diagnosis with RBD from 2006 to 2016 were identified. We excluded patients with a prior diagnosis of narcolepsy, PD, and other neurodegenerative diseases. We identified and compared randomly chosen controls matched for age, gender, geographic area, and civil status. Direct costs included frequencies of primary and secondary sector contacts and procedures, and medication. Indirect costs included the effect on labor supply. Social-transfer payments were included to illustrate the effect on national accounts.

RESULTS

A total of 246 iRBD patients and 982 matched controls were registered. iRBD patients had significantly higher rates of health-related contacts and of medication use, and higher socioeconomic costs than controls. The total additional direct net healthcare costs after the diagnosis (general practitioner services, hospital services, and medication) and indirect costs (loss of labor market income) was €13,088 for patients compared with controls. Patients already exhibited a negative social- and health-related status several years before the first diagnosis.

CONCLUSIONS

Diagnoses of iRBD have major socioeconomic consequences for patients, their partners, and society.

Economic and social cost of epilepsy in Poland: 5-year analysis

INTRODUCTION

Epilepsy affects nearly 50 million people around the world. As a common and chronic disease generates a high cost burden for healthcare system and patients.

AIM

We aimed to determine the most current direct and indirect costs of epilepsy in Poland from the social perspective for the years 2014-2018, to analyze the changes of expenditures over time, indicate trends and to determine key cost-drivers.

MATERIAL AND METHODS

Direct and indirect costs using a top-down approach were estimated based on the public institutions' data for the ICD-10 codes G40 and G41. Direct costs included pharmacotherapy, hospitalizations, outpatient specialist care and rehabilitation. A human capital approach was used to estimate loss of productivity due to sick leaves and long-term inability to work.

RESULTS

Annual total direct and indirect costs related to epilepsy accounted for EUR 410 million in 2014 and decreased in subsequent years to EUR 361 million in 2018. The indirect costs were dominant (76-83% of total costs) and in the majority related to the long-term absenteeism (87-92% of total indirect costs). In 2014-2018, patients with epilepsy generated EUR 341 million to EUR 282 million of indirect costs. Annual direct costs for patients with epilepsy were EUR 69 million in 2014 and increased to EUR 80 million in 2018. The biggest expenses were the costs of drugs (> 50%) and hospitalizations (~ 40%).

CONCLUSIONS

Epilepsy is an expensive disorder in terms of consumption of resources and social costs. Decision-makers should take it under special consideration.

Morbidity, Mortality, and Conversion to Neurodegenerative Diseases in Patients with REM Sleep Behavior Disorder and REM Sleep without Atonia

INTRODUCTION

The underlying pathophysiology of idiopathic REM sleep behavior disorder (iRBD) is not fully understood, although the condition is currently recognized as an early-stage alpha-synuclein disorder. We evaluated the morbidity, mortality, and rate of conversion to a neurodegenerative disorder in a national group of patients.

METHODS

All patients in Denmark with a diagnosis of RBD between 2006 and 2013 were identified from the Danish National Patient Registry (NPR) records. We excluded patients who had received a diagnosis of narcolepsy or any of the following neurodegenerative diseases before their diagnosis of RBD: Parkinson's disease, multiple system atrophy, progressive supranuclear paralysis, Alzheimer's, and Lewy body dementia. We used randomly chosen controls matched for age, gender, and municipality.

RESULTS

In total, 246 iRBD patients and 982 matched controls were analyzed. The mortality rate was the same in both groups. The morbidity rate was significantly higher in the years before and after an RBD diagnosis, due to a wide variety of disorders in the following major disease groups: mental/behavioral disorders; endocrine/metabolic diseases; diseases of the eye; diseases of the nervous, digestive, musculoskeletal, circulatory, and respiratory systems; abnormal findings not classified elsewhere; external causes; and factors influencing health status. The conversion rate from RBD to a neurodegenerative disease was 13% over the 8 years after a diagnosis of RBD.

CONCLUSIONS

A diagnosis of RBD is associated with increased morbidity several years before and after a diagnosis is made. Patients have a higher risk of converting to a neurodegenerative disorder than matched controls. Mortality rates are unchanged.

Working restrictions and disability benefits eligibility in patients with functional (psychogenic) seizures: An international survey of physicians' opinions

OBJECTIVES

In this international study, we aimed to investigate the opinions of physicians dealing with patients with functional seizures (FS) worldwide on working restrictions and disability benefits eligibility.

METHODS

International online survey of neurologists/mental health professionals from Argentina, Venezuela, Colombia, Italy, France, Iran, Iraq, United Arab Emirates (UAE), Qatar, Saudi Arabia, Georgia, and Russia.

RESULTS

Six hundred and twenty-seven physicians from 12 countries participated in the study. Working as a neurologist was a predictor to think that patients with FS should not be counseled to avoid performing all jobs or professions as long as they have active disease (OR: 0.46; 95% CI: 0.30 to 0.68; p < 0.001). Having managed more than 200 patients was associated with the opinion that patients should not be counseled to avoid performing any type of work (OR: 2.17; 95% CI: 1.02 to 4.59; p = 0.043). Working as a psychiatrist/psychologist was associated with the idea that patients with FS should be qualified for disability benefits (OR: 1.97; 95% CI: 1.21-3.21; p = 0.006), and receive these benefits lifelong (OR: 0.43; 95% CI: 0.22-0.84; p = 0.014).

CONCLUSION

Neurologists and mental health professionals have different attitudes and opinions toward working restrictions and disability benefits for patients with FS. Further studies should investigate the reasons for these differences, and propose solutions to avoid discrimination and unequal access to employment and disability benefits.

Long-term employment, education, and healthcare costs of childhood and adolescent onset of epilepsy

OBJECTIVE

Childhood- and adolescent-onset epilepsy may have a significant impact on long-term educational and vocational status, which in turn has consequences for individuals' socioeconomic status. We estimated the factual long-term socioeconomic consequences and healthcare costs of individuals with diagnosed epilepsy.

METHODS

The prospective cohort study included Danish individuals with epilepsy onset before the age of 18 years, diagnosed between 2002 and 2016. Healthcare costs and socioeconomic data were obtained from nationwide administrative and health registers. The prediction was made with a general estimating equation (GEE). A total of 15,329 individuals were found with the diagnosis during this period and were followed until the age of 30 years. These were compared with 31,414 controls. We used 30 years as this represent an age where most has finalized their education, and as such represent the final educational level. Patients and their controls were subdivided into debut age groups of 0-5 and 6-18 years. Individuals were matched for age, gender, and residential location.

RESULTS

Compared with control groups, patients with epilepsy at the age of 30 years tended to have the following: 1) parents with lower educational attainment; 2) a significantly lower educational level when controlling for parental education attainment; 3) lower grade-point averages; 4) a lower probability of being in employment and lower income, even when transfer payments were considered; and 5) elevated healthcare costs, including those for psychiatric care. It was also noted that the long-term educational consequences for patients with epilepsy were associated with parental educational level. Differences were more pronounced for those with early (0-5 years) rather than later (6-18 years) onset epilepsy.

CONCLUSIONS

Epilepsy is associated with severe long-term socioeconomic consequences: lower educational level, school grades, employment status, and earned income. The presence of epilepsy is associated with parental educational level.

LIMITATIONS

SIGNIFICANT OUTCOMES.

Occurrence, mortality and cost of brain disorders in Denmark: a population-based cohort study

OBJECTIVES

To examine the occurrence of brain disorders (ie, neurological and mental disorders) in Denmark and mortality and cost of illness among affected persons.

DESIGN

Matched cohort study.

SETTING

We obtained routinely collected registry data on all Danish residents during 1995-2015.

PARTICIPANTS

We identified all persons alive on 1 January 2015 with a diagnosis of 25 specific brain disorders (prevalent cohort) and all persons with an incident diagnosis during 2011-2015 (incident cohort). Each person was matched on age and sex with 10 persons from the general population without the brain disorder of interest.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence and incidence of hospital-diagnosed brain disorders, 1-year absolute and relative mortality, and attributable direct and indirect costs of illness compared with the corresponding matched cohorts.

RESULTS

We identified 1 075 081 persons with at least one prevalent brain disorder (any brain disorder) on 1 January 2015, corresponding to 18.9% of the Danish population. The incidence rate of any brain disorder during 2011-2015 was 1349 per 100 000 person-years (95% CI 1345 to 1353). One-year mortality after diagnosis was increased in persons with any brain disorder (HR 4.7, 95% CI 4.7 to 4.8) and in persons in every group of specific brain disorders compared with the matched cohort from the general population. The total attributable direct costs of brain disorders in 2015 were €5.2 billion and total attributable indirect costs were €11.2 billion. Traumatic brain injury, stress-related disorders, depression and stroke were the most common brain disorders. Attributable costs were highest for depression, dementia, stress-related disorders and stroke.

CONCLUSIONS

One in five Danish residents alive on 1 January 2015 had been diagnosed with at least one brain disorder, and mortality was five times higher in persons with any diagnosed brain disorder than in the general population. We found high attributable direct and indirect costs of brain disorders.

Welfare consequences for people diagnosed with attention deficit hyperactivity disorder (ADHD): A matched nationwide study in Denmark

There is insufficient data regarding the excess direct and indirect costs associated with attention deficit hyperactivity disorder (ADHD). Using the Danish National Patient Registry (2002-2016), we identified 83,613 people of any age with a diagnosis of ADHD or who were using central-acting medication against ADHD (primarily methylphenidate, with at least two prescriptions) and matched them to 334,446 control individuals. Additionally, 18,959 partners of patients aged ≥18 years with ADHD were identified, and compared with 74,032 control partners. Direct costs were based on data from the Danish Ministry of Health. Information about the use and costs of drugs were obtained from the Danish Medicines Agency. The frequencies of visits and hospitalizations, and costs of general practice were derived from data from the National Health Security. Indirect costs were obtained from Coherent Social Statistics. The average annual health care costs for people with ADHD and their partners were, respectively, €2636 and €477 higher than those of the matched controls. A greater percentage of people with ADHD and their partners compared with respective control subjects received social services (sick pay or disability pension). Those with ADHD had a lower income from employment than did controls for equivalent periods up to five years before the first diagnosis of ADHD. The additional direct and indirect annual costs (for those aged ≥18 years) including transfers of ADHD compared with controls were €23,072 for people with ADHD and €7,997 for their partners. ADHD has substantial socioeconomic consequences for individual patients, their partners and society.

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.

One-year follow-up of a remotely delivered epilepsy self-management program in high-risk people with epilepsy

OBJECTIVE

"Self-management for people with epilepsy and a history of negative health events" (SMART) is a novel group-format epilepsy self-management intervention demonstrated to reduce negative health events (NHEs) such as accidents, emergency department visits, and seizures in adults with epilepsy in a 6-month prospective randomized controlled trial (RCT); SMART also reduced depressive symptoms and improved health functioning and quality of life. This report describes the longer-term (12-month) post-efficacy RCT outcomes in adults with epilepsy who received SMART.

METHODS

After completing a 6-month, prospective RCT that demonstrated efficacy of SMART vs 6-month waitlist control (WL), adults ≥18 years of age with epilepsy were followed for an additional 12 months. Individuals originally randomized to WL received the 8-week SMART intervention immediately following the conclusion of the RCT. For this long-term extension analysis, assessments were conducted at 24 weeks (the 6-month primary outcome time-point of the efficacy RCT), at 32 weeks for individuals originally randomized to WL, and at 48 weeks and 72 weeks for all individuals. Outcomes assessed included past 6-month NHE counts, depressive symptoms assessed with the 9-item Patient Health Questionnaire (PHQ-9) and Montgomery-Asberg Depression Rating Scale (MADRS), and quality of life assessed with the 10-item Quality of Life in Epilepsy (QOLIE-10).

RESULTS

At the beginning of this long-term observational period (24-week follow-up time point for the original RCT), there were 50 individuals in the group originally randomized to SMART and 52 originally randomized to WL. Mean age was 41.4 years, 70% women (N = 71), 64% (N = 65) African-American, and 8% Hispanic (N = 8). Study attrition from week 24 to week 72 was 8% in the arm originally randomized to SMART and 17% in the arm originally randomized to WL. During the 12-month observation period (24 weeks to 72 weeks), there were a total of 44 serious adverse events and 4 deaths, none related to study participation. There was no significant change in total past 6-month NHE counts in the group originally randomized to SMART, although the group had significantly reduced 6-month seizure counts. The group originally randomized to WL, who received SMART during this observational period, had a reduction in total NHE counts. The group originally randomized to SMART had relatively stable levels on other outcome variables except for a trend for improved MADRS (p = 0.08). In the group originally randomized to WL, there were significant improvements in PHQ-9 (p = 0.01), MADRS (p ≤ 0.01), and QOLIE-10 (p = 0.004).

CONCLUSIONS

This post-RCT extension study suggests that adults with epilepsy who participate in the SMART intervention sustain clinical effects at 1-year follow-up and may have incremental improvements in seizure frequency and mood. Future research needs to identify opportunities for scale-up and outreach to other high-risk groups with epilepsy.

Morbidity and mortality of nonepileptic seizures (NES): A controlled national study

Nonepileptic seizures (NES, psychogenic NES-PNES) are associated with significant morbidities. We evaluated the morbidities and mortality in a national group of children, adolescent, and adult patients before and after a first diagnosis of PNES.

METHODS

From the Danish National Patient Registry (1998-2013), we identified 1057 people of all ages with a diagnosis of NES and matched them with 2113 control individuals by age, gender, and geography. Comorbidities were calculated three years before and after diagnoses.

RESULTS

Patients with PNES showed increased comorbidities 3 years before and after diagnosis in almost all the diagnostic domains. The strongest associations were identified with other neurological diseases (after diagnosis, Hazard Ratio (HR): 38.63; 95% Confidence Interval (CI): 21.58-69.13; P < 0.001), abnormal clinical and laboratory findings (HR: 46.59; 95 CI: 27.30-79.52; P < 0.001), other health-related factors (HR: 12.83; 95%CI: 8.45-19.46; P < 0.001), and psychiatric comorbidities (HR: 15.45; 95% CI: 9.81-24.33). Epilepsy was identified in 8% of the patients with PNES. We found especially frequent comorbidity involving overweight, depression, anxiety, dissociative somatoform condition, other convulsions, lipothymias, reports of pain and other symptoms in several organ systems, and several reports of minimal traumas to the head, trunk, and extremities. Mortality was higher in patients with NES than in controls (HR: 3.21; 95% CI: 1.92-5.34; P < 0.001).

CONCLUSION

Morbidity is more frequent in several domains, including neurological, psychiatric, and other diseases, before and after a diagnosis of NES. Mortality is significantly higher in patients with PNES as compared to controls.

Sleep Related Epilepsy and Pharmacotherapy: An Insight

In the last several decades, sleep-related epilepsy has drawn considerable attention among epileptologists and neuroscientists in the interest of new paradigms of the disease etiology, pathogenesis and management. Sleep-related epilepsy is nocturnal seizures that manifest solely during the sleep state. Sleep comprises two distinct stages i.e., non-rapid eye movement (NREM) and rapid eye movement (REM) that alternate every 90 min with NREM preceding REM. Current findings indicate that the sleep-related epilepsy manifests predominantly during the synchronized stages of sleep; NREM over REM stage. Sleep related hypermotor epilepsy (SHE), benign partial epilepsy with centrotemporal spikes or benign rolandic epilepsy (BECTS), and Panayiotopoulos Syndrome (PS) are three of the most frequently implicated epilepsies occurring during the sleep state. Although some familial types are described, others are seemingly sporadic occurrences. In the present review, we aim to discuss the predominance of sleep-related epilepsy during NREM, established familial links to the pathogenesis of SHE, BECTS and PS, and highlight the present available pharmacotherapy options.

Patient-reported outcome (PRO) measure-based algorithm for clinical decision support in epilepsy outpatient follow-up: a test-retest reliability study

OBJECTIVES

Patient-reported outcome (PRO) measures have been used in epilepsy outpatient clinics in Denmark since 2011. The patients' self-reported PRO data are used by clinicians as a decision aid to support whether a patient needs contact with the outpatient clinic or not based on a PRO algorithm. Validity and reliability are fundamental to any PRO measurement used at the individual level in clinical practice. The aim of this study was to evaluate the test-retest reliability of the PRO algorithm used in epilepsy outpatient clinics and to analyse whether the method of administration (web and paper) would influence the result.

DESIGN AND SETTING

Test-retest reliability study conducted in three epilepsy outpatient clinics in Central Denmark Region, Denmark.

PARTICIPANTS

A total of 554 epilepsy outpatients aged 15 years or more were included from August 2016 to April 2017. The participants completed questionnaires at two time points and were randomly divided into four test-retest groups: web-web, paper-paper, web-paper and paper-web. In total, 166 patients completed web-web, 112 paper-paper, 239 web-paper and 37 paper-web.

RESULTS

Weighted kappa with squared weight was 0.67 (95% CI 0.60 to 0.74) for the pooled PRO algorithm, and perfect agreement was observed in 82% (95% CI 78% to 85%) of the cases. There was a tendency towards higher test-retest reliability and agreement estimates within same method of administration (web-web or paper-paper) compared with a mixture of methods (web-paper and paper-web).

CONCLUSIONS

The PRO algorithm used for clinical decision support in epilepsy outpatient clinics showed moderate to substantial test-retest reliability. Different methods of administration produced similar results, but an influence of change in administration method cannot be ruled out.

The Burden of Severely Drug-Refractory Epilepsy: A Comparative Longitudinal Evaluation of Mortality, Morbidity, Resource Use, and Cost Using German Health Insurance Data

Purpose

To evaluate long-term outcome of three years and treatment patterns of patients suffering from severely drug-refractory epilepsy (SDRE).

Methods

This analysis was population-based and retrospective, with data collected from four million individuals insured by statutory German health insurance. ICD-10 codes for epilepsy (G40*) and intake of anticonvulsants were used to identify prevalent cases, which were then compared with a matched cohort drawn from the population at large. Insurance data were available from 2008 to 2013. Any patient who had been prescribed with at least four different antiepileptic drugs (AEDs) in an 18-month period was defined as an SDRE case.

Results

A total of 769 patients with SDRE were identified. Of these, 19% were children and adolescents; the overall mean age was 42.3 years, 45.4% were female and 54.6% male. An average of 2.7 AEDs per patient was prescribed during the first follow-up year. The AEDs most commonly prescribed were: levetiracetam (53.5%), lamotrigine (41.4%), valproate (41.3%), lacosamide (20.4%), and topiramate (17.8%). During 3-year follow-up, there was an annual rate of hospitalization in the range 42.7 to 55%, which was significantly higher than the 11.6–12.8% (p < 0.001) for the matched controls. Admissions to hospital because of epilepsy ranged between 1.7 and 1.9 per year, with an average duration for each epilepsy-caused hospitalization of 10–11.1 days. The number of comorbidities for SDRE patients was significantly increased compared with the matched controls: depression (28% against 10%), vascular disorders (22% against 5%), and injury rates were also higher (head 16% against 3%, trunk and limbs 16% against 8%). The 3-year mortality rate for SDRE patients was 14% against 2.1% in the matched cohort.

Conclusion

SDRE patients are treated with AED polytherapy for all of the 3-year follow-up period. They are hospitalized more frequently than the general population and show increased morbidity levels and a sevenfold increase in mortality rate over 3 years. Further examination is required of ways in which new approaches to treatment could lead to better outcomes in severely affected patients.